Assessing the impact of frailty in elderly patients undergoing emergency laparotomies in Singapore.

Introduction: The global rise in ageing populations poses challenges for healthcare systems. By 2030, Singapore anticipates a quarter of its population to be aged 65 or older. This study addresses the dearth of research on frailty's impact on emergency laparotomy (EL) outcomes in this demographic, emphasising the growing significance of this surgical intervention. Method: Conducted at 2 tertiary centres in Singapore from January to December 2019, a retrospective cohort study examined EL outcomes in patients aged 65 or older. Frailty assessment, using the Clinical Frailty Scale (CFS), was integrated into demographic, diagnostic and procedural analyses. Patient data from Tan Tock Seng Hospital and Khoo Teck Puat Hospital provided a comprehensive view of frailty's role in EL. Results: Among 233 participants, 26% were frail, revealing a higher vulnerability in the geriatric population. Frail individuals exhibited elevated preoperative risk, prolonged ICU stays, and significantly higher 90-day mortality (21.3% versus 6.4%). The study illuminated a nuanced connection between frailty and adverse outcomes, underlining the critical need for robust predictive tools in this context. Conclusion: Frailty emerged as a pivotal factor influencing the postoperative trajectory of older adults undergoing EL in Singapore. The integration of frailty assessment, particularly when combined with established metrics like P-POSSUM, showcased enhanced predictive accuracy. This finding offers valuable insights for shared decision-making and acute surgical unit practices, emphasising the imperative of considering frailty in the management of older patients undergoing emergency laparotomy.

Pre-emptive treatment of heart failure exacerbations in patients managed with the HeartLogic™ algorithm.

AIMS: Heart failure (HF) is a chronic disease affecting 64 million people worldwide and places a severe burden on society because of its mortality, numerous re-hospitalizations and associated costs. HeartLogic™ is an algorithm programmed into implanted devices incorporating several biometric parameters which aims to predict HF episodes. It provides an index which can be monitored remotely, allowing pre-emptive treatment of congestion to prevent acute decompensation. We aim to assess the impact and security of pre-emptive HF management, guided by the HeartLogic™ index. METHODS AND RESULTS: The HeartLogic™ France Cohort Study is an investigator-initiated, prospective, multi-centre, non-randomized study. Three hundred ten patients with a history of HF (left ventricular ejection fraction ≤40%; or at least one episode of clinical HF with elevated NT-proBNP ≥450 ng/L) and implanted with a cardioverter defibrillator enabling HeartLogic™ index calculation will be included across 10 French centres. The HeartLogic™ index will be monitored remotely for 12 months and in the event of a HeartLogic™ index ≥16, the local investigator will contact the patient for assessment and adjust HF treatment as necessary. The primary endpoint is unscheduled hospitalization for HF. Secondary endpoints are all-cause mortality, cardiovascular death, HF-related death, unscheduled hospitalizations for ventricular or atrial arrhythmia and HeartLogic™ index evolution over time. Blood samples will be collected for biobanking, and quality of life will be assessed. Finally, the safety of a HeartLogic™-triggered strategy for initiating or increasing diuretic therapy will be assessed. A blind and independent committee will adjudicate the events. CONCLUSIONS: The HeartLogic™ France Cohort Study will provide robust real-world data in a cohort of HF patients managed with the HeartLogic™ algorithm allowing pre-emptive treatment of heart failure exacerbations.

Killing of a Multispecies Biofilm Using Gram-Negative and Gram-Positive Targeted Antibiotic Released from High Purity Calcium Sulfate Beads.

BACKGROUND: Multispecies biofilm orthopedic infections are more challenging to treat than mono-species infections. In this in-vitro study, we aimed to determine if a multispecies biofilm, consisting of Gram positive and negative species with different antibiotic susceptibilities could be treated more effectively using high purity antibiotic-loaded calcium sulfate beads (HP-ALCSB) containing vancomycin (VAN) and tobramycin (TOB) in combination than alone. METHODS: Three sets of species pairs from bioluminescent strains of Pseudomonas aeruginosa (PA) and Staphylococcus aureus (SA) and clinical isolates, Enterococcus faecalis (EF) and Enterobacter cloacae were screened for compatibility. PA + EF developed intermixed biofilms with similar cell concentrations and so were grown on 316L stainless steel coupons for 72 h or as 24 h agar lawn biofilms and then treated with HP-ALCSBs with single or combination antibiotics and assessed by viable count or bioluminescence and light imaging to distinguish each species. Replica plating was used to assess viability. RESULTS: The VAN + TOB bead significantly reduced the PA + EF biofilm CFU and reduced the concentration of surviving antibiotic tolerant variants by 50% compared to single antibiotics. CONCLUSIONS: The combination of Gram-negative and positive targeted antibiotics released from HP-ALCSBs may be more effective in treating multispecies biofilms than monotherapy alone.

Facets of mindfulness among video game players: A latent profile analysis.

OBJECTIVE: This study explores the presence of different profiles of video game players across five mindfulness facets (i.e., describing, observing, nonreacting, nonjudging, and acting with awareness) and nonattachment (i.e., the ability to relate to experiences without clinging onto them). METHOD: Adults who play video games (N = 629) were recruited from Amazon's Mechanical Turk. Participants completed an online survey, assessing their dispositional mindfulness and nonattachment, problem video gaming, emotion-based impulsivity, psychological inflexibility, and mental health. RESULTS: The latent profile analysis identified four profiles, representing those who were highly mindful (n = 131; 20.8%), moderately mindful (n = 289; 46.0%), reactive and attached (n = 132; 21.0%), and judgmental and unaware (n = 77; 12.2%). Subsequent comparisons revealed that the judgmental and unaware profile reported the highest level of problem gaming, followed by the reactive and attached profile. The judgmental and unaware profile evidenced stronger general gaming motivations and higher emotion-based impulsivity; in contrast, the reactive and attached profile demonstrated greater psychological inflexibility and escapism motivation relative to the other profiles. Both the judgmental and unaware and the reactive and attached profiles had elevated levels of anxiety and depression. CONCLUSION: These findings provide a more nuanced assessment of the protective role of mindfulness. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Scaling Monte-Carlo-Based Inference on Antibody and TCR Repertoires.

Previously, it has been shown that maximum-entropy models of immune-repertoire sequence can be used to determine a person's vaccination status. However, this approach has the drawback of requiring a computationally intensive method to compute each model's partition function (Z), the normalization constant required for calculating the probability that the model will generate a given sequence. Specifically, the method required generating approximately 1010 sequences via Monte-Carlo simulations for each model. This is impractical for large numbers of models. Here we propose an alternative method that requires estimating Z this way for only a few models: it then uses these expensive estimates to estimate Z more efficiently for the remaining models. We demonstrate that this new method enables the generation of accurate estimates for 27 models using only three expensive estimates, thereby reducing the computational cost by an order of magnitude. Importantly, this gain in efficiency is achieved with only minimal impact on classification accuracy. Thus, this new method enables larger-scale investigations in computational immunology and represents a useful contribution to energy-based modeling more generally.

Resident and Family Physician Perspectives on Billing: An Exploratory Study.

Introduction: Within revenue cycle management, billing is an important activity for physicians with financial implications across remuneration models. We assessed the self-reported billing confidence of residents and attending physicians practicing at an academic family health team in a single payer setting. Methods: All residents and attending physicians working or who had worked at the team were invited to complete a 20-question electronic survey on their exposure to billing education and their self-reported confidence with various billing activities. Results: Twenty-five percent (n=40) of eligible physicians completed the survey. There were statistically significant differences between attending and resident physicians' billing experience (median 117.5 vs. 7.5 months). Analysis of free text comments revealed the positive impact of early billing exposure and opportunities for longitudinal feedback. Conclusion: Despite the small sample size, findings suggest that early exposure of family medicine residents to billing with standardized training contributes to a more positive experience during residency.

Effect of esophageal cooling on ablation lesion formation in the left atrium: Insights from Ablation Index data in the IMPACT trial and clinical outcomes.

INTRODUCTION: The IMPACT study established the role of controlled esophageal cooling in preventing esophageal thermal injury during radiofrequency (RF) ablation for atrial fibrillation (AF). The effect of esophageal cooling on ablation lesion delivery and procedural and patient outcomes had not been previously studied. The objective was to determine the effect of esophageal cooling on the formation of RF lesions, the ability to achieve procedural endpoints, and clinical outcomes. METHODS: Participants in the IMPACT trial underwent AF ablation guided by Ablation Index (30 W at 350-400 AI posteriorly, 40 W at ≥450 AI anteriorly). A blinded 1:1 randomization assigned patients to the use of the ensoETM® device to keep esophageal temperature at 4°C during ablation or standard practice using a single-sensor temperature probe. Ablation parameters and clinical outcomes were analyzed. RESULTS: Procedural data from 188 patients were analyzed. Procedure and fluoroscopy times were similar, and all pulmonary veins were isolated. First-pass pulmonary vein isolation and reconnection at the end of the waiting period were similar in both randomized groups (51/64 vs. 51/68; p = 0.54 and 5/64 vs. 7/68; p = 0.76, respectively). Posterior wall isolation was also similar: 24/33 versus 27/38; p = 0.88. Ablation effect on tissue, measured in impedance drop, was no different between the two randomized groups: 8.6Ω (IQR: 6-11.8) versus 8.76Ω (IQR: 6-12.2; p = 0.25). Arrhythmia recurrence was similar after 12 months (21.1% vs. 24.1%; 95% CI: 0.38-1.84; HR: 0.83; p = 0.66). CONCLUSIONS: Esophageal cooling has been shown to be effective in reducing ablation-related thermal injury during RF ablation. This protection does not compromise standard procedural endpoints or clinical success at 12 months.

The Association between the Fibrosis-4 Index and COVID-19: A Systematic Review and Meta-Analysis.

OBJECTIVE: The prognosis value of fibrosis-4 score (FIB-4) in COVID-19 is controversial. Hence, we conducted a systematic review and meta-analysis to investigate the association between the FIB-4 index and COVID-19 disease progression. METHODS: We performed meta-analysis using the PubMed, Embase, and Cochrane databases. A fixed- or random-effects model was used for evaluating heterogeneity. RESULTS: Thirteen studies were included. The meta-analysis of unadjusted results showed that compared to lower FIB-4 index, patients with higher FIB-4 index had increased odds of mortality (OR=5.1, 95%CI 3.67-7.09; P<0.001), ICU admission (OR=2.32, 95%CI: 1.65-3.25, P<0.00001) and need for mechanical ventilator support (OR=3.51, 95%CI: 2.1-5.85, P<0.001). In addition, the meta-analysis of adjusted results showed patients with higher FIB-4 index was associated with increased risk of mortality (OR=3.01, 95%CI: 2.21-4.09, P<0.001) and need for mechanical ventilator support (OR=3.76, 95%CI: 2.08-6.82, P<0.001) compared to patients with lower FIB-4 index. CONCLUSIONS: This meta-analysis indicated that high FIB-4 index score was associated with the severity and mortality in COVID-19 infected patients.

Contemporary Management of Complex Ventricular Arrhythmias.

Percutaneous catheter ablation is an effective and safe therapy that can eliminate ventricular tachycardia, reducing the risks of both recurrent arrhythmia and shock therapies from a defibrillator. Successful ablation requires accurate identification of arrhythmic substrate and the effective delivery of energy to the targeted tissue. A thorough pre-procedural assessment is needed before considered 3D electroanatomical mapping can be performed. In contemporary practice, this must combine traditional electrophysiological techniques, such as activation and entrainment mapping, with more novel physiological mapping techniques for which there is an ever-increasing evidence base. Novel techniques to maximise energy delivery to the tissue must also be considered and balanced against their associated risks of complication. This review provides a comprehensive appraisal of contemporary practice and the evidence base that supports recent developments in mapping and ablation, while also considering potential future developments in the field.

Fending off Delta - Hospital measures to reduce nosocomial transmission of COVID-19.

OBJECTIVES: Following the emergence of the Delta variant of SARS-CoV-2 in Singapore, our hospital experienced a Delta-linked ward cluster. In this study, we review the enhanced strategies in preventing nosocomial transmission of COVID-19 following widespread community transmission of the Delta variant. METHODS: We conducted a cohort study on exposures to unexpected COVID-19 cases for which contact tracing was initiated from June 2021 to October 2021. Strategies evaluated included upgraded personal protective equipment (PPE) and rostered routine testing (RRT) for staff and patients, surveillance of staff with acute respiratory illness (ARI), and expanded quarantining and testing for contacts of identified cases. RESULTS: From 193 unexpected COVID-19 exposures, 2,573 staff, 542 patients, and 128 visitor contacts were traced. Four staff contacts subsequently had SARS-CoV-2 infection. Two were likely from exposure in community settings, whereas 2 had exposure to the same COVID-19 positive staff in the hospital, forming the only hospital cluster. One inpatient had a nosocomial infection, possibly from visitors. The SARS-CoV-2 detection rate among staff was 0.3% (of 11,200 staff) from biweekly RRT and 2.5% (of 3,675 staff) from ARI surveillance. CONCLUSION: Enhanced hospital measures, including upgraded PPE and RRT for staff and patients, staff sickness surveillance, and more rigorous management of contacts of COVID-19 cases, were likely to have reduced nosocomial transmission amid the Delta variant.

Hourly variability in outflow tract ectopy as a predictor of its site of origin.

INTRODUCTION: Before ablation, predicting the site of origin (SOO) of outflow tract ventricular arrhythmia (OTVA), can inform patient consent and facilitate appropriate procedural planning. We set out to determine if OTVA variability can accurately predict SOO. METHODS: Consecutive patients with a clear SOO identified at OTVA ablation had their prior 24-h ambulatory ECGs retrospectively analysed (derivation cohort). Percentage ventricular ectopic (VE) burden, hourly VE values, episodes of trigeminy/bigeminy, and the variability in these parameters were evaluated for their ability to distinguish right from left-sided SOO. Effective parameters were then prospectively tested on a validation cohort of consecutive patients undergoing their first OTVA ablation. RESULTS: High VE variability (coefficient of variation ≥0.7) and the presence of any hour with <50 VE, were found to accurately predict RVOT SOO in a derivation cohort of 40 patients. In a validation cohort of 29 patients, the correct SOO was prospectively identified in 23/29 patients (79.3%) using CoV, and 26/29 patients (89.7%) using VE < 50. Including current ECG algorithms, VE < 50 had the highest Youden Index (78), the highest positive predictive value (95.0%) and the highest negative predictive value (77.8%). CONCLUSION: VE variability and the presence of a single hour where VE < 50 can be used to accurately predict SOO in patients with OTVA. Accuracy of these parameters compares favorably to existing ECG algorithms.