Pitfalls in diagnosing septic arthritis in Hong Kong children: ten years' experience.

OBJECTIVES: To evaluate the initial presentation of septic arthritis in Hong Kong children with respect to clinical and laboratory findings that can aid making a prompt diagnosis. DESIGN: Retrospective review. SETTING: Five public hospitals in Hong Kong. PATIENTS: Data concerning paediatric patients with septic arthritis were collected from January 2001 to December 2010. Patients with postoperative infections and those without enough retrievable information were excluded. RESULTS: Of 31 patients analysed, on admission only 52% had had a fever of <38.5°C and 71% had raised white blood cell count of <12 x 10(9) /L. In 74% of these patients, Gram stains of blood culture samples yielded no positive findings. The leading causative organism was Staphylococcus aureus (42%), followed by group A Streptococcus (23%). When group A Streptococcus was responsible, five out of seven patients had a complicated clinical course (repeated surgeries, Streptococcus-related organ failure, and chronic joint stiffness). Moreover, in 19% of instances, the empirical antibiotic therapy prescribed on admission did not provide a broad enough spectrum of cover. CONCLUSION: Signs of sepsis such as high fever, raised white blood cell count, and positive Gram smear from blood cultures were only present in around half of these patients with septic arthritis. Furthermore, group A Streptococcus tended to produce many complications. Regrettably, about a quarter of the empirical antibiotic regimens started by frontline staff were deemed not have a broad enough spectrum of cover. Improvement in the initial detection and management of septic arthritis patients is warranted.

Calcific tendinitis of the supraspinatus tendon in a 7-year-old boy: diagnostic challenges.

This report is of a case of acute calcific tendinitis of supraspinatus tendon in a 7-year-old boy who presented to the hospital with an acute painful shoulder after a fall. Initial radiographs mimicked fracture of the greater tuberosity of the humerus. Subsequent investigation confirmed that the appearance was due to a calcific tendinitis. The patient recovered shortly afterwards with complete resolution of the calcific lesion.

Epidemiological investigation of a case of nosocomial Legionnaires' disease in Taiwan: implications for routine environmental surveillance.

An epidemiological investigation with Legionella and molecular subtyping was conducted to determine the source of a case of nosocomial Legionnaires' disease (LD) who was hospitalized in three hospitals within a month. Legionella pneumophila serogroup 3, an uncommon serogroup for infection, was isolated from the patient's sputum. Environmental surveillance revealed Legionella colonization in all three hospitals; the patient isolate matched the isolate from the first hospital by molecular typing. Culturing the hospital water supply for Legionella is a pro-active strategy for detection of nosocomial LD even in hospitals experiencing no previous cases.

Fractures associated with non-accidental injury--an orthopaedic perspective in a local regional hospital.

OBJECTIVES: To identify the potential risk factors for fractures due to non-accidental injury in children, and to alert clinicians and health care workers to the diagnosis of child abuse. DESIGN: Retrospective review. SETTING: Regional hospital, Hong Kong. PATIENTS: Children who were admitted to the hospital with a clinical diagnosis of child abuse with associated fracture(s) between January 1996 and April 2004. MAIN OUTCOME MEASURES: Demographic data, site of fractures, and investigations performed. RESULTS: Of the 377 children presented with non-accidental injuries, 29 (15 male, 14 female) had bone fractures. The mean age of the 29 children at the time of injury was 5 years and 5 months. Of the nine records showing pregnancy, seven were unplanned. Approximately 75% of the families were living in public housing estates, and 28% were receiving social security subsidy. Over half (52%) of the abused children were aged 3 years or less. A total of 78 fractures were documented with a mean of 2.7 fractures per child. The most common sites of fracture were the forearm (29%), followed by the ribs (24%). Most long bone fractures occurred in those aged 3 years or less. Fractures were detected by skeletal survey and bone scan for 90% of the children. CONCLUSION: A number of potential risk factors were identified in children with fractures associated with non-accidental injury. They included age younger than 3 years, lower socio-economic status, presentation with long bone fracture, and unplanned pregnancy. Bone scan and skeletal survey are mutually complementary, and both should be performed in cases of suspected child abuse. Subsequent management requires cooperation of multi-disciplinary health care professionals.

A prospective evaluation of health-related quality of life in Hong Kong Chinese patients with chronic non-cancer pain.

OBJECTIVE: To evaluate the health-related quality of life in Hong Kong Chinese patients with chronic non-cancer pain. DESIGN: Prospective cross-sectional survey. SETTING: Regional public hospitals, Hong Kong. PATIENTS: Patients attending out-patient pain management clinics between 1 July 2002 and 28 February 2003 were approached to complete a set of standardised questionnaires. MAIN OUTCOME MEASURES: Demographic profiles, treatment modality, litigation, compensation, social welfare status, Hospital Anxiety Depression Scale, and Medical Outcomes Survey short-form health survey (SF36). RESULTS: Data from 166 patients were analysed. The median numeric pain rating score was 6 (interquartile range, 2-10). Work-related injury occurred in 34.3% of patients, while another 34% were involved in pain-related litigation and 32% were receiving disability or unemployment benefit. Sixty-four percent of patients were managed by three or more disciplines, while 54.8% were also receiving complimentary alternative medical treatment, mainly traditional Chinese medicine (49.7%). The Hospital Anxiety Depression Score indicated clinical anxiety or depression in 71.1% of patients. All SF36 subscale scores were lower than the local population norm. Unemployed patients had higher depression scores (P = 0.005), while students or retirees had lower physical functioning scores (P = 0.004). Patients who were single had higher role emotion scores than those who were married or separated/widowed (P = 0.011). Logistic regression analysis showed that younger age (odds ratio = 0.95), being married (6.62), work-related injury (15.63) or higher general scores (1.03) were more likely to be associated with litigation. Social welfare benefit was associated with unemployment (3.39) and a lower level of physical functioning (0.98). CONCLUSION: There was a high prevalence of clinical anxiety, depression, and severe impairment in the health-related quality of life in Hong Kong Chinese patients with chronic non-cancer pain. Specific factors affected the health-related quality of life, likelihood of litigation, and social benefit.

Microbial contamination of femoral head allografts.

OBJECTIVE: To study the incidence of microbial contamination at the bone bank of the United Christian Hospital. DESIGN. Retrospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: A total of 151 patients (33 men and 118 women) who underwent hip arthroplasty surgery and from whom femoral head allografts were retrieved between January 1994 and March 2000; and 81 patients in whom allografts were implanted. MAIN OUTCOME MEASURES: Bone biopsies were taken from the femoral head and used to detect any microbial contamination that might have occurred during removal and after storage. The rates of infection among recipients and donors were also assessed. RESULTS: Of the 151 allografts, 94 non-contaminated allografts were implanted by the end of the study. Fourteen (9.3%) heads showed positive culture results after retrieval and were discarded. Four (4.3%) of the 94 stored allografts that were implanted tested positive for microbial growth, but the recipients of these allografts did not develop any clinical infection. Three (3.2%) had wound infections after implantation of the stored allografts although the grafts had previously been tested negative for any microbial contamination. CONCLUSION: Our centre has a low allograft contamination rate. The wound infection rate among recipients was also low. The culture of a bone biopsy sample is a reliable method to detect contamination of bone grafts. However, the contamination rate among stored allografts should prompt orthopaedics departments to review allograft handling procedures, so as to minimise the chance of contamination.

D-2-Hydroxyglutaric aciduria and subdural haemorrhage.

UNLABELLED: D-2-Hydroxyglutaric aciduria (D-2-HG) is a rare metabolic disorder. First reported in 1980, it does not have any well-recognized presentation or specific treatment regimen. Neuroimaging findings are heterogeneous. Subdural haemorrhage has not been a feature of any of the reported cases. This report presents a boy with bilateral subdural haematoma in whom non-accidental injury was initially suspected and subsequent metabolic investigation led to a diagnosis of D-2-HG. CONCLUSION: In the management of childhood subdural haemorrhages, it is very important that potentially treatable metabolic disorders are detected and that parents are not wrongly accused of injuring their children.

The older adult: a comparison of long-term care in Glasgow and San Francisco.

Population trends show an increasing proportion of people older than 65 years of age. This report aims to describe the facilities/services accessible to the older adult living in Glasgow, Scotland and in San Francisco, United States of America. This comparative study serves to develop a broader understanding of what is involved in the process of ageing, and describes how these two cities are responding to the needs of older people. Long-term caring provision is complex and involves multiple agencies, often leaving both lay and professional individuals ill-informed as to which services exist and how best to use them. The nurse can be instrumental in providing information, viable alternatives and services. In this article, options available for caring of the older adult and financing of care are discussed along with a number of recommendations based on observations described, data collected and literature researched. With the advent of care being provided in the community, there is now a continuum of services ranging from independent living at home to dependent care in hospital. Whether an individual remains at home depends on the availability and affordability of, and access to, other resources/facilities. Creative alternatives are needed for care of the older adult in this millennium. This report describes the need for an integrated system of care, which can adjust to variations in clients' needs. Progressive care facilities, intergenerational sharing, community volunteer service programmes for the older person and Edenizing are a few recommendations discussed by the authors.

Use of EMLA cream or alfentanil for analgesia during ophthalmic nerve blocks.

This prospective double-blind study compared the effectiveness of EMLA with alfentanil and placebo in reducing the overall pain during ophthalmic nerve blocks. Seventy-five patients scheduled for cataract surgery were divided into three groups. Patients in the EMLA group had EMLA cream applied over skin areas corresponding to injection sites for retrobulbar and facial nerve blocks one hour before the nerve blocks, and placebo intravenous normal-saline injection 2 minutes before the first nerve block. The alfentanil group had placebo cream applied and intravenous alfentanil 10 micrograms.kg-1 while patients in the placebo group received placebo cream and intravenous normal-saline at similar time intervals prior to the nerve blocks. Patients then received facial nerve blocks and retrobulbar block by the same surgeon. Pain scores by patients and independent observers were significantly lower in the EMLA and alfentanil groups compared to placebo (P < 0.005) with no significant difference between the EMLA and alfentanil groups.

A case report of a patient with bronchial carcinoid tumour and late presentation of Cushing's syndrome.

Bronchial carcinoid tumour with ectopic adrenocorticotrophin (ACTH) production is an uncommon cause of Cushing's syndrome. In most instances, the patient presents with clinical hyperglucocorticolism and a search for its underlying pathology leads to the discovery of an inconspicuous bronchial carcinoid tumour, if at all. Often the tumour is not immediately detectable. We report a patient who presented in the reverse order--she initially had a large asymptomatic bronchial carcinoid tumour that subsequently manifested as clinical Cushing's syndrome after remaining quiescent for four years.

Gastrointestinal lymphoma--a review of 54 patients in Singapore.

Primary gastrointestinal (GI) lymphoma accounts for 2% to 5% of all GI malignancies. Primary therapy in uncomplicated GI lymphoma remains controversial. Fifty-four patients (male to female ratio of 4:3, median age 56 years) with GI lymphoma were studied to evaluate complications and results of therapy. The sites involved were the stomach (31), small bowel (12), large bowel (4), gallbladder (1) and multifocal (6). Distribution by stage and grade (Working Formulation or Kiel) were: IE-30%, IIE-43%, IIIE-6%, IV-20% and unknown-1%; low grade-33%, intermediate grade-59% and high grade-8%. Majority (54%) had diffuse large cell lymphoma. Twenty-three patients (43%) underwent primary resection of the tumour followed by chemotherapy in 14 or radiotherapy in 3. Seventeen patients (31%) had primary chemotherapy and 3 (6%) had primary radiotherapy. Of the 48 patients who underwent therapy, 52% had complete response. At the last follow-up (median 21 months), 25 patients were disease-free. Overall survival was 67% at two years. Treatment strategies employing surgery, radiotherapy and chemotherapy, alone or in combination, do not appear to influence outcome. Surgical resection plus chemotherapy appear to be effective in the control of local and distant disease.

Non-Hodgkin's lymphoma in an Asian population: 1968-1992 time trends and ethnic differences in Singapore.

BACKGROUND: Non-Hodgkin's lymphoma has increased in incidence in many countries, particularly in the West. Advances in diagnostic methods and the understanding of the disease over time pose a challenge to the interpretation of these trends. The aim of this study was to determine if the disease has increased in Singapore, a newly industrialized Asian country, and to examine the possible factors that may account for any observed changes. METHODS: Data from the population-based Singapore Cancer Registry for the period 1968 to 1992 were reviewed to determine time trends based on sex and ethnic group. The Poisson regression model was fitted to the cross-tabulated data to obtain the adjusted incidence density ratios. RESULTS: A total of 1988 cases of non-Hodgkin's lymphoma were included in the analysis. There was an overall increase in incidence among both Chinese and Malaysians. However, the rate of increase was greater in females (age-standardized rate from 1.8 per 100,000 in 1968-1972 to 4.5 per 100,000 in 1988-1992) than in males (3.2 per 100,000 to 5.9 per 100,000 in the same time periods). Between ethnic groups, Malay females were at higher overall risk compared with their Chinese counterparts (incidence density ratio 1.32; 95% confidence interval, 1.08-1.61). Although a substantial proportion of patients diagnosed with Hodgkin's disease between 1968 and 1972 were reclassified on review, using present criteria, as having non-Hodgkin's lymphoma, it is unlikely that this, and other recent changes in histologic interpretation, could have accounted for an increase of this magnitude. CONCLUSIONS: Non-Hodgkin's lymphoma has increased in incidence among the Chinese and Malay populations in Singapore. The pattern of increase differs from that of the common cancer sites, and suggests the need to look for environmental and genetic factors that have not yet been elucidated.

Case report of primary orbital hemangiopericytoma.

This is a case report on a 33-year-old man who had a right orbital tumour which was thought to be a cavernous hemangioma clinically and at the time of surgery. This tumour was shown to be hemangiopericytoma of borderline grade on histological study. The purpose of this paper is to present this rare orbital tumour, especially amongst Asians, which may seem benign at presentation. A review of the literature is done with emphasis on its malignant potential and the recommended mode of treatment.

The use of fine needle aspiration biopsy in patients with multiple lymphadenopathy before open biopsy.

When a clinician is faced with a patient who presents with lymphadenopathy and in whom the clinical examination and routine investigations are normal, excision biopsy is usually the next step of management to obtain a tissue diagnosis. In a patient who has multiple lymphadenopathy, deciding on which node to biopsy can be difficult because some of the enlarged nodes may not reflect the true disease process. When such a lymph node is biopsied, the actual diagnosis can be delayed or even missed. Fine needle aspiration biopsy has been shown to be an effective tool in the investigation of multiple lymphadenopathy. Many, if not all, of the enlarged lymph nodes can be sampled at one sitting. If this procedure fails to provide a definitive diagnosis, the clinician should then proceed on to an open biopsy. Two cases of multiple lymphadenopathy in which open biopsies failed to reveal the true nature of the disease but subsequent fine needle aspiration biopsies did are presented and discussed.

Further psychometric evaluation of the Spanish language health-promoting lifestyle profile.

The reliability and validity of the Spanish language version of the Health-Promoting Lifestyle Profile (Spanish-HPLP) was evaluated for a predominantly Central American sample. A convenience sample (N = 106) completed the demographic sheet and Spanish-HPLP. Alpha coefficients were 0.94 for the total scale and ranged from 0.64 to 0.89 for the subscales. Significant Pearson correlations were found between Spanish-HPLP scores and the variables of age, education, income, length of residence in the United States, and perceived health status. Significant differences based on sex and marital status were noted. The Spanish-HPLP was found to be reliable for this sample. Although content and construct validity were supported, the instrument is in need of further convergent, or criterion-related validation.

A longitudinal study of the relationships between overload, social support, and burnout among nursing educators.

The major purpose of this study was to examine the causal relationships between role overload, social support, and burnout among nursing educators over a period of time. Eighty-four nursing educators from eight campuses of a state university system completed a questionnaire twice, within a two-year interval. Data analyses consistently revealed the following: 1) Emotional exhaustion correlated significantly and positively with a demanding job, time pressure, and feelings of job inadequacy; 2) Burnout (i.e., emotional exhaustion, depersonalization of students, and a sense of decreased accomplishment) correlated significantly and negatively with social support from one's chairperson and peers. Predictor variables from the initial data set were regressed on the burnout data of two years later. The variable--job demands--was the strongest predictor of emotional exhaustion. Chairperson support was the strongest predictor of both depersonalization toward students and a person's sense of accomplishment two years later. The reported chronic exhaustion among educators in this study should be of concern. An awareness of the role of social support and overload as associated with burnout can help educators develop policies to assure peak performance on the job.

A model for peak performance.

This study identified major factors that contributed to peak performance among eight nursing educators. The peak performers were interviewed 3 times over 8 years. Intense commitment to a mission, continual performance assessment, concentration on satisfaction and rewards, and the ability to set priorities and seek social support were delineated as factors in peak performance. Commitment to a personal mission that aligns with the demands of the university was a peak performer's ultimate personal investment and service to students and the university.