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.
Background
The management of patients with haemodynamic instability related to pelvic fractures is a major challenge with high mortality and morbidity. The treatment priorities have long been a ...source of debate. Many advocate emergent external fixation (EX-FIX) as the first line of treatment, whereas another school favours the efficacy of transcatheter arterial embolisation (TAE). Decision-making within the ‘Golden Hour’ in the emergency department (ED) is crucial to patients' ultimate outcome. Our aim was to evaluate the current management pathways in our centre and to review the latest literature.
Methods
We present a 2-year case series (from January 2005 to December 2006) of patients with pelvic ring disruption and haemodynamic instability. Data were collected regarding patients' demographics, fracture patterns according to the Young & Burgess classification, concomitant intra-abdominal injuries, treatment pathway and the response to treatment.
Results
There were 7 patients identified. Five were males and 2 were females, with a mean age of 42 years. Fracture types included 3 lateral compression, 1 anteroposterior compression, 2 vertical shear, and 1 combined mechanism. Four patients had significant intraperitoneal haemorrhage identified by Focused Assessment by Sonography for Trauma (FAST). They all needed laporotomy and pelvic packing, initially or subsequently. EX-FIXs were offered to 6 patients as the primary intervention, and 4 of them subsequently required diagnosis with angiography followed by therapeutic embolisation to restore haemodynamic stability. Only 1 patient underwent a second angiographic study to control the arterial bleeding. Two patients died of severe intra-abdominal injuries within 24 hours after admission.
Conclusion
In patients with pelvic fractures and hypotension, EX-FIX is currently the first line of treatment, with variable efficacy. On the other hand, the high successful embolisation rate and reasonable safety profile of TAE in our patients have been impressive. The latter offers a much better alternative to surgical intervention in selected patients. However, precautions should be taken including proper pelvic stabilisation by non-invasive devices, creation of a safe environment in the angiography suite, and early multidisciplinary decision in the ED.
A couple of spouse mistook the Gelsemium elegans Benth. collected in countryside for Mussaenda pubescens Ait. f. and suffered toxicity soon after ingestion. One went into respiratory failure ...necessitating intubation and the other developed dizziness. The morphological differences between Gelsemium elegans Benth. and Mussaenda pubescens Ait. f. may not be easily recognised by the general public. Close monitoring and respiratory support are the cornerstones of management.
Traumatic aortic disruption is an uncommon but frequently emphasised condition in trauma management in the emergency department. We report a case in which a middle aged woman was hit by a moving ...vehicle, sustaining multiple severe injuries. Multidetector computed tomography revealed an unexpected but potentially fatal condition – traumatic aortic disruption. A pseudoaneurysm was detected over the aortic arch. In view of the multiple trauma, she was put on conservative treatment. Traumatic aortic disruption should be borne in mind during the emergency evaluation and management of unstable trauma victims, especially those with significant trauma mechanisms. Radiological evaluation plays an important diagnostic role.
Objective
To compare Macintosh laryngoscope with video-optical intubation stylet on rates and time durations of successful tracheal intubation in normal and simulated difficult airway.
Design
...Crossover experimental study.
Setting
Intubation training laboratory.
Methods
A group of novices (58 medical students) attempted intubation on manikin under normal and simulated difficult airway (grade 3 larygnoscopic view) settings using both Macintosh laryngoscope and video-optical intubation stylet. The success rate, duration to intubate and occurrence of complications (oesophageal intubation and incisor breakage) when using the two different devices were measured and compared. The time results were analysed by paired t-test and categorical results by chi square test or Fisher's exact test.
Results
The success rate to intubate difficult airway using video-optical intubation stylet (0.92) was significantly higher than using Macintosh laryngoscope (0.59) (p=0.002). The mean time taken to intubate difficult airway using video-optical intubation stylet was significantly shorter than using Macintosh laryngoscope by 10.90 seconds (p=0.004). Oesophageal intubation rate was significantly higher when using Macintosh laryngoscope to intubate difficult airway compared to video-optical intubation stylet (p=0.002). There was no significant difference on the rate of incisor breakage between the two instruments.
Conclusions
Novice can learn to use both Macintosh laryngoscope and video-optical intubation stylet to intubate successfully after a short training. Video-optical intubation stylet is an effective “Plan B” instrument because it shortens the duration and increases the rate of successful intubation in difficult airway situations.
A man sustained conjunctivitis of the left eye after being spat by the venom of a Chinese cobra (Naja atra). He received fluid irrigation, topical antibiotic and topical steroid treatment. The ...conjunctivitis resolved without sequalae after 4 days. Various treatment options are discussed.
A 45 years old gentleman with good past health developed on-and-off fever, malaise, bilateral lower limb rash, shortness of breath and palpitation for two weeks. Physical examination showed purpuric ...skin rash over both lower limbs. The cardiovascular examination showed a pansystolic murmur, best heard at the apex. Bedside echocardiography was performed in the emergency department and revealed vegetation over the mitral valve leaflet with severe mitral regurgitation. He was admitted to the medical ward with a provisional diagnosis of infective endocarditis and subsequently received a mitral valve replacement.
Objectives
To describe the structure and service pattern of a short stay ward (SSW) named as Emergency Observation and Pre-admission Ward (EOPW) in Hong Kong. The effectiveness of the EOPW was to be ...examined.
Methods
This was a retrospective observational cohort study. The facilities, staffing and operation of the EOPW were described. Consecutive patients admitted to the EOPW in the year 2006 were retrieved from the hospital computer database. Admission diagnoses, length of stay (LOS) and destination of disposal were the main outcome variables measured. The ICD coded admission diagnoses were categorised into 24 diagnosis-related groups. Different diagnosis-related groups were compared with respect to the selected efficacy cutoff points of LOS less than 24 hours and hospital admission rate less than 30% respectively.
Results
The service of the 30-bed short stay ward as started in year 2003 was a pilot project in Hong Kong. In year 2006, 10,111 patients were admitted and the mean age was 54.2 years. The five commonest diagnosis-related groups were psychiatric disease, chest pain, dizziness, musculoskeletal pain and poisoning. The overall hospital admission rate and the mean LOS were 26.8% and 23.4 hours respectively and were below the efficacy cutoff points. Musculoskeletal pain, chronic obstructive pulmonary disease and acute urinary retention were the three diagnostic groups with both LOS and hospital admission rate above the efficacy cutoff points.
Conclusion
This first SSW in Hong Kong was demonstrated to be effective according to the analysis result of the 2006 data. SSW has become an integral part of emergency medicine and provided an alternative way of effective management in contrast to traditional inpatient management for various selected disease conditions.
Objective
To find out predicting symptom(s) of non-traumatic subarachnoid haemorrhage in conscious patients without neurological deficit presenting with the primary complaint of severe headache.
...Design
Case control study.
Setting
Regional public hospital, Hong Kong.
Subjects
Non-traumatic subarachnoid haemorrhage (ICD 9 coding 430) patients, who were conscious and with normal neurological examination, presenting to the accident and emergency department with severe headache between April 2005 to March 2007 were searched from the hospital database. The control group was recruited prospectively from the accident and emergency department during the period from November 2007 to April 2008.
Results
A total of 33 cases were compared to 57 controls to study on five selected symptoms and the likelihood to predict risk of subarachnoid haemorrhage. All five symptoms were significant by univariate analysis at significance level of 25%: nuchal pain (p<0.001), transient syncope (p=0.137), dizziness (p=0.026), vomiting (0=0.016) and presence of precipitating events (coitus, defecation or quarrel) (p=0.132). Only nuchal pain was statistically significant in the multivariate logistic regression analysis (OR=11.44; 95% CI=2.14 to 61.19) with age and gender controlled.
Conclusions
The presence of nuchal pain as a presenting symptom significantly increases the likelihood of non-traumatic subarachnoid haemorrhage by ten times among severe headache patients with normal neurological examination. Other symptoms like transient syncope, dizziness and vomiting are non-specific and do not predict a higher chance of occurrence of subarachnoid haemorrhage.
Video-assisted airway management is a new concept for monitoring and managing both normal and difficult tracheal intubations, with the aid of video-transmission of the view from the tip of intubating ...devices such as stylets or intubating laryngoscopes. Its principle, practical application and local experience are illustrated by some sample cases and its future development is discussed.
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