Prediction of hospital mortality among critically ill patients in a single centre in Asia: comparison of artificial neural networks and logistic regression-based model.

INTRODUCTION: This study compared the performance of the artificial neural network (ANN) model with the Acute Physiologic and Chronic Health Evaluation (APACHE) II and IV models for predicting hospital mortality among critically ill patients in Hong Kong. METHODS: This retrospective analysis included all patients admitted to the intensive care unit of Pamela Youde Nethersole Eastern Hospital from January 2010 to December 2019. The ANN model was constructed using parameters identical to the APACHE IV model. Discrimination performance was assessed using area under the receiver operating characteristic curve (AUROC); calibration performance was evaluated using the Brier score and Hosmer-Lemeshow statistic. RESULTS: In total, 14 503 patients were included, with 10% in the validation set and 90% in the ANN model development set. The ANN model (AUROC=0.88, 95% confidence interval [CI]=0.86-0.90, Brier score=0.10; P in Hosmer-Lemeshow test=0.37) outperformed the APACHE II model (AUROC=0.85, 95% CI=0.80-0.85, Brier score=0.14; P<0.001 for both comparisons of AUROCs and Brier scores) but showed performance similar to the APACHE IV model (AUROC=0.87, 95% CI=0.85-0.89, Brier score=0.11; P=0.34 for comparison of AUROCs, and P=0.05 for comparison of Brier scores). The ANN model demonstrated better calibration than the APACHE II and APACHE IV models. CONCLUSION: Our ANN model outperformed the APACHE II model but was similar to the APACHE IV model in terms of predicting hospital mortality in Hong Kong. Artificial neural networks are valuable tools that can enhance real-time prognostic prediction.

Ten-year territory-wide trends in the utilisation and clinical outcomes of extracorporeal membrane oxygenation in Hong Kong.

INTRODUCTION: The utilisation of extracorporeal membrane oxygenation (ECMO) has been rapidly increasing in Hong Kong. This study examined 10-year trends in the utilisation and clinical outcomes of ECMO in Hong Kong. METHODS: We retrospectively reviewed the records of all adult patients receiving ECMO who were admitted to the intensive care units (ICUs) of public hospitals in Hong Kong between 2010 and 2019. Temporal trends across years were assessed using the Mann-Kendall test. Observed hospital mortality was compared with the Acute Physiology and Chronic Health Evaluation (APACHE) IV-predicted mortality. RESULTS: The annual number of patients receiving ECMO increased from 18 to 171 over 10 years. In total, 911 patients received ECMO during the study period: 297 (32.6%) received veno-arterial ECMO, 450 (49.4%) received veno-venous ECMO, and 164 (18.0%) received extracorporeal cardiopulmonary resuscitation. The annual number of patients aged ≥65 years increased from 0 to 47 (27.5%) [P for trend=0.001]. The median (interquartile range) Charlson Comorbidity Index increased from 1 (0-1) to 2 (1-3) [P for trend<0.001] while the median (interquartile range) APACHE IV score increased from 90 (57-112) to 105 (77-137) [P for trend=0.003]. The overall standardised mortality ratio comparing hospital mortality with APACHE IV-predicted mortality was 1.11 (95% confidence interval=1.01-1.22). Hospital and ICU length of stay both significantly decreased (P for trend=0.011 and <0.001, respectively). CONCLUSION: As ECMO utilisation increased in Hong Kong, patients put on ECMO were older, more critically ill, and had more co-morbidities. It is important to combine service expansion with adequate resource allocation and training to maintain quality of care.

Admission triage tool for adult intensive care unit admission in Hong Kong during the COVID-19 outbreak.

Intensive care is expensive, and the numbers of intensive care unit (ICU) beds and trained specialist medical staff able to provide services in Hong Kong are limited. The most recent increase in coronavirus disease 2019 (COVID-19) infections over July to August 2020 resulted in more than 100 new cases per day for a prolonged period. The increased numbers of critically ill patients requiring ICU admission posed a capacity challenge to ICUs across the territory, and it may be reasonably anticipated that should a substantially larger outbreak occur, ICU services will be overwhelmed. Therefore, a transparent and fair prioritisation process for decisions regarding patient ICU admission is urgently required. This triage tool is built on the foundation of the existing guidelines and framework for admission, discharge, and triage that inform routine clinical practice in Hospital Authority ICUs, with the aim of achieving the greatest benefit for the greatest number of patients from the available ICU resources. This COVID-19 Crisis Triage Tool is expected to provide structured guidance to frontline doctors on how to make triage decisions should ICU resources become overwhelmed by patients requiring ICU care, particularly during the current COVID-19 pandemic. The triage tool takes the form of a detailed decision aid algorithm based on a combination of established prognostic scores, and it should increase objectivity and transparency in triage decision making and enhance decision-making consistency between doctors within and across ICUs in Hong Kong. However, it remains an aid rather than a complete substitute for the carefully considered judgement of an experienced intensive care clinician.

Congenital infections in Hong Kong: beyond TORCH.

Congenital infections refer to a group of perinatal infections that are caused by pathogens transmitted from mother to child during pregnancy (transplacentally) or delivery (peripartum) which may have similar clinical presentations, including rash and ocular findings. TORCH is the acronym that covers these infections (toxoplasmosis, other [syphilis], rubella, cytomegalovirus, herpes simplex virus). Other important causes of intrauterine/perinatal infection include human immunodeficiency virus, varicella-zoster virus, Treponema pallidum, Zika virus, and parvovirus B19. This overview aims to describe various congenital infections beyond TORCH with a Hong Kong perspective. Intrauterine and perinatal infections are a major cause of in utero death and neonatal mortality, and an important contributor to childhood morbidity. A high index of suspicion for congenital infections and awareness of the prominent features of the most common congenital infections can help to facilitate early diagnosis, tailor appropriate diagnostic evaluation, and initiate appropriate early treatment. Intrauterine infections should be suspected in newborns with clinical features including microcephaly, seizures, cataract, hearing loss, congenital heart disease, hepatosplenomegaly, small for gestational age, and/or rash. Primary prevention of maternal infections during pregnancy is key to the prevention of congenital infection, and resources (if available) should focus on public health promotion and pre-marital counselling.

Brain death in children: a retrospective review of patients at a paediatric intensive care unit.

PURPOSE: Among patients in paediatric intensive care units (PICUs), death is sometimes inevitable despite advances in treatment. Some PICU patients may have irreversible cessation of all brain function, which is considered as brain death (BD). This study investigated demographic and clinical differences between PICU patients with BD and those with cardiopulmonary death. METHODS: All children who died in the PICU at a university-affiliated trauma centre between October 2002 and October 2018 were included in this retrospective study. Demographics and clinical characteristics were compared between patients with BD and patients with cardiopulmonary death. RESULTS: Of the 2784 patients admitted to the PICU during the study period, 127 died (4.6%). Of these 127 deaths, 22 (17.3%) were BD and 105 were cardiopulmonary death. Length of PICU stay was shorter for patients with cardiopulmonary death than for patients with BD (2 vs 8.5 days, P=0.0042). The most common mechanisms of injury in patients with BD were hypoxic-ischaemic injury (40.9%), central nervous system infection (18.2%), and traumatic brain injury (13.6%). The combined proportion of accident and trauma-related injury was greater in patients with BD than in patients with cardiopulmonary death (27.3% vs 3.8%, P<0.001). Organ donation was approved by the families of four of the 22 patients with BD (18.2%) and was performed successfully in three of these four patients. CONCLUSIONS: These findings emphasise the importance of injury prevention in childhood, as well as the need for education of the public regarding acceptance of BD and support for organ donation.

Congenital infections in Hong Kong: an overview of TORCH.

Congenital infections refer to a group of perinatal infections that may have similar clinical presentations, including rash and ocular findings. TORCH is the acronym that covers these infections (toxoplasmosis, other [syphilis], rubella, cytomegalovirus, herpes simplex virus). There are, however, other important causes of intrauterine/perinatal infections, including enteroviruses, varicella zoster virus, Zika virus, and parvovirus B19. Intrauterine and perinatal infections are significant causes of fetal and neonatal mortality and important contributors to childhood morbidity. A high index of suspicion for congenital infections and awareness of the prominent features of the most common congenital infections can help to facilitate early diagnosis, tailor appropriate diagnostic evaluation, and if appropriate, initiate early treatments. In the absence of maternal laboratory results diagnostic of intrauterine infections, congenital infections should be suspected in newborns with certain clinical features or combinations of clinical features, including hydrops fetalis, microcephaly, seizures, cataract, hearing loss, congenital heart disease, hepatosplenomegaly, jaundice, or rash. Primary prevention of maternal infections during pregnancy is the cornerstone of prevention of congenital infection. Available resources should focus on the promotion of public health.

Effects of thermal boundary condition on methane oxidation in landfill cover soil at different ambient temperatures.

Microbial aerobic methane oxidation (MAMO) has been considered as an environmental-friendly method for mitigating methane emission from municipal landfill sites. Soil column has in a landfill cover under one-dimensional (1-D) condition. However, most of the published soil column tests failed to simulate 1-D heat transfer due to the use of thermal conductive boundary at the sidewall. In the present study, a heavily instrumented soil column was developed to quantify the effects of thermal boundary condition on the methane oxidation efficiency under different ambient temperatures in landfill cover soil. The sidewall of the soil column was thermally insulated to ensure 1-D heat transport as would have been typically expected in the field condition. Two soil column tests with and without thermal insulation were conducted at a range of controlled ambient temperatures from 15 to 30°C, for studying how soil moisture, matric suction, gas pressure, soil temperature and gas concentration evolve with MAMO. The test results reveal that ignoring thermal insulation in a soil column test would result in a greater loss of soil heat generation by MAMO and hence oxidation efficiency by up to 100% for the range of temperature considered. When the ambient temperature increased to 30°C (but less than the optimum temperature for MAMO), the MAMO efficiency increased abruptly at first but then decreased substantially with time, and this is likely due to the accumulation of biomass generated by MAMO.

Rubella (German measles) revisited.

Rubella is generally a mild and self-limited disease in children. During pregnancy, rubella can have potentially devastating effects on the developing fetus. Postnatal rubella is transmitted primarily by inhalation of virus-laden airborne droplets or direct contact with infected nasopharyngeal secretions. In susceptible pregnant women, the virus may cross the placenta and spread through the vascular system of the developing fetus. Postnatally acquired rubella typically begins with fever and lymphadenopathy, followed by an erythematous, maculopapular rash. The rash classically begins on the face, spreads cephalocaudally, becomes generalised within 24 hours, and disappears within 3 days. Maternal rubella, especially during early pregnancy, may lead to miscarriage, intrauterine fetal death, premature labour, intrauterine growth retardation, and congenital rubella syndrome. Cataracts, congenital heart defects, and sensorineural deafness are the classic triad of congenital rubella syndrome and they typically occur if the fetal infection occurs in the first 11 weeks of gestation. Laboratory confirmation of rubella virus infection can be based on a positive serological test for rubella-specific immunoglobulin M antibody; a four-fold or greater increase in rubella-specific immunoglobulin G titres between acute and convalescent sera; or detection of rubella virus RNA by reverse transcriptase-polymerase chain reaction. Treatment is mainly symptomatic. Universal childhood immunisation and vaccination of all susceptible patients with rubella vaccine to decrease circulation of the virus are cornerstones to prevention of rubella and, more importantly, congenital rubella syndrome.

Numerical modelling of methane oxidation efficiency and coupled water-gas-heat reactive transfer in a sloping landfill cover.

Microbial aerobic methane oxidation in unsaturated landfill cover involves coupled water, gas and heat reactive transfer. The coupled process is complex and its influence on methane oxidation efficiency is not clear, especially in steep covers where spatial variations of water, gas and heat are significant. In this study, two-dimensional finite element numerical simulations were carried out to evaluate the performance of unsaturated sloping cover. The numerical model was calibrated using a set of flume model test data, and was then subsequently used for parametric study. A new method that considers transient changes of methane concentration during the estimation of the methane oxidation efficiency was proposed and compared against existing methods. It was found that a steeper cover had a lower oxidation efficiency due to enhanced downslope water flow, during which desaturation of soil promoted gas transport and hence landfill gas emission. This effect was magnified as the cover angle and landfill gas generation rate at the bottom of the cover increased. Assuming the steady-state methane concentration in a cover would result in a non-conservative overestimation of oxidation efficiency, especially when a steep cover was subjected to rainfall infiltration. By considering the transient methane concentration, the newly-modified method can give a more accurate oxidation efficiency.

Theoretical analysis of coupled effects of microbe and root architecture on methane oxidation in vegetated landfill covers.

Reduction of soil moisture by plant root-water uptake could improve soil aeration for microbial aerobic methane oxidation (MAMO) in a landfill cover, but excessive soil moisture removal could suppress microbial activity due to water shortage. Existing models ignore the coupled microbe-vegetation interaction. It is thus not known whether the presence of plants is beneficial or adverse to MAMO. This study proposes a newly-improved theoretical model that couples the effects of root-water uptake and microbial activity for capturing water-gas flow and MAMO in unsaturated soils. Parametric studies are conducted to investigate the effects of root characteristics and transpiration rate on MAMO efficiency. Uniform, parabolic, exponential and triangular root architectures are considered. Ignoring the effects of water shortage on microbe over-predicts the MAMO efficiency significantly, especially for plants with traits that give high root-water uptake ability (i.e., uniformly-rooted and long root length). The effects of plants on MAMO efficiency depends on the initial soil moisture strongly. If the soil is too dry (i.e., close to the permanent wilting point), plant-water uptake, with any root architecture considered, would reduce MAMO efficiency as further soil water removal by plants suppresses microbial activity. Plants with exponential or triangular root architectures could preserve 10% higher MAMO than the other two cases. These two architectures are more capable of minimizing the adverse effects of root-water uptake due to microbial water shortage. This implies that high-water-demand plants such as those with long root length and with uniform or parabolic root architectures require more frequent irrigation to prevent from excessive reduction of MAMO efficiency.

The use of a syndesmosis procedure for the treatment of hallux valgus: good clinical and radiological results two years post-operatively.

Metatarsus primus varus deformity correction is one of the main objectives in hallux valgus surgery. A 'syndesmosis' procedure may be used to correct hallux valgus. An osteotomy is not involved. The aim is to realign the first metatarsal using soft tissues and a cerclage wire around the necks of the first and second metatarsals. We have retrospectively assessed 27 patients (54 feet) using the American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographs and measurements of the plantar pressures after bilateral syndesmosis procedures. There were 26 women. The mean age of the patients was 46 years (18 to 70) and the mean follow-up was 26.4 months (24 to 33.4). Matched-pair comparisons of the AOFAS scores, the radiological parameters and the plantar pressure measurements were conducted pre- and post-operatively, with the mean of the left and right feet. The mean AOFAS score improved from 62.8 to 94.4 points (p < 0.001). Significant differences were found on all radiological parameters (p < 0.001). The mean hallux valgus and first intermetatarsal angles were reduced from 33.2° (24.3° to 49.8°) to 19.1° (10.1° to 45.3°) (p < 0.001) and from 15.0° (10.2° to 18.6°) to 7.2° (4.2° to 11.4°) (p < 0.001) respectively. The mean medial sesamoid position changed from 6.3(4.5 to 7) to 3.6 (2 to 7) (p < 0.001) according to the Hardy's scale (0 to 7). The mean maximum force and the force-time integral under the hallux region were significantly increased by 71.1% (p = 0.001), (20.57 (0.08 to 58.3) to 35.20 (6.63 to 67.48)) and 73.4% (p = 0.014), (4.44 (0.00 to 22.74) to 7.70 (1.28 to 19.23)) respectively. The occurrence of the maximum force under the hallux region was delayed by 11% (p = 0.02), (87.3% stance (36.3% to 100%) to 96.8% stance (93.0% to 100%)). The force data reflected the restoration of the function of the hallux. Three patients suffered a stress fracture of the neck of the second metatarsal. The short-term results of this surgical procedure for the treatment of hallux valgus are satisfactory.