In Situ Assembly of Transmembrane Proteins from Expressed and Synthetic Components in Giant Unilamellar Vesicles

Reconstituting functional transmembrane (TM) proteins into model membranes is challenging due to the difficulty of expressing hydrophobic TM domains, which often require stabilizing detergents that can perturb protein structure and function. Recent model systems solve this problem by linking the soluble domains of membrane proteins to lipids, using noncovalent conjugation. Herein, we test an alternative solution involving the in vitro assembly of TM proteins from synthetic TM domains and expressed soluble domains using chemoselective peptide ligation. We developed an intein mediated ligation strategy to semisynthesize single-pass TM proteins in synthetic giant unilamellar vesicle (GUV) membranes by covalently attaching soluble protein domains to a synthetic TM polypeptide, avoiding the requirement for detergent. We show that the extracellular domain of programmed cell death protein 1, a mammalian immune checkpoint receptor, retains its ligand-binding function at a membrane interface after ligation to a synthetic TM peptide in GUVs, facilitating the study of receptor-ligand interactions.

The feeding paradox in advanced dementia: a local perspective

Feeding problems are common in older people with advanced dementia. When eating difficulties arise tube feeding is often initiated, unless there is a valid advance directive that refuses enteral feeding. Tube feeding has many pitfalls and complications. To date, no benefits in terms of survival, nutrition, or prevention of aspiration pneumonia have been demonstrated. Careful hand feeding is an alternative to tube feeding with advanced dementia. In Hong Kong, the Hospital Authority has established clear ethical guidelines for careful hand feeding. Notwithstanding, there are many practical issues locally if tube feeding is not used in older patients with advanced dementia. Training of doctors, nurses, and other members of the health care team is vital to the promulgation of careful hand feeding. Support from the government and Hospital Authority policy, health care staff training, public education, and promotion of advance care planning and advance directive are essential to reduce the reliance on tube feeding in advanced dementia.

Evaluation of chronic disease self-management programme (CDSMP) for older adults in Hong Kong

OBJECTIVES

To evaluate the locally-adapted CDSMP for older adults with chronic diseases in Hong Kong in the primary care setting.

DESIGN

A longitudinal, quasi-experimental study.

SETTING

Community-based and primary care setting.

PARTICIPANTS

Seven hundred and seventy-two participants aged 55 or above with at least one chronic disease and were living in the community.

INTERVENTION

The 6-weeks programme consisted of 6 group sessions, with each session lasting for 2.5 hours. Trained professional and elder lay leaders facilitated participants to gain essential self-management knowledge and skills for the effective management of chronic diseases.

MEASUREMENTS

At baseline and 6 months, four categories of outcome measures were documented, covering self-management behaviours, self-efficacy, health status, and health care utilization.

RESULTS

302 and 298 participants in the intervention and control groups completed 6 months follow-up respectively. Participants in the intervention group reported significant improvements in all self-management behaviours and self-efficacy measures, and 5 health status measures (social role limitation, depressive symptoms, health distress, symptoms of pain and discomfort, and self-rated health) when compared with those in the control group.

CONCLUSIONS

The locally-adapted CDSMP may improve self-management behaviours, self-efficacy and health status among older adults with chronic diseases in Hong Kong. CDSMP may be integrated into primary care services for older adults.

Comparison of Humalog Mix 50 with human insulin Mix 30 in type 2 diabetes patients during Ramadan

AIMS

To compare hypoglycaemic events, glycated haemoglobin (HbA1c) and changes in body weight in Muslim patients with Type 2 diabetes receiving Humalog Mix 50 and human Mixtard 30 twice daily during Ramadan fasting.

METHODS

Data were collected from Muslim patients with Type 2 diabetes attending primary care practices in North-West London, who were on Mixtard 30 insulin twice daily before Ramadan. Group 1 had their evening insulin changed to Humalog Mix 50 (n = 26) 2 weeks before Ramadan, i.e. taking Mixtard 30 at predawn meal and Humalog Mix 50 at the sunset meal during Ramadan. As the major proportion of the daily caloric intake was consumed at the sunset meal, the rationale of switching the evening dose from human Mixtard 30 to Humalog Mix 50 was to provide more rapid-acting insulin that has shorter time of onset and peak time for the large evening meal to improve the postprandial glucose control without increasing the risk of hypoglycaemia. Group 2 continued on Mixtard 30 twice daily (n = 26). All patients received structured education about how to identify and manage hypoglycaemia during Ramadan.

RESULTS

Group 1 had a mean HbA1c reduction of 0.48% (p = 0.0001) before and after Ramadan, whereas group 2 had a mean HbA1c increase of 0.28% (p = 0.007). Group 1 was associated with a small reduction of 0.04 (p = 0.81) in the mean number of hypoglycaemic events during Ramadan compared with before Ramadan, whereas group 2 was associated with an increase of 0.15 (p = 0.43), although these differences between the groups were not statistically significant following adjustment for baseline factors [LSM difference between groups = 0.135, p = 0.36, 95% confidence limits (-0.16, 0.43)].

CONCLUSION

Changing to humalog Mix 50 during Ramadan resulted in improvement in glycaemic control without increasing the incidence of hypoglycaemia.

Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan

BACKGROUND AND AIMS

During Ramadan, Muslims fast from dawn to dusk for one lunar month. The majority of Muslim diabetic patients are unaware of complications such as hypoglycaemia during fasting. The safety of fasting has not been assessed in the UK Muslim population with diabetes. The aim of this study was to determine the impact of Ramadan-focused education on weight and hypoglycaemic episodes during Ramadan in a Type 2 diabetic Muslim population taking oral glucose-lowering agents.

METHODS

We retrospectively analysed two groups. Group A attended a structured education programme about physical activity, meal planning, glucose monitoring, hypoglycaemia, dosage and timing of medications. Group B did not. Hypoglycaemia was defined as home blood glucose < 3.5 mmol/l.

RESULTS

There was a mean weight loss of 0.7 kg after Ramadan in group A, compared with a 0.6-kg mean weight gain in group B (P < 0.001). The weight changes observed were independent of the class of glucose-lowering agents used. There was a significant decrease in the total number of hypoglycaemic events in group A, from nine to five, compared with an increase in group B from nine to 36 (P < 0.001). The majority were in patients treated with short-acting sulphonylureas (group A-100%, group B-94%). At 12 months after attending the programme, glycated haemoglobin (HbA(1c)) reduction were sustained in group A.

CONCLUSIONS

Ramadan-focused education in diabetes can empower patients to change their lifestyle during Ramadan. It minimizes the risk of hypoglycaemic events and prevents weight gain during this festive period for Muslims, which potentially benefits metabolic control.

Vildagliptin therapy and hypoglycaemia in Muslim type 2 diabetes patients during Ramadan

AIMS

To compare hypoglycaemic events, glycated haemoglobin (HbA(1c)) and changes in bodyweight in metformin-treated Muslim patients with type 2 diabetes receiving adjunctive treatment with vildagliptin or gliclazide during Ramadan fasting.

METHODS

Data were collected from Muslim patients with type 2 diabetes attending primary care practices in North West London, whose HbA(1c) was > 8.5% despite treatment with metformin 2 g daily before Ramadan and who received gliclazide 160 mg twice daily (n = 26) or vildagliptin 50 mg twice daily (n = 26) in addition to metformin. Hypoglycaemic events, HbA(1c) and weight were recorded 2 weeks before and 10 days after the Ramadan fast. All patients received education about how to identify and manage hypoglycaemia during Ramadan.

RESULTS

During Ramadan, at least one hypoglycaemic event (defined as blood glucose < 3.5 mmol/l with or without symptoms) was recorded in two patients receiving vildagliptin (7.7%) and 16 patients receiving gliclazide [61.5%; difference between groups -53.8%, 95% confidence interval (CI) -74.9 to -26.3, p < 0.001]. Vildagliptin was associated with a reduction in the mean number of hypoglycaemic events during Ramadan compared with before Ramadan, whereas gliclazide was associated with an increase (least squares mean difference between groups -0.66, 95% CI -1.20 to -0.13, p = 0.0168). Both gliclazide and vildagliptin were associated with similar reductions in HbA(1c) and a small, but insignificant, increase in weight.

CONCLUSIONS

Appropriate treatment adjustments can lead to improved diabetes management during Ramadan, with avoidance of significant weight gain and improved glucose control without hypoglycaemia. The addition of vildagliptin to metformin therapy during Ramadan in Muslim patients with type 2 diabetes was associated with a reduction in the incidence of hypoglycaemia.

Usefulness of the Chinese Nutrition Screening (CNS) tool in predicting 12 month mortality in elderly Hong Kong Chinese living in institutions

OBJECTIVES

To determine the cut off score of the CNS in predicting 12 months mortality.

DESIGN

Data was collected and followed up from a previous study among elderly subjects (n = 515) living in community institutional setting. The risk of malnutrition and 12 months mortality was ranked by the CNS and compared with that by SGA. Reliability was assessed by the sensitivity and specificity of the prediction with SGA as well as BMI alone. Sensitivity and specificity was calculated to determine validity as well as using positive and negative predictive values in predicting mortality at 12 months.

RESULTS

All three tools (BMI, SGA, CNS) demonstrated significant difference of higher mortality rate (P < .001) in the malnourished group. CNS at score < or = 21 showed comparable results to SGA tool and BMI at classifying malnutrition. And using cut off score > or = 22 also show significant results with SGA in classifying patients with normal nutrition. CNS score at > or = 22 sensitivity was 60.9% and specificity was 72.9% with a Negative Predictive value of 92.3% and a Positive Predictive value of 25.8%.

CONCLUSION

CNS tool at cut off > or = 22 is just as good as using BMI or SGA in identifying those who have a normal nutritional status. This is useful in particular, when biochemical or anthropometric data is not available. This further validates the use of > or = 22 as the best cut off point with the CNS tool and just as good at predicting of mortality when compared with SGA and BMI assessments.

A pilot study to examine the feasibility and acceptability of a community model for exercise prescription for patients with chronic disease

1. A model of community care for chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) that incorporates exercise prescription is lacking, although the benefits of exercise for these diseases are established. 2. Group programmes incorporating exercise, disease education, and social support consisting of weekly sessions for 12 weeks were designed for COPD and CHF patients, in groups of 8 to 10. A home exercise programme was also prescribed. 3. This model was feasible, enjoyed good compliance, improved symptoms and measures of psychosocial outcome for both disease and improved exercise tolerance in the CHF group. 4. This model could be further developed as an integral part of community management for patients with chronic diseases.

Influenza-like illness in residential care homes: a study of the incidence, aetiological agents, natural history and health resource utilisation

BACKGROUND

Influenza-like illness (ILI) among elderly people living in residential care homes (RCHEs) is a common cause for hospitalisation. A study was undertaken to examine the incidence, underlying aetiology, natural history and associated healthcare resource utilisation related to ILI in the RCHE population.

METHODS

A prospective study of ILI in four RCHEs in Shatin, Hong Kong was conducted from April 2006 to March 2007. Each RCHE was monitored daily for the occurrence of ILI and followed up until resolution of illness or death. Clinical features were recorded and sputum, nasopharyngeal aspirate, blood and urine specimens were examined for underlying aetiology.

RESULTS

259 episodes of ILI occurred in 194 subjects, with mild peaks in winter and summer, over a sustained level throughout the year. The infectious agent was identified in 61.4% of all episodes, comprising bacterial infection in 53.3% and viral in 46.7%. Multiple infections occurred in 16.2% of subjects. The most frequent organism was Streptococcus pneumoniae, followed by respiratory syncytial virus, Pseudomonas aeruginosa, metapneumovirus and parainfluenza virus types 1 and 3. Clinical features did not vary according to the underlying aetiology, the common presenting features being a decrease in general condition, cognitive and functional deterioration, and withholding of food in addition to fever and respiratory symptoms. Overall, mortality at 1 month/discharge was 9.7%. Infection with methicillin-resistant Staphylococcus aureus, low body mass index and poor function predisposed to mortality. No association was observed between influenza vaccination status and underlying aetiology, clinical features or outcome.

CONCLUSIONS

The clinical presentation of ILI is non-specific and is mainly due to bacterial and viral infections other than influenza in the RCHE population.

Detection of circulating tumor cells (CTCs) in patients with hepatocellular carcinoma (HCC)

15037

Background: Allard et al. (2004) has established the accuracy, sensitivity, reliability and linearity of circulating tumor cells (CTCs) detection using the CellSearch System. 57% prostate cancers, 37% breast cancers, 37% ovarian cancers, 30% colorectal cancers, and 20% lung cancers specimens had >= 2 CTCs per 7.5 mL of blood. Only 0.3% healthy non-malignant disease subjects had >= 2 CTCs per 7.5 mL of blood. Cristofanilli et al.(2004,2005) have shown that CTCs at baseline and first follow-up were a significant prognostic factor for survival in metastatic breast cancer patients. However, HCC data on CTCs are not available. Methods: 20 locally advance or metastatic HCC patients who had not received prior treatment had been recruited after informed consent and 7.5 mL of blood were collected using the CellSave Preservative tubes (Veridex LLC, Raritan, NJ) that prevents CTCs degradation. The CellSearch system (Veridex LLC) similar to the previous studies was used to analyze the specimen. The CellSearch system consists the CellPrep system, the CellSearch Epithelial Cell Kit, and the CellSpotter Analyzer. All the procedures and interpretation of results followed closely with the quality control procedure of Veridex LLC including accreditation of trained laboratory personnel. Results: 13/20 (65%) had locally advanced disease and the rest had metastatic HCC. All patients had multiple lesions. 9/20 (45%) patients had detectable CTCs, 7/20 (35%) had >= 2 CTCs, and about 5/20 (20%) had 5 or more CTCs. For locally advanced HCC 4/13 (31%) patients had >= 2 CTCs per 7.5 mL of blood. For HCC patients with metastatic diseases 3/7 (43%) patients had >= 2 CTCs per 7.5 mL of blood. Conclusions: HCC patients with locally advance or metastatic disease had detectable CTCs in 7.5 mL of blood. We expected that the performance of CTCs in HCC is similar to that of breast cancer. Future study of using CTCs as prognostic factor at baseline and during treatment for HCC is being planned.

No significant financial relationships to disclose.

Aromatase inhibitors and male breast cancer

The majority of breast cancers in male patients are hormone receptor positive. Tamoxifen has proven to be successful in both adjuvant and metastatic settings and remains the standard of care. Given the improved outcomes in female patients with aromatase inhibitors (AI), these drugs have become a potential therapeutic tool for male patients. Preliminary data show effective suppression of oestradiol levels in males treated with AI and some reports have demonstrated objective responses. Here we report a case of a male patient with metastatic breast cancer treated with letrozole who achieved clinical response associated with a decrease in blood oestradiol levels.

Development of the Chinese nutrition screen (CNS) for use in institutional settings

OBJECTIVES

To develop and validate a nutritional screening tool (CNS) for elderly Chinese subjects in the institutional setting.

DESIGN

Using the MNA as a guide, a questionnaire was developed appropriate for the Chinese health care system, diet, food customs and culture, using physician assessment for comparison.

PARTICIPANTS

200 men and 200 women aged 65 years or older, approximately equally distributed by age between two cities in China (Hong Kong and Shanghai), were recruited from hospitals and old age homes for the reliability study. 340 men and 527 women were recruited for the validity study.

RESULTS

The CNS compared with physician assessments based on two groups, normal or at risk with less than normal nutritional status, had kappa coefficients of 0.5 overall and were as high as 0.8 in Shanghai. CNS was able to identify about 90% of all persons with normal nutritional status and had about a 60% chance of correctly identifying a person at risk with a less than normal nutritional status.

CONCLUSION

The CNS can be used in a 2-group classification to identify those who have a normal nutritional status (CNS > or = 21). Those who do not fall into this group should have their nutritional status evaluated in greater detail (CNS score < or = 20). The applicability of screening tools may vary depending on the site and the population characteristics.

Low staffing level is associated with malnutrition in long-term residential care homes

OBJECTIVE

To determine if staffing level is associated with poor nutrition in the long-term residential care setting, adjusting for other confounding factors.

DESIGN

Cross-sectional survey.

SETTING

In total, 14 residential care facilities in Hong Kong, stratified by nature (government subvention or for-profit) to reflect the overall proportion in Hong Kong.

SUBJECTS

A total of 1914 subjects were assessed, using the Resident Assessment Instrument (RAI) 2.0. The response rate was 95% (1820 subjects), of which 1699 subjects had complete nutritional information.

INTERVENTION

Body mass index (BMI) was calculated by weighing and height measurement, and arm span was used if the subject could not stand. Subjects who were receiving parenteral or enteral nutrition via nasogastric of enterostomy tubes were excluded. A history of weight loss of 5% in the past month or 10% in the past 6 months, leaving 25% of food uneaten, and BMI < 18.5 kg/m(2) were examined as nutritional indicators. Association with age, gender, functional disability, oral problems, taste problems, presence of physical diseases and psychological well-being was examined using chi(2)-test, and multiple logistic regression.

RESULTS

In all, 26% of residents had a BMI < 18.5 kg/m(2), with a higher prevalence in the for-profit homes. History of weight loss and the record that 25% of food was left uneaten were poor indicators of low BMI. Multivariate analysis showed that having chronic obstructive airways disease, requiring help with feeding, being female, older age, were factors associated with an increased risk of poor nutrition, while being independent in activities of daily living and higher staff levels were associated with a reduced risk.

CONCLUSION

Poor nutrition is a persistent problem in the long-term care setting, and inadequate staffing levels may be a reversible cause. However, resource limitations may render efforts at improvement difficult.

SPONSORSHIP

SK Yee Memorial Fund.

Total daily energy expenditure in wasted chronic obstructive pulmonary disease patients

OBJECTIVES

To investigate total daily energy expenditure in chronic obstructive pulmonary disease (COPD) patients during a rehabilitation programme.

DESIGN

Observational study involving a case and a control group.

SUBJECTS

Ten COPD patients (six with body mass index (BMI) <18.5 kg/m(2) and four with BMI >18.5 kg/m(2)) were evaluated for their energy expenditure profile. Four additional healthy age-matched volunteers were also included for methodology evaluation.

INTERVENTIONS

Measurements of total daily energy expenditure (TEE), resting energy expenditure (REE) and diet-induced thermogenesis (DIT) and energy intake were undertaken by indirect calorimetry and bicarbonate-urea methods and dietary records.

RESULTS

REE in COPD patients was not significantly different from that predicted by the Harris-Benedict equation. Before the exercise day the mean TEE was 1508 kcal/day and physical activity level (PAL as calculated by TEE/REE) was 1.52. On the exercise day the TEE increased to 1568 kcal/day and PAL was 1.60, but neither of these changes were significant. The energy cost of increased physical activity during rehabilitation exercise was estimated to be 191 kcal/day. No significant change was found in DIT between the two patient groups. However, overall energy balances were found to be negative (-363 kcal/day).

CONCLUSION

The rehabilitation programme did not cause a significant energy demand in COPD patients. TEE in COPD patients was not greater than in free-living healthy subjects. Patients, who were underweight, did not have a higher TEE than patients with normal weight. This suggested that malnutrition in COPD patients was not due to an increased energy expenditure. On the other hand, a significant negative energy balance due to insufficient energy intake was found in seven out of 10 patients.

The Hong Kong Bridge Protocol. Immediate loading of mandibular Brånemark fixtures using a fixed provisional prosthesis: preliminary results

BACKGROUND

The Brånemark System Classic is well documented for its successful and predictable results in dental implant rehabilitation. However, the classic two-stage protocol is associated with problems, such as long treatment time and high treatment cost. To overcome these problems, new developments, including early functional loading protocol and Brånemark System Novum, have been introduced by various groups of researchers. In Hong Kong, a protocol has been developed to immediately load the Brånemark System fixtures with a fixed provisional prosthesis.

PURPOSE

The goal of this prospective study was to present the Hong Kong Bridge protocol and report the short-term evaluation of this protocol in a group of patients who had undergone dental implant treatment for their edentulous mandibles.

MATERIALS AND METHODS

Twenty-seven consecutive patients being treated at the Hong Kong Osseointegration Implant Centre between June 1998 and December 2000 were included in this study. A total of 123 Brånemark System fixtures were installed and regularly followed up for 3 to 30 months. The prosthesis stability and the marginal bone level were regularly evaluated clinically and radiographically, respectively, after the implant surgery.

RESULTS

Fifteen of the 27 patients had been followed up for 1 year or longer. Two patients with eight fixtures were withdrawn from the study. Two of the 115 remaining fixtures failed, resulting in an overall implant survival rate of 98.3%. The mean marginal bone change was reported on 49 fixtures that had passed the 1-year review. The mean marginal bone loss was 0.60 mm (p < .05) after 1 year of functional loading.

CONCLUSIONS

To load the mandibular Brånemark System fixtures immediately according to the Hong Kong Bridge protocol was a predictable and simple method with good results during this preliminary study period.

Immediate provisional for single-tooth implant replacement with Brånemark system: preliminary report

BACKGROUND

The success of osseointegrated implants ad modum Brånemark for single-tooth restorations is documented. Future developments should aim at improving the benefits to patients by decreasing treatment time, minimizing surgical stages, and maximizing esthetic outcomes. Using knowledge from studies of immediate implant placement, one-stage, immediate loading protocols, the authors developed the immediate provisional.

PURPOSE

The purpose of this study was to develop a protocol to provide an immediate solution for restoring a single missing tooth in the esthetic zone. The protocol should be simple, predictable, cost effective, and allow the use of other techniques to improve esthetic outcome.

MATERIALS AND METHOD

This prospective clinical study included 24 patients treated from August 1999 to October 2000. Single-tooth implant replacement was done according to immediate provisional protocol. Thirteen of the 24 patients had immediate implant placement after tooth extraction. All implants were placed in the esthetic zone. During surgery, emphasis was placed on obtaining primary stability by achieving bicortical anchorage and maximum insertion torque of at least 40 Ncm. CeraOne (Nobel Biocare) abutments were used, and provisional crowns were fabricated immediately before wound closure. The occlusion was protected by adjacent teeth.

RESULTS

Within the follow-up period of between 1 month and 15 months, all fixtures in the 24 patients were stable. Crestal bone loss greater than one thread-width was not detected. The esthetic result was considered satisfactory by all patients.

CONCLUSIONS

The implant placement and restoration protocol used in this study showed promising initial results for both the immediate implant and healed extraction site groups. The desirable goals of patient satisfaction, excellent esthetic outcomes, and no increase in treatment cost were achieved in this protocol. Further studies to elucidate the potential of the immediate provisional protocol are justified.

The role of telenursing in the provision of geriatric outreach services to residential homes in Hong Kong

A residential nursing home in Hong Kong was linked to the community geriatric assessment team based in a regional hospital using videoconferencing equipment operating at 384 kbit/s. The feasibility of providing nursing services and their acceptability to users were evaluated over 12 months. There were 198 occupants of the nursing home and their mean age was 82 years (range 60-101). Services included patient education regarding the use of a metered dose inhaler, wound management and a falls prevention programme, together with assessment of clients' need for infirmary care and the risk of aspiration. The acceptability of the system to the clients and nursing home staff was also assessed. It was found that 89% of such services could be carried out via telemedicine, and only 11% required on-site visits. There was an increase in the proportion of patients correctly using inhalers as well as a reduction in the number of falls. More consultations were conducted by the nurse (an increase of 76% per month) and an additional 8.4 patients per month could be attended to by the nurse compared with 5 patients when on-site visits were used. Acceptability to clients and nursing home staff was good. The problem of lack of resources to support elderly residential care institutions makes service delivery via telemedicine appear economically attractive, as well as facilitating improvements in the quality of long-term care.

Telemedicine: a pilot study in nursing home residents

BACKGROUND

Telemedicine has been applied successfully in various fields of medicine. This mode of health care delivery may potentially be useful in supporting frail nursing home residents who require multidisciplinary geriatric services.

OBJECTIVE

To assess the feasibility of telemedicine in providing geriatric services to nursing home residents, and whether this mode of care resulted in increased productivity and savings.

METHODS

A local 200-bed nursing home supported by the Community Geriatric Assessment Team (CGAT) was recruited. Over a 1-year period, teleconferencing was used to replace conventional geriatric outreach services. The feasibility of telemedicine was evaluated by participating specialists. Productivity gains, consumption of hospital services and user satisfaction were measured.

RESULTS

Telemedicine was adequate for service delivery in up to 99% of cases, depending on the specialty. A greater number of clients were served and follow-up intervals were shortened. The service was cheaper than conventional outreach or clinic activities, and acceptable to users and clients. In particular, savings were made through a 9% reduction in visits to the Accidents and Emergency Department and in 11% fewer admissions to acute hospital wards.

CONCLUSION

telemedicine is a feasible means of delivering multidisciplinary care to frail nursing home residents, and may result in increased productivity and significant savings.

Telepsychiatry in psychogeriatric service: a pilot study

A pilot study on telepsychiatry was conducted in which a videoconferencing link was established between a regional hospital and a care and attention home. Using this system, a psychogeriatric outreach team provided 149 psychiatric assessments to 45 residents of the care and attention home over 11 months. Videoconferencing was found to be highly feasible. It was acceptable to staff and patients and more cost-effective than on-site visits.

Influence of insect larvae and seedling roots on the host-finding ability of Steinernema feltiae (Nematoda: Steinernematidae)

The ability of nematode foragers to locate appropriate insect hosts is essential to their performance as successful biological control agents. We investigated the host-finding ability and chemotaxis of Steinernema feltiae in the presence of cues from Galleria mellonella larvae and tomato and radish seedling roots, given individually and in combination, over 120 min. In agar arena tests, infective juveniles of S. feltiae responded positively to unsterilized and sterilized larvae and tomato seedling roots and negatively to unsterilized radish seedling roots. This negative response changed following surface sterilization of these seeds. The response of the infective juveniles to a combination of larva and seedling roots depended on the nature of the individual cues and their proximity to each other. For example, the response of the nematodes to a combination of cues from a sterilized larva and an unsterilized tomato seedling root placed adjacent to each other was intermediate to the separate responses to cues from a sterilized larva and an unsterilized tomato seedling root given individually. However, the response of the nematodes to a combination of adjacent cues from a sterilized larva and an unsterilized radish seedling root was not significantly different from that to cues from an unsterilized radish seedling root given individually. When the cues from the larva and seedling roots were separated by a distance, the response of the nematodes favored the larva. However, this positive effect was lessened when the larva was surface sterilized as compared with the response to the unsterilized larva. The altered responses of the infective juveniles to target cues following surface sterilization suggest that cues from the larval cuticle and seedling roots, such as those associated with their surface microflora, may significantly influence their host-finding ability. The use of entomopathogenic nematodes as biological control agents under field applications can be improved by careful consideration of the application protocols and by the recognition that chemical alterations of the soil rhizosphere may influence their host-finding ability.

Genetic and environmental risk factors for Parkinson's disease in a Chinese population

An epidemiological study of the environmental and genetic factors as well as the possible interplay between them was conducted among 215 patients with Parkinson's disease and 313 controls in a Chinese population in Hong Kong. In univariate analysis, a regular tea drinking habit was found to be a protective factor, which had not been reported before. Smoking (a protective factor), family history, duration of pesticide exposure (in years) in farming and pesticide exposure during farming in women (both risk factors) have been reported previously. In multivariate analysis, current smoking reached borderline significance at the 5% level and the variables, years exposed to pesticides and family history were significant at the 10% level. By contrast with the common occurrence of polymorphism of the CYP2D6 gene (a gene involved with xenobiotic metabolism) in white people, it is very rare in China and is not thought to be a significant factor contributing to Parkinson's disease in Chinese people.

Attitudes toward life-sustaining treatment of older persons in Hong Kong

OBJECTIVES

There have been few studies of the attitudes of older Asians toward life-sustaining therapy. This paper presents the knowledge of and attitudes toward cardiopulmonary resuscitation (CPR) and life support in a group of subjects in Hong Kong.

DESIGN

Cross-sectional, descriptive study.

PARTICIPANTS

Of the 543 subjects, 382 were old-age home residents and 161 were in-patients of geriatric wards.

MEASUREMENTS

Sociodemographic data, functional ability (using the Barthel Index), self-perceived health scale, knowledge of life-sustaining procedures, and subjects' preferences for such treatments were studied. They were also asked to give the most important reason for wanting or declining CPR, and to indicate who they believe should be the decision-maker(s) regarding whether they should receive life-sustaining treatment.

RESULTS

Approximately 80% of old-age home residents and 60% of hospitalized patients had no knowledge of life-sustaining therapy. The success rate of CPR was overestimated by older subjects, and most wished to be resuscitated. However, up to 20% changed their minds and declined CPR after they knew the true outcome of the procedure. Half of the subjects wanted life support. Univariate analysis found that advanced age and not having a spouse were associated significantly with CPR preference, whereas subjects' knowledge was associated with preference for life support. Multivariate analysis revealed that advanced age, not having a spouse, and female sex were independently associated with a tendency to decline CPR. A considerable proportion of older people wished to be involved in decision-making regarding life-sustaining treatment.

CONCLUSION

Knowledge of life-sustaining procedures was poor among older people in Hong Kong compared with their counterparts in western countries. Although most older subjects wanted CPR, a number of them changed their minds after they knew the poor outcome. Therefore, older patients should be given more information about life-sustaining therapy and encouraged to take part in their treatment plans.

Helicobacter pylori infection increases the risk of peptic ulcers in chronic users of non-steroidal anti-inflammatory drugs

The objective was to study the gastrointestinal complications in chronic NSAID users with Helicobacter pylori infection. Eighty-two Chinese patients on long-term NSAID or aspirin treatment were studied for the occurrence of H. pylori infection and gastroduodenal mucosal injuries by upper endoscopy. H. pylori infection was confirmed by CLO test, histology and bacteriological cultures. Frequency and severity of symptoms of dyspepsia were also assessed. Thirty-three (40%) patients were diagnosed to have H. pylori infection and 49 (60%) patients were not infected. The two groups were comparable in age, sex, smoking and drinking habit and the use of anti-ulcer drags. Twenty-four out of 33 (72.7%) H. pylori-positive patients and 31 out of 49 (63%) of H. pylori-negative patients were found to have macroscopic lesions by endoscopy. The overall incidence of gastroduodenal lesions in the H. pylori positive patients was not significantly different from the H. pylori-negative patients (p = 0.34). However a higher incidence of duodenal ulcers in the H. pylori-infected group than the H. pylori-negative group (33% vs 6%, p = 0.0001) was found. The difference in severity and frequency of dyspeptic symptoms between the two groups did not reach statistical significance. H. pylori infected chronic NSAID users is associated with a higher rate of duodenal ulcer.

Apolipoprotein E genotype and Alzheimer's disease in Hong Kong elderly Chinese

We studied the apolipoprotein E (apoE) allele frequencies in 65 Chinese patients with late-onset Alzheimer's disease (AD) and 82 age- and sex-matched controls. The apoE epsilon 4 allele frequency was significantly higher in the AD group than in the control group (0.169 versus, p < 0.01). There were five homozygotes for epsilon 4 in the AD group but none among the controls. The odds ratio for AD was 1.6 for epsilon 4 heterozygotes. The age at onset was lower in the presence of the epsilon 4 allele and higher with the epsilon 2 allele, although neither of these differences reached statistical significance. The association between apoE alleles and AD previously reported in Caucasian populations was also present in this reports of lower prevalence of AD compared with the prevalence of multi-infarct dementia.

A geriatric day hospital in Hong Kong: an analysis of activities and costs

A survey of the activities of a geriatric day hospital in Hong Kong was carried out. It revealed that alternative modalities of hospital-based treatment were impractical and difficult to organize. Most patients and their carers were satisfied with the day hospital service, and the main area for improvement was in transportation. Costs of day hospital treatment were also calculated, and were found to be cheaper than an equivalent period of in-patient rehabilitation or out-patient therapy.

Outcomes of elderly stroke patients. Day hospital versus conventional medical management

BACKGROUND AND PURPOSE

Much controversy exists over the value of geriatric day hospitals in the rehabilitation of elderly patients, and cerebrovascular accident is a particularly common diagnosis among patients referred to these day hospitals. We carried out a prospective, randomized study to compare the outcomes of elderly stroke patients managed by a geriatric team using a day hospital facility versus conventional medical management.

METHODS

One hundred twenty elderly patients with acute stroke were randomized to inpatient care on a stroke ward under the care of either a neurologist or a geriatric team. Those under the care of neurologists were hospitalized until the attending physician felt that the patients had reached full rehabilitation potential. Patients under the care of the geriatric team were discharged home as soon as the team felt they were able to cope and given follow-up rehabilitation at the day hospital. Family or community support was arranged when necessary for both treatment groups. On recruitment, patient demographics, medical history, clinical features related to stroke, and functional ability as measured by the Barthel Index were noted. Subjects were reviewed at 3 and 6 months to assess functional level, hospital and outpatient services received, general well-being, mood, and level of satisfaction. Costs of treatment of the two groups were also compared.

RESULTS

Functional improvement (Barthel Index score) was greater in the group managed by the geriatricians with a day hospital facility compared with the conventional group at 3 months (P = .03). There were also fewer outpatient visits among the day hospital patients at 6 months (P = .03). No significant difference was found in costs between the two treatment groups.

CONCLUSIONS

Compared with conventional medical management, care in the geriatric day hospital hastened functional recovery and reduced outpatient visits in elderly stroke patients without additional cost.

Ondansetron for prevention of postoperative nausea and vomiting following minor oral surgery: a double-blind randomized study

The efficacy and safety of ondansetron in preventing postoperative nausea and vomiting following minor oral surgery was evaluated in a prospective randomized double-blind study. Of a total of seventy-seven patients, randomly 38 had 4 mg of ondansetron and 39 had normal saline as placebo intravenously immediately prior to induction of anaesthesia. A standard general anaesthetic with thiopentone, suxamethonium, fentanyl, nitrous oxide and isoflurane was employed. Postoperatively nausea was assessed verbally and on a visual analog scale at 1, 4 and 24 hours from the time of awakening. Episodes of vomiting were recorded. Eight patients (21.1%) in the ondansetron group compared to 19 (48.7%) in the placebo group had nausea (P < 0.05) and 1 (2.6%) in the ondansetron group compared with 9 (23.1%) in the placebo group vomited (P < 0.05). Patients who vomited twice or more and the number who required a rescue antiemetic were significantly fewer in the ondansetron group (P < 0.05). Cardiovascular parameters were stable and showed no significant difference in the two groups. There were no significant adverse effects that could be directly attributable to ondansetron.

Micronuclei induced by radon and its progeny in deep-lung fibroblasts of rats in vivo and in vitro

Genotoxic damage induced by radon and its progeny was investigated using the micronucleus assay in deep-lung fibroblasts to compare the response induced in vitro with that induced from inhalation of radon and its progeny in vivo. Male Wistar rats were exposed to 0, 115, 213 and 323 working-level months (WLM) of radon and its progeny by inhalation. After sacrifice, the cells were isolated and grown in culture, and the frequency of micronuclei was determined. A linear increase in the frequency of micronuclei was measured as a function of exposure [micronuclei/1000 binucleated cells = (29 +/- 9) + (0.47 +/- 0.04) WLM]. To compare exposure in WLM to dose in mGy, and to study how cell proliferation influences the way inhalation of radon and its progeny induces micronuclei, lung fibroblasts were isolated and exposed in vitro to graded doses from radon and its progeny after either 16 or 96 h in tissue culture. Cell cycle stage at the time of exposure was determined using flow cytometry. Primary lung fibroblasts exposed as either nondividing or dividing cells showed dose-dependent increases in micronuclei [micronuclei/1000 binucleated cells = (33 +/- 40) + (593 +/- 68)D and micronuclei/1000 binucleated cells = (27 +/- 69) + (757 +/- 88)D, respectively, where D is dose in Gy]. Results showed no significant influence (P = 0.20) of cell proliferation at the time of exposure on the frequency of micronuclei induced by radon and its progeny. Comparing dose-response relationships for nondividing cells to the exposure response for cells exposed by inhalation of radon and its progeny, it was estimated that a 1-WLM exposure in vivo caused the same amount of cytogenetic damage as produced by 0.79 mGy in vitro. In vivo/in vitro research using the micronucleus assay in lung fibroblasts serves as a powerful tool to estimate effective dose to cells in the respiratory tract after inhalation of radon and its progeny. Such studies form the basis for understanding the relationship between exposure, dose and biological damage.

Soft tissue changes following maxillary osteotomies in cleft lip and palate and non-cleft patients

A retrospective study of 25 patients with unilateral cleft lip and palate and 25 patients with hypoplastic maxillae without a cleft was carried out to evaluate the effects of maxillary osteotomies at the Le Fort I level on the lip and nose profile. The pre-surgical cephalometric tracing was superimposed twice on the post-surgical cephalogram, on the cranial structures and the anterior maxillary structures, for landmark movement measurement. Results showed statistically significant correlations between soft and hard tissue movement in the cleft group. On average, the ratios of horizontal nasal tip, nasal base and lip movement to underlying hard tissue movement were approximately one fourth, one half and two thirds respectively. The ratio of vertical lip to incisor movement was about one half. The correlations were less significant in the non-cleft group, only the upper lip movement showed statistically significant correlation with hard tissue movement, with a ratio of one half horizontally and one third vertically. It was concluded that in maxillary osteotomy, the cleft group showed a higher soft tissue to hard tissue movement ratio. The correlation between soft and hard tissue movements were more statistically significant in the cleft group than in the non-cleft group. However, though statistically significant, the level of correlation was not strong on an individual basis except in the horizontal lip response of the cleft group. Individual variation was wide and clinical judgement needs to be considered accordingly.

The 3-dimensional stability of maxillary osteotomies in cleft palate patients with residual alveolar clefts

OBJECTIVES

To evaluate the stability of maxillary osteotomies in cleft palate patients using miniplate fixation.

DESIGN

A prospective clinical study.

SUBJECTS

46 consecutive cleft palate patients with residual alveolar clefts and maxillary hypoplasia in one or more dimensions. These patients underwent standardised maxillary osteotomies and simultaneous bone grafting of the alveolar cleft over 44 months during 1988-1992. Titanium mini-plate fixation was used for the maxilla in all patients. Follow-up ranged from 6 to 51 months with a mean of 28 months.

MAIN OUTCOME MEASURES

The 3-dimensional stability of maxillary osteotomies in cleft palate patients in the long term.

RESULTS

In the unilateral clefts, relapse in the horizontal plane was 22% and in the vertical plane 22.5%; in bilateral clefts, the relapse was 17.5% and 7% respectively, with no statistically significant difference between the two groups. Longitudinal analysis of the repositioned maxilla over a 3-year period showed that most of the relapse occurred in the first 6 months and stabilised at 2 years postoperatively. Relapse in the transverse plane, based on analysis of the study models of 26 cases, ranged from 13.4% to 33.6%. A clockwise rotational relapse of the maxilla was noted in bilateral cases. Postoperative orthodontics compensated for the horizontal relapse by increasing incisor proclination to maintain positive overjet. There was no significant difference between the relapse of bimaxillary cases and that of maxillary osteotomies alone.

CONCLUSION

The long-term 3-dimensional surgical stability, using miniplate fixation, has decreased the relapse of cleft maxillary osteotomies with simultaneous alveolar bone grafting to a level comparable to that of maxillary osteotomies in non-cleft patients.

Flumazenil reversal of conscious sedation for minor oral surgery

In order to find out whether resedation occurred following antagonism with flumazenil of sedation for minor oral surgery, in a double-blind randomised cross-over study thirty healthy Hong Kong Chinese patients undergoing bilateral third molar surgery at two visits were sedated with midazolam. Following surgery they received either flumazenil or placebo at one visit and the alternative at the other visit. Recovery was monitored by observation and objective tests. Following recovery they were monitored for resedation for a total period of two hours from the injection of the reversal agent. Resedation, sufficient to prevent a patient from being discharged to be accompanied home with an escort, did not occur provided the patient responded to verbal command following sedation.