Incidence and risk factors for healthcare utilisation among patients discharged on outpatient parenteral antimicrobial therapy.

Outpatient parenteral antimicrobial therapy (OPAT) programmes facilitate hospital discharge, but patients remain at risk of complications and consequent healthcare utilisation (HCU). Here we elucidated the incidence of and risk factors associated with HCU in OPAT patients. This was a retrospective, single-centre, case-control study of adult patients discharged on OPAT. Cases (n = 63) and controls (n = 126) were patients that did or did not utilise the healthcare system within 60 days. Characteristics associated with HCU in bivariate analysis (P ≤ 0.2) were included in a multivariable logistic regression model. Variables were retained in the final model if they were independently (P < 0.05) associated with 60-day HCU. Among all study patients, the mean age was 55 ± 16, 65% were men, and wound infection (22%) and cellulitis (14%) were common diagnoses. The cumulative incidence of 60-day unplanned HCU was 27% with a disproportionately higher incidence in the first 30 days (21%). A statin at discharge (adjusted odds ratios (aOR) 0.23, 95% confidence intervals (CIs) 0.09-0.57), number of prior admissions in past 12 months (aOR 1.48, 95% CIs 1.05-2.10), and a sepsis diagnosis (aOR 4.62, 95% CIs 1.23-17.3) were independently associated with HCU. HCU was most commonly due to non-infection related complications (44%) and worsening primary infection (31%). There are multiple risk factors for HCU in OPAT patients, and formal OPAT clinics may help to risk stratify and target the highest risk groups.

Lumbar intervertebral disc allograft transplantation: healing and remodelling of the bony structure.

Previous human study suggested that fresh-frozen intervertebral disc allograft transplantation can relieve neurological symptoms and restore segmental kinematics. Before wide clinical application, research into the pathophysiology of the postoperative disc allograft is needed. One important question that remains to be answered in disc allografting is the healing process of the host-graft interface and the subsequent change of the endplates. With the goat model for lumbar disc allografting, histology, micro-computed tomography analysis, scanning electron microscopy and energy-dispersive X-ray spectroscopy mapping were applied to evaluate the healing of the host-graft interfaces, the remodelling of subchondral bone, and the changes of the bony and cartilaginous endplates after transplantation. It was found that healing of the host-graft interfaces started at 1.5 months and was completed at 6 months by natural remodelling. This bony remodelling was also noted in the subchondral bone area after 6 months. The bony endplate was well preserved initially, but was gradually replaced by trabecular bone afterwards; on the other hand, the cartilaginous endplate became atrophic at 6 months and nearly disappeared at the final follow-up. Collectively, after intervertebral disc allograft transplantation, bony healing and remodelling were seen which ensured the stability and mobility of the disc-transplanted segment, but the integrity of bony and cartilaginous endplates was gradually lost and nearly disappeared finally.

The dorsal skinfold chamber: A versatile tool for preclinical research in tissue engineering and regenerative medicine.

Previous human study suggested that fresh-frozen intervertebral disc allograft transplantation can relieve neurological symptoms and restore segmental kinematics. Before wide clinical application, research into the pathophysiology of the postoperative disc allograft is needed. One important question that remains to be answered in disc allografting is the healing process of the host-graft interface and the subsequent change of the endplates. With the goat model for lumbar disc allografting, histology, micro-computed tomography analysis, scanning electron microscopy and energy-dispersive X-ray spectroscopy mapping were applied to evaluate the healing of the host-graft interfaces, the remodelling of subchondral bone, and the changes of the bony and cartilaginous endplates after transplantation. It was found that healing of the host-graft interfaces started at 1.5 months and was completed at 6 months by natural remodelling. This bony remodelling was also noted in the subchondral bone area after 6 months. The bony endplate was well preserved initially, but was gradually replaced by trabecular bone afterwards; on the other hand, the cartilaginous endplate became atrophic at 6 months and nearly disappeared at the final follow-up. Collectively, after intervertebral disc allograft transplantation, bony healing and remodelling were seen which ensured the stability and mobility of the disc-transplanted segment, but the integrity of bony and cartilaginous endplates was gradually lost and nearly disappeared finally.

MicroRNA-21 promotes proliferation of rat hepatocyte BRL-3A by targeting FASLG.

Rat liver regeneration (RLR) induced by partial hepatectomy involves cell proliferation regulated by numerous factors, including microRNAs (miRNAs). miRNA high-throughput sequencing has been established and used to analyze miRNA expression profiles. This study showed that 39 miRNAs were related to RLR through the analysis of miRNA high-throughput sequencing. Their role toward rat normal hepatocyte line BRL-3A was studied by gain- and loss-of-function analyses, and one of them, microRNA-21 (miR-21), obviously upregulated and promoted BRL-3A cell proliferation. Using bioinformatics to search for miR-21 targets revealed that Fas ligand (FASLG) is one of miR-21's target genes. A dual-luciferase report assay and Western blot assay showed that miR-21 directly targeted the 3'-untranslated region of FASLG and inhibited the expression of FASLG, which suggests that miR-21 promoted BRL-3A cell proliferation by reducing FASLG expression.

The effect of a pain management program on patients with cancer pain.

BACKGROUND: Pain is 1 of the most common symptoms that a cancer patient would experience. A significant barrier to positive pain management is patients' misconceptions regarding analgesics and inadequate use of nonpharmacological strategies as pain relief. OBJECTIVE: The purpose of this study was to investigate the effectiveness of a pain management program (PMP) on pain intensity, use of PRN drugs and nonpharmacological strategies as pain relief, and barriers to managing pain in cancer patients. METHODS: The study was conducted in the palliative care and hospice ward of a public hospital in Hong Kong. Patients were randomized to either an experimental group (receiving the PMP) or a control group (routine care). There were 38 hospitalized patients, with 20 (13 males and 7 females) in the experimental group and 18 (11 males and 7 females) in the control group; mean age was 61.95 years (experimental group) to 63.94 years (control group). RESULTS: Upon the completion of PMP, pain scores were significantly reduced in both groups, yet patients in the experimental group showed a significant increase in the use of PRN analgesics and nonpharmacological strategies to relieve pain (P < .05) and significantly reduce barriers to managing their cancer pain (P < .05) compared with the control group. CONCLUSION: Cancer patients should be empowered with pain management education to gain knowledge and correct misconceptions in managing their cancer pain. IMPLICATIONS FOR PRACTICE: Integration of the PMP into routine clinical work may help to improve the standard of care for cancer patients. It is recommended to provide pain management education to all cancer patients.

Pressure prediction model for compression garment design.

Based on the application of Laplace's law to compression garments, an equation for predicting garment pressure, incorporating the body circumference, the cross-sectional area of fabric, applied strain (as a function of reduction factor), and its corresponding Young's modulus, is developed. Design procedures are presented to predict garment pressure using the aforementioned parameters for clinical applications. Compression garments have been widely used in treating burning scars. Fabricating a compression garment with a required pressure is important in the healing process. A systematic and scientific design method can enable the occupational therapist and compression garments' manufacturer to custom-make a compression garment with a specific pressure. The objectives of this study are 1) to develop a pressure prediction model incorporating different design factors to estimate the pressure exerted by the compression garments before fabrication; and 2) to propose more design procedures in clinical applications. Three kinds of fabrics cut at different bias angles were tested under uniaxial tension, as were samples made in a double-layered structure. Sets of nonlinear force-extension data were obtained for calculating the predicted pressure. Using the value at 0° bias angle as reference, the Young's modulus can vary by as much as 29% for fabric type P11117, 43% for fabric type PN2170, and even 360% for fabric type AP85120 at a reduction factor of 20%. When comparing the predicted pressure calculated from the single-layered and double-layered fabrics, the double-layered construction provides a larger range of target pressure at a particular strain. The anisotropic and nonlinear behaviors of the fabrics have thus been determined. Compression garments can be methodically designed by the proposed analytical pressure prediction model.

Casting versus percutaneous pinning for extra-articular fractures of the distal radius in an elderly Chinese population: a prospective randomised controlled trial.

We carried out a prospective randomised controlled clinical trial to compare the functional and radiological outcomes of casting with percutaneous pinning in treating extra-articular distal radial fracture in an elderly Chinese population. Sixty patients were randomly allocated by sealed envelopes to either a 'Cast' group (n = 30) or a 'K-wire' group (n = 30). All patients were available for final follow-up assessment. The radiological outcomes in terms of dorsal angulation, radial inclination and radial length were statistically significantly better in the K-wire group, whereas the Mayo wrist score and quality of life, healing rate, healing time, and complications were similar. The functional outcomes and quality of life were not affected by the treatments. Both treatments had a very low rate of complication and high healing rates.

Conventional muscle-reflection approach versus mini-incision muscle-splitting approach in dynamic hip screw fixation.

PURPOSE: To compare the short-term results of conventional versus mini-incision approaches to dynamic hip screw (DHS) fixation. METHODS: 41 geriatric patients with either basal femoral neck or intertrochanteric fractures (Kyle types I to III) who underwent closed reduction and DHS fixation by a single surgeon were retrospectively reviewed. From January 2001 to June 2005, 6 men and 19 women aged 60 to 94 (median, 83) years underwent DHS fixation through a conventional muscle-reflection approach with a skin incision of 10 cm or more. From July 2005 to March 2006, 9 men and 7 women aged 67 to 95 (median, 81) years underwent DHS fixation through a mini-incision (4 cm) approach at the lower border of the lesser trochanter. Operating time, drain output and duration of drain placement, decrease in haemoglobin level and receipt of blood transfusions, deterioration in ambulation status, analgesic intake, duration of hospital stay, and bone healing time for the 2 groups were compared. An independent observer retrospectively assessed the fracture pattern, reduction quality, and bone healing time. RESULTS: Compared to patients in the conventional group, those in the mini-incision group had shorter operating times (50 vs 43 minutes, p=0.02), a higher proportion whose drain was removed within 24 hours (28% vs 69%, p=0.01), and consumed fewer dosages of oral analgesics within 48 hours (8 vs 5, p=0.001). Classification of the fracture pattern in 21 of 38 patients were consistent between the surgeon and observer. The Kappa value for agreement was 0.32, denoting marginal agreement (p=0.003). Reduction quality (p=0.66) and bone healing time (p=0.73) assessed by the observer were not significantly different between the 2 groups. CONCLUSION: The short-term clinical outcome of mini-incision DHS fixation for geriatric pertrochanteric fractures was favourable.

A cluster of chilblains in Hong Kong.

OBJECTIVE: To report a recent clustering of chilblain cases in Hong Kong. DESIGN: Case series. SETTING: A regional hospital and a social hygiene clinic in the New Territories West, Hong Kong. PATIENTS: Patients with a clinical diagnosis of chilblains in February 2008. RESULTS: Eleven patients with chilblains were identified; seven (64%) gave an antecedent history of prolonged exposure to cold. They all presented with erythematous or dusky erythematous skin lesions affecting the distal extremities, especially fingers and toes. Laboratory tests revealed elevated antinuclear antibodies titres in two, positive rheumatoid factor in two, presence of cold agglutinins in one, and a raised anti-DNA titre (>300 IU/mL) in one. Skin biopsies were performed in six patients, four of them showed typical histopathological features of chilblains. In the patient with systemic lupus erythematosus, features of vasculitis were suspected, and in the one with pre-existing juvenile rheumatoid arthritis, there were features of livedo vasculitis. In 10 (91%) of the patients, the skin lesions had resolved when they were last assessed (at the end of March 2008), but had persisted in the patient who had pre-existing systemic lupus erythematosus. CONCLUSION: The recent clustering of chilblains was possibly related temporally to the prolonged cold weather at the end of January to mid-February. In our series, most of the patients developed chilblains as an isolated condition and resolved spontaneously within a few weeks. Laboratory tests and skin biopsies for chilblains are not necessary, unless the condition persists, the diagnosis in doubt or an underlying systemic disease is suspected.

Effects of gender, Helicobacter pylori and hepatitis B virus serology status on cardiovascular and renal complications in Chinese type 2 diabetic patients with overt nephropathy.

BACKGROUND: The aim of this study was to investigate whether chronic infections with Helicobacter pylori and hepatitis B virus (HBV) might affect clinical outcomes in Chinese type 2 diabetic patients with advanced nephropathy. METHODS: A prospective study of 97 type 2 diabetic patients with clinical proteinuria and renal insufficiency (median serum creatinine 200 micro mol/l). RESULTS: During a median follow-up period of 2 years, 34 developed end-stage renal disease (ESRD), 28 had cardiovascular endpoints and 11 patients had died (seven men and four women), and 52.7% developed a combined endpoint. Female patients had longer disease duration, higher blood pressure, lower body weight but higher serum creatinine and spot urine albumin : creatinine ratio as well as lower haemoglobin than male patients. On logistic regression analysis, female gender (hazard ratio: 5.91, p = 0.02), negative H. pylori serology (8.39, p = 0.004), baseline serum creatinine (1.04, p = 0.001) and haemoglobin (1.86, p = 0.01) were independent predictors for ESRD. Systolic blood pressure (1.04, p = 0.003), prior treatment with angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists (3.41, p = 0.04) and positive hepatitis B surface antigen (4.88, p = 0.025) were independent predictors for cardiovascular endpoints. Female gender (7.89, p = 0.002) and baseline serum creatinine (1.05, p < 0.001) were independent predictors for combined death and cardio-renal endpoints. CONCLUSIONS: In Chinese type 2 diabetic patients with clinical proteinuria renal insufficiency, there were high rates of death and cardio-renal outcomes. Female gender, low haemoglobin and negative H. pylori serology were important predictors for ESRD, whereas chronic HBV infection was associated with increased cardiovascular risks.

Performance evaluation of hybrid and conventional sequencing batch reactor and continuous processes.

Bench-scale systems, using conventional and compact hybrid activated sludge configurations, were set up to evaluate the systems' nitrification-denitrification performance, operating sludge age/MLSS concentration and sludge settleability at a Hong Kong municipal STW. Configurations tested were the continuous clarifier modified Ludzack Ettinger (MLE) and the sequencing batch reactor (SBR) with and without hybrid suspended biofilm carriers. Results demonstrated that the hybrid SBR and MLE systems consistently achieved close to complete nitrification (effluent NH4-N = 2.4 and 6.9 mg/L) and 75% and 67% removal of nitrogen (N) (effluent NO3-N < 10 mg/L) with an overall hydraulic retention time of only 7.5 hours, operating sludge age as short as 5.2 days, and mixed liquor suspended solids concentration of approximately 1,300 mg/L with a sludge volume index of 109 and 229 mL/g, respectively. The most sensitive and slowest growing nitrifiers attached to the hybrid biofilm carriers. This allowed the hybrid processes to be operated at a sludge age shorter than the critical nitrifying sludge age while still retaining near complete nitrification. In contrast, to achieve complete nitrification, the conventional MLE system needed to be operated at 1.5 to 2.5 times the critical sludge age. These results indicate that the hybrid MLE configuration is a suitable process for use in upgrading existing conventional works for N removal and for increasing hydraulic capacity of existing N removal works, without major civil works modifications, in Hong Kong. For new works, consideration might be given to the use of the hybrid SBR, which shows a more stable N removal performance than the MLE process due to its inherent in-basin equalization capacity and better reaction conditions for nitrification in terms of higher initial NH4-N level. It was also observed that the conventional SBR produced better nitrification performance than the hybrid MLE process tested. Design parameters and operating conditions of the hybrid systems should be subjected to further full-scale trial for higher hydraulic capacity and N removal performance.

The impact of sea water flushing on biological nitrification-denitrification activated sludge sewage treatment process.

The process performance of the two largest activated sludge processes in Hong Kong, the Sha Tin and the Tai Po Sewage Treatment Works (STW), deteriorated in the initial period after the introduction of seawater flushing in 1995 and 1996, respectively. High effluent ammonia nitrogen (NH4-N) and total suspended solids (TSS) in excess of the discharge standards resulted from incomplete nitrification and changes in floc characteristics. A desktop study on the inhibitory effects of salinity, particularly on nitrification, was subsequently conducted using the Tai Po STW operating data. To assist the upgrade of the Sha Tin STW a five-month extensive bench-scale investigation on a simple but flexible modified Ludzack-Ettinger configuration with bio-selector was conducted to quantify the inhibitory effects due to the saline concentration. The Sha Tin STW upgrade consists of restoration of its original design capacity (conventional process) of 205,000 m3/day from its currently much reduced capacity as a Bardenpho process. Only the volume of the existing biological process and clarifier is to be utilized. The saline concentration ranges from 3,500 up to 6,500 mg Cl-/L, both daily and seasonally. High and greatly fluctuating saline concentrations have been known to inhibit nitrification. Design consideration should also be given to the peak daily and seasonal TKN loading of up to three times the average. Although the nitrifiers maximum specific growth rate was significantly reduced to a low 0.25 day(-1), the inhibition was considered to be tolerable with effluent NH4-N and NO3-N consistently at < 1 and < 6 mg/L. The bio-selector was demonstrated to be efficient in control of sludge foaming and bulking with SVI consistently < or = 125 mL/g. Results from the IAWO Model No. 1 and the hydraulic model of the secondary clarifiers allowed overall process capacity maximization. With an anoxic mass fraction of 25-30%, operating sludge age of 9-14 days and SVI < or = 125 mL/g, both the design requirements and the effluent discharge standards could be met. Without these investigations, an unnecessarily large reaction basin and secondary clarifier volume, and hence capital investment, would have resulted.

Ruptured adrenocortical carcinoma as a cause of paediatric acute abdomen.

Adrenocortical carcinoma (ACC) is rare in children. Its presentation is usually related to hormonal activity of the tumour. We report a case of childhood ACC that presented as an acute abdomen due to tumour rupture. This is the first reported case of a ruptured ACC as a cause of paediatric acute abdomen.

Synthesis and photophysical properties of new fluorinated benzo[c]xanthene dyes as intracellular pH indicators.

Two new fluorinated benzo[c]xanthene dyes were synthesized by reaction of fluorinated 1,6-dihydroxynaphthalenes with 2,4- (and 2,5)-dicarboxy-3'-dimethylamino-2'-hydroxybenzophenone. The two critical fluorinated 1,6-dihydroxynaphthalene intermediates were prepared via a regioselective route. The fluorinated benzo[c]xanthene dyes exhibit desired lower pK(a) values (6.4 and 7.2, respectively) than their parent compound (pK(a)=7.5) while the pH-dependent dual-emission characteristics are well retained. Their cell-permeable esters have been prepared for intracellular applications.

Over-expression of FoxM1 stimulates cyclin B1 expression.

FoxM1 (previously named WIN, HFH-11 or Trident) is a Forkhead box (Fox) transcription factor widely expressed in proliferating cells. Various findings, including a recent analysis of FoxM1 knockout mice, suggest that FoxM1 is required for normal S-M coupling during cell cycle progression. To study the regulatory role of FoxM1 and its downstream regulatory targets, three stably transfected HeLa lines that display doxycycline (dox)-inducible FoxM1 expression were established. Over-expression of FoxM1 by dox induction facilitates growth recovery from serum starvation. Quantitation of cyclin B1 and D1 levels using flow cytometric, Western and Northern analyses reveals that elevated FoxM1 levels lead to stimulation of cyclin B1 but not cyclin D1 expression. Transient reporter assays in the dox-inducible lines and upon co-transfection with a constitutive FoxM1 expression plasmid suggest that FoxM1 can activate the cyclin B1 promoter.

Clinical outcome of stent implantation in small coronary arteries using different types of coronary stents.

PURPOSE: We evaluated the results of stent placement in small coronary arteries. SUBJECTS: The subjects were divided into 2 groups: the first contained 911 lesions treated with stenting in the coronary arteries (stent group), and the second contained 1,203 background- and patient-matched lesions treated with balloon angioplasty (POBA group). There was no significant difference in the background of patients or lesions between the groups. A "small coronary artery" was defined as a coronary artery with a reference vessel diameter < 3.0 mm. RESULTS: There was no significant difference in incidence of acute myocardial infarction (AMI), coronary artery bypass grafting, or death between the groups. In the stent group, acute occlusion (0.8%) and subacute thrombosis (2.1%) occurred. The restenosis rate of 29.8% in the stent group was significantly lower than in the POBA group (38.2%; p < 0.01). The restenosis rate of 19.4% in stented vessels 3.0 mm diameter was significantly lower than in vessels < 3.0 mm diameter (29.8%; p < 0.01). The rate of restenosis was 22.9% for the Multi-Link stent, 24.4% for the NIR stent, 34.1% for the GFX stent, and 35.3% for the PS stent. The restenosis rate of 23.8% in stented vessels > 2.5 mm diameter and < or = 20 mm length was significantly lower than in vessels , < or = 2.5 mm diameter and > 20 mm length (32.7%; p < 0.01). Factors associated with restenosis, analyzed using a stepwise multivariate logistic regression model, included ostial lesions and post-procedural minimum lumen diameter. CONCLUSIONS: Stent implantation in vessels < 3.0 mm diameter using a newly designed coronary stent yielded favorable clinical results, while there was a high prevalence of restenosis, leading to diffused stenotic lesions, in vessels < 2.5 mm diameter.