Hypertension in the Emergency Department.

Hypertension is the leading risk factor for the global burden of disease, yet more than 20% of adults with hypertension are unaware of their condition. Underlying hypertension affects over 25% emergency department attendees, and the condition is more commonly encountered in emergency departments than in primary care settings. Emergency departments are strategically well placed to fulfill the important public health goal of screening for hypertension, yet less than 30% of patients with mild to severe hypertension are referred for follow up. In predominantly African American populations, subclinical hypertensive disease is highly prevalent in ED attendees with asymptomatic elevated blood pressure. Although medical intervention is not usually required, in select patient populations, it may be beneficial for antihypertensive medications to be started or adjusted in the emergency department, aiming for optimizing blood pressure control earlier while waiting for continuing care.

Too tall for the tape: the weight of schoolchildren who do not fit the Broselow tape.

BACKGROUND: In paediatric resuscitation, for a rapid and accurate estimate of children's weight, the Broselow tape can be used in children who are 46-144 cm tall. The Broselow tape has previously been found to provide the most accurate estimate of children's weight internationally, but it is not known how many fall outside the range of the tape, or whether such children can be assumed to be of adult weight, or how otherwise to estimate the weight of these children. OBJECTIVES: To determine what proportion of children in different age groups falls outside the limits of the Broselow tape, how their weight compares with that of the adults and what correlates most strongly with weight in these children. METHODS: This was a population-based prospective observational study of Chinese children up to 12 years old, from schools in Hong Kong. Weight was measured to the nearest 0.2 kg, and the height, foot-length and mid-arm circumference (MAC) were measured to the nearest 0.1 cm. RESULTS: 40% of 10-year olds and 70% of 11-year olds were too tall for the tape. Their median weight was 41.9 kg. This was significantly less than the median weight of 18-year olds (55 kg, p<0.0001) in Hong Kong. The strongest correlate with weight in these children was MAC. CONCLUSIONS: The Broselow tape is inappropriate for use in most children over 10 years old. Children too tall for the tape cannot be assumed to be of adult weight; to do so would imply an average overestimate of 30%. Weight estimates in older children could be based on MAC.

THERM: the Resuscitation Management score. A prognostic tool to identify critically ill patients in the emergency department.

INTRODUCTION: Prognostic scores are widely used in the emergency department (ED) to stratify risk for critically ill patients. The Prince of Wales ED Score (PEDS) was derived specifically for patients in an ED resuscitation room to predict death or intensive care unit (ICU) admission. We aimed to validate and refine this score, in comparison with other scores including the National Early Warning Score (NEWS). METHODS: This was a single-centre prospective study of adult resuscitation-room patients over 3 months. Comparison of scores was made using receiver operating characteristic analysis. Physiological and blood test variables were compared according to the composite primary outcome: admission to ICU or death within 7 days of attendance. Multivariate logistic regression was used to derive a new prediction score, which was validated in comparison with NEWS using the historic dataset from which PEDS had been derived. RESULTS: 234 patients were included; 37 were admitted to ICU or died within 7 days. PEDS performed adequately but was not superior to other scores. A simple pragmatic score, The Resuscitation Management score (THERM) was derived which outperformed NEWS in derivation and validation sets. CONCLUSIONS: PEDS is at least as good as other scores, including NEWS. However, it is unwieldy and relies on results not immediately accessible in the ED. THERM is a new score, derived and validated in an ED setting, using variables readily available, and simple to calculate and stratify. THERM outperforms NEWS and could be used in preference in critically ill ED patients.

Capsule endoscopy in acute upper gastrointestinal hemorrhage: a prospective cohort study.

BACKGROUND AND STUDY AIMS: Capsule endoscopy may play a role in the evaluation of patients presenting with acute upper gastrointestinal hemorrhage in the emergency department. PATIENTS AND METHODS: We evaluated adults with acute upper gastrointestinal hemorrhage presenting to the emergency departments of two academic centers. Patients ingested a wireless video capsule, which was followed immediately by a nasogastric tube aspiration and later by esophagogastroduodenoscopy (EGD). We compared capsule endoscopy with nasogastric tube aspiration for determination of the presence of blood, and with EGD for discrimination of the source of bleeding, identification of peptic/inflammatory lesions, safety, and patient satisfaction. RESULTS: The study enrolled 49 patients (32 men, 17 women; mean age 58.3 ±â€†19 years), but three patients did not complete the capsule endoscopy and five were intolerant of the nasogastric tube. Blood was detected in the upper gastrointestinal tract significantly more often by capsule endoscopy (15 /18 [83.3 %]) than by nasogastric tube aspiration (6 /18 [33.3 %]; P = 0.035). There was no significant difference in the identification of peptic/inflammatory lesions between capsule endoscopy (27 /40 [67.5 %]) and EGD (35 /40 [87.5 %]; P = 0.10, OR 0.39 95 %CI 0.11 - 1.15). Capsule endoscopy reached the duodenum in 45 /46 patients (98 %). One patient (2.2 %) had self-limited shortness of breath and one (2.2 %) had coughing on capsule ingestion. CONCLUSIONS: In an emergency department setting, capsule endoscopy appears feasible and safe in people presenting with acute upper gastrointestinal hemorrhage. Capsule endoscopy identifies gross blood in the upper gastrointestinal tract, including the duodenum, significantly more often than nasogastric tube aspiration and identifies inflammatory lesions, as well as EGD. Capsule endoscopy may facilitate patient triage and earlier endoscopy, but should not be considered a substitute for EGD.

Anthropometric and physiological measurements in healthy children.

1. Normal ranges for ultrasonic cardiac output monitor-derived cardiovascular indices are derived for Chinese children aged 1 to 12 years in Hong Kong. 2. A simple formula for calculating stroke volume is constructed, but the error varies from 8 to 40%. 3. Stroke volume index and, to a lesser extent, the cardiac index generally increase from ages 1 to 5 years, but plateau or fall slightly thereafter.

Influenza virus load in hospitalised patients.

1. Hospitalised patients with severe influenza have persistently high viral loads, for whom a different therapeutic approach may be needed. 2. Active screening of influenza infection should be performed in all high-risk patients hospitalised with febrile respiratory illness. Early diagnosis and treatment to suppress the high viral load may maximise clinical benefit. 3. For late presenting high risk patients with severe symptoms, their viral load may remain high, and initiation of antiviral treatment may still be worthwhile. 4. More stringent infection control measures, including strict droplet precautions and preferably isolation for an extended period of time may be necessary owing to prolonged viral shedding. 5. Randomised, controlled trials are indicated to address timing and dosage of treatment for severe influenza infection.

Quality control in resting-state fMRI: the benefits of visual inspection.

Background: A variety of quality control (QC) approaches are employed in resting-state functional magnetic resonance imaging (rs-fMRI) to determine data quality and ultimately inclusion or exclusion of a fMRI data set in group analysis. Reliability of rs-fMRI data can be improved by censoring or "scrubbing" volumes affected by motion. While censoring preserves the integrity of participant-level data, including excessively censored data sets in group analyses may add noise. Quantitative motion-related metrics are frequently reported in the literature; however, qualitative visual inspection can sometimes catch errors or other issues that may be missed by quantitative metrics alone. In this paper, we describe our methods for performing QC of rs-fMRI data using software-generated quantitative and qualitative output and trained visual inspection. Results: The data provided for this QC paper had relatively low motion-censoring, thus quantitative QC resulted in no exclusions. Qualitative checks of the data resulted in limited exclusions due to potential incidental findings and failed pre-processing scripts. Conclusion: Visual inspection in addition to the review of quantitative QC metrics is an important component to ensure high quality and accuracy in rs-fMRI data analysis.

Predicting massive blood transfusion using clinical scores post-trauma.

BACKGROUND AND OBJECTIVES: Early prediction of massive transfusion (MT) post-trauma may reduce mortality by earlier delivery of blood products. A clinical prediction tool (PWH score) for this purpose was developed at the Prince of Wales Hospital, Hong Kong. The aims of this study were to apply this tool to major trauma patients in Victoria, Australia and compare the score to the Assessment of Blood Consumption (ABC) score and the Trauma-Associated Severe Haemorrhage (TASH) score. METHODS: A retrospective review of patients entered into the The Alfred Trauma Registry between January 2006 and December 2009 was conducted. The performance of the PWH score to predict MT defined by 5 units of packed red blood cells in 4 h was compared with the ABC and TASH scores. Included patients presented to the Emergency & Trauma Centre from the scene and had had complete datasets with respect to the components of the three scores. RESULTS: There were 1234 patients included in the study with 195 (15·8%) receiving a MT and an overall mortality of 14·0%. The PWH score had an area under the receiver operating characteristics (ROC) curve of 0·842 (95% CI: 0·820-0·862). The area under the ROC curve of the PWH score was significantly less than that of the TASH score (χ(2)=19·8, P<0·001) and significantly greater than that of the ABC score (χ(2)=9·3, P=0·002). CONCLUSIONS: The PWH score performs with similar accuracy when applied to an Australian population as in its derivation population. The relative simplicity of the PWH score makes it a viable tool for clinical use, although utility of such tools may be more suited for research in determining inclusion or exclusion criteria for comparative outcome studies.

Evaluating acute medical admissions through emergency departments in Hong Kong: can one adjust for case-mix variation?

BACKGROUND: Healthcare systems are under pressure to efficiently and safely reduce acute care admissions to hospital. There is a need to develop a standardised system for assessing emergency department performance which takes into account case-mix variation. The objective of this study was to derive and validate a standardised tool for assessing variations in medical admissions through emergency departments in Hong Kong. METHODS: Retrospective study of patients attending emergency departments of 14 acute hospitals in Hong Kong. Data were retrieved from a centralised administrative database. RESULTS: Of 2,531,225 patients who attended emergency departments between 1 January 2001 and 31 December 2003, 780,444 (30.8%) were admitted to medical wards. A model derived from 2001 data shows well-calibrated admission probabilities, with an area under the receiver operating characteristic curve for probability of admission of 90.3 (95% CI ±0.11). The areas under the receiver operating characteristic curves for 2002 and 2003 validation sets were 89.9 (95% CI ±0.11) and 89.0 (95% CI ±0.12), respectively. With an averaged benchmark, reductions in medical admissions of up to 19% could be achieved, while under the most optimistic assumption, reductions of up 36% could be achieved. CONCLUSIONS: A tool for benchmarking hospital medical admissions and minimising case-mix variation has been derived and validated in Hong Kong, but it requires further validation in other healthcare systems given the wide variations in admission thresholds internationally. This may be used as one potential method to evaluate the performance of emergency departments against a common standard.

Open-access colonoscopy: outcomes of referrals from the emergency department.

AIM: The study investigated the diagnostic outcome of colonoscopy referrals from the emergency department (ED) via an open-access system. METHOD: A retrospective cohort study over two years was performed on all patients under 65 years referred for open-access colonoscopy by the ED in a hospital with an annual ED attendance of 140,000. Patient characteristics and presenting symptoms were retrieved. Waiting times from presentation to colonoscopy were recorded. RESULTS: Over a 2-year period, 266 patients were referred, of whom 37 defaulted, leaving 229 patients who had a colonoscopy. The mean age was 48.3 ± 11.3 (SD) and the female/male ratio was 229/125. The most frequent presenting symptoms included: rectal bleeding (n = 142, 62%), change of bowel habit (n = 47, 20.5%) and abdominal pain (n = 40, 17.5%). The median waiting time from presentation to colonoscopy was 17 (range 1-69) days. A positive colonoscopic finding was recorded in 45.4%, including colorectal cancer in 12 (5.2%). CONCLUSION: The rate of a positive diagnoses from the ED-based colonoscopy referral service was comparable to that of the general Hong Kong population. This approach may help to reduce the waiting time for colonoscopy in a specialist colorectal clinic.

Age-based formulae to estimate children's weight in the emergency department.

OBJECTIVE: To develop an age-based weight estimation rule in a Chinese population and to compare its performance with existing formulae. DESIGN: Population-based observational study. SETTING: Schools and kindergartens in Hong Kong. SUBJECTS: Healthy Chinese children aged 1-10 years old on their last birthday. INTERVENTIONS: Weight was measured to the nearest 0.2 kg. MAIN OUTCOME MEASURES: Linear regression was used to derive a simple formula relating weight to the child's age on his or her last birthday. The accuracy and precision of different age-based weight formulae was compared using coefficient of variation, Bland Altman plots, and by determining the proportion of children with estimates >30% outside the actual weight. RESULTS: The Chinese Age Weight Rule is a simple linear formula that is more accurate than and at least as precise as any other age-based weight estimation rule: weight in kg=(3 × age last birthday)+5. It is accurate and precise in children <7 years old, but all age-based weight estimates are imprecise in older children. CONCLUSIONS: The Chinese Age Weight Rule should be used in a Chinese population in preference to any other age-based weight estimation rule. Caution should be taken when using it in older children in whom other weight-estimation tools may be more appropriate.

Disease severity prediction for nursing home-acquired pneumonia in the emergency department.

BACKGROUND: Prediction rules exist for the assessment of community-acquired pneumonia but their use in nursing home-acquired pneumonia (NHAP) remains undefined. The objectives of this study were to compare the prognostic ability for severe NHAP of five prediction rules (PSI, CURB-65, M-ATS, R-ATS, España rule), and to evaluate their usefulness to identify patients with less severe disease in the emergency department for outpatient care. METHODS: A prospective observational study of consecutive NHAP patients was conducted at a university teaching hospital emergency department in Hong Kong between January 2004 and June 2005. The primary outcome was severe pneumonia (defined as combined 30-day mortality and/or intensive care unit (ICU) admission). RESULTS: 767 consecutive NHAP patients were included. Mean (SD) age was 83.4 (9.0) years; 350 (45.6%) were male and 644 (84.0%) had coexisting illness. 95 patients died within 30 days (12.4%), five patients were admitted to the ICU (0.7%) and 98 patients had severe pneumonia (12.8%). Sensitivity and specificity of each decision rule ranged from 37.8% to 95.9% and 15.1% to 87.6% respectively. The overall predictive performance of each rule was between 0.627 and 0.712. The negative likelihood ratios of PSI (0.27) and CURB-65 (0.23) were lower than M-ATS (0.71), R-ATS (0.45) and España (0.39). After excluding 204 patients with either poor functional status or those >90 years of age, sensitivities of M-ATS (96.0%) and R-ATS (100%) improved greatly with negative likelihood ratios of <0.1. CONCLUSION: PSI and CURB-65 are useful for identification of patients with less severe NHAP.

Cadmium-Free and Efficient Type-II InP/ZnO/ZnS Quantum Dots and Their Application for LEDs.

It is a generally accepted perspective that type-II nanocrystal quantum dots (QDs) have low quantum yield due to the separation of the electron and hole wavefunctions. Recently, high quantum yield levels were reported for cadmium-based type-II QDs. Hence, the quest for finding non-toxic and efficient type-II QDs is continuing. Herein, we demonstrate environmentally benign type-II InP/ZnO/ZnS core/shell/shell QDs that reach a high quantum yield of ∼91%. For this, ZnO layer was grown on core InP QDs by thermal decomposition, which was followed by a ZnS layer via successive ionic layer adsorption. The small-angle X-ray scattering shows that spherical InP core and InP/ZnO core/shell QDs turn into elliptical particles with the growth of the ZnS shell. To conserve the quantum efficiency of QDs in device architectures, InP/ZnO/ZnS QDs were integrated in the liquid state on blue light-emitting diodes (LEDs) as down-converters that led to an external quantum efficiency of 9.4% and a power conversion efficiency of 6.8%, respectively, which is the most efficient QD-LED using type-II QDs. This study pointed out that cadmium-free type-II QDs can reach high efficiency levels, which can stimulate novel forms of devices and nanomaterials for bioimaging, display, and lighting.

Predictors of important neurological causes of dizziness among patients presenting to the emergency department.

OBJECTIVES: Dizziness is a common presenting complaint in the emergency department (ED). This prospective study describes the incidence, causes and outcome of ED patients presenting with dizziness and tries to identify predictors of central neurological causes of dizziness. METHODS: Single-centre prospective observational study in a university teaching hospital ED in Hong Kong. All ED patients (> or = 18 years old) presenting with dizziness were recruited for 1 month. Symptoms, previous health, physical findings, diagnosis and disposition were recorded. The outcome at 3 months was evaluated using hospital records and telephone interviews. Follow-up was also performed at 55 months using computerised hospital records to identify patients with subsequent stroke and those who had died. RESULTS: 413 adults (65% female, mean 57 years) were recruited. The incidence of dizziness was 3.6% (413/11 319). Nausea and/or vomiting (46%) and headache (20%) were the commonest associated findings. Hypertension (33%) was the commonest previous illness. Central neurological causes of dizziness were found in 6% (23/413) of patients. Age > or = 65 years (OR=6.13, 95% CI 1.97 to 19.09), ataxia symptoms (OR=11.39, 95% CI 2.404 to 53.95), focal neurological symptoms (OR=11.78, 95% CI 1.61 to 86.29), and history of previous stroke (OR=3.89, 95% CI 1.12 to 13.46) and diabetes mellitus (OR=3.57, 95% CI 1.04 to 12.28) predicted central causes of dizziness. CONCLUSIONS: Most dizzy patients had benign causes. Several clinical factors favoured a diagnosis of central neurological causes of dizziness.

Biological Efficacy and Safety of Niacinamide in Patients With ADPKD.

INTRODUCTION: Autosomal dominant polycystic kidney disease (ADPKD) is characterized by progressive cyst enlargement, leading to kidney failure. Sirtuin-1 is upregulated in ADPKD and accelerates disease progression by deacetylating p53. Niacinamide is a dietary supplement that inhibits sirtuins at high doses. METHODS: We conducted an open-label, single-arm intervention trial (study 1, N = 10), and a randomized, double blinded, placebo-controlled trial (study 2, N = 36) to assess the biological activity and safety of niacinamide. Patients with ADPKD were given 30 mg/kg oral niacinamide or placebo, for 12 months. The primary endpoint was the ratio of acetylated p53 to total p53 protein in peripheral blood mononuclear cells (PBMCs). RESULTS: There was no sustained effect of niacinamide on acetylated/total p53 in either study and no difference between placebo and niacinamide arms. There was no difference in the change in height-adjusted total kidney volume over 12 months between niacinamide and placebo. Niacinamide was generally well tolerated. The most common adverse effects were nausea, diarrhea, gastroesophageal reflux, headache, and acneiform rash but there was no difference in their incidence between niacinamide and placebo. CONCLUSIONS: In conclusion, niacinamide is safe and well-tolerated in patients with ADPKD. However, we were unable to detect a sustained inhibition of sirtuin activity over 12 months of treatment, and there was no signal to suggest a beneficial effect on any efficacy measure.

Cost-consequence analysis comparing 2-octyl cyanoacrylate tissue adhesive and suture for closure of simple lacerations: a randomized controlled trial.

STUDY OBJECTIVE: We investigate the cost difference between conventional suture and tissue adhesive methods in simple wound closure. METHODS: A cost-consequence analysis was conducted alongside a nonblinded randomized controlled trial comparing 2-octyl cyanoacrylate tissue adhesive with conventional suture in simple lacerations closure in emergency departments (EDs) of a university teaching hospital and a major regional hospital in Hong Kong. One hundred eighty-six adult patients with simple lacerations of length within 8 cm were randomized to receive tissue adhesive (93 patients) or conventional suture (93 patients) for wound closure. The primary outcome measures were the costs to the Hospital Authority and the charges on participants incurred in each treatment method. The secondary outcome measures included the cosmetic visual analog scale, visual analog scale, Wound Evaluation Score, total time spent in each closure method, and the overall patients' satisfaction on the whole process of wound management. RESULTS: The 2 groups had similar baseline characteristics. The tissue adhesive method incurred a higher cost to the Hospital Authority (216.12 [US $27.70] versus 171.33 [US $21.96]; absolute difference 44.79 [US $5.74] [95% confidence interval (CI) 32.76 to 55.95 [US $4.20 to 7.14]]) but a lower charge to patients (109.68 [US $14.06] versus 156.96 [US $20.12]; absolute difference 47.28 [US $6.06] [95% CI, 35.58 to 58.98 [US $4.56 to 7.56]) than the conventional suture method. The mean cosmetic visual analog scale score, visual analog scale score, and Wound Evaluation Score of the 2 groups were similar at various intervals within 3 months after wound closure. Compared with the suture group, the tissue adhesive group had a shorter median procedure time, fewer patients had wound erythema or swelling after wound closure, fewer patients required analgesics on discharge at ED, and there was a higher overall patient satisfaction score. CONCLUSION: Simple wounds closed by tissue adhesives incur a higher cost to the Hospital Authority than the conventional suture but may be favored by patients because of lower personal charge.