The effect of hypoxic ischemic encephalopathy towards multi-organ complications and its early outcome at a Malaysian district hospital.

INTRODUCTION: Hypoxic ischemic encephalopathy (HIE) is a clinically defined syndrome of disturbed neurologic function in the newborn with evidence of perinatal asphyxia. Stages of HIE are categorised into mild, moderate or severe based on the Sarnat classification. Neurological dysfunction constitutes a part of the wide spectrum of hypoxic ischemic insult as affected infants can have co-existing multi-organ dysfunction which further contributes to morbidities and mortality. This study aims to determine the relationship between the severity of HIE with multi-organ complications and early clinical outcomes. MATERIALS AND METHODS: All neonates who were admitted to the NICU at Hospital Sultan Abdul Halim between January 2018 to December 2022, who fulfilled the inclusion criteria were included. Demographic data, clinical course and investigation results were retrospectively obtained from the medical records. RESULTS: From a total of 90 infants (n = 90) who fulfilled our inclusion criteria, 31 (34%) were mild, 31 (34%) were moderate and 28 (31%) were severe HIE. The mean maternal age was 27 years. Common antenatal issues include diabetes mellitus (37.8%) and anaemia (22.2%). The Apgar scores at 1 and 5 minutes, initial resuscitation requiring intubation, chest compression and adrenaline were associated with higher severity of HIE (p < 0.05). Coagulation dysfunction was the most common complication (79.7%), followed by respiratory dysfunction (33.3%), cardiac dysfunction (28.9%), renal dysfunction (16.1%), haematological dysfunction (15.6%) and hepatic dysfunction (12%). Respiratory and haematological dysfunctions were significantly associated with higher mortality (p < 0.05). There was a significant longer hospital stay (p = 0.023), longer duration of ventilation (p < 0.001) and increase in frequency of seizures (p < 0.001) when comparing moderate and severe HIE patients to mild HIE patients. With increasing severity of HIE, there was also statistically significant higher mortality (p < 0.001). CONCLUSIONS: There is a significant relationship between multiorgan dysfunction, the severity of HIE and mortality. Early anticipation of multi-organ injury is crucial for optimal early management which would reduce the mortality and improve the neurological outcome of the patients.

The Risk Factors of mTORi-Associated Posttransplant Proteinuria.

Treatment with mammalian target of rapamycin inhibitors (mTORi) has been associated with an increased incidence of proteinuria after kidney transplantation as compared to other immunosuppressive agents. Proteinuria after mTORi use may occur in different clinical conditions and the precise mechanism remains unclear. The objective of this study was to investigate the related risk factors for proteinuria after mTORi treatment in kidney transplant recipients. This retrospective observational study population consisted of kidney transplant recipients followed up in a medical center in Southern Taiwan from January 1999 to April 2016. The baseline characteristics and transplantation-related profiles were collected at the time of enrollment. We examined risk factors for mTORi-associated proteinuria using a multivariate logistic regression analysis. P < .05 was considered as statistically significant. Hyperlipidemia and obesity at the initiation of mTORi treatment were strong predictors for proteinuria. Earlier identification of these risk factors may assist physicians in deciding the best candidate for mTORi conversion in order to optimize transplantation outcomes.

Risk Factors Associated With Mammalian Target of Rapamycin Inhibitor Withdrawal in Kidney Transplant Recipients.

BACKGROUND: Mammalian target of rapamycin inhibitors (mTORi) play an essential role as novel immunosuppressive agents in kidney transplantation (KT). Treatment cessation usually occurs after adverse effects occur. We investigated the risk factors associated with withdrawal of mTORi in KT recipients and evaluated the outcomes related to the withdrawal. METHODS: The study enrolled KT recipients being followed up in a medical center in southern Taiwan from January 1999 through December 2014. RESULTS: Risk factors associated with mTORi withdrawal were initial proteinuria level, higher initial serum creatinine level posttransplantation, and history of glomerulonephritis as the primary etiology of renal failure. mTORi withdrawal was associated with increased risk of graft failure (hazard ratio [HR], 9.97 [95% confidence interval (CI), 1.03-96.8]; P = .047). Higher body mass index (HR, 11.2 [95% CI, 1.63-76.6]; P = .01) and tacrolimus usage (HR, 8.30 [95% CI, 1.14-60.7]; P = .037) were associated with increased risk of new-onset diabetes after transplantation in mTORi withdrawal groups. CONCLUSIONS: Proteinuria, poor graft function, and primary glomerulonephritis were associated with cessation of mTORi treatment. Earlier identification of these risk factors may prevent further adverse events and optimize transplantation outcomes after mTORi conversion.

A single-center experience of cytomegalovirus infections in Asian pediatric patients undergoing allogeneic hematopoietic stem cell transplant for leukemia in Singapore.

INTRODUCTION: Cytomegalovirus (CMV) infection remains a significant cause of morbidity and mortality in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) despite improved surveillance and the current preemptive approach. Few data on its prevalence in the Asian pediatric population exist. METHODS: We retrospectively reviewed the prevalence of CMV infections in 33 patients with 37 transplants who received HSCT for leukemia from 1998 to 2008, and who were managed preemptively for infections. RESULTS: In the 37 transplants, 16 patients (43%) had CMV DNAemia. Of the patients who were CMV seropositive before transplant and received stem cells from seropositive donors (R+/D+), 69% had DNAemia; of those who received stem cells from seronegative donors (R+/D-), 36% had CMV DNAemia. Of the patients who were CMV naïve before transplant and received stem cells from seropositive donors (R-/D+), 25% had CMV DNAemia. In CMV-seronegative donor-recipient transplants (R-/D-), 20% of patients had CMV DNAemia. The median time to the first episode of CMV DNAemia was 21 (range: 10-107) days after the transplants, and the median duration of CMV DNAemia was 22 (range: 2-315) days. CMV DNAemia recurred in 44% (7 of 16) of these patients. Only 1 patient developed CMV disease (retinitis). No deaths were related to CMV infections. CONCLUSIONS: CMV infection manifesting as DNAemia is a common complication in pediatric patients undergoing allogeneic HSCT for leukemia. Pre-transplant serostatus predicts reactivation risks; invasive CMV disease is rare using the preemptive approach in our patient population.

Sinonasal blue naevus: case report and clinicopathological review.

OBJECTIVE: To highlight the important clinical and histological features of sinonasal blue naevi. METHODS: A case of blue naevus of the nasal cavity is described (including endoscopic and histological pictures) and the existing literature is reviewed. RESULTS: There have been five reported cases (including the presented case). Clinically, sinonasal blue naevi are heavily pigmented lesions that are small and asymptomatic. Histopathologically, blue naevi exhibit heavily pigmented dendritic melanocytes that are never abnormal in form. CONCLUSION: Blue naevus should be a differential diagnosis for pigmented lesions within the sinonasal cavity, despite its rarity. It may be initially suspected by its small size and asymptomatic nature. However, histological examination is required for definitive diagnosis, looking for the key microscopic features described above.

Registered nurses' medication management of the elderly in aged care facilities.

BACKGROUND: Data on adverse drug reactions (ADRs) showed a rising trend in the elderly over 65 years using multiple medications. AIM: To identify registered nurses' (RNs) knowledge of medication management and ADRs in the elderly in aged care facilities; evaluate an education programme to increase pharmacology knowledge and prevent ADRs in the elderly; and develop a learning programme with a view to extending provision, if successful. METHOD: This exploratory study used a non-randomized pre- and post-test one group quasi-experimental design without comparators. It comprised a 23-item knowledge-based test questionnaire, one-hour teaching session and a self-directed learning package. The volunteer sample was RNs from residential aged care facilities, involved in medication management. Participants sat a pre-test immediately before the education, and post-test 4 weeks later (same questionnaire). Participants' perceptions obtained. FINDINGS: Pre-test sample n = 58, post-test n = 40, attrition rate of 31%. Using Microsoft Excel 2000, descriptive statistical data analysis of overall pre- and post-test incorrect responses showed: pre-test proportion of incorrect responses = 0.40; post-test proportion of incorrect responses = 0.27; Z-test comparing pre- and post-tests scores of incorrect responses = 6.55 and one-sided P-value = 2.8E-11 (P < 0.001). CONCLUSION AND IMPLICATIONS: Pre-test showed knowledge deficits in medication management and ADRs in the elderly; post-test showed statistically significant improvement in RNs' knowledge. It highlighted a need for continuing professional education. Further studies are required on a larger sample of RNs in other aged care facilities, and on the clinical impact of education by investigating nursing practice and elderly residents' outcomes.

Orthopaedic patients' experience of motor vehicle accident in Singapore.

AIM: The purpose of this paper is to present a study that explored the experiences of orthopaedic patients injured in motor vehicle accidents (MVAs), from the time of the accident until 6 months after being discharged from hospital. BACKGROUND: Trauma injuries from MVAs are increasing, with the number of deaths from such injuries continuing to rise. Victims often sustain open fractures to more than one part of their body and need rehabilitation and support to adjust to long-term chronic or permanent disability. In the last decade, research pertaining to trauma nursing has concentrated on neurologically injured patients. Although there is a paucity of research on the nursing perspective of psychological care for non-neurologically injured patients, the majority of studies located were mainly quantitative in nature and did not analyse the personal experiences of orthopaedic patients. METHOD: A qualitative naturalistic inquiry approach was used, which provided a first-hand account of the traumatic MVA event experienced by six orthopaedic participants in Singapore. Data were collected from face-to-face in-depth interviews. Participants were voluntarily recruited through purposeful sampling and 'snowballing'. Interviews were audiotaped and transcribed verbatim in preparation for analysis. FINDINGS: The analysis of information explicated four main themes: the experience of the event, the effect of hospitalization, surviving the event and self-transformation. CONCLUSION: The study provided an understanding of orthopaedic patients' experience of MVA in Singapore. The findings of the study have the potential to contribute to the limited qualitative research available concerning victims' experiences of MVAs and nurses caring for MVA victims.

Global field power helps separate respiratory-related evoked potentials from EMG contamination.

Respiratory-related evoked potentials (RREPs) were stimulated by brief (200-ms) oral pressure pulses (-10 cmH(2)O) applied at the onset of inspiration in 12 subjects. Scalp potentials were measured at 30 sites on a rectangular grid that encompassed the right side of the scalp overlying the somatosensory cortex (SSC). Concurrent and significant masseter EMG (mEMG) activity was evoked by the pressure pulse, and we found correlational evidence for contamination of the RREP by the mEMG. The global field power (GFP) was used to provide a robust, reference-independent measure of SSC activation that provided partial insulation from mEMG contamination. The mean GFP from all subjects, reflective of afferent information from respiratory mechanoreceptors, showed a latency to onset of significant afferent SSC activity of approximately 25 ms. Scalp GFP activity during control experiments (absence of applied pressure) was significant and may reflect ongoing afferent activity from inspiration.

Quantitative assessment of variables that influence soft-tissue electrovaporization in a fluid environment.

OBJECTIVES: To evaluate the process of soft-tissue electrovaporization and to study variables that affect tissue clearance rates in a laboratory setting, in order to identify parameters that can optimize transurethral electrovaporization of the prostate. METHODS: Fresh bovine skeletal muscle, equivalent in impedance and surface properties to the human prostate, was submerged in 3.3% sorbitol solution and electrovaporized with a grooved monopolar electrode attached to the weighted arm of a linear actuator. The effects of excursion rate, applied mechanical load, power setting, electrode configuration, and generator performance on the volume of tissue removed, were assessed. RESULTS: Tissue removal increased significantly when electrode excursion rate was slowed from 25 to 15 mm/s (P < 0.05) and then to 10 mm/s (P < 0.05); when the load was increased from 20 to 50 g (P < 0.005); and when dial power was increased from 120 to 150 W (P < 0.01). Tissue removal was generator dependent. There was no significant difference between the Force 40 and the Force 2 (P > 0.4), but a new computer-controlled constant power output generator (Force FX) did significantly improve tissue vaporization at an equivalent power setting (P < 0.005 and P < 0.01, respectively). Tissue removal was also dependent upon electrode configuration, with the VaporTrode-Grooved Bar removing significantly more tissue than either an ungrooved roller bar of equivalent size or 2-mm smooth roller ball, respectively, both after a single pass (P < 0.001 and P < 0.05) and after five repeated passes (P < 0.05 and P < 0.005). The histologic depth of tissue thermal effect was less than 1 mm, but it was 38% greater for the VaporTrode-Grooved Bar (0.68 mm) than for the standard cutting loop (0.5 mm, P < 0.01). CONCLUSIONS: Using a novel method to quantify tissue removal, we have demonstrated that electrode configuration, excursion rate, applied load, power setting, and generator performance are interdependent factors that influence the efficacy of the electrovaporization process in a fluid environment.

Factors influencing electrovaporization in the treatment of benign prostatic hyperplasia.

Electrovaporization refers to the process of vaporizing tissue using electrical energy. Proposed as a new treatment method for benign prostatic hyperplasia (BPH), this technique allows removal of prostatic tissue with simultaneous coagulation, thereby minimizing blood loss. The recent increase in popularity of electrovaporization in the treatment of BPH warrants a quantitative assessment of the process, including an objective evaluation of its influencing factors. In this study, the effects of power, mechanical loading, and excursion rate on tissue removal by electrovaporization were examined in fresh skeletal muscle. A monopolar electrode was attached to the weighted arm of a linear motion system and rolled across the tissue surface while activated by a radio-frequency generator. The tissue samples were frozen and cut longitudinally to allow visualization and measurement of the vaporized groove using an optical imaging technique. The volume of tissue removed increased significantly when power was increased from 120 to 150 W (46 to 119 mm3, p = 0.006), when the load was increased from 20 to 50 gm (20 to 119 mm3, p = 0.002), and when the excursion rate was decreased from 25 to 15 mm/s (29 to 69 mm3, p < 0.05) and from 15 to 10 mm/s (69 to 137 mm3, p < 0.05). There was no significant gain in volume removed when power was increased to 180 W or when the load was increased to 70 gm, indicating that these factors are constrained with regard to optimal tissue removal. Using a novel method to quantitatively assess tissue removal by electrovaporization, this study has demonstrated that greater tissue removal can be achieved by increasing power, increasing the load, or decreasing the excursion rate, but only within limits.