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Complicated skin and soft tissue infections (cSSTIs) represent the severe form of infectious disease that involves deeper soft tissues. Involvement of methicillin-resistant (MRSA) further complicates cSSTI with increased hospitalization, health care costs, and overall mortality. Various international guidelines provide recommendations on the management of cSSTIs, with the inclusion of newer antibiotics. This literature-based review discusses the overall management of cSSTI, including appropriate use of antibiotics in clinical practice. Successful treatment of cSSTIs starts with early and precise diagnosis, including identification of causative pathogen and its load, determination of infection severity, associated complications, and risk factors. The current standard-of-care for cSSTIs involves incision, drainage, surgical debridement, broad-spectrum antibiotic therapy, and supportive care. In recent years, the emergence of newer antibiotics (eg, ceftaroline, tigecycline, daptomycin, linezolid, etc) has provided clinicians wider options of antimicrobial therapy. Selection of antibiotics should be based on the drug characteristics, effectiveness, safety, and treatment costs, alongside other aspects such as host factors and local multidrug resistance rates. However, larger studies on newer antibiotics are warranted to refine the decision making on the appropriate antimicrobial therapy. Local Antimicrobial Stewardship Program strategies in health care settings could guide clinicians for early initiation of specific treatments to combat region-specific antimicrobial resistance, minimize adverse effects, and to improve outcomes such as reduction in infections. These strategies involving iv-to-oral switch, de-escalation to narrow-spectrum antibiotics, and dose optimization have an impact on the overall improvement of cSSTI therapy outcomes, especially in countries like Singapore that has a high disease burden.

We assessed the effectiveness of a brief structured diabetes education programme based on the concept of self-efficacy on self-care and giycaemic control using single-blind study design. One hundred and sixty-four participants with poorly controlled diabetes from two settings were randomized using computer-generated list into control (n = 82) and intervention (n = 82) groups, of which 151 completed the study. Monthly interventions over 12 weeks addressed the self-care practices of diet, physical activity, medication adherence and self-monitoring of blood glucose (SMBG). These self-care practices were assessed at Weeks 0 and 12 using pre- and post-questionnaires in both groups together with glycated haemoglobin Ale (HbAlc) and diabetes knowledge. In the intention-to-treat analysis (n = 164), the intervention group improved their SMBG (P = <0.001), physical activity (P = 0.001), HbAlc (P = 0.03), diabetes knowledge (P = <0.001) and medication adherence. At Week 12, HbAlc difference adjusted for SMBG frequency, medication adherence and weight change remained significant (P = 0.03) compared with control group. For within group comparisons, diabetes knowledge (P = <0.001), HbAlc level (P = <0.001), SMBG (P = <0.001) and medication adherence (P = 0.008) improved from baseline in the intervention group. In the control group, only diabetes knowledge improved (P = <0.001). These findings can contribute to the development of self-management diabetes education in Malaysia.

The creep behavior of line-type micro-scale Cu/Sn–3.0Ag–0.5Cu/Cu joints under electro-thermo-mechanical coupled loads with a high current density of 1.0 × 10 4  A/cm 2 was characterized, in comparison with those without current stressing. Results show that under electro-thermo-mechanical coupled loads all joints exhibit typical three-stage creep characteristics similar with that of joints under the mechanical stress only, implying that the mechanical stress still dominates the creep deformation process of joints. The steady-state creep rate increases with the externally applied stress and temperature regardless of current stressing. Notably, the creep of joints under electro-thermo-mechanical coupled loads is accelerated in terms of an increase in the steady-state creep rate, compared with that without current stressing. The essential factors influencing the steady-state creep rate of joints are the damage effect and Joule heating induced by electro-thermo-mechanical coupled loads. Moreover, the results manifest that the creep activation energy and stress exponent of joints are independent of current stressing. The creep mechanisms of solder joints under electro-thermo-mechanical coupled loads and without current stressing are lattice diffusion.

IntroductionThe 2015 NCEPOD report1 found high rebleeding and mortality rates in patients with significant UGIB and recommended clearly documented rebleed plans. We audited the adequacy of rebleed plans at Nottingham University Hospitals, where 800 suspected UGIB patients are admitted annually.MethodPatients who underwent emergency endoscopy for suspected acute UGIB between June - August 2015 were identified. We analysed patient demographics, endoscopy (OGD) findings, re-bleed plans and clinical outcomes. Focused recommendations and education were delivered to all endoscopy unit staff. Re-audit was performed during June - July 2016 and outcomes compared.Results130 patients: 81 (62.6%) men, median (range) age 61 (14-92); 49 (37.4%) women, median (range) age 73 (34-96) years underwent urgent OGD following suspected acute UGIB between June -August 2015. 42 (32.3%) had endoscopic evidence of active UGIB (21 (16%) variceal haemorrhage (VH), and 21 (16%) non-variceal haemorrhage (NVH)) and 88 (67.7%) had no evidence of bleeding. Only 23.1% (n=30) who underwent urgent OGD had a re-bleed plan but was higher in those with (20/42 (47.6%); 11.9% re-bled, 5% mortality) rather than without (10/88 (11.4%); 5.7% re-bled; 0% mortality) endoscopic signs of bleeding.During the 4 week re-audit period after staff engagement and education, 42 patients (66.7% men, median age 60.5; 33.3% female, median age 77 years) underwent OGD for suspected UGIB. 21.4% had endoscopic evidence of active UGIB (7.1% VH; 14.3% NVH) and 78.6% had no evidence of bleeding. Rebleed plans improved overall from 23.1% to 46.3% and were higher in those with ((77.8%); 11.1% re-bled; 0% mortality) rather than without ((37.5%); 3.1% re-bled; 0% mortality) endoscopic signs of bleeding.Most frequent re-bleed plans were repeat OGD (34.7%), CT angiogram/interventional radiology (34.7%), conservative management (16.3%) or lower GI endoscopy (6.1%). Surgery was not recommended in any initial rebleed plan.ConclusionMost patients with suspected acute UGIB did not have endoscopic evidence of active bleeding, but still had rebleed rates of between 3%–11%. Clear documentation of rebleed plans initially was poor, but was better in those with endoscopic signs of active bleeding. Following focused education, rebleed plans improved substantially overall from 23.1% to 46.3%, particularly in those with active bleeding from 47.6% to 77.8%, who had a higher risk of rebleeding and in-hospital mortality.Reference. McPherson SJ, et al. Time to get Control; NCEPOD report 2015. Disclosure of InterestNone Declared

The Sendai Consensus Guidelines (SCG) were formulated in 2006 to guide the management of mucinous cystic lesions of the pancreas (CLPs) and were updated in 2012 (International Consensus Guidelines, ICG 2012). This study aims to evaluate the clinical utility of the ICG 2012 with the SCG based on initial cross-sectional imaging findings. One hundred fourteen patients with mucinous CLPs were reviewed and classified according to the ICG 2012 as high risk (HRICG2012), worrisome (WICG2012), and low risk (LRICG2012), and according to the SCG as high risk (HRSCG) and low risk (LRSCG). On univariate analysis, the presence of symptoms, obstructive jaundice, elevated serum carcinoembryonic antigen (CEA)/carbohydrate antigen (CA)19-9, solid component, main pancreatic duct ≥10 mm, and main pancreatic duct ≥5 mm was associated with high grade dysplasia/invasive carcinoma in all mucinous CLPs. Increasing number of HRSCG or HRICG2012 features was associated with a significantly increased likelihood of malignancy. The positive predictive value of HRSCG and HRICG2012 for high grade dysplasia/invasive carcinoma was 46% and 62.5% respectively. The negative predictive value of both LRSCG and LRICG2012 was 100%. Both the guidelines were useful in the initial cross-sectional imaging evaluation of mucinous CLPs. The ICG 2012 guidelines were superior to the SCG guidelines.

Background and Aims Since redo surgery is associated with a high risk of morbidity and mortality after bariatric surgery in case of leakage, we sought to evaluate whether endoscopic drainage and debridement of collections following bariatric surgery is an efficient step-up approach to the management of these complications. Methods From 2007 to 2011, we retrospectively studied our cohort of nine cases treated by endoscopic drainage and debridement of abdominal abscesses secondary to postbariatric surgery leaks performed via the transluminal or percutaneous route. Results Three patients were treated by percutaneous endoscopic debridement of abscesses knowing that their leak was already closed by other endoscopic means and that their collection did not improve despite external drain in place. Six patients were treated by transluminal endoscopic drainage to perform necrosectomy as a first-line option or after failure of improvement after endoscopic treatment. The number of sessions required ranged from 1 to 3. Most severe patients had rapid improvement of their hemodynamic and respiratory conditions. In eight of the nine patients, we were able to close the fistula by stent, fistula plugs, or a macroclip. Resolution of collections was seen in seven out of nine patients, but two required further surgery. Conclusions Endoscopic necrosectomy via the transluminal or percutaneous route is a feasible option in postbariatric surgery patients with necrotic abscesses not adequately managed by the classical combination of percutaneous drainage and stenting. Further wide-scale studies are needed to compare this non-surgical method with surgical necrosectomy in postbariatric surgery patients.

A novel Schiff base ligand derived from 2,2'-bis(p-methoxyphenylamine) and salicylicaldehyde and its transition metal complexes with Cu (Ⅱ), Co (Ⅱ) and Mn (Ⅱ) have been synthesized. Their spectral properties and electrochemical behavior were investigated.

BackgroundEUS gastrojejunostomy (GJ) is emerging as an alternative novel technique in patients with symptomatic gastric outlet obstructions (GOO) who have advanced malignancy. Recent studies have shown that the EUS-guided approach has less adverse events and is more cost-effective compared to laparoscopic GJ. We share our experience of 5 patients who underwent EUS Guided GJ with favourable outcomes.Methods5 patients with symptomatic gastric outlet obstruction underwent EUS-guided GJ interventions from May. 2017 to Nov. 2017. Patients were informed of the potential risks and informed consent was taken. Technical success was defined as successful deployment of lumen apposing metal stents (LAMS); while clinical success was the ability to tolerate diet.ResultsMedian age was 61.5 (Range 53–83) years. GOO was secondary to advanced pancreatic malignancy (4) and duodenal malignancy (1). Two patients had altered anatomy from previous post bilroth gastrectomy and Roux-en-Y hepaticojejunostomy. For all five patients with GOO, LAMS 15 mm diameter with electrocautery-enhanced delivery system was used to create the GJ anastomosis. Identification of the distal jejunal limb was done with an inflated balloon catheter and this was use as a target for direct puncture with a 19G needle. All five interventions had technical success with median procedure time of 80 min (38–163 range). All stents were dilated up to their corresponding diameters. Duration of stay after procedure was 3–7 days and there were no adverse events post procedure such as bleeding or perforation. There were no stent migrations and stents were left in place for the rest of their life expectancy. One patient developed intermittent vomiting four weeks after stent deployment. This was possibly secondary to proximal stomach deployment, as repeated endoscopy showed a patent stent. The rest of the patients had clinical success and could tolerate diet on discharge. Range of follow up time was 1-6 months and at time of analysis GOO did not recur in all 5 patients. Three patients died due to disease progression with no symptoms of GOO prior to terminal event.ConclusionsEUS guided GJ is a novel procedure with favourable outcomes in patients with symptomatic GOO.Abstract IDDF2018-ABS-0171 Figure 1

Background Down syndrome (DS), or trisomy 21, is one of the most common autosomal mutations. People with DS have intellectual disability (ID) and are at significantly increased risk of developing Alzheimer’s disease (AD). The biological associates of both ID and AD in DS are poorly understood, but glutamate has been proposed to play a key role. In non-DS populations, glutamate is essential to learning and memory and glutamate-mediated excitotoxicity has been implicated in AD. However, the concentration of hippocampal glutamate in DS individuals with and without dementia has not previously been directly investigated. Proton magnetic resonance spectroscopy ( 1 H MRS) can be used to measure in vivo the concentrations of glutamate-glutamine (Glx). The objective of the current study was to examine the hippocampal Glx concentration in non-demented DS (DS-) and demented DS (DS+) individuals. Methods We examined 46 adults with DS (35 without dementia and 11 with dementia) and 39 healthy controls (HC) using 1 H MRS and measured their hippocampal Glx concentrations. Results There was no significant difference in the hippocampal Glx concentration between DS+ and DS-, or between either of the DS groups and the healthy controls. Also, within DS, there was no significant correlation between hippocampal Glx concentration and measures of overall cognitive ability. Last, a sample size calculation based on the effect sizes from this study showed that it would have required 6,257 participants to provide 80% power to detect a significant difference between the groups which would indicate that there is a very low likelihood of a type 2 error accounting for the findings in this study. Conclusions Individuals with DS do not have clinically detectable differences in hippocampal Glx concentration. Other pathophysiological processes likely account for ID and AD in people with DS.

Down syndrome (DS), or trisomy 21, is one of the most common autosomal mutations. People with DS have intellectual disability (ID) and are at significantly increased risk of developing Alzheimer's disease (AD). The biological associates of both ID and AD in DS are poorly understood, but glutamate has been proposed to play a key role. In non-DS populations, glutamate is essential to learning and memory and glutamate-mediated excitotoxicity has been implicated in AD. However, the concentration of hippocampal glutamate in DS individuals with and without dementia has not previously been directly investigated. Proton magnetic resonance spectroscopy ((1)H MRS) can be used to measure in vivo the concentrations of glutamate-glutamine (Glx). The objective of the current study was to examine the hippocampal Glx concentration in non-demented DS (DS-) and demented DS (DS+) individuals. We examined 46 adults with DS (35 without dementia and 11 with dementia) and 39 healthy controls (HC) using (1)H MRS and measured their hippocampal Glx concentrations. There was no significant difference in the hippocampal Glx concentration between DS+ and DS-, or between either of the DS groups and the healthy controls. Also, within DS, there was no significant correlation between hippocampal Glx concentration and measures of overall cognitive ability. Last, a sample size calculation based on the effect sizes from this study showed that it would have required 6,257 participants to provide 80% power to detect a significant difference between the groups which would indicate that there is a very low likelihood of a type 2 error accounting for the findings in this study. Individuals with DS do not have clinically detectable differences in hippocampal Glx concentration. Other pathophysiological processes likely account for ID and AD in people with DS.