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Background/Introduction In out-of-hospital cardiac arrest (OHCA), bystander cardiopulmonary resuscitation (BCPR) increases survival [1]. Understanding the social determinants of BCPR receipt can inform the design of public health interventions to increase BCPR. The association of socioeconomic status (SES) with BCPR is generally poorly understood. Purpose We aimed to evaluate the effect of SES on BCPR in OHCA using a building-level SES marker. Methods This was a retrospective cohort study based on the Singapore cohort of the Pan-Asian Resuscitation Outcomes Study registry, an ongoing long-term prospective registry for OHCA in the Asia-Pacific region, between 2010 to 2018. We categorized patients into low, medium and high Singapore Housing Index (SHI) levels. The SHI, which appraises a residential property value on an ordinal scale of 1 to 7 (low to high), is a building-level marker that has a robust association with income and residence value [2]. The primary outcome was receipt of BCPR. The secondary outcomes were pre-hospital return of spontaneous circulation (ROSC) and survival – defined as survival to 30 days or hospital discharge, whichever occurred first. Results A total of 12,730 OHCA cases were included (Figure 1), the median age was 71 years and 58.9% were male. BCPR rate was 56.7%. OHCA patients in the low SHI tier were the youngest, most likely male, and least likely to have any medical co-morbidities (Table 1). Compared the low SHI category, those in the medium and high SHI categories were more likely to receive BCPR (medium SHI: adjusted odds ratio [aOR] 1.483, 95% CI 1.301–1.691, p Conclusions Lower building-level SES was independently associated with lower rate of BCPR. Higher SES was associated with higher 30-day survival on unadjusted analysis but not adjusted analysis, and this study may be under-powered for this outcome. Females were more susceptible to the effect of low SES on lower rate of BCPR, and community CPR training should focus on recognizing OHCA and performing BCPR in women in low SES communities. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council, Clinician Scientist Awards, Singapore (NMRC/CSA/024/2010, NMRC/CSA/0049/2013 and NMRC/CSA-SI/0014/2017) and Ministry of Health, Health Services Research Grant, Singapore (HSRG/0021/2012).

Medication use among elite athletes has received growing attention over the past decades. However, only limited studies have focused on para athletes, and trends in medication use among this cohort remain unclear. The aims of this study were (1) to describe the pattern of medication use in elite Paralympic athletes, with a particular focus on analgesics, (2) to analyze whether medications declared by athletes were included in the 2018 World Anti-Doping Agency's prohibited list and monitoring program, (3) to report on a variety of novel supplements, and (4) to review whether athlete analgesic needs will be met by the new OlympicParalympic Model Formulary.This is a retrospective, descriptive cohort study.Of all athletes who underwent doping control, 21% declared the use of an analgesic medication. Athletes with limb deficiency and para snowboarders declared the most analgesic medications in their respective categories. It was determined that 84% of the athletes' analgesic medication needs were provided from the new OlympicParalympic Model Formulary.Analgesic use among athletes who participated at the 2018 PyeongChang Winter Paralympics was high. Para snowboarders and athletes with limb deficiency declared the most analgesics. The new OlympicParalympic Model Formulary adequately addressed the medication needs of the athletes attending the 2018 games.

Highlights • Dose to the heart and all its substructures were significantly lower with IMPT compared to VMAT. • Our analysis showed that not all patients benefit equally from proton beam therapy. • Patients with disease involvement overlapping with or are inferior to the most superior aspect of the heart contour appear to have the highest benefit. The median level of the superior aspect of the heart contour began was T7 vertebra., Purpose/objective To use a model-based approach to identify a sub-group of patients with locally advanced lung cancer who would benefit from proton therapy compared to photon therapy for reduction of cardiac toxicity. Material/methods Volumetric modulated arc photon therapy (VMAT) and robust-optimised intensity modulated proton therapy (IMPT) plans were generated for twenty patients with locally advanced lung cancer to give a dose of 70 Gy (relative biological effectiveness (RBE)) in 35 fractions. Cases were selected to represent a range of anatomical locations of disease. Contouring, treatment planning and organs-at-risk constraints followed RTOG-1308 protocol. Whole heart and ub-structure doses were compared. Risk estimates of grade⩾3 cardiac toxicity were calculated based on normal tissue complication probability (NTCP) models which incorporated dose metrics and patients baseline risk-factors (pre-existing heart disease (HD)). Results There was no statistically significant difference in target coverage between VMAT and IMPT. IMPT delivered lower doses to the heart and cardiac substructures (mean, heart V5 and V30, P

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) is an effective treatment for patients with basilar artery occlusion (BAO) acute ischemic stroke. It remains unclear whether bridging intravenous thrombolysis (IVT) prior to MT confers any benefit. This study compared the outcomes of acute BAO patients who were treated with direct MT versus combined IVT plus MT. METHODS: This multicenter retrospective cohort study included patients who were treated for acute BAO from eight comprehensive stroke centers between January 2015 and December 2019. Patients received direct MT or combined bridging IVT plus MT. Primary outcome was favorable functional outcome defined as modified Rankin Scale 0-3 measured at 90 days. Secondary outcome measures included mortality and symptomatic intracranial hemorrhage (sICH). RESULTS: Among 322 patients, 127 (39.4%) patients underwent bridging IVT followed by MT and 195 (60.6%) underwent direct MT. The mean±standard deviation age was 67.5±14.1 years, 64.0% were male and median National Institutes of Health Stroke Scale was 16 (interquartile range, 8 to 25). At 90-day, the rate of favorable functional outcome was similar between the bridging IVT and direct MT groups (39.4% vs. 34.4%, P=0.361). On multivariable analyses, bridging IVT was not as Comorbidisociated with favorable functional outcome, mortality or sICH. In subgroup analyses, patients with underlying atherosclerosis treated with bridging IVT compared to direct MT had a higher rate of favorable functional outcome at 90 days (37.2% vs. 15.5%, P=0.013). CONCLUSIONS: Functional outcomes were similar in BAO patients treated with bridging IVT versus direct MT. In the subgroup of patients with underlying large-artery atherosclerosis stroke mechanism, bridging IVT may potentially confer benefit and this warrants further investigation.

Speech is central to communication among humans. Meaning is largely conveyed by the selection of linguistic units such as words, phrases and sentences. However, prosody, that is the variation of acoustic cues that tie linguistic segments together, adds another layer of meaning. There are various features underlying prosody, one of the most important being pitch and how it is modulated. Recent fMRI and ECoG studies have suggested that there are cortical regions for pitch which respond primarily to resolved harmonics and that high-gamma cortical activity encodes intonation as represented by relative pitch. Importantly, this latter result was shown to be independent of the cortical tracking of the acoustic energy of speech, a commonly used measure. Here, we investigate whether we can isolate low-frequency EEG indices of pitch processing of continuous narrative speech from those reflecting the tracking of other acoustic and phonetic features. Harmonic resolvability was found to contain unique predictive power in delta and theta phase, but it was highly correlated with the envelope and tracked even when stimuli were pitch-impoverished. As such, we are circumspect about whether its contribution is truly pitch-specific. Crucially however, we found a unique contribution of relative pitch to EEG delta-phase prediction, and this tracking was absent when subjects listened to pitch-impoverished stimuli. This finding suggests the possibility of a separate processing stream for prosody that might operate in parallel to acoustic-linguistic processing. Furthermore, it provides a novel neural index that could be useful for testing prosodic encoding in populations with speech processing deficits and for improving cognitively controlled hearing aids.

PURPOSE/OBJECTIVE(S) Evaluation of visceral organ motion and dosimetric impact during pancreas SABR in non-patient subjects during the time frame of an MR-guided online adaptive radiotherapy (MRgART). MATERIALS/METHODS Breath-hold MR images were acquired from six subjects on 0.35T MR-Linac at 30-minute intervals up to 90 minutes (intra-fraction images: F1a-d). A fifth image was acquired on a separate day (inter-fraction images: F2). SABR plans were generated to a prescription of 50 Gy in 5 fractions to mock pancreatic head tumors (median GTV 9 cc (range 8-10)) based on F1a images. Dose to visceral organs were recalculated on F1b-d and F2 images. For each visceral organ, the dose constraints used were V36 < 0.1 cc (volume of organ receiving 36 Gy < 0.1 cc), V33 < 0.5 cc and V25 < 10 cc. Volume of stomach, duodenum, small bowel and large bowel within 3 cm and 0.5 cm of PTV were recorded from each image and compared. Dosimetric impact of visceral organ motion was evaluated by comparing dose delivered to visceral organs at baseline (F1a) and the other time points (F1b-d, F2). RESULTS For each subject, there was low degree of correlation between timepoint and volume of visceral organ within 3cm and .5cm of PTV (R = 0.01 and .23). Dose constraint violations were observed intra-fractionally. The highest number of dose constraint violations occurred for the duodenum, followed by stomach and large bowel (see table). No dose constraint violation was observed for the small bowel. The median magnitude of dose violations, defined as volume of organ receiving dose above constraints over mandatory volume limit, were statistically significantly lower in intra-fraction compared to inter-fraction images for the duodenum (median = .6 vs 1.9, P = 0.01). CONCLUSION There is irregular visceral organ motion within the time frame of pancreas MRgART. This would not have been accounted for with respiratory gating. Although the magnitude of intra-fraction dose violation appears to be lower compared to inter-fraction, violations may have significant impact on toxicity. These violations are likely to be present in patients currently undergoing MRgART. However, given the reported low toxicity of dose-escalated MRgART, estimation of normal tissue toxicity based on current constraints may be limited. Further work is required to validate these findings in patients. Management of peristalsis may need to be considered. Table: Total number of dose constraint violations at each time point for 6 subjects. Each visceral organ has to meet 3 constraints V36, V33 and V25.

Endovascular thrombectomy (EVT) is the standard of care for anterior circulation acute ischemic stroke (AIS) with large vessel occlusion (LVO). Young patients with AIS-LVO have distinctly different underlying stroke mechanisms and etiologies. Much is unknown about the safety and efficacy of EVT in this population of young AIS-LVO patients. All consecutive AIS-LVO patients aged 50 years and below were included in this multicenter cohort study. The primary outcome measured was functional recovery at 90 days, with modified Rankin Scale of 0–2 deemed as good functional outcome. A total of 275 AIS-LVO patients that underwent EVT from 10 tertiary centers in Germany, Sweden, Singapore, and Taiwan were included. Successful reperfusion was achieved in 85.1% (234/275). Good functional outcomes were achieved in 66.0% (182/275). Arterial dissection was the most prevalent stroke etiology (42/195, 21.5%). National Institutes of Health Stroke Scale (NIHSS) score at presentation was inversely related to good functional outcomes (aOR: 0.92, 95% CI: 0.88–0.96 per point increase, p

Humans have the remarkable ability to selectively focus on a single talker in the midst of other competing talkers. The neural mechanisms that underlie this phenomenon remain incompletely understood. In particular, there has been longstanding debate over whether attention operates at an early or late stage in the speech processing hierarchy. One way to better understand this is to examine how attention might differentially affect neurophysiological indices of hierarchical acoustic and linguistic speech representations. In this study, we do this by using encoding models to identify neural correlates of speech processing at various levels of representation. Specifically, we recorded EEG from fourteen human subjects (nine female and five male) during a “cocktail party” attention experiment. Model comparisons based on these data revealed phonetic feature processing for attended, but not unattended speech. Furthermore, we show that attention specifically enhances isolated indices of phonetic feature processing, but that such attention effects are not apparent for isolated measures of acoustic processing. These results provide new insights into the effects of attention on different prelexical representations of speech, insights that complement recent anatomic accounts of the hierarchical encoding of attended speech. Furthermore, our findings support the notion that, for attended speech, phonetic features are processed as a distinct stage, separate from the processing of the speech acoustics.SIGNIFICANCE STATEMENTHumans are very good at paying attention to one speaker in an environment with multiple speakers. However, the details of how attended and unattended speech are processed differently by the brain is not completely clear. Here, we explore how attention affects the processing of the acoustic sounds of speech as well as the mapping of those sounds onto categorical phonetic features. We find evidence of categorical phonetic feature processing for attended, but not unattended speech. Furthermore, we find evidence that categorical phonetic feature processing is enhanced by attention, but acoustic processing is not. These findings add an important new layer in our understanding of how the human brain solves the cocktail party problem.

The large number of commentaries in this special issue reflect the need that so many people have to express themselves as a way of releasing the anxieties and integrating the hopes that the COVID-19 pandemic has engendered in individuals and groups around the world. The guest editors of this special issue provide the following comments in reflecting on the major themes that are envisioned for travel and tourism in a COVID-19 world. Comments from the guest editors are individually identified in this conclusion editorial. Refereed/Peer-reviewed

Humans can easily distinguish many sounds in the environment, but speech and music are uniquely important. Previous studies, mostly using functional magnetic resonance imaging, have identified separate regions of the brain that respond selectively for speech and music. Yet there is little evidence that brain responses are larger and more temporally precise for human-specific sounds like speech and music, as has been found for responses to species-specific sounds in other animals. We recorded EEG as healthy, adult subjects listened to various types of two-second-long natural sounds. By classifying each sound based on the EEG response, we found that speech, music, and impact sounds were classified better than other natural sounds. But unlike impact sounds, the classification accuracy for speech and music dropped for synthesized sounds that have identical frequency and modulation statistics based on a subcortical model, indicating a selectivity for higher-order features in these sounds. Lastly, the trends in average power and phase consistency of the two-second EEG responses to each sound replicated the patterns of speech and music selectivity observed with classification accuracy. Together with the classification results, this suggests that the brain produces temporally individualized responses to speech and music sounds that are stronger than the responses to other natural sounds. In addition to highlighting the importance of speech and music for the human brain, the techniques used here could be a cost-effective and efficient way to study the human brain’s selectivity for speech and music in other populations. Significance Statement In other species, ecologically important sounds such as vocalizations generate larger responses in the auditory cortex than other types of natural sounds, but it is unclear if this is true for humans. We recorded EEG as subjects listened to various natural sounds. Classification analysis based on the EEG responses as well as analysis of the average power of the EEG responses showed increased activation in the brain to speech and music sounds compared to other natural sounds. This study demonstrates the human brain’s selectivity to speech and music sounds and suggests a cost-effective and efficient way to study the brain’s selectivity for speech and music in other populations.

Objective: We compared the sensitivity of intensity modulated proton therapy (IMPT) and photon volumetric modulated arc therapy (VMAT) plans to setup uncertainties in locally advanced non-small cell lung cancer (NSCLC) using probabilistic scenarios. Methods: Minimax robust (MM) and planning target volume (PTV) optimised IMPT and VMAT nominal plans were created with physical dose of 70 Gy in 35 fractions in 10 representative patients. Using population data of setup errors, a fractionated treatment course was simulated, summed (Dsum) and compared to the nominal plan. Three treatment-course simulations were done for each plan. Target robustness criteria were: dose deviation of ≤5% to clinical target volume (CTV) D98% and CTV V95% ≥ 99.9%. Voxelwise simulation repeatability was analysed using Bland–Altman plots. Acceptable limits of agreement were 2% of the prescription dose. Results: All Dsum met target robustness criteria. While fraction VMAT and MM-IMPT doses were excellent, simulated fraction doses in PTV-IMPT were suboptimal. Almost all (>99%) of VMAT and MM-IMPT fraction doses met both target robustness criteria. For PTV-IMPT, only 96.9 and 80.3% of fractions met CTVD98% and V95% criteria respectively. Simulation repeatability was excellent (limits of agreement range: 0.41–1.1 Gy) with strong positive correlations. Conclusion: When considering the whole treatment course, setup errors do not influence robustness irrespective of planning techniques used. However, on a fraction level, VMAT and MM-IMPT plans are superior compared to PTV-IMPT plans. Advances in knowledge: Probabilistic analysis provides a fast and practical method for evaluating VMAT and IMPT plan sensitivity against setup uncertainty. VMAT and robust-optimised IMPT plans have comparable sensitivity to setup uncertainties in conventionally fractionated treatment for NSCLC.

Breathing sound is an extremely low SPL that results from inspiration and expiration process in the lung. Breathing sound can be used to diagnose persons with complications with breathing. Also, the sound can indicate the effectiveness of treatment of lung disease such as asthma. the purpose of this study was to identify SPL of breathing sounds, over six one octave center frequencies from 63 Hz to 4000 Hz, from the recorded breathing sounds in .wav files. Breathing sounds of twenty participants with normal weight BMI had been recorded in an audiometry room. the breathing sound was acquired in two states: at rest and after a 300 meters walk. Matlab had been used to process the breathing sounds that are in .wav files to come up with SPL (in dB). It has been found out that the SPL of breathing sound of all participants are positive at frequencies 63 Hz and 125 Hz. On the other hand, the SPL are all negatives at frequency 1000 Hz, 2000 Hz and 4000 Hz. In conclusion, SPL of breathing sounds of the participants, at frequencies 250 Hz and 500 Hz that have both positive and negative values are viable to be studied further for physiological and medicinal clues.

A UNESCO World Heritage Listed historic city, Melaka embodies a vibrant multi-ethnic Asian heritage, straits-colonial legacy and cultural landscape that has been attracting tourists from within Asia and the wider world. In particular, Melaka is renowned for its rich Peranakan (Straits Chinese) cultural heritage and history. This work presents the divergent narratives of two Peranakan Chinese on a nostalgic, ancestral tourism journey in Melaka. Specifically, it explores the dimensions of nostalgia, authenticity and diaspora in cultural heritage tourism, framed within the affecting gaze of cultural, diasporic and reminiscent lenses through which we consume tourism experiences. Through our tourism lived experience and duo-ethnographic conversations, we explore our shared Southeast Asian ancestry, reflect on past traditions and question representations of our Peranakan Chinese heritage within four main themes: (1) reflective nostalgia, (2) the imagined past, (3) objective authenticity, and (4) existential authenticity.

The use of intensity-modulated radiotherapy in rectal cancer is attractive in that it may reduce acute and late toxicities and potentially facilitate dose escalation. Intensity-modulated radiotherapy probably has a role in selected patients, but further investigation is required to identify the parameters for selection. Delineation of specific nodal groups allows maximal sparing of bladder and small bowel. In locally advanced tumours a simultaneous integrated boost allows dose escalation incorporating hypofractionation and a shorter overall treatment time. However, due to a sparsity of data on late toxicity in doses ≥ 60 Gy, doses at this level should be used with caution, ideally within prospective trials. Future studies investigating dose escalation must ascertain late toxicity as well as local control, as both can significantly affect quality of life and without both, the risk-benefit ratio cannot be calculated.

Sir, Enterococccus casseliflavus infection has been rarely implicated in ophthalmic infections. We report a case of E. casseliflavus exogenous endophthalmitis due to a metallic intraocular foreign body (IOFB).

Objective Tumor necrosis factor (TNF) is an important proinflammatory cytokine that mediates inflammatory synovitis and articular matrix degradation in rheumatoid arthritis (RA). We investigated the ability of adalimumab, a human anti–TNF monoclonal antibody, to inhibit the progression of structural joint damage, reduce the signs and symptoms, and improve physical function in patients with active RA receiving concomitant treatment with methotrexate (MTX). Methods In this multicenter, 52-week, double-blind, placebo-controlled study, 619 patients with active RA who had an inadequate response to MTX were randomized to receive adalimumab 40 mg subcutaneously every other week (n = 207), adalimumab 20 mg subcutaneously every week (n = 212), or placebo (n = 200) plus concomitant MTX. The primary efficacy end points were radiographic progression at week 52 (total Sharp score by a modified method [TSS]), clinical response at week 24 (improvements of at least 20% in the American College of Rheumatology core criteria [ACR20]), and physical function at week 52 (disability index of the Health Assessment Questionnaire [HAQ]). Results At week 52, there was statistically significantly less radiographic progression, as measured by the change in TSS, in the patients receiving adalimumab either 40 mg every other week (mean ± SD change 0.1 ± 4.8) or 20 mg weekly (0.8 ± 4.9) as compared with that in the placebo group (2.7 ± 6.8) (P ≤ 0.001 for each comparison). In addition, there were statistically significant changes in the components of the TSS. At week 24, ACR20 responses were achieved by 63% and 61% of patients in the adalimumab 40 mg every other week and 20 mg weekly groups, respectively, versus 30% of patients in the placebo group (P ≤ 0.001 for each comparison). At week 52, ACR20 responses were achieved by 59% and 55% of patients taking adalimumab 40 mg every other week and 20 mg weekly, respectively, versus 24% of patients taking placebo (P ≤ 0.001 for each comparison). At week 52, physical function as measured by the HAQ demonstrated statistically significant improvement with adalimumab 40 mg every other week and 20 mg weekly compared with placebo (mean change in HAQ score −0.59 and −0.61, respectively, versus −0.25; P ≤ 0.001 for each comparison). A total of 467 patients (75.4%) completed 52 weeks of treatment. Adalimumab was generally well tolerated. Discontinuations occurred in 22.0% of adalimumab-treated patients and in 30.0% of placebo-treated patients. The rate of adverse events (both serious and nonserious) was comparable in the adalimumab and placebo groups, although the proportion of patients reporting serious infections was higher in patients receiving adalimumab (3.8%) than in those receiving placebo (0.5%) (P ≤ 0.02), and was highest in the patients receiving 40 mg every other week. Conclusion In this 52-week trial, adalimumab was more effective than placebo at inhibiting the progression of structural joint damage, reducing the signs and symptoms, and improving physical function in patients with active RA who had demonstrated an incomplete response to MTX.

The design of microstrip ferrite coupled line (MFCL) circulators using normal mode theory and the first proof-of-principle experiments are described. The longitudinally magnetized ferrite slab is positioned on top of a pair of microstrip lines to form the FCL and this is used with a T-junction and a novel hybrid coupler to form a three-port and a four-port circulator, respectively. The results show MFCL circulator behavior for the first time, and impedance levels and discontinuities are discussed. © 2001 John Wiley & Sons, Inc. Int J RF and Microwave CAE 11: 121–130, 2001

The potential harms of herbs to the pregnant mothers and their foetuses as well as the effect of herbs taken by nursing mothers on their babies remain largely unknown. Common perception is that herbal medicines ingestion during pregnancy and confinement period is a common practice among multi-racial Malaysian mothers. The purpose of this study was to explore the usage of herbal medicines during pregnancy and post-partum period among mothers who gave birth at a tertiary hospital in a metropolitan city of Malaysia. This cross sectional study was conducted between October and December 2010. The subjects were interviewed twice after giving birth: before hospital discharge and 6 to 8 weeks later. A total of 323 mothers were recruited for this study. The prevalence of herbs ingestion during pregnancy was 13.9%, with half of the users consuming it during the first trimester. A total of 163 (52.9%) mothers ingested herbs during the post-partum period. Significantly more Chinese (p=0.01) and Malay (p=0.04) mothers ingested herbs during pregnancy and post-partum period, respectively. Infants of mothers who ingested herbs had a higher rate of neonatal jaundice compared to infants of mothers who did not ingest herbs during the post-partum period (P=0.001).

Purpose: The paper is primarily done on the purpose of introducing new concept in defining the Overall Equipment Effectiveness (OEE) with the consideration of both machine utilization and customer demand requested. Previous literature concerning the limitation and difficulty of OEE implementation has been investigated in order to track out the potential opportunities to be improved, since the OEE has been widely accepted by most of the industries regardless their manufacturing environment.Design/methodology/approach: The paper is conducting the study based on literature review and the computerized data collection. In details, the novel definition and method of processing the computerized data are all interpreted based on similar studies performed by others and supported by related journals in proving the validation of the output. Over the things, the computerized data are the product amount and total time elapsed on each production which is automatically recorded by the system at the manufacturing site.Findings: The finding of this paper is firstly the exposure and emphasis of limitation exists in current implementation of OEE, which showing that high utilization of the machine is encouraged regardless of the customer demand and is having conflict with the inventory handling cost. This is certainly obvious with overproduction issue especially during low customer demand period. The second limitation in general implementation of OEE is the difficulty in obtaining the ideal cycle time, especially those equipments with constant process time. The section of this paper afterward comes out with the proposed solution in fixing this problem through the definition of performance ratio and then usage of this definition in measuring the machine utilization from time to time. Before this, the time available for the production is calculated incorporating the availability of OEE, which is then used to get the Takt time.Research limitations/implications: Future research should be conducted to test the possibility and to verify the definition of such performance ratio including Takt time on those processes of which its operating time is possibly to be reduced, especially those are not constant and fixed. This piece of research is temporarily done on the process where its operating time is constant from time to time and there is no ideal cycle time possible.Practical implications: The awareness of the overproduction should be emphasized and raised in the intention of pursuing higher OEE value. As the definition proposed such, the process with constant cycle time could even be defined in different performance ratio from time to time regarding to the customer demands and corresponding production rate. These two variables can be adjusted and balanced to increase the OEE value through optimization of average cycle time. Over this, optimization of average cycle time on equipment with constant operating time can be achieved through the optimization of loading number per each processing.Originality/value: The novelty of the paper is the inclusion of customer demand in obtaining OEE value of any particular equipment. Besides that, the equipment without ideal cycle time, which means those processes carried out in constant cycle time are possibly to be evaluated with performance ratio. As consequence of that, the machine utilization and capability used could be quantified and visualized using the performance ratio data of the OEE proposed.

The quality of laryngoscopy and tracheal intubation with propofol augmented by alfentanil was investigated as an alternative technique for rapid tracheal intubation. 119 patients aged between 18 and 60 years (ASA 1 and 2) undergoing elective surgery were prospectively studied in a randomized double-blind controlled fashion. Tracheal intubation facilitated by suxamethonium 1.0 mg/kg, alfentanil 15 μg/kg, alfentanil 30 μg/kg or saline control was compared after propofol induction. The quality of laryngoscopy and intubation were graded according to jaw relaxation, ease of insertion of the endotracheal tube and coughing on intubation. Failure to intubate occurred in 4% and 17% with alfentanil 15 μg/kg and saline control respectively. Tracheal intubation was successful in all patients with alfentanil 30 μg/kg and suxamethonium 1.0 mg/kg. Alfentanil 15 μg/kg was not statistically significantly different from saline (P = 0.112). Alfentanil 30 μg/kg provided similar overall intubating conditions (P = 0.5) to suxamethonium 1.0 mg/kg. Alfentanil in both dosages effectively attenuated the haemodynamic responses to laryngoscopy and tracheal intubation.

A prototype knowledge-based system for automated production scheduling has been developed for a press shop, which manufactures laminations for stator and rotor packs and cores for electric motor production. The system is PC (personal computer) based, user friendly, and may be interfaced to the existing computer-based MRP (material requirements planning) system, making the transfer of production data quick and easy. The knowledge-based system has been tested and validated over a range of production circumstances and the predicted production schedules show close agreement with those manually produced, over longer time-scales, by the human scheduler. The knowledge elicitation procedures developed are described and, in particular, the use of a large flow diagram to describe the decision-making process during scheduling is discussed. The visual representation of the structure of the decision-making process is of particular benefit in aiding clarity of communication between the knowledge engineer and the domain expert. The techniques for knowledge acquisition within the production scheduling environment have been formalized and their use is advocated for use in the development of scheduling systems. For the prototype system to be of practical benefit within the press shop, further development of the system is necessary to enable all the presses and lamination combinations to be scheduled. This is currently being carried out within the company.

Purpose To compare the characteristics and treatment outcomes of HIV patients with cytomegalovirus retinitis (CMVR), with and without extra-ocular CMV (EO-CMV) infection in Singapore. Methods This is a retrospective cohort study. All HIV patients diagnosed with CMVR at the Singapore Communicable Disease Centre from January 2005 through November 2009 were included. Results 101 patients (138 eyes) were included. 92% were male, with a mean age of 48.6±10.4 years. Median follow-up was 8 months (range 0.5-58). 11% defaulted at a median of 6 months, and overall mortality was 24% at a median of 4 months. There were 68 patients (88 eyes) with only CMVR and 33 patients (50 eyes) with CMVR and EO-CMV. 36% had multiple sites of EO-CMV infection. In the EO-CMV group, 24% developed EO-CMV after CMVR, of which 6 were diagnosed with EO-CMV infection within 3 months after initiation of anti-retroviral therapy. Bilateral CMVR was significantly higher in the EO-CMV group (52% versus 29%; p=0.03). Patients with EO-CMV were less likely to develop immune reactivation uveitis (OR 0.8; CI 0.3-2.4), although mortality was higher (42% versus 15%, p=0.002). Multivariate logistic regression analysis showed that a longer duration of prior anti-CMV treatment had higher odds (OR 1.127, p=0.037) of CMVR recurrence, but no significant difference between both groups (OR 0.886, p=0.866). Conclusion EO-CMV infection was significantly associated with increased mortality, bilateral CMVR disease and can manifest as CMV-associated immune reconstitution inflammatory syndrome. Our results also suggest that CMVR recurrence is multi-factorial and cessation of anti-CMV therapy should be tailored to an individualized risk factor profile.

The Singapore Armed Forces (SAF) Medical Corps and the Ministry of Health (MOH) have published clinical practice guidelines on Management of Heat Injury to provide doctors and patients in Singapore with evidence-based guidance on the prevention and clinical management of exertional heat injuries. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the SAF Medical Corps-MOH clinical practice guidelines on Management of Heat Injury, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/mohcorp/publications.aspx?id=25178. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

The idea of world records does not immediately bring to mind the field of obstetrics and gynaecology but rather is more commonly associated with events such as the worlds fastest 100 m sprint. However this is not to say that such records do not exist. For example who is the worlds youngest mother? How many fetuses have been found in any one person at a time? What is the biggest ovarian mass ever removed intact from a woman? But more importantly how and why did these things happen? Such medical world records represent either very rare conditions or are presentations of extremes of conditions that are hardly ever seen in practice. We aim here to draw attention to such conditions and extremes to create awareness among others of their existence and to remind them that while such cases may seem highly improbable it does not mean that they are impossible. (excerpt)

Background: Because traditional therapies for rheumatoid arthritis (RA) such as methotrexate (MTX) do not produce an adequate response in many patients, newer therapies that block the proinflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) are increasingly being used in combination with MTX. Objective: This study evaluated the efficacy, pharmacokinetics, and safety profile of adalimumab, a fully human anti-TNF alpha monoclonal antibody, when added to continuing MTX therapy. Methods: This Phase I, randomized, dose-titration study consisted of a 4-week, double-blind, placebo-controlled treatment phase and a 26-month, open-label continuation phase. Patients with RA who had been taking stable doses of MTX (mean dose, 17 mg/wk) for ≥3 months before enrollment with an inadequate response were randomly assigned to receive 2 single doses of either adalimumab 0.25, 0.5, 1, 3, or 5 mg/kg IV or placebo in the double-blind phase. In the open-label phase, patients received treatment with 1 of the doses of adalimumab every other week or monthly for 18 months; patients were then switched to adalimumab 40 mg IV or SC every other week or monthly. The main efficacy end point was 20% improvement in American College of Rheumatology response criteria (ACR20). Other efficacy end points included 50% (ACR50) and 70% improvements in ACR response criteria. Pharmacokinetic parameters were analyzed for adalimumab and MTX during both phases of the study. Serum adalimumab concentrations were analyzed using a validated enzyme-linked immunosorbent assay relying on the double-antigen principle. Peak and trough concentrations were determined from observed concentration-time data, and a modeling approach was used to estimate total serum clearance, mean apparent terminal half-life, apparent volume of distribution at steady state, and area under the concentration-time curve. Results: Sixty patients entered the double-blind phase, 45 receiving adalimumab and 15 receiving placebo; 1 placebo recipient chose not to continue into the open-label phase. Overall, the study population included 47 (78.3%) women and 13 (21.7%) men. The mean age was 52.9 years (range, 24–73 years), and the mean body weight was 69.7 kg (range, 43–98 kg). ACR20 and ACR50 responses were achieved on at least 1 assessment during the 4-week double-blind phase by a respective 29 (64.4%) and 11 (24.4%) of 45 patients receiving active treatment and by 4 (26.7%) and none of the 15 patients receiving placebo. Responses to adalimumab were rapid, with 10 (22.2%) of 45 patients achieving an ACR20 response within 24 hours of dosing. Of 29 adalimumab recipients who had an ACR20 response, 18 (62.1%) had a duration of response (time from first occurrence of a response to first occurrence of a nonresponse) of 1 to 2 weeks, and 11 (37.9%) had a duration of response of 3 to 13 weeks. The pharmacokinetic properties of adalimumab appeared to be linear. The mean apparent terminal half-life after a single intravenous dose of adalimumab ranged from 15 to 19 days in the 5 dose groups. Repeated administration of adalimumab had no statistically significant effect on the pharmacokinetics of MTX, indicating that dose adjustment of MTX is not necessary. Adalimumab was well tolerated, and there were no dose-related adverse events. Conclusions: Among patients with active RA who had not had an adequate response to MTX, addition of adalimumab to MTX achieved statistically significant, long-term improvement compared with placebo plus MTX ( P ≤ 0.05), as indicated by ACR responses at 26 months. The combination was well tolerated. Adalimumab exhibited linear pharmacokinetics. In this selected patient population, adalimumab's long half-life of 15 to 19 days supports every-other-week dosing. Coadministration of adalimumab did not alter serum levels of MTX.

In our project, we are adopting a new approach for handling video data. We view the video as a well-defined data type with its own description, parameters and applicable methods. The system is based on PREDATOR, an open-source object-relational DBMS. PREDATOR uses Shore as the underlying storage manager. Supporting video operations (storing, searching-by-content and streaming) and new query types (query-by-example and multi-feature similarity searching) requires major changes in many of the traditional system components. More specifically, the storage and buffer manager has to deal with huge volumes of data with real-time constraints. Query processing has to consider the video methods and operators in generating, optimizing and executing the query plans.

An admixture of thiopentone and propofol was evaluated against propofol for laryngeal mask airway (LMA) insertion. Eighty-one ASA 1 and 2 18- to 65-year-old patients, premedicated with 7.5 mg midazolam orally were assigned randomly to receive either propofol 1% or an admixture of thiopentone and propofol (1.25% and 0.5% respectively), both at a dose of 0.25 ml.kg–1. Satisfactory conditions for insertion were achieved with the admixture, which was comparable to propofol (73% vs 85%, P>0.05). There was no statistical difference in the incidence or severity of gagging, coughing, inadequate jaw relaxation and laryngospasm. The incidence of hypotension was lower in the admixture group (51% vs 78%, P=0.02). The duration of apnoea was not different between the admixture and propofol group (mean 103s vs 109 s respectively, P>0.05). We conclude that thiopentone/propofol admixture can be a suitable alternative to propofol for LMA insertion, producing less hypotension while allowing cost savings of up to 45%. An admixture of thiopentone and propofol (1.25% and 0.5% respectively) can produce suitable conditions compared to propofol 1%, for laryngeal mask insertion. In addition to cost containment, the admixture also produces less hypotension.

A BiCMOS device which was having low yield problem at sort was systematically analyzed. In this case the failure was delaying shipment and pressure ofreducing analysis time was extremely high. This paper presents a method employed to quickly identify the failure signature and localize the defect to a minimum area of the device. The physical defect, silicon fault/dislocation, found by TEM has been fully characterized and reported in this paper. It is believed that the information presented in this paper will be helpful for failure analysis and product personnel. Emission microscopy system since its creation in 1980's, has dramatically demonstrated its ability to reduce failure analysis cycle time by providing qualitative evidence of the suspected failure. Together with other failure analysis techniques such as OBIC, TEM etc. can put failure analysis to its full capability. This paper describes in details and demonstrates a successful application of the emission microscope to pinpoint the location of a dislocation defect that caused C-E leakage in a NPNtransistor. Both frontside and backside emission were performed and will be discussed in the paper. A quick sample preparation for backside emission is proposed.

Terbuthylazine, a non-selective herbicide developed by Ciba Geigy, is a triazine herbicide, as are simazine, terbutryn and atrazine. Terbuthylazine is a broad-spectrt~n herbicide registered for control of most annual grasses and broadleaf weeds in rubber, oil palm and cocoa plantations and in orchards as well as on non-crop land. This herbicide was introduced ir~to the Malaysian market in the 1980's under the name of Gardporin~'. The persistence of triazine in soil depends on the rate of application and such envir~tal factors as soil moisture, temperature, pH and constituents (WSSA 1989). Weber and Weed (1974) reported that higher soil temperature and moisture enhance degradation of triazine, and that adsorption and bioactivity of the herbicide was correlated with organic matter and clay content and other soil parameters. Organic matter was the primary adsorbing surface in the soil (Weber and Weed 1974; Nishimoto and RaW, ran 1985). The influence of organic content of the soil is illustrated by the fact that the half-life of simazine ranged from 22 to 44 days, depending on organic content of the soil (Walker and Th~son 1977). Degradation of atrazine has been reported to be faster in moist soil than in dry soil (Walker and Zimdahl 1981). The active ingredients of triazine are stable chemical compounds which, however, degrade rapidly in soil due to microbial activity (WSSA 1989). The maximum movement of terbuthylazine under natural rainfall was 20 am after 21 days (Bowman 1989). While much is known about the activity and mode of action of other compounds in the triazine group, little quantitative information is available concerning the mode of dissipation of terbuthylazine from soil, especially under tropical conditions. Experiments were therefore conducted to determine the persistence of terbuthylazine at various moisture levels and temperatures in two different soil types.

A good overall assessment of the severity of illnesses of patients admitted to a general intensive care unit (ICU) is not without problems. The APACHE (acute physiology and chronic health evaluation) prognostic scoring system enables us to stratify acutely ill patients and compare efficiency of ICU therapy in different hospitals. This preliminary study carried out on 100 consecutive admissions to the ICU in University Hospital, Kuala Lumpur showed the spectrum of ICU admissions and the direct relationship between APACHE II score and mortality.