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In Vitro Evaluation of Novel Phenytoin-Loaded Alkyd Nanoemulsions Designed for Application in Topical Wound Healing

Teo SY, Yew MY, Lee SY, Rathbone MJ, Gan SN, Coombes AGA

J Pharm Sci, 2017 01;106(1):377-384.
PMID: 27522920 DOI: 10.1016/j.xphs.2016.06.028

Phenytoin-loaded alkyd nanoemulsions were prepared spontaneously using the phase inversion method from a mixture of novel biosourced alkyds and Tween 80 surfactant. Exposure of human adult keratinocytes (HaCaT cells) for 48 h to alkyd nanoemulsions producing phenytoin concentrations of 3.125-200 μg/mL resulted in relative cell viability readings using tetrazolium dye 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide of 100% confirming nontoxicity and suggesting cell proliferation activity. Phenytoin-loaded alkyd nanoemulsions generally resulted in higher mean cell viability compared with equivalent concentration of phenytoin solutions, suggesting that the nanoemulsions provided a controlled-release property that maintained the optimum phenytoin level for keratinocyte growth. HaCaT cell proliferation, measured by 5-bromo-2-deoxyuridine uptake, was found to increase following exposure to increasing phenytoin concentration from 25 to 50 μg/mL in solution or encapsulated in nanoemulsions but declined at a drug concentration of 100 μg/mL. An in vitro cell monolayer wound scratch assay revealed that phenytoin solution or nanoemulsions producing 50 μg/mL phenytoin concentration resulted in 75%-82% "scratch closure" after 36 h, similar to medium containing 10% fetal bovine serum as a cell growth promoter. These findings indicate that phenytoin-loaded alkyd nanoemulsions show potential for promoting topical wound healing through enhanced proliferation of epidermal cells.
Impact of Double Expression of C-MYC/BCL2 Protein and Cell of Origin Subtypes on the Outcome among Patients with Diffuse Large B-Cell Lymphoma: a Single Asian Center Experience

Teoh CS, Lee SY, Chiang SK, Chew TK, Goh AS

Asian Pac J Cancer Prev, 2018 May 26;19(5):1229-1236.
PMID: 29801406

Background: Diffuse large B-cell lymphoma (DLBCL) with double expression of c-MYC and BCL2 protein is
associated with dismal outcome after treatment with R-CHOP. Local data on disease burden and survival outcome in
DLBCL is limited. We investigated the prognostic values of c-MYC/BCL2 protein co-expression and cell of origin
subtypes using immunohistochemistry (IHC) and to determine their associations with multiethnic groups under
resource limited setting. Methods: This was a retrospective study which recruited 104 patients in between June 2012
and December 2015 for IHC review and analysis. Result: We demonstrated that patients with high International
Prognostic Index (IPI) (score 3-5) and co-expression of c-MYC/BCL2 protein had significant inferior overall survival
(OS) and event free survival (EFS) respectively (P<0.05). c-MYC/BCL2 protein co-expression was more common in
non-germinal center B-cell (non-GCB) (P=0.048) and contributed to adverse prognosis in this group of patients (OS,
P=0.004; EFS, P=0.005). In multivariate analysis, double-protein co-expression was a significant independent predictor
of inferior outcome after adjusted for IPI and cell of origin subtypes (OS hazard ratio [HR], 2.11; 95% CI, 1.01 to 4.04;
P=0.048; EFS HR, 2.31; 95% CI, 1.05 to 5.04; P=0.036). In addition, non-GCB subtype was more common than GCB
in Malays (60% vs 40%, P=0.106) and Chinese (81.2% vs 18.8%, P=0.042). Indians had more DLBCL without c-MYC/
BCL2 protein co-expression compared to double-protein positive cases (66.7% vs 33.3%, P=0.414). Otherwise, the
prognostic impact of ethnicity on survival outcome was insignificant (P=0.961). Conclusion: c-MYC/BCL2 protein
co-expression in non-GCB subtype constituted a unique group with extremely inferior outcome regardless of ethnicity.
Gene expression profile (GEP) may possibly provide insights into the cause of discrepancies in DLBCL subtypes and
protein expression among the multiethnic groups.
Diversity and characterization of lignocellulolytic fungi isolated from oil palm empty fruit bunch, and identification of influencing factors of natural composting process

Md Tahir P, Liew WP, Lee SY, Ang AF, Lee SH, Mohamed R, et al.

Waste Manag, 2019 Dec;100:128-137.
PMID: 31536923 DOI: 10.1016/j.wasman.2019.09.002

Oil palm empty fruit bunch (EFB) is the most significant waste generated from the agricultural industry in Malaysia. Composting is one of the potential approaches to utilize EFB. However, composting of EFB is a time-consuming process, thus impractical for industrial application. The composting process can be shortened by introducing competent fungi into an optimal EFB composting system. This study was conducted to isolate and identify competent fungi that can naturally compost EFB. Samplings were carried out at eight different time points over a 20-weeks experimental period. The physical properties of EFB samples such as pH, residual oil content, and moisture content were measured and the EFB composting process that was indicated by the contents of cellulose, hemicellulose, and lignin were assessed. The fungal growth, distribution, and lignocellulolytic enzyme activities were evaluated. The results indicated that the changes in physical properties of EFB were correlated to the fungal growth. The gradual reduction in moisture content and residual oil, and the increment in pH values in EFB samples throughout the experimental period resulted in reduced fungal growth and diversity. Such phenomenon delayed EFB composting process as revealed by the changes in EFB lignin, hemicellulose, and cellulose contents. The most dominant and resilient fungi (Lichtheimia ramosa and Neurospora crassa) survived up to 16 weeks and were capable of producing various lignocellulolytic enzymes. Further understanding of these factors that would contribute to effective EFB composting could be useful for future industrial applications.
Fulltext Plasmodium knowlesi infection: a diagnostic challenge

Fan L, Lee SY, Koay E, Harkensee C

BMJ Case Rep, 2013;2013:bcr2013009558.
PMID: 23608876 DOI: 10.1136/bcr-2013-009558

Plasmodium knowlesi malaria is an uncommon, but highly prevalent parasitic infection in parts of Malaysia. This is the case of a 14-year-old Singaporean boy presenting to our emergency department with an 11-day history of fever following a school trip to Malaysia. Hepatosplenomegaly was the only clinical finding; laboratory tests showed thrombocytopaenia, lymphopaenia, mild anaemia and liver transaminitis. Specific malaria antigen tests were negative, but the peripheral blood film showed plasmodia with atypical features, with a parasite load of 0.5%. PCR confirmed the diagnosis of P knowlesi. The patient was successfully treated with chloroquine. The clinical course of P knowlesi malaria is indistinguishable from that of Plasmodium falciparum. This case highlights the importance of taking detailed travel history, careful examination of malaria blood films and judicious use of molecular techniques. Antigen tests alone may have missed a malaria diagnosis altogether, while blood film examination may wrongly identify the species as Plasmodium malariae or P falciparum. Third-generation PCR assays can be used to reliably identify P knowlesi.
Fulltext An Ultrasensitive Voltammetric Genosensor for the Detection of Bacteria Vibrio cholerae in Vegetable and Environmental Water Samples

Futra D, Tan LL, Lee SY, Lertanantawong B, Heng LY

Biosensors (Basel), 2023 Jun 04;13(6).
PMID: 37366981 DOI: 10.3390/bios13060616

In view of the presence of pathogenic Vibrio cholerae (V. cholerae) bacteria in environmental waters, including drinking water, which may pose a potential health risk to humans, an ultrasensitive electrochemical DNA biosensor for rapid detection of V. cholerae DNA in the environmental sample was developed. Silica nanospheres were functionalized with 3-aminopropyltriethoxysilane (APTS) for effective immobilization of the capture probe, and gold nanoparticles were used for acceleration of electron transfer to the electrode surface. The aminated capture probe was immobilized onto the Si-Au nanocomposite-modified carbon screen printed electrode (Si-Au-SPE) via an imine covalent bond with glutaraldehyde (GA), which served as the bifunctional cross-linking agent. The targeted DNA sequence of V. cholerae was monitored via a sandwich DNA hybridization strategy with a pair of DNA probes, which included the capture probe and reporter probe that flanked the complementary DNA (cDNA), and evaluated by differential pulse voltammetry (DPV) in the presence of an anthraquninone redox label. Under optimum sandwich hybridization conditions, the voltammetric genosensor could detect the targeted V. cholerae gene from 1.0 × 10-17-1.0 × 10-7 M cDNA with a limit of detection (LOD) of 1.25 × 10-18 M (i.e., 1.1513 × 10-13 µg/µL) and long-term stability of the DNA biosensor up to 55 days. The electrochemical DNA biosensor was capable of giving a reproducible DPV signal with a relative standard deviation (RSD) of <5.0% (n = 5). Satisfactory recoveries of V. cholerae cDNA concentration from different bacterial strains, river water, and cabbage samples were obtained between 96.5% and 101.6% with the proposed DNA sandwich biosensing procedure. The V. cholerae DNA concentrations determined by the sandwich-type electrochemical genosensor in the environmental samples were correlated to the number of bacterial colonies obtained from standard microbiological procedures (bacterial colony count reference method).
Fulltext Effect of chlorhexidine pretreatment on bacterial contamination at rhinoplasty field

Kim SH, Tan KL, Lee SY, Kim DW, Shin S, Jin HR

Springerplus, 2016;5(1):2116.
PMID: 28090430 DOI: 10.1186/s40064-016-3679-y

This study investigated on bacterial contamination of the rhinoplasty field. The effect of preoperative chlorhexidine treatment on decreasing bacterial contamination in the rhinoplasty field is examined.
Evaluating new bio-hydrogen producers: Clostridium perfringens strain JJC, Clostridium bifermentans strain WYM and Clostridium sp. strain Ade.TY

Wong YM, Wu TY, Ling TC, Show PL, Lee SY, Chang JS, et al.

J Biosci Bioeng, 2018 May;125(5):590-598.
PMID: 29352712 DOI: 10.1016/j.jbiosc.2017.12.012

Three newly discovered H2 producing bacteria namely Clostridium perfringens strain JJC, Clostridium bifermentans strain WYM and Clostridium sp. strain Ade.TY originated from landfill leachate sludge have demonstrated highly efficient H2 production. The maximum H2 production attained from these isolates are in the descending order of strain C. perfringens strain JJC > C. bifermentans strain WYM > Clostridium sp. strain Ade.TY with yield of 4.68 ± 0.12, 3.29 ± 0.11, and 2.87 ± 0.10 mol H2/mol glucose, respectively. The result has broken the conventional theoretical yield of 4 mol H2/mol glucose. These isolates were thermodynamically favourable with Gibbs free energy between -33 and -35 kJ/mol (under process conditions: pH 6, 37 °C and 5 g/L glucose). All three isolates favour butyrate pathway for H2 production with the ratio of acetate and butyrate of 0.77, 0.65 and 0.80 for strain JJC, WYM and Ade.TY, respectively. This study reported provides a new insight on the potential of unique bacteria in H2 production.
N-O, carboxymethyl chitosan enhanced scaffold porosity and biocompatibility under e-beam irradiation at 50 kGy

Lee SY, Kamarul T

Int J Biol Macromol, 2014 Mar;64:115-22.
PMID: 24325858 DOI: 10.1016/j.ijbiomac.2013.11.039

In this study, a chitosan co-polymer scaffold was prepared by mixing poly(vinyl alcohol) (PVA), NO, carboxymethyl chitosan (NOCC) and polyethylene glycol (PEG) solutions to obtain desirable properties for chondrocyte cultivation. Electron beam (e-beam) radiation was used to physically cross-link these polymers at different doses (30 kGy and 50 kGy). The co-polymers were then lyophilized to form macroporous three-dimensional (3-D) matrix. Scaffold morphology, porosity, swelling properties, biocompatibility, expression of glycosaminoglycan (GAG) and type II collagen following the seeding of primary chondrocytes were studied up to 28 days. The results demonstrate that irradiation of e-beam at 50 kGy increased scaffold porosity and pore sizes subsequently enhanced cell attachment and proliferation. Scanning electron microscopy and transmission electron microscopy revealed extensive interconnected microstructure of PVA-PEG-NOCC, demonstrated cellular activities on the scaffolds and their ability to maintain chondrocyte phenotype. In addition, the produced PVA-PEG-NOCC scaffolds showed superior swelling properties, and increased GAG and type II collagen secreted by the seeded chondrocytes. In conclusion, the results suggest that by adding NOCC and irradiation cross-linking at 50 kGy, the physical and biological properties of PVA-PEG blend can be further enhanced thereby making PVA-PEG-NOCC a potential scaffold for chondrocytes.
Supermacroporous poly(vinyl alcohol)-carboxylmethyl chitosan-poly(ethylene glycol) scaffold: an in vitro and in vivo pre-assessments for cartilage tissue engineering

Lee SY, Wee AS, Lim CK, Abbas AA, Selvaratnam L, Merican AM, et al.

J Mater Sci Mater Med, 2013 Jun;24(6):1561-70.
PMID: 23512151 DOI: 10.1007/s10856-013-4907-4

This study aims to pre-assess the in vitro and in vivo biocompatibility of poly(vinyl alcohol)-carboxylmethyl-chitosan-poly(ethylene glycol) (PCP) scaffold. PCP was lyophilised to create supermacroporous structures. 3-(4, 5-dimethyl-thiazol-2yl)-2, 5-diphenyltetrazolium bromide (MTT) assay and immunohistochemistry (IHC) were used to evaluate the effectiveness of PCP scaffolds for chondrocytes attachment and proliferation. The ultrastructural was assessed using scanning electron microscopy (SEM) and transmission electron microscopy (TEM). Extracellular matrix (ECM) formation was evaluated using collagen type-II staining, glycosaminoglycan (GAG) and collagen assays. Histological analysis was conducted on 3-week implanted Sprague-Dawley rats. The MTT, IHC, SEM and TEM analyses confirm that PCP scaffolds promoted cell attachment and proliferation in vitro. The chondrocyte-PCP constructs secreted GAG and collagen type-II, both increased significantly from day-14 to day-28 (P
Unconfined compression properties of a porous poly(vinyl alcohol)-chitosan-based hydrogel after hydration

Lee SY, Pereira BP, Yusof N, Selvaratnam L, Yu Z, Abbas AA, et al.

Acta Biomater, 2009 Jul;5(6):1919-25.
PMID: 19289306 DOI: 10.1016/j.actbio.2009.02.014

A poly(vinyl alcohol) (PVA) hydrogel composite scaffold containing N,O-carboxymethylated chitosan (NOCC) was tested to assess its potential as a scaffold for cartilage tissue engineering in a weight-bearing environment. The mechanical properties under unconfined compression for different hydration periods were investigated. The effect of supplementing PVA with NOCC (20wt.% PVA:5vol.% NOCC) produced a porosity of 43.3% and this was compared against a non-porous PVA hydrogel (20g PVA: 100ml of water, control). Under non-hydrated conditions, the porous PVA-NOCC hydrogel behaved in a similar way to the control non-porous PVA hydrogel, with similar non-linear stress-strain response under unconfined compression (0-30% strain). After 7days' hydration, the porous hydrogel demonstrated a reduced stiffness (0.002kPa, at 25% strain), resulting in a more linear stiffness relationship over a range of 0-30% strain. Poisson's ratio for the hydrated non-porous and porous hydrogels ranged between 0.73 and 1.18, and 0.76 and 1.33, respectively, suggesting a greater fluid flow when loaded. The stress relaxation function for the porous hydrogel was affected by the hydration period (from 0 to 600s); however the percentage stress relaxation regained by about 95%, after 1200s for all hydration periods assessed. No significant differences were found between the different hydration periods between the porous hydrogels and control. The calculated aggregate modulus, H(A), for the porous hydrogel reduced drastically from 10.99kPa in its non-hydrated state to about 0.001kPa after 7days' hydration, with the calculated shear modulus reducing from 30.92 to 0.14kPa, respectively. The porous PVA-NOCC hydrogel conformed to a biphasic, viscoelastic model, which has the desired properties required for any scaffold in cartilage tissue engineering.
Repurposing Pentoxifylline for the Treatment of Fibrosis: An Overview

Wen WX, Lee SY, Siang R, Koh RY

Adv Ther, 2017 06;34(6):1245-1269.
PMID: 28484954 DOI: 10.1007/s12325-017-0547-2

Fibrosis is a potentially debilitating disease with high morbidity rates. It is estimated that half of all deaths that occur in the USA are attributed to fibrotic disorders. Fibrotic disorders are characterized primarily by disruption in the extracellular matrix deposition and breakdown equilibrium, leading to the accumulation of excessive amounts of extracellular matrix. Given the potentially high prevalence of fibrosis and the paucity of agents currently available for the treatment of this disease, there is an urgent need for the identification of drugs that can be utilized to treat the disease. Pentoxifylline is a methylxanthine derivative that is currently approved for the treatment of vascular diseases, in particular, claudication. Pentoxifylline has three main properties: improving the rheological properties of blood, anti-inflammatory, and antioxidative. Recently, the effectiveness of pentoxifylline in the treatment of fibrosis via attenuating and reversing fibrotic lesions has been demonstrated in several clinical trials and animal studies. As a result of the limited availability of antifibrotic agents in the long-term treatment of fibrosis that can attenuate and even reverse fibrotic lesions effectively, it would be of particular importance to consider the potential clinical utility of pentoxifylline in the treatment of fibrosis. Thus, this paper discusses the evolving roles of pentoxifylline in the treatment of different types of fibrosis.
Prevalence and risk factors for proteinuria: the National Kidney Foundation of Malaysia Lifecheck Health Screening programme

Ong LM, Punithavathi N, Thurairatnam D, Zainal H, Beh ML, Morad Z, et al.

Nephrology (Carlton), 2013 Aug;18(8):569-75.
PMID: 23782264 DOI: 10.1111/nep.12112

Aim: Treatment of chronic kidney disease (CKD) poses a huge burden to the healthcare system. To address the problem, the National Kidney Foundation of Malaysia embarked on a programme to screen for proteinuria and educate the public on CKD.

Methods: The public was invited for health screening and the data collected over a 21 month period was analyzed.

Results: In total, 40400 adults from all the states in Malaysia were screened. The screening population had a mean age of 41 years, 30.1% had hypertension and 10.6% had diabetes. Proteinuria was detected in 1.4% and haematuria in 8.9% of the participants. Factors associated with the highest risk for proteinuria were the presence of diabetes (adjusted odds ratio (OR) 2.63 (95% confidence interval (CI) 2.16-3.21)), hypertension (OR 2.49 (95% CI 2.03-3.07)) and cardiac disease (OR 2.05 (95% CI 1.50-2.81)). Other risk factors identified were lower educational level, family history of kidney disease, hypercholesterolaemia, obesity and lack of regular exercise. Chinese had the lowest risk for proteinuria among the races (OR 0.71 (95% CI 0.57-0.87) compared with Malays). The combination of high blood glucose and high blood pressure (BP) substantially increased the risk for proteinuria (OR 38.1 for glucose ≥ 10 mmol/L and systolic BP ≥ 180 mm Hg and OR 47.9 for glucose ≥ 10 mmol/L and diastolic BP ≥ 110 mm Hg).

Conclusion: The prevalence of proteinuria in Malaysia is similar to other countries. The major risk factors for proteinuria were diabetes, hypertension and cardiac disease. The presence of both high blood pressure and high blood glucose exert a synergistic effect in substantially increasing the risk for proteinuria.

Keywords: epidemiology; population studies; proteinuria.
Fulltext Characterization of the complete plastid genome and phylogenetic analysis of Oreocharis argyreia var. angustifolia (Gesneriaceae)

Xu G, Li Z, Chen Z, Lee SY, Kong X

Mitochondrial DNA B Resour, 2023;8(10):1137-1140.
PMID: 37928400 DOI: 10.1080/23802359.2023.2270207

Oreocharis argyreia var. angustifolia of Gesneriaceae is widely distributed in South China, including Guangdong, Guangxi, Hunan, and Jiangxi provinces. However, genetic information of this species is limited, further contributing to the taxonomic complications surrounding this species. Thus, in this study, we assembled and characterized the complete chloroplast genome of O. argyreia var. angustifolia as a genomic resource for future studies. The complete plastid genome was 154,675 bp in size, with a pair of inverted repeat regions of 25,329 bp each, separating the 85,977-bp large and 18,040-bp small single copy regions. A total of 131 genes were predicted, consisting of 86 protein-coding, 37 tRNA, and eight rRNA genes. The overall GC content was 37.6%. Phylogenetic analysis based on 79 shared unique CDS resulted in a fully resolved phylogenetic tree using both the maximum likelihood and Bayesian inference methods. Based on current circumscription, both methods indicated that Oreocharis is monophyletic; O. argyreia var. angustifolia diverged after O. chienii, which then followed by the divergence of the other three species included namely, O. continifolia, O. esquirolii, and O. mileensis. The genomic data obtained will be useful for future studies on the phylogenetics and evolution of Gesneriaceae.
Managing anticoagulation and antiplatelet medications in GI endoscopy: a survey comparing the East and the West

Lee SY, Tang SJ, Rockey DC, Weinstein D, Lara L, Sreenarasimhaiah J, et al.

Gastrointest Endosc, 2008 Jun;67(7):1076-81.
PMID: 18384789 DOI: 10.1016/j.gie.2007.11.037

Anticoagulation and antiplatelet medications may potentiate GI bleeding, and their use may lead to an increased need for a GI endoscopy. We hypothesized that there might be different practice patterns among international endoscopists.
Fulltext Perioperative outcome of severe rigid idiopathic scoliosis: Single-staged posterior spinal fusion utilizing a dual attending surgeon strategy. A report of 41 patients

Chan CYW, Chung WH, Mihara Y, Lee SY, Ch'ng PY, Hasan MS, et al.

J Orthop Surg (Hong Kong), 2020 8 9;28(3):2309499020936005.
PMID: 32762498 DOI: 10.1177/2309499020936005

PURPOSE: Various surgical strategies including combined approach and spinal osteotomies in severe rigid scoliosis had been reported with significant perioperative complication rates. The use of single-staged posterior spinal fusion (PSF) utilizing a dual attending surgeon strategy for severe rigid scoliosis has not been widely reported.
METHODS: This was a retrospective study aimed to evaluate the perioperative outcome of single-staged PSF in severe rigid idiopathic scoliosis patients (Cobb angle ≥90° and ≤30% flexibility). Forty-one patients with severe rigid idiopathic scoliosis who underwent single-staged PSF were included. The perioperative outcome parameters were operation duration, intraoperative blood loss, intraoperative hemodynamic parameters, preoperative and postoperative hemoglobin, transfusion rate, patient-controlled anesthesia morphine usage, length of postoperative hospital stay, and perioperative complications. Radiological parameters included preoperative and postoperative Cobb angle, correction rate, side-bending flexibility, and side-bending correction index.
RESULTS: The mean age was 16.9 ± 5.6 years. The mean preoperative Cobb angle was 110.8 ± 12.1° with mean flexibility of 23.1 ± 6.3%. The mean operation duration was 215.5 ± 45.2 min with mean blood loss of 1752.6 ± 830.5 mL. The allogeneic blood transfusion rate was 24.4%. The mean postoperative hospital stay was 76.9 ± 26.7 h. The mean postoperative Cobb angle and correction rate were 54.4 ± 12.8° and 50.9 ± 10.1%, respectively. The readmission rate in this cohort was 2.4%. Four perioperative complications were documented (9.8%), one somatosensory evoke potential signal loss, one superficial infection, one lung collapse, and one superior mesenteric artery syndrome.
CONCLUSIONS: Severe rigid idiopathic scoliosis treated with single-staged PSF utilizing a dual attending surgeon strategy demonstrated an average correction rate of 50.9%, operation duration of 215.5 min, and postoperative hospital stay of 76.9 h with a 9.8% perioperative complication rate.
Parents'/Patients' Perception of the Informed Consent Process and Surgeons Accountability in Corrective Surgery for Adolescent Idiopathic Scoliosis: A Prospective Study

Chan CYW, Chong JSL, Lee SY, Ch'ng PY, Chung WH, Chiu CK, et al.

Spine (Phila Pa 1976), 2020 Dec 01;45(23):1661-1667.
PMID: 32756286 DOI: 10.1097/BRS.0000000000003641

STUDY DESIGN: Prospective study.
OBJECTIVE: To determine the parents'/patients' perception on the informed consent process prior to posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) patients.
SUMMARY OF BACKGROUND DATA: Understanding parents/patients perspective on the process is important in order to achieve the goal of consent and prevent medico-legal implications.
METHODS: Fifty AIS patients operated between August 2019 and November 2019 were prospectively recruited. Parents'/patients' perceptions on three sections were evaluated: the process of the informed consent, specific operative risk which they were most concerned with and the accountability of surgeons for the surgical risks. These data were ranked and scored using a 5-point Likert Scale. Preferences were reported in mean and standard deviation. Differences in terms of preferences were studied using One-way analysis of variance (ANOVA) analysis and deemed significant when P
Perioperative Outcome of Severe Idiopathic Scoliosis (Cobb Angle ≥ 90°): Is There Any Difference Between "Daytime" Versus "After-hours" Surgeries?

Mihara Y, Chung WH, Chiu CK, Hasan MS, Lee SY, Ch'ng PY, et al.

Spine (Phila Pa 1976), 2020 Mar 15;45(6):381-389.
PMID: 31574058 DOI: 10.1097/BRS.0000000000003274

STUDY DESIGN: Retrospective study from a prospectively collected database.
OBJECTIVE: To compare the perioperative outcome between after-hours and daytime surgery carried out by a dedicated spinal deformity team for severe Idiopathic Scoliosis (IS) patients with Cobb angle ≥ 90°.
SUMMARY OF BACKGROUND DATA: There were concerns that after-hours corrective surgeries in severe IS have higher morbidity compared to daytime surgeries.
METHODS: Seventy-one severe IS patients who underwent single-staged Posterior Spinal Fusion (PSF) were included. Surgeries performed between 08:00H and 16:59H were classified as "daytime" group and surgeries performed between 17:00H and 06:00H were classified as "after-hours" group. Perioperative outcome parameters were average operation start time and end time, operation duration, intraoperative blood loss, intraoperative hemodynamic parameters, preoperative and postoperative hemoglobin, blood transfusion rate, total patient-controlled anesthesia (PCA) morphine usage, length of postoperative hospitalization, and complications. Radiological variables assessed were preoperative and postoperative Cobb angle, side bending flexibility, number of fusion levels, number of screws used, Correction Rate, and Side Bending Correction Index.
RESULTS: Thirty patients were operated during daytime and 41 patients were operated after-hours. The mean age was 16.1 ± 5.8 years old. The mean operation start time for daytime group was 11:31 ± 2:45H versus 19:10 ± 1:24H for after-hours group. There were no significant differences between both groups in the operation duration, intraoperative blood loss, intraoperative hemodynamic parameters, postoperative hemoglobin, hemoglobin drift, transfusion rate, length of postoperative hospitalization, postoperative Cobb angle, Correction Rate, and Side Bending Correction Index. There were four complications (1 SSEP loss, 1 massive blood loss, and 2 superficial wound infections) with no difference between daytime and after-hours group.
CONCLUSION: After-hours elective spine deformity corrective surgeries in healthy ambulatory patients with severe IS performed by a dedicated spinal deformity team using dual attending surgeon strategy were as safe as those performed during daytime.
LEVEL OF EVIDENCE: 4.
Dual attending surgeon strategy learning curve in single-staged posterior spinal fusion (PSF) surgery for 415 idiopathic scoliosis (IS) cases

Chan CYW, Chiu CK, Ch'ng PY, Lee SY, Chung WH, Hasan MS, et al.

Spine J, 2021 07;21(7):1049-1058.
PMID: 33610804 DOI: 10.1016/j.spinee.2021.02.009

BACKGROUND CONTEXT: The implementation of a dual attending surgeon strategy had improved perioperative outcomes of idiopathic scoliosis (IS) patients. Nevertheless, the learning curve of a dual attending surgeon practice in single-staged posterior spinal fusion (PSF) surgery has not been established.
OBJECTIVE: To evaluate the surgical learning curve of a dual attending surgeon strategy in IS patients.
STUDY DESIGN: Retrospective study.
PATIENT SAMPLE: 415 IS patients (Cobb angle <90°) who underwent PSF using a dual attending surgeon strategy OUTCOME MEASURES: Primary outcomes included operative time, total blood loss, allogenic blood transfusion requirement, length of hospital stay and perioperative complication rate.
METHODS: Regression analysis using Locally Weighted Scatterplot Smoothing (LOWESS) method was applied to create the best-fit-curve between case number versus operative time and total blood loss in identifying cut-off points for the learning curve.
RESULTS: The mean Cobb angle was 60.8±10.8°. Mean operative time was 134.4±32.1 minutes and mean total blood loss was 886.0±450.6 mL. The mean length of hospital stay was 3.0±1.6 days. The learning curves of a dual attending surgeon strategy in this study were established at the 115th case (operative time) and 196th case (total blood loss) respectively (p
Fulltext Preoperative "Cervical Axis" Deviation Increases the Risk of Distal Adding-On Following Surgery in Lenke 1 and 2 Adolescent Idiopathic Scoliosis Patients

Chan CYW, Ch'ng PY, Lee SY, Chung WH, Chiu CK, Kwan MK

Global Spine J, 2023 Mar;13(2):443-450.
PMID: 33691529 DOI: 10.1177/2192568221998642

STUDY DESIGN: Retrospective.
PURPOSE: To evaluate the relationship between shoulder/ neck imbalance with distal adding-on phenomenon and to identify other risk factors in Lenke 1 and 2 (non-AR curves) adolescent idiopathic scoliosis (AIS) patients.
METHODS: 100 Lenke 1 and 2 AIS patients with lowest instrumented vertebra (LIV) cephalad to or at L1 were recruited. Medial shoulder/ neck balance was represented by T1-tilt and cervical axis (CA). Lateral shoulder balance was represented by clavicle angle (Cla-A) and radiographic shoulder height (RSH). Distal adding-on phenomenon was diagnosed when there was disc wedging below LIV of >5o at final follow-up. Predictive factors and odds ratio were derived using univariate and multivariate logistic regression analysis.
RESULTS: Mean age of this cohort was 15.9 ± 4.4 years. Mean follow-up duration was 30.9 ± 9.6 months. Distal adding-on phenomenon occurred in 19 patients (19.0%). Only Risser grade, preoperative CA and final follow-up lumbar Cobb angle were the independent factors. A positive preoperative CA deviation increased the odds of distal adding-on by 5.4 times (95% CI 1.34-21.51, P = 0.018). The mean immediate postoperative T1-tilt, CA, RSH and Cla-A were comparable between the group with distal adding-on and the group without.
CONCLUSION: Distal adding-on phenomenon occurred in 19.0% of patients. Preoperative "Cervical Axis" was an important factor and it increased the risk of distal adding-on by 5.4 times. Other significant predictive factors were Risser grade and lumbar Cobb angle at final follow-up. Immediate postoperative shoulder or neck imbalance was not a significant factor for postoperative distal adding-on phenomenon.
Fulltext Patients' Perception and Satisfaction on Neck and Shoulder Imbalance in Adolescent Idiopathic Scoliosis

Lee SY, Ch'ng PY, Wong TS, Ling XW, Chung WH, Chiu CK, et al.

Global Spine J, 2023 Apr;13(3):752-763.
PMID: 33823628 DOI: 10.1177/21925682211007795

STUDY DESIGN: Cross-sectional.
OBJECTIVES: To evaluate the perception and satisfaction among adolescent idiopathic scoliosis (AIS) patients on Neck Tilt with Medial Shoulder Imbalance and Lateral Shoulder Imbalance.
METHODS: Lenke 1 and 2 AIS patients were stratified into 6 groups of preoperative/ postoperative Balanced (B), Lateral Shoulder Imbalance (LSI) (>2 cm), and Neck Tilt with Medial Shoulder Imbalance (NT) (Grade 3). Patients were interviewed using Modified Neck and Shoulder Appearance and SRS-22r questionnaires. T1 tilt, Cervical Axis (CA), Clavicle Angle (Cla-A) and Radiographic Shoulder Height (RSH) were measured.
RESULTS: A total of 120 Lenke 1 and 2 AIS patients were recruited. NT patients were aware and unhappy with their abnormal neck with medial shoulder appearances (P < .001). Similarly, LSI patients were aware and unhappy with their abnormal lateral shoulder appearances (P < .001). NT group had larger preoperative/ postoperative T1 tilt (9.2 ± 5.0°; 9.5 ± 5.3°) and CA (4.6 ± 3.1°; 7.0 ± 2.0°) (P < .01). LSI group had larger preoperative/ postoperative Cla-A (4.8 ± 2.8°; 4.0 ± 1.3°) and RSH (20.1 ± 9.4 mm; 17.0 ± 6.6 mm) (P < .001). Postoperative B group scored higher in overall SRS-22r scores, self-image and satisfaction domains (4.2 ± 0.3; 4.0 ± 0.5; 4.4 ± 0.5) while preoperative LSI scored the lowest comparatively (3.5 ± 0.4; 2.4 ± 0.5; 3.3 ± 0.5) (P < .001).
CONCLUSION: NT and LSI were major concerns among AIS patients. Both NT and LSI groups were unhappy with their appearances. NT group had larger T1 tilt/ CA whereas LSI group had larger Cla-A/ RSH. Postoperative B group scored higher in overall SRS-22r scores, self-image and satisfaction domains.

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