Management decision of hospital surge: assessing seasonal upsurge in inpatient medical bed occupancy rate among public acute hospitals in Hong Kong.

BACKGROUND: There were recurrent upsurges in demand for public hospital services in Hong Kong. An understanding of the contribution of some possible factors for the rise in health care burden would help to inform hospital management strategies. AIM: To evaluate the utilization patterns of hospitalizations in medical wards among public acute hospitals in Hong Kong during surge periods. DESIGN: Retrospective study. METHODS: By extracting the information in press releases between 2014 and 2018, descriptive statistics about medical ward occupancy situation during six surge periods were generated. A time series model was constructed to estimate the occupancy rate at each hospital and assess its relationship with the intensity of seasonal influenza activity, extreme weather, day of week and long holidays. RESULTS: There was a significant increase in the number of admissions to medical wards in all six surge periods. A significant variation in occupancy rate between weekdays and geographic regions was observed. The occupancy rate in 10, out of 15, hospitals was significantly associated with the influenza activity, while there was limited effect of weather on the occupancy rate. A significant holiday effect was observed during Christmas and Chinese New Year, resulting in a lower bed occupancy rate. CONCLUSIONS: A differential burden in public hospitals during surge periods was reported. Contingency bed and staff management shall be tailored to individual hospitals, given their differences in the determinants for inpatient bed occupancy.

Inflammatory state of type II diabetic patients with chronic ulcers in response to herbal treatment.

BACKGROUND: Type II diabetic patients easily develop ulcers over their feet which heal with great difficulties and not infrequently, end up in amputations. In the quest for innovative means to avoid amputation, herbal medicine has been used in China to heal ulcers. METHOD: A randomized placebo controlled clinical trial involving 80 patients was conducted to test whether a herbal formula taken orally could help to preserve the ulcerated leg. Other parameters measured included granulation maturation time, skin temperature and circulation, and tumor necrosis factor alpha (TNF-α). RESULTS: showed a 85% limb rescue with the herbal treatment group showing superiority over placebo group. TNF-α decline was observed with gradual ulcer healing and the herbal supplement group showed a more impressive decline (p=0.037).

Electrical characterizations of biomimetic molecular layers on gold and silicon substrates.

Electrical impedance technology was used to characterize DNA recognition in a monolayer containing single-stranded DNA probes immobilized on a gold substrate using thiol self-assembly chemistry. Recognition of targeted complementary DNA was principally correlated with an eight-fold increase in the conductance of the monolayer and attributed to electron conduction through double helices formed upon the binding of the DNA targets to the probes. The high recognitive sensitivity was possible without the use of the redox labels or large bias voltages required for recognition using cyclic and Osteryoung square wave voltammetry. The impedance technology also provided atomic resolution of a hybrid bimolecular lipid membrane formed by deposition of a phospholipid:cholesterol monolayer onto a hydrophobic alkyl monolayer covalently attached to a silicon substrate via silicon-carbon bonds. Atomic resolution was achieved through preparation of membranes on surfaces approaching atomic flatness and the performance of impedance measurements over precisely defined areas of the surface in contact with solutions. Principally capacitive properties distinguished between the immobilized (octadecyl) and more fluidic (lipid:cholesterol) leaflets of the hybrid membrane. The lipid:cholesterol leaflets were structurally similar to those leaflets in free-standing bimolecular lipid membranes. The hybrid membrane therefore provides a highly stable and physiologically relevant surface for studying biomolecular interactions with membrane surfaces.

Temporal trends in sexually transmitted infection prevalence and condom use following introduction of the female condom to Madagascar sex workers.

We followed 1000 sex workers in Madagascar for 18 months to assess whether adding female condoms to male condom distribution led to increased protection levels and decreased sexually transmitted infections (STIs). For months 1-6, participants had access to male condoms only; in the final 12 months, they had access to male and female condoms. We interviewed participants about condom use every two months and tested for chlamydia, gonorrhoea and trichomoniasis every six months. Following six months of male condom distribution, participants used protection in 78% of sex acts with clients. Following female condom introduction, protection at months 12 and 18 rose to 83% and 88%, respectively. Aggregate STI prevalence declined from 52% at baseline to 50% at month 6. With the female condom added, STI prevalence dropped to 41% and 40% at months 12 and 18, respectively. We conclude female condom introduction is associated with increased use of protection to levels that reduce STI risk.

A prospective study assessing the effects of introducing the female condom in a sex worker population in Mombasa, Kenya.

OBJECTIVE: To assess the impact and costs of adding female condoms to a male condom promotion and distribution peer education programme for sex workers in Mombasa, Kenya. DESIGN: A 12 month, prospective study of 210 female sex workers. METHODS: We interviewed participants about their sexual behaviour every 2 months for a total of seven times and introduced female condoms after the third interview. We also collected cost data and calculated the cost and cost effectiveness of adding the female condom component to the existing programme. RESULTS: Introduction of the female condom in an HIV/AIDS prevention project targeting sex workers led to small, but significant, increases in consistent condom use with all sexual partners. However, there was a high degree of substitution of the female condom for male condoms. The cost per additional consistent condom user at a programme level is estimated to be 2160 dollars (1169 pounds sterling, 1711 euros) (95% CI: 1338 to 11 179). CONCLUSIONS: The female condom has some potential for reducing unprotected sex among sex workers. However, given its high cost, and the marginal improvements seen here, governments should limit promotion of the female condom in populations that are already successfully using the male condom. More research is needed to identify effective methods of encouraging sex workers to practise safer sex with their boyfriends.

Effectiveness of a Chinese herbal medicine preparation in the treatment of cough in uncomplicated upper respiratory tract infection: a randomised double-blinded placebo-control trial.

BACKGROUND: Rigorous scientific and well-designed clinical trials to evaluate the effect of traditional Chinese medicine (TCM) is lacking. We, therefore, designed this study to evaluate the effectiveness of a commonly used TCM preparation in treating acute cough of uncomplicated URTI in adults and to search for a safe, effective and affordable alternative treatment for this common condition. METHODS: A randomised, double-blinded, placebo-control study comparing this TCM preparation with a placebo was conducted in 82 patients who attended the Family Medicine Training Centre, Prince of Wales Hospital, Hong Kong between November and December, 2003. The TCM herbal preparation includes nine commonly used TCM herbs for cough such as chuanbei, fangfeng, jiegeng, gancao and baibu (see Table 1). The treatment lasted for 5 days and patients were followed-up for another 6 days. Patients were asked to fill in a cough score and validated Leicester cough questionnaire (LCQ). RESULTS: 62 patients (75.6%) had completed the trial and no adverse effects were reported. Both intervened and control groups had improved in cough score and LCQ in the follow-up period, despite no overall statistical significance was observed in the differences of scores between the two groups. Women taking TCM had significantly fewer problems with sputum production (p = 0.03) and older subjects (>35 years of age) reported a significant improvement in hoarseness (p = 0.05) when compared to those using placebo. CONCLUSION: TCM was well-tolerated and received among the Hong Kong Chinese population. This TCM preparation appeared to have some benefits in the treatment of cough. Future research on TCM should concentrate more on commonly encountered conditions such as UTRI and cough. Our experience on the sensitivity of assessment tools used in detecting subtle differences in an otherwise self-limiting illness and clinical trial methodology when applying the underlying theory of how TCM works in disease management was invaluable.

Immunomodulatory effects of a traditional Chinese medicine with potential antiviral activity: a self-control study.

Traditional Chinese medicine (TCM) has been used for prevention and treatment of severe acute respiratory syndrome (SARS) in Hong Kong during the outbreak in spring 2003. We investigated the immunomodulating effects of an innovative TCM regimen derived from two herbal formulas (Sang Ju Yin and Yu Ping Feng San) for treating febrile diseases. Thirty-seven healthy volunteers were given the oral TCM regimen daily for 14 days. Peripheral venous blood samples were taken on days 0, 15 and 29 for hematology, biochemistry and immunology tests, including the measurement of blood lymphocyte subsets and plasma T-helper lymphocyte types 1 and 2 cytokines and receptor. After 3 months, 23 of the volunteers participated in a control study without TCM treatment for the same time course of blood tests. Two volunteers withdrew on day 2, due to headache and dizziness. All others remained well without any side effects. No participants showed significant changes in their blood test results, except that the T-lymphocyte CD4/CD8 ratio increased significantly from 1.31 +/- 0.50 (mean +/- SD) on day 0 to 1.41 +/- 0.63 on day 15 (p < 0.02), and reduced to 1.32 +/- 0.47 on day 29 (p < 0.05). In the control study, there were no changes in the CD4/CD8 ratio. The transient increase in CD4/CD8 ratio was likely due to the TCM intake. We postulate that the administration of the innovative TCM may have beneficial immunomodulatory effects for preventing viral infections including SARS.

Shoulder arthrodesis in brachial plexus injuries--a review of six cases.

Shoulder arthrodesis is a secondary reconstructive option for patients with brachial plexus injuries requiring a stable shoulder. This study was undertaken to evaluate the clinical and radiological outcomes of shoulder fusion in six patients with flail upper limbs following complete brachial plexus injuries. The shoulder was fused in 30 degrees abduction, 30 degrees internal rotation and 30 degrees flexion via a direct lateral approach by using a 4.5 mm reconstruction plate without bone grafting. The average follow-up was 10.3 months. Radiological union was obtained in all patients. Five patients (83%) had relief of pain after the shoulder fusion. Improvement of function was observed in all patients with a mean improvement of 56.6 degrees (range 30 degrees-75 degrees) and 47.5 degrees (range 30 degrees-60 degrees) active flexion and abduction respectively. One patient developed humeral fracture distal to the plate and the fracture eventually healed with a splint. Successful stable fusion of the shoulder in patients with brachial plexus injuries requires rigid fixation with a single 4.5 mm reconstruction plate, protection of bone healing with a triangular abduction brace for 12 weeks and functional trapezius, levator scapulae, serratus anterior and rhomboid muscles for optimizing the functional result.

Successful revascularisation of near total amputation of the upper limb after ten hours of warm ischaemia.

Near total amputation of the upper limb if unsalvageable would cause severe disability. However, delayed revascularisation can be life threatening. We report two cases of revascularisation of the upper limb following near total amputation that was successful and functional after a warm ischaemic time of ten hours. The first was a traction avulsion injury of the arm leaving major nerves contused but in continuity. The second was a sharp injury through the mid-forearm attached by only a bridge of skin. Attempting revascularisation of a proximal injury beyond 6 hours, in selected cases is worthwhile.

Using herbal medicine as a means of prevention experience during the SARS crisis.

At the peak of the SARS epidemic in Hong Kong, hospital workers were under high risks of contraction of the infection. Herbal preparations had been used historically in China to treat influenza-like diseases. During the SARS outbreak, herbal preparations had been used jointly with standard modern treatment in China. As a means to protect the at-risk hospital workers, an innovative herbal formula was created and consumed by 3160 of them in two weeks. During the two weeks, symptoms and adverse effects were close monitored; 37 of them had their serum checked for immunological responses. The results showed that none of the herb consumers contracted the infection, compared to 0.4% among the non-consumers. Adverse effects had been infrequent and mild. There were hardly any influenza-like symptoms and the quality of life improved. In the group who volunteered to have their immunological state checked, significant boosting effects were found. It was concluded that there might be a good indication for using suitable herbal preparations as a means of preventing influenza-like infection. The mode of preventive effect could be treatment of the infection at its very early stage instead of producing a period of higher immunological ability, as in the case of vaccination.

The use of an herbal formula by hospital care workers during the severe acute respiratory syndrome epidemic in Hong Kong to prevent severe acute respiratory syndrome transmission, relieve influenza-related symptoms, and improve quality of life: a prospective cohort study.

OBJECTIVES: To investigate the efficacy of an herbal formula in the prevention of severe acute respiratory syndrome (SARS) transmission among health care workers. The secondary objectives are to investigate quality of life (QOL) and symptomology changes among supplement users, and to evaluate the safety of this formula. DESIGN: Controlled clinical trial. SETTINGS: Hong Kong during epidemic of SARS. SUBJECTS: Two cohorts of health care workers from 11 hospitals in Hong Kong, 1 using an herbal supplement for a 2-week period (n = 1063) and a control cohort comprising all other health care workers who did not receive the supplement (n = 36,111) were compared prospectively. INTERVENTIONS: Taking an herbal supplement for a 2-week period. OUTCOME MEASURES: SARS attack rates and changes in quality of life and influenza-like symptoms were also examined at three timepoints among herbal supplement users. RESULTS: None of the health care workers who used the supplement subsequently contracted SARS compared to 0.4% of the health care workers who did not use the supplement (p = 0.014). Improvements in influenza-like symptoms and quality of life measurements were also observed among herbal supplement users. Less than 2% reported minor adverse events. CONCLUSION: The results of this pilot study suggest that there is a good potential of using Traditional Chinese Medicine (TCM) supplements to prevent the spread of SARS.

Immunomodulatory effects of yun zhi and danshen capsules in health subjects--a randomized, double-blind, placebo-controlled, crossover study.

Immunostimulating polysaccharides extracted from the Chinese medicinal plant Yun Zhi (Coriolus versicolor) have been found to enhance various immunological functions, and Danshen (Salvia miltiorrhiza) to show beneficial effects on the circulatory system. In the present clinical study, we investigated if regular consumption of Yun Zhi and Danshen capsules could improve cellular immunity in healthy subjects. One hundred healthy subjects were recruited to take Yun Zhi (50 mg/kg body weight) plus Danshen (20 mg/kg body weight) or placebo capsules daily for four successive months and, after a 2-month wash-out period, crossover to take placebo or Yun Zhi plus Danshen capsules for four successive months. Flow cytometry was used to assess the lymphocyte subtypes and concentration of T helper (Th) cell cytokines in culture supernatant. Gene expression of cytokines and cytokine receptors of peripheral blood mononuclear cells (PBMC) was analyzed by cDNA expression array. Results showed that regular oral consumption of Yun Zhi-Danshen capsules could significantly elevate PBMC gene expression of interleukin (IL)-2 receptor, increase the percentage and absolute counts of T helper cell and ratio of CD4(+) (T helper)/CD8(+) (T suppressor and cytotoxic T) cell, and significantly enhance the ex vivo production of typical Th1 cytokine interferon-gamma from PBMC activated by phytohemagglutinin and lipopolysaccharide (all p<0.005). Such consumption had no adverse effects on liver and renal functions, and the biochemical bone profile. Therefore, regular consumption of Yun Zhi and Danshen could be beneficial for immunological functions by potential enhancement of cell-mediated immunity in healthy subjects without any adverse effects.

Association of serum albumin concentration and mortality risk in critically ill patients.

In this study we aimed to examine the association between serum albumin concentration and mortality risk in critically ill patients. We retrospectively studied 1003 patients admitted to ourIntensive Care Unit (ICU) over an 18-month period. Serial albumin measurements over 72 hours were compared between survivors and non-survivors, and medical and surgical patients were also compared. Our results showed that serum albumin decreased after ICU admission, most rapidly in the first 24 hours, in both survivors and non-survivors. Serum albumin was lower in non-survivors than in survivors, but albumin concentrations poorly differentiated the two groups. Medical patients had higher admission albumin levels than surgical patients, but both subgroups showed a similar albumin profile over 72 hours. We evaluated the prognostic value of serum albumin using receiver operator characteristic (ROC) curves. We constructed ROC curves for APACHE II score, admission albumin, albumin at 24 and 48 hours. We also combined APACHE II with albumin values and constructed the corresponding ROC curves. Our data showed that serum albumin had low sensitivity and specificity for predicting hospital mortality. Combining APACHE II score with serum albumin concentrations did not improve the accuracy of outcome prediction over that of APACHE II alone.

Spinal ropivacaine for cesarean section: a dose-finding study.

BACKGROUND: The dose-response relation for spinal ropivacaine is undetermined, and there are few data available for obstetric patients. METHODS: In a prospective, randomized, double-blind investigation, the authors studied 72 patients undergoing elective cesarean delivery. An epidural catheter was placed at the L2-L3 vertebral interspace. Lumbar puncture was then performed at the L3-L4 vertebral interspace, and patients were randomized to receive a dose of spinal ropivacaine diluted to 3 ml with normal saline: 10 mg (n = 12), 15 mg (n = 20), 20 mg (n = 20), or 25 mg (n = 20). Sensory changes assessed by ice and pin prick and motor changes assessed by modified Bromage score were recorded at timed intervals. A dose was considered effective if an upper sensory level to pin prick of T7 or above was achieved and epidural supplementation was not required intraoperatively. RESULTS: Anesthesia was successful in 8.3, 45, 70, and 90% of the 10-, 15-, 20-, and 25-mg groups, respectively. A sigmoid dose-response curve and a probit log dose-response plot were obtained, and the authors determined the ED50 (95% confidence interval) to be 16.7 (14.1-18.8) mg and the ED95 (95% confidence interval) to be 26.8 (23.6-34.1) mg. Duration of sensory and motor block and degree of motor block, but not onset of anesthesia, were positively related to dose. CONCLUSIONS: The ED50 and estimated ED95 for spinal ropivacaine were 16.7 and 26.8 mg, respectively. Ropivacaine is a suitable agent for spinal anesthesia for cesarean delivery.

Prospective evaluation of patients refused admission to an intensive care unit: triage, futility and outcome.

OBJECTIVES: To evaluate factors associated with decisions to refuse ICU admission and to assess the outcome of refused patients. DESIGN AND SETTING: Prospective, descriptive evaluation in a multi-disciplinary intensive care unit, university referral hospital. PATIENTS AND PARTICIPANTS: All adult emergency referrals over a 7-month period. INTERVENTIONS: The number of beds available at the time of referral, the patient's age, gender, diagnosis, mortality probability model score and hospital survival were documented. The outcome of the referral and the reason for refusal were recorded. MEASUREMENTS AND RESULTS: Of 624 patients 388 were admitted and 236 (38%) refused. Reasons for refusal were triage (n=104), futility (n=82) and inappropriate referral (too well; n=50). The standardised mortality ratio (SMR) for refused and admitted groups was 1.24 (95% CI 1.05-1.46) and 0.93 (0.78-1.09) respectively. The SMR ratio (refused SMR/admitted SMR) was highest in the middle range of illness (1.95, 1.19-3.20). Inappropriate referrals had a better than expected outcome despite refusal, with a SMR ratio of 0.39 (0.11-0.99). Excluding inappropriate referrals, multivariate analysis demonstrated that refusal was associated with older age, diagnostic group and severity of illness. Triage decisions were associated with a diagnosis of sepsis, and futility decisions with greater severity of illness and recent cardiac arrest. CONCLUSIONS: Refusal of admission to our ICU is common. Excess mortality of patients refused is most marked in the middle range of severity of illness. Age, diagnostic group, and severity of illness are important in decision making. Strategies should be developed to create admission criteria that would identify patients in the middle range of severity of illness who should benefit most from ICU care.

Measuring women's psychological well-being in Indonesia.

This paper describes the development of a set of measures of women's psychological well-being in Indonesia, identifies meaningful clusters of women based on the well-being measures, and explores the sociodemographic factors associated with these well-being clusters. This is the first published study to measure psychological well-being among a large sample of Indonesians and the first to focus on women in that country. Rather than use standard measures of psychological well-being developed in Western nations and untested among Asian women, focus groups were conducted to develop an understanding of Indonesian women's perceptions of their own well-being. The focus group findings were used to develop 41 questionnaire items to measure psychological well-being, and the questionnaire was administered to 796 women in Sumatra and Lampung. Factor analysis reduced the well-being variables into five factors accounting for 45% of the total variance: (1) general negative feelings; (2) satisfaction with relationships and ability to control fertility; (3) satisfaction with economic, family and personal conditions; (4) negative feelings regarding marital and domestic issues; and (5) ability to pursue activities outside the home. We constructed five scales based on these factors. Based on their scores on these scales, women grouped into three clusters differentiated by their scores on four of the five scales. Low levels of psychological well-being were associated in bivariate analyses with: (1) rural residence; (2) young age (under age 30); (3) marriage before age 20; (4) low socioeconomic status; and (5) lower educational attainment.

Dose-response study of epidural ropivacaine for labor analgesia.

BACKGROUND: Ropivacaine has been introduced for use in epidural analgesia in labor. However, there have been few formal dose-response studies of ropivacaine in this setting. METHODS: The authors performed a prospective, randomized, double-blind study examining the effectiveness of five different doses of ropivacaine (10, 20, 30, 40, and 50 mg) administered epidurally in a volume of 10 ml to establish analgesia in 66 parturients who were in active labor with cervical dilatation less than 4 cm. A dose was considered effective when the visual analog scale pain score decreased by 50% or more from baseline. RESULTS: A sigmoid dose-response curve and a probit log dose-response plot (linear regression coefficient, r = 0.84; coefficient of determination, r2 = 0.71) were obtained. The ED50 (median effective dose) obtained based on the maximum likelihood estimation was 18.4 mg (95% confidence interval, 13.4-25.4 mg). Time to onset of analgesia, duration of analgesia, time to two-segment regression of sensory block level, and incidence of motor block were not affected by the dosage of ropivacaine administered (P = 0.93, 0.12, 0.55, and 0.39, respectively). However, the upper level of sensory block was dose-related (P < 0.01). CONCLUSION: In a traditional dose-response study, the ED50 of ropivacaine required to initiate epidural analgesia in early labor was found to be 18.4 mg (95% confidence interval, 13.4-25.4 mg).

Female condom introduction and sexually transmitted infection prevalence: results of a community intervention trial in Kenya.

OBJECTIVE: To measure the impact on sexually transmitted infection (STI) prevalence of a female condom introduction and risk-reduction program at Kenyan agricultural sites. DESIGN: We conducted a cluster-randomized trial to determine whether a replicable, community-level intervention would reduce STI prevalence. METHODS: Six matched pairs of tea, coffee and flower plantations were identified. The six intervention sites received an information/motivation program with free distribution of female and male condoms, and six control sites received only male condoms and related information. Participants were tested for cervical gonorrhea and chlamydia by ligase chain reaction on urine specimens, and vaginal trichomoniasis by culture, at baseline, 6 and 12 months. RESULTS: Participants at intervention (n = 969) and control sites (n = 960) were similar; baseline STI prevalence was 23.9%. Consistent male condom use was more than 20% at 12 months. Consistent female condom use was reported by 11 and 7% of intervention site women at 6 and 12 months. Unadjusted STI prevalence was 16.5 and 17.4% at 6 months, and 18.3 and 18.5% at 12 months, at the intervention and control sites, respectively. Logistic regression models confirmed the null effect of the female condom intervention. CONCLUSIONS: Female condom introduction did not enhance STI prevention at these sites. It is unclear which aspects of the intervention -- STI education, condom promotion, case management -- were associated with decreased STI prevalence from baseline to follow-up.