Princess Margaret Hospital

Coastal fisheries are essential to Pacific Island communities, providing vital nutrition, livelihoods, and cultural value, yet microplastic (MP) contamination poses a growing threat to both ecosystem and human health. This study presents a regional assessment of microplastic contamination in coastal fish across four Pacific Island Countries and Territories (Fiji, Tonga, Tuvalu, and Vanuatu), based on the compilation of four methodologically standardized datasets, enabling us to evaluate whether regional patterns of contamination are linked to the ecological traits of fish. A total of 878 fish from 138 species were analysed to reveal widespread ingestion (32.7% prevalence; 0.76 ± 0.05 MPs/individual), with Fiji exhibiting the highest contamination (74.5% frequency). Reef-associated invertivores such as Lethrinus harak showed elevated risks (80% contaminated in Fiji), driven by fiber-dominated particles (65–95%), while ecological traits (benthic feeding, reef habitats) increased exposure compared to nearshore pelagic species. Disparities emerged between nations, with Fiji’s sites exceeding global averages despite remoteness, whereas Vanuatu’s low fish contamination suggests restricted dispersal, successful waste management influences, or differential bioaccumulation pathways. Polypropylene, polyethylene, polyethylene terephthalate, and nylon were the dominant (~11–43%) polymer types across all countries. The findings highlight the essential need to incorporate the Pacific Island data into global pollution assessments to better represent tropical Pacific marine ecosystems. This work establishes a standardized baseline for microplastics in the Pacific coastal fish, providing a framework to guide future research on ecological impacts while highlighting the need to integrate these data into regional and global plastics negotiations. The study underscores the importance of expanding monitoring to underrepresented PICTs to better understand contamination drivers in island ecosystems.

Background:Emergency medical services (EMS) encounters with palliative care patients present unique operational challenges. As EMS providers increasingly care for individuals with life-limiting illnesses, understanding the intersection of emergency care and palliative medicine has become essential to optimizing healthcare delivery.Objective:This study examines EMS operational metrics, resource allocation patterns, and clinical outcomes among palliative care patients in Thailand.Methods:This retrospective analysis study investigated operational times, resource utilization, and clinical outcomes in palliative care patients utilizing EMS services, derived from electronic medical records and EMS documentation. This study was conducted at the Srinagarind Hospital EMS unit from October 2019 to September 2024. All patients diagnosed with palliative care (ICD-10 code Z51.5) who utilized EMS services were included.Results:Palliative care patients represented 6.9% (N = 340) of total EMS utilization (N = 4520), with cases increasing from 51 patients (15.0%) in 2019–2020 to 89 patients (26.2%) in 2023–2024. The median age was 72 years, with 62.9% male patients. Palliative care patients demonstrated significantly prolonged EMS operational times: activation (1.51 min vs 1.27 min), response (10.21 min vs 9.35 min), and scene time (22.05 min vs 10.02 min, p < 0.001). Resource utilization showed higher rates of pain medication administration (30.88% vs 7.79%) and exclusive use of comfort-focused interventions. Patient outcomes revealed significantly higher discharge rates.Conclusion:Palliative care patients utilizing EMS services represent a distinct population requiring specialized operational approaches. Extended scene times reflect appropriate symptom-focused care delivery rather than rapid transport protocols. Higher discharge rates validate the EMS role as a symptom management bridge.

SummaryDevice-detected atrial fibrillation (DDAF), including atrial high-rate episodes recorded at a cardiovascular implantable electronic device and subclinical atrial fibrillation detected by insertable cardiac monitor and smart wearables, poses an increasing challenge in stroke prevention. Although oral anticoagulants (OACs) are effective in clinical AF, their benefit-risk balance in DDAF remains uncertain. In response, the Asia Pacific Heart Rhythm Society (APHRS) proposes the 4S-DDAF approach (Strip documentation and longest AF duration, Symptoms, Stroke [ischemic] history, and Score) to guide anticoagulation decisions. This approach integrates electrogram review, symptom assessment, history of ischemic stroke or transient ischemic attack (TIA), and CHA2DS2-VASc scoring, emphasizing individualized care. OACs are recommended for patients with AF episodes ≥24 h, prior stroke/TIA, CHA2DS2-VASc score ≥4, or vascular disease. In patients not meeting these thresholds, close monitoring and risk factor management are advised. The 4S-DDAF approach provides a practical and evidence-informed strategy for clinical decision-making in the management of DDAF.

IntroductionNeutropenic fever (NF) has a crude mortality rate of 3–18%. International guidelines recommend that all patients with NF receive ultrabroad-spectrum antibiotics (UBSAs) within 1 hour of emergency department (ED) registration. However, over 70% patients presenting to hospital with suspected NF (sNF) cannot access absolute neutrophil count (ANC) result within 1 hour, do not have NF and do not require UBSAs. In ED and hospitalised patients with sNF, we hypothesise that the ASTERIC protocol effectively and safely reduces the use of UBSAs compared with standard care alone.Methods and analysisThis pragmatic, parallel, multicentre, type 1, hybrid effectiveness-implementation, stepped-wedge, before-and-after, cluster randomised controlled trial aims to evaluate whether antibiotic prescribing can be safely reduced through implementing a multifaceted antibiotic stewardship intervention (ASTERIC) in adult patients with sNF presenting to EDs. The sNF was defined as a fever with a single oral temperature of ≥38.3°C (101°F) within 24 hours before ED registration or a temperature of ≥38.0°C (100.4°F) sustained over a 1-hour period, following last chemotherapy or targeted therapy within 6 weeks for any solid tumour, or in any period following therapies against leucaemia, lymphoma, myelodysplastic syndrome, aplastic anaemia, multiple myeloma or recipient of HSCT. The study will involve eight hospitals in Hong Kong with variable baseline practice. We will include 704 adult patients (352 patients in pre-implementation and post-implementation periods, respectively) with sNF (tympanic temperature ≥38.3°C) and 48 staff participants (6 staff participants in each hospital). Healthcare professionals will receive a multifaceted stewardship intervention consisting of risk assessment tools, fast-track ANCs, a decision tool for patient management and antibiotic use, supported by an educational package and staff interaction programmes (ASTERIC protocol). Patients’ blood ANC, and cancer therapy and chronic illness therapy scores will be measured. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) and Proctor conceptual frameworks will be followed for evaluation of implementation. The main outcome measures are the mean total dose of UBSAs prescribed in 7 days and serious adverse events at 30 days. Data analysis will incorporate intention-to-treat, per-protocol and as-treated analyses for service outcomes (effectiveness, safety, quality of life assessments and cost-effectiveness) and mixed methods for implementation outcomes, informed by the Theoretical Domains Framework. We expect that the study results will inform health policy with improvement in hospital services in treating stable sNF, evidenced by improved safe antibiotic stewardship, early antibiotic de-escalation and reduced costs and length of stay.Ethics and disseminationThe institutional review boards of all study sites approved this study. This study will establish the ASTERIC protocol safely improves antibiotic stewardship and clinical management in adult patients with sNF. We will disseminate the findings through peer-reviewed publications, conference presentations and educational activities. All patients with sNF will be influenced by the new protocol which is agreed at hospital level. Randomisation is at hospital level, not patient level. Patient consent is sought for follow-up and data access, not for treatment. Staff consent is sought for interviewing.Trial registration numberNCT06794320.

ABSTRACT H9N2 is currently the second most common avian influenza A virus subtype infecting humans. Monitoring viral phenotypic and genotypic adaptation to humans is crucial for risk assessment. Here, we compared the replication of an H9N2 human isolate collected in 2024 (A/HK/2346/2024) to a human isolate collected in 1999 (A/HK/1073/1999). In Madin Darby canine kidney (MDCK) cells, A/HK/2346/2024 and A/HK/1073/1999 replicated to 8 and 5 log10 plaque-forming units (PFU) per ml, respectively. In both human nasal and lung organoids, A/HK/2346/2024 replicated to 6 log10 PFU/ml, but A/HK/1073/1999 failed to replicate in either organoid. The infection rates of both ciliated and non-ciliated cells and the ratios of infected 2,6/2,3 cells were higher for A/HK/2346/2024 than A/HK/1073/1999. Apart from the mammalian adaptive substitutions that were present in the nasopharyngeal specimen collected on day 1 post-symptom onset (pso) (HA-D183N/D190 T/Q192R/Q226L; NA-del62-64; PB2-A588V/K702R; PB1-I368V; PA-K356R/S409N; M1-R95K), the mammalian-adaptive substitution PB2-D253N emerged de novo on day 7 pso. Analysis of all human (n = 96) and avian influenza (n = 14,762) H9N2 deposited at GISAID showed the dominance of several human-adaptive substitutions in H9N2 strains collected from humans in recent years. In summary, we demonstrated that a recent H9N2 virus is more adapted to humans, and is able to replicate to high titres in both upper and lower human respiratory tract which may confer higher person-to-person transmissibility and virulence. Our study underscores the importance of human organoid-based phenotypic monitoring and inter/intrahost genotypic monitoring for assessing the zoonotic risk of avian influenza viruses.

Although computed tomography (CT) can predict round window (RW) visibility at posterior tympanotomy pre-operatively, there is a trend towards the application of using magnetic resonance imaging (MRI) alone for cochlear implant (CI) planning. This study assessed the potential of a novel "Black Bone" (BB) MRI sequence to determine RW visibility during posterior tympanotomy. Patients underwent BB MRI as part of pre-operative CI planning. Two independent radiologists performed 5 landmark-based MRI measurements. RW visibility was recorded during posterior tympanotomy as > 50% or < 50% visibility. Patients with undefinable landmarks or absent surgical grading were excluded. Mann-Whitney U or t-tests compared MRI measurements to RW visibility whilst step wise logistic regression determined significant predictors. 86 patients (40 male; median 10.5 years) and 129 implanted ears (43 unilateral, 43 bilateral; 52 adult, 77 paediatric) were evaluated. There were 109/129 ears with > 50% and 20/129 ears with < 50% RW visibility. The external auditory canal (EAC) angle was increased in paediatric patients with > 50% RW visibility (P = 0.033; AUROC 0.689; 73.4% sensitive, 69.2% specific with threshold 6.2o) with ICC = 0.598. The facial recess distance, facial nerve location, and modified RW niche angle were increased in adult patients with > 50% RW visibility but only modified RW niche angle was significant on stepwise regression (P = 0.016; AUROC 0.805; 82.2% sensitive, 71.4% specific with threshold 17.95o) with ICC = 0.578. The visibility of RW at posterior tympanotomy may be determined with pre-operative BB MRI. The optimal predictive measurements differ between adult and paediatric patients and there is superior performance in adults.