Clinical management and outcomes of acute pancreatitis: Identifying areas for quality improvement in a tertiary Asian setting.

BACKGROUND: This study aims to review the clinical management of patients with acute pancreatitis in a tertiary institute in Singapore, and to identify areas qualiy improvement based on validation against the recommendations in the IAP/APA and the Japanese guidelines. METHODS: 391 patients from a prospective electronic database were included and reviewed for compliance to the International Association of Pancreatology (IAP)/American Pancreatic Association (APA) guidelines (2013) and the Japanase Guidelines (2015). RESULTS: The 90 day mortality was 8.4% for moderately severe and 11.9% for severe pancreatitis. The accuracy of SIRS in predicting severe acute pancreatitis on admission was 72.1% and at 48 h 80.8%. Only 61.1% patients had ultrasound scan during their admission of whom 32.9% had it within 24 h of admission. 18.3% patients with initial diagnosis of idiopathic pancreatitis had EUS. 50% received Ringer lactate for initial fluid resuscitation. 38.7% received antibiotics as prophylaxis. 21.4% with severe acute pancreatitis had early enteral nutrition. Only 21.4% patients with biliary pancreatitis had index admission cholecystectomy. CONCLUSION: The compliance to existing guidelines for management of acute pancreatitis is variable. Identifying gaps and implementing measures to address them allows for continued improvement in the management of patients with acute pancreatitis.

Quality of life with minimally invasive repair of pectus excavatum: a systematic review and meta-analysis.

Background: Minimally invasive repair of pectus excavatum (MIRPE) is a popular method for surgical correction of PE, and its impact on quality of life is a growing area of interest. We performed a systematic review and meta-analysis to evaluate the impact of MIRPE on the quality of life of patients. Methods: This study was registered with PROSPERO under reference number CRD42020222061. A literature search of PubMed, Cochrane Library, EMBASE and Scopus was conducted from the date of inception till November 23, 2020. We included studies which administered one or more questionnaires on patients up to 60 years old, parents or both, to assess the quality of life before and after MIRPE. Studies not written in English, abstracts, articles without primary data, reviews and studies which combined data on PE and other deformities were excluded. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions and the Cochrane risk of bias tool. A random-effects meta-analysis was performed to obtain mean differences for key themes of quality of life before and after MIRPE. Responses from the same questionnaires, as well as common themes across different questionnaires, were compared. Results: Of the 20 studies identified for systematic review, 7 studies that reported the responses of 478 patients were included in the meta-analysis. Patients who underwent MIRPE experienced an increased self-esteem [standardized mean difference (SMD): 1.38, 95% confidence interval (CI): 0.95 to 1.81, P<0.00001] and a smaller degree of chest interference with their social activities (SMD: 0.84, 95% CI: 0.60 to 1.08, P<0.00001). These findings were consistent even after the implanted bar was removed. Conclusions: MIRPE may be associated with a better quality of life for patients with PE as self-esteem and extent of chest interference with social activities are improved after the procedure. The key limitations of this study are the lack of high-quality evidence due to paucity of randomized trials, and the significant heterogeneity in reported outcomes due to variations in the questionnaires and timepoints of administration.

Insight parameter drug design for human ß-tryptase inhibition integrated molecular docking, QSAR, molecular dynamics simulation, and pharmacophore modelling studies of α-keto-[1,2,4]-oxadiazoles.

Dengue hemorrhagic fever (DHF) is severe dengue with a hallmark of vascular leakage. ß-tryptase has been found to promote vascular leakage in DHF patients, which could be a potential target for DHF treatment. This study aims to develop a theoretical background for designing and selecting human ß-tryptase inhibitors through computational studies. Thirty-four α-keto-[1,2,3]-oxadiazoles scaffold-based compounds were used to generate 2D-QSAR models and for molecular docking studies with ß-tryptase (PDB Code 4A6L). In addition, molecular dynamics (MD) simulation and molecular mechanics generalised born surface area (MM-GBSA) analysis on the binding of the reported most active compound, compound 11e, towards ß-tryptase were performed. Finally, a structure-based pharmacophore model was generated. The selected 2D-QSAR models have statistically proven good models by internal and external validation as well as the y-randomization test. The docking results of compound 11e showed lower CDOCKER energy than the 4A6L co-crystallised ligand and a similar binding pattern as the 4A6L co-crystallised ligand. From molecular dynamics simulation, 4A6L in compound 11e bound state has RMSD below 2 Å throughout the 500 ns simulation, indicating the docked complex is stable. Besides, MM-GBSA analysis suggested the 4A6L-compound 11e docked complex (-66.04 Kcal/mol) is structurally as stable as the 4A6L-native ligand co-crystallized structure (-66.84 Kcal/mol). The best pharmacophore model identified features included hydrogen bond acceptor, ionic interaction, hydrophobic interaction, and aromatic ring, which contribute to the inhibitory potency of a compound. This study supplied insight and knowledge for developing novel chemical compounds with improved inhibition of ß-tryptase.Communicated by Ramaswamy H. Sarma.

Incorporation of an intercostal catheter into a multimodal analgesic strategy for uniportal video-assisted thoracoscopic surgery: a feasibility study.

BACKGROUND: Well-controlled postoperative pain is essential for early recovery after uniportal video-assisted thoracoscopic surgery (UVATS). Conventional analgesia like opioids and thoracic epidural anaesthesia have been associated with hypotension and urinary retention. Intercostal catheters are a regional analgesic alternative that can be inserted during UVATS to avoid these adverse effects. This feasibility study aims to evaluate the postoperative pain scores and analgesic requirements with incorporation of an intercostal catheter into a multimodal analgesic strategy for UVATS. METHODS: In this observational study, 26 consecutive patients who underwent UVATS were administered a multilevel intercostal block and oral paracetamol. All of these patients received 0.2% ropivacaine continuously at 4 ml/h via an intercostal catheter at the level of the incision. Rescue analgesia including etoricoxib, gabapentin and opioids were prescribed using a pain ladder approach. Postoperative pain scores and analgesic usage were assessed. The secondary outcomes were postoperative complications, days to ambulation and length of stay. RESULTS: No technical difficulties were encountered during placement of the intercostal catheter. There was only one case of peri-catheter leakage. Mean pain score was 0.31 (range 0-2) on post-operative day 1 and was 0.00 by post-operative day 5. 16 patients (61.6%) required only oral rescue analgesia. The number of patients who required rescue non-opioids only increased from 1 in the first 7 months to 8 in the next 7 months. There were no cases of hypotension or urinary retention. Median time to ambulation was 1 day (range 1-2). Mean post-operative length of stay was 4.17 ± 2.50 days. CONCLUSIONS: Incorporation of an intercostal catheter into a multimodal analgesia strategy for UVATS is feasible and may provide adequate pain control with decreased opioid usage.

[Investigation on emission characteristics of methanol vehicle's aldehyde and ketone pollutants].

Investigation on the character and quantity of aldehydes and ketones emitted from methanol vehicle was implemented respectively by using high performance liquid chromatograph (HPLC) method. Experiments of vehicles equipped with and without three-way catalyst (TWC) under transient and steady mode were carried out. The emission results were compared with that of gasoline vehicle. The data showed that the efficiency of aldehydes and ketones emitted from methanol vehicle and gasoline vehicle were 22.53% and 48.95% with TWC under transient state respectively. When the vehicle is fueled with methanol, the main emissions are formaldehyde, acetaldehyde, acraldehyde + acetone, and these three matters account for 97.18% of the total emission. This proportion is 39.07% when the vehicle is fueled with gasoline. However, the total quantity of aldehydes and ketones from methanol vehicle without TWC was less than that from gasoline vehicle without TWC. Whether with or without TWC, aldehydes and ketones from methanol vehicle were more than that from gasoline vehicle under steady states. When the vehicle is fueled with methanol, the emission of aldehydes and ketones is on the top level at the speed of 60 km/h, and the converting efficiency is also the highest, which is 88.50%. When at the speed of 60 km/h, 90 km/h, 120 km/h, the formaldehyde quantity of methanol vehicle was 332.94%, 374.47% and 357.58% as much as that from gasoline vehicle respectively.

[Effects of oxygenated fuels on emissions and carbon composition of fine particles from diesel engine].

Acetal (1,1-diethoxyethane) is considered as an alternative to ethanol as bio-derived additive for diesel fuel, which is miscible in diesel fuel. Biodiesel can improve the oxygen content and flash point of the fuel blend of acetal and diesel fuel. Two oxygenated fuels were prepared: a blend of 10% acetal + 90% diesel fuel and 10% acetal + 10% biodiesel + 80% diesel fuel. The emissions of NO(x), HC and PM2.5 from oxygenated fuels were investigated on a diesel engine bench at five modes according to various loads at two steady speeds and compared with base diesel fuel. Additionally, the carbon compositions of PM2.5 were analyzed by DRI thermal/optical carbon analyzer. Oxygenated fuels have unconspicuous effect on NO(x) emission rate but HC emission rate is observed significantly increased at some modes. The emission rate of PM2.5 is decreased by using oxygenated fuels and it decreases with the increase of fuel oxygen content. The emission rates of TC (total carbon) and EC (elemental carbon) in PM2.5 are also decreased by oxygenated fuels. The emission rate of organic carbon (OC) is greatly decreased at modes of higher engine speed. The OC/EC ratios of PM2.5 from oxygenated fuels are higher than that from base diesel fuel at most modes. The carbon compositions fractions of PM2.5 from the three test fuels are similar, and OC1 and EC1 are contributed to the most fractions of OC and EC, respectively. Compared with base diesel fuel, oxygenated fuels decrease emission rate of PM2.5, and have more OC contribution to PM2.5 but have little effect on carbon composition fractions.

[Effects of biodiesel on fine particles (PM2.5) and polycyclic aromatic hydrocarbons from diesel engine].

PM2.5 emissions and polycyclic aromatic hydrocarbons (PAHs) in PM2.5 of pure biodiesel derived from different feedstocks were investigated and compared with diesel fuel. B100-1 (soyabean oil derived), B100-2 (waste oil derived) and diesel fuel were tested on a diesel engine bench at four operating conditions, including two steady speeds of different loads. The fine particles were collected by fiber quartz filter and particle phase PAHs were analyzed by GC-MS. Compared with diesel fuel, biodiesel decreased PM2.5 emission rates with a maximal reduction rate of 37.3% at operating modes of high loads, while increased PM2.5 emission rates at low loads. PAHs emission rates from biodiesel decreased at all tested modes, with a maximal reduction rate of 77.6%. The emission rates of PM2.5 and PAHs of B100-2 were 14.7% and 17.8% times of B100-1. Low molecular weight PAHs dominated in the emission of three fuels with phenanthrene as maxima and 2-ring and 3-ring PAHs accounted for more than 50% of the total PAHs. Toxic equivalence of PAHs emissions of biodiesel was decreased greatly compared with that of diesel.