Objective: To study the transmission of tuberculosis using conventional and molecular epidemiology in Hong Kong.
Methods: All patients with positive sputum culture for Mycobacterium tuberculosis ...residing on the Island of Hong Kong were recruited from May 1999 to April 2002. The restriction fragment length polymorphism technique was used to determine DNA patterns of isolates of M. tuberculosis using the IS6110 probe, supplemented by pTBN12 as a secondary probe.
Results: One thousand five hundred and fifty‐three of 2337 (66%) of the patients with bacteriologically confirmed tuberculosis had restriction fragment length polymorphism analysis of their M. tuberculosis isolates. Four hundred and fifty‐four (29.2%) patients belonging to 143 clusters were identified; the estimated rate of recent transmission was 20–24%. Significant predictors of clustering included young‐age groups (<40 years) versus those >60 years of age (adjusted odds ratio (OR) 1.96, 95% confidence interval 1.47–2.62), permanent residency versus new or non‐residents (adjusted OR 3.40, 95% 1.84–6.26) and previous default from treatment versus new cases (adjusted OR 6.12, 95% confidence interval 1.82–20.5). Alcohol and drug abuse, history of imprisonment and HIV infection were not significant risk factors for molecular clustering. Of patients belonging to clusters, 5.1% had definite, 5.5% had probable and 24.4% had possible epidemiological link, suggesting casual contact may be responsible for a high proportion of the clustered cases.
Conclusion: One‐fifth to one quarter of the new cases of active tuberculosis in Hong Kong are due to recent transmission. In addition to early diagnosis and successful treatment of all active disease, treatment of latent disease should receive more attention in the control of tuberculosis in Hong Kong.
Abstract Background Although high-density resequencing microarray is useful for detection and tracking the evolution of viruses associated with respiratory tract infections, no report on using this ...technology for the detection of viruses in patients with conjunctivitis is available. Objectives To test if high-density resequencing microarray can be applied to detection of viruses in conjunctival swabs for patients with conjunctivitis. Study design In this prospective proof-of-concept study, every 4 or 5 bacterial culture-negative conjunctival swab samples were pooled and subject to viral detection using TessArray™ Resequencing Pathogen Microarrays-Flu 3.1 (RPM-Flu-3.1). Results were compared with human adenovirus (HAdV) hexon gene PCR sequencing and viral culture. Results Thirty-two of the 38 conjunctival swab samples were bacterial culture-negative. Four of the 7 pooled samples were positive for HAdV using RPM-Flu-3.1. Hexon gene PCR sequencing on the 38 original individual samples showed that 3 and 4 samples contained HAdVs species D and B respectively. All the 6 samples that were positive for hexon gene PCR but negative for bacterial culture were also positive by the resequencing microarray. Viral culture was positive for HAdV type 3 in 1 sample, which was also positive by PCR and resequencing microarray. Conclusions Resequencing microarray is as sensitive as PCR for detection of HAdV in conjunctival swabs. Unlike viral culture and hexon gene PCR sequencing, resequencing microarray was not able to differentiate the type and species of HAdV. Development of microarrays for conjunctivitis can be performed for rapid diagnosis of the viral cause of conjunctivitis.
Summary Introduction Numerous prognostic predictive models have been developed for critically ill patients, many of which are primarily designed for use in intensive care units. The objective of this ...study was to evaluate the accuracy of a modified Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system in predicting the mortality for critically ill patients managed in emergency department (ED) resuscitation rooms in Hong Kong. Method A multi-centre, prospective study was conducted for patients managed in the resuscitation rooms of the EDs of four major hospitals, including one university teaching hospital. The primary outcome measure was 14 day all-cause mortality and the secondary outcome measure was the length of stay in hospital. Results Of 867 patients recruited between 4 and 30 April 2004, 106 (12.2%) patients died. The modified APACHE II score was found to be significantly higher in non-survivors compared to survivors (mean ± S.D.: 21.2 ± 7.7 versus 14.4 ± 7.1, p < 0.001). The area under the curve for modified APACHE II in predicting mortality was 0.743 (95% CI, 0.696–0.790). Conclusion The modified APACHE II score is only a moderate predictor of mortality for critically ill patients managed in the resuscitation rooms of EDs in Hong Kong. A more ED specific scoring method is required.
Most cases of methemoglobinemia result from exposure to certain medications and chemicals such as nitrates, nitrites, aniline, dapsone, phenazopyridine, benzocaine, and chlorates which oxidize the ...iron from the ferrous state. Intoxication with zopiclone is expected to produce drowsiness, confusion and coma but not methemoglobinemia. We report two cases of zopiclone overdose with methemoglobinemia.
Case one: A 43-year-old woman presented to the emergency department two hours after ingesting 100 tablets of 7.5 mg zopiclone. Her initial vital signs, physical examination, chest x-ray, and electrocardiogram were normal. Two hours post-ingestion her methemoglobin level was 9.8%; 14 hours post-arrival she showed cyanosis of the lips and extremities and dyspnea after walking. The blood sample 16 hours post-ingestion was dark brown in color and the methemoglobin was 23.8%. Shortly after the second of two doses of methylene blue (1 mg/kg each) her methemoglobin was 3.6%. Case two: A 30-year-old woman came to the emergency department 50 hours after ingesting 150 to 200 tablets of 7.5 mg zopiclone. Her vital signs and physical examination were normal. Her methemoglobin level was 5.2% at 52 hours post-ingestion and it peaked at 10.4% one hour later. She recovered following symptomatic care.
Methemoglobinemia has not previously been reported following acute zopiclone overdose. In our patients, there were no identifiable alternative causes explaining the methemoglobinemia and zopiclone was confirmed in both patients by laboratory analysis. These two cases suggest that zopiclone overdose is capable of producing delayed methemoglobinemia, which may be related to formation of a sufficient quantity of the N-oxide metabolite.
BACKGROUND: Thoracostomy tube insertion is one of the common bedside procedures in emergency medicine and many acute specialties. Dislodgement of thoracostomy tube from the connection tube of chest ...drainage system is an important problem with potential complications such as contamination, infection and pneumothorax. Besides, mere loosening can also lead to malfunction. It is a common practice to tape the connection of the system. This study aimed to evaluate the materials and methods of connection of chest drain system to minimize drainage dislodgement. METHODS: We conducted an experimental study to assess the tightness of the connection with various taping materials and methods. We selected three commonly used adhesive materials(3Mtm Transporetm Medical tape, 3Mtm Microporetm Medical tape, 3Mtm Soft Cloth Tape on Liner) and three different methods（cross method, straight method, nylon band） to secure the junction between the thoracostomy tube and the bi-conical adaptor in the drainage system. The measured outcome was the weight causing visible loosening of the junction between thoracotomy tube and the adaptor.RESULTS: For each taping material and taping method, 10 trials were performed. The median weight required to disconnect the junction is 26.22 lb for Transporetm, 31.29 lb for Microporetm and 32.44 lb for Soft Cloth Tape on Liner. A smaller force was required to disconnect if Transporetm is used（P<0.001）. There was no statistical signifi cant difference between Microporetm and Soft Cloth Tape on Liner（P=0.98）. The median disconnecting force is 32.44 lb for straight taping method, 40.55 lb for cross taping method and 21.15 lb for plastic band. The cross-taping method was the more secure method（P<0.0001 when compared with plastic band）（P=0.033 when compared with straight method）.CONCLUSION: Cross-taping is the most secure method among the tested varieties in connecting the thoracostomy tube to the chest drainage system. Transporetm is not a recommended material for thoracostomy tube taping.
Studies have found that one-third to two-thirds of all patients attending Accident and Emergency (A&E) Departments could be managed appropriately by general practitioners (GPs). There is also ...evidence that referral to GPs can be acceptable to patients. The question of primary concern is screening non-urgent cases with high degrees of sensitivity (S), specificity (SP), and positive predictive value (PPV). This paper reports the findings of the validity (S, SP and PPV) of nurses and patients in triaging A&E visitors. A cross sectional study was conducted over a 1 year period and subjects were randomly selected from four A&E Departments located across the four principle geographic regions of Hong Kong by stratified, two-stage sampling. S, SP and PPVs were computed for both non-weighted and weighted conditions. The gold standard for defining the true urgency status of each selected patient was based on a review of the patient's record 3–21 days (or longer if necessary) following the A&E visit. The record review in each A&E was blinded and done independently by a panel of two (and if disagreement existed, three) senior emergency physicians who did not practice in the same hospital. The greatest weights would be for incorrect decisions with greatest impact on patients’ well being. The most accurate unweighted nurses’ triage classification had an average sensitivity of 87.8%, specificity of 83.9%, and a PPV of 70.1%. When weighted, the average sensitivity reduced to 75%, specificity to 65.7%, and PPV to 54%. The most accurate unweighted patients’ self-triage classification yielded a sensitivity of 62.5%, specificity of 69.2%, and a PPV of 58.1%, and correspondingly reduced to 43.3, 49.2 and 38.6% if weights were applied. Validity of the derived patients’ self-classifications was too inaccurate for practical use. Hong Kong's current use of a five-point urgency scale by nurses would be further refined for identifying non-urgent visitors. If a mechanism was put in place for additional screening on visitors with a borderline semi-urgent or non-urgent status, the nurses could safely reassign non-urgent patients to GP care. If implemented, a significant impact on hospital costs could be realized.
Currently existing predictive models for massive blood transfusion in major trauma patients had limitations for sequential evaluation of patients and lack of dynamic parameters.
To establish a ...predictive model for predicting the need of massive blood transfusion major trauma patients, integrating dynamic parameters.
Multi-center retrospective cohort study.
Four designated trauma centers in Hong Kong.
Trauma patients aged >12years were recruited from the trauma registries from 2005 to 2012. MBT was defined as delivery of ≥10units of packed red cells within 24h. Split sampling method was adopted for model building and validation. Multivariate logistic regression was adopted for model building, with weight assigned based on logarithmic of adjusted odds ratios. The performance of the dynamic MBT score (DMBT) was compared with the PWH score and the Trauma Associated Severe Hemorrhage (TASH) score in the validation data set.
4991 patients were included in the study. The DMBT was established with 8 parameters: systolic blood pressure, heart rate, hemoglobin, hemoglobin drop within the first 2h, INR, base deficit, unstable pelvic fracture and hemoperitoneum in radiological imaging. At cut-off score of 6 the DMBT achieved sensitivity of 78.2% and specificity of 89.2%. In the validation set, the AUCs of the DMBT, PWH score, and TASH score were 0.907, 0.844, and 0.867 respectively.
The DMBT score allows both snapshot and sequential activation along the trauma care pathway and has better performance than the PWH score and TASH score.
: Sarcoidosis is rarely reported in Hong Kong. We report cutaneous and pulmonary sarcoidosis in a 54‐year‐old Chinese woman, who presented with papular lesions over the face and neck. She had ...silicone breast augmentation surgery 4 years earlier. Skin biopsy revealed granulomatous inflammation and anti‐tuberculosis treatment was started empirically but stopped 2 months later owing to a poor response. A right supraclavicular lymph node was aspirated and revealed granulomatous inflammation. The CXR was normal initially but subsequently showed diffuse reticulonodular opacities and a small right‐sided pleural effusion. High‐resolution CT of the thorax showed mediastinal lymphadenopathy and diffuse perilymphatic nodular opacities consistent with sarcoidosis. Sputum mycobacterial culture was negative. Fibreoptic bronchoscopy showed no endobronchial lesion but the transbronchial biopsy showed granulomatous inflammation with no evidence of infection, malignancy or foreign body. Pulmonary function tests were normal except for impairment of transfer factor. One year later, most of the cutaneous lesions had healed spontaneously. The CXR showed partial improvement of the right pleural opacification but little change in the lung field. The features of sarcoidosis and its association with silicone are reviewed.
This editorial aims to refine the severe polytrauma management principles. While keeping ABCDE priorities, the termination of futile resuscitation and the early use of tourniquet to stop ...exsanguinating limb bleeding are crucial. Difficult-airway-management (DAM) is by a structured 5-level approach. The computerised tomography (CT) scanner is the tunnel to death for hemodynamically unstable patients. Focused Abdominal Sonography for Trauma-Ultrasonography (FAST USG) has replaced diagnostic peritoneal lavage (DPL) and is expanding to USG life support. Direct whole-body multidetector-row computed tomography (MDCT) expedites diagnosis & treatment. Non-operative management is a viable option in rapid responders in shock. Damage control resuscitation comprising of permissive hypotension, hemostatic resuscitation & damage control surgery (DCS) help prevent the lethal triad of trauma. Massive transfusion protocol reduces mortality and decreases the blood requirement. DCS attains rapid correction of the deranged physiology. Mortality reduction in major pelvic disruption requires a multi-disciplinary protocol, the novel pre-peritoneal pelvic packing and the angio-embolization. When operation is the definitive treatment for injury, prevention is best therapy.
Methods RE-VERSE AD is an ongoing multinational, single cohort study investigating the safety and efficacy of 5 g idarucizumab to reverse dabigatran in patients with life-threatening or uncontrolled ...bleeding (Group A) or who require an emergency procedure (Group B).
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