Epidemiology and clinical characteristics of invasive mould infections: A multicenter, retrospective analysis in five Asian countries.

Formal, large-scale, multicenter studies of invasive mould infection (IMI) in Asia are rare. This 1-year, retrospective study was designed to assess the incidence and clinical determinants of IMI in centers in five countries (Thailand, Taiwan, Singapore, China, India). Patients treated in a single year (2012) were identified through discharge diagnoses, microbiology, and histopathology logs, and entered based on published definitions of IMI. A total of 155 cases were included (median age 54 years; 47.7% male). Of these, 47.7% had proven disease; the remainder had probable IMI. The most frequent host factors were prolonged steroid use (39.4%) and recent neutropenia (38.7%). Common underlying conditions included diabetes mellitus (DM; 30.9%), acute myeloid leukemia (19.4%), and rheumatologic conditions (11.6%). DM was more common in patients with no recent history of neutropenia or prolonged steroid use (P = .006). The lung was the most frequently involved site (78.7%), demonstrating a range of features on computed tomography (CT). Aspergillus was the most common mould cultured (71.6%), primarily A. fumigatus and A. flavus, although proportions varied in different centers. The most often used antifungal for empiric therapy was conventional amphotericin. Ninety-day mortality was 32.9%. This is the first multicenter Asian study of IMI not limited to specific patient groups or diagnostic methods. It suggests that DM and rheumatologic conditions be considered as risk factors for IMI and demonstrates that IMI should not be ruled out in patients whose chest features on CT do not fit the conventional criteria.

Recurrent trichosporonosis with central nervous system involvement in an allogeneic hematopoietic stem cell transplant recipient.

Trichosporon is an ubiquitous yeast that has emerged as an opportunistic pathogen in the immunocompromised host. We describe a case of invasive trichosporonosis in an allogeneic hematopoietic stem cell transplant (allo-HSCT) recipient while on caspofungin antifungal prophylaxis. She developed disseminated trichosporonosis in the pre-engraftment period and was successfully treated with voriconazole. She later developed 2 further episodes of invasive trichosporonosis involving the central nervous system. This case highlights the challenges of managing trichosporonosis in allo-HSCT recipients and suggests the need for lifelong therapy in some patients.

Ulnar fractures with bisphosphonate therapy: a systematic review of published case reports.

SUMMARY: A systematic review of eight ulnar fractures in seven patients with bisphosphonate therapy was performed to describe the characteristics and predisposing factors. The proximal ulna is likely to be fractured, especially in the dominant limb of elderly female patients using walking aids after 7 to 15 years of bisphosphonate use. INTRODUCTION: Long-term bisphosphonate use has been suggested to result in decreased bone remodelling and increased risk of atypical fractures. While the relationship between bisphosphonate use and atypical femoral fractures has been extensively studied, there is relative rarity and unawareness of these fractures in the forearm. We conducted a systematic review of existing case reports to better describe the characteristics and predisposing factors for fractures occurring in patients with bisphosphonate therapy. METHODS: The systematic review was conducted according to PRISMA guidelines. All studies with ulnar fractures in individuals with history of bisphosphonate use were included, with data extracted and analysed in totality. RESULTS: Seven patients with eight fractures are included. Predisposing factors include elderly females requiring walking aids. There is a propensity for the proximal ulna to be fractured, especially in the dominant limb used for ambulation or transfer. All patients were on bisphosphonate for 7 to 15 years. All fractures were atraumatic, non-comminuted, transverse in configuration, had localised periosteal or endosteal thickening at the fracture site and generalised cortical thickening of the diaphysis. CONCLUSION: Ulnar fractures in patients with bisphosphonate therapy demonstrate features similar to those described for atypical femoral fractures, suggesting that these fractures could also possibly be due to bisphosphonate use. However, the ulna appears to be able to tolerate longer periods of alendronate use prior to fracture development. The mechanism and characteristics of these fractures additionally suggest the presence of repetitive stress that accumulates over time due to suppressed bone remodelling in patients on bisphosphonates, eventually resulting in these fractures.

Disseminated Mycobacterium marinum infection in a hematopoietic stem cell transplant recipient.

Mycobacterium marinum is a photochromogenic mycobacterium that is ubiquitous in the aquatic environment. In the general population, exposure to aquaria is the most common cause of M. marinum infection. Known as "swimmer's granuloma" or "fish tank granuloma," M. marinum is an occupational hazard for aquarium cleaners and fishermen. There are several reports in the literature of M. marinum infection in immunocompromised hosts, including those with solid organ transplants, but none in patients who have received stem cell transplants (SCTs). To our knowledge, this is a first report of disseminated M. marinum infection in an SCT recipient who continued to develop new skin lesions even after months of targeted therapy. The implications are that elderly patients who receive T-cell-depleted SCTs may be at prolonged risk for pathogens dependent on cellular immunity, and the presentation of illness with such pathogens may be more severe and widely disseminated than might otherwise be expected.

Failure of sterilization in a dental outpatient facility: Investigation, risk assessment, and management.

In 2017, an incident of failed sterilization of dental instruments occurred at a large dental outpatient facility in Singapore. We aim to describe findings of the investigation of the sterilization breach incident, factors related to risk of viral transmission to the potentially affected patients, and the contact tracing process, patient management, and blood test results at a 6-month follow-up. A full assessment of the incident was immediately carried out. The factors related to risk of viral transmission due to affected instruments were analyzed using 3 keys points: breached step(s) and scale of the incident, prevalence of underlying bloodborne diseases and immunity in the Singapore population, health status of potential source patients, and type of dental procedure performed, and health status of affected patients and type of dental procedure received. Up to 72 affected instrument sets were used in 714 potentially affected patients who underwent noninvasive dental procedures. The investigation revealed that there was a lapse in the final step of steam sterilization, resulting in the use of incompletely sterilized items. The assessment determined that there was an extremely low risk of bloodborne virus transmission of diseases to the patients. At the 6-month follow-up, there were no infected/colonized cases found related to the incident. Lapses in the sterilization process for medical and dental instruments can happen, but a risk assessment approach is useful to manage similar incidents. Quick response and proper documentation of the sterilization process can prevent similar incidents.

Stable dispersions of hybrid nanoparticles induced by stereocomplexation between enantiomeric poly(lactide) star polymers.

We report the formation and characterization of stable dispersions of hybrid nanoparticles in solution formed via stereocomplexation of enantiomeric poly(lactide) hybrid star polymers. The hybrid starlike polymers, having polyhedral oligomeric silsesquioxane (POSS) nanocages as the core and either poly(L-lactide) (PLLA) or poly(D-lactide) (PDLA) as the arms, are synthesized via ring-opening polymerization of lactide using octafunctional POSS as the macroinitiator. In the solid state, differential scanning calorimetry and wide-angle X-ray scattering measurements confirmed the formation of the stereocomplex in the mixture of POSS-star-PLLA and POSS-star-PDLA (50:50, wt %). In a solution of the same mixture in tetrahydrofuran (THF), sterocomplexation leads to formation of hybrid nanaoparticles. Detailed accounts of the nanoparticle formation and influence of aging and concentration have been presented. It was observed that at low concentration the stereocomplexed nanaoparticles remain stable over 45 days and are not sensitive to dilution, suggesting the formation of a stable hybrid nanoparticle dispersion in solution. In contrast, the aggregates of the individual POSS-star-PLLA or POSS-star-PDLA in THF, formed via weak solvophobic interactions, tended to disintegrate into smaller aggregates on dilution. Exploiting the PLLA-PDLA stereocomplexation with an appropriate molecular design can be a versatile route to develop stable organic/inorganic hybrid nanoparticle dispersions.

Bilateral adrenal histoplasmosis: endoscopic ultrasound-guided fine needle aspiration as a method of diagnosis and assessment.

We report a case of a healthy 78-year-old indonesian man who presented with chronic weight loss, poor appetite and lethargy. CT abdomen showed bilateral adrenal masses. EUS-guided FNA was performed on the left adrenal gland. Histopathology report was Histoplasma Capsulatum. He recovered well with antifungal treatment without any complication. In this case, we found that the role of EUS -guided FNA was not only limited to diagnosis but also helped in the prognosis of the disease since the method was able to assess the general anatomy of the adrenal gland better than other imaging modalities due to its close proximity and direct visualization.

Plasma MIC-1 correlates with systemic inflammation but is not an independent determinant of nutritional status or survival in oesophago-gastric cancer.

BACKGROUND: Macrophage inhibitory cytokine-1(MIC-1) is a potential modulator of systemic inflammation and nutritional depletion, both of which are adverse prognostic factors in oesophago-gastric cancer (OGC). METHODS: Plasma MIC-1, systemic inflammation (defined as plasma C-reactive protein (CRP) of > or =10 mg l(-1) or modified Glasgow prognostic score (mGPS) of > or =1), and nutritional status were assessed in newly diagnosed OGC patients (n=293). Healthy volunteers (n=35) served as controls. RESULTS: MIC-1 was elevated in patients (median=1371 pg ml(-1); range 141-39 053) when compared with controls (median=377 pg ml(-1); range 141-3786; P<0.001). Patients with gastric tumours (median=1592 pg ml(-1); range 141-12 643) showed higher MIC-1 concentrations than patients with junctional (median=1337 pg ml(-1); range 383-39 053) and oesophageal tumours (median=1180 pg ml(-1); range 258-31 184; P=0.015). Patients showed a median weight loss of 6.4% (range 0.0-33.4%), and 42% of patients had an mGPS of > or =1 or plasma CRP of > or =10 mg l(-1) (median=9 mg l(-1); range 1-200). MIC-1 correlated positively with disease stage (r(2)=0.217; P<0.001), age (r(2)=0.332; P<0.001), CRP (r(2)=0.314; P<0.001), and mGPS (r(2)=0.336; P<0.001), and negatively with Karnofsky Performance Score (r(2)=-0.269; P<0.001). However, although MIC-1 correlated weakly with dietary intake (r(2)=0.157; P=0.031), it did not correlate with weight loss, BMI, or anthropometry. Patients with MIC-1 levels in the upper quartile showed reduced survival (median=204 days; 95% CI 157-251) when compared with patients with MIC-1 levels in the lower three quartiles (median=316 days; 95% CI 259-373; P=0.036), but MIC-1 was not an independent prognostic indicator. CONCLUSIONS: There is no independent link between plasma MIC-1 levels and depleted nutritional status or survival in OGC.

Synthesis and self-assembly of brush-type poly[poly(ethylene glycol)methyl ether methacrylate]-block-poly(pentafluorostyrene) amphiphilic diblock copolymers in aqueous solution.

Well-defined fluorinated brush-like amphiphilic diblock copolymers of poly[poly(ethylene glycol)methyl ether methacrylate] (P(PEGMA)) and poly(pentafluorostyrene) (PPFS) have been successfully synthesized via atom transfer radical polymerization (ATRP). The self-assembly behavior of these polymers in aqueous solutions was studied using (1)H NMR, fluorescence spectrometry, static and dynamic light scattering and transmission electron microscopy techniques. The micellar structure comprised of PPFS as the core and brush-like (hydrophobic main chain and hydrophilic branches) polymers as the coronas. The hydrodynamic radius (R(h)) of the micelles in aqueous solution was in the nanometer range, independent of the polymer concentration, consistent with a closed association model. Diblock copolymers with a longer P(PEGMA) block formed micelles with smaller R(h) and lower aggregation numbers consistent with an improved solubilization of the core. The micelles possessed a thick hydration layer as verified by the ratio of the radius of gyration, R(g) to the hydrodynamic radius, R(h). The aggregation number and ratio of R(g) to R(h) were observed to increase with temperature (20-50 degrees C), while the R(h) of the micelle decreased slightly over the same temperature range. An increase in temperature induced the brush-like PEG segments in the corona to dehydrate and shrink while forming micelles with larger aggregation numbers.

Micelle formation and gelation of (PEG-P(MA-POSS)) amphiphilic block copolymers via associative hydrophobic effects.

A series of well-defined amphiphilic di- and triblock copolymers have been synthesized, using atom transfer radical polymerization, with poly(ethylene glycol) (PEG) and poly(methacrylisobutyl polyhedral oligomeric silsesquioxane) P(MA-POSS) as the hydrophilic and hydrophobic blocks, respectively. The detailed self-assembly behavior of the amphiphilic macromolecules in aqueous media was studied using both static and dynamic light scattering (SLS and DLS) techniques. The evolution of block copolymer micelle formation in THF/water mixture (20/80 v/v) was monitored as the THF evaporated from the solvent mixture. Initially the block copolymer chains existed as unimers in solution, followed by the formation of smaller aggregates (R(h) < 2 nm) after 30 min, eventually growing in size to reach an equilibrium size when all the THF evaporated within 24 h. The micelles formed by the block copolymers were found to be kinetically unstable (not frozen); i.e., they tended to revert to individual copolymer chains on dilution. The hydrodynamic radii, R(h), of the micelles varied with the degree of polymerization (DP) of the hydrophobic P(MA-POSS); for example, for PEG(5K)-b-P(MA-POSS), an increase from R(h) approximately 13.3 +/- 1.1 nm to R(h) approximately 17.5 +/- 1.4 nm was observed with a nominal change in the DP of P(MA-POSS) from 4 to 6. The micelles formed by the triblock copolymers (P(MA-POSS)-b-PEG(10K)-b-P(MA-POSS)) were comparable in size to the diblock copolymer micelles; e.g., R(h) approximately 14.0 +/- 1.3 nm was found for P(MA-POSS)(4)-b-PEG(10K)-b-P(MA-POSS)(4). The micellar structures created by the triblocks in aqueous media were "flowerlike", where the PEG middle block adopted a loop conformation in the micelle corona. In addition to micelles, larger aggregates formed by P(MA-POSS)-b-PEG(10K)-b-P(MA-POSS) were also detected in solution. The larger aggregates may suggest a contribution from some PEG blocks adopting an extended conformation with one end dangling in solution, causing gelation at higher copolymer concentrations via intermicellar interactions. The P(MA-POSS)(4)-b-PEG(10K)-b- P(MA-POSS)(4) formed a gel in water at approximately 8.8 wt % copolymer concentration. No gel formation by diblock copolymers was observed; however, the addition of a small amount of triblock copolymer to an aqueous solution of diblock copolymer results in gel formation. Finally, rheological behavior of the obtained gels was also investigated.

The influence of systemic inflammation, dietary intake and stage of disease on rate of weight loss in patients with gastro-oesophageal cancer.

Although weight loss is often a dominant symptom in patients with upper gastrointestinal malignancy, there is a lack of objective evidence describing changes in nutritional status and potential associations between weight loss, food intake, markers of systemic inflammation and stage of disease in such patients. Two hundred and twenty patients diagnosed with gastric/oesophageal cancer were studied. Patients underwent nutritional assessment consisting of calculation of body mass index, measurement of weight loss, dysphagia scoring and estimation of dietary intake. Serum acute-phase protein concentrations were determined by enzyme-linked immunosorbent assay. In all, 182 (83%) patients had lost weight at diagnosis (median loss, 7% body weight). Weight loss was associated with poor performance status, advanced disease stage, dysphagia, reduced dietary intake and elevated serum C-reactive protein (CRP) concentrations. Multiple regression identified dietary intake (estimate of effect, 38%), serum CRP concentrations (estimate of effect, 34%) and stage of disease (estimate of effect, 28%) as independent variables in determining degree of weight loss. Mechanisms other than reduced dietary intake or mechanical obstruction by the tumour appear to be involved in the nutritional decline in patients with gastro-oesophageal malignancy. Recognition that systemic inflammation plays a role in nutritional depletion may inform the development of appropriate therapeutic strategies to ameliorate weight loss, making patients more tolerant of cancer-modifying treatments such as chemotherapy.

Selective phagocytosis: a new concept in protein catabolism.

The clearance of different metabolic products derived from two plasma proteins, prothrombin and fibrinogen, was studied with the aid of the isolated, perfused rat liver. Active thrombin and fibrin were rapidly cleared by the Kupffer cells. Inactive thrombin and a partially degraded fibrin molecule were also cleared but at much slower rates. This difference in clearance rates suggests the presence of a high degree of selectivity in the clearance of altered plasma proteins.

Tracheal intubation with videolaryngoscopes in patients with cervical spine immobilization: a randomized trial of the Airway Scope and the GlideScope.

BACKGROUND: The GlideScope (Verathon Inc., Bothell, WA, USA) and Airway Scope (Hoya Corp., Tokyo, Japan) have both been used for difficult airway management, including in patients with cervical spine pathology. The Airway Scope's disposable blade has a tube channel to guide tracheal tube insertion through the glottis. Our hypothesis is that this tube guidance system improves the ease of tracheal intubation compared with the GlideScope, which does not have a tube guiding system. We tested this hypothesis in a randomized comparison of the two videolaryngoscopes in patients whose cervical spines were immobilized. METHODS: Seventy consenting patients were randomized to have tracheal intubation with the GlideScope (n=35) or the Airway Scope (n=35). In all patients, we applied manual in-line stabilization of the cervical spine throughout airway management. All the airway procedures were carried out by two anaesthetists experienced in the use of both videolaryngoscopes. RESULTS: The tracheal intubation time was 34.2 (sd 25.1) s with the Airway Scope compared with 71.9 (47.9) s with the GlideScope (P<0.001). Tracheal intubation was successful with the Airway Scope in 35 (100%) patients compared with 31 (88.6%) patients with the GlideScope (P=0.114). Tracheal intubation was successful within 60 s in 33 (94.3%) patients with the Airway Scope and 22 (62.9%) patients with the GlideScope (P=0.003). CONCLUSIONS: These results suggest that the Airway Scope's tube guide system enables more rapid tracheal intubation compared with the GlideScope in patients with cervical spine immobilization.

Ease of intubation with the GlideScope or Airway Scope by novice operators in simulated easy and difficult airways--a manikin study.

The GlideScope and Airway Scope are video laryngoscopes that have been found to be useful in difficult airway situations. With the GlideScope, there are frequently problems associated with insertion of the tracheal tube despite the ability to view the glottis. The Airway Scope's imaging system and disposable PBlade aid alignment of the PBlade with the glottis and guide insertion of the tracheal tube. We performed a randomised crossover study of 20 medical students using both videolaryngoscopes in a manikin, with simulated normal and difficult airway scenarios. We found that the students required less time for tracheal intubation with the Airway Scope and reported greater ease of intubation with the Airway Scope in both scenarios. A greater number of students chose the Airway Scope as their device of choice. Our results suggest that the Airway Scope's features may improve the ease of tracheal intubation compared with the GlideScope.

A general experimental system for the development of acoustic logging tools.

Laboratory testing is a pre-requisite for the practical application of new methods and techniques, and it is crucial in the research and development of acoustic well-logging tools. Various tools have been developed based on different acoustic logging theories and methods. Thus, these tools are equipped with different acoustic sonde structures. To meet the test requirements of different tools in a laboratory environment, we designed a general experimental system that includes hardware platform, software platform, and model wells according to the common structure of actual logging tools. Similar to the internal electrical structure of downhole tools, the hardware platform consists of several main parts, such as power supply, control and telemetering, acoustic emission, and data acquisition. The functions of this hardware platform include controlling the working sequence of the experiment, exciting the transmitter sonde, and collecting the acoustic signals received by the receiver sonde. The software platform installed in the host computer provides a human-computer interface for the experimental system to complete the data transmission between the host computer and the hardware platform, store measured data, and process the data in real time. The model wells approximate the actual engineering environment and stratum condition for system testing. A series of practical laboratory experiments is conducted in the model wells by using this experimental system. The process proves that the hardware and software of the experimental system can work in coordination, and the experimental system meets the basic testing requirements of conventional acoustic logging tools.

Use of the cytomegalovirus pp65 antigenemia assay for preemptive therapy in allogeneic hematopoietic stem cell transplantation: a real-world review.

Despite advances in surveillance strategies and antivirals, cytomegalovirus (CMV) infection continues to pose problems to patients receiving hematopoietic stem cell transplants (HSCTs). The bone marrow transplant (BMT) unit at the Singapore General Hospital embraced the preemptive strategy in late 2003. Although several studies have demonstrated its usefulness, we conducted this review to document CMV-related events at our institution. Forty-six patients underwent CMV surveillance using the CMV pp65 antigenemia (CMV Ag) assay from January 2004 to December 2005. Twenty-seven patients had CMV infection, and 19 remained antigenemia-negative. No differences were found between the 2 groups for the following potential risk factors for CMV infection: age, total number of co-morbidities, duration of neutropenia after conditioning, baseline creatinine, type of conditioning regimen (conventional vs. reduced intensity), type of transplant (matched sibling vs. others), recipient CMV status, donor CMV status, and use of total body irradiation. Two patients received alemtuzumab; both developed CMV Ag. Twelve episodes of CMV infection occurred after the 100th post-HSCT day. Two patients developed CMV disease. One of them could be considered a failure of the preemptive strategy, as she had CMV gastritis diagnosed on the same day that she became pp65-positive. The other developed CMV disease despite prompt institution of ganciclovir, although she had multiple post-HSCT complications requiring enhanced immunosuppression, as well as relapsed disease. One-year disease-free survival was 55.5% in those with CMV infection and 52.3% in those without infection. Survival was not affected by CMV infection.

Donor-Derived Candida dubliniensis Resulting in Perigraft Abscesses in a Liver Transplant Recipient Proven by Whole Genome Sequencing: A Case Report.

BACKGROUND: The transmission of fungi via transplant, although well-known, has not often been molecularly proven. We describe a case of donor-derived candidiasis verified by whole genome sequencing. CASE DESCRIPTION: The multiorgan donor was a 42-year-old woman with subdural hemorrhage. Procurement of the thoracic organs was performed followed by the abdominal organs. Tissue from the left bronchus grew Candida dubliniensis. The liver recipient was a 63-year-old woman with cryptogenic liver cirrhosis. She was noted to have worsening leukocytosis on postoperative day (POD) 9. Computed tomography of the abdomen and pelvis showed multiple rim-enhancing collections around the graft. Percutaneous drainage was performed. Fluid cultures grew C dubliniensis. C dubliniensis isolated from the donor's left bronchus and the liver recipient's abscesses were verified to be related by whole genome sequencing. We postulate that C dubliniensis colonizing the donor's transected trachea could have contaminated the inferior vena cava when the former was left open after explant of the donor's lungs. A portion of the donor's contaminated inferior vena cava was transplanted along with the liver graft, resulting in the infected collections in the recipient. CONCLUSIONS: Our case report highlights the importance of maintaining a sterile field during organ procurement, especially in a multiorgan donor whose organs are explanted in succession.