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Purpose of Review: The introduction of minimally invasive glaucoma surgery (MIGS) has changed the surgical landscape of glaucoma surgery. For more than four decades, the most commonly performed glaucoma surgery around the world has been the trabeculectomy. This article examines whether trabeculectomy is still the predominant procedure in glaucoma today, in the context of rapidly emerging MIGS devices and procedures., Recent Findings: There is a growing trend of mild to moderate glaucoma cases undergoing MIGS procedures instead of trabeculectomy. Glaucoma drainage device implantation may also have taken away a significant share of the filtering surgery performed for more severe glaucoma. In addition, the availability and economics of implants has an influence on the prevalence of trabeculectomy., Summary: Currently, trabeculectomy surgery is still the most common glaucoma surgery performed around the world. However, the proportion of glaucoma surgeries undergoing MIGS is increasing rapidly., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Screening for depression in caregivers of children with developmental disabilities is not routine, representing missed opportunities for support., Method: A quality improvement project was initiated in our pediatric clinic. Root causes of limited screening included unclear guidelines for support, caregiver perception that help is unavailable, and lack of a quick screening tool. A clinical pathway was constructed and integrated into existing practice using quality improvement methodology., Results: Baseline screening rate was 5%-10%. During the 12-week pilot, weekly rates ranged from 46.0% to 91.0% (mean 70.2%). Monthly rates subsequently averaged 55.0%. Approximately 20% had a positive screen; over half were caregivers of children with autism. About 5% had moderate depression, of whom 40% required referral to social workers., Discussion: Structured depression screening of caregivers of children with developmental disabilities is feasible and sustainable in a busy clinic. Further research is needed to measure the impact on child and family outcomes., Competing Interests: CONFLICTS OF INTEREST The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2024 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Colorectal cancer (CRC), an emerging public health concern, is one of the leading causes of cancer morbidity and mortality worldwide. An increasing body of evidence shows that dysfunction in metabolic reprogramming is a crucial characteristic of CRC progression. Specifically, metabolic reprogramming abnormalities in glucose, glutamine and lipid metabolism provide the tumour with energy and nutrients to support its rapid cell proliferation and survival. More recently, microRNAs (miRNAs) appear to be involved in the pathogenesis of CRC, including regulatory roles in energy metabolism. In addition, it has been revealed that dysbiosis in CRC might play a key role in impairing the host metabolic reprogramming processes, and while the exact interactions remain unclear, the link may lie with miRNAs. Hence, the aims of the current review include first, to delineate the metabolic reprogramming abnormalities in CRC; second, to explain how miRNAs mediate the aberrant regulations of CRC metabolic pathways; third, linking miRNAs with metabolic abnormalities and dysbiosis in CRC and finally, to discuss the roles of miRNAs as potential biomarkers.

Introduction: The influence of pregnancy-related pelvic girdle pain (PPGP) on lumbopelvic muscles has not been comprehensively examined in postpartum individuals. Previous research also presented self-reported activity limitations without objective measures., Methods: Thirty postpartum individuals with PPGP (PPGP group) and 30 age-, parity-, and postpartum duration-matched asymptomatic individuals (healthy group) were recruited. Transabdominal ultrasonography was used to measure muscle thickness or activation changes of the external oblique (EO), internal oblique (IO), transverse abdominals, lumbar multifidus, and pelvic floor muscles (PFMs) during rest and while performing the active straight leg raise (ASLR). Muscle changes were compared separately in the painful and nonpainful sides between the PPGP and health control group. Physical function was assessed using the ASLR fatigue (ASLRF), timed up-and-go, and 6-m walking (6MW) tests., Results: The PPGP group had greater thickening changes in the bilateral IO during ASLR compared with the healthy group (nonpainful side, 16.34 vs 3.52 mm; P = .010; painful side, 18.83 vs 6.60 mm; P = .02) but became thinner in the EO (nonpainful side, -2.19 vs 19.97 mm; P < .001; painful side, -5.97 vs 21.43 mm; P < .001). Thicker IO and EO on the nonpainful side (IO, 6.60 vs 5.78 mm; P = .004; EO, 5.37 vs 4.54 mm; P = .011) and a lower bladder base (indication of PFMs) (91.87 vs 78.61 mm; P = .002) during rest were also observed in the PPGP group. Furthermore, the performance of the ASLRF and 6MW tests was poorer in the PPGP than in the healthy group (ASLRF nonpainful side, 82.36 vs 59.09 sec; P = .01; painful side, 75.73 vs 59.26 sec; P = .04; 6MW, 3.48 vs 3.17 sec; P = .02)., Discussion: Postpartum individuals with PPGP demonstrated altered abdominal muscle recruitment strategies during loading tasks, with objectively impaired physical functions. These findings are critical for developing effective muscle training interventions for PPGP., (© 2024 by the American College of Nurse‐Midwives.)

Background: Many mothers experience poor psychological outcomes during their perinatal period. The presence of depression and anxiety has a significant adverse impact on the mother's health and the infant's development., Aim: This review aimed to examine the effectiveness of peer support interventions in improving depression, anxiety, and perceived social support among mothers during the perinatal period., Methods: This study was a systematic review and meta-analysis of randomized controlled trials. The reporting of this review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020. Cochrane's Risk of Bias Tool for randomized controlled trials was used to examine the methodological quality of the included studies. The certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. A comprehensive search was conducted from inception till May 2024 across seven databases: Pubmed, Scopus, CINAHL, Web of Science, ProQuest, PsycINFO, and Embase., Results: The results of the meta-analysis of the 12 included studies showed that peer support interventions could reduce depression and anxiety levels but not perceived social support levels. Sub-group analyses based on the mode of intervention delivery showed significant reductions on depression levels in online and face-to-face groups but not telephone call groups. Follow-up data analyses showed that peer support interventions could improve depression, anxiety, and perceived social support across a duration of 1-6 months post-intervention., Linking Evidence to Action: This review provides a deeper understanding of the effect of peer support interventions on mothers in the perinatal period. This can have a positive impact on current knowledge aimed at improving the well-being of mothers and thus, their infants, partners, and entire family unit. Findings showed that peer support interventions can positively improve psychological well-being of mothers in the perinatal period in the short and long term. Peer support can ultimately be considered as a standardized part of perinatal care. Future recommendations include implementing a combination of face-to-face and online approaches to peer support interventions delivered with both individual and group components., (© 2024 Sigma Theta Tau International.)

Despite proven efficacy, fatherhood interventions face challenges in attracting and retaining participants. This qualitative systematic review aims to inform the future design of fatherhood interventions by consolidating and synthesizing the evidence around fathers' experiences with interventions aimed at enhancing their involvement and relationships with their children. Following PRISMA guidelines, we analyzed 10 studies from a search of six electronic databases. Our analysis coalesced into three pivotal themes: (a) creating a sense of belonging: facilitating participation; (b) transformative takeaways; and (c) challenges of negotiating expectations of masculinity. Our findings indicate that group-based, culturally sensitive programs are advantageous but also reveal that fathers grapple with reconciling evolving fatherhood roles with societally entrenched expectations of masculinity. This review offers actionable insights for the future development, evaluation, and implementation of fatherhood interventions, particularly those utilizing qualitative research methodologies., (© 2024 Family Process Institute.)

Aims: We aim to determine the association of seven major candidate protein biomarkers and diabetic kidney disease (DKD) progression among Asians with young-onset type 2 diabetes mellitus (T2DM)., Methods: 824 T2DM patients (onset ≤ 40 years old) were classified as DKD progressors based on yearly estimated glomerular filtration rate (eGFR) decline of >3 ml/min/1.73 m 2 or >40 % from baseline. Plasma leucine-rich α-2-glycoprotein 1 (pLRG1), tumor necrosis factor-receptor 1 (pTNF-R1), pigment epithelium-derived factor (pPEDF), urinary α-1-microglobulin (uA1M), kidney injury molecular 1 (uKIM-1), haptoglobin (uHP) and uromodulin (uUMOD) were measured using enzyme-linked immunoassays., Results: Over 5.7 years of follow-up, 25.2 % of patients were DKD progressors. Elevated levels of pLRG1, pTNF-R1, pPEDF, uA1M, uKIM-1 and uHP were associated with DKD progression. The association between pTNF-R1 levels and DKD progression persisted after adjusting for clinical covariates (OR 1.84, 95 %CI 1.44-2.34, p < 0.001). The effects of pTNF-R1 were partially mediated through hyperglycemia (8 %) and albuminuria (10 %). Inclusion of pTNF-R1 in a clinical variable-based model improved the area under the receiver operating characteristics curve for predicting DKD progression by 0.02, from 0.72 (95 %CI 0.68-0.76) to 0.74 (95 %CI 0.70-0.78), p = 0.099., Conclusions: Among seven major candidate proteins, pTNF-R1, partially mediated through hyperglycemia and albuminuria, robustly predicted DKD progression among Asians with young-onset T2DM., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: This study aimed to determine patterns of screen viewing time (SVT) in preschool children with developmental, behavioural or emotional (DBE) issues, and to identify its relationship with social-emotional development., Method: This cross-sectional study involved children aged 0-5 years who were referred to a developmental paediatric clinic for DBE issues. Parents completed a screen time questionnaire, and the Devereux Early Childhood Assessment-Clinical (DECA-C) question-naire which assessed the social-emotional competence of the children. Data were analysed using logistic regression, correlational analyses and tests of comparison., Results: Among 225 children (mean age: 32.4 months), mean daily SVT was 138 minutes. More than half (51.1%) of the children had clinical features of language delay, while 26.6% had features suggestive of autism spectrum disorder. Screen time was first introduced at a mean age of 13.8 months, with 32.4% of children previously experiencing higher SVT. Compared to SVT introduction after 1 year of age, SVT in the first 12 months was primarily to facilitate feeding ( P <0.05). Children with higher past SVT had poorer attention, more aggression, and increased behavioural concerns. Children with DBE issues have significantly more screen time than same-aged peers., Conclusion: Children with DBE issues are exposed to SVT at a very young age and have significantly more screen time than their peers. It is crucial to guide parents to reduce SVT in early childhood, particularly around mealtimes.

Introduction: Reducing neonatal deaths in premature infants in low- and middle-income countries is key to reducing global neonatal mortality. International neonatal networks, along with patient registries of premature infants, have contributed to improving the quality of neonatal care; however, the involvement of low-to-middle-income countries was limited. This project aims to form an international collaboration among neonatal networks in Asia (AsianNeo), including low-, middle- and high-income countries (or regions). Specifically, it aims to determine outcomes in sick newborn infants, especially very low birth weight (VLBW) infants or very preterm infants, with a view to improving the quality of care for such infants., Methods and Analysis: Currently, AsianNeo comprises nine neonatal networks from Indonesia, Japan, Malaysia, Philippines, Singapore, South Korea, Sri Lanka, Taiwan and Thailand. AsianNeo will undertake the following four studies: (1) institutional questionnaire surveys investigating neonatal intensive care unit resources and the clinical management of sick newborn infants, with a focus on VLBW infants (nine countries/regions); (2) a retrospective cohort study to describe and compare the outcomes of VLBW infants among Asian countries and regions (four countries/regions); (3) a prospective cohort study to develop the AsianNeo registry of VLBW infants (six countries/regions); and (4) implementation and evaluation of educational and quality improvement projects in AsianNeo countries and regions (nine countries/regions)., Ethics and Dissemination: The study protocol was approved by the Research Ethics Board of the National Center for Child Health and Development, Tokyo, Japan (reference number 2020-244, 2022-156). The study findings will be disseminated through educational programmes, quality improvement activities, conference presentations and medical journal publications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The aim of this study was to evaluate the accuracy, comprehensiveness, and safety of a publicly available large language model (LLM)-ChatGPT in the sub-domain of glaucoma., Design: Evaluation of diagnostic test or technology., Subjects Participants And/or Controls: We seek to evaluate the responses of an artificial intelligence chatbot ChatGPT (version GPT-3.5, OpenAI)., Methods Intervention or Testing: We curated 24 clinically relevant questions in the domain of glaucoma. The questions spanned four categories: pertaining to diagnosis, treatment, surgeries, and ocular emergencies. Each question was posed to the LLM and the responses obtained were graded by an expert grader panel of three glaucoma specialists with combined experience of more than 30 years in the field. For responses which performed poorly, the LLM was further prompted to self-correct. The subsequent responses were then re-evaluated by the expert panel., Main Outcome Measures: Accuracy, comprehensiveness, and safety of the responses of a public domain LLM., Results: There were a total of 24 questions and three expert graders with a total number of responses of n  = 72. The scores were ranked from 1 to 4, where 4 represents the best score with a complete and accurate response. The mean score of the expert panel was 3.29 with a standard deviation of 0.484. Out of the 24 question-response pairs, seven (29.2%) of them had a mean inter-grader score of 3 or less. The mean score of the original seven question-response pairs was 2.96 which rose to 3.58 after an opportunity to self-correct (z-score - 3.27, p  = 0.001, Mann-Whitney U). The seven out of 24 question-response pairs which performed poorly were given a chance to self-correct. After self-correction, the proportion of responses obtaining a full score increased from 22/72 (30.6%) to 12/21 (57.1%), ( p  = 0.026, χ 2 test)., Conclusion: LLMs show great promise in the realm of glaucoma with additional capabilities of self-correction. The application of LLMs in glaucoma is still in its infancy, and still requires further research and validation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Tan, Tham, Koh, Loon, Aquino, Lun, Cheng, Ngiam and Tan.)

The Academy of Medicine of Malaysia College of Paediatrics acknowledges the role of children in research and this position statement explores the ethical considerations in obtaining assent from minors in the Malaysian context. It highlights the importance in respecting children's agency and navigating cultural complexities. The College proposes flexibility in the minimum age for assent of at least nine years old, while emphasising the need for a tailored assent procedure. Addressing language and cultural diversities and expanding local empirical research on a formal assent process are some building blocks in developing a standardised nationwide process in obtaining assent from children.

Prcis: In our case series, the 3-year failure for Paul Glaucoma Implant (PGI) implantation was 14.6%. At 3 years postoperatively, there was a significant reduction in mean intraocular pressure (IOP) and the number of glaucoma medications used., Objective: To determine the 3-year efficacy and safety of the PGI, a novel glaucoma tube shunt in patients with glaucoma., Methods: Retrospective review of all patients who had undergone PGI implantation in a single tertiary institution in Singapore between May 1, 2017 and January 1, 2022. Data were extracted from electronic health records (Computerized Patient Support System 2 and Epic). The primary outcome measure was failure, defined as IOP >18 mm Hg or <6 mm Hg on 2 consecutive visits after 3 months, reoperation for IOP-related indication, explantation of implant, or loss of light perception vision. Complete success was defined as the absence of failure without medications at 36 months, and qualified success similarly, but with medications. Postoperative mean IOP, mean number of IOP-lowering medications used, and visual acuity were also assessed., Results: Forty-eight eyes in 48 patients were identified. Thirty-one patients (64.6%) had primary open angle and angle closure glaucoma, and 18 (37.5%) had previous existing tube implants or trabeculectomy. At 3 years postoperatively, 7 cases (14.6%) fulfilled the criteria for failure and 36 (75%) met the criteria for complete success. The mean IOP at 36 months was 14.9 ± 4.11 mm Hg, from the mean preoperative IOP of 20.6 ± 6.13 mm Hg ( P < 0.001). The mean number of IOP-lowering medications used was reduced from 3.13 ± 0.959 preoperatively to 0.167 ± 0.476 at 36 months ( P < 0.001). The most common postoperative complication was hypotony (n = 17, 35.4%), of which the majority were self-limiting, followed by hyphema (n = 5, 10.4%) and tube exposure (n = 4, 8.3%)., Conclusion: The PGI demonstrated sustained IOP reduction and a reduction of medication burden at 3 years postoperatively., Competing Interests: Disclosure: P.T.K.C. and C.C.A.S. are co-inventors of the Paul Glaucoma Implant (PGI; Advanced Ophthalmic Innovations Pvt Ltd, Singapore) and hold related patents. The remaining authors declare no conflict of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Lay Abstract: Systematic screening for autism in early childhood has been suggested to improve eventual outcomes by facilitating earlier diagnosis and access to intervention. However, clinical implementation of screening has to take into account effectiveness and feasibility of use within a healthcare setting for accurate diagnosis of autism. In Singapore, autism screening using a structured screening tool is not currently employed as a part of routine well-child visits for children in primary care clinics. In this study, 5336 children (aged 17-20 months) were screened for autism using the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) during their 18-month well-child visit in seven primary care clinics. Screening and follow-up interviews were administered by nursing staff at each clinic. Children screened positive and a portion of those screened negative then underwent diagnostic assessments to determine whether they met the diagnostic criteria for autism. In total, 113 (2.1%) were screened positive, of which 54 (1.0%) met the criteria for autism. Children who screened positive and received a diagnosis accessed autism-specific intervention at an average age of 22 months. Nurses and physicians rated the acceptability and practicality of the M-CHAT-R/F highly. Therefore, the M-CHAT-R/F questionnaire was an effective and feasible tool for autism screening among 18-month-old children in this study. Future studies will be designed to determine the optimal age of screening and role of repeated screening in Singapore, as well as to better understand any potential improved outcomes nationwide compared with pre-implementation of autism screening., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This cross-sectional study aimed to assess Quality of life (QoL) of parents of children on the autism spectrum in Singapore and identify its associated factors. Parents of children (age ≥ 5 years) completed the Quality of Life in Autism scale which measures parental self-rated QoL (higher scores denote greater QoL), and the perceived impact of the child's autism-related behaviors on parents (higher scores denote lesser impact). Information on the child's degree of autism (measured by the Social Responsiveness Scale, second edition [SRS-2]), community and social participation and cognitive and adaptive functioning were also obtained. Participants were 86 parents with mean child age 6.3 years (SD 1.0). Univariate analysis results revealed greater participation in community and social events to be two modifiable factors associated with higher parental QoL. However, these factors were not found to be significant in the multivariate model. Higher autism features (represented by higher parent-rated SRS scores) was associated with a greater perceived impact of the child's behaviors by parents in both univariate and multivariate analyses. Of note, child's cognitive or adaptive skills were not significantly associated with either QoL measure. Equipping parents to handle autism-related behaviors can be useful to reduce their impact on parental QoL. Facilitating community participation for these children may positively influence caregiver QoL as well., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Children from low-income (LI) families often suffer from poor health, with sub-optimal health practices. This cross-sectional study examined the differences in health habits and health-related quality of life (HRQoL) of LI preschool children compared to non-low-income preschool peers (PPG)., Method: Using data from the social-health Circle of Care-Health Development Screening Programme (CoC-HDSP) in Singapore, 118 LI children and 304 PPG children aged 18 months to 6 years old and their families were recruited from 13 government-funded preschools. Health practices examined included screen time habits, sleep, nutrition, dental health and the children's HRQoL using PedsQL 4.0 Generic Core Scales., Results: Majority of the children were aged 4-6 years in kindergarten 1 and 2. There were more Malay children in the LI than the PPG (61.9% versus [vs] 29.3%, P<0.001). Low-income children were more likely to have lower-educated parents (P<0.001). The completed vaccination rate in the LI group was lower than those in PPG (84.7% vs 98.0%, P<0.001). More in the LI group utilised emergency services for acute illnesses (P<0.05). Fewer LI children had ever visited a dentist (47.4% vs 75.4%, P<0.001), and more LI children consumed sweetened drinks daily (33.3% vs 8.6%, P<0.001). The LI group reported poorer-quality sleep (48.3% vs 27.2%, P<0.001), though both groups exceeded the daily recommended screen viewing duration. The LI group scored higher in the social (mean 92.4±12.2 vs 84.3±15.3, P<0.001) and emotional (mean 85.2±15.1 vs 76.6±17.3, P<0.001) domains of the PedsQL 4.0 when compared to PPG., Conclusion: Low-income children have poorer health practices, receive less preventive paediatric care, and utilise more emergency services for acute illnesses. These findings are important for developing interventions that work towards improving the health of LI children., Competing Interests: None to declare.

Background: The indications for septoplasty are practice-based, rather than evidence-based. In addition, internationally accepted guidelines for the management of nasal obstruction associated with nasal septal deviation are lacking., Objective: The objective was to determine the clinical effectiveness and cost-effectiveness of septoplasty, with or without turbinate reduction, compared with medical management, in the management of nasal obstruction associated with a deviated nasal septum., Design: This was a multicentre randomised controlled trial comparing septoplasty, with or without turbinate reduction, with defined medical management; it incorporated a mixed-methods process evaluation and an economic evaluation., Setting: The trial was set in 17 NHS secondary care hospitals in the UK., Participants: A total of 378 eligible participants aged > 18 years were recruited., Interventions: Participants were randomised on a 1: 1 basis and stratified by baseline severity and gender to either (1) septoplasty, with or without turbinate surgery ( n = 188) or (2) medical management with intranasal steroid spray and saline spray ( n = 190)., Main Outcome Measures: The primary outcome was the Sino-nasal Outcome Test-22 items score at 6 months (patient-reported outcome). The secondary outcomes were as follows: patient-reported outcomes - Nasal Obstruction Symptom Evaluation score at 6 and 12 months, Sino-nasal Outcome Test-22 items subscales at 12 months, Double Ordinal Airway Subjective Scale at 6 and 12 months, the Short Form questionnaire-36 items and costs; objective measurements - peak nasal inspiratory flow and rhinospirometry. The number of adverse events experienced was also recorded. A within-trial economic evaluation from an NHS and Personal Social Services perspective estimated the incremental cost per (1) improvement (of ≥ 9 points) in Sino-nasal Outcome Test-22 items score, (2) adverse event avoided and (3) quality-adjusted life-year gained at 12 months. An economic model estimated the incremental cost per quality-adjusted life-year gained at 24 and 36 months. A mixed-methods process evaluation was undertaken to understand/address recruitment issues and examine the acceptability of trial processes and treatment arms., Results: At the 6-month time point, 307 participants provided primary outcome data (septoplasty, n = 152; medical management, n = 155). An intention-to-treat analysis revealed a greater and more sustained improvement in the primary outcome measure in the surgical arm. The 6-month mean Sino-nasal Outcome Test-22 items scores were -20.0 points lower (better) for participants randomised to septoplasty than for those randomised to medical management [the score for the septoplasty arm was 19.9 and the score for the medical management arm was 39.5 (95% confidence interval -23.6 to -16.4; p < 0.0001)]. This was confirmed by sensitivity analyses and through the analysis of secondary outcomes. Outcomes were statistically significantly related to baseline severity, but not to gender or turbinate reduction. In the surgical and medical management arms, 132 and 95 adverse events occurred, respectively; 14 serious adverse events occurred in the surgical arm and nine in the medical management arm. On average, septoplasty was more costly and more effective in improving Sino-nasal Outcome Test-22 items scores and quality-adjusted life-years than medical management, but incurred a larger number of adverse events. Septoplasty had a 15% probability of being considered cost-effective at 12 months at a £20,000 willingness-to-pay threshold for an additional quality-adjusted life-year. This probability increased to 99% and 100% at 24 and 36 months, respectively., Limitations: COVID-19 had an impact on participant-facing data collection from March 2020., Conclusions: Septoplasty, with or without turbinate reduction, is more effective than medical management with a nasal steroid and saline spray. Baseline severity predicts the degree of improvement in symptoms. Septoplasty has a low probability of cost-effectiveness at 12 months, but may be considered cost-effective at 24 months. Future work should focus on developing a septoplasty patient decision aid., Trial Registration: This trial is registered as ISRCTN16168569 and EudraCT 2017-000893-12., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/226/07) and is published in full in Health Technology Assessment ; Vol. 28, No. 10. See the NIHR Funding and Awards website for further award information.

Disorders of esophagogastric junction (EGJ) outflow, including achalasia and EGJ outflow obstruction, are motility disorders characterized by inadequate relaxation of lower esophageal sphincter with or without impaired esophageal peristalsis. Current guidelines are technical and less practical in the Asia-Pacific region, and there are still massive challenges in timely diagnosis and managing these disorders effectively. Therefore, a Malaysian joint societies' task force has developed a consensus on disorders of EGJ outflow based on the latest evidence, while taking into consideration the practical relevance of local and regional context and resources. Twenty-one statements were established after a series of meetings and extensive review of literatures. The Delphi method was used in the consensus voting process. This consensus focuses on the definition, diagnostic investigations, the aims of treatment outcome, non-surgical or surgical treatment options, management of treatment failure or relapse, and the management of complications. This consensus advocates the use of high-resolution esophageal manometry for diagnosis of disorders of EGJ outflow. Myotomy, via either endoscopy or laparoscopy, is the preferred treatment option, while pneumatic dilatation can serve as a secondary option. Evaluation and management of complications including post-procedural reflux and cancer surveillance are recommended., (© 2023 The Authors. Journal of Gastroenterology and Hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Objectives: The management of patent ductus arteriosus (PDA) is a critical concern in premature infants, and different hospitals may have varying treatment policies, fluid management strategies, and incubator humidity. The Asian Neonatal Network Collaboration (AsianNeo) collected data on prematurity care details from hospitals across Asian countries. The aim of this study was to provide a survey of the current practices in the management of PDA in premature infants in Asian countries., Methods: AsianNeo performed a cross-sectional international questionnaire survey in 2022 to assess the human and physical resources of hospitals and clinical management of very preterm infants. The survey covered various aspects of hospitals resources and clinical management, and data were collected from 337 hospitals across Asia. The data collected were used to compare hospitals resources and clinical management of preterm infants between areas and economic status., Results: The policy of PDA management for preterm infants varied across Asian countries in AsianNeo. Hospitals in Northeast Asia were more likely to perform PDA ligation ( p  < 0.001) than hospitals in Southeast Asia. Hospitals in Northeast Asia had stricter fluid restrictions in the first 24 h after birth for infants born at <29 weeks gestation ( p  < 0.001) and on day 14 after birth for infants born at <29 weeks gestation ( p  < 0.001) compared to hospitals in Southeast Asia. Hospitals in Northeast Asia also had a more humidified environment for infants born between 24 weeks gestation and 25 weeks gestation in the first 72 h after birth ( p  < 0.001). A logistic regression model predicted that hospitals were more likely to perform PDA ligation for PDA when the hospitals had a stricter fluid planning on day 14 after birth [Odds ratio (OR) of 1.70, p  = 0.048], more incubator humidity settings (<80% vs. 80%-89%, OR of 3.35, p  = 0.012 and <80% vs. 90%-100%, OR of 5.31, p  < 0.001)., Conclusions: In advanced economies and Northeast Asia, neonatologists tend to adopt a more conservative approach towards fluid management, maintain higher incubator humidity settings and inclined to perform surgical ligation for PDA., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (© 2024 Hsieh, Jeng, Lin, Lin, Rohsiswatmo, Dewi, Chee, Neoh, Velasco, Imperial, Nuntnarumit, Ngerncham, Chang, Kim, Quek, Amin, Kusuda, Miyake and Isayama.)

Background: One of the core features of autism spectrum disorder (ASD) is restricted, repetitive patterns of behavior, interests and activities (RRBs). RRBs are known to adversely affect cognition and adaptive functioning. We explored the relationship of RRBs with cognition and adaptive functioning in children with ASD in an Asian setting., Methods: This cross-sectional study was conducted at a tertiary developmental pediatrics center in Singapore from September 2019 to October 2021. Parent-child dyads (parents and their children ≤7 years old diagnosed with ASD) were recruited. Parents completed the Repetitive Behavior Questionnaire-2 (RBQ-2), which reports total score and two subscales - Motor/Sensory Behaviors (RBQ-2 MS) and Rigidity/Routines/Preoccupation with Restricted Interests (RBQ-2 RRPRI). Standardized assessments included Mullen Scales of Early Learning (MSEL) and Vineland Adaptive Behavior Scales (VABS-II). Data analysis utilized descriptive statistics and Pearson's correlation., Results: Parents of 113 children [75.2% male, mean (SD) age 5.0 (1.2) years] participated. Median (IQR) RBQ-2 score was 29.0 (11.0). Significant negative correlations (adjusted for age, gender and family history of ASD) were observed for total RBQ-2 scores with MSEL ELC scores ( r  = -0.248, n  = 101, p  = 0.014) and VABS-II ABC scores ( r  = -0.281, n  = 88, p  = 0.009). Specifically, these correlations of fair strength were seen only with the RBQ-2 MS subscale for both ELC ( r  = -0.321, n  = 101, p  = 0.001) and ABC ( r  = -0.3478, n  = 88, p  = 0.001)., Conclusion: In children with ASD, severity of RRBs correlated with adverse cognition and adaptive functioning measures in our study, consistent with Western literature. While our study does not show causality, it adds to literature serving as a foundation for further research for both clinicians and researchers to target RRBs in improving outcomes with children in ASD., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Lin, Chan, Kiing, Lim, Chong, Kang, Aishworiya, Mulay and Tan.)

Background: Pre-medical emergency team (MET) calls are an increasingly common tier of Rapid Response Systems, but the epidemiology of patients who trigger a Pre-MET is not well understoof., Objectives: This study aims to examine the epidemiology and outcomes of patients who trigger a pre-MET activation and identify risk factors for further deterioration., Methods: This is a retrospective cohort study of pre-MET activations in a university-affiliated metropolitan hospital in Australia, between 13 April 2021 and 4 October 2021. A multivariable regression model was used to identify variables associated with further deterioration, defined as a MET call or Code Blue within 24 h of pre-MET activation., Results: From a total of 39 664 admissions, there were 7823 pre-MET activations (197.2 per 1000 admissions). Compared to inpatients that did not trigger a pre-MET, the patients were older (68.8 vs 53.8 years, p < 0.001), were more likely to be male (51.0 vs 47.6%, p < 0.001), had an emergency admission (70.1% vs 53.3%, p < 0.001), and were under a medical specialty (63.7 vs 54.9%, p < 0.001). They had a longer hospital length of stay (5.6 vs 0.4 d, p < 0.001) and higher in-hospital mortality (3.4% vs 1.0%, p < 0.001). A pre-MET was more likely to progress to a MET call or Code Blue if it was activated for fever, cardiovascular, neurological, renal, or respiratory criteria (p < 0.001), if the patient was under a paediatric team (p = 0.018), or if there had been a MET call or Code Blue prior to the pre-MET activation (p < 0.001)., Conclusion: Pre-MET activations affect almost 20% of hospital admissions and are associated with a higher risk of mortality. Certain characteristics may predict further deterioration to a MET call or Code Blue, suggesting the potential for early intervention via clinical decision support systems., Competing Interests: Conflicts of interest The authors have no conflicts of interest to declare., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Advances in perinatal care have led to the increased survival of preterm infants with subsequent neonatal morbidities, such as retinopathy of prematurity (ROP). This study aims to compare the differences of neonatal healthcare systems, resources, and clinical practice concerning ROP in Asia with review of current literature. An on-line survey at the institutional level was sent to the directors of 336 neonatal intensive care units (NICU) in 8 collaborating national neonatal networks through the Asian Neonatal Network Collaboration (AsianNeo). ROP screening was performed in infants born at < 34 weeks in Indonesia and Japan. In South Korea, Malaysia, and Taiwan, most screened for ROP in infants born at < 32 weeks. In all networks, majority of NICUs conducted ROP screening to infants with birth weight < 1500 g. In most NICU's in-hospital ophthalmologists performed indirect ophthalmoscopy and some were supplemented with digital imaging. Both laser photocoagulation and anti-vascular endothelial growth factor injection are performed for treatment and, vitreous surgeries are conducted less frequently in all countries. Despite limited information collected by the survey, this first study to compare ROP practices implemented in eight Asian countries through AsianNeo will enable an understanding of the differences and facilitate quality improvement by sharing better practices., (© 2023. Springer Nature Limited.)

Background: Screentime (ST) has been increasingly pervasive in young children. Evidence suggests positive and negative effects of ST on children's development. Parents play a crucial role in influencing their children's ST. There is limited research consolidating the parental perceptions related to children's ST. This review consolidates the evidence on the perception of parents on their children's ST., Methods: Six electronic databases (PubMed, Embase, CINAHL, PsycINFO, Scopus, and ProQuest) were searched from their inception to September 2022. Critical appraisal was conducted using the Critical Appraisal Skills Program (CASP) checklist. Data synthesis was performed using Sandelowski and Barroso's approach., Results: Twenty studies were included in this review, encapsulating the experiences of 1,311 parents. Three main themes with corresponding subthemes were identified: (1) Varied reasons behind ST; (2) Attitudes toward ST; and (3) Strategies and approaches to managing ST., Conclusion: The findings highlighted the varied reasons parents promote ST. Parents reported their concerns and confusion about ST and shared some strategies and approaches for better ST. Future research is needed to develop and evaluate educational programs to ensure that parents understand the risks and benefits of ST and in turn, ensure the appropriate adoption of ST for their children., Impact: In the digital era, parents' attitudes towards screentime (ST) for their children are mixed. This review presents the dilemma parents face and their struggles with using optimal screen time for their children. This review provides up-to-date evidence on the parents' confusion and concerns about ST as well as strategies and approaches used by the parents for better ST. There is an urgent need for evidence-based educational programs to enhance parental knowledge about ST so that they can ensure appropriate ST among children., Clinical Trial Registration: PROSPERO Registration No. CRD42022356083., (© 2023. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Background: Early parent-implemented intervention enhances parent-child interaction and improves language skills in children with autism spectrum disorders (ASD). Parent coaching is often delivered as standard care for children with ASD, where parents are taught to apply strategies in their child's play activities and daily routines to achieve the prior stated goals. However, the ability to conduct parent coaching in physical in-clinic sessions is limited by resource constraints such as clinic space and therapist manpower. Furthermore, parents may experience difficulties with the generalisation of intervention strategies taught in the clinic to their natural home environments. In this study, telerehabilitation is evaluated as an alternative platform to deliver parent coaching for parent-implemented interventions to children with ASD in their homes., Methods: This parallel-group, randomised, controlled, non-inferiority trial aims to evaluate the effectiveness of parent coaching delivered through video conferencing (telerehabilitation) versus in-clinic (standard care) delivery. Children aged 15 to 48 months (n = 200) who meet the cut-off score for ASD on the Autism Diagnostic Observation Schedule-2 are eligible. Parent-child dyads are randomly assigned to receive parent coaching either through weekly telerehabilitation or standard care. The primary outcome is the child's development as measured by the subscale and composite scores of a standardised developmental assessment. Primary analysis will determine if the lower boundary of the 95% confidence interval for the mean difference in pre-post change between groups exceeds -5 (the non-inferiority margin). Secondary outcomes are the child's adaptive behaviour, parent-child interaction, parental stress, and family quality of life. Outcomes will be measured pre-intervention, midterm, and post-intervention. Secondary analysis will determine if there is any between-group difference for the pre-post change in scores at the 5% significance level using two-sample t-test or Mann-Whitney U test., Discussion: As a randomised controlled trial of a moderately large scale, this study will contribute to the limited existing literature on the effectiveness of parent coaching via telerehabilitation for early parent-implemented intervention for children with ASD. The results of this study will provide insights on whether telerehabilitation is comparable to conventional in-clinic parent coaching in enhancing parent-child interaction and improving language skills., Trial Registration: ClinicalTrials.gov NCT05792449. Registered (retrospectively) on 31 March 2023., (© 2023. The Author(s).)

Objective: To investigate in-hospital mortality among people admitted to Australian intensive care units (ICUs) with conditions other than coronavirus disease 2019 (COVID-19) during the COVID-19 pandemic., Design: National, multicentre, retrospective cohort study; analysis of data in the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS CORE) Adult Patient Database., Setting, Participants: Adults (16 years or older) without COVID-19 admitted to Australian ICUs, 1 January 2016 - 30 June 2022., Main Outcome Measures: All-cause in-hospital mortality, unadjusted and relative to the January 2016 value, adjusted for illness severity (Australian and New Zealand Risk of Death [ANZROD] and hospital type), with ICU as a random effect. Points of change in mortality trends (breakpoints) were identified by segmental regression analysis., Results: Data for 950 489 eligible admissions to 186 ICUs were available. In-hospital mortality declined steadily from January 2016 to March 2021 by 0.3% per month (P < 0.001; March 2021 v January 2016: adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.62-0.80), but rose by 1.4% per month during March 2021 - June 2022 (P < 0.001; June 2022 v January 2016: aOR, 1.03; 95% CI, 0.90-1.17). The rise in mortality continued after the number of COVID-19-related ICU admissions had declined; mortality increased in jurisdictions with lower as well as in those with higher numbers of COVID-19-related ICU admissions., Conclusion: The rise in in-hospital mortality among people admitted to Australian ICUs with conditions other than COVID-19 from March 2021 reversed the improvement of the preceding five years. Changes to health service delivery during the pandemic and their consequences should be investigated further., (© 2023 The Authors. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Clinical informatics is a cornerstone in the delivery of safe and quality critical care in Australia and New Zealand. Recent advances in the field of clinical informatics, including new technologies that digitise healthcare data, improved methods of capturing and storing these data, as well as innovative analytic methods using machine learning and artificial intelligence, present exciting new opportunities to leverage data for improving the delivery of critical care and patient outcomes. However, ICU training in Australian and New Zealand does not adequately address capability gaps in this area, potentially leaving future intensivists without the necessary skills to provide leadership in the application of informatics within ICUs. This highlights the need to examine how competency in clinical informatics can be incorporated into ICU training, potentially through a range of activities such as curriculum redesign, the formal project, and workshops or datathons. Further work to identify relevant informatics competencies and methods to develop and assess these competencies within ICU training is needed., (© 2023 Published by Elsevier B.V. on behalf of College of Intensive Care Medicine of Australia and New Zealand.)

Satellite aerosol optical depth (AOD) provides an alternative way to depict the spatial distribution of near-surface PM 2.5 . In this study, a mathematical formulation of how PM 2.5 is related to AOD is presented. When simplified to a linear equation, a functional dependence of the slope on the aerosol type, scattering enhancement factor f(RH), and boundary layer height is revealed, while the influence of the vertical aerosol profile is embedded in the intercept. Specifically, we focus on the effects of aerosol properties and employ a new aerosol index (Normalized Gradient Aerosol Index, NGAI) for classifying aerosol subtypes. The combination of AOD difference at shorter wavelengths over longer-wavelength AOD from AERONET data could distinguish and subclassify aerosol types previously indistinguishable by AE (i.e., urban-industrial pollution, U/I, and biomass burning, BB). AOD-PM 2.5 regressions are performed on these aerosol subtypes at various relative humidity (RH) levels. The results suggest that BB aerosols are nearly hydrophobic until the RH exceeds 80 %, while the AOD-PM 2.5 regressions for U/I depend on RH levels. Moreover, the scattering enhancement factor f(RH) can be calculated by taking the ratio of intercepts between dry and humidity conditions, which is proposed and tested for the first time in this study. Our results show an f(RH ≥ 80 %) of ∼2.6 for U/I-dominated aerosols, whereas the value is not over 1.5 for BB aerosols. The f(RH) can be further used to derive the optical hygroscopicity parameter (κ sca ), demonstrating that the NGAI can be used to exploit differences in aerosol hygroscopicity and improve the AOD-PM 2.5 relationship., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ta-Chih Hsiao reports financial support was provided by Ministry of Education (MOE) in Taiwan. Ta-Chih Hsiao reports financial support was provided by Research Centre for Environmental Changes (RCEC), Academia Sinica in Taiwan., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Successful implementation of rapid response teams (RRTs) requires robust data collection and reporting processes. However, there is variation in data collection practice in RRT activity between hospitals, leading to difficulties in quality review, collaboration and research. Although a standardised RRT data collection model would be a key step in addressing this, there is uncertainty regarding existing RRT data collection practice across Victoria., Objectives: This study was endorsed by Safer Care Victoria (SCV) to evaluate existing RRT data collection practice across Victoria., Methodology: Between 2016 and 2017, hospitals in Victoria were surveyed on data collection practice for RRT activity. Data collected included the fields populated and the mode of data collection. Qualitative content analysis, utilising a blend of pre-existing frameworks and ground-up data-driven approaches for derivation of a coding frame, was used to identify common categories. Validation of the analysis and results was performed by consultation with stakeholder groups., Results: Twenty five hospitals across 18 health networks contributed data, with a mix of tertiary (9/25), metropolitan (11/25) and rural (5/25) hospitals. Seven hospitals collected data electronically, the remainder using paper with abstraction to electronic spreadsheets. None of the hospitals linked with existing hospital data systems to reduce manual data entry requirements. Dataset size varied from 16 to 97 variables but demonstrated content consistency and could be mapped onto seven key categories (comprising antecedent, afferent, event, post-event, audit, context and patient data). Within each category, there was substantial variation in terminology and variable values, but consistency in the collection of a certain subset of variables., Conclusion: Despite broad variation in data collection practice, existing datasets can be readily mapped into seven key categories, with the consistent collection of a subset of variables within each category. These variables could inform the development of a minimum dataset within a standardised RRT reporting framework and accommodate data submission from hospitals of differing resource bases., (Copyright © 2021 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Material fluxes at the land-ocean interface impact seawater composition and global cycling of elements. However, most attention has been focused on the fluvial dissolved fluxes. For elements like lead (Pb), whose fluvial particulate flux into the ocean is two orders of magnitude higher than the dissolved counterpart, the role of particulates in elemental cycling is potentially important but currently less appreciated. Using both chemical analyses on samples collected from around equatorial Southeast Asia and model simulations, we show that particulate-dissolved exchange is an important mechanism controlling the concentration and isotopic composition of dissolved Pb in the ocean. Our model indicates that Pb contributed from particulate-dissolved exchange at ocean boundaries is larger than, or at least comparable to, other major Pb sources to the seawater before the Anthropocene, when the anthropogenic Pb was absent. Our work highlights the importance of boundary exchange in understanding marine element cycling and weathering-climate feedback.

This study applied positive matrix factorization (PMF) to identify the sources of size-resolved submicrometer (10-1000 nm) particles and quantify their contributions to impaired visibility based on the particle number size distributions (PNSDs), aerosol light extinction (b p ), air pollutants (PM 10 , PM 2.5 , SO 2 , O 3 , and NO), and meteorological parameters (temperature, relative humidity, wind speed, wind direction, and ultraviolet index) measured hourly over an urban basin in central Taiwan between 2017 and 2021. The transport of source-specific PNSDs was evaluated with wind and back trajectory analyses. The PMF revealed six sources to the total particle number (TPN), surface (TPS), volume (TPV), and b p . Factor 1 (F1), the key contributor to TPN (35.0 %), represented nucleation (<25 nm) particles associated with fresh traffic emission and secondary new particle formation, which were transported from the west-southwest by stronger winds (>2.2 m s -1 ). F2 represented the large Aitken (50-100 nm) particles transported regionally via northerly winds, whereas F3 represented large accumulation (300-1000 nm) particles, which showed elevated concentrations under stagnant conditions (<1.1 m s -1 ). F4 represented small Aitken (25-50 nm) particles arising from the growth and transport of the nucleation particles (F1) via west-southwesterly winds. F5 represented large Aitken particles originating from combustion-related SO 2 sources and carried by west-northwesterly winds. F6 represented small accumulation (100-300 nm) particles emitted both by local sources and by the remote SO 2 sources found for F5. Overall, large accumulation particles (F3) played the greatest role in determining the TPV (66.4 %) and TPS (34.8 %), and their contribution to b p increased markedly from 17.3 % to 40.7 % as visibility decreased, indicating that TPV and TPS are better metrics than TPN for estimating b p . Furthermore, slow-moving air masses-and therefore stagnant conditions-facilitate the build-up of accumulation mode particles (F3 + F6), resulting in the poorest visibility., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

In the 21st century, plastic production continues to increase at an unprecedented rate, leading to the global issue of plastic pollution. In marine environments, a significant fraction of plastic litter are microplastics, which have a wide range of effects in marine ecosystems. Here, we examine the spatiotemporal distribution of microplastics along the Johor and Singapore Straits, at surface and at depth. Generally, more microplastics were recorded from the surface waters across both Straits. Fragments were the dominant microplastic type (70%), followed by film (25%) and fiber (5%). A total of seven colours of microplastics were identified, with clear microplastics as the most abundant (64.9%), followed by black (25.1%) and blue (5.5%). Microplastics under 500 μm in size accounted for 98.9%, followed by particles 500-1000 μm (1%) and 1-5 mm (0.1%). During the monsoon season, the abundance of microplastics across various sites were observed to be > 1.1 times when compared to the inter-monsoon period. Rainfall was a closely related to the increased microplastic abundance across various sites in the Singapore Strait. This suggests that weather variations during climate change can play critical roles in modulating microplastic availability. Beach sediments facing the Singapore Strait recorded an abundance of 13.1 particles/kg, with polypropylene fragments, polyethylene pellets and thermoplastic polyester foam identified via Fourier transform infrared spectroscopy. Hence, it is crucial to profile the spatiotemporal variation of microplastic abundance in both the surface and in the water column to gain a better understanding of the threat caused by microplastic pollution in the coastal regions of Singapore., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

The marine aquaculture industry has caused a suite of adverse environmental consequences, including offshore eutrophication. However, little is known about the extent to which aquaculture effluents affect nearby wetland ecosystems. We carried out a field experiment in a mangrove stand located between two effluent-receiving creeks to estimate the extent to which marine aquaculture affects the soil nutrient distribution and plant nutrient status of adjacent mangroves. Carbon (C), nitrogen (N), and phosphorus (P) contents and C isotopic signatures were determined seasonally in creeks, pore water, surface soils, and in the leaves of the dominant mangrove species Kandelia obovata. The creeks exhibited nutrient enrichment (2.44 mg N L -1 and 0.09 mg P L -1 on average). The soils had N (from 1.40 to 2.70 g kg -1 ) and P (from 0.58 to 2.76 g kg -1 ) much greater than those of pristine mangrove forests. Combined analyses of the N:P ratio, nutrient resorption efficiency, and proficiency indicated that soil P met plant demands, but plants in most plots showed N limitation, suggesting that soil nutrient accumulation did not fundamentally impact the plant nutrient status. Collectively, this case study shows that marine aquaculture farms can affect adjacent mangrove stands even though their effluents are not directly discharged into the mangrove stands, but mangrove forests may have substantial buffering capabilities for long-term nutrient loading., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objectives: To determine the incidence, causative pathogens, morbidities, mortality, and risk factors associated with blood culture-positive early-onset sepsis (EOS, ≤72 hours of age) in symptomatic neonates admitted to the neonatal intensive care units (NICUs) of a middle-income country., Study Design: Retrospective cohort study using data submitted prospectively to the Malaysian National Neonatal Registry (MNNR)., Setting: 44 Malaysian NICUs., Participants: All neonates born in 2015- 2020., Results: EOS was reported in 991 neonates. The annual incidence of EOS increased from 0.46 to 0.49/1000 livebirths over the six years. The most common pathogen was Streptococcus agalactiae or Group B haemolytic streptococcus (GBS) (n=388, 39.2%), followed by Escherichia coli (E. coli) (n=80, 8.1%), Klebsiella spp (n=73, 7.4%), coagulase negative staphylococcus (CONS) (n=73, 7.4%), Pseudomonas spp (n=44, 4.4%) and methicillin-sensitive Staphylococcus aureus (n=34, 3.4%). The incidence of EOS due to GBS increased from 0.17 to 0.22/1000 livebirths. Morbidities and mortality were higher in those with EOS than without EOS. Multiple logistic regression analysis showed that Indian ethnic group, chorioamnionitis, gestation≥37weeks, female, spontaneous vaginal delivery, instrumental delivery, and surfactant therapy were significantly associated with increased risk of EOS due to GBS. Four factors were significantly associated with increased risk of non-GBS EOS (outborns, birthweight lt;1000 g, vaginal delivery, and surfactant therapy). Early continuous positive airway pressure was associated with significantly lower risk of EOS., Conclusion: The incidence of EOS showed an increasing trend in Malaysian NICUs. GBS was the most common causative pathogen. Several modifiable risk factors associated with EOS have been identified.

Purpose: Previous studies show that customer loyalty and purchase intentions were influenced by perceived product value, but little is known about the factors that influence patients' perceptions of the value of their subsidized prescriptions, when purchasing of medications were not required, and how these factors influence their medication adherence. Hence, this study aims to investigate perceptions of patients receiving subsidized medications regarding the value of their medication., Patients and Methods: This qualitative study involved semi-structured, face-to-face interviews with patients diagnosed with type 2 diabetes mellitus at a government district hospital in Selangor state, Malaysia between June to September 2019. Using purposive sampling, patients were identified at an out-patient pharmacy during prescription refill. They were asked how they perceived the value of their medication. Interviews were audio recorded and then transcribed verbatim for thematic analysis., Results: A total of thirty patients were interviewed. Patients' perceptions on the value of medications were influenced by several factors such as trust, how the medications impact on their physical and social well-beings, and the perceived sacrificed made when the medications were procured and used. Perceptions on medication values were influenced by the recommendation received from someone they trust such as their doctors or significant others. It was also influenced by their perceptions of how the medication helps to improve their disease symptoms and affect their religious and social activities. Other factors include the perceived worth of the sacrifices made to access and use the medication., Conclusion: Identifying factors that may influence patients' perceived value of the medication may help improve healthcare practices., Competing Interests: The authors report no conflicts of interest in this work., (© 2022 Lim et al.)

This study investigated the hourly inorganic aerosol chemistry and its impact on atmospheric visibility over an urban area in Central Taiwan, by relying on measurements of aerosol light extinction, inorganic gases, and PM 2.5 water-soluble ions (WSIs), and simulations from a thermodynamic equilibrium model. On average, the sulfate (SO 4 2- ), nitrate (NO 3 - ), and ammonium (NH 4 + ) components (SNA) contributed ∼90% of WSI concentrations, which in turn made up about 50% of the PM 2.5 mass. During the entire observation period, PM 2.5 and SNA concentrations, aerosol pH, aerosol liquid water content (ALWC), and sulfur and nitrogen conversion ratios all increased with decreasing visibility. In particular, the NO 3 - contribution to PM 2.5 increased, whereas the SO 4 2- contribution decreased, with decreasing visibility. The diurnal variations of the above parameters indicate that the interaction and likely mutual promotion between NO 3 - and ALWC enhanced the hygroscopicity and aqueous-phase reactions conducive for NO 3 - formation, thus led to severely impaired visibility. The high relative humidity (RH) at the study area (average 70.7%) was a necessary but not sole factor leading to enhanced NO 3 - formation, which was more directly associated with elevated ALWC and aerosol pH. Simulations from the thermodynamic model depict that the inorganic aerosol system in the study area was characterized by fully neutralized SO 4 2- (i.e. a saturated factor in visibility reduction) and excess NH 4 + amidst a NH 3 -rich environment. As a result, PM 2.5 composition was most sensitive to gas-phase HNO 3 , and hence NOx, and relatively insensitive to NH 3 . Consequently, a reduction of NOx would result in instantaneous cuts of NO 3 - , PM 2.5 , and ALWC, and hence improved visibility. On the other hand, a substantial amount of NH 3 reduction (>70%) would be required to lower the aerosol pH, driving more than 50% of the particulate phase NO 3 - to the gas phase, thereby making NH 3 a limiting factor in shifting PM 2.5 composition., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Gastric cancer is one of the most common malignancies around the world, and a variety of neoadjuvant chemotherapies with different drug combinations are available for the treatment. R0 resection refers to a microscopically negative margin on resection, where no gross or microscopic tumour remains in the primary tumour. We aimed to find evidence on the relative effectiveness of neoadjuvant therapies for patients with advanced gastroesophageal and gastric cancer on the R0 resection rate., Methods: Relevant randomised controlled trials were searched using appropriate keywords in health-related databases. We performed network meta-analysis within a frequentist framework. The endpoint assessed was the R0 resection rate. We assessed consistency and transitivity assumptions that are necessary for network meta-analysis. This study only used data from published studies. The need for consent from participants was waived by the Ethics Review Committee of the International Medical University in Malaysia., Results: Six randomised controlled trials involving 1700 patients were identified. A network plot was formed with five neoadjuvant regimens [DLX (pyrimidine analogue + platinum compounds + chemoradiotherapy), DELX (pyrimidine analogue + epipodophylllotoxins/etoposide + platinum compounds + chemoradiotherapy), ADL (anthracycline + pyrimidine analogue + platinum compounds), ADM (anthracycline+ pyrimidine analogue + anti-folate compounds) and LTX (platinum compounds + taxane + chemoradiotherapy)] and surgery alone for management of patients with advanced gastroesophageal and gastric cancer. Assumptions required for a network meta-analysis such as consistency ((global test: Chi2 (1): 3.71; p:0.054)), and the transitivity in accord to the characteristics of interventions considered in this review were not violated. In the network comparison, surgery alone has a lower R0 resection rate compared with LTX (OR 0.2, 95%CI:0.01, 0.38) or DLX (OR 0.48, 95%CI: 0.29, 0.79). LTX has higher resection rate compared with DLX (OR 2.47, 95%CI: 1.08 to 5.63), DELX (OR 106.0, 95%CI: 25.29 to 444.21), ADM (OR 5.41, 95%CI: 1.56 to 18.78) or ADL (OR 3.12, 95%CI: 1.27 to 7.67). There were wide or very wide CIs in many of these comparisons. Overall certainty of the evidence was low or very low. Further research in this field is very likely to have an important impact on our confidence in the R0 resection rates between LTX versus other neoadjuvant chemotherapy is likely to change the estimate., Conclusions: Findings suggest that overall quality of evidence on the relative effectiveness of neoadjuvant chemotherapies was low to very low level. Therefore, we are very uncertain about the true effect of neoadjuvant therapies in the R0 resection rate in patients with gastroesophageal and gastric cancer. Future well-designed large trials are needed. To recruit large samples in this field, multicountry trials are recommended. Future trials also need to assess treatment-related adverse events, and patients-centered outcomes such as health-related quality of life., Competing Interests: The authors have declared that no competing interests exist.

We evaluated factors affecting psychological ill-effects and resilience of caregivers of children with developmental disabilities during the coronavirus pandemic. Depression, Anxiety, and Stress Scales (DASS-21) and Connor-Davidson Resilience Scale 25-item were administered. Logistic regression was used to identify factors associated with psychological ill-effects and resilience. DASS-21 depression, anxiety and stress scores were high; these were associated with difficulties with infection control measures, autism diagnosis, and need for early intervention services. For caregivers of children with ASD, our DASS-21 scores were significantly higher than non-pandemic scores locally and in other Asian sites. Resilience scores correlated inversely with DASS-21 scores. Targeted support to selected at-risk caregivers and improving resilience can help their coping., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The mechanisms by which insulin activates the insulin receptor to promote metabolic processes and cellular growth are still not clear. Significant advances have been gained from recent structural studies in understanding how insulin binds to its receptor. However, the way in which specific interactions lead to either metabolic or mitogenic signalling remains unknown. Currently there are only a few examples of insulin receptor agonists that have biased signalling properties. Here we use novel insulin analogues that differ only in the chemical composition at the A6-A11 bond, as it has been changed to a rigid, non-reducible C=C linkage (dicarba bond), to reveal mechanisms underlying signaling bias. We show that introduction of an A6-A11 cis- dicarba bond into either native insulin or the basal/long acting insulin glargine results in biased signalling analogues with low mitogenic potency. This can be attributed to reduced insulin receptor activation that prevents effective receptor internalization and mitogenic signalling. Insight gained into the receptor interactions affected by insertion of an A6-A11 cis- dicarba bond will ultimately assist in the development of new insulin analogues for the treatment of diabetes that confer low mitogenic activity and therefore pose minimal risk of promoting cancer with long term use., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ong, Belgi, Merriman, Delaine, van Lierop, Andrikopoulos, Robinson and Forbes.)

Objectives: To investigate the types of therapeutic hypothermia (TH) used and risk factors associated with mortality in late-preterm and term neonates (LPTN, gestation of ≥35 weeks) with hypoxic-ischemic encephalopathy (HIE) in a middle-income country., Design: This was an observational retrospective cohort study., Setting: A total of 44 neonatal intensive care units (NICUs) in the Malaysian National Neonatal Registry participated in the study., Patients: All LPTN without major malformations and diagnosed to have HIE were included., Main Outcome Measures: Number of in-hospital mortality, and types of TH used [no TH, TH using commercially available servo-controlled devices (SCDs), passive TH by exposing neonates to NICU's air-conditioned ambient temperature with/without the use of cooled gel packs (P±CGPs)]., Results: Of a total of 2,761 HIE neonates, 66.3% received TH. All NICUs provided TH; 55.4% NICUs had SCDs, which was administered to 43.6% (248/569) of severe, 51.6% (636/1,232) of moderate, and 18.6% (179/960) of mild HIE neonates. P±CGPs was used on 26.9% of severe, 33.4% of moderate, and 21.1% of mild HIE neonates. There were 338 deaths. Multiple logistic regression analysis showed that 5-min Apgar scores <5 (aOR: 1.436; 95% CI: 1.019, 2.023), Cesarean section (aOR: 2.335; 95% CI: 1.700, 3.207), receiving no TH (aOR: 4.749; 95% CI: 3.201, 7.045), TH using P±CGPs (aOR: 1.553; 95% CI: 1.031, 2.338), NICUs admitted <50 HIE cases (aOR: 1.898; 95% CI: 1.225, 2.940), NICUs admitted 50-<100 HIE cases (aOR: 1.552; 95% CI: 1.065, 2.260), moderate HIE (aOR: 2.823; 95% CI: 1.495, 5.333), severe HIE (aOR: 34.925, 95% CI: 18.478, 66.012), Thompson scores of 7-13 (aOR: 1.776; 95% CI: 1.023,3.082), Thompson scores of ≥14 (aOR: 3.641; 95% CI: 2.000, 6.629), pneumothorax (aOR: 3.435; 95% CI: 1.996, 5.914), and foreigners (aOR: 1.646; 95% CI: 1.006, 2.692) were significant risk factors associated with mortality., Conclusion: Both SCD and P±CGP were used for TH. Moderate/severe HIE and receiving passive/no TH were among the risk factors associated with mortality., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Boo, Neoh and Chee.)

We describe the design and implementation of an intensive care unit (ICU) virtual visiting program in a metropolitan ICU in Melbourne, Victoria, Australia, to examine patterns of use, and describe clinician acceptance of this technology. This was a mixed-methods study, comprising a retrospective analysis of virtual visits from 18 August to 30 September 2020. Patterns of utilisation included duration and time of visits, as well as bandwidth used. A post-implementation survey on a Virtual Visiting program based on the technology acceptance model was sent to clinicians; results were reported on separate scales for usefulness and usability. Publicly available telecommunication solutions were unsuitable for virtual visiting, whereas dedicated telehealth solutions needed modification to improve accessibility by patients and families. During the study period, 69 virtual visits were made with a median length of 10 min (range 1-80 min). A total of 72.5% of calls were made during office hours (09:00-17:00 h), with the latest occurring at approximately 21:30 h. Virtual visits required a mean bandwidth of 1224 kbps (download) and 940 kbps (upload), and consumed 0.7 GB (range 0.0-7.0 GB) and 0.5 GB (range 0.0-6.7 GB) of download and upload data. Clinicians reported a mean score of 2 (range 1-4) for perceived usefulness and 3 (range 1-6) for the perceived ease of use. Virtual visiting is a feasible alternative in the ICU, with good acceptance by clinicians. Challenges include safety and usability of videoconferencing platforms, as well as bandwidth requirements. Future health service design should consider support for dedicated virtual visiting solutions, as well as ensuring adequate bandwidth capabilities for this service. Further studies are needed to assess patient and family acceptability of this technology.

Purpose: To determine 2-year efficacy of the PAUL Glaucoma Implant (PGI), a novel glaucoma tube shunt in patients with advanced glaucoma., Participants: Patients with glaucoma refractory to maximum medical therapy or previous failed glaucoma surgery., Methods: Retrospective review of all patients who had underwent PGI implantation in a single tertiary institution between May 1, 2017 and March 30, 2021., Main Outcome Measures: Primary outcome measure was failure defined as intraocular pressure (IOP) >18 mm Hg or <6 mm Hg on 2 consecutive visits after 3 months, reoperation for IOP-related indication, explantation of implant or loss of light perception vision. Complete success was defined as unmedicated IOP ≤18 mm Hg or ≥6 mm Hg in the absence of failure., Results: Forty-five eyes in 45 patients were identified, with mean follow-up duration of 24.9±2.0 months. Thirty patients (66.7%) had primary glaucoma and 11 (24.4%) with previous glaucoma surgery. At 2 years following surgery, 8 eyes (17.8%) fulfilled the failure criteria with 32 eyes (71.1%) achieving complete success. Compared with mean medicated preoperative IOP (19.8±6.3 mm Hg), postoperative IOP at 24 months was 13.9±3.7 (P<0.01). Mean number of medications decreased from 3.2±0.8 preoperatively to 0.29±0.65 at 24 months (P<0.01). Significant complications included self-limiting shallow anterior chamber (n=10; 22.2%), hypotony requiring intervention (n=4; 8.9%) and tube occlusion (n=4; 8.9%)., Conclusions: The PGI was able to achieve sustained IOP reduction with reduction of medications at 2 years postsurgery in patients with advanced glaucoma., Competing Interests: Disclosure: P.C.T.K. and C.C.A.S. are co-inventors of the PAUL Glaucoma Implant (PGI) (Advanced Ophthalmic Innovations Pte Ltd, Singapore) and hold related patents. The remaining authors declare no conflict of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

The deterioration of visibility due to air pollutants and relative humidity has been a serious environmental problem in eastern Asia. In most previous studies, chemical compositions of atmospheric particles were provided using filter-based offline analyses, which were unable to provide long-term and in-situ measurements that resolve sufficient temporal variations of air pollution and meteorology, hindering the resolution of the relationship between air quality and visibility. Here, we present a year-long continuously measured data from a comprehensive suite of online instruments to investigate diurnal and seasonal impacts of the aerosol chemical compositions in PM 2.5 on visibility seasonally and diurnally. The measured dry aerosol extinction at λ = 550 nm reached a closure with that predicted by aerosol compositions within 12%. However, the hygroscopic growth of particles under ambient RH could enhance the aerosol extinction by a factor of 2-6, matching the perceptive visibility of the public. Particulate ammonium nitrate was most sensitive to reducing visibility, while ammonium sulfate contributed the most to the light extinction. In spring and winter, the monsoon and stagnant air masses reduced the visibility and increased PM 2.5 (>35 μg m -3 ). The moisture was found to substantially enhance the light extinction under RH = 60-90%, reducing visibility by approximately 15 km, largely attributed to hygroscopic inorganic salts. This study serves as a metric to highlight the need to consider the influence of RH, and aqueous reactions in producing secondary inorganic aerosols on atmospheric visibility, underpinning the more accurate mitigation strategies of air pollution., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: With more frail elderly living and likely to die in nursing homes, advance care planning (ACP) is critical in overall efforts to provide good palliative care. However, it is unclear how willing older, vulnerable residents in nursing homes are to take on an active role in care decisions., Aim: The objective of this pilot study was to examine nursing homes' healthcare professionals' and residents' views on ACP and the extent of similarities and differences in their views., Methods: Our sample of 24 healthcare professionals and 24 residents were identified and recruited through contacts established from existing collaborations with the nursing homes. Surveys were administered to the participants by a trained research assistant between April 2015 and August 2015., Results: Almost all the healthcare professionals (95.8%) would like to make an ACP for themselves in the future, while residents were divided in their choices (P<<0.01). Most residents (79.1%) felt that the most important guide for their surrogate in making decisions for them when they lose decision-making capacity should be based on their best interests. However, most healthcare professionals (75.0%) felt that it should be based on the resident's wishes and values., Conclusions: Healthcare professionals tended to overestimate the importance of patient autonomy compared to the residents. This study demonstrates that as much as advocacy and awareness are ongoing, nursing home residents' motivation to participate in ACP is lacking. The lack of motivation in ACP participation could be due to medical paternalism and familial determination, which have been a cultural norm for older Singaporeans. This study demonstrates there is a lack of cultural sensitivity in this group of healthcare professionals in approaching nursing home residents' end-of-life care decision-making.

Background: Inhaler technique errors can affect the disease outcome through reduced deposition of medication in the lungs with certain errors were more likely to deter the optimum drug from reaching the lung. The objective of this study was to evaluate the pressurized metered-dose inhaler (pMDI) critical technique errors among asthma and COPD patients, and to investigate the predictors of those errors. Methods: A cross-sectional, observational, and multi-centered study conducted in 3 major hospitals in the state of Penang, Malaysia. Asthma and COPD patients aged 18 years or older consented to the study were consecutively recruited if they were at least on 1 pMDI without mouthpiece spacer or facemask space. Direct observation of the patient's technique was recorded using a standard checklist and certain steps in the checklist were pre-determined as critical steps. The number of patients missed or incorrectly performed the steps including the critical steps were documented. Using logistic regression, the factors associated with the critical errors were determined, and the correlation was evaluated between age and pMDI knowledge score with critical inhalation steps score. Results: Of 209 patients observed, only less than half (40.7%) could perform all the critical pMDI steps correctly. Low education level was the only factor associated with critical inhaler errors. The increased knowledge of their inhaled medication was found to positively correlate with the correct critical inhalation steps. The critical errors also increase with the increased age of patients. Conclusion: The majority of the study population make inhalation error particularly in critical steps. Training and education intervention programs may help patients with lower education level, as well as those of advanced age and lack of knowledge of their inhaled medication because those populations are at a greater risk of committing critical errors in their use of pMDI., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Objective: There is a growing recognition of the impact of lockdowns on non-COVID-19 demand for critical care services. While a reduction in demand has been postulated, there remains a paucity of quantitative data on the extent and nature of this reduction. The present study aims to quantify the impact of lockdown on critical care services, namely ED, intensive care unit (ICU), medical emergency team (MET) and emergency theatre (ET) demand, during the lockdown in Victoria, Australia., Methods: This is a single-centred, retrospective observational study on critical service demand, comparing activity levels during the lockdown (31 March to 27 October 2020) with the matched time period from 1 year prior., Results: There was a reduction in presentations to ED (27.2%), MET calls (27.4%), ICU patient episodes (14.5%) and ET bookings (5.8%). There was an unexpected increase in ICU admissions for metabolic diagnoses, comprising drug overdoses and diabetic ketoacidosis, and a reduction in respiratory ICU admissions. There was a reduction across all ED triage categories, which included triage 1 and 2 patients, indicating a reduction even in life-threatening and emergency presentations., Conclusion: Lockdowns lead to a significant reduction in ICU, MET call and ED demand, and to a lesser extent ET demand. This pattern should be considered in surge capacity and workforce redeployment planning. There are also impacts on public health epidemiology, with potential adverse consequences on mental health and chronic disease management. Further research on the impact of lockdowns on long-term disease outcomes is needed., (© 2021 Australasian College for Emergency Medicine.)

The identification of nitrogen sources and cycling processes is critical to the management of nitrogen pollution. Here, we used both stable (δ 15 N-NO 3 - , δ 18 O-NO 3 - , δ 15 N-NH 4 + ) and radiogenic ( 222 Rn) isotopes together with nitrogen concentrations to evaluate the relative importance of point (i.e. sewage) and diffuse sources (i.e. agricultural-derived NO 3 - from groundwater, drains and creeks) in driving nitrogen dynamic in a shallow coastal embayment, Port Phillip Bay (PPB) in Victoria, Australia. This study is an exemplar of nitrogen-limited coastal systems around the world where nitrogen contamination is prevalent and where constraining it may be challenging. In addition to surrounding land use, we found that the distributions of NO 3 - and NH 4 + in the bay were closely linked to the presence of drift algae. Highest NO 3 - and NH 4 + concentrations were 315 μmol L -1 and 2140 μmol L -1 , respectively. Based on the isotopic signatures of NO 3 - (δ 15 N: 0.17 to 21‰; δ 18 O: 3 to 26‰) and NH 4 + (δ 15 N: 30 to 39‰) in PPB, the high nitrogen concentrations were attributed to three major sources which varied between winter and summer; (1) nitrified sewage effluent and drift algae derived NH 4 + mainly during winter, (2) NO 3 - mixture from atmospheric deposition, drains and creeks predominantly observed during summer and (3) groundwater and sewage derived NO 3 - during both surveys. The isotopic composition of NO 3 - also suggested the removal of agriculture-derived NO 3 - through denitrification was prevalent during transport. This study highlights the role of terrestrial-coastal interactions on nitrogen dynamics and illustrates the importance of submarine groundwater discharge as a prominent pathway of diffuse NO 3 - inputs. Quantifying the relative contributions of multiple NO 3 - input pathways, however, require more extensive efforts and is an important avenue for future research., Competing Interests: Declaration of competing interest All authors declare no conflict of interest., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Image noise is a variation of uneven pixel values that occurs randomly. A good estimation of image noise parameters is crucial in image noise modeling, image denoising, and image quality assessment. To the best of our knowledge, there is no single estimator that can predict all noise parameters for multiple noise types. The first contribution of our research was to design a noise data feature extractor that can effectively extract noise information from the image pair. The second contribution of our work leveraged other noise parameter estimation algorithms that can only predict one type of noise. Our proposed method, DE-G, can estimate additive noise, multiplicative noise, and impulsive noise from single-source images accurately. We also show the capability of the proposed method in estimating multiple corruptions.

Background: To characterize the nature and severity of feeding difficulties in Asian young children with Autism Spectrum Disorders (ASD) and identify potential predictors of poorer feeding outcomes., Methods: Cross sectional study of children aged 1-7 years with ASD. Parents completed the following: demographic information, brief autism mealtime behavior inventory, aberrant behavior checklist (ABC), behavioral pediatrics feeding assessment scale (BPFAS) and caregiver feeding style questionnaire. Additional information (medical data, cognitive and developmental assessment results, e.g., Autism Diagnostic Observation Schedule Second Edition, Autism Diagnostic Interview, Revised, Vineland Adaptive Behaviour Scales, etc.) were subsequently obtained from electronic medical records retrospectively by one of the study team members., Results: Of the 67 children, 28.4% had feeding difficulties (high BPFAS total frequency score). Caregiver feeding styles were authoritarian (34.8%) or indulgent (39.4%). Child characteristics did not significantly predict for the severity of feeding difficulties. Univariate analysis revealed that authoritarian feeding style (p = 0.001) and ABC hyperactivity score (p = 0.006) were significantly associated with BPFAS severity score. Multivariate analysis revealed that ABC hyperactivity score remained significantly associated with BPFAS severity score after controlling for all other ABC subscale scores. A final regression model including all child characteristics and ABC scores did not reveal any significant predictors of BPFAS total frequency score (R2 = 0.557)., Conclusion: Our findings suggest an association between hyperactivity, authoritarian feeding style and feeding difficulties. Children with ASD who have significant hyperactivity behaviors in the context of parents with an authoritarian feeding style should be actively screened for problematic feeding behaviors., Competing Interests: Declaration of competing interest The study did not receive any funding to declare. The authors have no conflict of interest to declare., (Copyright © 2021. Published by Elsevier B.V.)