Citrobacter freundii infections have not been previously described as an aetiology for lymphadenitis in healthy adults. Non-tuberculous mycobacteria (NTM) infections typically occur in young children or immunocompromised individuals, with few cases seen in adults. A woman in her 20s presented with lymphadenitis that was subsequently positive for C. freundii and NTM on needle biopsy and was treated with antibiotics. The patient was followed up for 3 months with regular ultrasound scans and is currently asymptomatic. The excisional biopsy was cancelled as a result. This case highlights the complexity of making a diagnosis in some patients with cervical adenopathy, and as such, it is crucial to use the patient’s clinical course to guide treatment modalities. Contamination was a possibility in this case given the number of organisms shown on biopsy and the lack of response to treatment, and we provide an approach to management in this case of uncertainty.

Road traffic collisions are among the top ten causes of death worldwide with more than 1.3 million deaths annually (WHO, 2018). Riders of motorised two- and three-wheelers are more vulnerable to injury and death and make up 28% of global road traffic deaths. In some regions, such as South-East Asia, this number is as high as 43% (WHO, 2018). Correct helmet use reduces the risk of death by 42% and the risk of head injuries by 62% (Liu, Ivers, Blows, Lo, & Norton, 2008). Increasing motorcycle helmet usage to close to 100% by 2030 has been identified as one of the twelve road safety targets by the Global Road Safety Partnership (WHO, 2018). Despite the clear benefits of wearing a helmet, increasing helmet use is challenging especially in low- and middle-income countries (LMICs). A large-scale helmet use media campaign in Thailand over five years showed no benefit (Patummasut, Phewchean, & Sirirattanapa, 2019). While legislating helmet use has shown a clear benefit, there is a disparity between the legislative benefit in high-income countries (HICs) compared to LMICs, with LMICs showing lower use of helmets and less reduction in brain injuries (Lepard, Spagiari, & Park, 2021).

Background and objective Excessive noise in the neonatal intensive care unit (NICU) may lead to serious long-term effects on hearing and sensory development in newborns. As such, the maximum allowed noise level is 45 A-weighted decibels (dBA). Studies regarding noise exposure to ventilated preterm infants show inconsistent results; however, these studies also vary considerably in their methodology in terms of noise ascertainment. We hypothesized that the study methodology can significantly influence data quality when measuring noise levels. In this study, we aimed to investigate whether the variations in ventilator noise levels in NICUs could be a result of methodological differences in study designs. Methods A ventilator circuit was set up using nasal continuous positive airway pressure (nCPAP) and high-frequency (HF) modes with nasal prongs. Noise levels were measured using a commercially calibrated noise meter. Three different scenarios were tested: (1) measurements were taken at different angles (0° to 180°), with 180° facing the end of the nasal prongs, without a mannequin, with the membrane/orifice of the noise meter placed 2 mm laterally from the prongs; (2) noise levels were measured at 180° at distances of 0-20 mm from the nasal prongs; (3) measurements were taken in the oral cavity of a life-size intubation mannequin of a newborn baby. Results Overall, the noise levels produced at different settings varied significantly, ranging from 45.7 dB to 82.2 dB. The average environmental background noise was 44.4 dB. Noise levels typically increased as the angle increased, with the highest noise level recorded at 180° for both HF and nCPAP modes, at 58.4 dB and 58.2 dB, respectively. Noise levels recorded at HF were slightly higher than nCPAP values. Furthermore, with regard to distance, the highest mean value, 82.2 dB, was recorded with the noise meter approximately 3 mm from the nasal prongs, and the lowest mean value, 47.6 dB, was recorded at ~20 mm. During trials with the mannequin, the lowest value, 50.1 dB, was recorded at the entrance of the mouth with slightly higher values being recorded within the oral cavity. Conclusion The results indicate that small changes in experimental settings, such as positioning and distance from the nasal prongs, can greatly influence noise levels, particularly above the recommended levels for neonates. These differences may be attributed to wind-generated noise. In summary, some study results are potentially influenced more by the study design than the device type or ventilator setting. We recommend further research and detailed reporting in the NICU to gain deeper insights into the topic.

Background Excessive noise in the NICU may lead to serious long-term effects on hearing impairment and sensory development in newborns. As such, the maximum recommended noise level is 45 dBA. Reported studies regarding noise exposure of ventilated preterm infants show inconsistent results; however, these studies also vary considerably in their methodology in terms of noise ascertainment (Table 1). We hypothesize that the study methodology significantly influenced data quality. Objectives Our aim is to investigate if measured ventilator noise levels from previous literature could potentially be the result of methodological shortfalls of the study design rather than perceivable noise levels. Design/Methods A ventilator circuit was set up using nCPAP and high frequency mode with nasal prongs. Noise levels were measured using a commercially calibrated noise meter. Three different scenarios were tested. (1) Measurements were taken at different angles of (0°to 180°), with 180° facing the end of the nasal prongs, without a mannequin, with the membrane/orifice of the noise meter placed 2 mm laterally from the prongs. (2) Noise levels were measured at 180° at distances of 0 to 20 mm from the nasal prongs. (3) Measurements were taken in the oral cavity of a life-size intubation mannequin of a newborn baby. Results Overall, the noise levels produced at different settings varied significantly, ranging from 45.7 dB to 82.2 dB. The average environmental background noise was 44.4 dB. Noise levels typically increased as the angle increased, with the highest noise level at 180° for both high frequency and nCPAP mode, at 58.4 dB and 58.2 dB, respectively (Figure 1). Noise levels recorded at high frequency were slightly higher than nCPAP values. Furthermore, in regards to distance, the highest mean value, 82.2 dB was recorded with the noise meter approximately 3 mm from the nasal prongs, with the lowest mean value, 47.6 dB, being recorded at ~20 mm. During trials with the mannequin, the lowest value, 50.1 dB, was recorded at the entrance of the mouth with slightly higher values being recorded within the oral cavity. Conclusion The results indicate that small changes in experimental settings, such as positioning and distance from the nasal prongs, can greatly influence noise levels, particularly above the recommended levels for neonates. In summary, some study results are potentially influenced more by the study design than the device type or ventilator setting. Further research and detailed reporting in the NICU is recommended.