A case study exploring the 'real world' process of 'naturalizing' school playgrounds

Background: The aim of this study was to examine the lived experiences of teachers and administrators at two schools (one elementary Kindergarten-Grade 5 and one middle school, grades 6-8) following the 'naturalizing' of a portion of their schoolyard. Methods: A qualitative case study design was used. Focus groups and interviews allowed participants to express their rationale, identify implementation facilitators and barriers and critical processes/steps for realizing their naturalization goals. Researcher questions explored (1) factors which led to naturalizing the schoolyard, (2) key planning and process steps (3) challenges and successes experienced, and, (4) lessons learned. Findings: Six themes were identified as rationale for naturalizing including: re-integration of outdoor play into children's daily lives, pro-active mental health, opportunity for inclusion, nature as a positive space for learning, it fit with our values and principles, we had a need. Implementation was facilitated by having champions and support from multiple levels, adopting a phased approach, resources and having the buy-in to persevere over time. Significant challenges and 'how to' steps were also identified. Conclusions: Naturalizing schoolyards does not happen without a supportive context, significant time and effort. Implementation steps and issues were those commonly found in other school-based health promotion efforts.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

Cardiovascular phenotyping of the first mouse model of Sarcoidosis

Introduction

Sarcoidosis is a potentially life-threatening, inflammatory, granulomatous disease that affects multiple organs including the heart. Heretofore, its unknown etiology had hindered the creation of experimental models and the understanding of the molecular mechanisms of pathogenesis behind it.

Purpose

To extensively phenotype the heart of the first mouse model of sarcoidosis created through deletion of the tuberous sclerosis 2 (Tsc2) gene in the CD11c-positive macrophage population.

Methods

Tsc2 fl/fl CD11c Cre+ (Tsc2-KO; n=7) and Tsc2 fl/fl CD11c Cre- (Tsc2-WT; n=7) mice were subjected to echocardiography at 25 weeks of age (woa) to assess myocardial dimensions and function. Hearts of 13 and 25woa animals were subjected to histological and immunological stains to assess tissue changes, subtype inflammatory infiltrates and examine the localization of key proteins shown to be re-distributed in patients.

Results

At 13 woa, Tsc2-KO animals show inflammatory infiltrates; subtyped mainly as macrophages as well as evidence of myocyte destruction. At 25 woa, the number of inflammatory cells is significantly higher and there is heavy fibrotic replacement primarily in the septum and trabeculae. Older animals also show giant cells and non-necrotizing granulomas. The hearts show heterogeneous gap junction remodeling known to constitute an arrhythmogenic substrate and lack of immunoreactive signal for the desmosomal protein plakoglobin from the cell-cell junctions just as described in patients. The left ventricular ejection fraction and LV morphology was not significantly different between the two groups (EF: 64±4% in Tsc2-KO vs 64±2% in Tsc2-WT; LV end-systolic diameter: 4.51±0.54 mm in Tsc2-KO vs 4.59±0.29 mm in Tsc2-WT). However, there was a strong trend towards increasing filling pressure (E/e'ratio; 14.24±4.01 vs 12.15±2.54) and mean pulmonary pressure (21±6 vs 18±3 mmHg) in Tsc2-KO mice compared to controls suggesting diastolic dysfunction.

Conclusion

Hearts of the Tsc2 fl/fl CD11c Cre+ animals show a phenotype highly reminiscent of cardiac sarcoidosis in patients. We anticipate that this model will be very useful in deciphering molecular mechanisms of pathogenesis as well as testing much-needed mechanism-based therapies.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation - PG/18/27/33616

Increasing the interval between repeated anesthetic exposures reduces long-lasting synaptic changes in late post-natal mice

While recent studies strongly suggest that a single, short anesthetic exposure does not affect neurodevelopment, the effects of multiple exposures remain unclear. Unfortunately, studying "multiple exposures" is challenging as it is an extremely heterogeneous descriptor comprising diverse factors. One potentially important, but unrecognized factor is the interval between anesthetic exposures. In order to evaluate the significance of interval, we exposed post-natal day 16, 17 mice to three sevoflurane exposures (2.5%, 1 hr) with short (2 hr) or long (24 hr) intervals. Changes in synaptic transmission, plasticity, protein expression, and behavior were assessed in male and female mice. We discovered that short-interval exposures induced a female-dependent decrease in miniature inhibitory post-synaptic current (mIPSC) frequency 5 days after the last exposure (control: 18.44 ± 2.86 Hz, sevoflurane:14.65 ± 4.54 Hz). Short-interval sevoflurane exposed mice also displayed long-term behavioral deficits at adult age (hypoactivity, anxiety). These behavioral changes were consistent with the sex-dependent changes in inhibitory transmission, as they were more robust in female mice. Although there was no change in learning and memory, short-interval sevoflurane exposures also impaired LTP in a non-sex-dependent manner (control: 171.10 ± 26.90%, sevoflurane: 149.80 ± 26.48 %). Most importantly, we were unable to find long-lasting consequences in mice that received long-interval sevoflurane exposures. Our study provides novel insights regarding the significance of the interval between multiple exposures, and also suggests that the neurotoxic effects of multiple anesthetic exposures may be reduced by simply increasing the interval between each exposure.

Anesthetics and long-term survival after cancer surgery-total intravenous versus volatile anesthesia: a retrospective study

Background

Intravenous anesthesia has been reported to have a favorable effect on the prognosis of cancer patients. This study was performed to analyze data regarding the relation between anesthetics and the prognosis of cancer patients in our hospital.

Methods

The medical records of patients who underwent surgical resection for gastric, lung, liver, colon, and breast cancer between January 2006 and December 2009 were reviewed. Depending on the type of anesthetic, it was divided into total intravenous anesthesia (TIVA) or volatile inhaled anesthesia (VIA) group. The 5-year overall survival outcomes were analyzed by log-rank test. Cox proportional hazards modeling was used for sensitivity.

Results

The number of patients finally included in the comparison after propensity matching came to 729 in each group. The number of surviving patients at 5 years came to 660 (90.5%) in the TIVA and 673 (92.3%) in the VIA. The type of anesthetic did not affect the 5-year survival rate according to the log-rank test (P = 0.21). Variables associated with a significant increase in the hazard of death after multivariable analysis were male sex and metastasis at surgery.

Conclusions

There were no differences in 5-year overall survival between two groups in the cancer surgery.

Trial registration

Trial registration: CRIS KCT0004101. Retrospectively registered 28 June 2019.

P110 External ventricular drain-related infections: a single centre study

Objectives

To quantify the External Ventricular Drain-related infection (ERI) rate in a one year period at Cork University Hospital, and to identify any risk factors for infection.

Design

A retrospective audit of all External Ventricular Drains (EVDs) inserted in a one year period.

Subjects

All patients who had an EVD inserted between February 2017 and February 2018.

Methods

Patients were identified from operating theatre logbooks. All relevant data was obtained from a retrospective review of medical and operative records. ERI was defined as evidence of positive CSF culture.

Results

41 EVDs were inserted in a total of 30 patients during the study period. The average age was 52.9 years. 46.6% of patients were female. The average length of EVD insertion was 8.85 days. The most common reason for EVD insertion was subarachnoid haemorrhage (31.7%) followed by supratentorial tumour (24.4%). 78% of EVDs were antibiotic-impregnated. Average EVD sampling rate was 0.7. ERI rate was 1/41 (2.4%). The infection occurred in a patient who had an EVD inserted for haemorrhage secondary to an AVM which had remained in situ for 13 days. The patient subsequently developed problems with repeated shunt infections resulting in a nine-month hospital stay.

Conclusions

The ERI rate in our patient cohort was 2.4%. We recommend using a strict EVD sampling protocol to minimise manipulation of EVDs and where possible to limit the length of time an EVD remains in situ. EVD-related infections can result in lengthy hospital stays and increased healthcare costs.

Prevalence and Characteristics of Smoking Among School-Going Adolescents in Kuala Lumpur, Malaysia

Background: According to the World Health Organization (WHO) (2014), noncommunicable diseases (NCDs) such as cancer, cardiovascular disease and respiratory disease account for a majority of premature deaths in the Malaysian population. Tobacco smoking remains a leading risk factor for these diseases. Although there have been previous population-level studies which have highlighted adolescent smokers in Malaysia, little has been done to specifically ascertain smoking prevalence within a school-going population using objective measurement tools. Aim: This study aimed to identify the prevalence of school-going adolescent smokers in Kuala Lumpur via an objective measurement - expired carbon monoxide (CO) in parts per million (ppm). Methods: This study was a cross-sectional study that involved 2,679 high school-going adolescents aged between 13 to 18 years old in Kuala Lumpur, Malaysia. The level of exhaled CO (Smokerlyzer test) of all the participants was measured. Participants were also administered with a survey conducted right after the Smokerlyzer test to determine i) whether they smoked or not; ii) type of tobacco products used if smoked; iii) vaping or shisha usage; and iv) exposure to secondhand smoke. The categorization of smoking status was based on CO-ppm reading: ≤ 3 ppm (nonsmoker); 3 < ppm ≤ 6 (light smoker or nonsmoker breathing in poor air quality or passive smoke inhalation); ≥ 7 ppm (regular smoker with higher levels of CO in blood). Descriptive analysis was conducted to determine the demographics of the study population. Inferential analysis was carried out utilizing χ2 tests or Student t-tests to test associations between smoking status and other independent variables. One-way ANOVA test was conducted to compare the differences in CO-ppm readings. Results: The mean age of the adolescents (n=2,679) was 14.5 ± 1.2 years old (median: 14) and 55.1% were male. Interestingly, vaping was the most commonly used method of tobacco use among the studied adolescents, regardless of gender, followed by cigarettes and shisha. The mean CO-ppm reading for male adolescents was significantly higher than female adolescents. Passive smoke inhalation (exposure to secondhand smoke) was significantly associated with higher readings of CO-ppm. A significant association was determined between status of exposure to secondhand smoke and a history of usage of any form of tobacco products. Conclusion: The prevalence of smoking adolescents, regardless of gender, in Kuala Lumpur remains at a worrying state. Objective measurements such as Smokerlyzer test can be coupled with self-reported questionnaire in targeting adolescent smokers within a structured setting such as a school and can help form part of an effective school-based smoking cessation intervention program targeting adolescents in Malaysia. This is in line with efforts to make Malaysia a smoke-free nation by 2045.

N, Low K, Hashim HM, Munisamy M. Losing Themselves From Following Up: Barriers to Accessing Further Clinical Investigations for Women With Abnormal Clinical Breast Examination (CBE) Findings in Klang Valley, Malaysia

Background: Clinical breast examination (CBE) is one of the most accessible screening methods for breast cancer and widely used in the Malaysian public health system due to the wide availability of trained healthcare personnel and low costs; especially in government hospitals. However, discovery of an abnormal finding from the CBE does not necessarily translate into action for further clinical investigations. An understanding of the patients' motivations in decision making, which causes them to ignore the need for further clinical investigations despite abnormal findings in CBEs may be an important element to improve holistic cancer prevention efforts; of which early detection is a key strategy. Aim: The aim of this study was to investigate the barriers for women to receive follow-up care upon obtaining abnormal results for CBE. Methods: The National Cancer Society of Malaysia has an active ongoing public outreach program in which trained healthcare personnel conduct CBEs at various screening campaigns throughout the Klang Valley with a total of 1017 women screened in 2017. Women who were screened and found to have an abnormal finding from the CBE were referred for further investigations at a center of their choice. Women found to have an abnormal CBE finding were reached via a phone call to determine whether they had proceeded to i) get an appointment for further clinical examination; or ii) had already undergone a further clinical examination. Those who had done neither were interviewed via phone to determine their reasons for not proceeding with further clinical investigations despite an abnormal CBE finding. Results: Out of the 1017 women screened, 38 were found to have an abnormal CBE finding. Of them, 16 women had not sought further investigations. Qualitative interviews revealed that there strong issues that posed barriers to these women pursuing further investigations. These barriers included a lack of knowledge and understanding about breast cancer or rationale of undergoing a CBE; a lack of urgency pertaining to CBE results and feeling of embarrassment engaging with family members on facilitating attendance to the investigation. Conclusion: Significant barriers remain which deter women who have abnormal CBE findings from pursuing further clinical investigations which ultimately reduces the effectiveness of current breast cancer screening strategies. These findings may prove to be important for designing effective methods to encourage confirmatory clinical examination among those already found to have abnormal findings from tests such as the CBE.

Would You Like A Free Mammogram? Effectiveness of Utilizing WhatsApp As a Social Marketing Tool in Improving Uptake for a Free Mammography Service in Kuala Lumpur Malaysia

Background: Social media and messaging services are increasingly targeted by health providers as an avenue to spread health messages, increase awareness and also for social marketing. WhatsApp is a social media application which has wide penetration in Malaysia, with more than half the population relying on WhatsApp for news. Aim: This study aimed to determine the effectiveness of WhatsApp as a social marketing tool to increase uptake for a free mammography service for underprivileged women. Methods: This was a randomized clinical trial conducted in Kuala Lumpur, Malaysia. Individuals from the National Cancer Society of Malaysia database were randomized into 1 of 3 arms receiving a WhatsApp message; i) a poster of a free mammography service for underprivileged women; ii) a poster of the free mammography service for underprivileged women with a personal message from the Director of the National Cancer Society of Malaysia; and iii) the poster, personal message from the director and a specific Saturday screening date with the exhortation that there were only 40 places available for that date on a first-come first-serve basis. The outcomes of the trial were i) number of women who returned a call or WhatsApp message to the designated numbers; ii) number of women who booked an appointment for the mammography service; and iii) numbers of women who attended the appointment. Results: The number of calls and inquiries to designated numbers increased by more than 200% as a result of the WhatsApp messages. There were statistically significant differences between the three delivery arms; with the highest percentages of women booking and attending their mammography appointments coming from the arm which had a designated screening date with limited availability. Conclusion: WhatsApp was highly effective at increasing community penetration and marketing a free mammography service for underprivileged women in Kuala Lumpur. Messages with an appeal from a personage and with a specific date of “expiry” were more effective at getting the targeted group to avail themselves of the service.

Factors Associated With an Abnormal Mammogram Finding in Women Undergoing Screening in Kuala Lumpur, Malaysia

Background: Breast cancer is the most common cancer among Malaysian women, with a rising incidence from 16.5% in 2006%–17.7% in 2011. One of the key strategies in breast cancer control is early screening; of which mammography is a highly accurate tool, having been shown to reduce the number of mortality rates due to breast cancer up to 30%. However, mammography is often not as widely available in Malaysia; and in many local settings, healthcare providers have to limit screenings to only particular groups such as those with abnormal clinical breast examinations due to limited resources. Knowledge of other predictive factors may assist in further decision-making to prioritize patients for screening mammography in a low-resource setting. Aim: This study aimed to determine such predictive factors for abnormal mammogram findings among women who underwent mammography examination at a center in Kuala Lumpur, Malaysia. Methods: This was a cross-sectional study of women (n = 5491) who underwent a three-dimensional tomosynthesis mammography procedure at the Cancer and Health Screening Clinic, National Cancer Society of Malaysia (NCSM) in Kuala Lumpur, from Jan 2016 until Dec 2017 (2 years). Patients were surveyed on: i) age, ii) ethnicity, iii) family history of breast or any cancers, if any, iv) reproductive history (age of menarche, age of first delivery, age of menopause); and v) history of postmenopausal estrogen and hormone replacement therapy (HRT). Bivariate analysis was conducted by using χ2 tests in determining associations between variables and a multiple logistic regression model built to identify factors which were predictive of an abnormal mammogram finding (BI-RADS 4 & 5). Results: From the bivariate analysis; nulliparous status ( P = 0.02), a family history of breast cancer ( P = 0.04), and a history of postmenopausal hormone replacement therapy (HRT) ( P = 0.01) were determined to significantly associated with an abnormal mammogram finding. There were also significant ethnic differences between women who had abnormal mammogram findings; with Chinese women having highest odds of this (OR:3.22; 95% CI 1.86-5.74). Women within the age group of 45-54 (OR:1.84, 95% CI 1.19-3.12), a family history of breast cancer (OR 2.03, 95% CI 1.31-3.27) or any cancer (OR 1.56, 95% CI 1.06-2.94), age of menopause (OR 2.86; 95% CI 1.43-4.02) and age of first delivery above 30 (OR 1.73, 95% CI 1.26-3.45) were significantly associated with abnormal mammogram findings. Conclusion: Factors which predict abnormal mammogram findings in a Malaysian setting can be used as baseline evidence to formulate criteria which can be used to carry out targeted screening programs or even as cutoff criteria for focusing screening resources in resource-limited settings. This data may be of benefit in aiding healthcare providers in provisioning of services at a macro level as well as for frontline healthcare personnel in helping them profile women who should be focused on to be screened for the disease.

Hi, I Have Cancer, What Can I Do? An Analysis of Caller Characteristics of a Malaysian Cancer-Specific Information Hotline

Background: Despite the advancement of technology in information dissemination, patients and caregivers often cite difficulties in getting the right cancer information, care and psychosocial support. It is crucial to optimize the availability of cancer information to increase knowledge among the public and for better decision making by patients and their families. In line with these strategies, the National Cancer Society of Malaysia (NCSM) established a toll-free, Cancer Information Service Helpline (CIS) in 2016 to act as a tool for provision of cancer-related information and psychosocial support. Aim: This study aimed to analyze caller characteristics and trends of calls received by the CIS between January 1 to December 31, 2017. Methods: A cross sectional study was conducted on the CIS call logs for the ascertained study period. Descriptive analysis was carried out to determine characteristics of callers including i) socio-demographics; ii) geographical location; iii) caller's cancer disease status or relationship with cancer patient and iv) reason(s) for calling the helpline. ANOVA was used to determine possible associations between the different variables and reasons for calling the helpline. Results: A total of 1613 calls were received during the study period. Majority of the callers were female (72%) and almost half of the callers were healthcare professionals (43%). 36% of the calls were inquiries on availability of screening services and this was significantly associated with calls from healthcare professionals ( P = 0.04). Callers of Malay ethnicity ( P = 0.03) and newly diagnosed cancer patients ( P = 0.001) were significantly associated with calling to seek for financial help. Conclusion: While being used as a source of some aspects of information pertaining to cancer, the CIS's capabilities in providing psychosocial support is not being maximized as yet. These results provide insight that targeted promotional efforts to raise awareness about CIS's psychosocial support capabilities is required to further maximize its potential among Malaysian patients, families and the public at large.

Experience and Impact of a Locally-Based Peer, Volunteer Cancer Support Programme in Hospital Melaka, Melaka Malaysia

Background: Melaka is a small southern state in Peninsular Malaysia. On average, the state has an annual incidence of 200 odd breast cancer patients, largely treated out of its public, subsidized, single tertiary treatment center of Hospital Melaka. Hospital Melaka is an 800-bedded hospital with multiple specialties including surgery and radiology. Though the hospital does not have a dedicated oncology department, cancer treatment is carried out via phone consultations and visiting oncologists as well as a team of on-site nursing staff who are trained to initiate and monitor treatment. Feedback from Hospital Melaka staff highlighted that there was a drop-out rate of about 30% of patients from the treatment journey. Qualitative interviews with different stakeholders including patient revealed that the drop-out may be driven by factors such as: i) fear of surgery, ii) fear of chemotherapy, iii) fear of disfigurement, iv) loss of spouse v) emotional distress and shock; and vi) delay in waiting times for different levels of diagnostics and treatment. Aim: The aim of the initiative was to reduce the rate of patients who defaulted out from the cancer treatment journey via a three-pronged approach: a) improving understanding about cancer and treatment by patients and family members; b) integrating peer-support into the clinical treatment pathway at the hospital and reduction of waiting times; and c) maintaining a continuous interaction with the patient throughout the treatment journey. Methods: The inception and deployment of a locally-based peer, volunteer support program for breast cancer patients and families as part of the formal cancer treatment process in Hospital Melaka. Volunteers were consisted of a trained mix of cancer survivors, current and retired healthcare practitioners and provided information pertaining to treatment and care aspects of breast cancer as well as emotional support and follow-up of patients via phone or in person to ensure compliance to treatment. In this study, we engaged with various stakeholders including hospital management and clinicians. Then, support group's services were formalized into the care pathway for all patients with breast cancer; with both volunteers able to send and receive patient referrals. Results: Statistically significant reductions in patient delays in decision-making to seek treatment as well as a significant decrease of 12.5% in the number of defaulters. Conclusion: A support program built with support from all stakeholders and run by volunteers and embedded within the formal care process acts as a catalyst to enhance both service delivery as well as keeping patients engaged on the cancer care journey.

Is the Quality of Life in Breast Cancer Survivors the Same as Healthy Women? A Case Control Study Among Women in Klang Valley, Malaysia

Background: One of the positive outcomes of improvements in cancer care is the increasing number of people who survive the disease. Worldwide, the number of cancer survivors will continue to increase, with a threefold increase predicted from 25 million in 2008 to 75 million in 2030. Breast cancer survivors have the highest survival rates compared other types of cancer. Following a diagnosis of breast cancer, issues that women often worry about include the possibility of cancer recurrence, challenges with reacclimatizing to daily life posttreatment completion and numerous other emotional and physical challenges. It is unknown whether over time the coping skills of these survivors enable them to have a similar quality of life (QOL) as other normal women. This study aimed to assess and compare the quality of life (QOL) among breast cancer survivors and nonbreast cancer survivors in the Klang Valley, Malaysia. Methods: This case-control study used the European Organization for Research and Treatment of Cancer - Quality of Life Questionnaire (EORTC-QLQ) to ascertain QOL within breast cancer survivors and nonbreast cancer survivors. Simple random sampling was used to identify i) participants from the case arm -from four cancer-related NGOs in the Klang Valley; and ii) participants from the control arm - from women attending Kuala Lumpur Hospital. 176 number of participants were involved in this study with a 1:1 ratio. Result: There was no significant difference in quality of life (QOL) between breast cancer survivors and nonbreast cancer survivors in the Klang Valley, Malaysia. The longer the period of survival (5 years and above), the higher the QOL levels in breast cancer survivors. Conclusion: In conclusion, women with breast cancer especially those who had survived more than 5 years, had similar quality of life (QOL) levels as women who did not suffer from the disease. Women with breast cancer may have developed additional coping skills which could be taught to other patients living with cancer or even those with other chronic illnesses.

First Results from the DEAP-3600 Dark Matter Search with Argon at SNOLAB

This Letter reports the first results of a direct dark matter search with the DEAP-3600 single-phase liquid argon (LAr) detector. The experiment was performed 2 km underground at SNOLAB (Sudbury, Canada) utilizing a large target mass, with the LAr target contained in a spherical acrylic vessel of 3600 kg capacity. The LAr is viewed by an array of PMTs, which would register scintillation light produced by rare nuclear recoil signals induced by dark matter particle scattering. An analysis of 4.44 live days (fiducial exposure of 9.87 ton day) of data taken during the initial filling phase demonstrates the best electronic recoil rejection using pulse-shape discrimination in argon, with leakage <1.2×10^{-7} (90% C.L.) between 15 and 31  keV_{ee}. No candidate signal events are observed, which results in the leading limit on weakly interacting massive particle (WIMP)-nucleon spin-independent cross section on argon, <1.2×10^{-44}  cm^{2} for a 100  GeV/c^{2} WIMP mass (90% C.L.).