Diagnostic accuracy of a prehospital electrocardiogram rule-based algorithm for ST-elevation myocardial infarction: results from a population-wide project.

INTRODUCTION: This study reviewed the diagnostic accuracy of the prehospital electrocardiogram (PHECG) rule-based algorithm for ST-elevation myocardial infarction (STEMI) universally utilised in Hong Kong. METHODS: This prospective observational study was linked to a population-wide project. We analysed 2210 PHECGs performed on patients who presented to the emergency medical service (EMS) with chest pain from 1 October to 31 December 2021. The diagnostic accuracy of the adopted rulebased algorithm, the Hannover Electrocardiogram System, was evaluated using the adjudicated blinded rating by two investigators as the primary reference standard. Diagnostic accuracy was also evaluated using the attending emergency physician's diagnosis and the diagnosis on hospital discharge as secondary reference standards. RESULTS: The prevalence of STEMI was 5.1% (95% confidence interval [CI]=4.2%-6.1%). Using the adjudicated blinded rating by investigators as the reference standard, the rule-based PHECG algorithm had a sensitivity of 94.6% (95% CI=88.2%-97.8%), specificity of 87.9% (95% CI=86.4%-89.2%), positive predictive value of 29.4% (95% CI=24.8%-34.4%), and negative predictive value of 99.7% (95% CI=99.3%-99.9%) [all P<0.05]. CONCLUSION: The rule-based PHECG algorithm that is widely used in Hong Kong demonstrated high sensitivity and fair specificity for the diagnosis of STEMI.

Noise and thermal performance of a sub-attofarad capacitance sensor for precision measurements, with applications in gravitational wave detectors.

We describe the design principles, fabrication, and characterization of a precision AC resonant capacitance bridge (RCB) sensor, based on a resonant differential planar printed circuit board transformer with a solid (ungapped) MnZn ferrite core, demonstrating a short-term sensitivity at 293 K of 0.225 ± 0.005 aF/√Hz at around 120 kHz resonance frequency and 1 Hz Fourier measurement frequency. At 120 K, the RCB short term noise sensitivity is 0.118 ± 0.005 aF/√Hz. We compare the ungapped configuration to five different RCBs: three with a core gap of 65 µm and two with a core gap of 130 µm. Their average room temperature short term noise sensitivities are 0.30 ± 0.01 and 0.45 ± 0.01 aF/√Hz, while the cryogenic operation of these transformers at 120 K resulted in averaged sensitivities of 0.23 ± 0.01 and 0.36 ± 0.01 aF/√Hz, respectively. Multi-hour room temperature runs, with one core of each of the three gap types, proved the stability of their long-term sensitivities of 0.234 ± 0.005, 0.338 ± 0.009, and 0.435 ± 0.010 aF/√Hz for the ungapped (40-h duration) and the 65 and 130 µm (28-h duration) cores, respectively. At 0.1 mHz, a critical frequency for space gravitational wave detectors, the respective sensitivities are 0.25 ± 0.02, 0.35 ± 0.02, and 0.53 ± 0.07 aF/√Hz. Measurements with the ungapped transformer configuration for temperatures from 325 to 349 K further validate the dependence of the noise model on temperature and permeability. The performance of our RCB with an ungapped core matches the calculated performance value and shows an improvement in signal-to-noise ratio of two or more compared with capacitance bridges developed for similar applications. A further factor of about two noise reductions is achieved by cooling to 120 K.

Internal medicine residents' and program directors' perception of virtual interviews during COVID-19: a national survey.

Purpose: Due to the coronavirus disease 2019 pandemic, all Canadian Resident Matching Service interviews for internal medicine subspecialty programs were conducted virtually for the first time. This study explored the perceptions and experiences of internal medicine residents, subspecialty medicine program directors, and interviewers during virtual interviews. Methods: We invited all Canadian third-year IM residents, subspecialty program directors, and interviewers who participated in the 2020 medical subspecialty medicine interviews to complete a branching survey with a section for residents and one for program directors and interviewers. We distributed the anonymous survey after the submission of the rank order lists, to not affect residency match outcomes. Qualitative data were open-coded thematically and quantitative data were cleaned and then statistically analyzed using descriptive statistics and Analysis of Variance tests. Results: 62 residents, 59 program directors, and 113 interviewers responded to the survey with representation from almost all Canadian medical faculties and medical subspecialties. Strengths of virtual interviews included reduced cost, stress, pandemic infection risk, and carbon footprint. Weaknesses of virtual interviews included decreased ability to connect personally and informally, and inability to tour medical facilities and cities. A majority of both resident respondents (59.6%) and program directors/interviewer respondents (54.6%) supported conducting interviews virtually in the future. Conclusions: This study showed that the majority of both sampled residents and program directors/interviewers would prefer to conduct medicine subspecialty match interviews virtually in the future, and provides suggestions on how to improve the virtual interviews for the next iteration.

Objectif: En raison de la pandémie du coronavirus 2019, toutes les entrevues du Service canadien de jumelage des résidents pour les programmes de sur-spécialités en médecine interne ont été menées virtuellement pour une première fois. Cette étude a exploré les perceptions et les expériences des résidents en médecine interne, des directeurs de programmes de médecine de sur-spécialités et des intervieweurs à l'égard des entrevues virtuelles. Méthodes: Nous avons invité tous les résidents canadiens de troisième année en médecine interne, les directeurs de programmes de sur-spécialités et les intervieweurs qui ont participé aux entrevues de médecine de sur-spécialités de 2020 à répondre à un sondage à branchement conditionnel comportant une section pour les résidents et une autre section pour les directeurs de programmes et les intervieweurs. Nous avons distribué le sondage anonyme après la soumission des listes de classement, afin de ne pas affecter les résultats du jumelage des résidents. Les données qualitatives ont fait l'objet d'un codage thématique et les données quantitatives ont été épurées, puis analysées statistiquement à l'aide de statistiques descriptives et de tests d'analyse de la variance. Résultats: Au total, 62 résidents, 59 directeurs de programmes et 113 intervieweurs, ont complété le sondage avec une représentation de presque toutes les facultés de médecine et de toutes les sur-spécialités médicales au Canada. Les avantages des entrevues virtuelles comportaient la réduction des coûts, du stress, du risque d'infection pandémique et de l'empreinte carbone. Les inconvénients des entrevues virtuelles incluaient la possibilité restreinte d'établir des contacts personnels et informels ainsi que l'impossibilité de visiter les installations médicales et les villes. La majorité des résidents (59,6 %) et des directeurs de programme/intervieweurs (54,6 %) supportent l'utilisation d'entretiens virtuels dans le futur. Conclusions: Cette étude a montré que la majorité des résidents et des directeurs de programme/intervieweurs de l'échantillon préféreraient désormais mener les entretiens pour le jumelage de sur-spécialités virtuellement. Elle propose également des suggestions sur la façon d'améliorer les entretiens virtuels pour la prochaine itération.

Update to the Hong Kong Epilepsy Guideline: evidence-based recommendations for clinical management of women with epilepsy throughout the reproductive cycle.

Since the publication of the Hong Kong Epilepsy Guideline in 2009, there has been significant progress in antiepileptic drug development. New AEDs have emerged, and data about their uses have been published. Women require special attention in epilepsy care. Drug teratogenicity, pregnancy, breastfeeding, contraception, reproduction technology, menopause, and catamenial epilepsy are major topics. Antiepileptic drugs should be chosen individually for patients who are pregnant or may become pregnant with consideration of their teratogenicity and seizure control properties. Folate is commonly prescribed for women of childbearing age who are taking antiepileptic drugs. Spontaneous vaginal delivery and breastfeeding are not contra-indicated in most cases but need to be considered individually based on the patient's medical condition and wishes. Serum drug level monitoring of certain antiepileptic drugs during pregnancy and puerperium can guide dosage adjustment. For catamenial epilepsy, intermittent benzodiazepines such as clobazam during the susceptible phase of the menstrual cycle could be a treatment option.

Decision rule to predict pneumonia in children presented with acute febrile respiratory illness.

BACKGROUND: It is a frequent challenge for physicians to identify pneumonia in patients with acute febrile respiratory symptoms, particularly in stable pediatric patients without respiratory distress. A decision rule is required to assist judgement on the need of ordering a chest radiograph. METHOD: This was a multicenter prospective study in 3 emergency departments. Children younger than 6 years old with an acute onset of fever and respiratory symptoms were recruited. Split sample method was adopted for derivation and validation of the Pediatric Acute Febrile Respiratory Illness rule (PAFRI Rule). PAFRI was derived from logistic regression with weighting based on adjusted odds ratios. RESULTS: Out of 967 children evaluated, 530 had taken chest radiograph examination, with 91 demonstrated evidence of pneumonia on radiograph. PAFRI Rule was derived from logistic regression with 5 weighed predictors: duration of fever <3 days (0 points), 3-4 days (2 points), 5-6 days (4 points), ≥7 days (5 points), chills (2 points), nasal symptoms (-2 points), abnormal chest examination (3 points), SpO2 ≤96% or tachypnea (3 points). The Area under ROC curve of the PAFRI Rule, the Bilkis Decision Rule and Bilkis Simpler Rule were 0.733, 0.600 and 0.579 respectively. A PAFRI score of ≥0 gives a sensitivity of 91.7% and negative predictive value of 97.7%. CONCLUSION: PAFRI rule can be used as a reference tool for guiding the need for taking Chest radiograph examination for pediatric patients. While promising, the PAFRI rule requires further validation. WHAT'S KNOWN ON THIS SUBJECT: It is often a challenge for physicians to identify pneumonia in children acutely febrile with respiratory symptoms, particularly in those who are stable without respiratory distress. The decision to order chest radiograph was based on clinical assessment with heterogenous practice. A valid and verified clinical prediction rule for ordering chest radiograph examination for stable febrile children without signs of respiratory distress would therefore assist in management of this group of patients. WHAT THIS STUDY ADDS: The PAFRI rule, based on parameters from clinical bedside assessment, can be used as a reference tool for guiding the need for referral to emergency department or taking use of chest radiograph for pediatric patients, and triaging for higher priority of clinical care.

Questionnaire survey on medical futility and termination of resuscitation in cardiac arrest patients among emergency physicians in Hong Kong.

INTRODUCTION: The perceptions of medical futility and decisions about termination of resuscitation (TOR) for out-of-hospital cardiac arrest (OHCA) are highly heterogeneous and dependent on the practice of the attending emergency physicians. The objective of this study was to report and investigate the knowledge, attitudes, and practices regarding medical futility and TOR during management of OHCA in Hong Kong. METHODS: A cross-sectional survey was conducted among emergency medicine physicians in Hong Kong. The questionnaire assessed participants' background, knowledge, attitudes, and behaviours concerning medical futility and TOR in management of OHCA. Composite scores were calculated to reflect knowledge, attitudes, and practices of OHCA treatment. Subgroup analysis and multiple regression analysis were used to explore the relationship between participants' background, knowledge, attitudes, and behaviours. RESULTS: The response rate to this survey was 57% (140/247). Independent predictors of less aggressive resuscitation in OHCA patients included status as a Fellow of the Hong Kong College of Emergency Medicine (ß= -0.314, P=0.028) and being an Advanced Cardiac Life Support instructor (ß= -0.217, P=0.032). There was no difference in aggressiveness of resuscitation in terms of years of clinical experience (ß=0.015, P=0.921), knowledge of TOR (ß=0.057, P=0.509), or attitudes about TOR (ß= -0.103, P=0.214). The correlation between knowledge and attitudes was low (Spearman's coefficient=0.02, P=0.795). CONCLUSION: Clinical practice and behaviour of TOR was not demonstrated to have associations with knowledge or attitude. Status as a Fellow of the Hong Kong College of Emergency Medicine or Advanced Cardiac Life Support instructor were the only two parameters identified that had significant relationships with earlier TOR in medically futile patients with OHCA.

Hong Kong needs a territory-wide registry for out-of-hospital cardiac arrest.

Out-of-hospital cardiac arrest (OHCA) is an urgent disease entity, and the outcomes of OHCA are poor. This causes a significant public health burden, with loss of life and productivity throughout society. Internationally, successful programmes have adopted various survival enhancement measures to improve outcomes of OHCA. A territory-wide organised survival enhancement campaign is required in Hong Kong to maintain OHCA survival rates that are comparable to those of other large cities. One key component is to establish an OHCA registry, such as those in Asia, the United States, Europe, Australia, and New Zealand. An OHCA registry can provide benchmarking, auditing, and surveillance for identification of weak points within the chain of survival and evaluation of the effectiveness of survival enhancement measures. In Hong Kong, digitisation of records in prehospital and in-hospital care provides the infrastructure for an OHCA registry. Resources and governance to maintain a sustainable OHCA registry are necessary in Hong Kong as the first step to improve survival and outcomes of OHCA.

Title.

Epilepsy is defined as drug-resistant after failure of two adequate trials of appropriately chosen and administered antiepileptic drugs. Approximately 30% of patients with epilepsy have drug-resistant epilepsy. Reasons for treatment failure include failure to recognise epilepsy syndrome, poor drug compliance, and lifestyle factors. Patients with drug-resistant epilepsy should be encouraged to have early referral to a tertiary epilepsy centre for presurgical evaluation. Comprehensive neurophysiology, structural neuroimaging, neuropsychological, and psychiatric assessments are regarded as essential for determining suitability for epilepsy surgery. Epilepsy surgery, whether resection, disconnection, or neuromodulation, should be recommended only after multidisciplinary consensus agreement based on these assessments.

Validation and modification of the Ottawa subarachnoid haemorrhage rule in risk stratification of Asian Chinese patients with acute headache.

OBJECTIVE: To validate the Ottawa subarachnoid haemorrhage (SAH) rule in an Asian Chinese cohort and to explore the roles of blood pressure and vomiting in prediction of SAH in patients with nontraumatic acute headache. METHODS: A retrospective cohort study was conducted in two regional hospitals. All patients aged ≥16 years who presented with non-traumatic acute headache to the study centres from July 2013 to June 2016 were included. A logistic regression model was created for the variables of the Ottawa SAH rule and other potential predictors, including vomiting and systolic blood pressure (SBP) >160 mm Hg. Model discrimination was evaluated using the area under the receiver operating characteristic curve. Net reclassification improvement and integrated discrimination improvement indices were evaluated. The model's diagnostic characteristics, including sensitivities and specificities, were evaluated. RESULTS: A total of 500 eligible headache cases were included, in 50 of which SAH was confirmed (10%). In addition to the predictors of the Ottawa SAH rule, vomiting and SBP >160 mm Hg were found to be significant independent predictors of SAH. Net reclassification improvement and integrated discrimination improvement indices indicated that including vomiting and SBP >160 mm Hg would improve the model prediction. The Ottawa SAH rule had 94% sensitivity and 32.9% specificity. The modified Ottawa SAH rule that included both vomiting and SBP >160 mm Hg as criteria improved sensitivity to 100%, specificity to 13.1%, positive predictive value to 11.3%, and negative predictive value to 100%. CONCLUSIONS: The Ottawa SAH rule demonstrated high sensitivity. Addition of vomiting and SBP >160 mm Hg to the Ottawa SAH rule may increase its sensitivity.

Understanding breast cancer screening--past, present, and future.

This article provides an up-to-date overview of breast cancer mammography screening and briefly discusses its history, controversies, current guidelines, practices across Asia, and future directions. An emphasis is made on shared decision-making--instead of giving just a 'yes' or 'no' answer to patients, the focus should be on providing sufficient information about the pros and cons of screening to help women make a personal, informed choice. Frontline experts, including breast surgeons, oncologists, breast radiologists, and their representative professional associations should all participate in guideline panels, with the goal of improving cancer detection, reducing mortality, and improving patient outcome.

Public access defibrillation in Hong Kong in 2017.

The concept of public access defibrillation was proposed more than 20 years ago. Since then, various programmes have been implemented in many major cities although not all have been successful. Fourteen years ago, the question of whether Hong Kong needed public access defibrillation was raised. This article aimed to answer this question based on the best available evidence. Over the years, the clinical effectiveness of public access defibrillation in out-of-hospital cardiac arrest has been proven. Nonetheless various studies have indicated that among others, cost-effectiveness, knowledge and attitudes of the public, and incidence of ventricular fibrillation are important factors that will affect the likelihood of success of such programmes. In Hong Kong, because of the long interval between recognition of arrest and first defibrillation, public access defibrillation is probably needed. To ensure the success of such a programme, careful planning in addition to the installation of more automated external defibrillators are essential.

Gamma radiation treatment applied to microbial decontamination of products derived from eggs collected from the retail market in São Paulo / Tratamento por radiação gama aplicado na descontaminação microbiana de produtos derivados de ovos coletados no mercado varejista da cidade de São Paulo

The quality of products derived from eggs depends on the quality of the raw material source and the industrial production. The contamination by fungi and bacteria can occur after exposure of the product in the retail market. The objective of this study was to evaluate the microbiological quality of 60 samples of derivated egg products and evaluate the effects of gamma radiation of cobalt-60, using the dose of 5 and 10 kGy, for decontamination of products collected in the retail market in the São Paulo city. The bacterial count was performed by the most probable number (MPN) and the fungal counts by serial dilution after plating surface. It was observed a decrease in the humidity and water activity (Aw) values of irradiated whole egg powder and white egg powder samples (p<0.05), but there was no significant change in the pH of the same samples irradiated with 5 and 10 kGy (p>0.05). In the powdered yolk the values of pH and Aw presented a significant difference (p<0.05), but no significant difference in the humidity values of 5 and 10 kGy irradiated samples (p>0.05). Effective microbial sterilization of all products occurred at the dose of 10 kGy.(AU)

A qualidade dos produtos derivados de ovos depende da qualidade da matéria-prima e da produção industrial. A contaminação por fungos e bactérias pode ocorrer após a exposição do produto no mercado varejista. O objetivo deste estudo foi avaliar a qualidade microbiológica de 60 amostras de derivados de ovos e avaliar os efeitos da radiação gama de cobalto-60, utilizando-se as doses de 5 e 10 kGy, para descontaminação dos produtos coletados no mercado varejista da cidade de São Paulo. A contagem bacteriana foi realizada pelo número mais provável (MPN), e as contagens fúngicas por diluição seriada em plaqueamento de superfície. Foi observada uma diminuição dos valores da umidade e da atividade de água (Aa) das amostras irradiadas de ovo integral em pó e clara em pó (p<0,05), mas sem alteração significativa do pH nas mesmas amostras irradiadas com 5 e 10 kGy (p>0,05). Em gema em pó, observou-se diferença significativa (p<0,05) nos valores de pH e Aa, mas não houve mudança expressiva nos valores de umidade nas amostras irradiadas com 5 e 10 kGy (p>0,05). A esterilização microbiana eficaz de todos os produtos ocorreu com a dose de 10 kGy.(AU)

Observation of Exciton Redshift-Blueshift Crossover in Monolayer WS2.

We report a rare atom-like interaction between excitons in monolayer WS2, measured using ultrafast absorption spectroscopy. At increasing excitation density, the exciton resonance energy exhibits a pronounced redshift followed by an anomalous blueshift. Using both material-realistic computation and phenomenological modeling, we attribute this observation to plasma effects and an attraction-repulsion crossover of the exciton-exciton interaction that mimics the Lennard-Jones potential between atoms. Our experiment demonstrates a strong analogy between excitons and atoms with respect to interparticle interaction, which holds promise to pursue the predicted liquid and crystalline phases of excitons in two-dimensional materials.

An update of the Hong Kong Epilepsy Guideline: consensus statement on the use of antiepileptic drugs in Hong Kong.

OBJECTIVE: New information about antiepileptic drugs has arisen since the publication of the Hong Kong Epilepsy Guideline in 2009. This article set out to fill the knowledge gap between 2007 and 2016 on the use of antiepileptic drugs in Hong Kong. PARTICIPANTS: Between May 2014 and April 2016, four consensus meetings were held in Hong Kong, where a group comprising 15 professionals (neurologists, paediatricians, neurosurgeons, radiologists, and clinical psychologists) from both public and private sectors aimed to review the best available evidence and update all practising physicians on a range of clinical issues including drug-related matters. All participants were council members of The Hong Kong Epilepsy Society. EVIDENCE: A literature review of the clinical use of antiepileptic drugs as monotherapy suggested Level A evidence for levetiracetam and Level B evidence for lacosamide. No change in the level of evidence was found for oxcarbazepine (Level A evidence) or pregabalin (undesignated), and no evidence was found for perampanel. A literature review on the clinical use of antiepileptic drugs as adjunctive therapy suggested Level A evidence for both lacosamide and perampanel. No change to the level of evidence was found for levetiracetam (Level A evidence), oxcarbazepine (Level A evidence), or pregabalin (Level A evidence). A literature search on the use of generic antiepileptic drugs suggested Level A evidence for the use of lamotrigine in generic substitution. CONSENSUS PROCESS: Three lead authors of the Subcommittee drafted the manuscript that consisted of two parts-part A: evidence on new antiepileptic drugs, and part B: generic drugs. The recommendations on monotherapy/adjunctive therapy were presented during the meetings. The pros and cons for our health care system of generic substitution were discussed. The recommendations represent the 'general consensus' of the participants in keeping with the evidence found in the literature. CONCLUSIONS: Recommendations for the use of levetiracetam, lacosamide, oxcarbazepine, pregabalin, and perampanel were made. The consensus statements may provide a reference to physicians in their daily practice. Controversy exists over the use of generic products among patients who are currently taking brand medications. In this regard, approvals from prescriber and patient are pivotal. Good communication between doctors and patients is essential, as well as enlisting the assistance of doctors, nurses, and pharmacists, therapeutic blood monitoring if available, and the option of brand antiepileptic drug as a self-financed item. The physical appearance of generic drugs should be considered as it may hamper drug compliance. Support from medical services is recommended. In the longer term, the benefit of flexibility and the options to have a balance between the generic and brand drug market may need to be addressed by institutions and regulatory bodies.

Prevalence of Glucosamine and Omega-3 Fatty Acid Use and Characteristics of Users among Mid-Age Women: Analysis of a Nationally Representative Sample of 10,638 Women.

BACKGROUND: There has been a dramatic increase in the use of dietary supplements over the last few decades and both omega-3 fatty acids and glucosamine are two of the best-selling dietary supplements in many countries. An understanding of omega-3 fatty acids and glucosamine consumption is of significance to health care providers and for future health promotion activities. METHODS: This research involved analysis of data collected from a nationally-representative sample of Australian women as part of the Australian Longitudinal Study on Women's Health (ALSWH). Participants' use of omega-3 fatty acids (FA), glucosamine, their demographics, health status and health care utilisation were measured. Analysis included logistic regression modelling. RESULTS: Of the 10,638 women in the study, 26.8% reported use of omega-3 FA and 15.9% glucosamine. Women with osteoarthritis (OR=2.529; 95% CI: 2.190, 2.921), other arthritis (OR= 1.618; 95% CI: 1.375, 1.905), and joint pain (OR= 2.699; 95% CI: 2.305, 3.160) were more likely to use glucosamine (all p<0.001). In contrast, those with diabetes (OR= 0.471; 95% CI: 0.343, 0.646) or depression (OR= 0.764; 95% CI: 0.657, 0.887) were less likely to use glucosamine (both p<0.001). Women with osteoarthritis (OR=1.481; 95% CI: 1.297, 1.691) and joint pain (OR= 1.456; 95% CI: 1.306, 1.622) were more likely to use omega-3 FA (all p<0.001). CONCLUSIONS: Substantial prevalence rates for use of glucosamine and omega-3 FA amongst mid-aged women highlights the need for health practitioners and policymakers to be mindful of the possible significant role of such supplement use as part of patient health-seeking behaviours.