From the 20th to the 21st century: the first 100 years of paediatrics in Singapore

In Singapore, paediatrics as a separate discipline was started in 1921 at Singapore General Hospital (SGH). From Mistri Wing to Alexandra Hospital (AH) and Tan Tock Seng Hospital (TTSH), paediatrics was started at National University Hospital (NUH) and the Children’s Hospital at KK Women’s and Children’s Hospital (KKH) from 1997. After World War II, neonatology started in KKH, followed by Toa Payoh Hospital (TPH), AH, NUH and SGH. Neonates from TPH and AH were moved to KKH in 1990. Our pioneering giants include Dr Gopal Haridas, Professors Wong Hock Boon (First Paediatrics Professor), Tan Cheng Lim and Tan Kim Leong. Paediatrics in Singapore is resplendent with many achievements. Prof Wong identified the relationship of hyperbilirubinaemia/kernicterus with glucose-6-phosphate dehydrogenase (G6PD) deficiency and initiated G6PD deficiency screening. This has saved many lives and improved the overall health of children in Singapore. 100 years on, we stand firmly on the shoulders of our pioneering clinician giants as we face the paediatric millennial health needs of this new century.

Effects of Senior Simulation Suit Programme on nursing students' attitudes towards older adults: A randomized controlled trial

BACKGROUND

As populations age worldwide, nursing educational institutions need to train nurses not only to provide health care services specific to the elderly, but also to have a positive attitude as they work. The present study aimed to investigate the efficacy of a Senior Simulation Suit Programme (SSSP). The SSSP, which focused on mimicking the physiological experiences of an 80 year-old person, was hypothesized to increase the wearer's positive attitude towards older adult care.

METHODS

A single-blinded, randomized controlled trial was used to evaluate the efficacies of SSSP. One hundred and thirty-nine (139) nursing students were randomly assigned to either SSSP group (n = 69) or to a control group (n = 70) with "placebo clothing", i.e. clothing that mimicked old age but did not actually impair faculties. Two instruments-Kogan Attitudes Towards Old People Scale (KAOP) and a 1-item scale on Willingness To Care for Older People Scale (WCOP)-were used for data collection at baseline and at completion of SSSP. A Chinese version of Palmore's Facts Aging Quiz (C-FAQ) was used to assess nursing students' knowledge about adult care, and a questionnaire was developed to collect demographic information at baseline.

RESULTS

No significant difference between the two groups was found. A significant increase of positive attitudes and of willingness to serve older adults was found in both the control group and the group wearing SSSP.

CONCLUSION

Both the SSSP and control intervention could improve the attitudes of nursing students towards older adult care. This study suggests that wearing whatever the nursing students associate with being old, will improve their attitude towards older adult care.

P3129Rheumatic heart diseases screening in Bornean Malaysia: a pilot echocardiography study

Background

Rheumatic heart disease is a major public health issue in developing countries including Malaysia. RHD is a preventable disease. Early detection and appropriate treatment may decrease the disease burden to the society. Rheumatic heart disease screening using portable echocardiography may improve early detection among school children in vulnerable community. This is a pilot study of rheumatic heart disease screening using Vscan among primary school students in the Bornean state of Sabah Malaysia.

Purpose

To evaluate the resources required for RHD screening, prevalence of RHD among school children and awareness among the parents and teachers.

Methods

A cohort of 211 students from a primary school were recruited in 2017–2018. Parental consents were obtained. Seven sessions were conducted at the school. Echocardiography was performed by 2–3 experienced ultrasonographers. Image interpretation as per the 2012 WHF RHD echocardiographic diagnostic criteria.

Results

Of the 211 students, 50% female, age range 7–12 year-old. Ethnic groups include Kadazandusun (87%), Rungus (2.4%), Lundayeh (2%), Chinese (2%). Overall, the average number of student scanned was 4.6 students/device/hour. There was a learning curve observed, whereby initial session only scanned 2 students/device/hour which improved to a maximum of 5.9 students/device/hour. Preliminary findings noted probable RHD among 36% (n=76) of screened subjects. Incidental diagnosis of congenital heart disease among 5 students. The suspected RHD cases were referred for formal echocardiography in the tertiary centre for confirmation. Thus far, 12 students were diagnosed with borderline RHD; the main diagnostic criteria in these cases were at least two morphological features of RHD of the MV without pathological MR or MS. Secondary prophylaxis with antibiotic, dental hygiene and patient education were given.

Conclusion

This is a pilot RHD screening using portable Vscan echocardiography among primary school students in Malaysia. Our study showed it is feasible to conduct RHD screening in the field using portable Vscan. The number of students screened improved with practice. Our preliminary finding suggest RHD is prevalent in this population in Sabah, Malaysia.

Effect of interferon alpha and cyclosporine treatment separately and in combination on Middle East Respiratory Syndrome Coronavirus (MERS-CoV) replication in a human in-vitro and ex-vivo culture model

Middle East Respiratory Syndrome Coronavirus (MERS-CoV) has emerged as a coronavirus infection of humans in the past 5 years. Though confined to certain geographical regions of the world, infection has been associated with a case fatality rate of 35%, and this mortality may be higher in ventilated patients. As there are few readily available animal models that accurately mimic human disease, it has been a challenge to ethically determine what optimum treatment strategies can be used for this disease. We used in-vitro and human ex-vivo explant cultures to investigate the effect of two immunomodulatory agents, interferon alpha and cyclosporine, singly and in combination, on MERS-CoV replication. In both culture systems the combined treatment was more effective than either agent used alone in reducing MERS-CoV replication. PCR SuperArray analysis showed that the reduction of virus replication was associated with a greater induction of interferon stimulated genes. As these therapeutic agents are already licensed for clinical use, it may be relevant to investigate their use for therapy of human MERS-CoV infection.

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The effect of interferon-α and/or cyclosporine on MERS-CoV replication was evaluated with a human ex-vivo culture model.

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All treatments were able to reduce MERS-CoV replication.

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The combined treatment was more effective than either agent used alone in reducing MERS-CoV replication.

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The effect of the combined treatment group was associated with a greater induction of interferon stimulated genes.

Feasibility of a real-time hand hygiene notification machine learning system in outpatient clinics

BACKGROUND

Various technologies have been developed to improve hand hygiene (HH) compliance in inpatient settings; however, little is known about the feasibility of machine learning technology for this purpose in outpatient clinics.

AIM

To assess the effectiveness, user experiences, and costs of implementing a real-time HH notification machine learning system in outpatient clinics.

METHODS

In our mixed methods study, a multi-disciplinary team co-created an infrared guided sensor system to automatically notify clinicians to perform HH just before first patient contact. Notification technology effects were measured by comparing HH compliance at baseline (without notifications) with real-time auditory notifications that continued till HH was performed (intervention I) or notifications lasting 15 s (intervention II). User experiences were collected during daily briefings and semi-structured interviews. Costs of implementation of the system were calculated and compared to the current observational auditing programme.

FINDINGS

Average baseline HH performance before first patient contact was 53.8%. With real-time auditory notifications that continued till HH was performed, overall HH performance increased to 100% (P < 0.001). With auditory notifications of a maximum duration of 15 s, HH performance was 80.4% (P < 0.001). Users emphasized the relevance of real-time notification and contributed to technical feasibility improvements that were implemented in the prototype. Annual running costs for the machine learning system were estimated to be 46% lower than the observational auditing programme.

CONCLUSION

Machine learning technology that enables real-time HH notification provides a promising cost-effective approach to both improving and monitoring HH, and deserves further development in outpatient settings.

Acute Infectious Diarrhoea in Adults: Identifying Clinical Parameters Associated with Specific Pathogens

Introduction

Infectious diarrhoea may be caused by viral, bacterial or protozoan agents. The objective of this study was to explore the possibility of correlating presenting clinical and demographic features with the specific types of stool pathogens subsequently identified.

Materials & Methods

A retrospective study was performed in the setting of an Accident & Emergency (A&E) department of an urban acute-care hospital in Hong Kong. The inclusion criteria were adults (age ≥16); presentation with features of acute infectious diarrhoea; treated as out-patients with or without observation; and with stool cultures requested from A&E. All consecutive culture-positive cases (n=130) satisfying the above criteria were included. The control-group (n=119) consisted of a random sample of culture-negative cases during the same study period. For each of the six pathogens identified, statistical analyses were performed to compare differences in clinical features amongst three groups: (i) cases positive for the specific pathogen; (ii) cases positive for other pathogens; and (iii) cases with negative culture.

Results

Salmonella was associated with significantly higher body temperatures at presentation. Vibrio parahaemolyticus (VP) was associated with a significantly shorter duration of diarrhoea and of abdominal pain at presentation. Other variables were not helpful in predicting the type of stool pathogen.

Conclusion

In patients presenting with acute infectious diarrhoea in an A&E setting in Hong Kong, Salmonella and VP may be suspected according to the clinical features identified in this study.

Refined energy-conserving dissipative particle dynamics model with temperature-dependent properties and its application in solidification problem

It has been observed previously that the physical behaviors of Schmidt number (Sc) and Prandtl number (Pr) of an energy-conserving dissipative particle dynamics (eDPD) fluid can be reproduced by the temperature-dependent weight function appearing in the dissipative force term. In this paper, we proposed a simple and systematic method to develop the temperature-dependent weight function in order to better reproduce the physical fluid properties. The method was then used to study a variety of phase-change problems involving solidification. The concept of the "mushy" eDPD particle was introduced in order to better capture the temperature profile in the vicinity of the solid-liquid interface, particularly for the case involving high thermal conductivity ratio. Meanwhile, a way to implement the constant temperature boundary condition at the wall was presented. The numerical solutions of one- and two-dimensional solidification problems were then compared with the analytical solutions and/or experimental results and the agreements were promising.

Gasless single-incision laparoscopic inguinal hernia repair: initial experience

PURPOSE

Laparoscopic hernioplasty has been gaining its popularity in the past decade for its rapid recovery. Single-incision surgery, as its possible advancement, has also received more attention. Traditional laparoscopic surgery with carbon dioxide insufflation precluded patients with underlying cardiovascular or pulmonary disease from minimal invasive surgery. We report our early experience with gasless single-incision laparoscopic inguinal hernia repair via totally extraperitoneal (TEP) approach.

METHODS

Between 2010 and 2012, 15 consecutive patients underwent gasless laparoscopic inguinal hernia repair by the same surgeon, using abdominal wall lifting technique with a self-tailored device. Patient demographics, hernia characteristics, operative findings and postoperative outcomes were analyzed prospectively.

RESULTS

Of the 15 patients, all had unilateral hernia. Two presented with acute incarceration, in which one required bowel resection. There was no conversion to open surgery or insertion of additional ports. The median operating time was 80 min (range 51-130) for elective repair and 178 min (range 135-220) for emergency repair. The median hospital stay was 1 day (range 1-6) with minimal requirement of analgesics. Median time taken to resume normal activity was 2 days (range 1-6). No major medical complications or mesh infection was encountered. One patient developed hematoma and was successfully managed by salvage laparoscopic reoperation. During a median follow-up of 54 months (range 38-60), none experienced recurrence.

CONCLUSION

Gasless single-incision TEP is feasible with favorable results, even in high-risk patients with compromised cardiorespiratory status. This technique can also be applied to emergency setting in patients with incarcerated inguinal hernia requiring bowel resection. Future large scale randomized study is needed to verify the effectiveness of this technique.

Minimally invasive enteroscopically guided small bowel resection

Localisation of small bowel pathology is often difficult, especially intramural small bowel lesions. Even with the use of laparoscopy, visualisation of small bowel lesion is not always possible. The most accurate method to identify such a lesion is by laparotomy with direct visualisation and palpation of the lesion. However, the recent trend in surgical development aims for minimally invasive procedures while keeping the excision of surgical pathology safe and complete, with less surgical trauma. This report illustrates a case of minimally invasive enteroscopically guided small bowel resection.

On the thermodynamics of refrigerant + heterogeneous solid surfaces adsorption

This Article presents a theoretical framework for the understanding of pressurized adsorption systems using the statistical rate methodology. Utilizing results from the statistical rate theory, basic thermodynamic variables including enthalpy (h(a)), entropy (s(a)), and the specific heat capacity (c(p,a)) of the adsorbed phase are derived using the thermodynamic requirements of chemical equilibrium, Gibbs law, as well as Maxwell relations. A built-in constant (K) describes the adsorbed molecular partition function (q(s)), and it captures the heterogeneous properties of the adsorbent + adsorbate pair at equilibrium states. Improved adsorbed-phase volume considerations were incorporated in the formulations of these variables where they could be utilized with relative ease for analyzing the energetic performances of any practical adsorption system. In this Article, we have demonstrated how derived thermodynamic quantities can bridge the information gap with respect to the states of adsorbed phase, as well as resolved some theoretical inconsistencies that were found in previously derived quantities. Experimentally, the adsorption isotherms of propane (refrigerant) on activated carbon powder (Maxsorb III) for temperatures from 5 to 75 °C and pressures up to 8 bar are presented, and they are used to illustrate the behaviors of the adsorbed-phase during uptakes, temperatures, and pressure excursions or changes.

Note: A method to isolate and detect a large number of single molecules by microdroplet fluorescence spectroscopy

A laser induced fluorescence system, in combination with a glass-frit nebulizer and a photo-voltaic cell detector, is described for single molecule detection. The glass-frit nebulizer continuously generates a large number of droplets with an average droplet size of three micrometers in diameter. Rhodamine 6G molecules were detected at the 10(-12) M level. Concentrations 10(-12)-10(-10) M would provide mostly single molecules (0, 1, 2, 3, ...) in the individual droplets, as determined by Poisson distribution.

Sero-immunity and serologic response to pandemic influenza A (H1N1) 2009 virus in Hong Kong

To study the serologic response to the new pandemic influenza A (H1N1) 2009 virus in Hong Kong, the level of immunity was measured before and after the occurrence of the outbreak, and the titer of antibody to the pandemic influenza A (H1N1) 2009 virus in serum samples of laboratory confirmed cases. The presence of pre-outbreak pandemic influenza A (H1N1) 2009 virus antibodies in 37% of individuals older than >65 years suggested previous exposures to heterologous virus strains may have elicited cross-reacting antibody. Following large outbreaks of pandemic influenza A 2009 virus that peaked in September 2009, there is a change in immunity level in various age groups consistent with the attack rates among population in Hong Kong. Among individuals with mild clinical presentation, the antibody response to pandemic influenza A (H1N1) 2009 virus was stronger in those individuals aged ≤ 24 years but took more time to reach a titer of 40 when compared with those aged >24 years; however, the antibody level declined slower among individuals aged ≤ 24 years. Regardless of age, the antibody response rose rapidly and reached much higher titer among individuals with severe clinical presentation. Further study is required to collect additional data on antibody persistence and determine how much protection is conferred by previous exposure to seasonal influenza A (H1N1) viruses.

Performance of laboratory diagnostics for the detection of influenza A(H1N1)v virus as correlated with the time after symptom onset and viral load

BACKGROUND

To diagnose influenza A(H1N1)v virus infection, accurate and rapid detection are important. However, there is scanty data on the performance of various laboratory diagnostics.

OBJECTIVE

To compare the performance of rapid antigen test (RAT), viral culture and RT-PCR for the detection of influenza A(H1N1)v virus and to correlate their performance with the time after symptom onset and viral load.

STUDY DESIGN

From May 1, 2009 to June 25, 2009, respiratory samples were collected from 5740 individuals suspected of having influenza A(H1N1)v infection. The performance of viral culture and RT-PCR were investigated and correlated with the time after symptom onset. The sensitivity of RAT ESPLINE influenza A & B-N (Fujirebio Inc, Tokyo) was evaluated using a subset of 60 samples from patients diagnosed as having influenza A(H1N1)v infection.

RESULTS

Using respiratory samples from 587 patients diagnosed with influenza A(H1N1)v infection, comparison of laboratory diagnostics showed viral culture and RT-PCR gave comparable results with overall sensitivity of 93.9% and 98.1%, respectively. For RAT, when testing a subset of 60 samples collected < or =3 days following symptom onset, the sensitivity was 62%.

CONCLUSIONS

Although viral shedding is prolonged and of higher titre in influenza A(H1N1)v infection, RAT showed a low sensitivity of 62% among patients presenting < or =3 days after symptom onset. Viral culture showed comparable performance with RT-PCR and with sensitivity better than that documented for seasonal influenza.

Nanoscale magnetic biotransport with application to magnetofection

We present a model for predicting the transport of biofunctional magnetic nanoparticles in a passive magnetophoretic system that consists of a fluidic chamber positioned above a rare-earth magnet. The model is based on a drift-diffusion equation that governs the particle concentration in the chamber. We solve this equation numerically using the finite volume method. We apply the model to the magnetofection process wherein the magnetic force produced by the magnet attracts magnetic carrier particles with surface-bound gene vectors toward the bottom of the chamber for transfection with target cells. We study particle transport and accumulation as a function of key variables. Our analysis indicates that the particles are magnetically focused toward the center of the chamber during transport, and that the rate of accumulation at the base can be enhanced using larger particles and/or by reducing the spacing between the magnet and the chamber. The model provides insight into the physics of particle transport at the nanoscale and enables rapid parametric analysis of particle accumulation, which is useful for optimizing novel magnetofection systems.

A model for predicting magnetic particle capture in a microfluidic bioseparator

A model is presented for predicting the capture of magnetic micro/nano-particles in a bioseparation microsystem. This bioseparator consists of an array of conductive elements embedded beneath a rectangular microfluidic channel. The magnetic particles are introduced into the microchannel in solution, and are attracted and held by the magnetic force produced by the energized elements. Analytical expressions are obtained for the dominant magnetic and fluidic forces on the particles as they move through the microchannel. These expressions are included in the equations of motion, which are solved numerically to predict particle trajectories and capture time. This model is well-suited for parametric analysis of particle capture taking into account variations in particle size, material properties, applied current, microchannel dimensions, fluid properties, and flow velocity.

Analytical model of magnetic nanoparticle transport and capture in the microvasculature

An analytical model is presented for predicting the transport and capture of therapeutic magnetic nanoparticles in the human microvasculature. The nanoparticles, with surface bound drug molecules, are injected into the vascular system upstream from malignant tissue, and are captured at the tumor site using a local applied magnetic field. The applied field is produced by a rare-earth cylindrical magnet positioned outside the body. An analytical expression is derived for predicting the trajectory of a particle as it flows through the microvasculature in proximity to the magnet. In addition, a scaling relation is developed that enables the prediction of the minimum particle radius required for particle capture. The theory takes into account the dominant magnetic and fluidic forces, which depend on the position and properties of the magnet, the size and magnetic properties of the nanoparticles, the dimensions of the microvessel, the hematocrit level of the blood, and the flow velocity. The model is used to study noninvasive drug targeting, and the analysis indicates that submicron particles can be directed to tumors that are several centimeters from the field source.

Bacterial meningitis in Hong Kong: 10-years’ experience

OBJECTIVE

We studied the etiology, clinical features and outcome of patients with bacterial meningitis from an urban Chinese city over a 10-years period.

METHODS

We reviewed the files of all persons aged 15-years old or above diagnosed with community-acquired bacterial meningitis from a regional hospital. The clinical findings, relevant laboratory and imaging results as well as outcome were recorded in cases with microbiological evidence of meningitis. Neurosurgical and pediatric patients were excluded.

RESULTS

Sixty-five patients between the ages of 15 and 86 years of age (mean 52 years) were identified of whom 18 (28%) died. The four most common causes were Mycobacteria tuberculosis (46%), Streptococcus pneumoniae (11%), Streptococcus suis (9%) and Klebsiella pneumoniae (8%). Neisseria meningitidis and Haemophilus influenzae were rare pathogens. The annual incidence of community-acquired bacterial meningitis was 1.27/100,000 adults. Delay in treatment was associated with a poorer prognosis (p<0.001, OR=38.84, CI=7.33-205.80).

CONCLUSION

The causative organisms found in this region of China differ from that reported from Europe and the US; tuberculous meningitis is the most common cause of bacterial meningitis.

Otorhinolaryngeal foreign bodies in children presenting to the emergency department

INTRODUCTION

Accidents with foreign bodies are common in the paediatric population. It is impossible to mandate that all foreign bodies (FB) in the ear, nose and throat (ENT) of children should be removed by the specialty-trained physicians. This study evaluates the management of ENT FB removal in children achieved by emergency physicians not trained in otolaryngology in an urban tertiary care paediatric emergency department.

METHODS

A retrospective study was conducted on consecutive paediatric patients presenting with suspected foreign body in the ear, nose or throat to the children's emergency department (ED) of KK Women's and Children's Hospital over a 10-month period. Removal methods, foreign body types, rates of successful removal and associated complications were evaluated.

RESULTS

There were 353 patients, most of whom presented after office hours. An attempt at removal of FB by the emergency physician was made in 76.8 percent of the cases. ENT specialist referral in the ED was made in 1.7 percent of the cases. 50.1 percent of cases were discharged after successful removal of FB in the ED. 4.2 percent of cases were admitted for removal of FB and 44.8 percent of cases were referred to the ENT specialist clinic for further assessment.

CONCLUSION

The emergency physician managed most cases in the ED and urgent referral to ENT specialists was not required. Complications and morbidity often occur from repeated attempts at removal of the FB. ENT opinion should be sought whenever there is doubt. The ED physician should be skilled in techniques of FB removal, especially throat FB, which had the lowest rate of success in our study.

Overall obesity and abdominal obesity and the risk of metabolic abnormalities

BACKGROUND

Obesity is a risk factor for multiple chronic diseases.

AIM

To determine the relationship between overall or abdominal obesity and various metabolic abnormalities.

METHODS

The medical records of participants undergoing examination from January 2000 to December 2002 were analysed. Body mass index (BMI; kg/m2) for overall obesity and waist circumference (WC; cm) indicating abdominal obesity were measured. Four groups were studied: (1) BMI < 27kg/m2, WC: female < 80cm or male < 90cm; (2) BMI > or = 27kg/m2, WC: female < 80cm or male < 90cm; (3) BMI < 27kg/m2, WC: female > or = 80cm or male > or = 90cm; (4) BMI > or = 27kg/m2, WC: female > or = 80cm or male > or = 90cm.

RESULTS

There were 1,342 (44%) females and 1,711 males aged 20-87 years. The prevalence of overall obesity was 20.4% and abdominal obesity was 48%. Obese subjects had more metabolic abnormalities than non-obese in terms of risk of hypertension, hyperglycaemia, hypercholesterolaemia, hypertriglyceridaemia, high level of LDL, low level of HDL, high ratio of TC/HDL, hyperuricaemia and fatty liver.

CONCLUSIONS

As overall and abdominal obesity may predict clustering of metabolic abnormalities we suggest that BMI and WC are convenient methods for assessing metabolic abnormalities in primary healthcare settings.

Severe acute respiratory syndrome-associated coronavirus infection

Whether severe acute respiratory syndrome–associated coronavirus (SARS-CoV) infection can be asymptomatic is unclear. We examined the seroprevalence of SARS-CoV among 674 healthcare workers from a hospital in which a SARS outbreak had occurred. A total of 353 (52%) experienced mild self-limiting illnesses, and 321 (48%) were asymptomatic throughout the course of these observations. None of these healthcare workers had antibody to SARS CoV, indicating that subclinical or mild infection attributable to SARS CoV in adults is rare.

Risk factors and clinical consequences of human herpesvirus 7 infection in paediatric haematopoietic stem cell transplant recipients

Human herpesvirus 7 (HHV-7) is the least studied beta-herpesvirus in transplant settings. This prospective study examined the activity of HHV-7 during the first 12 weeks post-stem cell transplant in 59 paediatric patients. The presence of HHV-7, human cytomegalovirus (HCMV) and human herpesvirus 6 (HHV-6) in blood was monitored weekly by a multiplex nested polymerase chain reaction. Overall, 33 (55.9%) patients had one or more surveillance blood sample(s) positive for HHV-7. In contrast to HCMV and HHV-6, no obvious peak time of reactivation was observed for HHV-7. The occurrence of HHV-7 DNAaemia showed a significant negative association with HHV-6 (P=0.022), but with no association with HCMV. A significant higher positive rate for HHV-7 was found in autologous versus allogeneic (P=0.002), and in peripheral blood versus umbilical cord/marrow (P<0.001) transplant. Acyclovir had no effect, whereas ganciclovir was associated with a lower rate of HHV-7 reactivation (P=0.009). One patient died of HHV-7 associated brain stem encephalitis. The administration of colony stimulating factor, occurrence of acute graft versus host disease, time to neutrophil and platelet engraftment showed no significant association with the occurrence of HHV-7 DNAaemia.

Spermine reduces infarction and neurological deficit following a rat model of middle cerebral artery occlusion: a magnetic resonance imaging study

The role of nitric oxide (NO) in post-ischemic cerebral infarction has been extensively examined, but few studies have investigated its role on the neurological deficit. In the present study, we investigated the effect of spermine on the temporal evolution of infarct volume, NO production and neurological deficit using magnetic resonance imaging in a model of permanent focal cerebral ischemia in rats. Spermine given at 10 mg/kg 2 h after ischemia reduced the infarct volume by 40% and abolished brain NO production and improved the neurological score 24 h, 48 h and 72 h after ischemia. Spermine also reduced the neurological deficit as evaluated by rotamex, grip strength and neurological severity score tests.

Acute bacterial gastroenteritis: a study of adult patients with positive stool cultures treated in the emergency department

OBJECTIVES

To investigate the presenting clinical features of acute bacterial gastroenteritis in adult patients treated as outpatients in the emergency department (ED), and the pathogens responsible in this setting and population; and to identify the frequency with which positive stool culture result changes management.

METHOD

This was a retrospective study of all patients who attended the accident and emergency department of an university affiliated hospital in Hong Kong over a 12 month period, who satisfied the following inclusion criteria: (a) age >/=16, (b) presented with acute gastroenteritis, (c) treated as outpatients with or without observation, and (d) had positive stool cultures.

RESULTS

One hundred and thirty patients were included. Pathogens identified were Vibrio parahaemolyticus (42.3%), Samonella spp (34.6%), Plesiomonas spp (9.2%), Campylobacter spp (6.9%), Aeromonas spp (6.9%), and Shigella spp (6.2%). Mean highest body temperature was 37.5 degrees C (95% confidence intervals (CI) 37.3 to 37.6). Bloody diarrhoea was present in 14 patients (10.8%). Mean duration of diarrhoea, from onset to the completion of stay in ED, was 2.2 days (95% CI 1.7 to 2.7). Likewise, mean duration of abdominal pain was 1.8 days (95% CI 1.5 to 2.1). Mean number of unformed stools per day was 9.3 (95% CI 8.3 to 10.3). Change of management, subsequent to the availability of positive stool culture results, was not required in 115 (88.5%) patients. Ciprofloxacin resistance occurred in eight (6.2%) cases, and seven of nine campylobacter isolates. Campylobacter positive patients had a significantly longer duration of abdominal pain (p=0.0236) and were less likely to be dehydrated (p=0.0103).

CONCLUSIONS

Most patients with bacterial gastroenteritis do not present with high fever, bloody diarrhoea, or persistent diarrhoea, but generally have quite severe diarrhoea. Stool cultures do not change management for most patients. Vibrio parahaemolyticus is the commonest bacterial pathogen identified.

Significance of genomic DNA group delineation in comparative studies of antimicrobial susceptibility of Acinetobacter spp

There were significant differences in antimicrobial susceptibilities in isolates of genomic DNA groups 2 (Acinetobacter baumannii), 3, and 13TU collected from the same sources, e.g., patients in intensive care units and general wards, and in isolates of the same group collected from different sources. The delineation of genomic groups is important in comparative surveillance studies of antimicrobial susceptibilities.

Paracetamol ingestions at the Children's Emergency Department--a three year series

This is a three-year retrospective review of 96 cases of paracetamol ingestions seen by KK Children's Emergency Department. Paracetamol is the commonest substance (23%) involved in childhood poisonings. More than 60% occurred in children aged one to three years old with an equal gender distribution. Eighty-six percent were accidental ingestions and the intentional ones had a significant female bias, all occurring in children aged 12 and above. These older children ingested higher doses of paracetamol (average dose of 233 mg/kg) and had potentially serious serum paracetamol levels. There was no significant morbidity and no mortality in this series.

Homocysteine, folate and vitamin B12 as risk factors for acute myocardial infarction in a Southeast Asian population

INTRODUCTION

Hyperhomocysteinaemia is an emerging risk factor for coronary artery disease (CAD) and most studies done to date are in Caucasian populations. We aimed to determine whether hyperhomocysteinaemia is a risk factor for acute myocardial infarction (AMI) in a Southeast Asian population comprising different ethnic groups and relate it to the traditional risk factors and plasma vitamin B12 and folate levels.

MATERIALS AND METHODS

This was a case-control study comprising 168 AMI patients and 141 controls with a median age of 55 years (range, 27 to 77 years), living in Singapore. Homocysteine was measured by fluorescence polarisation immunoassay and vitamin B12 and folate were measured by electrochemiluminescence immunoassay. Logistic regression analysis was use to test the association of homocysteine, vitamin B12 and folate with the occurrence of AMI. The study was approved by the Tan Tock Seng Ethics Committee.

RESULTS

We found that the odds of having AMI was higher for subjects with hypertension, smoking habit, lower plasma folate and vitamin B12 levels and non-Chinese ethnic group. On the other hand, plasma homocysteine level was not significantly associated with AMI. The baseline levels of plasma total homocysteine in both AMI patients and controls were higher than other studies (median values between 12 and 14 umol/L).

CONCLUSION

In our population, plasma total homocysteine levels were not associated with AMI but low plasma levels of folate and vitamin B12 were independently associated.

Sedation with ketamine for paediatric procedures in the emergency department--a review of 500 cases

Ketamine has been used to "consciously" sedate patients for a variety of paediatric procedures in our department since 1998. This is a retrospective review of the first 500 paediatric patients given ketamine for conscious sedation. Ketamine was given, either intramuscularly (3-4 mg/kg) or intravenously (1-2 mg/kg) together with atropine (0.02 mg/kg), with or without intravenous midazolam (0.05 mg/kg). The main indications for giving ketamine were for laceration repair, especially those of the lip, tongue and buccal mucosa (54.4%); manipulation and reduction of upper limb fractures (25.8%); incision and drainage of abscesses (12%), removal of foreign bodies (6.4%) and a potpourri of other conditions. Seventy-five point six percent of our patients were less than six years old and the male to female ratio was 1.9:1. Ninety-six percent of our patients were discharged home well and only one child (0.2%) was admitted for observation possibly as a consequence of ketamine. We find ketamine to be a relatively effective drug for use for conscious sedation in children.

Temperature-entropy formulation of thermoelectric thermodynamic cycles

A temperature-entropy formulation is derived for thermoelectric devices. Thermoelectric chiller and generator cycles can then be cast in the same irreversible thermodynamics framework commonly applied to conventional large-scale cooling and power generation equipment, including a transparent identification of the principal energy flows and performance bottlenecks (dissipation). Distinct differences in chiller versus generator mode are highlighted and illustrated with data from commercial thermoelectric units.

Were there enough physicians in an emergency department in the affected area after a major earthquake? An analysis of the Taiwan Chi-Chi earthquake in 1999

STUDY OBJECTIVE

The purpose of this study was to evaluate physician manpower and mobilization in an urban emergency department receiving patients after a major earthquake.

METHODS

Patient charts were reviewed. The workload of physicians was assessed semiquantitatively before and after a major earthquake. The physicians' mobilization in the postearthquake emergency response was assessed by using a confidential questionnaire.

RESULTS

In the 3 days after the earthquake, 566 patients with earthquake-related illnesses or injuries were sent to the urban ED. Three hundred one (53.2%) patients arrived within the initial 10 hours. In the initial hours, there was no significant difference between the number of patients per physician per hour before and after the earthquake. Workloads of wound treatment and advanced life support procedures were significantly higher after the earthquake compared with before the earthquake, during the first to sixth hour and second to fifth hour, respectively. Sixty-five percent of the hospital's physicians did not assist in either the ED or in any other parts of the hospital in the initial 6 hours after the earthquake.

CONCLUSION

The number of physicians in the ED was insufficient in the initial hours after the earthquake because of the sudden influx of a large number of patients. Future disaster planning must address the issue of physicians' behavior with regard to their priorities immediately after a major earthquake and include greater provision for efficient mobilization of physicians.

Falls amongst institutionalised psycho-geriatric patients

Falls are common among the elderly patients in the psycho-geriatric wards and yet they have been understudied. A fall is a multi-factorial syndrome involving the patient and the environment. Psycho-geriatric patients who fall may suffer serious physical injuries that result in morbidity, further institutionalisation or even mortality. This study aims to examine the contributing factors to, and morbidity and outcome of falls among institutionalised psycho-geriatric patients so that preventive strategies can be refined. Data of patients who fell over a year's period in four psycho-geriatric wards were collected retrospectively and compared with those who had not fallen within the same period. The general profile of the psycho-geriatric patient who falls is one who is: above seventy-five years old; on three or more medications; and having recent changes in medication and mental status. About one in three fallers fell repeatedly. The rate of serious injury and mortality was low. In conclusion, while many factors are attributable to the common effects of aging and physical illnesses; psychotropic medication, change in mental state and specific environmental factors also play significant contributory roles to falls in this group of patients.

Body mass index and its related factors in the elderly

BACKGROUND

A cross-sectional study was conducted in May 1998 in Chung-Hsing Village, Taiwan to evaluate the relationship between body mass index (BMI) and its related factors in the elderly.

METHODS

Individuals aged 65 years and over were recruited as study subjects. A total of 1093 persons, out of 1774 registered residents, were contacted for face-to-face interview (61.6%). However, only 586 respondents completed the questionnaire and had blood tests. Analysis was based on these 586 subjects.

RESULTS

There were 66.0% men and 34.0% women. The mean age was 73.1 +/- 5.3 years. The BMI was 24.13 +/- 4.64 kg/m2 and 24.07 +/- 3.99 kg/m2 for men and women, respectively (P > 0.05). In univariate analysis, high systolic pressure, high diastolic pressure, hypertriglyceridaemia, hyperglycaemia and hyperuricaemia were related to obesity. After controlling for the other covariates, the multivariate logistic regression analysis showed that significant related factors of obesity were hyperglycaemia and hyperuricaemia.

CONCLUSIONS

Significant related factors of obesity in the elderly were hyperglycaemia and hyperuricaemia. A large-scale investigation will be suggested in the future to address causal-effect issues between obesity and hyperglycaemia or hyperuricaemia.

Prevalence and genotype distribution of TT virus in various specimen types from thalassaemic patients

Peripheral blood mononuclear cells (PBMC), plasma, saliva and urine samples were collected from 50 thalassaemic patients for TT virus (TTV) detection by two sets of PCR. The set B nested PCR was more sensitive than the widely used NG hemi-nested PCR with TTV positive rates approximately PBMC: 98% vs. 70%; plasma: 92% vs. 66%; saliva: 62% vs. 22%; urine: 22% vs. 6%. All 50 patients had TTV detected in one or more specimens, with 16% of patients being positive in all four specimen types: 40% positive in PBMC, plasma and saliva; 30% positive in PBMC and plasma. In 82 NG hemi-nested PCR-positive samples TTV genotype was identified, 68.3% had a single genotype, 25.6% had multiple genotypes and 6.1% were uncharacterized. The positive rates for genotypes by specimen were: G1 (36/82), G2 (49/82), G3 (2/82), G4 (7/82), G5 (1/82) and G6 (3/82). Among the 42 patients for whom the genotype was examined, 42.9% had single-type infection, 45.2% had co-infections and 11.9% had uncharacterized genotypes. Sixteen of them had TTV detected both in PBMC and plasma with seven having identical genotypes in both samples. Eight patients had TTV detected in PBMC, plasma and saliva; two of them harboured identical genotypes in all three samples. The results indicate that, apart from hepatocytes, PBMC is a major cell type for TTV infection occurs. Shedding of TTV in urine and saliva is common and may have a significant role in nonblood-borne transmission among the general population. TTV-infected patients often harbour multiple genotypes suggesting infection with one genotype does not necessarily confer protection against the others. No correlation between TTV infection and liver dysfunction was observed.

Hyperglycemia and its related factors in Taiwanese middle-aged adults

Our study used data collected in Chung-Hsing Village to evaluate the relationship between hyperglycemia and its related factors in Taiwanese middle-aged adults in May 1998. All government employees at the Taiwan Provincial Government in Chung-Hsing Village aged 40-64 years were candidates for this study. Only 708 volunteers completed a structured questionnaire and underwent venous blood tests. To study the significant related factors of hyperglycemia, the t-test, chi(2) analysis and multivariate logistic regression were used. Our results showed that 40% of the 708 subjects were men and 60% were women. The mean age was 50.5 plus minus 6.8 years. The mean values of fasting glucose were 4.68 plus minus 1.92 mmol/L in men and 4.70 plus minus 1.70 mmol/L in women (P > 0.05). The proportions of hyperglycemia were 6.4% in men and 5.7% in women (P > 0.05). After controlling for other covariates, the multivariate logistic regression analysis showed that the significant related factors for hyperglycemia were older age (odds ratio=2.86, 95%; confidence interval=1.36-6.05; P < 0.01) and hypertriglyceridemia (odds ratio=3.34, 95%; confidence interval=1.68-6.64; P < 0.001).

Neoadjuvant chemotherapy for Chinese women with locally advanced breast cancer

Locally advanced breast cancer carries a poor prognosis and is still prevalent in developing countries. The current management usually involves administration of neoadjuvant chemotherapy (NCT). From March 1990 through December 1997, 173 Chinese patients with tumor size greater than 4 cm were treated; 38 received NCT and the other 135 postoperative adjuvant chemotherapy. The regimens for NCT were FEC (5-fluorouracil 600 mg/m2, epirubicin 50 mg/m2, and cyclophosphamide 600 mg/m2) for 29 patients and Adriamycin 75 mg/m2 for the rest of the group. Postoperatively the NCT patients received the standard CMF regimen (oral cyclophosphamide 100 mg/m2 for 14 days and intravenous methotrexate 40 mg/m2 and 5-fluorouracil 600 mg/m2 on days one and eight of each cycle). The postoperative adjuvant chemotherapy group received only the CMF regimen. Tumor response after NCT was measured clinically and histologically. The response rate was 75 per cent with 13.2 per cent being complete response. Although there is no difference in response rate the actual reduction in size was greater for patients receiving Adriamycin than FEC (P = 0.001). The only predictive factor of response to NCT was the type of chemotherapy administered. None of the tumor characteristics such as size, nodal status, histological grading, lymphovascular permeation, hormonal receptor status, and c-erb-B2 expression were found to be significant. The overall 5-year probability of survival was 0.44, and there was no difference between groups. The factor important for prognosis was axillary nodal status on histology. The use of NCT did not improve outcome. In summary our results showed that NCT was feasible for Chinese women and good response could be achieved. However, it is the axillary nodal status that determines the final outcome.

Epidemiology of hyperuricemia in the elderly

BACKGROUND

Our study used data collected in Chung-Hsing Village to evaluate the relationship between hyperuricemia and the cardiovascular risk factors and the socio-demographic factors in the elderly in May 1998.

METHODS

All individuals aged 65 and over were studied. A total of 1093 subjects, out of 1774 registered residents, were contacted by face-to-face interview. The response rate was 61.6 percent. However only 586 respondents had blood tests and completed questionnaires. Analysis in this study was based on these 586 subjects. To study the significant correlates of hyperuricemia, t- test, two-way ANOVA, chi-square test and multivariate logistic regression were used.

RESULTS

Our results showed that 66 percent were men and 34 percent were women. The mean age was 73.1+/-5.3 years. The proportions of hyperuricemia were 57.3 percent in men and 40.9 percent in women (p < .01). In chi-square test, hypercholesterolemia, hypertriglyceridemia, renal function impairment, retirement status and marital status were related to hyperuricemia. After controlling the other covariates, the multivariate logistic regression analysis showed that the significant related factors of hyperuricemia were hypercholesterolemia, hypertriglyceridemia, and renal function impairment.

CONCLUSIONS

Hyperuricemia is often found in the elderly. Hyperuricemia is more common in elderly men than in elderly women. A large-scale investigation will be suggested in the future to address causal-effect issues between hyperuricemia and hypercholesterolemia, hypertriglyceridemia, or renalfunction impairment.

Mucocele of the appendix with hematuria

Mucocele of the appendix, a nonspecific and descriptive term for an abnormal mucous accumulation within the appendiceal lumen, regardless of the underlying cause, is a rare clinical disease that is not usual as a consideration in the differential diagnosis of right lower quadrant lesions. The reported prevalence of mucocele of the appendix in appendectomy specimens is 0.2-0.3 percent. Hematuria due to mucocele of the appendix is extremely rare. Up to now, only few cases of such condition have been recorded in the literature. We describe a woman who experienced intermittent episodes of right lower quadrant pain and hematuria. Abdominal exploration incidentally displayed mucocele of the appendix. No evidence of other lesions was found. The patient was still in good health after operation. This case highlights mucocele of the appendix as a consideration in the differential diagnosis of right lower quadrant pain with hematuria.

Epidemiology and infection control implications of Acinetobacter spp. in Hong Kong

In a previous study, we showed that Acinetobacter genomic DNA group 3 was the most common species among blood culture isolates and was commonly found on superficial carriage sites of the healthy and the sick, which are different findings from those reported in Europe and North America. We used amplified ribosomal DNA restriction analysis and pulsed-field gel electrophoresis to study further the molecular epidemiology of acinetobacters in our region. Over a study period of 6 weeks with 136 consecutive routine clinical isolates (1.33% of all specimens), genomic DNA groups 2 (Acinetobacter baumannii), 3, and 13TU were obtained from 59 of 69 positive patients. There is a significant difference in the specimen sources of the three genomic DNA groups, with group 13TU being significantly associated with the respiratory tract (chi-square exact test, P = 0.0064). Settle plates showed a significantly heavier environmental load from the intensive care unit (ICU) than from the four surgical wards examined (22 of 70 versus 76 of 120 plates with <5 colonies; chi-square test, P < 0. 0001). Genomic group 3 accounted for 6 of 12 clusters of possibly related strains among patients, between patients and the ICU environment, and in the ICU environment. Genomic groups 2 and 3 accounted for 21% of the 132 genomically identified isolates recovered from 21 of 41 local vegetables, 53 of 74 fish and meat samples, and 22 of 60 soil samples. Group 13TU was present only in patients' immediate surroundings. The role played by the environment and by human carriage should be evaluated in order to devise a cost-effective infection control program pertinent to our situation of acinetobacter endemicity.

Association between obesity and hyperlipidemia among children

BACKGROUND

This study was undertaken to show the association between obesity and hyperlipidemia among the children.

METHODS

In March 2000, while conducting a comprehensive health examination, we analyzed 2011 children from the first grade of primary schools in Taichung City in Taiwan. To study the association between obesity and hyperlipidemia, the t test, chi-square analysis, and multivariate logistic regression were used.

RESULTS

There were 1057 boys (52.56 percent) and 954 girls (47.44 percent). The mean age was 7.27 +/- 0.46 years. The proportion of overweight was 11.07 percent in boys and 11.64 percent in girls. The proportion of obesity was 14.19 percent in boys and 12.89 percent in girls. After controlling the other covariates, the multivariate logistic regression analysis showed that overweight was associated with a low level of high density lipoprotein cholesterol. Obesity was associated with hypertriglyceridemia, a high level of low density lipoprotein cholesterol, and a low level of high density lipoprotein cholesterol.

CONCLUSIONS

Our findings disclosed that the prevalence of overweight and obesity was high in childhood. Early intervention to control and prevent childhood obesity might be warranted. Obesity was associated with hyperlipidemia in children. A wide-scale survey will be suggested in the future to establish causal-effect issues between obesiyy and hyperlipidemia.

Hypertension and its related factors in Taiwanese elderly people

BACKGROUND

Our study used data collected in Chung-Hsing Village in May 1998 to evaluate the prevalence of hypertension and its correlates in Taiwanese elderly people.

METHODS

All of individuals aged 65 and over were recruited as study subjects. A total of 1,093 persons, out of 1,774 registered residents, were contacted by face-to-face interview The response rate was 61.6 percent. However, only 586 respondents had blood tests and completed questionnaires. Analysis in this study was based on these 586 subjects. In order to study the significant correlates of hypertension, the t-test, chi-square analysis, and multivariate logistic regression were used.

RESULTS

Our results showed that 66 percent were men and 34 percent were women. The mean age was 73.1 +/- 5.3 years. The proportions of hypertension were 53.09 percent in men and 56.06 percent in women (p > 0.05). After controlling the other covariates, the multivariate logistic regression analysis showed that the significant related factors of hypertension were obesity (OR = 1.88, 95 percent CI = 1.06-3.34, p < 0.05) and renalfunction impairment (OR = 1.69, 95 percent CI = 1.02-2.80, p < 0.05).

CONCLUSIONS

The prevalence of hypertension was high in elderly people. Hypertension is significantly associated with obesity and renalfunction impairment in elderly people.