A study of hospitalized COVID-19 patients with AKI in a setting of multiracial developing country.

BACKGROUND: The commonest indication for hospitalization in COVID-19 patients is hypoxemia or severe respiratory symptoms. However, COVID-19 disease may result in extrapulmonary complications including kidney-related pathology. The reported incidence of renal involvement related to COVID infection varies based on geographical location. OBJECTIVE: This study aimed to assess the incidence rate of AKI in hospitalized COVID-19 patients and identify risk factors and prognostic predictors. METHOD: In this retrospective study, we recruited hospitalized COVID-19 patients from January 2021 until June 2021 at the University Malaya Medical Center. The inclusion criteria were hospitalized for ≥ 48 h with confirmed COVID-19 infection and at least 18 years old. Patient demographic and clinical data were collected from electronic medical records. The staging of AKI was based on criteria as per KDIGO guidelines. RESULTS: One thousand five hundred twenty-nine COVID patients fulfilled the inclusion criteria with a male-to-female ratio of 759 (49.6%) to 770 (50.3%). The median age was 55 (IQR: 36-66). 500 patients (32.7%) had diabetes, 621 (40.6%) had hypertension, and 5.6% (n = 85) had pre-existing chronic kidney disease (CKD). The incidence rate of AKI was 21.1% (n = 323). The percentage of COVID patients in different AKI stages of 1,2 and 3 were 16.3%, 2.1%, and 2.7%, respectively. Fifteen hospitalized patients (0.98%) required renal replacement therapy. 58.8% (n = 190) of AKI group had complete recovery of kidney function. Demographic factors included age (p < 0.001), diabetes (p < 0.001), hypertension (p < 0.012), CKD (p < 0.001), and vaccination status (p = 0.042) were associated with an increased risk of developing AKI. We found that the AKI cohort had statistically significant lower platelet counts and higher ferritin levels than the non-AKI cohort. AKI is a risk predictor of prolonged hospitalization (p < 0.001) and higher mortality rates (P < 0.001). CONCLUSION: AKI is a common clinical complication among hospitalized COVID-19 patients. The etiology of AKI is multifactorial and may have an adverse impact on patient morbidity and mortality.

B-cell lymphoma research in Malaysia - A narrative review.

Lymphomas are a diverse group of malignant proliferations that arise as discrete tissue masses. The most widely accepted taxonomy for lymphoma is the World Health Organization classification of tumours of haematopoietic and lymphoid tissues, the 5th edition of which was released in June 2022. Most (85% to 90%) lymphoid neoplasms are of B cell origin. Mature B-cell neoplasms are a heterogeneous group of malignancies with similar disease courses and treatment paradigms. This review focuses on the various mature B-cell lymphomas in Malaysia, including Hodgkin lymphoma. A literature search was performed in various bibliographic databases. A total of 64 papers were included in this review. We found 15 papers on Hodgkin lymphoma, 14 on follicular lymphoma, 12 on Burkitt lymphoma, 5 on mucosa-associated lymphoid tissue (MALT) lymphoma, 4 on plasmablastic lymphoma, 3 on mantle cell lymphoma, 1 each on primary mediastinal large B-cell lymphoma, B-lymphoblastic lymphoma, and 3 on other unspecified B-cell lymphomas. The site, age, distribution, prognostic markers, and the various subclassification of B cell lymphomas were studied from these papers. Prognostic genetic markers in B-cell lymphomas include C-MYC, BCL2 and BCL6 as they are the most prevalent mutations in this condition. Anecdotal outcomes range from rapid fatality to unexplained spontaneous remission. This review adds to the existing literature on lymphoma in Malaysia by compiling the evidence that may lead to further research on the diagnosis and treatment of lymphoma in Malaysia and worldwide.

Resting Hypoconnectivity of Theoretically Defined Addiction Networks during Early Abstinence Predicts Subsequent Relapse in Alcohol Use Disorder.

Theoretical models of addiction suggest that alterations in addiction domains including incentive salience, negative emotionality, and executive control lead to relapse in alcohol use disorder (AUD). To determine whether the functional organization of neural networks underlying these domains predict subsequent relapse, we generated theoretically defined addiction networks. We collected resting functional magnetic resonance imaging data from 45 individuals with AUD during early abstinence (number of days abstinent M = 25.40, SD = 16.51) and calculated the degree of resting-state functional connectivity (RSFC) within these networks. Regression analyses determined whether the RSFC strength in domain-defined addiction networks measured during early abstinence predicted subsequent relapse (dichotomous or continuous relapse metrics). RSFC within each addiction network measured during early abstinence was significantly lower in those that relapsed (vs. abstained) and predicted subsequent time to relapse. Lower incentive salience RSFC during early abstinence increased the odds of relapsing. Neither RSFC in a control network nor clinical self-report measures predicted relapse. The association between low incentive salience RSFC and faster relapse highlights the need to design timely interventions that enhance RSFC in AUD individuals at risk of relapsing faster.

Time for change? Feasibility of introducing micromodules into medical student education: a randomised controlled trial.

INTRODUCTION: Didactic lectures have been the foundation of learning for many medical students. However, in recent years, the flipped classroom model has become increasingly popular in medical education. This approach enhances pre-class learning, allowing the limited contact time between clinicians and medical students to be focused on practical issues. This study evaluated the effectiveness and non-inferiority of online micromodule teaching in terms of knowledge transfer concerning specific urology topics. METHODS: Medical students without prior exposure to the urology subspecialty were enrolled in the study, then randomised to a traditional didactic lecture group or an online micromodule group. Knowledge transfer was assessed by pre-intervention and post-intervention multiple-choice questions and objective structured clinical examinations that involved the acquisition of medical histories from real patients. RESULTS: In total, 45 medical students were enrolled (22 in the traditional didactic group and 23 in the online micromodule group). In terms of knowledge transfer (assessed by objective structured clinical examinations), the efficacy of online micromodules was comparable to traditional didactic lectures, although the difference was not statistically significant (P=0.823). There were no significant differences in terms of knowledge acquisition, retention, or clinical application between the two groups. CONCLUSION: In terms of acquiring, retaining, and applying foundational urological knowledge, online micromodules can help medical students to achieve outcomes comparable with the outcomes of didactic lectures. Online micromodules may be a viable alternative to traditional didactic lectures in urology education.

Efficacy and safety of adjunctive treatment with perampanel in epilepsy patients.

INTRODUCTION: Epilepsy is a neurological disease with high global prevalence. Almost one-third of epilepsy patients continue having seizures despite adequate treatment. Perampanel has been widely used in the Western countries as an adjunctive therapy for both generalized and focal seizures. Owing to its high cost, the use of perampanel is limited in our country. MATERIALS AND METHODS: We conducted a descriptive, retrospective study among epilepsy patients treated with perampanel. We aimed to assess the efficacy and safety of perampanel as an adjunctive in our hospital. RESULTS AND CONCLUSIONS: From our cohort of 25 patients, most of the patients were either on one or three anti-seizure medications (ASMs) prior to initiation of perampanel. Perampanel was added in 88% of them due to persistent seizures. Twenty-two (88%) patients experienced reduction in seizure frequency. 12% experienced mild side effects, which were leg cramps, hyponatremia and drowsiness. Only 1 patient stopped perampanel due to its side effects. CONCLUSION: Perampanel is a well-tolerated ASM that should be widely used as an adjunctive. More studies with regards to its efficacy and safety involving more centres are encouraged in Malaysia.

Clinical and radiological outcomes of SARS-CoV-2 related organising pneumonia in COVID-19 survivors.

INTRODUCTION: COVID-19 patients frequently demonstrate radiological organising pneumonia (OP) pattern. The longterm outcome and treatment options for this group of patients remain uncertain. We aim to describe the clinical and radiological outcomes of patients with COVID-19-related OP and identify possible clinical factors associated with inferior radiological outcome. MATERIALS AND METHODS: Post-COVID-19 clinic attendees, consisting of post-COVID-19 patients discharged from major hospitals in the state of Selangor during the third pandemic wave of COVID-19 in Malaysia, were enrolled in this retrospective study for 6 months. Physician-scored Modified Medical Research Council (mMRC), patient self-reported quality of life (EQ-VAS) score and follow-up CT scan were evaluated. RESULTS: Our cohort comprised 131 patients, with a median age of 52 (IQR 39-60) years and median BMI of 29.40 (IQR 25.59-34.72). Majority (72.5%) had co-morbidities, and 97.7% had severe disease requiring supplementary oxygen support during the acute COVID-19 episode. 56.5% required intensive care; among which one-third were invasively ventilated. Median equivalent dose of methylprednisolone prescribed was 2.60 (IQR 1.29-5.18) mg/kg during admission, while the median prednisolone dose upon discharge was 0.64 (IQR 0.51-0.78) mg/kg. It was tapered over a median of 8.0 (IQR 5.8-9.0) weeks. Upon follow-up at 11 (IQR 8-15) weeks, one-third of patients remained symptomatic, with cough, fatigue and dyspnoea being the most reported symptoms. mMRC and EQ-VAS scores improved significantly (p<0.001) during follow-up. Repeat CT scans were done in 59.5% of patients, with 94.8% of them demonstrating improvement. In fact, 51.7% had complete radiological resolution. Intensive care admission and mechanical ventilation are among the factors which were associated with poorer radiological outcomes, p<0.05. CONCLUSION: Approximately one-third of patients with SARSCoV- 2-related OP remained symptomatic at 3 months of follow-up. Majority demonstrated favourable radiological outcomes at 5-month reassessment, except those who required intensive care unit admission and mechanical ventilation.

Stress perceived by drivers in public healthcare facilities in Negeri Sembilan during the first year of the COVID-19 pandemic.

INTRODUCTION: Healthcare drivers, including ambulance drivers, were less concerned about health and safety during the COVID-19 pandemic, with not only the risk of COVID-19 infection but also a higher risk of prolonged states of alertness, stress, burnout, fatigue and road traffic accident. This study aimed to determine the prevalence of stress and its associated factors among healthcare drivers, especially during the COVID-19 pandemic. MATERIALS AND METHODS: This study employs a crosssectional study design and utilises self-reported data obtained from locally validated personal stress inventory questionnaires. The data collection period spanned from August 1 to 31, 2020. The study sample consisted of 163 healthcare drivers affiliated with the Negeri Sembilan State Health Department. The Chi-square test and Fisher's exact test were the first used to determine the association between variables prior to conducting multiple logistic regression to predict the relationship between dependent and independent variables. RESULTS: In COVID-19's first year, 7.4% (n = 12) of healthcare drivers reported perceived stress with ambulance drivers reporting more stress (10.6%; n = 5) than non-ambulance drivers (6.0%; n = 7). Simple statistical analysis identified perceived stress significantly associated with household income, smoking status and performing on-call. Further analysis by multiple logistic regression found that perceived stress was significantly related to smoking (aOR 19.9, 95% CI: 1.86-213.90), and performing on-call (aOR 8.69, 95% CI 1.21-62.28). Nevertheless, no association was found between perceived stress and age, ethnicity, marital status, education, household income, co-morbidities, driving assignment, employment duration, needing a part-time job or motor vehicle accident history. CONCLUSION: The study found that the perceived stress amongst Malaysian healthcare drivers during the COVID-19 pandemic was relatively low. This could be due to fewer lifethreatening tasks, emergencies, assigned tasks and increase income due to overtime during the COVD-19 pandemic. The OSH team's efforts to provide consistent safety and health training, including stress management, may have contributed to the healthcare driver's ability to effectively manage the stressful circumstances encountered during the pandemic. In order to enhance salary competitiveness, employers should provide financial management education alongside subsidised housing and childcare provisions. Healthcare drivers who smoke should be taught different stress reduction techniques so that they can handle their stress in a healthy way.

Diffuse large B-cell lymphoma research in Malaysia: A review.

Lymphomas are prevalent worldwide and a common malignancy reported in Malaysia. Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of B-cell lymphomas accounting for 54% to 65% of all B-cell lymphomas and 39% to 57% of all malignant lymphomas. However, DLBCL comprises a heterogeneous group of diseases with different clinical presentations, biology and response to treatment. Recent advances in understanding the genetic landscape and molecular features of DLBCL have identified high-risk subsets with poor outcomes to chemo-immunotherapy that are actively being studied in various clinical trials. C-MYC is a proto-oncogene located in chromosome 8q24. 10 to 15 % of patients with newly diagnosed DLBCL have an underlying rearrangement of the MYC oncogene, resulting in dysregulated cellular survival and proliferation. Approximately half of these cases also carry a rearrangement of the anti-apoptotic proto-oncogene BCL2 and/or its transcription repressor BCL6. Over 20 case reports of DLBCL cases with notable features in Malaysia have found in the literature, in addition to a few extensive case series and included in this review. R-CHOP remains the mainstay of therapy and can help achieve control of long-term disease in nearly 90% of patients presenting with limited-stage and in up to 60% of those presenting with advanced stages. This review captures all 52 studies that reported DLBCL in Malaysia and summarises the essential aspects, including prevalence, subtype, prognostic markers clinical features in presentation and limited outcomes of cases when available.

The endosymbiont Wolbachia rebounds following antibiotic treatment.

Antibiotic treatment has emerged as a promising strategy to sterilize and kill filarial nematodes due to their dependence on their endosymbiotic bacteria, Wolbachia. Several studies have shown that novel and FDA-approved antibiotics are efficacious at depleting the filarial nematodes of their endosymbiont, thus reducing female fecundity. However, it remains unclear if antibiotics can permanently deplete Wolbachia and cause sterility for the lifespan of the adult worms. Concerns about resistance arising from mass drug administration necessitate a careful exploration of potential Wolbachia recrudescence. In the present study, we investigated the long-term effects of the FDA-approved antibiotic, rifampicin, in the Brugia pahangi jird model of infection. Initially, rifampicin treatment depleted Wolbachia in adult worms and simultaneously impaired female worm fecundity. However, during an 8-month washout period, Wolbachia titers rebounded and embryogenesis returned to normal. Genome sequence analyses of Wolbachia revealed that despite the population bottleneck and recovery, no genetic changes occurred that could account for the rebound. Clusters of densely packed Wolbachia within the worm's ovarian tissues were observed by confocal microscopy and remained in worms treated with rifampicin, suggesting that they may serve as privileged sites that allow Wolbachia to persist in worms while treated with antibiotic. To our knowledge, these clusters have not been previously described and may be the source of the Wolbachia rebound.

Perceptions of the use of artificial intelligence in the diagnosis of skin cancer: an outpatient survey.

BACKGROUND: Convolutional neural networks (artificial intelligence, AI) are rapidly appearing within the field of dermatology, with diagnostic accuracy matching that of dermatologists. As technologies become available for use by both the health professionals and the general public, their uptake in healthcare will become more acceptable. National Health Service England recognizes the potential of AI for healthcare but emphasizes that patient-centred care should be at the forefront of these technological advancements. AIM: To obtain opinions of patients on the use of AI in a dermatology setting, when aiding the diagnosis of skin cancers. METHODS: A cross-sectional 14-point questionnaire was handed out to patients attending dermatology outpatient skin cancer clinics in two UK hospitals, between March and August 2018. RESULTS: In total, 603 patient questionnaires were completed. Nearly half (47%; n = 282) of respondents were not concerned if AI technology was used by a skin specialist to aid skin cancer diagnosis. However, the majority (81%; n = 491) of respondents, considered it important for a dermatologist to examine and confirm a diagnosis and to be present for discussion of a cancer diagnosis. CONCLUSION: Although the majority of respondents were not reluctant about the use of AI for skin cancer diagnosis, respondents still considered it important that dermatologists are involved in the diagnosis and/or confirmation of skin cancer. Furthermore, the study results demonstrate that personal interaction with a clinician is important. This is in keeping with proposals that AI be used as an adjunctive technology to increase accuracy of skin cancer diagnoses, but not as a substitute for a dermatologist.

Molecular Imprinting Using a Functional Chain Transfer Agent.

This study demonstrates the feasibility of molecular imprinting using a functional chain transfer agent sans a functional monomer. Ethylene glycol dimethacrylate (EGDMA)-based MIPs were synthesised in the presence of thioglycolic acid (TGA) possessing a carboxylic acid group, capable of interacting with the chosen test template R,S-(±)-propranolol (PNL) and a labile S-H bond to facilitate an efficient chain transfer reaction. Quantitative 1H NMR measurements showed high PNL and TGA incorporation within the MIP, indicating an efficient chain transfer process and a favourable interaction between PNL and TGA. TGA-50, with the lowest amount of CTA, showed the largest imprinting effect and an imprinting factor (IF) of 2.1. The addition of MAA to the formulation improved the binding capacity of PNL to the MIP but also increased NIP binding, resulting in a slightly decreased IF of 1.5. The Kd for the high-affinity sites of the TGA/MAA MIP were found to be two times lower (10 ± 1 µM) than that for the high-affinity sites of the TGA-only MIPs, suggesting that the incorporation of the functional monomer MAA increases the affinity towards the PNL template. Selectivity studies, cross-reactivity as well as binary competitive and displacement assays showed the TGA-based MIPs to be highly selective towards PNL against pindolol and slightly competitive against atenolol. The morphologies of the polymers were shown to be affected by the concentration of the TGA, transforming into discrete macrospheres (from small aggregates) at a higher TGA concentration.

Aquatic disaster activation plan and tactic: The natural history and management conceptual framework of aquatic disasters.

INTRODUCTION: In the past decades, water-related disasters had been accounted for about three-quarters of all-natural disasters worldwide. Asia is the most affected region with more than 45% of fatalities and more than 90% of the victims affected by aquatic disasters. Aquatic events progress differently and rapidly as compared to inland disasters. Thus, apart from additional equipments and trained aquatic rescuers, aquatic disaster operation requires specific strategies and tactics. MATERIALS AND METHODS: This qualitative study was conducted using mixed methods involving the Delphi method and decision-conferencing approach. Two rounds of open-ended questionnaires were sent to subject matter experts from rescue agencies that involved in aquatic disaster rescue and management. Feedback from the panel was reviewed, the natural history of different aquatic disasters was appraised, and the decision-analysis model on the command, control and management of aquatic disaster was developed. The model was then reassessed through an iteration process at decision-conferencing among the expert panel until the final framework was accepted by all members of the panel. RESULTS: The fast progression of aquatic disasters with multiple hazards on the scene and unique technical challenges of the operation increase the risk of rescuers to become victims themselves. The developed conceptual framework, namely Aquatic Disaster Activation Plan and Tactic (ADAPT), was found able to guide rescuers in risk assessment, judgment, and response in aquatic disasters based on strategies and tactics for different phases along the natural history of aquatic disasters. CONCLUSION: With realistic scenario-based training and drills, ADAPT can be the blueprint in aquatic disaster management. It is designed to facilitate rescue agencies and organizations in preparing and executing the technical aquatic rescue operations safely, according to the resources available and the capability of the respective rescue organization.

Achalasia cardia: A five-year review in Hospital Tuanku Ja'afar, Seremban.

INTRODUCTION: Achalasia cardia is an oesophageal motility disorder that affects various age groups. This study focused on the epidemiological features of achalasia, its risk factors, treatment modalities offered and the clinical outcomes in a tertiary hospital. MATERIALS AND METHODS: A retrospective search was carried out on all patients with a diagnosis of achalasia cardia in Hospital Tuanku Ja'afar (HTJ), Seremban, Malaysia between 2014 and 2018. Demographic data, patient symptomatology, and definitive management options were determined from the records. Telephone interviews were conducted to evaluate patient satisfaction with the outcome of treatment. RESULTS: There were 30 patients with a newly diagnosed achalasia cardia in that 5-year period, with an equal incidence among men and women. The mean age of presentation was 44.63 ± 18.21 years. Malays formed the largest group. The mean weight and body mass index were 46.8 ± 10.4 kg and 18.0 ± 4.4 kg/m2 respectively. There was a wide range of duration of symptoms at presentation with a mean of 30.11 ± 35.29 months. Almost all patients presented with dysphagia (96.7%) while 70% also noted loss of weight. All patients underwent oesophagogastroduodenoscopy (OGDS) and 26 patients (86.7%) had barium swallow as part of diagnostic workup. A total of 18 patients underwent a laparoscopic Heller myotomy with or without Dor Fundoplication and/or cruroplasty while two patients (6.7%) underwent pneumatic dilatation as first treatment. Iatrogenic mucosal perforations were detected in 8 patients who underwent myotomy and fundoplication and were repaired intraoperatively. Of the patients who underwent myotomy and fundoplication, the mean weight increase was 15.6kg, increasing from 43.0 ± 8.4 kg to 58.6 ± 13.7 kg. All the patients who underwent treatment were satisfied with their treatment outcomes. CONCLUSION: Most patients with achalasia cardia deemed suitable for surgery and counselled accordingly accept surgery resulting in high levels of satisfaction and weight gain in almost all these patients. A small minority who opt for pneumatic dilatation may also achieve satisfactory outcomes comparable to surgery in the short term. Although rare, clinicians should be able to recognise this disease early as early intervention often leads to satisfactory longterm outcomes.

Systematic review and meta-analysis of the prevalence of neuropathic-like pain and/or pain sensitization in people with knee and hip osteoarthritis.

OBJECTIVE: To determine the prevalence of neuropathic-like pain (NP) and pain sensitization (PS) defined by self-report questionnaires in knee and hip osteoarthritis, and whether prevalence is potentially explained by disease-severity or affected joint. DESIGN: MEDLINE, EMBASE, CINAHL were systematically searched (1990-April 2020) for studies describing the prevalence of NP and PS in knee and hip osteoarthritis using self-report questionnaires. Random-effects meta-analysis was performed. Statistical heterogeneity between studies and sub-groups (affected joint and population source as a proxy for disease severity) was assessed (I2 statistic and the Chi-squared test). RESULTS: From 2,706 non-duplicated references, 39 studies were included (2011-2020). Thirty-six studies reported on knee pain and six on hip pain. For knee osteoarthritis, the pooled prevalence of NP was: using PainDETECT, possible NP(score ≥13) 40% (95%CI 32-48%); probable NP(score >18) 20% (95%CI 15-24%); using Self-Report Leeds Assessment of Neuropathic Symptoms and Signs, 32% (95%CI 26-38%); using Douleur Neuropathique (DN4) 41% (95% CI 24-59%). The prevalence of PS using Central Sensitization Inventory (CSI) was 36% (95% CI 12-59%). For hip osteoarthritis, the pooled prevalence of NP was: using PainDETECT, possible NP 29% (95%CI 22-37%%); probable NP 9% (95%CI 6-13%); using DN4 22% (95%CI 12-31%) in one study. The prevalence of possible NP pain was higher at the knee (40%) than the hip (29%) (difference 11% (95% CI 0-22%), P = 0.05). CONCLUSIONS: Using self-report questionnaire tools, NP was more prevalent in knee than hip osteoarthritis. The prevalence of NP in knee and hip osteoarthritis were similar for each joint regardless of study population source or tool used. Whether defining NP using self-report questionnaires enables more effective targeted therapy in osteoarthritis requires investigation.

Risk factors and outcome of community onset Pseudomonas aeruginosa bacteraemia in two Malaysian district specialist hospitals.

INTRODUCTION: Despite the ever-growing number of community onset (CO) Pseudomonas aeruginosa (P. aeruginosa) bacteraemia, there is a dearth of district hospital-based research examining this significant infection, which is associated with high mortality. The objectives of this study were as following: (1) to determine the risk factors of CO P. aeruginosa bacteraemia, (2) to compare the 30-day mortality rate between P. aeruginosa and Escherichia coli bacteraemia and (3) to identify the predictors of 30-day mortality for CO gram negative bacteraemia. METHODS: This is a retrospective case control study in Hospital Seri Manjung and Hospital Teluk Intan, Perak, Malaysia. P. aeruginosa bacteraemia cases that occurred between 1st January 2015 to 31st December 2019 were included, whilst E. coli bacteraemia cases that occurred within the same period were recruited successively until 1:2 case control ratio was achieved. Subjects below 12-year-old and those with polymicrobial bacteraemia were excluded. Demographic, clinical and treatment data were collected using pre-tested data collection forms by trained investigators. RESULTS: A total of 61 patients with P. aeruginosa bacteraemia and 122 patients with E. coli bacteraemia were included. Recent admission in the earlier three months, regular haemodialysis, immunosuppressive therapy in the past 30 days, chronic wound/pressure sore at presentation and indwelling urinary catheter at presentation were identified as independent predictors of CO pseudomonal bacteraemia. Whilst older age was identified as a negative predictor of CO Pseudomonal bacteraemia (all p<0.05). The 30-day mortality rate was 34.4% in subjects with P. aeruginosa bacteraemia and 27.0% in those with E. coli bacteraemia (p=0.302). Predictors of 30-day mortality for community onset gram negative bacteraemia were as follow: older age, underlying solid tumours, neutropaenia at presentation, in-patient mechanical ventilation, and inpatient nasogastric tube insertion. Unexpectedly, receipt of inappropriate empirical antibiotics which was switched later (delayed and non-delayed switching) was identified as the negative predictors of mortality (all p<0.05). CONCLUSION: It is prudent to restrict the usage of empirical anti-pseudomonal antibiotics among individuals at risk as liberal usage of broad-spectrum antibiotics engenders emergence of drug resistant organism, particularly in district setting where community onset pseudomonal bacteraemia remains scarce. Subjects with elevated risk of mortality should receive early escalation of care as per sepsis management guidelines.

Correlation between biochemical features and outcomes of preoperative imaging (SPECT-CT and Ultrasound) in primary hyperparathyroidism.

Background: Primary hyperparathyroidism is the third most common endocrine disorder, diagnosed by elevated parathyroid hormone (PTH) in hypercalcaemia. Several biochemical factors have been described to suggest severity of disease and may be correlated with preoperative imaging. Methods: This was a retrospective study of patients who underwent parathyroidectomy over a 3-year period. Preoperative calcium, PTH, vitamin D levels, ALP (alkaline phosphatase), vitamin D, serum phosphate and US and SPECT-CT positivity was noted. Results: 176 patients underwent parathyroidectomy and these were divided into 4 groups based on preoperative calcium. Overall, 61% of patients showed concordance between imaging and operative findings. Severe hypercalcaemia was associated with higher PTH levels, lower vitamin D levels, an increased rate of abnormal ALP levels, lower phosphate, male gender and highest rate of imaging concordance. Imaging positivity was associated with severe hypercalcaemia and elevated PTH levels. Level of PTH >125 pmol/L and hypercalcaemia >2.8 mmol/L are the most accurate cut-off levels for scan positivity. Conclusion: Biochemical factors associated with severity of the disease are directly correlated with positivity of preoperative imaging while ALP and vitamin D did not influence the preoperative imaging positivity but are associated with disease adversity. Serum phosphate level independently predicted results of parathyroid US.

Autologous stem cell transplantation for untreated transformed indolent B-cell lymphoma in first remission: an international, multi-centre propensity-score-matched study.

High-dose chemotherapy (HDC) and autologous stem cell transplantation (ASCT) are used as consolidation in first remission (CR1) in some centres for untreated, transformed indolent B-cell lymphoma (Tr-iNHL) but the evidence base is weak. A total of 319 patients with untreated Tr-iNHL meeting prespecified transplant eligibility criteria [age <75, LVEF ≥45%, no severe lung disease, CR by positron emission tomography or computed tomography ≥3 months after at least standard cyclophosphamide, doxorubicin, vincristine and prednisolone with rituximab (R-CHOP) intensity front-line chemotherapy] were retrospectively identified. Non-diffuse large B-cell lymphoma transformations were excluded. About 283 (89%) patients had follicular lymphoma, 30 (9%) marginal-zone lymphoma and six (2%) other subtypes. Forty-nine patients underwent HDC/ASCT in CR1, and a 1:2 propensity-score-matched cohort of 98 patients based on age, stage and high-grade B-cell lymphoma with MYC, BCL2 and/or BCL6 rearrangements (HGBL-DH) was generated. After a median follow-up of 3·7 (range 0·1-18·3) years, ASCT was associated with significantly superior progression-free survival [hazard ratio (HR) 0·51, 0·27-0·98; P = 0·043] with a trend towards inferior overall survival (OS; HR 2·36;0·87-6·42; P = 0·1) due to more deaths from progressive disease (8% vs. 4%). Forty (41%) patients experienced relapse in the non-ASCT cohort - 15 underwent HDC/ASCT with seven (47%) ongoing complete remission (CR); 10 chimeric antigen receptor-modified T-cell (CAR-T) therapy with 6 (60%) ongoing CR; 3 allogeneic SCT with 2 (67%) ongoing CR. Although ASCT in CR1 improves initial duration of disease control in untreated Tr-iNHL, the impact on OS is less clear with effective salvage therapies in this era of CAR-T.

Does preoperative neuropathic-like pain and central sensitisation affect the post-operative outcome of knee joint replacement for osteoarthritis? A systematic review and meta analysis.

BACKGROUND: Almost a third of those undergoing knee replacement for osteoarthritis have poor outcomes despite technically successful surgery. Preoperative neuropathic-like pain and/or pain sensitisation may increase the risk of pain following joint replacement. OBJECTIVE: To examine whether preoperative neuropathic-like pain and pain sensitisation predicts pain, function and satisfaction following joint replacement for knee osteoarthritis. DESIGN: Systematic review with meta-analysis. METHODS: Medline, EMBASE and CINAHL were systematically searched until March 2020. Studies detecting neuropathic-like pain and/or sensitisation using self-report questionnaires prior to knee replacement for osteoarthritis, and relating this to post-operative outcomes were identified. Data extraction, risk of bias assessment and meta-analysis were performed, where appropriate. RESULTS: Five manuscripts, including one preprint, examining six cohorts were included: four used painDETECT or modified painDETECT, one the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs, and another the Central Sensitisation Inventory to identify preoperative characteristics. Three studies showed preoperative neuropathic-like pain or sensitisation was associated with more intense post-operative pain. All four studies examining the risk of significant pain after knee replacement suggested it was increased after >3 months. The only study examining patient satisfaction and function found reduced satisfaction, but no difference in function in those with preoperative sensitisation. Meta-analysis found the relative risk of increased pain following knee replacement in those with neuropathic-like pain (painDETECT ≥13) to be 2.05 (95% confidence intervals 1.51, 2.79). CONCLUSION: These results provide consistent but limited evidence that self-report tools detecting neuropathic-like pain and/or pain sensitisation, predict patients at higher risk of pain following knee replacement.

Effect of fall characteristics on the severity of hip impact during a fall on the ground from standing height.

The magnitude of hip impact force during a fall on the ground (i.e., concrete surface) from standing height was determined. We found that this force decreases up to 59%, depending on how they land on the ground. INTRODUCTION: We determined the magnitude of hip impact force that humans may experience in the event of a fall from standing height on the ground, in order to examine how the hip impact force was affected by characteristics of a fall. METHODS: Twenty subjects mimicked a typical older adults' falls on a mat. Trials were acquired with three initial fall directions: forward, sideways, and backward. Trials were also acquired with three knee positions at the time of hip impact: knee together, knee on the mat, and free knee. During falls, attenuated vertical hip impact forces and corresponding depression of the mat were measured via a force plate placed under the mat and motion capture system, respectively. Using a mass-spring model, actual hip impact force and body stiffness during a fall on the ground were estimated. RESULTS: Hip impact force averaged 4.0 kN (SD = 1.7). The hip impact force was associated with knee condition (F = 25.6, p < 0.005), but not with fall direction (F = 0.4, p = 0.599). Compared with "knee on the mat," hip impact force averaged 59% and 45% greater in "free knee" and "knee together," respectively (4.6 versus 2.9 kN, p < 0.005; 4.3 versus 2.9 kN, p < 0.005). However, the hip impact force did not differ between "free knee" and "knee together (4.6 versus 4.3 kN, p = 0.554). CONCLUSION: Our results suggest that hip fracture risk during a fall decreases substantially, depending on how they land on the ground, informing the development of safe landing strategies to prevent fall-related hip fractures in older adults.

Prediction models and questionnaires developed to predict vitamin D status in adults: a systematic review.

A systematic review of prediction models/questionnaires developed to identify people with deficient/insufficient vitamin D status shows the potential of self-reported information to estimate vitamin D status. The objective is to identify and compare existing screening tools, developed to identify vitamin D deficiency or insufficiency in adults. A systematic search of literature was conducted using MEDLINE, Scopus, Web of Science and CINAHL databases. Risk of bias and applicability concerns were assessed by quality assessment of diagnostic accuracy studies (QUADAS-2). Data were extracted on socio-demographic, anthropometric, risk factors, serum 25 hydroxyvitamin D [25(OH)D] levels, statistical methods and predictive ability. A total of 12 studies were considered for inclusion for this systematic review after screening of 4851 abstracts and 15 full-text articles. Ten of twelve studies developed prediction models and 2 studies developed questionnaires. The majority of studies had low risk of bias and applicability as assessed by QUADAS-2. All studies included only self-reported predictors of vitamin D status in their final models and development of scores. Sunlight exposure and related factors were important significant contributors to the predictive ability of the models and/or questionnaires. Sensitivity and specificity of the prediction models or questionnaires ranged from 55 to 91% and 35 to 84%, respectively. Six out of twelve studies converted final models to scores associated with vitamin D status. There was no evidence that any of these existing tools have been translated into clinical practice. The prediction models or questionnaires identified in this systematic review were moderately sensitive and specific for identifying people with vitamin D deficiency or insufficiency. The substantial contribution of sunlight exposure to the prediction of vitamin D status highlights the importance of including this information when developing vitamin D screening tools.