Knowledge, attitudes, practices, and perceived challenges for healthcare workers on waterless intensive care unit (ICU) care at a neonatal ICU in Singapore.

BACKGROUND: Implementation of waterless care, including removal of sinks from patient care areas, is an emerging approach to reduce waterborne infections in high-risk areas such as intensive care units (ICUs). This approach, however, requires significant changes from traditional infection control practices and acceptance by healthcare workers (HCWs) for successful transition. AIM: To explore the knowledge, attitudes, practices (KAPs), and perceived challenges of HCWs who transitioned from working in a unit with standard infection control practices to one with waterless ICU care practices. METHODS: The study was conducted using a customized 30-item self-reported survey instrument administered to HCWs working in tertiary neonatal units at a single hospital. FINDINGS: Participation rate was 88.6% (101/114), comprising 66.3% (67/101) nurses, 31.0% (31/101) doctors, and 3.0% (3/101) allied health professionals; 90.1% (91/101) had positive attitudes and 53.5% (54/101) had good knowledge regarding waterless ICU care; 83.1% (84/101) followed the appropriate practice of hand hygiene when their hands were visibly soiled. Main challenges with waterless ICU care were perceived compromise of personal (46.5% (47/101)) and patient (22.8% (23/101)) hygiene. A total of 43.6% (44/101) reported an increase in skin-related conditions: 10.9% (11/101) had to visit a doctor for this reason, of whom 64.0% (7/11) had pre-existing skin conditions. CONCLUSION: Despite overall good attitudes and practices toward waterless ICU care, HCWs may have specific concerns related to hygiene and skin conditions which need to be addressed. For units transiting to waterless ICU care, similar surveys may provide valuable information by identifying gaps in KAP to improve compliance.

Safety of elexacaftor/tezacaftor/ivacaftor dose reduction: Mechanistic exploration through physiologically based pharmacokinetic modeling and a clinical case series.

INTRODUCTION: Elexacaftor/tezacaftor/ivacaftor (ETI) treatment is associated with significant improvement in lung function in people with cystic fibrosis (pwCF); however, some patients experience adverse effects (AEs) including hepatotoxicity. One potential strategy is dose reduction in ETI with the goal of maintaining therapeutic efficacy while resolving AEs. We report our experience of dose reduction in individuals who experienced AEs following ETI therapy. We provide mechanistic support for ETI dose reduction by exploring predicted lung exposures and underlying pharmacokinetics-pharmacodynamics (PK-PD) relationships. METHOD: Adults prescribed ETI who underwent dose reduction due to the AEs were included in this case series, and their percent predicted forced expiratory volume in 1 s (ppFEV1 ) and self-reported respiratory symptoms were collected. The full physiologically based pharmacokinetic (PBPK) models of ETI were developed incorporating physiological information and drug-dependent parameters. The models were validated against available pharmacokinetic and dose-response relationship data. The models were then used to predict lung concentrations of ETI at steady-state. RESULTS: Fifteen patients underwent dose reduction in ETI due to AEs. Clinical stability without significant changes in ppFEV1 after dose reduction was observed in all patients. Resolution or improvement of AEs occurred in 13 of the 15 cases. The model-predicted lung concentrations of reduced dose ETI exceeded the reported half maximal effective concentration (EC50 ) from measurement of in vitro chloride transport, providing a hypothesis as to why therapeutic efficacy was maintained. CONCLUSION: Albeit in a small number of patients, this study provides evidence that reduced ETI doses in pwCF who have experienced AEs may be effective. The PBPK models enable exploration of a mechanistic basis for this finding by simulating target tissue concentrations of ETI that can be compared with drug efficacy in vitro.

Headache associated with refractive errors: Characteristics and risk factors.

INTRODUCTION: The purpose of our work was to study the characteristics of Headache associated with refractive errors (HARE)1, and to search for the correlation between headaches characteristics and some risk factors. We aimed also to assess the impact of these headaches on the quality of life of patients. METHODS: A cross-sectional, retrospective, comparative study including 90 patients followed between August 2019 and January 2020. These patients were divided into two groups: Group 1 including patients presenting headaches due to uncorrected ametropia, and group 2 including control subjects. We studied HARE characteristics, the influence of certain risk factors (profession, triggers factors, characteristics of ametropia, and orthoptic abnormalities) on them, their evolution after one month of treatment, and their impact on patients' quality of life with the HIT-6 score. RESULTS: Headaches due to ametropia were mainly chronic (20.9±15.76 months on average) progressive (100% of cases), daily (90% of cases) predominantly during the second half of the day (82% of cases). They were moderate (64% of cases), with a fronto-orbital topography in 52% of cases. Headaches were compression-type in 36% of cases (18 patients) and pressure-type in 64% (32 patients). The multivariate study retained prolonged screen working (P=0.013), combined ametropias (P=0.001), moderate hyperopia (P=0.01) and astigmatism (P=0.03) to be risk factors of HARE. Headaches induced a substantial to major impact on the quality of life in 68% (34 patients had a score greater than 55), the latter is significantly influenced by the presence of high myopia. After optical correction and orthoptic treatment, we noted an improvement in headache in 100% of cases. The multivariate analysis did not identify any independent factor that impact the evolution of headache at one month. CONCLUSION: HARE may influence life quality; it needs an appropriate treatment based on risk factor management. A healthy lifestyle in addition to adequate refractive error correction is essential in children and, sometimes in adults. Oculomotor abnormalities treatment leads to improve long term results.

Hepatic alveolar hydatid disease (Echinococcus multilocularis), a mimic of liver malignancy: a review for the radiologist in non-endemic areas.

Alveolar hydatid disease or alveolar echinococcosis (AE) is caused by the parasite Echinococcus multilocularis and is increasingly seen as an imported disease in non-endemic areas such as the UK. It is rare compared to cystic echinococcosis (CE), but like CE commonly affects the liver. AE does have imaging features that can aid in diagnosis, but is often initially misdiagnosed as liver malignancy. It is usually fatal if untreated, underscoring the importance of early diagnosis. This review highlights the role of imaging in AE diagnosis with the broader objective of increasing radiologists' awareness of this unusual, but increasingly prevalent disease.

Systematic review and pooled analysis of the rate of carpal tunnel syndrome after prophylactic carpal tunnel release in patients with a distal radius fracture.

The aim of this study was to determine the rate of carpal tunnel syndrome (CTS) in patients with a volar plated distal radius fracture (DRF), with or without prophylactic carpal tunnel release (CTR). The PubMed database was searched for studies reporting on CTS in patients with a DRF fixed by a volar plate. Selected patients were those who underwent prophylactic CTR versus patients who did not. Pooled rates of CTS were calculated using inverse - variance weighting assuming a random effects model. Tests for heterogeneity were applied. In this study, 172 patients in the CTR group and 1839 patients in the non-CTR group were included. The pooled rate for CTS in the CTR group was 28.1% (95% CI: 11.8% to 48.2%) while it was 4.4% (95% CI: 3.1% to 6.0%) in the non-CTR group. CTR is of no prophylactic value for postoperative CTS in volar plated DRF patients.

Acute invasive fungal rhinosinusitis: our experience in immunocompromised host.

Acute invasive fungal rhinosinusitis (AIFRS) is a potentially fatal infection that usually affects immunocompromised patients. Early diagnosis and treatment, including aggressive surgical debridement, antifungal medication and correction of underlying predisposing factors are essential for recovery. The records of 13 patients histopathologically diagnosed with invasive fungal rhinosinusitis were retrospectively reviewed. Demographic data, presenting symptoms and signs, underlying diseases, and outcomes of the patients are presented. The most common underlying disease was diabetes mellitus. Mucoraceae (n-8) and aspergillus (n-5) were the main fungi found in AIFRS. Mucosal biopsy confirmed fungal invasion to the nasal mucosa in all cases. Computed tomography and endoscopic findings showed a predominance of unilateral disease, with various stages of nasal involvement. All patients underwent surgical debridement and systemic antifungal therapy immediately after diagnosis. Four patients died due to AIFRS. A poor prognosis was detected to the extensiveness of AIFRS and to the underlying disease (patients with diabetes and haematological diseases had the worst outcomes), but not to fungus isolated. Invasive fungal rhinosinusitis is discussed in light of the current literature.

Presentation of primary hyperparathyroidism due to adenoma.

This descriptive study was done to evaluate the clinical, biochemical and radiological findings of primary hyperthyroidism (pHPT) patients with parathyroid adenoma. This study was done in the department of Otolaryngology and Head-Neck surgery, BIRDEM, Dhaka from July 2000 to June 2007. We retrospectively reviewed the clinical presentation, biochemical and radiological features from the case records from the last 7 years of 32 patients at a tertiary care centre in Dhaka who had documented pHPT due to adenoma. Of them 18 were male and 14 were female. Mean age±SD of the patients was 42.16±11.64 years. Median preoperative serum calcium, serum phosphate and serum parathyroid hormone (PTH) levels were 11.42 mg/dL (range 8.4-14.0mg/dL), 3.11 mg/dL (range 2.5-4.5) and 293.22 pg/mL (range 65-700 pg/mL), respectively. Of all patients 75% had raised serum calcium level and 100.0% had raised serum PTH levels but all had normal serum phosphate level. Common radiological features were nephrocalcinosis, renal calculi, osteopenic changes in finger and toe, Brown tumour in forearm, 'Salt and pepper' appearance in skull, fracture of femur, fracture radius. pHPT due to adenoma in Bangladesh continues to be a symptomatic disorder with skeletal and renal manifestations.

The analgesic requirement after thyroid surgery under general anaesthesia with bilateral superficial cervical plexus block.

In this study we evaluated the analgesic efficacy of bilateral superficial cervical plexus block after thyroid surgery. Sixty patients were assigned to two groups. General anesthesia was induced with 2mg/kg propofol, 0.1mg/kg vecuronium and 1.5µg fentanyl IV for both group. After endotracheal intubation, bilateral superficial cervical plexus block with 0.25% bupivacaine 15ml in each side was performed in Group I. In Group II (control) no regional block was administered. Intravenous on demand analgesic was used to evaluate postoperative analgesic requirement. Neither visual analog scale scores nor intravenous analgesics doses were different between the groups. The first analgesic requirement time in Group I was significantly longer than for the control group. The incidence of nausea and vomiting was significantly lower in Group I than Group II. We concluded that bilateral superficial cervical plexus block with 0.25% bupivacaine did not decrease analgesic requirement after thyroid surgery.

Prevalence of Clostridium perfringens type A isolates in commercial broiler chickens and parent broiler breeder hens in Egypt.

The aim of this study was to determine the presence of genes coding for alpha (cpalpha), beta (cpbeta), epsilon (epsilontx), iota (iotaA), enterotoxin (cpepsilon) and beta2 (cpbeta2) toxins in Clostridium perfringens isolates from broiler chickens and parent broiler breeder hens, using multiplex polymerase chain reaction (PCR) assay. The prevalence of C. perfringens in the intestinal segments and the effects of age were also investigated. The highest isolation rate was from the duodenum, at 41.7% in broiler chickens and 58.4% in parent broiler breeder hens; the lowest isolation rates came from the ileum, at 15.6% and 27.1%, respectively. Chickens harboured C. perfringens in the intestine and this increased with age. Clostridium perfringens was detected in 35.4% (17/48) of asymptomatic broiler chickens and 22.1% (17/77) of asymptomatic parent broiler breeder hens. The bacterium was detected in 100% of the broiler chickens and parent broiler breeder hens with clinical signs (31/31 and 60/60, respectively). The multiplex PCR assay indicated that in 99 (79.2%) of the 125 samples that tested positive for C. perfringens the strains isolated were type A and were shown to carry the cpalpha gene (99/99, or 100%). The gene encoding cpbeta2-toxin was present in 62.6% (62/99) of the isolates. A significant association was found between C. perfringens possessing the beta2-toxin gene and necrotic enteritis in broiler chickens and parent broiler breeder hens, suggesting that this gene might play a key role in the pathogenesis of the disease in Egypt. The authors suggest that the presence of the cpbeta2-toxin gene in C. perfringens isolates found in broiler chickens and parent broiler breeder hens during this study poses a risk of transmission to humans through the food chain.

Head and neck follicular dendritic cell sarcoma: disease associations and treatment review.

Currently, of less than 50 cases of head and neck follicular dendritic cell (FDC) sarcoma reported in the literature, 5 have been found to occur in the background of Castleman disease. We report another case of head and neck FDC sarcoma with emphasise on its associated lesions and review the outcome of treatment from the existing cases in the literature.

Mycoplasma gallisepticum: an emerging challenge to the poultry industry in Egypt.

In this study, the authors examined the technical performance of culture methodology using specific media: Mycoplasma isolation media of pleuropneumonia-like organisms (PPLO) broth and PPLO agar. Digitonin sensitivity, growth inhibition, the serum plate agglutination test, a commercially available enzyme-linked immunosorbent assay (ELISA) and a commercially available simplex polymerase chain reaction (PCR) test were used to detect Mycoplasma gallisepticum infections in samples collected from the lungs, trachea and tracheal swabs of poultry. These samples were collected from broiler-breeder flocks, broiler flocks and layer flocks. In addition, genomic bacterial deoxyribonucleic acid (DNA) was extracted and amplified, using a simplex PCR. The seroprevalence of M. gallisepticum antibodies in chickens and chicks was also investigated. The prevalence of M. gallisepticum was found to be highest in the layer flocks, at 33.3% (17/51), when the tracheal swab procedure was adopted. In young birds, the serum plate agglutination test and ELISA assay detected antibodies against M. gallisepticum in 69.9% (320/458) and 58.3% (267/458) of the chicken samples, respectively, and 48.7% (146/300) and 60% (180/300) of the samples from the chicks.

Paediatric airway reconstruction: a preliminary study.

To set the foundation for developing a centre for airway reconstruction, we performed a retrospective database review of patients operated at a tertiary-care university hospital. Over the past 3-year period from 2004 onwards, five paediatric cases of airway reconstruction procedures were performed. All cases had a two stages laryngotracheal reconstruction (TSLTR) for laryngotracheal stenosis (LTS). All patients were children below 15 years and the mean age was 9 years. Only one patient had a Grade IV Myer-Cotton stenosis, the rest all had Grade III stenosis. Three out of four of the Grade III stenosis patients were successfully decannulated within one year, the other one died of causes unrelated to LTS. The grade IV patient was still under followup and surgery was done only recently. This paper highlights the complexity of managing LTS in the paediatric age group and recommends the use of LTR with rib graft as a choice for the management of LTS.

Head injury with temporal bone fracture: one year review of case incidence, causes, clinical features and outcome.

To investigate the case incidence, causes, clinical profile and outcome of temporal bone fracture complicating head trauma. A 1-year (2005) retrospective study of head injured patients presented to the Emergency Department, Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia. Gender distribution, cause of injury, radiological findings and otorhinolaryngological clinical presentations were analyzed. Of 1309 patients, 61 patients were diagnosed to have temporal bone fracture (4.7%). Majority of cases were caused by motor vehicle accident (85.9%) and were predominantly male (88.5%). The right temporal bone was more frequently fractured (62.3%). Most (88.5%) were petro-mastoid fractures. Sixty-seven percent of the petrous fractures were longitudinal type. Clinical presentations mostly reported were blood rhinorrhea (36%) and blood otorrhea (32.7%). Other clinical presentations were hearing loss (9.8%), cranial nerve palsy (8.2%), cerebrospinal fluid oto-rhinorrhea (8.2%) and labyrinth concussion (6.5%). Four out of five cranial nerve palsies were facial nerve. Out of the 61 cases, 16 (26.2%) had no clinical presentation at the time of Emergency Department consultation. Thirteen (21.3%) died due to severe head injury. The case incidence of temporal bone fracture in head injured patients in our centre is 4.7%. The petro-mastoid type fracture predominates. Proper early diagnosis and management minimize complications.

Diagnosing pancreatic cancer: the role of percutaneous biopsy and CT.

AIMS: To determine the sensitivity and complications of percutaneous biopsy of pancreatic masses, and whether typical computed tomography (CT) features of adenocarcinoma can reliably predict this diagnosis. MATERIALS AND METHODS: A 5 year retrospective analysis of percutaneous core biopsies of pancreatic masses and their CT features was undertaken. Data were retrieved from surgical/pathology databases; medical records and CT reports and images. RESULTS: Three hundred and three patients underwent 372 biopsies; 56 of 87 patients had repeat biopsies. Malignancy was diagnosed in 276 patients, with ductal adenocarcinoma in 259 (85%). Final sensitivity of percutaneous biopsy for diagnosing pancreatic neoplasms was 90%; for repeat biopsy it was 87%. Complications occurred in 17 (4.6%) patients, in three of whom the complications were major (1%): one abscess, one duodenal perforation, one large retroperitoneal bleed. CT features typical of ductal adenocarcinoma were: hypovascular pancreatic mass with bile and/or pancreatic duct dilatation. Atypical CT features were: isodense or hypervascular mass, calcification, non-dilated ducts, cystic change, and extensive lymphadenopathy. Defining typical CT features of adenocarcinoma as true-positives, CT had a sensitivity of 68%, specificity of 95%, positive predictive value (PPV) of 98%, and negative predictive value of 41% for diagnosing pancreatic adenocarcinoma. CONCLUSION: Final sensitivity of percutaneous biopsy for establishing the diagnosis was 90%. CT features typical of pancreatic adenocarcinoma had high specificity and PPV. On some occasions, especially in frail patients with co-morbidity, it might be reasonable to assume a diagnosis of pancreatic cancer if CT features are typical, and biopsy only if CT shows atypical features.

Perventricular device closure of muscular ventricular septal defects on the beating heart.

This report describes our initial experience with intraoperative device closure of muscular ventricular septal defects under echocardiographic guidance without cardiopulmonary bypass in two patients.

Immunogenicity and reactogenicity of two regimens of diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated polio and Haemophilus influenzae type b vaccines administered to infants primed at birth with hepatitis B vaccine.

An open, randomized study evaluated the immune response and safety of two different regimens of diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliovirus-Haemophilus influenzae type b (DTPa-HBV-IPV-Hib) immunization in infants primed at birth with hepatitis B vaccine. One-half of the 150 healthy, full-term infants received a DTPa HBV-IPV-Hib vaccine at 1 1/2, 3 and 5 months of age; the other received a DTPa-IPV-Hib vaccine at 1 1/2, 3 and 5 months of age with separate HBV vaccine at 1 and 5 months of age. Immune response was similar following the two regimens with 100% of the vaccinees seroprotected for HBV, diphtheria, tetanus, Hib and poliovirus types 2 and 3 diseases after the full vaccination course. One vaccinee in the DTPa HBV-HPV- Hib group failed to respond to the poliovirus type 1 antigen. Response to the three pertussis antigens ranged from 92-97% in the DTPa-IPV-Hib plus separate HBV group and 100% in the DTPa HBV-IPV-Hib group. The most frequently reported post-vaccination symptoms were irritability in the DTPa-IPV-Hib plus separate HBV group (49% of vaccinees) and fever, defined as axillary temperature > or =37.5 degrees C, in the DTPa HBV- IPV-Hib group (50% of vaccinees).