Trajectory of functional outcome and health status after moderate-to-major trauma in Hong Kong: A prospective 5 year cohort study.

BACKGROUND: Trauma care systems in Asia have been developing in recent years, but there has been little long-term outcome data from injured survivors. This study aims to evaluate the trajectory of functional outcome and health status up to five years after moderate to major trauma in Hong Kong. METHODS: We report the five year follow up results of a multicentre, prospective cohort from the trauma registries of three regional trauma centres in Hong Kong. The original cohort recruited 400 adult trauma patients with ISS ≥ 9. Telephone follow up was conducted longitudinally at seven time points, and the extended Glasgow Outcome Scale (GOSE) and Short-Form 36 (SF36) were tracked. RESULTS: 119 out of 309 surviving patients (39%) completed follow up after 5 years. The trajectory of GOSE, PCS and MCS showed gradual improvements over the seven time points. 56/119 (47.1%) patients reported a GOSE = 8 (upper good recovery), and the mean PCS and MCS was 47.8 (95% CI 45.8, 49.9) and 55.8 (95% CI 54.1, 57.5) respectively at five years. Univariate logistic regression showed change in PCS - baseline to 1 year and 1 year to 2 years, and change in MCS - baseline to 1 year were associated with GOSE = 8 at 5 years. Linear mixed effects model showed differences in PCS and MCS were greatest between 1-month and 6-month follow up. CONCLUSIONS: After injury, the most rapid improvement in PCS and MCS occurred in the first six to 12 months, but further recovery was still evident for MCS in patients aged under 65 years for up to five years.

Investigation of availability and accessibility of community automated external defibrillators in a territory in Hong Kong.

OBJECTIVE: To evaluate the availability and accessibility of community automated external defibrillators in a territory in Hong Kong. DESIGN: Cross-sectional study. SETTING: Two public hospitals in New Territories West Cluster in Hong Kong. PARTICIPANTS: Information about the locations of community automated external defibrillators was obtained from automated external defibrillator suppliers and through community search. Data on locations of out-of-hospital cardiac arrests from August 2010 to September 2013 were obtained from the local cardiac arrest registry of the emergency departments of two hospitals. Sites of both automated external defibrillators and out-of-hospital cardiac arrests were geographically coded and mapped. The number of out-of-hospital cardiac arrests within 100 m of automated external defibrillators per year and the proportion of out-of-hospital cardiac arrests with accessible automated external defibrillators (100 m) were calculated. The number of community automated external defibrillators per 10,000 population and public access defibrillation rate were also calculated and compared with those in other countries. RESULTS: There were a total of 207 community automated external defibrillators in the territory. The number of automated external defibrillators per 10,000 population was 1.942. All facilities with automated external defibrillators in this territory had more than 0.2 out-of-hospital cardiac arrests per automated external defibrillator per year within 100 m. Among all out-of-hospital cardiac arrests, 25.2% could have an automated external defibrillator reachable within 100 m. The public access defibrillation rate was 0.168%. CONCLUSIONS: The number and accessibility of community automated external defibrillators in this territory are comparable to those in other developed countries. The placement site of community automated external defibrillators is cost-effective. However, the public access defibrillation rate is low.

Assessment of quality of life and functional outcome in patients sustaining moderate and major trauma: a multicentre, prospective cohort study.

BACKGROUND: Trauma care systems aim to reduce both death and disability, yet there is little data on post-trauma health status and functional outcome. OBJECTIVES: To evaluate baseline, discharge, six month and 12 month post-trauma quality of life, functional outcome and predictors of quality of life in Hong Kong. METHODS: Multicentre, prospective cohort study using data from the trauma registries of three regional trauma centres in Hong Kong. Trauma patients with an ISS≥9 and aged≥18 years were included. The main outcome measures were the physical component summary (PCS) score and mental component summary (MCS) scores of the Short-Form 36 (SF36) for health status, and the extended Glasgow Outcome Scale (GOSE) for functional outcome. RESULTS: Between 1 January 2010 and 31 September 2010, 400 patients (mean age 53.3 years; range 18-106; 69.5% male) were recruited to the study. There were no statistically significant differences in baseline characteristics between responders (N=177) and surviving non-responders (N=163). However, there were significant differences between these groups and the group of patients who died (N=60). Only 16/400 (4%) cases reported a GOSE≥7. 62/400 (15.5%) responders reached the HK population norm for PCS. 125/400 (31%) responders reached the HK population norm for MCS. If non-responders had similar outcomes to responders, then the percentages for GOSE≥7 would rise from 4% to 8%, for PCS from 15.5% to 30%, and for MCS from 31% to 60%. Univariate analysis showed that 12-month poor quality of life was significantly associated with age>65 years (OR 4.77), male gender (OR 0.44), pre-injury health problems (OR 2.30), admission to ICU (OR 2.15), ISS score 26-40 (OR 3.72), baseline PCS (OR 0.89), one-month PCS (OR 0.89), one-month MCS (OR 0.97), 6-month PCS (OR 0.76) and 6-month MCS (OR 0.97). CONCLUSION: For patients sustaining moderate or major trauma in Hong Kong at 12 months after injury<1 in 10 patients had an excellent recovery, ≤3 in 10 reached a physical health status score≥Hong Kong norm, although as many as 6 in 10 patients had a mental health status score which is≥Hong Kong norm.

Green pit viper antivenom from Thailand and Agkistrodon halys antivenom from China compared in treating Cryptelytrops albolabris envenomation of mice.

OBJECTIVE: To compare the relative efficacy of the green pit viper antivenom from Thailand and Agkistrodon halys antivenom from China. DESIGN. In-vivo experimental study. SETTING: A wildlife conservation organisation, a university, a poison information centre, and a regional hospital in Hong Kong. MAIN OUTCOME MEASURES: Pre- and post-antivenom lethal dose 50 (LD50) of the Cryptelytrops albolabris venom, median effective dose (ED50) of green pit viper antivenom and Agkistrodon halys antivenom against a lethal dose of the venom. SUBJECTS. Adult mice. RESULTS: The intraperitoneal LD50 of the venom from locally caught Cryptelytrops albolabris was 0.14 microL. After post-exposure treatment with 10 microL of antivenom, it was elevated to 0.36 microL and 0.52 microL by the green pit viper antivenom and the Agkistrodon halys antivenom, respectively. The ED50 was 32.02 microL for green pit viper antivenom and 6.98 microL for Agkistrodon halys antivenom. Both green pit viper antivenom and Agkistrodon halys antivenom ameliorated the lethality of Cryptelytrops albolabris venom in mice. CONCLUSION: The overall superior neutralisation capacity of Agkistrodon halys antivenom over green pit viper antivenom may be related to the geographic proximity of the venoms used for antivenom preparation. The results point towards the need for further comparison of the two antivenoms on protein or immunoglobulin weight basis, and with respect to non-lethal clinically significant toxicities.

The first 5 years since trauma center designation in the Hong Kong Special Administrative Region, People's Republic of China.

BACKGROUND: In 1994, the Hong Kong Special Administrative Region (HKSAR) introduced plans to implement a trauma system based on the recommendations outlined by Professor Donald Trunkey in his report to the local Hospital Authority. Five government-subsidized public hospitals were subsequently designated as trauma centers in 2003. This article reviews the initial experience in these five centers. METHODS: Prospective trauma registries from January 2004 to December 2008 were reviewed. Primary clinical outcome measures were hospital mortality. The Trauma and Injury Severity Score methodology was used for benchmarking with the Major Trauma Outcome Study (MTOS) database. RESULTS: The majority (83.3%) of the 10,462 patients suffered from blunt trauma. Severe injury, defined as Injury Severity Score>15, occurred in 29.7% of patients. The leading causes of trauma were motor vehicle collisions and falls, with crude hospital mortality rates of 6.9% and 10.7%, respectively. The M-statistic was 0.95, indicating comparable case-mix with the MTOS. The worst outcome occurred in the first year. Significant improvement was seen in patients with penetrating injuries. By 2008, these patients had significantly higher survival rates than expected (Z-statistic=0.85). Although the overall mortality rates for blunt trauma were higher than expected, the difference was no longer statistically significant from the second year onward. CONCLUSIONS: The case-mix of trauma patients in the HKSAR is comparable with that of the MTOS. A young trauma system relatively unburdened by dissimilar reimbursement and patient access issues may achieve significant improvement and satisfactory patient outcomes. Our findings may serve as a useful benchmark for HK and other Southeast Asian cities and trauma systems to establish local coefficients for future evaluations.

Oral bacterial flora of the Chinese cobra (Naja atra) and bamboo pit viper (Trimeresurus albolabris) in Hong Kong SAR, China.

OBJECTIVE: To determine the oral bacterial flora associated with two common local venomous snakes in Hong Kong, namely the Chinese cobra (Naja atra) and the bamboo pit viper (Trimeresurus albolabris). DESIGN: Cross-sectional study. SETTING: A non-government organisation and a regional hospital in Hong Kong. SUBJECTS: Thirty-two Chinese cobras and seven bamboo pit vipers. MAIN OUTCOME MEASURES: Species identification of bacteria in the oral cavity of both snakes and their antibiotic susceptibilities. RESULTS: The oral cavity of Chinese cobra harbour a wide range of pathogenic bacteria, including: Gram-negative bacterial species like Morganella morganii, Aeromonas hydrophila and Proteus, and Gram-positive bacteria like Enterococcus faecalis, coagulase-negative Staphylococcus as well as anaerobic species (clostridia). The oral cavity of the Chinese cobra is more likely than that of the bamboo pit viper to harbour pathogenic bacteria associated with snakebite infection (P<0.001). The median number of pathogenic bacteria per snake was significantly higher in the Chinese cobra (P<0.001). All pathogenic Gram-negative bacteria isolated were susceptible to levofloxacin. Amoxicillin/clavulanate provided good coverage against pathogenic Gram-positive bacteria (Enterococcus faecalis) and anaerobes. CONCLUSION: 'Prophylactic' antibiotic treatment for Chinese cobra bites may be beneficial, owing to the multiple pathogenic bacteria in its oral cavity and the higher risk of ensuing necrosis. The regimen of levofloxacin plus amoxicillin/clavulanate appears promising for this purpose, but further study is required to confirm its clinical utility in patients.

1700 Victims of intimate partner violence: characteristics and clinical outcomes.

OBJECTIVE: To investigate the demographics and clinical outcomes of intimate partner violence victims presenting to an emergency department. DESIGN: Retrospective, observational study. SETTING: Emergency department of a regional hospital in Hong Kong. PATIENTS: Adults presented with intimate partner violence during years 1999 to 2004. RESULTS: We assessed 1695 victims of intimate partner violence with a mean age of 39 (range, 18-84) years, of whom 87% were female. Most of the patients were in the age-group of 31 to 40 years and the overall male-to-female ratio was 1:7. In Tin Shui Wai and Yuen Long districts, such cases appeared to be on the increase. Nearly two thirds (65%) of all the victims presented to the emergency department outside the office hours of medical social workers. Approximately 10% had been abused once before, and 40% more than twice. The head (39%), face (30%), upper limbs (37%), and lower limbs (17%) were commonly the injured parts. The majority (73%) had mild injuries; severe injuries being relatively less common. The latter included lacerations or cuts (6.6%), nasal bone fractures (0.3%), limb fractures (0.8%), and ruptured tympanic membranes (0.9%). In-patient management was undertaken for 8% of the victims, due to physical injury in 68% of these individuals and psychological trauma in the remaining 32%. The hospital admission rate dropped from 12% in 2001 to 4% in 2004. CONCLUSIONS: Variations in demographic data had a significant impact on future service planning and management of intimate partner violence. Accident and Emergency Department and Emergency Medicine Ward services together with extended social worker support could provide timely, multidisciplinary care to meet the various needs of victims and subsequently reduce hospital admissions.

Evaluation of a point-of-care transcutaneous bilirubinometer in Chinese neonates at an accident and emergency department.

OBJECTIVE: To evaluate the use of a point-of-care transcutaneous bilirubinometer, JM-103 Minolta, for estimation of the serum bilirubin level in the management of neonatal jaundice in term or near-term Chinese neonates. DESIGN: Prospective correlation study. SETTING: Accident and Emergency Department of a regional hospital in Hong Kong. PATIENTS: All term or near-term Chinese neonates aged 3 to 7 days, who attended the Accident and Emergency Department because of jaundice between September and November 2007. MAIN OUTCOME MEASURES: Paired transcutaneous bilirubin measurements by the JM-103 Minolta and the total serum bilirubin measurement by a direct spectrophotometric method in the laboratory. RESULTS: The mean age of the 113 neonates at the time of data collection was 5 days (range, 3-7 days). Transcutaneous bilirubin showed a good correlation with total serum bilirubin; the highest correlation coefficient was 0.83 (P < 0.001). Transcutaneous bilirubin cutoff values of 230 micromoles per litre and 298 micromoles per litre could have 100% sensitivity and specificity respectively, to predict a total serum bilirubin level of higher than 250 micromoles per litre (the accepted threshold for treatment). The mean difference between transcutaneous and total serum bilirubin was 14 micromoles per litre (standard deviation, 28 micromoles per litre; P < 0.001); the JM-103 tended to overestimate total serum bilirubin. The 95% limits of agreement were between -40 and 69 micromoles per litre. CONCLUSION: The new point-of-care transcutaneous bilirubinometer, JM-103 Minolta, demonstrated good correlation with the serum bilirubin measurement in Chinese neonates aged 3 to 7 days. Thus, it is a useful screening device to facilitate quick decisions on disposal of jaundiced neonates presenting to accident and emergency departments or in out-patient clinic settings.

High risk trauma in older adults in Hong Kong: a multicentre study.

BACKGROUND: Trauma is the eighth leading cause of death in Hong Kong. In 2002, 18.5% of the population of Hong Kong was aged 55 years or above, which increased to 22.1% in 2006. The increasing older population in Hong Kong presents a challenge to the health care system yet there is little local data on older trauma patients. The objectives of this study are firstly to describe the epidemiology of high risk trauma in older patients in Hong Kong, and secondly to identify predictors of trauma mortality. METHOD: Retrospective analysis of prospectively collected data from a centralised trauma database; data collected from 2002 to 2004 from four trauma centres in Hong Kong. RESULTS: Between 2002 and 2004, the four trauma centres had a total of 2,124,175 emergency department attendances of which 376,021 (17.7%) were trauma patients, and 80,827 (3.8%) were aged 55 years or older. 810 injured older patients met the inclusion criteria for this study. 380 (46.9%) patients had co-morbidity at the time of injury. Common causes of injury were falls (50.0%, 405/810) and motor vehicle crashes (33.6%, 272/810) of which (77.2%, 210/272) were pedestrians. Mortality was 24.4% (198/810) and increased with advancing age (p<0.0001). 53.5% (433/810) of patients had major trauma (ISS>15). Head injury contributed to 80.3% (159/198) of deaths. 38.4% (311/810) of patients required operations. Most patients were discharged home (40.5%, 328/810) and one-third (270/810) required rehabilitation. Significant predictors of mortality included co-morbidity, injury severity score, age and decreasing Glasgow Coma Score. CONCLUSION: Pedestrians struck by motor vehicles and falls are the principal causes of trauma in older patients in Hong Kong. Mortality increased with advancing age. The independent indicators of trauma mortality in older patients are co-morbidity, age, ISS and GCS.

Risk factors for injury to married women from domestic violence in Hong Kong.

OBJECTIVE: To examine risk factors for injury to married women from domestic violence in Hong Kong. DESIGN: Case control study. SETTING: Regional public hospital, Hong Kong. PATIENTS: All married women aged 18 to 60 years who attended an accident and emergency department for treatment of a domestic violence injury from January 2004 to June 2005. MAIN OUTCOME MEASURES: Social and health characteristics of abused women and their husbands. RESULTS: A total of 293 cases were compared to 313 controls. Eight predictive variables were found to be significant by univariate analysis: woman who is a new immigrant (P = 0.003), woman with no job (P = 0.019), husband with low educational level (P < 0.001), presence of extramarital affairs (P < 0.001), husband's unemployment (P < 0.001), husband's alcohol abuse (P < 0.001), husband's illicit drug abuse (P = 0.032), husband's mental illness (P < 0.001). Five factors were found to be significant in a logistic regression analysis: husband with a low educational level (nil to primary) [adjusted odds ratio = 2.78; 95% confidence interval, 1.149-6.727], husband unemployed (adjusted odds ratio = 9.031; 95% confidence interval, 5.163-15.796), presence of extramarital affairs (adjusted odds ratio = 5.218; 95% confidence interval, 2.899-9.395), husband's alcohol abuse (adjusted odds ratio = 6.089; 95% confidence interval, 3.460-10.716), husband's mental illness (adjusted odds ratio = 9.443; 95% confidence interval, 2.351-37.926). CONCLUSIONS: Several significant risk factors have been identified for injury incurred during domestic violence to married women in Hong Kong. It provides information useful for developing local preventive strategies.

Psychiatric inpatients' perceptions of positive and negative aspects of physical restraint.

This qualitative study explored the experiences and feelings of psychiatric inpatients concerning their first encounter with physical restraint. Its purpose was to determine whether restraint has any other effects, other than the intended one of protection. Thirty psychiatric inpatients who had experienced physical restraint in two acute admission wards within the previous two days, were interviewed by the principal researcher. About two-thirds of the participants expressed positive feelings towards staff who had shown concern about their needs and had been willing to help. Positive therapeutic effects, other than physical protection, were largely related to the caring attitudes and behavior demonstrated by the staff. Negative effects were related to the inability of staff to satisfy patients' needs for: concern, empathy, active listening, and information about restraint during and after its use. The conclusion of the study was that physical restraint could be a therapeutic intervention when health professionals were able to provide psychological and informational support to patients throughout the procedure. A perceived unsatisfactory caring attitude and behavior by the restraint provider would cause negative feelings in the patient and would be more likely to result in the patient struggling physically with the restrainer. Additional physical and psychological harm would also be experienced by patients in these circumstances.

Smoking among secondary school students in Negeri Sembilan, Malaysia.

This study was done to determine the prevalence of smoking and factors influencing cigarette smoking among secondary school students in Negeri Sembilan, Malaysia. This is a cross-sectional school survey conducted on 4500 adolescent students based on a structured questionnaire. Data was collected using the supervised self-administered questionnaire the Youth Risk Behaviour Surveillance in the Malaysian National Language Bahasa Malaysia. The prevalence of smoking among the students was 14.0%. About a third of the students (37.8%) started smoking at 13 to 14 years of age. The prevalence of smoking among the male students was higher (26.6%) compared to the female students (3.1%). Adolescent smoking was associated with (1) sociodemographic factors (age, ethnicity, rural/urban status); (2) environmental factors (parental smoking, staying with parents); (3) behavioural factors (playing truant and risk-taking behaviours such as physical fighting, drug use, alcohol use, sexual activity, lack of seatbelt use, riding with a drunk driver); (4) lifestyle behaviours (being on diet and lack of exercise); (5) personal factors (feeling sad and suicidal behaviours). In conclusion, smoking is a major problem among Malaysian adolescents. Certain groups of adolescents tend to be at higher risk of smoking. This problem should be curbed early by targeting these groups of high risk adolescents.

Non-accidental carbon monoxide poisoning from burning charcoal in attempted combined homicide-suicide.

OBJECTIVE: To describe an emerging form of serious child abuse in combined homicide-suicide in Hong Kong. METHOD: This is a retrospective hospital chart review in a regional hospital in Hong Kong from January to December 2000. RESULTS: Eight children, with a mean age of 7.8 years (range 0.5-11 years), from four families were admitted to hospital because of non-accidental exposure to carbon monoxide when their parents attempted suicide by burning charcoal. A 7-year-old boy died on arrival. His 5.6-year-old sister and another 6-month-old boy had cerebral hypoxia on admission. Hyperbaric oxygen therapy was used in both cases, with rapid improvement, although there were persistent neurological deficits in the girl. The other children in the present study were asymptomatic and none had delayed neurological sequelae. Concomitant use of sedatives was also detected in three of the surviving patients. CONCLUSIONS: Non-accidental poisoning with carbon monoxide appears to be a new means of child abuse with potentially serious consequences. Concomitant intoxication with psychotropic drugs is common in such cases. The reason for parents killing their own children under such circumstances was unclear, but a desire to exact revenge on an estranged partner was suggested.

Morbidity patterns of non-urgent patients attending accident and emergency departments in Hong Kong: cross-sectional study.

OBJECTIVES: To study the morbidity patterns of non-urgent patients utilising accident and emergency services and compare these patients with 'true' accident and emergency cases. To analyse the morbidity pattern of non-urgent cases over different time periods, and across different age groups. DESIGN: A cross-sectional study completed over a 1-year period. SETTING: Four accident and emergency departments in Hong Kong. PATIENTS: Two thousand, four hundred and ten patients randomly selected from four accident and emergency departments. MAIN OUTCOME MEASURES: The morbidity patterns by body system, according to the International Classification of Primary Care, were tabulated and analysed for 'true' accident and emergency cases versus non-urgent cases. The ten most frequent diagnoses for the 'true' accident and emergency and non-urgent cases were also compared. Further analysis of accident and emergency service utilisation was conducted comparing different age groups, and also different time periods. RESULTS: Significantly more cases presenting to the accident and emergency service with respiratory and digestive problems were found to be non-urgent, rather than appropriate accident and emergency cases. In contrast, significantly more cases presenting with circulatory and neurological problems were appropriate cases for accident and emergency department management. The morbidity pattern for the ten most frequent diagnoses seen in non-urgent cases was noted to be similar to the Hong Kong general practice morbidity pattern for self-limiting conditions. Utilisation of accident and emergency services for acute self-limiting conditions was more marked in the late evening, and also among children and the younger population in general. CONCLUSION: The utilisation of accident and emergency services by patients requiring a general practice service only, reflects problems in the primary health care delivery system. These may be solved by appropriate interfacing between general practitioners and other service providers, with the aim of providing seamless health care. Without revision of primary health care services, accident and emergency departments will continue to be used inappropriately by patients as an alternative to general practice care.

Growth and nutrition of Chinese vegetarian children in Hong Kong.

OBJECTIVE: The study investigated the nutritional status of Chinese lacto-ovo-vegetarian children aged 4-14 years. METHODOLOGY: Dietary intake over 7 days was assessed using a computer program, previously used for a local population-based dietary survey. Anthropometric measurements were made and fasting venous blood was examined for serum lipids, haematological data, iron, vitamin B12 and folate status. Bone mineral density (BMD) of the spine (L2 - L4) was measured as a reflection of calcium status. RESULTS: Fifty-one lacto-ovo-vegetarians aged 4-14 years were investigated. The mean +/- standard deviation (SD) daily energy intake was 1600 +/- 425 kcal. The mean (+/- SD) daily protein intake was 1.6 +/- 0.6 g/kg bodyweight which met the United States recommended dietary allowance. Compared to that of the local omnivore diet, the vegetarian diet was closer to the recommended healthy diet with lower fat (20-23%), more fibre (5.8-8.7 g/day) and better polyunsaturated to saturated fatty acid ratio (1.0-1.1). Growth and BMD of the vegetarian children were comparable to the general omnivore population. Two children had iron deficiency and two children had anaemia. The calcium status, as reflected by the BMD, was not impaired. Serum folate and vitamin B12 were within the normal range. Six (25%) boys and four (15%) girls were obese. Three boys had hyperlipidaemia. CONCLUSIONS: A Hong Kong Chinese vegetarian diet appears healthy, providing adequate iron and vitamin B12 nutrition, but the prevalence of obesity was high.