OBJECTIVE. To validate the Hong Kong Accident and Emergency Triage guidelines.

DESIGN. Retrospective chart review.

SETTING. The Accident and Emergency Department of a tertiary hospital in Hong Kong.

PARTICIPANTS. Patients who attended the Accident and Emergency Department on one day in February 2012.

MAIN OUTCOME MEASURES. The inter-rater reliability in two pairs of nurses grouped according to experience and validity as compared with an expert panel.

RESULTS. Of the 100 patients recruited and triaged into levels 1 to 5, the weighted kappa coefficient (inter-rater reliability) for the two pairs of nurses was 0.699 and 0.717, respectively. The weighted kappa coefficient for validity was 0.766. When only patients in triage levels 3 and 4 were included, the weighted kappa coefficient for reliability dropped to 0.632 and 0.585, respectively. The weighted kappa coefficient for validity also decreased to 0.558.

CONCLUSIONS. The overall inter-rater reliability and validity of the Guidelines appeared acceptable. Further revision of the Guidelines on triaging patients to levels 3 or 4 is probably necessary.

Key words: Emergency service, hospital; Triage; Validation studies

View this abstract indexed in MEDLINE:

OBJECTIVES. (1) To evaluate the safety and efficacy of supine percutaneous nephrostomy, nephrolithotomy, and combined percutaneous nephrolithotomy and ureteroscopic lithotripsy. (2) To describe the skill-acquiring process in supine procedures and share our initial experience.

DESIGN. Three-staged case series with prospective data collection. SETTING. Two public hospitals in Hong Kong.

PATIENTS AND INTERVENTION. Stage 1: Forty patients indicated for percutaneous renal access were recruited for supine percutaneous nephrostomy with prospective data collection. Stage 2: A prospective comparative study of percutaneous nephrolithotomy involving 60 patients allocated non-randomly to a supine (n=25) or prone (n=35) approach was conducted. Stage 3: Data of 11 patients who underwent simultaneous supine percutaneous nephrolithotomy and ureteroscopic lithotripsy were prospectively captured.

RESULTS. Stage 1: The procedural success rate was 100%. The mean operating time in unilateral procedures was 44 minutes; one patient had perinephric haematoma as a complication. Stage 2: Overall stone-free rates for prone and supine procedures were 46% and 68%, respectively (P=0.087), and mean operating times were 122 and 123 minutes, respectively (P=0.905). Stage 3: Of the 11 patients, six were rendered stone-free after the first combined procedure, and one experienced transient postoperative fever. There was no major complication.

CONCLUSION. Percutaneous nephrolithotomy was feasible via both prone and supine approaches. With the exception of staghorn stones, the supine percutaneous approach was an equally safe and effective option for patients with specific conditions favouring such an approach. The ability to incorporate simultaneous ureteroscopic lithotripsy was an additional benefit of adopting the supine approach.

Key words: Kidney calculi; Nephrostomy, percutaneous; Patient positioning; Supine position

View this abstract indexed in MEDLINE:

OBJECTIVE. To evaluate potential risk factors, presenting symptoms, management, and outcomes of intracranial haemorrhage in Chinese children with immune thrombocytopenia managed in a regional hospital.

DESIGN. Retrospective case series.

SETTING. A regional hospital in Hong Kong.

PATIENTS. All paediatric patients with immune thrombocytopenia complicated by intracranial haemorrhage in the period January 1996 to December 2009.

RESULTS. Nine episodes of intracranial haemorrhage were reported in eight patients (aged 0.9 to 19 years) with immune thrombocytopenia; three of the patients had acute immune thrombocytopenia and the other five had chronic immune thrombocytopenia. Intracranial haemorrhage occurred as early as the initial presentation with immune thrombocytopenia (n=2) and as late as up to 5 years after the diagnosis. The median platelet count at the time of intracranial haemorrhage was 12 x 10⁹ /L (<10 x 10⁹ /L [n=4]; 10-20 x 10⁹ /L [n=2]; >20 x 10⁹ /L [n=3]). The bleeding was considered spontaneous in six episodes, while head trauma (n=2) and vascular malformation (n=1) were identified in three patients with mild-to-moderate thrombocytopenia (42-82 x 10⁹ /L) at the time of the bleed. Headache and mucosal bleeding were the commonest presenting symptoms (n=5). All patients received multimodal treatment after diagnosis of intracranial haemorrhage, and included platelet transfusion (n=8), intravenous immunoglobulin (n=6), methylprednisolone (n=4), and splenectomy (n=4); three individuals underwent neurosurgical interventions. One (11%) patient died of posterior fossa bleeding and one (11%) had neurological sequelae. All survivors achieved remission of their immune thrombocytopenia with a median follow-up of 5.3 years.

CONCLUSION. Intracranial haemorrhage can occur anytime during the course of immune thrombocytopenia. A high index of suspicion for intracranial haemorrhage should be maintained during follow-up, as favourable outcomes can be achieved after early and vigorous interventions.

Key words: Child; Chinese; Intracranial hemorrhages; Purpura, thrombocytopenic, idiopathic

View this abstract indexed in MEDLINE:

OBJECTIVE. To review clinical characteristics, imaging modalities, and treatment outcomes of patients referred to a multidisciplinary clinic for management of vascular malformations.

DESIGN. Retrospective case series. SETTING. Multidisciplinary vascular malformation out-patient referral clinic in a teaching hospital in Hong Kong.

PATIENTS. The 141 attendees of the clinic from August 2005 to November 2011.

MAIN OUTCOME MEASURES. Management and treatments offered, and responses to treatment.

RESULTS. Of the 141 patients, 46% were diagnosed to have low-flow vascular malformations, 16% were diagnosed to have high-flow vascular malformations, and 15% were diagnosed to have a haemangioma. Prior to attending the clinic, approximately one third (32%) of the patients had a clinical diagnosis that was consistent with the final diagnosis. Overall, the radiological and clinical diagnoses were consistent in 43% of the patients. Magnetic resonance imaging and ultrasonography were the most commonly used imaging modalities. Of the 73 patients who received active treatment, 70% had a good response, 12% had minimal improvement, 8% had no change, and 7% had a recurrence or a major complication; in 3% of the patients the outcome was unknown.

CONCLUSION. From this retrospective case series, it is evident that confusion still exists over vascular malformations and haemangiomas. Multidisciplinary clinics have a role in providing an accurate diagnosis and facilitating appropriate management and treatment plans. Magnetic resonance imaging and ultrasonography had demonstrable utility in determining the extent of the lesions and flow type.

Key words: Hemangioma; Patient care team; Port-wine stain

View this abstract indexed in MEDLINE:

OBJECTIVE. To evaluate the performance of the locally developed universal Down syndrome screening programme.

DESIGN. Population-based cohort study in the period July 2010 to June 2011 inclusive.

SETTING. Four Hong Kong Hospital Authority Departments of Obstetrics and Gynaecology and a central university-based laboratory for maternal serum processing and risk determination.

PARTICIPANTS. Women were offered either a first-trimester combined test (nuchal translucency, free beta human chorionic gonadotropin, and pregnancy-associated plasma protein-A) or nuchal-translucency-only test, or a second-trimester double test (alpha-fetoprotein and total human chorionic gonadotropin) for detection of Down syndrome according to their gestational age. Those with a trisomy 21 term risk of 1:250 or higher were offered a diagnostic test.

RESULTS. A total of 16 205 pregnancies were screened of which 13 331 (82.3%) had a first-trimester combined test, 125 (0.8%) had a nuchal-translucency test only, and 2749 (17.0%) had a second-trimester double test. There were 38 pregnancies affected by Down syndrome. The first-trimester screening tests had a 91.2% (31/34) detection rate with a screen-positive rate of 5.1% (690/13 456). The second-trimester test had a 100% (4/4) detection rate with a screen-positive rate of 6.3% (172/2749). There were seven (0.9%) pregnancies that miscarried following an invasive diagnostic test. There were two Down syndrome-affected live births, both with an estimated first-trimester trisomy 21 term risk lower than 1:250.

CONCLUSION. The universal screening programme offered at the four units was effective and achieved the expected detection rates and low false-positive rates, and to maintain these, the current emphasis on training, quality control, and regular auditing must continue.

Key words: Down syndrome; First trimester screening; Second trimester screening; Nuchal translucency; Quality control

View this abstract indexed in MEDLINE: