Development of a Spatial Decision Support System for Real-Time Flood Early Warning in the Vu Gia-Thu Bon River Basin, Quang Nam Province, Vietnam.

Vu Gia-Thu Bon (VGTB) river basin is an area where flash flood and heavy flood events occur frequently, negatively impacting the local community and socio-economic development of Quang Nam Province. In recent years, structural and non-structural solutions have been implemented to mitigate damages due to floods. However, under the impact of climate change, natural disasters continue to happen unpredictably day by day. It is, therefore, necessary to develop a spatial decision support system for real-time flood warnings in the VGTB river basin, which will support in ensuring the area's socio-economic development. The main purpose of this study is to develop an online flood warning system in real-time based on Internet-of-Things (IoT) technologies, GIS, telecommunications, and modeling (Soil and Water Assessment Tool (SWAT) and Hydrologic Engineering Center's River Analysis System (HEC-RAS)) in order to support the local community in the vulnerable downstream areas in the event of heavy rainfall upstream. The structure of the designed system consists of these following components: (1) real-time hydro-meteorological monitoring network, (2) IoT communication infrastructure (Global System for Mobile Communications (GSM), General Packet Radio Service (GPRS), wireless networks), (3) database management system (bio-physical, socio-economic, hydro-meteorological, and inundation), (4) simulating and predicting model (SWAT, HEC-RAS), (5) automated simulating and predicting module, (6) flood warning module via short message service (SMS), (7) WebGIS, application for providing and managing hydro-meteorological and inundation data, and (8) users (citizens and government officers). The entire operating processes of the flood warning system (i.e., hydro-meteorological data collecting, transferring, updating, processing, running SWAT and HEC-RAS, visualizing) are automated. A complete flood warning system for the VGTB river basin has been developed as an outcome of this study, which enables the prediction of flood events 5 h in advance and with high accuracy of 80%.

Diabetic foot infection and surgical treatment in a secondary health care centre in Malaysia.

INTRODUCTION: Diabetic foot infection is often associated with high morbidity, disability and poor quality of life. This study focuses on the demography, the number of repetitive surgery and length of stay in hospital of patients with diabetic foot infection. METHOD: This is a retrospective observational study. Patients who were admitted to the Orthopaedic ward of Hospital Segamat (HS), Johor, Malaysia from January 2016 to December 2018 and required surgical intervention were included in the study. Data was collected from the computer system of HS and medical notes of patients. RESULTS: 35.6% of the total orthopaedic emergency surgeries performed were for patients with diabetic foot infection, 25% of the surgical procedures performed were major amputations of lower limb and 40% of the patients with diabetic foot infection required more than one surgical operation. DISCUSSION: The demographics of the patients is consistent with the demographics of Malaysia where majority of them are Malays followed by Chinese, Indians and others. Despite being only 10% of total admission to the department, this group of patients contributed to 35.6% of the total emergency surgeries performed. The amputation rate in the centre is comparable to the other local studies. The average length of stay in hospital was found to be shorter compared to overseas due to different rehabilitation protocols.

Bedside Continuous Irrigation and Drainage as an Interim Local Treatment for Septic Arthritis of the Knee in the Medically Unstable Patient: A Case Report.

Septic arthritis is a surgical emergency. Prompt diagnosis and immediate treatment reduce the destruction of articular cartilage and give better outcome. We describe a simple, minimally invasive closed tube irrigation system for the initial treatment of septic arthritis of the knee in a patient with complex medical problems who was unfit to undergo surgery.

Methotrexate treatment for ectopic pregnancy at the KK Women's and Children's Hospital, Singapore.

INTRODUCTION: Ectopic pregnancy is an acute emergency in the first trimester where surgery is the mainstay of treatment. With the advent of improved diagnostic techniques like high-resolution transvaginal ultrasonography and expedient serum human chorionic gonadotrophin (HCG) assay, ectopic pregnancy is now diagnosed early. At this stage, the conceptus is often small, causing minimal or no symptoms. Medical management may then present an appealing alternative to surgery. Methotrexate has been widely used to treat ectopic pregnancy. A methotrexate ectopic treatment protocol was introduced by the Minimally Invasive Surgery Centre at KK Women's and Children's Hospital, Singapore. We present the results of this treatment. METHODS: A prospective review of 110 cases of medical management of ectopic pregnancy since the implementation of the treatment protocol was undertaken. Demographical data, clinical presentation, treatment progress and outcome were captured using a computer database. All patients were managed as outpatients, and a telephone call-out service was provided to ensure that treatment side effects were monitored and potential treatment failures were identified early. RESULTS: From August 2003 to October 2006, 93 (84.5 percent) patients with ectopic pregnancy were successfully treated with intramuscular methotrexate. 16 patients eventually required surgery and only one patient defaulted on follow-up. There was no major side effect detected in this cohort. The minor side effects reported included mucositis (19.1 percent) and abdominal pain (28.2 percent). CONCLUSION: Methotrexate treatment of ectopic pregnancy is safe. Our treatment protocol enabled us to achieve a reasonable treatment success rate of 84.5 percent.

Revisional bariatric surgery.

BACKGROUND: Revisional surgery is required in a significant number of patients because of failure to lose weight, loss of quality of life, weight regain, or complications of the previous procedure. It has traditionally been associated with higher complication rates, and there appears to be no standardized surgical approach to revisional surgery. The aim of the study was to review the revisional procedures performed at St George Private Hospital and analyze the outcomes of the different types of revisional surgery. METHODS: We performed a retrospective review of 75 patients who underwent revisional surgery between December 2003 and October 2007. Demographic, anthropometric, perioperative, and clinical follow-up data were collected, and statistical analyses were performed using SPSS version 14.0. RESULTS: Sixty-six of the 75 patients were female. The mean age at the time of revision was 46.32 (22-68) years. Mean initial weight was 119.08 kg, and body mass index (BMI) was 43.42 kg/m(2). The lowest BMI and excess weight loss (EWL) recorded after primary surgery was 36.9% and 53.5%, respectively. At the time of revision, the mean EWL was 24.79. The EWL at 3 months and 6 months were 41.7% and 47.8%, respectively. Revision was performed laparoscopically in 51 patients and via laparotomy in 24 patients. There was no mortality in the cohort, but there were 17.3% minor and 4.0% major perioperative morbidities. CONCLUSION: Our study suggests that revision can be performed safely. Weight loss is satisfactory, and complications of the previous operations were all reversed. Furthermore, revisions may be done laparoscopically, including those who had previous open procedures.

A cumulative embryo scoring system for the prediction of pregnancy outcome following intracytoplasmic sperm injection.

INTRODUCTION: The ability to select the embryos that would lead to pregnancy would help to reduce multiple pregnancy rates. The objective was to evaluate the use of a cumulative embryo scoring system (CES) based on a five-point embryo scoring system for the prediction of pregnancy outcome following intracytoplasmic sperm injection (ICSI). METHODS: A retrospective cohort study was performed on 364 triple embryo transfers from fresh ICSI cycles only. Embryo quality was assessed using a five-point scoring system. The CES was the summation of the individual scores. For the purpose of analysis, these were categorised into three groups: CES group one (score 9-10), CES group two (score 11-13) and CES group three (score 14-15). Main outcome measures were clinical pregnancy, implantation, live-births and multiple birth rates. RESULTS: There was a trend towards better outcome with increasing CES scores. This trend was significant with CES groups one, two and three, corresponding with increasing pregnancy rates (30.3 vs. 45.1 vs. 51.7 percent), increasing implantation rates (12.4 vs. 20.5 vs. 21.8 percent), and increasing live-birth rates (12.4 vs. 26.4 vs. 31.0 percent). Age was also a significant independent predictor of clinical pregnancy. However, only CES group score was significant in predicting live-births, while age was significant in predicting multiple births. CONCLUSION: CES based on the proposed five-point scoring system is useful for the prediction of pregnancy outcome in triple embryo transfers. In younger patients, a policy of transferring fewer embryos to reduce multiple births should be adopted.

A review of 93 cases of severe preeclampsia in Singapore: are there risk factors for complications?

INTRODUCTION: This study aims to assess the epidemiology of severe preeclampsia in Singapore, the disease characteristics, maternal and perinatal outcome, and to identify risk factors for complications. METHODS: Data of 93 consecutive women with severe preeclampsia in KK Women's and Children's Hospital in Singapore was collected prospectively and analysed using the unpaired t-test for normally-distributed continuous variables and Fisher's exact chi-square test for discrete variables. Multivariate logistic regression analysis was performed for prediction of complicated cases. RESULTS: The incidence of severe pre-eclampsia was 29.3 per 10,000 deliveries, with an increased risk in women who were aged more than 35 years and who were nulliparous. The risk was also increased in women of the Malay race and they also had the tendency to book later, compared with the other races. 43 percent of women had maternal complications, including eclampsia, haemolysis/elevated liver enzymes/low platelets syndrome, oliguria, pulmonary oedema and placental abruption. Significantly raised levels of uric acid (439.5 +/- 114.1 micromol/L versus 395.4 +/- 96.7 micromol/L, p-value equals 0.047) and aspartate transaminase (80.1 +/- 107.4 IU/L versus 38.8 +/- 16.1 IU/L, p-value equals 0.021) were found in those with complications, compared to those without complications. The average gestation at time of diagnosis was 33 weeks and the average gestation at delivery was 34 weeks. 89.3 percent of women required caesarean section and 59.1 percent of women were admitted to intensive care. CONCLUSION: Age, parity and race are risk factors for severe preeclampsia with increased levels of uric acid and aspartate transaminase found in the complicated cases. The morbidity and cost of treatment of severe preeclampsia are high with a large percentage requiring caesarean section and intensive care admission.

Massive pre-placental and subchorionic haematoma.

We report an unusual case of massive pre-placental and subchorionic haematoma occurring in a 26-year-old woman who presented with antepartum haemorrhage at 24 weeks gestation. Ultrasonography showed a subchorionic haematoma in the lower posterior uterine wall measuring 5.0 cm in largest diameter. There was also a separate irregular multiloculated structure measuring 4.3 cm in largest diameter on the surface of the placenta, due to a pre-placental haematoma. The subchorionic haematoma diminished in size over time, while the pre-placental haematoma continued to grow, measuring 9.0 cm at 28 weeks, and 9.3 cm at 32 weeks. At 32 weeks, the patient presented with premature rupture of membranes and four days later, an emergency caesarean section was performed when the patient had another episode of severe antepartum haemorrhage. Both mother and child recovered well. The current literature on such haematomas is reviewed.

Use of a vaccine strain of measles virus genetically engineered to produce carcinoembryonic antigen as a novel therapeutic agent against glioblastoma multiforme.

Despite the most aggressive medical and surgical treatments, glioblastoma multiforme remains incurable with a median survival of <1 year. We investigated the antitumor potential of a novel viral agent, an attenuated strain of measles virus (MV), derived from the Edmonston vaccine lineage, genetically engineered to produce carcinoembryonic antigen (CEA). CEA production as the virus replicates can serve as a marker of viral gene expression. Infection of a variety of glioblastoma cell lines including U87, U118, and U251 at MOIs 0.1, 1, and 10 resulted in significant cytopathic effect consisting of excessive syncycial formation and massive cell death at 72-96 h from infection. terminal deoxynucleotidyltransferase-mediated nick end labeling assays demonstrated the mechanism of cell death to be predominantly apoptotic. The efficacy of this approach in vivo was examined in BALB/c nude mice by using both s.c. and intracranial orthotopic U87 tumor models. In the s.c. U87 model, mice with established xenografts were treated with a total dose of 8 x 10(7) plaque forming units of MV-CEA, administered i.v. Mice treated with UV light inactivated MV, and untreated mice with established U87 tumors were used as controls. There was statistically significant regression of s.c. tumors (P < 0.001) and prolongation of survival (P = 0.007) in MV-CEA treated animals compared with the two control groups. In the intracranial orthotopic U87 model, there was significant regression of intracranial U87 tumors treated with intratumoral administration of MV-CEA at a total dose of 1.8 x 10(6) plaque forming units as assessed by magnetic resonance image (P = 0.002), and statistically significant prolongation of survival as compared with mice that received UV-inactivated virus and untreated mice (P = 0.02). Histological examination of brains of MV-CEA-treated animals revealed complete regression of the tumor with the presence of a residual glial scar and reactive changes, mainly presence of hemosiderin-laden macrophages. In addition, CEA levels in the peripheral blood in both the s.c. and orthotopic models increased before tumor regression, indicating viral gene expression, and returned to normal when the tumors regressed. Ifnar(ko) CD46 Ge transgenic mice, susceptible to MV infection, were used to assess central nervous system toxicity of MV-CEA. Intracranial administration of MV-CEA into the caudate nucleus of Ifnar(ko) CD46 Ge did not result in clinical neurotoxicity. Pathologic examination demonstrated limited microglial infiltration surrounding the injection site. In summary, MV-CEA has potent antitumor activity against gliomas in vitro, as well as in both s.c. and orthotopic U87 animal models. Monitoring CEA levels in the serum can serve as a low-risk method of detecting viral gene expression during treatment, and could allow dose optimization and individualization of treatment.

Management of intracranial infectious aneurysms: a series of 16 cases.

OBJECTIVE: The purpose of this study was to better define the management of intracranial infectious aneurysms. METHODS: We present a retrospective review of the management of 16 patients with intracranial infectious aneurysms. The mean follow-up period was 86 months. RESULTS: None of the patients had a rehemorrhage during antibiotic treatment. The mortality and long-term outcome from ruptured intracranial infectious aneurysms may be better than previously thought. There was no significant difference in long-term outcome between patients with single or multiple infectious aneurysms or between patients who underwent surgical resection and those who were treated only with antibiotics. CONCLUSION: Operative treatment should be pursued for patients with ruptured infectious aneurysms. Patients with unruptured intracranial infectious aneurysms should be observed during antibiotic therapy and followed up with cerebral angiography. Surgical resection should be considered if the aneurysm enlarges and the patient's general medical condition allows general anesthesia to be tolerated.

Far lateral extraforaminal lumbar synovial cyst: report of two cases.

OBJECTIVE AND IMPORTANCE: We present two cases of a far lateral extraforaminal synovial cyst at the L5-S1 level of the spine. Neither case was diagnosed as a synovial cyst before surgery because of their atypical location. Only one other case of an extraforaminal synovial cyst, located at L4-L5, has been reported in the literature. CLINICAL PRESENTATION: Both women presented with radicular leg pain and examination findings consistent with L5 root compression. INTERVENTION: During surgery, the cyst was not associated with the facet joint. One cyst was adherent to the nerve root. Both cysts were completely resected, with excellent pain relief. CONCLUSION: These cases serve as a stimulus to look outside the spinal canal and foramen in patients with symptoms suggesting nerve root compression. Far lateral extraforaminal synovial cyst should be included in the differential diagnosis.

Stereotactic radiosurgery for idiopathic trigeminal neuralgia.

OBJECT: Each year a greater number of patients with trigeminal neuralgia (TN) undergo radiosurgery, including a large number of patients who are candidates for microvascular decompression (MVD). METHODS: The case characteristics and outcomes of 117 consecutive patients who underwent radiosurgery were retrieved from a prospectively maintained database. The mean patient age was 67.8 years; and the majority (58%) of patients had undergone surgery previously. The dependent variable for all analyses of facial pain was complete pain relief without medication (excellent outcome). Median follow-up duration was 26 months (range 1-48 months). The actuarial rate of achieving and maintaining an excellent outcome was 57% and 55% at 1 and 3 years, respectively, after radiosurgery. A greater percentage of patients who had not previously undergone surgery achieved and maintained excellent outcomes (67% at 1 and 3 years) than that of patients who had undergone prior surgery (51% and 47% at 1 and 3 years, respectively; relative risk [RR] = 1.77, 95% confidence interval [CI] 1.01-3.13, p = 0.04). New persistent trigeminal dysfunction was noted in 43 patients (37%). Tolerable numbness or paresthesias occurred in 29 patients (25%), whereas bothersome dysesthesias developed in 14 patients (12%). Only a radiation dose of 90 Gy correlated with new trigeminal deficits or dysesthesias (RR = 3.10, 95% CI 1.64-5.81, p < 0.001). Excellent outcomes in patients with new trigeminal dysfunction were achieved and maintained at rates of 76% and 74% at 1 and 3 years, respectively, after radiosurgery, compared with respective rates of 46% and 42% in patients who did not experience postradiosurgery trigeminal dysfunction (RR = 4.53, 95% CI 2.03-9.95, p < 0.01). CONCLUSIONS: Radiosurgical treatment provides complete pain relief for the majority of patients with idiopathic TN. There is a strong correlation between the development of new facial sensory loss and achievement and maintenance of pain relief after this procedure. Because the long-term results of radiosurgery still remain unknown, MVD should continue to be the primary operation for medically fit patients with TN.

Natural history of tethered cord in patients with meningomyelocele.

OBJECTIVE: The purpose of this study was to describe the natural history of tethered cord in patients who have undergone meningomyelocele repair. METHODS: We performed a retrospective review of 45 patients with a history of neonatal meningomyelocele repair who subsequently developed symptoms of tethered cord. Symptoms of tethered cord in this cohort consisted of the development of bladder spasticity or orthopedic foot deformity. None of these patients were treated with cord untethering; instead, they were treated symptomatically. RESULTS: On follow-up, 40 (88.9%) of these patients subsequently required additional orthopedic or urological procedures because of further symptoms of tethered cord. The incidence of progression of tethered cord syndrome is 27.5, 40, and 60% at 1, 2, and 5 years, respectively. CONCLUSION: Although this study does not address the question whether cord untethering will prevent further symptom development, these results do provide a strong rationale for consideration of an untethering procedure in patients with repaired meningomyelocele at the time of the onset of symptoms of tethered cord.

Percutaneous endoscopic gastrostomy--indications and outcome of our experience at the Singapore General Hospital.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is widely used for patients with dysphagia from neurological causes and head and neck malignancy. We examined the indications, complication rates and long term outcome of PEG inserted in our department. METHODS: We performed a study of PEG inserted in our department between January 1995 to March 2000. Consecutive patients with PEG inserted during this period were identified from our database that contained demographic data, primary and secondary underlying medical conditions, and immediate complications after the procedure. Casenotes were reviewed and caregivers (relatives or staff at nursing homes) were contacted for information on long term outcome at the time of this study between April 2000. Data was collected in standard form designed for this study. RESULTS: 181 cases of PEG insertion were performed during the study period. 174 patients were successfully followed up and reviewed. The median age was 70.5 (range 24 to 93) years old and there were 111 males. Indications for PEG insertion were: cerebrovascular diseases (60.4%), Parkinson's disease and other neuromuscular disorders (10.9%), nasopharyngeal carcinoma and other upper gastrointestinal malignancies (24.7%), and head injury (4%). Superficial wound infection (22.4%) and granuloma formation (31%) were common minor complications. Major complications were infrequent: peritonitis (2.3%) and gastrointestinal bleeding (0.6%). The mortality rates were 11.5% and 28.2% at one and six months respectively. Only one death from peritonitis was directly attributed to the procedure, most deaths were due to underlying co-morbidities with pneumonia being the most common cause. The proportion of the first PEG tubes removed or replaced were 12.2% and 35.5% at one and six months respectively. Thirty tubes were replaced due to blockage at median interval of 9.6 months. 9.7% of PEG tubes functioned longer than 24 months. CONCLUSIONS: Our results confirm the safety of PEG tubes in elderly patients with multiple co-morbidities. Major complications of the procedure were infrequent but produced grave consequences in these elderly patients with multiple co-morbidities. As such, patients considered for PEG feeding should have reasonable prognosis and the procedure is inappropriate for patients with rapidly progressive and incurable diseases.