Comparing the acute toxicities of co-exposure to cocaine and ethanol versus cocaine alone.

INTRODUCTION: Cocaine is commonly consumed with ethanol, which leads to the formation of cocaethylene through transesterification. Cocaethylene is an active metabolite of cocaine with a longer duration of action. Literature on the combined toxicity of cocaine, ethanol, and cocaethylene is conflicting. We aimed to compare the acute toxicities of co-exposure to cocaine and ethanol versus cocaine alone in Hong Kong. METHODS: This was a retrospective study on acute cocaine toxicities reported to the Hong Kong Poison Control Center from 1 January 2010 to 22 January 2023. Cocaine exposure was confirmed by urine immunoassays/laboratory tests and ethanol co-ingestion was confirmed by blood ethanol concentrations. A serious outcome was defined as a National Poison Data System outcome moderate or above. Univariate analyses and multivariable logistic regression were performed to compare the associations of clinical outcomes with and without ethanol, followed by subgroup analyses of cases with complete data. RESULTS: We analyzed 109 patients (median age 29 years, 71% men, 68% Chinese), of whom 20 had confirmed ethanol co-ingestion (mean blood ethanol concentration 1350 mg/L). Multivariable analysis showed that co-exposure to cocaine and ethanol was associated with a lower risk of serious outcomes (adjusted odds ratio 0.09, 95% confidence interval 0.01-0.77; p = 0.03) after adjusting for age, sex, ethnicity, route of cocaine administration, and physical health status. Subgroup analyses showed similar findings. CONCLUSIONS: In contrast to previous studies, we did not identify a higher risk of serious outcomes after co-exposure to cocaine and ethanol compared to cocaine alone in a predominantly Chinese cohort.

Comparing 11 early warning scores and three shock indices in early sepsis prediction in the emergency department.

BACKGROUND: This study aimed to evaluate the discriminatory performance of 11 vital sign-based early warning scores (EWSs) and three shock indices in early sepsis prediction in the emergency department (ED). METHODS: We performed a retrospective study on consecutive adult patients with an infection over 3 months in a public ED in Hong Kong. The primary outcome was sepsis (Sepsis-3 definition) within 48 h of ED presentation. Using c-statistics and the DeLong test, we compared 11 EWSs, including the National Early Warning Score 2 (NEWS2), Modified Early Warning Score, and Worthing Physiological Scoring System (WPS), etc., and three shock indices (the shock index [SI], modified shock index [MSI], and diastolic shock index [DSI]), with Systemic Inflammatory Response Syndrome (SIRS) and quick Sequential Organ Failure Assessment (qSOFA) in predicting the primary outcome, intensive care unit admission, and mortality at different time points. RESULTS: We analyzed 601 patients, of whom 166 (27.6%) developed sepsis. NEWS2 had the highest point estimate (area under the receiver operating characteristic curve [AUROC] 0.75, 95%CI 0.70-0.79) and was significantly better than SIRS, qSOFA, other EWSs and shock indices, except WPS, at predicting the primary outcome. However, the pooled sensitivity and specificity of NEWS2 ≥ 5 for the prediction of sepsis were 0.45 (95%CI 0.37-0.52) and 0.88 (95%CI 0.85-0.91), respectively. The discriminatory performance of all EWSs and shock indices declined when used to predict mortality at a more remote time point. CONCLUSION: NEWS2 compared favorably with other EWSs and shock indices in early sepsis prediction but its low sensitivity at the usual cut-off point requires further modification for sepsis screening.

Early sepsis care with the National Early Warning Score 2-guided Sepsis Hour-1 Bundle in the emergency department: hybrid type 1 effectiveness-implementation pilot stepped wedge randomised controlled trial (NEWS-1 TRIPS) protocol.

INTRODUCTION: Early sepsis treatment in the emergency department (ED) is crucial to improve patient survival. Despite international promulgation, the uptake of the Surviving Sepsis Campaign (SSC) Hour-1 Bundle (lactate measurement, blood culture, broad-spectrum antibiotics, 30 mL/kg crystalloid for hypotension/lactate ≥4 mmol/L and vasopressors for hypotension during/after fluid resuscitation within 1 hour of sepsis recognition) is low across healthcare settings. Delays in sepsis recognition and a lack of high-quality evidence hinder its implementation. We propose a novel sepsis care model (National Early Warning Score, NEWS-1 care), in which the SSC Hour-1 Bundle is triggered objectively by a high NEWS-2 (≥5). This study aims to determine the feasibility of a full-scale type 1 hybrid effectiveness-implementation trial on the NEWS-1 care in multiple EDs. METHODS AND ANALYSIS: We will conduct a pilot type 1 hybrid trial and prospectively recruit 200 patients from 4 public EDs in Hong Kong cluster randomised in a stepped wedge design over 10 months. All study sites will start with an initial period of standard care and switch in random order at 2-month intervals to the NEWS-1 care unidirectionally. The implementation evaluation will employ mixed methods guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, which includes qualitative and quantitative data from focus group interviews, staff survey and clinical record reviews. We will analyse the 14 feasibility outcomes as progression criteria to a full-scale trial, including trial acceptability to patients and staff, patient and staff recruitment rates, accuracy of sepsis screening, protocol adherence, accessibility to follow-up data, safety and preliminary clinical impacts of the NEWS1 care, using descriptive statistics. ETHICS AND DISSEMINATION: The institutional review boards of all study sites approved this study. This study will establish the feasibility of a full-scale hybrid trial. We will disseminate the findings through peer-reviewed publications, conference presentations and educational activities. TRIAL REGISTRATION NUMBER: NCT05731349.

Applying artificial neural network in predicting sepsis mortality in the emergency department based on clinical features and complete blood count parameters.

A complete blood count (CBC) is routinely ordered for emergency department (ED) patients with infections. Certain parameters, such as the neutrophil-to-lymphocyte ratio (NLR), might have prognostic value. We aimed to evaluate the prognostic value of the presenting CBC parameters combined with clinical variables in predicting 30-day mortality in adult ED patients with infections using an artificial neural network (ANN). We conducted a retrospective study of ED patients with infections between 17 December 2021 and 16 February 2022. Clinical variables and CBC parameters were collected from patient records, with NLR, monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) calculated. We determined the discriminatory performance using the area under the receiver operating characteristic curve (AUROC) and performed a 70/30 random data split and supervised ANN machine learning. We analyzed 558 patients, of whom 144 (25.8%) had sepsis and 60 (10.8%) died at 30 days. The AUROCs of NLR, MLR, PLR, and their sum were 0.644 (95% CI 0.573-0.716), 0.555 (95% CI 0.482-0.628), 0.606 (95% CI 0.529-0.682), and 0.610 (95% CI 0.534-0.686), respectively. The ANN model based on twelve variables including clinical variables, hemoglobin, red cell distribution width, NLR, and PLR achieved an AUROC of 0.811 in the testing dataset.

Impact of community mental health services on the adult psychiatric admission through the emergency unit: a 20-year population-based study.

Background: There is a lack of real-life population-based study examining the effect of community mental health services on psychiatric emergency admission. In Hong Kong, Integrated Community Center for Mental Wellness (ICCMW) and telecare service were introduced in 2009 and 2012, respectively. We examined the real-life impact of these services on psychiatric emergency admissions over 20 years. Methods: Number of psychiatric emergency admissions between 2001 and 2020 was retrieved from the Hong Kong Clinical Data Analysis & Reporting System. We used an interrupted time series analysis to examine monthly psychiatric admission trend before and after service implementation, considering socioeconomic and environmental covariates. Findings: A total of 108,492 psychiatric emergency admissions (47.8% males; 64.9% aged 18-44 years) were identified from the study period, of which 56,858, 12,506, 12,295, 11,791, and 15,051 were that for schizophrenia-spectrum disorders, bipolar affective disorders, unipolar mood disorders, neuroses, and substance use disorders. ICCMW introduction has an immediate effect on psychiatric emergency admission (adjusted estimate per 100,000: -10.576; 95% CI, -16.635 to -4.518, p < 0.001), particularly among adults aged 18-44 years (-8.543; 95% CI, -13.209 to -3.877, p < 0.001), females (-5.843; 95% CI, -9.647 to -2.039, p = 0.003), and with neuroses (-3.373; 95% CI, -5.187 to -1.560, p < 0.001), without a significant long-term effect. Unemployment, seasonality, and infectious disease outbreak were significant covariates. Interpretation: ICCMW reduced psychiatric emergency admission, but no further reduction following full implementation. Community mental health services should be dynamically tailored for different populations and socioeconomic variations over time. Funding: None.

Derivation and internal validation of a clinical prediction score to predict major effect or death in acute metamfetamine toxicity.

OBJECTIVE: Metamfetamine use can cause serious complications or death. We aimed to derive and internally validate a clinical prediction score to predict major effect or death in acute metamfetamine toxicity. METHODS: We performed secondary analysis of 1,225 consecutive cases reported from all local public emergency departments to the Hong Kong Poison Information Centre between 1 January 2010 and 31 December 2019. We split the entire dataset chronologically into derivation (first 70% of cases) and validation (the remaining 30% of cases) cohorts. Univariate analysis was conducted, followed by multivariable logistic regression in the derivation cohort to identify independent predictors of major effect or death. We developed a clinical prediction score based on the regression coefficients of the independent predictors in the regression model and compared its discriminatory performance with five existing early warning scores in the validation cohort. RESULTS: The MASCOT (Male, Age, Shock, Consciousness, Oxygen, Tachycardia) score was derived based on the six independent predictors: male gender (1 point), age (≥35 years, 1 point), shock (mean arterial pressure <65 mmHg, 3 points), consciousness (Glasgow Coma Scale <13, 2 points), need for supplemental oxygen (1 point), and tachycardia (pulse rate >120 beats/min, 1 point). The score ranges from 0-9, with a higher score indicating higher risk. The area under the receiver operating characteristic curve of the MASCOT score was 0.87 (95% CI 0.81-0.93) in the derivation cohort and 0.91 (95% CI 0.81-1.00) in the validation cohort, with a discriminatory performance comparable with existing scores. CONCLUSIONS: The MASCOT score enables quick risk stratification in acute metamfetamine toxicity. Further external validation is warranted before wider adoption.

Factors associated with seizure in tramadol overdose: a 12-year retrospective study in Hong Kong.

BACKGROUND: Early identification of patients at risk of seizure after acute tramadol overdose is crucial. Yet, current evidence has been inconclusive regarding the factors associated with the seizure. There is a lack of study on the Chinese population and the value of electrocardiogram (ECG) in risk prognostication has not been fully evaluated. OBJECTIVES: We aimed 1) to characterise the clinical presentations of isolated tramadol overdose in Hong Kong; 2) to study the frequency of seizure in such overdose and the factors associated with it using multivariable analysis; and 3) to explore the association between individual ECG parameters and seizure. METHODS: This was a retrospective observational study on consecutive patients reported to the Hong Kong Poison Information Centre for tramadol overdose from 1 January 2008 to 30 November 2020. Duplicate cases or patients with an overdose of other co-ingestants were excluded. Univariate and multivariable logistic regression was performed to identify factors significantly associated with seizures in general and seizures that occurred after emergency department (ED) arrival. RESULTS: We identified 93 patients, including 54 women and 39 men, with a median age of 38 years during the study period. The majority was Chinese (90%) and only five patients had a history of seizure. The seizure occurred in 23 patients. Multivariable analysis showed that sinus tachycardia > 100 beats/min was significantly associated with a higher seizure risk (OR 27.95, 95% CI 2.22-351.84, p = 0.010) and age per 10 years increase was associated with a lower risk (OR 0.61; 95% CI 0.39-0.96, p = 0.033). No reliable predictors of seizure after ED arrival were identified. Many patients had ECG features consistent with sodium channel blockade but none of them was predictive of seizure. CONCLUSIONS: A younger age and sinus tachycardia > 100 beats/min were associated with a higher seizure risk after tramadol overdose but no reliable predictors of seizure after ED arrival were identified. Individual ECG parameters were not predictive of seizure.

The limited value of triage vital signs in predicting influenza infection in children aged 5 years and under in the emergency department: A single-center retrospective cross-sectional study.

ABSTRACT: Diagnosing influenza in children aged 5 years and under can be challenging because of their difficulty in verbalizing symptoms. This study aimed to explore the value of the triage heart rate (HR), respiratory rate (RR), and temperature, either alone or when combined with individual symptoms and signs, in predicting influenza infection in this age group.This was a retrospective study covering 4 influenza seasons from 2017 to 2019 in an emergency department (ED) in Hong Kong. We recruited patients ≤5 years of age who had an reverse transcription polymerase chain reaction influenza test within 48 hours of ED presentation. The diagnostic performance of the triage HR, RR, and temperature was evaluated as dichotomized or categorized values with diagnostic odds ratios (DORs) calculated based on different age-appropriate thresholds. Linear discriminant analysis was performed to assess the combined discriminatory effect of age, HR, RR, and temperature as continuous variables.Of 322 patients (median age 26 months), 99 had influenza A and 13 had influenza B infection. For HR and RR dichotomized based on age-appropriate thresholds, the DORs ranged from 1.16 to 1.54 and 0.78 to 1.53, respectively. A triage temperature ≥39.0 °C had the highest DOR (3.32) among different degrees of elevation of temperature. The diagnostic criteria that were based on the presence of fever and cough and/or rhinitis symptoms had a higher DOR compared with the Centers for Disease Control and Prevention influenza-like illness criteria (4.42 vs 2.41). However, combining HR, RR, or temperature with such diagnostic criteria added very little to the diagnostic performance. The linear discriminant analysis model had a high specificity of 92.5%, but the sensitivity (18.3%) was too low for clinical use.Triage HR, RR, and temperature had limited value in the diagnosis of influenza in children ≤5 years of age in the ED. Fever and cough and/or rhinitis symptoms had a better diagnostic performance than the Centers for Disease Control and Prevention influenza-like illness criteria in predicting influenza in this age group.

Comparison of the Efficiency and Usability of Aerosol Box and Intubation Tent on Intubation of a Manikin Using Personal Protective Equipment: A Randomized Crossover Study.

BACKGROUND: The aerosol box and intubation tent are improvised barrier-enclosure devices developed during the novel coronavirus pandemic to protect health care workers from aerosol transmission. OBJECTIVE: Using time to intubation as a crude proxy, we aimed to compare the efficiency and usability of the aerosol box and intubation tent in a simulated manikin. METHODS: This was a single-center, randomized, crossover manikin study involving 28 participants (9 anesthetists, 16 emergency physicians, and 3 intensivists). Each participant performed rapid sequence intubations in a random sequence of three different scenarios: 1) no device use; 2) aerosol box; 3) intubation tent. We compared the time to intubation between different scenarios. RESULTS: The median total intubation time with no device use, aerosol box, and intubation tent were 23.7 s (interquartile range [IQR] 19.4-28.4 s), 30.9 s (IQR 24.1-52.5 s), and 26.0 s (IQR 22.1-30.8 s), respectively. Post hoc analysis showed a significantly longer intubation time using the aerosol box compared with no device use (p < 0.001) and compared with the intubation tent (p < 0.001). The difference between the intubation tent and no device use was not significant. The first-pass intubation success rate did not differ between the groups. Only aerosol box use had resulted in breaches of personal protective equipment. Participants considered intubation with the intubation tent more favorable than the aerosol box. CONCLUSIONS: The intubation tent seems to have a better barrier-enclosure design than the aerosol box, with a reasonable balance between efficiency and usability. Further evaluation of its efficacy in preventing aerosol dispersal and in human studies are warranted prior to recommendation of widespread adoption.

Antibiotics create a shift from mutualism to competition in human gut communities with a longer-lasting impact on fungi than bacteria.

BACKGROUND: Antibiotic treatment has a well-established detrimental effect on the gut bacterial composition, but effects on the fungal community are less clear. Bacteria in the lumen of the gastrointestinal tract may limit fungal colonization and invasion. Antibiotic drugs targeting bacteria are therefore seen as an important risk factor for fungal infections and induced allergies. However, antibiotic effects on gut bacterial-fungal interactions, including disruption and resilience of fungal community compositions, were not investigated in humans. We analysed stool samples collected from 14 healthy human participants over 3 months following a 6-day antibiotic administration. We integrated data from shotgun metagenomics, metatranscriptomics, metabolomics, and fungal ITS2 sequencing. RESULTS: While the bacterial community recovered mostly over 3 months post treatment, the fungal community was shifted from mutualism at baseline to competition. Half of the bacterial-fungal interactions present before drug intervention had disappeared 3 months later. During treatment, fungal abundances were associated with the expression of bacterial genes with functions for cell growth and repair. By extending the metagenomic species approach, we revealed bacterial strains inhibiting the opportunistic fungal pathogen Candida albicans. We demonstrated in vitro how C. albicans pathogenicity and host cell damage might be controlled naturally in the human gut by bacterial metabolites such as propionate or 5-dodecenoate. CONCLUSIONS: We demonstrated that antibacterial drugs have long-term influence on the human gut mycobiome. While bacterial communities recovered mostly 30-days post antibacterial treatment, the fungal community was shifted from mutualism towards competition. Video abstract.

Clinical, laboratory, and radiological features indicative of novel coronavirus disease (COVID-19) in emergency departments: a multicenter case-control study in Hong Kong.

Objectives: Little is known about the value of routine clinical assessment in identifying patients with coronavirus disease 2019 (COVID-19) in the emergency department (ED). We aimed to compare the exposure history, signs and symptoms, laboratory, and radiographic features of ED patients who tested positive and negative for COVID-19. Methods: This was a case-control study in 7 EDs in Hong Kong from 20 January to 29 February 2020. Thirty-seven patients with laboratory-confirmed COVID-19 were age- and sex-matched to 111 controls. We compared the groups with univariate analysis and calculated the odds ratio (OR) of having COVID-19 for each characteristic that was significantly different between the groups with adjustment for age and presumed location of acquiring the infection. Results: There were no significant differences in patient characteristics and reported symptoms between the groups. A positive contact history within 14 days (adjusted OR 37.61, 95% CI: 10.86-130.19), bilateral chest radiograph shadow (adjusted OR 13.19, 95% CI: 4.66-37.35), having prior medical consultation (adjusted OR 7.43, 95% 2.89-19.09), a lower white blood cell count (adjusted OR 1.30, 95% CI: 1.11-1.51), and a lower platelet count (adjusted OR 1.07, 95% CI: 1.01-1.12) were associated with a higher odds of COVID-19 separately. A higher neutrophil count was associated with a lower odds of COVID-19 (adjusted OR 0.77, 95% CI: 0.65-0.91). Conclusion: This study highlights a number of clinical features that may be useful in identifying high-risk patients for early testing and isolation while waiting for the test result. Further studies are warranted to verify the findings.

Performance of a three-level triage scale in live triage encounters in an emergency department in Hong Kong.

BACKGROUND: Despite its continued use in many low-volume emergency departments (EDs), 3-level triage systems have not been extensively studied, especially on live triage cases. We have modified from the Australasian Triage Scale and developed a 3-level triage scale, and sought to evaluate its validity, reliability, and over- and under-triage rates in real patient encounters in our setting. METHOD: This was a cross-sectional study in a single ED with 24,000 attendances per year. At triage, each patient was simultaneously assessed by a triage nurse, an adjudicator (the "criterion standard"), and a study nurse independently. Predictive validity was determined by comparing clinical outcomes, such as hospitalization, across triage levels. The discriminating performance of the triage tool in identifying patients requiring earlier medical attention was determined. Inter-observer reliability between the triage nurse and criterion standard, and across providers were determined using kappa statistics. RESULTS: In total, 453 triage ratings of 151 triage cases, involving 17 ED triage nurses and 57 nurse pairs, were analysed. The proportion of hospital admission significantly increased with a higher triage rating. The performance of the scale in identifying patients requiring earlier medical attention was as follows: sensitivity, 68.2% (95% CI 45.1-86.1%); specificity, 99.2% (95% CI 95.8-100%); positive predictive value, 93.8% (95% CI 67.6-99.1%); and negative predictive value, 94.8% (95% CI 90.8-97.1%). The over-triage and under-triage rates were 0.7% and 4.6%, respectively. Agreement between the triage nurse and criterion standard was substantial (quadratic-weighted kappa = 0.76, 95% CI, 0.60-0.92, p < 0.001), so was the agreement across nurses (quadratic-weighted kappa = 0.81, 95% CI 0.65-0.97, p < 0.001). CONCLUSIONS: The 3-level triage system appears to have good validity and reasonable reliability in a low-volume ED setting. Further studies comparing 3-level and prevailing 5-level triage scales in live triage encounters and different ED settings are warranted.

Retrospective evaluation of resuscitation medication utilization in hospitalized adult patients with cardiac arrest.

BACKGROUND: Early medication administration in cardiac arrest improves outcomes. The primary objective was to evaluate the association between epinephrine administration in in-hospital cardiac arrest (IHCA) patients with non-shockable rhythm and the patient outcomes. The secondary objective was to assess the compliance of epinephrine and amiodarone administration in accordance with the advanced cardiovascular life support (ACLS) guideline. METHODS: IHCA patients aged 18 years or above were identified from the resuscitation registry of 2016 of two public hospitals and categorized according to their initial rhythms. For patients with non-shockable rhythms, the associations between IHCA outcomes, return of spontaneous circulation (ROSC), and survival to discharge, and the time of epinephrine administration were analyzed by logistic regression. The compliance rate of epinephrine and amiodarone administration during resuscitation to ACLS guideline were reported. RESULTS: Among 349 patients with non-shockable rhythm, the median time to epinephrine administration was 3 min (interquartile range, 1-6 min). Early epinephrine administration (<5 min), compared with late epinephrine administration (>5 min), was significantly associated with the rate of ROSC (49.2% vs 34.9%; adjusted odds ratio, 1.630; 95% confidence interval 1.008-2.635, p = 0.046). The time to epinephrine administration (as continuous interval) was significantly associated with the rate of ROSC (p = 0.002) and survival to discharge (p = 0.029). In addition, the compliance rate of epinephrine and amiodarone administration during resuscitation were 83.6% and 33.3%, respectively. CONCLUSION: Our study found that time of epinephrine administration was significantly associated with better results in ROSC and survival to discharge in IHCA patients with non-shockable rhythm. When we divided the IHCA patients with non-shockable rhythms into early and late administration group, early epinephrine administration was associated with significantly improved ROSC, but not survival to discharge after adjusting with potential confounding factors.

Injury patterns of mass casualty incidents involving high-speed passenger ferries presenting to accident and emergency departments in Hong Kong: a retrospective review.

BACKGROUND: Accidents involving high-speed passenger ferries have the potential to cause mass-casualty incidents (MCIs), yet there is a lack of relevant studies available to inform hospital disaster preparedness planning. OBJECTIVE: The objective was to study the injury patterns and outcomes of MCI victims involved in high-speed passenger ferry accidents in Hong Kong waters. METHODS: A retrospective study was conducted from 1 January 2005 to 31 December 2015. All MCIs involving high-speed passenger ferries were captured from the Marine Department of Hong Kong. Victims of all age who were sent to the accident and emergency departments (A&Es) of seven public hospitals around Victoria Harbour, including three trauma centres, were identified from electronic disaster registries of the study hospitals. Data on injury patterns and outcomes were extracted from medical records with the Injury Severity Score (ISS) calculated for each victim. The Kruskal-Wallis test was used to compare medians of the ISS across different mechanisms of injury. Multivariable logistic regression was performed to identify independent predictors for major trauma (ISS≥16). RESULTS: During the study period, eight MCIs involving high-speed passenger ferries were reported and 512 victims (median age: 44 years, age range: 2-85 years) were sent to the study hospitals. The A&E triage categories were Cat 1, 3.1%; Cat 2, 4.3%; Cat 3, 19.3%; Cat 4, 72.9%; and Cat 5, 0.4%, respectively. The median ISS was 1.0 (interquartile range: 1.0-2.0). Fourteen victims (2.7%) had an ISS≥16 and age was the only independent predictor for major trauma (OR 1.06, p = 0.025, 95% CI 1.01-1.11). Trauma call was activated at A&E for 11 victims. In total, 100 victims (19.5%) were admitted to the study hospitals, including 19 (3.5%) and 15 (2.9%) who required surgery and intensive care unit stay, respectively. Eleven victims (2.1%) died, mostly due to drowning. CONCLUSION: MCIs involving high-speed passenger ferries can result in a sudden surge in demand for both A&E and in-patient care, though the majority of victims may have minor injuries. Better access to lifejackets and mandatory seatbelt use may help to reduce injuries and deaths.

Acupuncture in the emergency department: a systematic review of randomised controlled trials.

INTRODUCTION: A comprehensive review of both English and Chinese language literature to inform acupuncture practice in emergency department (ED) settings is lacking. Accordingly, we aimed to conduct a systematic review of English and Chinese randomised controlled trials (RCTs) of acupuncture use in the ED. METHODS: Four English databases (Embase, PubMed, AMED and CENTRAL) and two Chinese databases (CNKI and Wanfang) were systematically searched using the keywords 'acupuncture' and 'emergency department', followed by a bibliographic search of references. The data were extracted and assessed by two independent authors. RCTs were selected based on pre-defined criteria. Data were extracted and a risk of bias assessment was performed using the Cochrane risk of bias tool. The quality of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS: In total, 1461 articles were screened and six RCTs involving 651 patients were included. For various acute pain conditions, acupuncture was superior to sham acupuncture, more effective than intravenous morphine, comparable to conventional ED treatment, and superior to standard ED care alone when used on an adjuvant basis; however, the overall level of evidence was low. Studies that applied acupuncture in hypertension and cardiac arrest were deemed to be at high risk of bias, and the level of evidence for these outcomes was very low. No major adverse events were reported in the included studies. CONCLUSION: There is a lack of high-quality evidence to support the use of acupuncture in the ED. Multicentre RCTs with rigorous designs are warranted.

Self-efficacy and barriers to disaster evacuation in Hong Kong.

OBJECTIVES: To investigate specific challenges to Hong Kong's capacity for effective disaster response, we assessed perceived barriers to evacuation and citizens' self-efficacy. METHODS: Global positioning system software was used to determine random sampling locations across Hong Kong, weighted by population density. The resulting sample of 1023 participants (46.5% female, mean age 40.74 years) were invited to complete questionnaires on emergency preparedness, barriers to evacuation and self-efficacy. Latent profile analysis and multinomial logistic regression were used to identify self-efficacy profiles and predictors of profile membership. RESULTS: Only 11% of the sample reported feeling prepared to respond to a disaster. If asked to evacuate in an emergency, 41.9% of the sample cited significant issues that would preclude them from doing so. Self-efficacy was negatively associated with barriers to disaster response so that participants reporting higher levels of self-efficacy cited fewer perceived barriers to evacuation. CONCLUSIONS: Hong Kong has established effective strategies for emergency response, but concerns regarding evacuation and mobilisation remain. The findings indicate that improving self-efficacy for disaster response has potential to increase evacuation readiness.