Achieving health equity through conversational AI: A roadmap for design and implementation of inclusive chatbots in healthcare

BACKGROUND

The rapid evolution of conversational and generative artificial intelligence (AI) has led to the increased deployment of AI tools in healthcare settings. While these conversational AI tools promise efficiency and expanded access to healthcare services, there are growing concerns ethically, practically and in terms of inclusivity. This study aimed to identify activities which reduce bias in conversational AI and make their designs and implementation more equitable.

METHODS

A qualitative research approach was employed to develop an analytical framework based on the content analysis of 17 guidelines about AI use in clinical settings. A stakeholder consultation was subsequently conducted with a total of 33 ethnically diverse community members, AI designers, industry experts and relevant health professionals to further develop a roadmap for equitable design and implementation of conversational AI in healthcare. Framework analysis was conducted on the interview data.

RESULTS

A 10-stage roadmap was developed to outline activities relevant to equitable conversational AI design and implementation phases: 1) Conception and planning, 2) Diversity and collaboration, 3) Preliminary research, 4) Co-production, 5) Safety measures, 6) Preliminary testing, 7) Healthcare integration, 8) Service evaluation and auditing, 9) Maintenance, and 10) Termination.

DISCUSSION

We have made specific recommendations to increase conversational AI's equity as part of healthcare services. These emphasise the importance of a collaborative approach and the involvement of patient groups in navigating the rapid evolution of conversational AI technologies. Further research must assess the impact of recommended activities on chatbots' fairness and their ability to reduce health inequalities.

Sex and Relationships in Later Life: Older Adults' Experiences and Perceptions of Sexual Changes

The aim of this study was to explore the sexual lives of older adults in the UK to elucidate their experiences of sexual changes and problems, and the role of intimacy and interpersonal support in coping with these changes. We conducted in-depth semi-structured interviews with 31 participants (aged 66-92, mean = 74, 16 women and 15 men), analyzed using reflexive thematic analysis. Our analysis generated three themes: Sexual Changes are "Natural," Sex is the Icing on the Cake, and Maintaining Sexual Connection and Relationship Satisfaction. The participants often rationalized and accepted sexual changes and problems as part of the natural aging process, or as a consequence of other age-related health issues. Sexual activity was seen by many as the "icing on the cake" of a satisfying romantic relationship, built on strong foundations of intimacy, connection, and companionship. Relationship satisfaction and sexual wellbeing can be maintained despite changes to sexual function by retaining a sexual connection through shared experiences, emotional closeness, and support. The findings have important implications for researchers and health providers, and suggest that adopting an "affirmative older age" perspective would be useful for not only future research but also when providing support for older adults with sexual difficulties.

User perceptions of COVID-19 telemedicine testing services, disease risk, and pandemic preparedness: findings from a private clinic in Hong Kong

INTRODUCTION

During the coronavirus disease 2019 (COVID-19) pandemic, telemedicine has been regarded as a method for providing safe access to healthcare. Here, we explored the experiences of individuals using telemedicine in Hong Kong during the COVID-19 pandemic to understand their risk perceptions and preparedness measures.

METHODS

We conducted a cross-sectional online survey of telemedicine users of private clinic-based COVID-19 testing services from 6 April to 11 May 2020. All users were invited to complete an anonymous online survey regarding COVID-19 risk perception and preparedness measures. The results of the survey were compared with the findings of a previous territory-wide survey.

RESULTS

In total, 141 of 187 telemedicine users agreed to participate; the response rate was 75.4%. Of the participants, 95.1% (116/122) believed that telemedicine consultations were useful. Nearly half of the participants (49.0%) agreed or strongly agreed that telemedicine consultations were appropriate during the COVID-19 pandemic. Most participants believed that telemedicine consultations could perform the functions of 'health protection, promotion and disease prevention' (73.6%) and 'diagnosis' (64.0%). Concerning the choice of telemedicine provider, almost all participants (99.2%) were willing to consult medical doctors; more than half of the participants (54.1%) were willing to consult registered nurses, but only 13.1% were willing to consult non-clinical staff who had been trained to provide telemedicine services.

CONCLUSION

The use of telemedicine for screening and patient education can be encouraged during the COVID-19 pandemic in Hong Kong.

The Role of Mutual Masturbation within Relationships: Associations with Sexual Satisfaction and Sexual Self-Esteem

Objectives

We explored mutual masturbation among women and men and investigated associations with sexual satisfaction and sexual self-esteem.

Methods

117 women and 151 men (Mage = 29.7 years), mostly heterosexual, all in current relationships, completed an online survey covering experiences of solo and partnered sexual activities, feelings about mutual masturbation, sexual self-esteem, and sexual satisfaction.

Results

Mutual masturbation was common among both genders. Men reported significantly higher positive feelings about mutual masturbation than women. Recent mutual masturbation was positively associated with sexual satisfaction but not with sexual self-esteem.

Conclusions

These findings have implications for sex and couple therapy and research.

Reasons for incomplete STI vaccination among men who have sex with men in an English sexual health service

BACKGROUND

In England, vaccination for human papillomavirus, hepatitis A, and hepatitis B is recommended for men who have sex with men (MSM). However, uptake is sub-optimal and some men do not complete all recommended vaccine doses. This service evaluation aimed to explore reasons for lack of uptake for each of these vaccines among MSM in one English sexual health service and to inform improvements in service delivery to increase full dose completion rates.

METHODS

MSM, ≥18 years, who had previously attended NHS Solent Sexual Health for at least one vaccination, and who had not completed the full dosing regimen for at least one of these vaccines, were invited to participate in an anonymous, online survey between 14/12/2020-11/04/2021.

RESULTS

Among 246 MSM (M = 42.1 years), the most common reason for non-vaccination was that participants thought it was unneeded and had not been recommended by a doctor or healthcare provider. None reported vaccine hesitancy. Likewise, the most common reasons for vaccination were doctor/healthcare provider recommendation (51.7-65.6%) and self-protection (60.9-68.1%). The most common reason for not having completed the full course of vaccination was being unaware that the next dose was due (30.0-37.8%). Many participants who had not completed vaccination indicated that a doctor/healthcare provider recommendation would be a motivating factor and that reminder messages and being able to book subsequent appointments in advance would facilitate vaccination.

CONCLUSIONS

Sexual health clinicians should be encouraged to discuss STI vaccination with MSM and services should explore possibilities to improve ease and access to vaccine appointments to increase uptake and completion rates.

An exploratory test of a couples-based condom-use intervention designed to promote pleasurable and safer penile-vaginal sex among university students

Objective: Dual use of male condoms and female contraceptives is widely advocated for unplanned pregnancy prevention, yet college students often neglect condoms. This feasibility and acceptability study assessed the efficacy of a self-guided home-based condom-promotion intervention among college students in heterosexual relationships. Participants: Fifty-nine couples who had been together at least 30 days and had penile-vaginal sex at least twice weekly. Methods: Assessments were done at baseline and 6 months later. Outcomes were frequency of condom-unprotected penile-vaginal sex and four psychosocial mediators of condom use. Results: Frequency of unprotected penile-vaginal sex decreased over time. Several corresponding psychosocial mediators showed change, particularly among women. Using actor-partner interdependence modeling, men's increase in condom use was associated with an increase in women's sexual pleasure. Conclusion: Findings support implementation of a brief, self-guided, home-based condom-use intervention that could lower incidence of unplanned pregnancy and STIs among heterosexually active college students.

Prevalence of Masturbation and Associated Factors Among Older Adults in Four European Countries

Solitary sexual activity is a free, safe, and accessible way to experience sexual pleasure. Despite these advantages, research on masturbation in later life is highly understudied. Using data from a cross-sectional probability-based survey of 3816 European adults (mean age 67 years; range 60-75 years), we explored several sociodemographic, health, attitudinal, and sexual behavioral factors associated with reported masturbation frequency. Across all countries, between 41% and 65% of men and 27% and 40% of women reported any masturbation in the preceding month. Satisfaction with sexual activity and attitudes related to disapproval of sex without love were significant predictors of reported masturbation in almost all countries and in both genders. Age, education, self-perceived health, and depression were for the most part predictive of men's reported masturbation, but not women's. Generally, those believing sex is beneficial to older people were more likely to masturbate, while less permissive attitudes decreased the likelihood of reporting masturbation. To improve healthy sexual aging, misinformation about masturbation and sexual attitudes in older people need to be addressed.

Feasibility study of the Home-based Exercises for Responsible Sex (HERS) intervention to promote correct and consistent condom use among young women

Background

Male condoms are effective in preventing common sexually transmitted infections (STIs) and unintended pregnancy, if used correctly and consistently. However, condom use errors and problems are common and young people report negative experiences, such as reduced pleasure. The Kinsey Institute Home-Based Exercises for Responsible Sex (KIHERS) is a novel condom promotion intervention for young women, which aims to reduce condom errors and problems, increase self-efficacy and improve attitudes towards condoms, using a pleasure-focussed approach. The study objective was to test the operability, viability and acceptability of an adapted version of the KIHERS intervention with young women aged 16–25 years in the United Kingdom (UK) (Home-Based Exercises for Responsible Sex-UK (HERS-UK).

Methods

A repeated-measures single-arm design was used, with a baseline (T1) and two follow-up assessments (T2 and T3), conducted 4 weeks and 8 weeks post intervention over a 3-month period. Participants were provided a condom kit containing different condoms and lubricants and were asked to experiment with condoms alone using a dildo and/or with a sexual partner. Ten process evaluation interviews were conducted post intervention.

Results

Fifty-five young women received the intervention; 36 (65%) completed T2 and 33 (60%) completed T3. Condom use errors and problems decreased, self-efficacy increased and attitudes towards condoms improved significantly. The proportion of participants who reported using a condom for intercourse in the past 4 weeks increased from T1 (20; 47%) to T2 (27; 87%) and T3 (23; 77%) and using lubricant with a condom for intercourse increased from T1 (6; 30%) to T2 (13; 48%)) and T3 (16; 70%). However, motivation to use condoms did not change. Cronbach’s alpha scores indicated good internal consistency of measures used. Qualitative data provided strong evidence for the acceptability of the intervention.

Conclusions

HERS-UK was implemented as intended and the recruitment strategy was successful within a college/university setting. This feasibility study provided an early indication of the potential effectiveness and acceptability of the intervention, and the benefits of using a pleasure-focussed approach with young women. Measures used captured change in outcome variables and were deemed fit for purpose. Future research should explore cost-effectiveness of this intervention, in a large-scale controlled trial using a diverse sample and targeting young women most at risk of STIs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00885-1.

Thermographic visualization of facial vasoconstriction is associated with 30-day all-cause mortality in medical patients; prospective observational two-site cohort study

INTRODUCTION

Quick and reliable assessment of acute patients is required for accurate triage. The temperature gradient between core and peripheral temperature could possibly instantly provide information on circulatory status.

METHODS

Adult medical patients, who did not receive supplementary oxygen, attending two emergency departments, had a thermographic image taken on arrival. The association between 30-day mortality and gradients was tested using logistic regression.

RESULTS

726 patients were studied, median age was 64 years and 14 (1.9%) died within 30 days. There was a significant association between mortality and temperature gradient, comparable to vital signs, age, and clinical intuition.

CONCLUSION

Temperature gradient between nose and eye had an acceptable discriminatory power for 30-day all-cause mortality.

Evaluation of systemic vasoconstriction and prognosis using thermography: a systematic review

PURPOSE

This systematic review investigates whether infrared thermography (IRT) can measure systemic vasoconstriction and addresses the value of IRT in assessing circulatory deficiency and prognoses.

METHODS

Design was based on the PRISMA criteria and a systematic search of 6 databases was performed.

RESULTS

Of 3,198 records, five articles were included. Three clinical studies were identified; two found significant correlations between IRT obtained temperatures and mortality. An experimental study found an association between peripheral temperature and stroke volume. An animal study found that central-peripheral temperature differences correlated with shock index, mean arterial pressure, and disease progression.

CONCLUSIONS

Data from the most valid study suggests that central-peripheral temperature differences should be investigated further, both on its own, and integrated with other variables.

Prevalence and Predictors of Sexual Difficulties and Associated Distress Among Partnered, Sexually Active Older Women in Norway, Denmark, Belgium, and Portugal

There has been little comparative, cross-cultural research on sexual difficulties and associated distress, and factors associated with these, among older women. Therefore, the aim of this study was to investigate prevalence rates of sexual difficulties, distress related to these difficulties, and associated sociodemographic, relational, and health factors, among sexually active older women (60-75 years) in committed relationships across four European countries (Norway, Denmark, Belgium, and Portugal). These data could inform us about what differentiates women who do and do not experience distressing sexual difficulties and facilitate the identification of older women who might benefit from clinical interventions as well as the development of new interventions. In total, 1057 women (357 Norwegian; 322 Danish; 237 Belgian; 141 Portuguese) completed a cross-sectional questionnaire assessing six sexual difficulties-vaginal dryness, orgasmic difficulties, lacking interest in sex, lacking enjoyment in sex, pain during sex, and no excitement/arousal during sex-and associated distress. We found a high prevalence of sexual difficulties lasting 3 months or longer in the past year (between 23.5 and 50.2%, depending on the specific difficulty). With the exception of vaginal dryness and pain during sex, however, the majority of women reporting sexual difficulties (50.0% to 86.1%, depending on the specific difficulty) reported no or mild distress. There were relatively few cross-country differences, either in the prevalence of sexual difficulties or related distress. Few sociodemographic or health variables were associated with distressing sexual difficulties, but higher sexual intimacy, higher emotional intimacy, and better mental health were associated with less distress about some sexual difficulties. The findings underline the importance of healthcare professionals asking older women about sexual function and especially associated distress, and suggest that careful attention to the psychological and relationship context of these sexual difficulties is needed, as these could be important targets in the treatment process.

A home-practice intervention for increasing condom use among university undergraduates

The consistently high rate of sexually transmitted infections among people 18-24 years old warrants novel strategies promoting condom use among large segments of this population. Ample opportunity exits to employ such strategies in university settings. This study evaluated a sex-positive, home-practice intervention designed to promote condom use among university undergraduates engaging in penile-vaginal intercourse (PVI). A sample of 29 opposite-sex undergraduate couples, engaging in PVI, was recruited from a large university. After teaching couples about condom use, a health educator helped couples select condoms/lubricants from options comprising various sizes, fits, shapes, textures, and other features. A 30-day 'homework assignment' was made to use these products while reducing condom use errors/problems and enhancing sexual pleasure. A repeated measures design, with a six-month observation period, was used to evaluate the program. Over the six-month period, the mean frequency of condomless PVI decreased from 26.4 to 3.9 times (P < .001). Significant and favorable changes were also found relative to attitudes toward condom use (P = .027) and in condom use self-efficacy (P < .001). Most students completing the follow-up assessment indicated the intervention would favorably impact their future condom use. Findings suggest this intervention program may be important to promoting condom use among university couples engaging in PVI.

The role of body image in sexual satisfaction among partnered older adults: a population-based study in four European countries

Body image issues can affect all domains of sexual functioning. The aim of this study was to examine how, in a sociocultural context where physical and sexual attractiveness is equated with young and slim body ideals, appearance dissatisfaction and importance are related to sexual satisfaction in older adults in four European countries. A cross-sectional survey with probability samples of the population aged 60-75 years was used. Only respondents with a partner were included in this paper, and the countries included Norway (n = 957), Denmark (n = 846), Belgium (n = 612), and Portugal (n = 367). Sexual satisfaction, appearance dissatisfaction, and importance were assessed, and frequency of intercourse/kissing and cuddling, relationship satisfaction, age, and body mass index were all used as control variables. Belgian men scored significantly lower on sexual satisfaction, while there was no difference in sexual satisfaction in women. Appearance dissatisfaction was lower in Scandinavian women and men, and in Belgian men, and appearance salience was lower in Norwegian men and women, and in Portuguese women. Linear regression analysis revealed that, adjusting for confounders, appearance dissatisfaction was significantly related to sexual satisfaction in Scandinavian women and men, as well as in Belgian men. Compared to research on younger adults, appearance evaluation appeared to play an equally important role in sexual satisfaction in older adults in our study. The variation in appearance dissatisfaction in older adults across European countries is a novel finding that needs to be examined further.

Decision making over condom use during menses to avert sexually transmissible infections

Background The aim of this study was to test the hypothesis that receptive partners in penile-vaginal intercourse (PVI) who exercise independent decision making over condom use during menses do so to avert sexually transmissible infection (STI) transmission or acquisition.

METHODS

Data were collected through a partnership with Clue, the industry-leading female health app. A brief web-based questionnaire was developed, translated into 10 languages, and made accessible via a URL link sent to Clue users and posted on social media. Inclusion criteria were: age ≥14 years, not being currently pregnant and engaging in PVI and condom use during menses in the past 3 months. The analytical subsample comprised 12889 respondents residing in 146 countries.

RESULTS

Twenty per cent indicated independent decision making about condom use during menses. Independent decision making was associated with lower odds of reporting that condoms were used for contraception (adjusted odds ratio (aOR) 0.65; 99% confidence interval (CI) 0.57-0.73) and higher odds that they were used for the prevention of STIs (aOR 1.44; 99% CI 1.28-1.61). A third significant finding pertained to always using condoms during menses; this was less likely among those indicating independent (female only) decision making (aOR 0.69; 99% CI 0.62-0.78). Non-significant associations with another two outcomes were found: protecting the partner against menstrual blood and protecting themselves against semen.

CONCLUSIONS

Findings from people in 146 countries strongly support the hypothesis that those exercising independent decision making over condom use during menses do so to avert STI transmission or acquisition. That only one-fifth of this global sample reported this type of independent decision making suggests that empowerment-oriented (structural-level) interventions may be advantageous for individuals who are the receptive partner in PVI that occurs during menses.

What Does Research Tell Us About Women's Experiences, Motives and Perceptions of Masturbation Within a Relationship Context?: A Systematic Review of Qualitative Studies

This systematic review provides an overview of what qualitative research has revealed about partner-related factors around women's masturbation and explores how these factors relate to women's behavior, perceptions, and motives toward masturbation. Eleven studies were identified and secondary thematic analysis was used for synthesis. Women's perceptions often focus on the (potential) negative influences of masturbation on current or future relationships. Motivations some women reported for masturbating due to partner-related factors were diverse. Findings suggested that some women modify their masturbation behavior when in a relationship. The implications of these findings for sexual health educators and clinicians are discussed.

Evidence for behavioural interventions addressing condom use fit and feel issues to improve condom use: a systematic review

Continuing high rates of sexually transmissible infections (STIs) in many countries highlight the need to identify effective behavioural interventions. Consistent and correct use of male condoms is a key strategy for the prevention of STIs. However, some men report problems with condom fit (e.g. the size and shape of the condom) and feel (e.g. tightness, irritation, sensitivity), which inhibits their use. We conducted a systematic review to identify existing interventions addressing condom use fit and feel problems. We searched electronic databases for peer-reviewed articles and searched reference lists of retrieved studies. Five studies met the inclusion criteria. These were generally small-scale pilot studies evaluating behavioural interventions to promote safer sex with men aged under 30 years, addressing, among other things, barriers to condom use relating to fit and feel. There were significant increases in the reported use of condoms, including condom use with no errors and problems. Improvements in some condom use mediators were reported, such as condom use self-efficacy, knowledge, intentions and condom use experience. There were mixed findings in terms of the ability of interventions to reduce STI acquisition. Behavioural interventions addressing condom fit and feel are promising in terms of effectiveness but require further evaluation.

Help-Seeking for Sexual Difficulties and the Potential Role of Interactive Digital Interventions: Findings From the Third British National Survey of Sexual Attitudes and Lifestyles

Sexual difficulties are common and can negatively impact health and well-being. A wide range of support is available, but there are multiple barriers to accessing help. Interactive digital interventions (IDIs) for sexual difficulties have the potential to provide a convenient, wide-reaching, and cost-effective source of support, but little is known about who might use them. We explored the potential reach of IDIs by assessing the prevalence of help-seeking among people with distressing sexual difficulties, including who seeks which sources of help. Data came from sexually active men and women, ages 16 to 74, participating in Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) (N = 11,637). Help/advice was sought by less than half of those with distressing sexual difficulties, and help-seeking was associated with younger age in women but not men. The most popular sources of support were family doctor (47.5% to 54.8%), Internet (22.0% to 25.6%), and family/friend (20.7% to 41.8%), with older participants (≥ 35), particularly men, preferring to seek help from a family doctor, and younger participants (<35) preferring to seek help from the Internet or family/friend. Despite a paucity of good digital support sites for sexual function, the Internet is a common source of help. As Internet access continues to increase, so too does the potential for well-designed IDIs to support those with sexual difficulties.

Does attractiveness influence condom use intentions in women who have sex with men?

Objectives

Attractiveness judgements have been shown to affect interpersonal relationships. The present study explored the relationships between perceived attractiveness, perceived sexual health status, condom use intentions and condom use resistance in women.

Setting

The study data were collected using an online questionnaire.

Participants

480 English-speaking women who have sex with men, between 18–32 years old.

Outcome measures

Women were asked to rate the attractiveness of 20 men on the basis of facial photographs, to estimate the likelihood that each man had a sexually transmitted infection (STI), and to indicate their willingness to have sex with each man without a condom. Condom resistance tactics were also measured and their influence on condom use intentions was assessed.

Results

The more attractive a man was judged to be, the more likely it was that participants were willing to have sex with him (r (478) = 0.987, p < .001). Further, the more attractive a man was judged to be, the less likely women were to intend to use a condom during sex (r = -0.552, df = 478, p = .007). The average perceived STI likelihood for a man had no significant association with his average perceived attractiveness or with participants’ average willingness to have sex with him. The more attractive a participant judged herself to be, the more she believed that, overall, men are likely to have a STI (r = 0.103, df = 478, p < .05).

Conclusions

Women’s perceptions of men’s attractiveness influence their condom use intentions; such risk biases should be incorporated into sexual health education programmes and condom use interventions.

Corrigendum to: Decision making over condom use during menses to avert sexually transmissible infections

Background:The aim of this study was to test the hypothesis that receptive partners in penile-vaginal intercourse (PVI) who exercise independent decision making over condom use during menses do so to avert sexually transmissible infection (STI) transmission or acquisition. Methods: Data were collected through a partnership with Clue, the industry-leading female health app. A brief web-based questionnaire was developed, translated into 10 languages, and made accessible via a URL link sent to Clue users and posted on social media. Inclusion criteria were: age ≥14 years, not being currently pregnant and engaging in PVI and condom use during menses in the past 3 months. The analytical subsample comprised 12889 respondents residing in 146 countries. Results: Twenty per cent indicated independent decision making about condom use during menses. Independent decision making was associated with lower odds of reporting that condoms were used for contraception (adjusted odds ratio (aOR) 0.65; 99% confidence interval (CI) 0.57-0.73) and higher odds that they were used for the prevention of STIs (aOR 1.44; 99% CI 1.28-1.61). A third significant finding pertained to always using condoms during menses; this was less likely among those indicating independent (female only) decision making (aOR 0.69; 99% CI 0.62-0.78). Non-significant associations with another two outcomes were found: protecting the partner against menstrual blood and protecting themselves against semen. Conclusions: Findings from people in 146 countries strongly support the hypothesis that those exercising independent decision making over condom use during menses do so to avert STI transmission or acquisition. That only one-fifth of this global sample reported this type of independent decision making suggests that empowerment-oriented (structural-level) interventions may be advantageous for individuals who are the receptive partner in PVI that occurs during menses.

Trajectory of functional outcome and health status after moderate-to-major trauma in Hong Kong: A prospective 5 year cohort study

BACKGROUND

Trauma care systems in Asia have been developing in recent years, but there has been little long-term outcome data from injured survivors. This study aims to evaluate the trajectory of functional outcome and health status up to five years after moderate to major trauma in Hong Kong.

METHODS

We report the five year follow up results of a multicentre, prospective cohort from the trauma registries of three regional trauma centres in Hong Kong. The original cohort recruited 400 adult trauma patients with ISS ≥ 9. Telephone follow up was conducted longitudinally at seven time points, and the extended Glasgow Outcome Scale (GOSE) and Short-Form 36 (SF36) were tracked.

RESULTS

119 out of 309 surviving patients (39%) completed follow up after 5 years. The trajectory of GOSE, PCS and MCS showed gradual improvements over the seven time points. 56/119 (47.1%) patients reported a GOSE = 8 (upper good recovery), and the mean PCS and MCS was 47.8 (95% CI 45.8, 49.9) and 55.8 (95% CI 54.1, 57.5) respectively at five years. Univariate logistic regression showed change in PCS - baseline to 1 year and 1 year to 2 years, and change in MCS - baseline to 1 year were associated with GOSE = 8 at 5 years. Linear mixed effects model showed differences in PCS and MCS were greatest between 1-month and 6-month follow up.

CONCLUSIONS

After injury, the most rapid improvement in PCS and MCS occurred in the first six to 12 months, but further recovery was still evident for MCS in patients aged under 65 years for up to five years.

Supporting informed choice in acupuncture: effects of a new person-, evidence- and theory-based website for patients with back pain

OBJECTIVES

To test whether a newly developed person-, theory- and evidence-based website about acupuncture helps patients make informed decisions about whether or not to use acupuncture for back pain.

METHODS

A randomised online study compared a newly developed 'enhanced website' to a 'standard website'. The enhanced website provided evidence-based information in a person-based manner and targeted psychological constructs. The standard website was based on a widely used patient information leaflet. In total, 350 adults with recent self-reported back pain were recruited from general practices in South West England. The two primary outcomes were knowledge change and making an informed choice about using acupuncture. Secondary outcomes were beliefs about and willingness to have acupuncture.

RESULTS

Participants who viewed the enhanced acupuncture website had a significantly greater increase in knowledge about acupuncture (M = 1.1, standard deviation (SD) = 1.7) than participants who viewed the standard website (M = 0.2, SD = 1.1; F(1, 315) = 37.93, p < 0.001, η² = .107). Participants who viewed the enhanced acupuncture website were also 3.3 times more likely to make an informed choice about using acupuncture than those who viewed the standard website (χ²(1) = 23.46, p < 0.001). There were no significant effects on treatment beliefs or willingness to have acupuncture.

CONCLUSION

The enhanced website improved patients' knowledge and ability to make an informed choice about acupuncture, but did not optimise treatment beliefs or change willingness to have acupuncture. The enhanced website could be used to support informed decision-making among primary care patients and members of the general public considering using acupuncture for back pain.

Relationship Quality and Perceived Partner's Body Appreciation Is Related to Women's Own Body Appreciation and Sexual Functioning

Research on body appreciation is limited, especially when examining its relationship to sexual functioning. The aim of this study was to explore the relationship between body appreciation and sexual functioning, while measuring perceived partner's body appreciation and general relationship quality. A sample of 244 women aged 18 to 30 completed measures of sexual functioning, relationship quality, and body image online. General relationship quality and perceived partner's appreciation of one's body predicted levels of sexual functioning. Levels of body appreciation did not predict sexual functioning over and above general relationship quality and perceived partner's appreciation of one's body. This study is the first to demonstrate the significance of general relationship quality and perceived partner's body appreciation in relation to levels of body appreciation and sexual functioning. The findings highlight the importance of understanding body appreciation and its role in buffering the harmful impacts of viewing idealized images within the media.

Informing Adults With Back Pain About Placebo Effects: Randomized Controlled Evaluation of a New Website With Potential to Improve Informed Consent in Clinical Research

Background

Placebo effects and their underpinning mechanisms are increasingly well understood. However, this is poorly communicated to participants in placebo-controlled trials. For valid informed consent, participants should be informed about the potential benefits and risks of participating in placebo-controlled trials. Existing information leaflets often fail to describe the potential benefits and adverse effects associated with placebo allocation. This study tested the effects of a new website designed to inform patients about placebo effects (The Power of Placebos, PoP). PoP was designed using qualitative methods in combination with theory- and evidence-based approaches to ensure it was engaging, informative, and addressed patients’ concerns.

Objective

This study aimed to test the effects of PoP, compared with a control website, on people’s knowledge about placebo and the ability to make an informed choice about taking part in a placebo-controlled trial.

Methods

A total of 350 adults with back pain recruited from 26 general practices in Southern England participated in this Web-based study. Participants were randomly assigned to PoP (which presented scientifically accurate information about placebo effects in an engaging way) or a control website (based on existing information leaflets from UK trials). Participants self-completed Web-based pre- and postintervention questionnaire measures of knowledge about placebo effects and preintervention questionnaire measures of attitudes toward and intentions to participate in a placebo-controlled trial. The 2 primary outcomes were (1) knowledge and (2) informed choice to take part in a placebo-controlled trial (computed from knowledge, attitudes, and intentions).

Results

After viewing PoP, participants had significantly greater knowledge about placebos (mean 8.28 [SD 1.76]; n=158) than participants who viewed the control (mean 5.60 [SD 2.24]; n=174; F_1,329=173.821; P<.001; η²=.346). Participants who viewed PoP were 3.16 times more likely than those who viewed the control to make an informed choice about placebos (χ²₁=36.5; P<.001).

Conclusions

In a sample of adults with back pain, PoP increased knowledge and rates of informed choice about placebos compared with a control website. PoP could be used to improve knowledge about placebo effects in back pain. After essential further development and testing in clinical trial settings, it could support informed consent in placebo-controlled trials.

Assessing the perceived benefits of a new condom wrapper/integrated applicator: an exploratory study

Errors and problems associated with male condom use are very prevalent and increase the likelihood of inconsistent and incomplete use, thereby compromising condom effectiveness. The aim of this study was to assess the perceived benefits of a new condom wrapper/integrated applicator designed to reduce barriers to condom use and lessen the likelihood of user errors and problems. After viewing videos depicting features of the wrapper/applicator, participants (N = 547; 62.9% male, M age = 29.2) completed online questionnaires. Most participants reported that the product would make condom application easier and quicker, make them more confident that condoms had been applied correctly and make sex more pleasurable and playful. The majority of participants who had recent experience of condom use errors/problems reported that the use of the product would likely prevent these issues from occurring. Reduced chance of condom damage, the design features of the wrapper and not having to touch the condom itself during application were perceived as particular benefits of the product. The findings suggest that the product might reduce the likelihood of a range of condom user errors and problems and enhance pleasure during condom-protected sex. Future larger-scale studies that involve participants physically testing the condom wrapper/applicator are warranted.

Cross-sectional study on emergency department management of sepsis

INTRODUCTION

Emergency departments (EDs) play an important role in the early identification and management of sepsis. Little is known about local EDs' processes of care for sepsis, adoption of international recommendations, and the impact of the new Sepsis-3 definitions.

METHODS

Structured telephone interviews based on the United Kingdom Sepsis Trust 'Exemplar Standards for the Emergency Management of Sepsis' were conducted from January to August 2017 with nominated representatives of all responding public hospital EDs in Hong Kong, followed by a review of hospital/departmental sepsis guidelines by the investigators.

RESULTS

Sixteen of the 18 public EDs in Hong Kong participated in the study. Among various time-critical medical emergencies such as major trauma, sepsis was perceived by the interviewees to be the leading cause of in-hospital mortality and the second most important preventable cause of death. However, only seven EDs reported having departmental guidelines on sepsis care, with four adopting the Quick Sequential Organ Failure Assessment score or its modified versions. All responding EDs reported that antibiotics were stocked within their departments, and all EDs with sepsis guidelines mandated early intravenous antibiotic administration within 1 to 2 hours of detection. Reported major barriers to optimal sepsis care included lack of knowledge and experience, nursing human resources shortages, and difficulty identifying patients with sepsis in the ED setting.

CONCLUSION

There are considerable variations in sepsis care among EDs in Hong Kong. More training, resources, and research efforts should be directed to early ED sepsis care, to improve patient outcomes.

The PARIS score can reliably predict 7-day all-cause mortality for both acute medical and surgical patients: an international validation study

BACKGROUND

We believe errors in the risk assessment of acutely ill patients occur because only vital signs without concurrent functional capacity are considered. We, therefore, developed the PARIS risk score based on blood pressure, age, respiratory rate, loss of independence and oxygen saturation.

AIM

Validation of the PARIS score in four independent cohorts from three countries.

METHODS

Retrospective cohort study of acutely ill patients admitted to hospitals in Denmark, Ireland and Uganda. Vital signs and functional capacity (registered as ability to stand or walk or get into bed unaided) was recorded upon arrival. Patients were followed up for 7 days (Denmark and Ireland) or until discharge (Uganda) and mortality recorded. The discriminatory power (ability to identify patients at increased risk) was determined using area under the receiver operating characteristics curve (AUROC) and calibration (precision) using Hosmer-Lemeshow goodness of fit test.

RESULTS

Out of 14 447 patients, 327 (2.3%) died within 7 days: median age was 59 (39-75) years and 7458 (51.8%) were female. Seven-day mortality increased from 0.3% with a score of 0-26.7% with a score of 5. The score's AUROC as 0.833 [95% confidence interval (95% CI) 0.811-0.856], 0.817 (95% CI 0.792-0.842) and 0.894 (95% CI 0.813-0.974) for all patients, medical patients and surgical patients, respectively. However, except for surgical patients, calibration of the score was poor.

CONCLUSION

The PARIS score can identify both high and low risk acutely admitted medical and surgical patients, but calibration was poor for medical patients.

A pilot test of a self-guided, home-based intervention to improve condom-related sexual experiences, attitudes, and behaviors among young women

OBJECTIVE

To conduct a pilot test of a brief, self-guided, home-based program designed to improve male condom use attitudes and behaviors among young women.

PARTICIPANTS

Women aged 18-24 years from a large Midwestern University reporting having had penile-vaginal sex with two or more partners in the past 3 months. Sixty-seven enrolled; 91.0% completed the study.

METHODS

A repeated measures design was used, with assessments occurring at baseline, immediately  post intervention (T2), and 30 days subsequent (T3).

RESULTS

Condom use errors and problems decreased, condom-related attitudes and self-efficacy improved, and experiences of condom-protected sex were rated more positively when comparing baseline with T2 and T3 scores. Further, the proportion of condom-protected episodes more than doubled between T1 and T3 for those in the lowest quartile for condom use at baseline.

CONCLUSION

This low-resource, home-based program improved condom-related attitudes and promoted the correct and consistent use of condoms.

The Protective Value of Discussing Condom Use: A Study of Young Black Men Attending STI Clinics in the Southern United States

Young Black men (YBM) experience disparities in both HIV incidence and incidence of bacterial sexually transmitted infections (STIs); thus, developing efficacious behavioral interventions is an especially critical goal. One potential avenue for intervention involves improving sexual health communications among YBM and their partners, before sex occurs. Such discussions may serve several purposes, including improving condom use and facilitating the negotiation of correct and consistent condom use. The aim of the current study was to determine the STI-protective effects of discussing condom use with sex partners, among medically underserved YBM. A total of 702 YBM were recruited from three STI clinics in the Southern United States. YBM completed a self-interview at baseline and again 6 months later. At 12 months postenrollment, a chart review determined incidents of STIs. The majority of YBM participants (61.1%) had recently discussed condom use with partners before sex. Of the 12 assessed outcomes, 7 were significantly associated with this measure. In each case, a protective effect was observed. In controlled analyses, the 12-month incidence of STIs was significantly ( p = .05) greater among YBM not discussing condoms with sex partners. The results of the current study suggest that, among YBM attending clinics, discussing condom use with sex partners may promote safer sex practices. This behavior was also predictive of lower STI incidence in the ensuing 12 months, suggesting that it may be an ideal intervention target for programs designed to protect YBM against STI acquisition, including HIV.

Feasibility and Preliminary Effectiveness of the Homework Intervention Strategy (eHIS) Program to Enhance Male Condom Use: Research Protocol

BACKGROUND

Although condoms are effective in reducing the risk of sexually transmitted infections (STIs) and unintended pregnancy, they are still often not used consistently and correctly. Negative impact on sensation and pleasure, ruining the mood, causing problems with maintaining erection, and condom slippage or breakage are some of the reasons given by men explaining why they do not want to use condoms. Although many interventions promoting condom use exist, some of them delivered online are complex and time- and resource-intensive. The Homework Intervention Strategy (eHIS) program, adapted from the existing face-to-face Kinsey Institute Homework Intervention Strategy (KIHIS) program, aims to address these issues by encouraging men to focus on sensation and pleasure when trying different types of condoms and lubricants in a low-pressure situation (on their own, without a partner present).

OBJECTIVE

The objectives of this study are to assess the feasibility, acceptability, and users' engagement with the eHIS program, its preliminary effectiveness in increasing condom use frequency and consistency, as well as the feasibility of the program's evaluation approach, including choice of measures and participant recruitment and retaining strategies (primary outcomes). Secondary outcomes include condom use experience, condom use attitudes, condom use self-efficacy, condom use errors and problems, and condom fit-and-feel. All of these will be analyzed in the context of participants' demographics, sexual history, and previous condom use.

METHODS

The study has a pre-post-test, within-subjects design. Men aged 18 to 69 and living in the United Kingdom are recruited through posters, leaflets, social media, and emails. Study participants are asked to complete T1 (baseline) measures before entering the eHIS website. After completing the T1 measures, they can order a free condoms and lubricants kit and have access to the eHIS website for 4 weeks. During that time they are asked to practice using different types of condoms and lubricants on their own in a no-pressure situation. Following T1, participants are asked to complete the T2 and T3 measures at 4 and 10 weeks, respectively.

RESULTS

Data collection for the study is completed. Data analysis is in progress and is expected to be completed by February 2018.

CONCLUSIONS

This brief, home-based, self-guided program may lead to increased consistent and correct condom use. Online delivery can make the program an easily accessible and low-cost health promotion intervention, which has the potential to reach a wide and diverse audience. If results of the current study show the program's feasibility and preliminary effectiveness in changing condom use related outcomes, a larger scale randomized controlled trial (RCT) will be conducted.

TRIAL REGISTRATION

Research Registry: researchregistry2325; http://www.researchregistry.com/browse-the-registry.html# home/registrationdetails/58da6cad1d7ab0314337d076/ (Archived by WebCite at http://www.webcitation.org/6vXs6S9XW).

Do Associations Between Pleasure Ratings and Condom Use During Penile-Vaginal Intercourse Vary by Relationship Type?: A Study of Canadian University Students

Research suggests the relationship between pleasure and condom use during penile-vaginal intercourse (PVI) is associated with relationship status. This online study examined pleasure ratings and condom use at last PVI, stratifying by partner type, among a national sample of Canadian university students. Participants were 715 undergraduates (60.7% women, 39.3% men) who reported on their most recent sexual experience. Condom use decreased with level of relationship commitment, whereas ratings of pleasure increased. Overall, participants were more likely to rate their most recent PVI as Very pleasurable when condoms were not used compared to when condoms were used. However, when stratified by partner type, these differences largely disappeared. For women, with one exception, there were no differences in pleasure between PVI with and without condoms across most partner-type categories. Women in committed dating relationships were more likely to report their last PVI as very pleasurable if condoms were not used than women in these same relationships who had used condoms. Across relationship categories, men who did and did not use condoms did not differ in terms of their pleasure ratings. The results of this study suggest relationship context should be taken into account when assessing condom use experiences.

Health Status following Major Trauma in the West of Scotland: Pilot Descriptive Study

Background

Data on the long-term outcome of major trauma survivors in the United Kingdom (UK) is lacking. This pilot study aimed to investigate the health status of survivors of major trauma without significant head injury in the West of Scotland, and to compare the Short-Form 12 (SF12) questionnaire administered by telephone (TSF12) to the longer Short-Form 36 (SF36) questionnaire.

Methods

This was a descriptive, comparative, pilot clinical study. Eligible patients had an injury severity score (ISS) >15, sustained their injuries >2 years ago, abbreviated injury score (AIS) <2 for head trauma and were treated in two Glasgow hospitals. The Short-Form 36 (SF36) health status questionnaire was completed at home, and the Short-Form 12 (SF12) questionnaire was administered by telephone (TSF12).

Results

From 141 eligible patients (85% male, median age 35 years, median ISS 19 and median Ps 0.981), 13 patients completed the study. Despite small numbers, mean SF36 scores were significantly lower in four dimensions compared to UK means. SF36 summary scores were non-significantly below US and UK means. The TSF12 physical summary score was significantly below US and UK means. Correlations between the SF36 and TSF12, and SF12 intra-class correlations were high. One-way ANOVA showed significantly lower mental summary scores for patients with spinal injuries.

Conclusions

This small study suggests that non-head injured survivors of major trauma have lower health status than the UK average. The TSF12 appears to be a practical alternative to the conventional SF36 and warrants larger scale evaluation.

Pain and Pain Management in a Hong Kong Emergency Department

Background

The prevalence of pain is high in emergency departments (ED), according to previous studies. There is little information on the epidemiology of pain in Hong Kong EDs. This study aimed to explore the epidemiology of pain in a single academic ED in Hong Kong, and to evaluate the pain management policy in the ED.

Methods

Retrospective case review study with explicit record review of ED clinical records; records obtained by means of systematic sampling of a seven-consecutive-day period attendance. Data on the prevalence and location of pain, waiting time for drugs for pain relief, and pain drug prescription rates were obtained. Descriptive data analysis was performed.

Results

A total of 494 ED clinical records were reviewed. The prevalence of pain was 60.7% (300/494) during the study period. 72.3% (217/300) of patient attendances with pain had duration of pain not exceeding three days; 79.0% (237/300) of them were classified as ‘semi-urgent’ or ‘non-urgent’. 41.7% (125/300) of patients suffering from pain were given drugs for pain relief. The median time for patients to receive analgesic drugs was 56.0 (IQR 25.0-104.5) minutes after registration. Pain assessment using a numerical rating scale was positively associated with drug prescriptions for pain relief.

Conclusion

The prevalence of pain in ED patients was high, and comparable with the figures from studies in other EDs. Patients attending with pain had to wait more than 60 minutes for drugs for pain relief on average. (Hong Kong j.emerg.med. 2011;18:406-411)

Emergency Physicians' Preparedness for CBRNE Incidents in Hong Kong

Background

Recent terrorist attacks with biological and chemical weapons have caused much concern for the public. The purpose of this study was to assess emergency doctors' preparedness in handling Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) incidents.

Methods

This is a cross sectional survey of all emergency doctors working in public emergency departments (ED) in Hong Kong. Apart from the experience and confidence to handle these events, data on participants' willingness to participate in CBRNE incidents and training motivations were also analysed.

Results

Biological and radiological events were found to be the least commonly encountered. Few respondents reported they were confident to manage biological events (10.6% to 29.8%), despite 66% of respondents reported having prior training in CBRNE management.

Conclusions

This study demonstrates ED doctors' low confidence in managing specific CBRNE incidents. Current strengths identified include the good awareness of hospital emergency plans and high motivation to get more training.

The Epidemiology of Patients with Dizziness in an Emergency Department

Objectives

The aims of this prospective study were (1) to describe the patterns of presentation, causes and disposition of patients with dizziness in an emergency department (ED) and (2) to identify the factors that predict central vestibular disorder.

Methods

All adult patients (≥18 years) attending our ED with a chief complaint of dizziness were included. Demographic characteristics, presenting complaint, symptoms, past medical illnesses, physical findings, provisional diagnosis and disposition were recorded in a data collection sheet by the medical officers.

Results

A total of 104 consecutive dizzy patients were recruited from 12th to 19th December 2003. The incidence of adult patients with dizziness was 4.0% (104/2594). There were 34 (32.7%) male and 70 (67.3%) female patients; 64 (61.5%) patients were below 65 and 40 (38.5%) were above 65. Lightheadedness (61.5%), vertigo (31.7%) and disequilibrium (4.8%) were the most frequent complaints. Nausea and/or vomiting (32.7%) and raised blood pressure on arrival (23.1%) were the most common associated symptoms and physical finding respectively. Hypertension (38.5%) was the most common pre-existing medical illness. Of all patients, 63.5% had non-vestibular disorder, 31.7% had peripheral vestibular disorder and 4.8% had central vestibular disorder. A clinical diagnosis could be made in 52.9% of our dizzy patients and about 20 different diagnoses were made. The majority (82.7%) of the patients were discharged from the ED. A presenting complaint of lightheadedness, altered mental state, focal neurological signs, raised blood pressure and history of stroke were predictors of central vestibular disorder (p<0.05).

Conclusions

Lightheadedness and vertigo were the two commonest presentations of dizzy patients. Most dizzy patients had benign causes and could be discharged from the ED. Lightheadedness, focal neurological symptoms and signs, altered mental state, hypertension and previous stroke were factors that would help to diagnose central vestibular disorder.

Fatal Pulmonary Embolism in a Teenager: Case Report

Massive pulmonary embolism is unusual in young people. We present a case of massive pulmonary embolism in a teenage Chinese patient. Initially he presented to the emergency department with dyspnoea and fever. Influenza B was diagnosed during his four-day stay in the paediatric ward. One week later he suddenly collapsed and presented to the emergency department with chest pain, syncope and dyspnoea. Despite undergoing rapid assessment, along with prompt admission to intensive care and cardiopulmonary resuscitation, he died. Autopsy revealed massive pulmonary embolism, which is rare at this age. Computed tomography pulmonary angiography and early thrombolytic therapy may improve the outcome in similar cases.

Preferences and Perceptions of Patients Attending Emergency Departments with Low Acuity Problems in Hong Kong

Objective

To explore why patients in Hong Kong seek medical advice from the emergency department (ED) and to identify the methods by which patients would prefer to be updated on the likely waiting time for medical consultation in the ED.

Methods

The study recruited 249 semi-urgent and non-urgent patients in the ED of Prince of Wales Hospital from 26th September 2005 to 30th September 2005 inclusive. A convenience sample of subjects aged ≥15 years old in triage categories 4 or 5 were verbally consented and interviewed by research nurses using a standardized questionnaire.

Results

From 1715 potential patients, 249 were recruited ad hoc (mean age 44 years [SD18]; 123 females). About 63% indicated that an acceptable ED waiting time was less than or equal to two hours, and 88% felt that having individual number cards and using a number allocation screen in the ED waiting area would be useful. Perceived reasons for attending the ED rather than other health care providers such as primary health care or the general outpatient clinic (GOPC) included: a desire for more detailed investigations (56%); a perception that more professional medical advice was given in the ED (35%); patients were under the continuing care of the hospital (19%); and patients were referred to the ED by other health care professionals (11%). Notably, 26% of participants had considered attending the GOPC prior to attending the ED. Patients educated to tertiary level expected a shorter waiting time than those educated to lesser degrees (p=0.026, Kruskal-Wallis test). Suggestions were made on how to provide a more pleasant ED environment for the wait for consultations, which included the provision of a television screen with sound in the waiting area (43%), more comfortable chairs (37%) and health care promotion programs (32%).

Conclusion

Patients chose ED services because they believed they would receive more detailed investigations and more professional medical advice than available alternatives. Clear notification of the likely waiting times and enhancement of comfort before consultation are considered desirable by patients. Enhanced public education about the role of the ED and making alternatives to ED care more accessible may be useful in reducing inappropriate ED attendances in Hong Kong.

Undergraduate Emergency Medicine Training: Past, Present and Future

This article briefly reviews the development of emergency medicine (EM) in Hong Kong with particular focus on the parallel development of training in EM at the undergraduate level. The practice of EM in Hong Kong started more than 50 years ago but the development of the specialty progressed slowly until the 1980s. Since then, although there have been major advances in postgraduate training, the specialty still features poorly in undergraduate medical training. We compared emergency medicine training in Hong Kong, Australia, USA, UK and Singapore, in order to identify areas in the medical curriculum where EM could contribute more to undergraduate medical training. The growth of EM in Hong Kong depends on recruiting good trainees who are attracted by what they observe and what they learn during their undergraduate EM clerkship.

A Pilot Randomised Clinical Trial of 3-In-1 Femoral Nerve Block and Intravenous Morphine as Primary Analgesia for Patients Presenting to the Emergency Department with Fractured Hip

Background

Fractured neck of femur (NOF) is a leading cause of morbidity and mortality in the elderly. Published clinical guidelines suggest early adequate analgesia as a key management aim. The femoral nerve ‘3-in-1 block’ has previously been shown to provide effective analgesia for these patients in the peri- and post-operative phase of care. The aim of this study was to examine the use of the ‘3-in-1’ femoral nerve block as primary analgesia for patients with a fractured NOF presenting to the emergency department.

Methods

This was a single centre pragmatic randomised controlled open-label trial comparing femoral nerve block (using a ‘3-in-1’ technique) with intravenous (IV) morphine. A convenience sample of patients presenting to the emergency department of a district general hospital with a clinically or radiologically suspected fractured NOF were recruited. They were randomised to receive either 0.1 mg/kg IV bolus of morphine or a ‘3-in-1’ femoral nerve block with 30 ml of 0.5% plain bupivacaine. Visual analogue pain scores were noted prior to treatment and at 30 minutes, 2 hours, 6 hours and 12 hours after treatment. Immediate complications such as vascular puncture or the requirement for naloxone were noted.

Results

Forty patients were recruited, 22 patients were randomised to IV morphine and 18 patients were randomised to ‘3-in-1’ femoral nerve block. Complete data were available for 33 patients. There was no significant difference in initial median pain score (p=0.45). Analysis using the Wilcoxon test showed a significant decrease in pain score for the morphine group (p=0.01) and the nerve block group (p<0.01) at 30 minutes compared with baseline. Analysis using the Mann-Whitney U test between median pain scores at each time point showed a significant lower pain score in the nerve block group at 30 minutes (p=0.046). There were no immediate complications in either group.

Conclusion

Our results suggest that a ‘3-in-1’ femoral nerve block is at least as effective as IV morphine when used as primary analgesia for patients with fractured NOF. Our results suggest that the femoral nerve block may provide better analgesia at 30 minutes. Further larger scale randomised trials are warranted.

Differences in Injury Pattern and Mortality between Hong Kong Elderly and Younger Patients

Background

The rapidly aging population in Hong Kong is causing an impact on our health care system. In Hong Kong, 16.5% of emergency department trauma patients are aged ≥65 years.

Objective

We aim to compare factors associated with trauma and differences in trauma mortality between elderly (≥65 years) and younger adult patients (15 to 64 years) in Hong Kong.

Methods

A retrospective observational study was performed using trauma registry data from the Prince of Wales Hospital, a 1200–bed acute hospital which is a regional trauma centre.

Results

A total of 2172 patients (331 [15.2%] elderly and 1841 [84.8%] younger) were included. Male patients predominated in the younger adult group but not in the elderly group. Compared with younger patients, elderly patients had more low falls and pedestrian-vehicle crashes and sustained injuries to the head, neck and extremities more frequently. The odds ratio (OR) for death following trauma was 5.5 in the elderly group (95% confidence interval [CI] 3.4–8.9, p>0.0001). Mortality rates increased progressively with age (p>0.0001) and were higher in the elderly at all levels of Injury Severity Score (ISS). Age ≥65 years independently predicted mortality (OR=5.7, 95% CI 3.5–9.3, p>0.0001). The elderly had a higher co-morbidity rate (58.6% vs. 14.1%; p>0.01). There was a lower proportion of trauma call activations for the elderly group (38.6% vs. 53.3%; p>0.01).

Conclusion

Elderly trauma patients differ from younger adult trauma patients in injury patterns, modes of presentation of significant injuries and mortality rates. In particular, the high mortality of elderly trauma requires renewed prevention efforts and aggressive trauma care to maximise the chance of survival.

Management of Suspected Deep Venous Thrombosis in an Emergency Medicine Ward in Hong Kong

Introduction

Clinical signs and symptoms can vary for patients with deep venous thrombosis (DVT). DVT is an important diagnosis to recognise as it can lead to proximal embolism into the pulmonary circulation resulting in sudden collapse and death. The objective of this study is to describe the management of patients with suspected DVT in the emergency medicine ward (EMW) setting in Hong Kong using a standardised clinical pathway.

Methods

A retrospective review was conducted for patients with suspected DVT admitted to the EMW from April to December 2008 using a standardised protocol. The use of a clinical prediction rule and diagnostic tests (including the modified Well's score, D-dimer and ultrasound examination) and outcomes (including the length of stay and secondary admission rate) were investigated.

Results

A total of 100 patients with suspected DVT were admitted to the EMW in the nine-month study period. DVT was confirmed in 30% using ultrasonography. Fifty-two percent of patients were in the high-risk category according to the modified Well's score. Seventy-six percent of patients had positive D-dimer results. Ten percent of patients were safely discharged without an ultrasound examination. Mean length of stay in the EMW was 1.99 days. Thirteen percent of patients required second admission to other specialties.

Conclusions

This study suggests that a standardised clinical pathway based in the EMW can be used for patients with suspected DVT to reduce hospital admission.

Treatment and Outcome of Acute Cardiogenic Pulmonary Oedema Presenting to an Emergency Department in Hong Kong: Retrospective Cohort Study

Objectives

To explore the epidemiology, treatment and outcome of acute cardiogenic pulmonary oedema (ACPO) in a Hong Kong emergency department (ED).

Methods

This was a retrospective cohort study in a university hospital ED. Cases were identified from ED records and resuscitation room logbooks. The study extended from 1 September 2004 to 30 April 2005. Parametric tests and logistic regression were used to identify predictors of survival.

Results

A total of 140 patients were identified, with a mean age of 75 years and male:female ratio of 1:1.4. Mean values (range) on presentation were as follows: pulse rate 103 beats/minute (36–108); blood pressure (BP) 169/88 mmHg (77-274/20-162) and respiratory rate 31 breaths/minute (12–88). Past medical history included previous ACPO (12.1%), diabetes (45.7%), chronic obstructive pulmonary disease (9.3%), ischaemic heart disease (45.0%), hypertension (72.1%) and congestive heart failure (40.7%). On admission, 47.1% had pH<7.35 and 40.7% had PaCO2>5.5kPa. ED treatments included: sublingual nitrates (n=2), intravenous (IV) nitrates (n=89, median 10 mg/hr), IV frusemide (n=85, median 40 mg), IV morphine (n=25, median 3 mg). There were 21 patients on non-invasive ventilation; 27 intubations and 41 patients were admitted to the intensive care unit. Survival to discharge was 95.7%; and median length of hospital stay was 8 days. The 90-day all-cause hospital readmission rate was 30.0%. The 30-day mortality was 12.9% (n=18) and 90-day mortality was 29.3% (n=41). Logistic regression showed that past history of hypertension (p=0.0061), higher systolic BP on ED discharge (p=0.0102) and lower creatinine following treatment (p=0.035) were predictors of improved survival at 90 days.

Conclusion

ACPO commonly presents to the ED in Hong Kong and has a high 90-day mortality. Previous hypertension, higher systolic blood pressure on leaving the ED and lower creatinine following treatment predict improved survival at 90 days.