Coda and Catharsis: Exploring the Emotional Challenges and Coping of Junior Palliative Physicians Through Cinematic Reflection.

Background: There has been little research on reflective tools for junior doctors, whom may have encountered challenges working in palliative care whereby grief and losses are high. This is a qualitative study aiming to firstly explore the emotional challenges of junior doctors and secondly whether the movie is an effective reflective tool. Setting/participants: 32 junior doctors rotating through the palliative care unit were recruited and underwent a combined movie screening with a focus group discussion after. Results: Emotional challenges highlighted were (1) lifting the veil of death (2) impeded call of action (3) manifesting inner fatigue. Majority found the movie relatable to their clinical practice and felt that the focus group discussion was helpful. Conclusion: Junior doctors do have certain emotional challenges during their palliative care posting. Having a movie session combined with a focus group discussion is a reasonable method to help them reflect about their challenges.

Evaluation of a three-axial acceleromyography monitor in dogs compared with mechanomyography.

OBJECTIVE: To compare the ratio of the train-of-four (TOF) and double burst stimulation (DBS) obtained with three-axial acceleromyography (AMG) and mechanomyography (MMG) in dogs during recovery from a rocuronium-induced neuromuscular block. STUDY DESIGN: Prospective, randomized, experimental study. ANIMALS: A total of six intact healthy adult male Beagle dogs, weighing 9.1 ± 1.9 kg and aged 3-5 years. METHODS: Dogs were anesthetized with intravenous (IV) dexmedetomidine and propofol, and isoflurane in oxygen. Neuromuscular function was measured with AMG and MMG in the contralateral thoracic limbs. Rocuronium (0.5 mg kg-1) was administered IV, and the TOF and DBS ratios measured. During neuromuscular block offset, MMG values were recorded when AMG first reached ratios of 0.9 and 1.0. True recovery from neuromuscular block was determined as MMG ratio ≥ 0.9. The false-positive (AMG ≥ 0.9 or 1.0, and MMG ratio < 0.9) rate was determined. Paired values were compared, and bias and limits of agreement were calculated. Receiver operating characteristic (ROC) curves were created. RESULTS: When AMG first reached 0.9 and 1.0 during recovery, MMG values were lower (p < 0.040). When AMG reached 0.9, the false-positive rate was 29% with TOF and 27% with DBS. It decreased to 12% (TOF) and 11% (DBS) when a ratio of 1.0 was used. AMG values were higher than paired MMG values (p < 0.001). The AMG overestimated MMG by 24% and 22% for TOF and DBS, respectively. Areas under the ROC curves (95% confidence interval) were 0.91 (0.89, 0.94) and 0.86 (0.81, 0.94) for TOF and DBS, respectively. CONCLUSIONS: and clinical relevance The three-axial AMG monitor overestimated neuromuscular function and, in some cases, indicated adequate recovery despite the MMG ratio being < 0.9. A TOF or DBS ratio of at least 1.0 should be considered when monitoring recovery of neuromuscular block with this AMG device.

Sex-based differences in bacterial meningitis in adults: Epidemiology, clinical features, and therapeutic outcomes.

BACKGROUND: To investigate the sex-based differences in clinical features, causative pathogens, and outcomes of hospital-based culture-proven adult bacterial meningitis. OBJECTIVE: This retrospective study enrolled 621 patients at a tertiary medical center. To compare changes over time, the presentation of disease among the enrolled patients was divided into two equal time periods: the first study period (1986-2002) and the second study period (2003-2019). RESULTS: Of the 621 patients enrolled in this study, 396 were males and 225 were females. The overall case fatality rate was 30.4% with 30.1% and 31.1% in males and females, respectively. Regarding the causative pathogens, there was a rising incidence of coagulase-negative staphylococcal infections and a decreasing incidence of Klebsiella pneumoniae infection in both male and female in the second study period. The prevalence of patients with nosocomial infection in a postneurosurgical state were 41.9% (68/162) in the first study period and 58.1% (94/162) in the second study period in male group, and 34.8% (32/92) in the first study period and 65.2% (60/92) in the second study period in female group, respectively. Significant factors between the sexes difference included age (P = 0.004), traumatic brain injury (P = 0.01), alcoholism (P < 0.001), brain tumor (P < 0.001), systemic lupus erythematosus (SLE) (P = 0.004), presence of diabetic ketoacidosis/hyperglycemic hyperosmolar state (P = 0.033), brain abscess (P = 0.042), and total protein (P = 0.002) and white blood cell count (P = 0.036) of cerebrospinal fluid data. CONCLUSION: Our study revealed an increase in the number of patients with nosocomial infection with a postneurosurgical state in both male and female in the second study period. Males were younger and frequently presented with a history of head trauma and alcoholism with concomitant brain abscesses while females presented with SLE and brain tumor. The therapeutic outcome did not show differences between the sexes.

Inhibition of L-NAME-induced hypertension by combined treatment with apocynin and catalase: the role of Nox 4 expression.

Reactive oxygen species (ROS) such as superoxide (O2-) generated by NAD(P)H oxidases have emerged as important molecules in blood pressure regulation. This study investigated the effect of apocynin and catalase on blood pressure and renal haemodynamic and excretory function in an L-NAME induced hypertension model. Forty Male Wistar-Kyoto (WKY) rats (n=8 per group) were treated with either: vehicle (WKY-C); L-NAME (WKY-L, 15 mg/kg/day in drinking fluid); WKY-L given apocynin to block NAD(P)H oxidase (WKY-LApo, 73 mg/kg/day in drinking water.); WKY-L given catalase to enhance ROS scavenging (WKY-LCat, 10000 U/kg/day i.p.); and WKY-L receiving apocynin plus catalase (WKY-LApoCat) daily for 14 days. L-NAME elevated systolic blood pressure (SBP), 116+/-1 to 181±4 mmHg, reduced creatinine clearance, 1.69+/-0.26 to 0.97+/-0.05 ml/min/kg and fractional sodium excretion, 0.84+/-0.09 to 0.55+/-0.09 % at day 14. Concomitantly, plasma malondialdehyde (MDA) increased six fold, while plasma total superoxide dismutase (T-SOD), plasma nitric oxide (NO) and plasma total antioxidant capacity (T-AOC) were decreased by 60-70 % and Nox 4 mRNA expression was increased 2-fold. Treatment with apocynin and catalase attenuated the increase in SBP and improved renal function, enhanced antioxidative stress capacity and reduced the magnitude of Nox4 mRNAs expression in the L-NAME treated rats. This study demonstrated that apocynin and catalase offset the development of L-NAME induced hypertension, renal dysfunction and reduced oxidative stress status, possibly contributed by a reduction in Nox4 expression during NOS inhibition. These findings would suggest that antioxidant compounds such as apocynin and catalase have potential in treating cardiovascular diseases.

The place of cadaveric dissection in post-COVID-19 anatomy education.

From time immemorial, cadaveric dissection has been commonly employed as a method of practical teaching and learning for anatomical education globally. Conventionally, cadaveric dissection has been embraced and widely accepted as the best fit for comprehensive and gross teaching in anatomy education, thus placing an undue rise in cadavers' demands. The emergence of the new coronavirus disease 2019 (COVID-19) has posed significant effects on medical education with substantial impacts on anatomy education, as seen in the shift from classroom to virtual learning. An essential area of anatomy education and training requiring immediate consideration is the position of cadaveric dissection in a post-COVID-19 era, which entails the safety of cadavers from possible SARS-CoV-2 infection before their use. This article explores the place of cadaveric dissection in post-COVID-19 anatomy education.

Post-COVID-19 pandemic: Standard operating procedures for gross anatomy laboratory in the new standard.

The culture of cadaver dissection remains the most commonly used method of practical teaching and learning of human anatomy. Anatomist and medical professionals considered cadaver dissection as the gold standard for teaching and learning anatomy in detail. The increase seen in the establishment of new medical training institutions globally has consequently led to a proportionate increase in the sourcing for cadavers. Moreover, the surge in mortality rates following the recent coronavirus disease 2019 (COVID-19) pandemic with no cure or approved vaccine has been a source of concern for academia, especially on the safety in the usage of cadavers for dissection. Notwithstanding, several countries continue to depend on unclaimed bodies as the primary source for cadavers, regardless of the cause of death. Besides, body donation is also usually reported to be strained during disease outbreaks thereby putting countries that depend solely on it in a dilemma. This study highlighted the recommended standard operating procedures (SOPs) to be imbibed in gross anatomy dissection halls during and post-COVID-19 pandemic.

The restorative effect of apocynin and catalase in l-arginine induced hypotension on normotensive subjects - the role of oxidative stress.

L-arginine is a substrate for nitric oxide synthase (NOS) responsible for the production of NO. This investigation studied the effect of apocynin, an NADPH oxidase inhibitor and catalase, an H2O2 scavenger on L-arginine induced oxidative stress and hypotension. Forty Wistar-Kyoto rats were treated for 14 days with vehicle, L-arginine (12.5mg/ml p.o.), L-arginine+apocynin (2.5mmol/L p.o.), L-arginine+catalase (10000U/kg/day i.p.) and L-arginine plus apocynin+catalase respectively. Weekly renal functional and hemodynamic parameters were measured and kidneys harvested at the end of the study for histopathological and renal NADPH oxidase 4 (Nox4) assessments. L-arginine administration in normotensive rats decreased systolic blood pressure (120±2 vs 91±2mmHg) and heart rate (298±21 vs 254±15b/min), enhanced urinary output (21.5±4.2 vs 32±1.9ml/24h , increased creatinine clearance (1.72±0.56 vs 2.62±0.40ml/min/kg), and fractional sodium excretion (0.88±0.16 vs 1.18±0.16 %), caused proteinuria (28.10±1.93 vs 35.26±1.69mg/kg/day) and a significant decrease in renal cortical blood perfusion (292±3 vs 258±5bpu) and pulse wave velocity (3.72±0.20 vs 2.84±0.13m/s) (all P<0.05). L-arginine increased plasma malondialdehyde (by ~206 % P<0.05) and NO (by~51 %, P<0.05) but decreased superoxide dismutase (by~31 %, P<0.05) and total antioxidant capacity (by~35 %, P<0.05) compared to control. Renal Nox4 mRNA activity was approximately 2.1 fold higher (P<0.05) in the L-arginine treated rats but was normalized by apocynin and apocynin plus catalase treatment. Administration of apocynin and catalase, but not catalase alone to rats fed L-arginine, restored the deranged renal function and structure, prevented hypotension and enhanced the antioxidant capacity and suppressed Nox4 expression. These findings suggest that apocynin and catalase might be used prophylactically in states of oxidative stress.

Fighting the Coronavirus disease (Covid-19) pandemic: Employing lessons from the Ebola virus disease response.

Coronavirus disease (COVID-19) is caused by a beta-coronavirus (SARS-CoV-2) that affects the lower respiratory tract and appears as pneumonia in humans. COVID-19 became apparent in December 2019 in Wuhan City of China, and has propagated profusely globally. Despite stringent global quarantine and containment drives, the incidence of COVID-19 keeps soaring high. Measures to minimize human-to-human transmission have been implemented to control the pandemic. However, special efforts to reduce transmission via efficient public health communications and dissemination of risks should be applied in susceptible populations including children, health care providers, and the elderly. In response to this global pandemic, this article summarizes proven strategies that could be employed to combat the COVID-19 disease outbreak, taking a cue from lessons learned from the Ebola virus disease response.

La maladie à coronavirus (COVID-19) est causée par un bêta-coronavirus (SARS-CoV-2) qui affecte les voies respiratoires inférieures et se présente sous forme de pneumonie chez l'homme. La COVID-19 est apparue en décembre 2019 dans la ville chinoise de Wuhan, et s'est propagée à grande échelle dans le monde entier. Malgré des mesures de quarantaine et de confinement rigoureuses, l'incidence de COVID-19 continue de grimper en flèche. Des mesures visant à minimiser la transmission interhumaine ont été mises en œuvre pour contrôler la pandémie. Toutefois, des efforts particuliers pour réduire la transmission par le biais de communications efficaces en matière de santé publique et de diffusion des risques doivent être déployés dans les populations sensibles, notamment les enfants, les prestataires de soins de santé et les personnes âgées. En réponse à cette pandémie mondiale, cet article résume les stratégies éprouvées qui pourraient être employées pour combattre l'épidémie de maladie COVID-19, en s'inspirant des leçons tirées de la réponse à la maladie du virus Ebola.

Bombax Costatum extract abrogates piroxicam-mediated hepatic and gastric toxicities in rats.

OBJECTIVE: Concurrent administration of orthodox drugs and herbs is common in tropical Africa. This study investigates the effect of co-administration of piroxicam and Bombax costatum on hepatic and gastric toxicities and levels of oxidative stress markers. MATERIALS AND METHODS: Twenty male wistar rats were grouped into four. Rats in group one were administered 1mL/kg distilled water as normal control; group two were treated with 400mg/kg of extract; group three were treated with 20mg/kg of piroxicam; while those in group four were treated with both extract and piroxicam at 400mg/kg and 20mg/kg, respectively. All treatments were given orally for 14 days. At the end of the treatment period, the rats were euthanised; blood samples and stomach were collected for determination of hepatic and gastro-toxicity alongside with oxidative stress markers. RESULTS: Treatment with piroxicam alone shows the presence of oxidative stress with marked hepatic and gastric toxicities. Oxidative stress markers, hepatic and gastric toxicity indices after treatment with extract alone and in combination with piroxicam appear like that of the control group. CONCLUSION: Concurrent administration of piroxicam and Bombax costatum prevents piroxicam-induced hepatic and gastric toxicities with a positive effect on antioxidant levels. This may indicate important health benefits of this drug-herb combination.

Postoperative oxygenation in healthy dogs following mechanical ventilation with fractions of inspired oxygen of 0.4 or >0.9.

OBJECTIVE: To evaluate arterial oxygenation during the first 4 postoperative hours in dogs administered different fractions of inspired oxygen (FiO2) during general anesthesia with mechanical ventilation. STUDY DESIGN: Prospective, randomized clinical trial. ANIMALS: A total of 20 healthy female dogs, weighing >15 kg and body condition scores 3-7/9, admitted for ovariohysterectomy. METHODS: Dogs were randomized to breathe an FiO2 >0.9 or 0.4 during isoflurane anesthesia with intermittent positive pressure ventilation. The intraoperative PaO2:FiO2 ratio was recorded during closure of the linea alba. Arterial blood was obtained 5, 60 and 240 minutes after extubation for measurement of PaO2 and PaCO2 (FiO2 = 0.21). Demographic characteristics, duration of anesthesia, PaO2:FiO2 ratio and anesthetic agents were compared between groups with Wilcoxon tests. The postoperative PaO2, PaCO2, rectal temperature, a visual sedation score and events of hypoxemia (PaO2 < 80 mmHg) were compared between groups with mixed-effects models or generalized linear mixed models. RESULTS: Groups were indistinguishable by demographic characteristics, duration of anesthesia, anesthetic agents administered and intraoperative PaO2:FiO2 ratio (all p > 0.08). Postoperative PaO2, PaCO2, rectal temperature or sedation score were not different between groups (all p > 0.07). During the first 4 postoperative hours, hypoxemia occurred in three and seven dogs that breathed FiO2 >0.9 or 0.4 during anesthesia, respectively (p = 0.04). CONCLUSIONS AND CLINICAL RELEVANCE: The results identified no advantage to decreasing FiO2 to 0.4 during anesthesia with mechanical ventilation with respect to postoperative oxygenation. Moreover, the incidence of hypoxemia in the first 4 hours after anesthesia was higher in these dogs than in dogs breathing FiO2 >0.9.

Speech stimuli and nasalance scores for the assessment of resonance in in Mandarin speaking Malaysian children.

This study was designed to develop language-specific stimuli for the assessment of resonance and to obtain nasalance scores using the newly developed speech stimuli in Mandarin. Gender and age influences on nasalance scores for each of the stimulus were also examined. Participants recruited were typically developing Mandarin-speaking ethnic Chinese children aged 6;00-7;11 growing up in Malaysia. Perceptual ratings of nasality were made based on the GOS.SP.ASS.'98 (revised) for children while nasalance scores were recorded for each stimulus using the Nasometer II (Model 6400). Fifty Mandarin-speaking children (24 males and 26 females) were recruited. None of the participants were perceived with abnormal nasality on the three stimuli. The mean nasalance scores for the Mandarin stimuli were 16.08% (SD = 2.57, 95% CI = 15.35-16.81) for the Oral passage, 25.20% (SD = 3.63, 95% CI = 24.17-26.23) for the Oral-Nasal passage and 55.44% (SD = 4.17, 95% CI = 54.25-56.63) for the Nasal passage. No significant age- and gender-related differences were observed for all the three stimuli. This is the first set of Mandarin stimuli and nasalance norms for Mandarin-speaking children in Malaysia. The influence of phonetic content on nasalance is supported. Findings call for language-specific normative nasalance data and careful selection of stimuli for the assessment of resonance.

Evaluation of Constructing Care Collaboration - nurturing empathy and peer-to-peer learning in medical students who participate in voluntary structured service learning programmes for migrant workers.

BACKGROUND: Experiential learning through service provides opportunities to nurture and practice empathy. Of growing concern, studies showed significantly decreased empathy scores as students progress through medical school. Additionally, peer-to-peer learning provides an effective way for students to learn. Constructing Care Collaboration (CCC) is a student initiated, structured-service-learning-program that promotes the development of empathy and peer-to-peer teaching. CCC is conducted in cycles of 6 sessions. This is a mixed methods study that explores the effectiveness of CCC as a service learning platform in developing student participants' empathy, social and cultural competencies, communication skills and peer-to-peer teaching skills, ultimately aiming to promote a culture of serving the underprivileged. METHODS: The study comprised of a self-administered quantitative questionnaire and qualitative interviews. Both evaluated if CCC participation developed volunteers' social-awareness, cultural competency, communication, confidence and motivation to teach their peers. RESULTS: Quantitative data were collated from 38 completed student volunteers' questionnaires. Volunteers generally agreed CCC improved social-awareness and cultural competency. It increased confidence of participants in approaching migrant-workers, communicating with people from different social backgrounds, and promoted a culture of peer-to-peer teaching. Thematic analysis of 17 interviews was conducted. Themes identified include: increased empathy towards migrant-workers, improved communication skills, and identifying benefits and challenges in peer-to-peer teaching. CONCLUSION: From the quantitative and qualitative information gathered, CCC has been shown to be effective in nurturing participants' self-reported empathy, cultural competence, communication skills and improved attitude towards peer-to-peer teaching. Given its effectiveness, CCC can be adopted as a model for structured service-learning.

Can we see fade? A survey of anesthesia providers and our ability to detect partial neuromuscular block in dogs.

OBJECTIVE: To assess the ability to visually detect fade during train-of-four (TOF) or double burst stimulation (DBS) in anesthetized dogs recovering from nondepolarizing neuromuscular block. STUDY DESIGN: Online anonymous survey. POPULATION: Data from 112 participants. METHODS: A web-based survey containing 12 videos of the response to ulnar nerve stimulation with TOF and 12 with DBS obtained at different levels of recovery from rocuronium-induced block was distributed to participants of the American College of Veterinary Anesthesia and Analgesia and the Academy of Veterinary Technicians in Anesthesia and Analgesia e-mail lists. Participants were asked to provide their highest training degree in anesthesiology, watch each video no more than twice, and determine whether fade was present. The probability to correctly recognize fade was calculated using binomial general linear models. General linear models and Tukey's tests were used to assess the effects of level of neuromuscular block, pattern of stimulation, and observers' training on the probability to detect fade. RESULTS: The survey was completed by 53 diplomates, 29 licensed veterinary technicians, 24 residents and six doctors of veterinary medicine (DVMs). The probability to detect fade decreased as partial neuromuscular block became more shallow (p < 0.0001). A TOF or DBS ratio of 0.7 had a 50% chance of being detected. DBS was superior to TOF for detecting fade when the ratio was 0.3-0.69. TOF was superior to DBS when the ratio was 0.7-0.9 (p < 0.0001). There were no differences among groups of observers when assessing fade with TOF or DBS. CONCLUSIONS AND CLINICAL RELEVANCE: Detection of fade from observations of the response to TOF in dogs is unreliable. Advance training in anesthesiology or the use of DBS confers little to no advantage for this subjective test.