Characteristics, management process, and outcome of patients suffering in-hospital cardiopulmonary arrests in a teaching hospital in Hong Kong

ABSTRACT
Hong Kong Med J 2007;13:258-65 | Number 4, August 2007
ORIGINAL ARTICLE
Characteristics, management process, and outcome of patients suffering in-hospital cardiopulmonary arrests in a teaching hospital in Hong Kong
HY Yap, Thomas ST Li, KS Tan, YS Cheung, PT Chui, Philip KN Lam, Desmond WL Lam, YF Tong, MC Chu, PN Leung, Gavin M Joynt
Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVES. To examine the demographics, process indicators of adult in-hospital cardiopulmonary arrest resuscitation, and outcomes in a teaching hospital in Hong Kong.
 
DESIGN. Retrospective study.
 
SETTING. A university-affiliated tertiary referral hospital with 997 acute adult beds in Hong Kong.
 
PATIENTS. Those who suffered a cardiopulmonary resuscitation event, as documented in retrieved records of all in-patients during the inclusive period January 2002 to December 2005.
 
RESULTS. There were 531 resuscitation events; the mean (standard deviation) age of the corresponding patients was 70.7 (15.4) years. Most (83%) occurred in non-monitored areas and most (97%) were cardiopulmonary arrests. The predominant initial rhythm was asystole (52%); only 8% of patients had ventricular tachycardia/fibrillation. All the resuscitations were initiated by on-site first responders. The median times from collapse to arrival of the resuscitation team, to defibrillation, to administration of adrenaline, and to intubation were: 5 (interquartile range, 2-6) minutes, 5 (1-7) minutes, 5 (3-10) minutes, and 9 (5-13) minutes, respectively. The overall hospital survival (discharge) rate was 5%. The survival rate was higher among patients in monitored areas (9 vs 4%, P=0.046), among patients with isolated respiratory arrests (61 vs 3%, P<0.001), primary ventricular tachycardia/fibrillation arrests (13 vs 4%, P<0.001), shorter interval times from collapse to medication (1.5 vs 5 min, P=0.013), and longer interval times to intubation (12 vs 8 min, P=0.013).
 
CONCLUSION. Hospital survival after in-hospital cardiopulmonary arrests was poor. Possible strategies to improve survival include shorten time interval to defibrillation, and provision of more monitored beds.
 
Key words: Cardiopulmonary resuscitation; Emergency Service, hospital; Heart arrest; Survival rate; Treatment outcome
 
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Delayed presentation and treatment of newly diagnosed pulmonary tuberculosis patients in Hong Kong

ABSTRACT
Hong Kong Med J 2007;13:221-7 | Number 3, June 2007
ORIGINAL ARTICLE
Delayed presentation and treatment of newly diagnosed pulmonary tuberculosis patients in Hong Kong
Eric CC Leung, CC Leung, CM Tam
TB and Chest Service, Centre of Health Protection, Department of Health, Hong Kong
 
 
OBJECTIVE. To measure patients' and providers' delays in the presentation and treatment of newly diagnosed pulmonary tuberculosis.
 
DESIGN. Retrospective study using structured questionnaires.
 
SETTING. Tuberculosis and Chest Service, Centre of Health Protection, Department of Health.
 
PARTICIPANTS. Tuberculosis patients notified to the Department of Health, selected by systematic sampling of all notifications in the first 2 weeks of every even month in the year 2004.
 
MAIN OUTCOME MEASURES. Health-seeking behaviour of pulmonary tuberculosis patients, including respective demographic, clinical, and disease factors.
 
RESULTS. Of a total of 6262 notified tuberculosis patients in 2004, 1662 (26.5%) were recruited into the study; of these, 42.6% first presented to private doctors, and 57.4% to the public sector. The diagnosis of tuberculosis was made in 13.7% of these patients by the former and 86.3% by the latter. The median patient delay (elapsed time from symptoms to medical consultation) and provider delay (elapsed time from medical consultation to treatment) were both 20 days; 25th to 75th percentiles being 7-37 and 6-55 days, respectively. Longer patient delay was associated with positive sputum smear and culture, and more extensive radiological disease. On multiple regression analysis, unemployment independently predicted longer patient delay, while haemoptysis predicted shorter patient and total delay. Patients older than 60 years, with no initial sputum and chest X-ray examination predicted longer provider and total delays.
 
CONCLUSIONS. Our patient and provider delays compared favourably with those of other countries, and very likely reflect easy service access. Adverse social factors and non-specific presentations prolong patient delay, whilst older age and unavailable bacteriological/radiological evidence delay diagnosis and treatment.
 
Key words: Diagnosis; Time factors; Tuberculosis, pulmonary
 
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Adulteration of over-the-counter slimming products with pharmaceutical analogue - an emerging threat

ABSTRACT
Hong Kong Med J 2007;13:216-20 | Number 3, June 2007
ORIGINAL ARTICLE
Adulteration of over-the-counter slimming products with pharmaceutical analogue - an emerging threat
YP Yuen, CK Lai, WT Poon, SW Ng, Albert YW Chan, Tony WL Mak
Department of Pathology, Princess Margaret Hospital, Laichikok, Kowloon, Hong Kong
 
 
OBJECTIVES. To review pharmaceutical analogue adulteration of nonprescription slimming products.
 
DESIGN. Retrospective study.
 
SETTING. Tertiary referral centre for toxicology analysis, Hong Kong.
 
PATIENTS. All patients known to have been hospitalised after taking slimming products adulterated with pharmaceutical analogues from September 2004 to December 2006.
 
MAIN OUTCOME MEASURES. Age, reasons for hospital admission, major biochemical findings, and toxicology analysis results of the offending slimming products.
 
RESULTS. N-nitrosofenfluramine, an analogue of fenfluramine with hepatotoxic effect, was found in two slimming products. Three patients were hospitalised after taking these slimming products, one of whom developed liver failure treated by liver transplantation. Another slimming product was found to contain N-desmethyl-sibutramine, an analogue of sibutramine. A patient with an unremarkable medical history developed acute psychosis after taking the latter product for 1 week.
 
CONCLUSIONS. Analogues, created by modifying the chemical structures of pharmaceuticals, are used as adulterants in non-prescription slimming products, in an attempt to evade regulatory inspection. The imperceptible use of these analogues is very dangerous because they have not been tested formally for efficacy and safety. In view of the potential harm to the public, more effective and proactive measures are required to guard against the illicit use of pharmaceutical analogues. There is also a need for increased awareness among the public and the medical professionals about this emerging threat.
 
Key words: Anti-obesity agents; Fenfluramine; Liver failure, acute; Weight loss
 
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A questionnaire survey on patients' attitudes towards epidural analgesia in labour

ABSTRACT
Hong Kong Med J 2007;13:208-15 | Number 3, June 2007
ORIGINAL ARTICLE
A questionnaire survey on patients' attitudes towards epidural analgesia in labour
William WK To
Department of Obstetrics and Gynaecology, United Christian Hospital, Kwun Tong, Hong Kong
 
 
OBJECTIVES. To evaluate patient attitudes about epidural services in labour and correlate them with patient options and actual usage of epidural analgesia.
 
DESIGN. Questionnaire survey.
 
SETTING. Eight Hospital Authority obstetrics units.
 
PARTICIPANTS. A cohort of new antenatal patients and a cohort of postnatal in-patients over 1 calendar month.
 
MAIN OUTCOME MEASURES. Antenatal patient awareness of epidural services and attitudes towards epidural analgesia during labour; the actual usage of such analgesia and the reported experience of postnatal patients.
 
RESULTS. A total of 2109 and 2851 patients completed the antenatal and postnatal survey, respectively. The former revealed that only 47% of patients had been exposed to the concept of epidural analgesia in labour, and only 13% opted for such analgesia. In the postnatal cohort, the overall epidural analgesia rate was 10%, although 19% had actually requested it. Patients who received epidural analgesia in labour were more likely to consider their experience as favourable (85%) compared to those who went through labour without such analgesia (26%) [P<0.001]. There was no significant improvement in knowledge about epidural analgesia among postnatal as compared to antenatal patients. The main reasons generally ascribed by patients for not being able to obtain an epidural service despite it being requested, were related to limited resources.
 
CONCLUSION. The results showed poor general awareness of pregnant women about the proper role of epidural analgesia in labour, leading to a low patient demand for such services. Despite the low prevailing request rate for epidural analgesia in labour, there appears to be a lack of adequate resources to meet the demand.
 
Key words: Analgesia, epidural; Labor, obstetric; Patient satisfaction
 
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Universal antenatal human immunodeficiency virus (HIV) testing programme is cost-effective despite a low HIV prevalence in Hong Kong

ABSTRACT
Hong Kong Med J 2007;13:199-207 | Number 3, June 2007
ORIGINAL ARTICLE
Universal antenatal human immunodeficiency virus (HIV) testing programme is cost-effective despite a low HIV prevalence in Hong Kong
PM Lee, KH Wong
Red Ribbon Centre, Public Health Services Branch, Centre for Health Protection, Department of Health, Hong Kong
 
 
OBJECTIVE. To evaluate the cost-effectiveness of universal antenatal human immunodeficiency virus (HIV) testing in Hong Kong.
 
DESIGN. Cost-effectiveness analysis from the health care provider's perspective.
 
SETTING. Public antenatal clinics in Hong Kong.
 
PARTICIPANTS. All pregnant women who gave birth in Hong Kong during the inclusive period 1 September 2001 and 31 December 2004.
 
MAIN OUTCOME MEASURES. The primary endpoints were (i) the cost per HIV infection avoided and (ii) the cost per life-year gained.
 
RESULTS. From 2001 to 2004, a total of 160 878 deliveries were recorded in Hong Kong; and 75% of the corresponding women had HIV-testing before delivery. In all, 28 women tested HIV-positive and gave birth to 15 babies, one of which was HIV-positive. The mother of the infected baby presented late in labour, without her HIV status being diagnosed and thus missed the opportunity for prompt intervention. Assuming a natural transmission rate of 25%, it was estimated that six out of seven anticipated HIV infections among the newborns had been avoided. The cost for implementation of the programme for the first 3 years was HKD12 227 988. Hence, the average costs per HIV infection averted and per discounted life-year gained were HKD2 037 998 and HKD79 099, respectively. Sensitivity analysis showed that both the coverage and the loss-to-follow-up rate were the major determinants of the cost-effectiveness of the universal antenatal testing programme in Hong Kong.
 
CONCLUSION. The universal antenatal testing programme in Hong Kong is largely efficient. In view of the low prevalence of HIV infection, high rates of HIV testing and uptake of antiretroviral prophylaxis are crucial to the success of the programme.
 
Key words: Cost-benefit analysis; Disease transmission, vertical; HIV infections; Mass screening; Quality-adjusted life years
 
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Clinicopathological correlates in a cohort of Hong Kong breast cancer patients presenting with screen-detected or symptomatic disease

ABSTRACT
Hong Kong Med J 2007;13:194-8 | Number 3, June 2007
ORIGINAL ARTICLE
Clinicopathological correlates in a cohort of Hong Kong breast cancer patients presenting with screen-detected or symptomatic disease
Amy W Leung, Joyce Mak, Polly SY Cheung, Richard J Epstein
Department of Medicine, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
 
 
OBJECTIVES. To examine the differences in breast cancer presentation by analysing our recent experience in the diagnosis and management of breast cancer patients.
 
DESIGN. Retrospective study.
 
SETTING. Private hospital, Hong Kong.
 
PATIENTS. Consecutive patients (702 in all) referred to the hospital with newly diagnosed breast cancer over the 5-year period from 2001 to 2006.
 
MAIN OUTCOME MEASURES. Methods of detection; tumour size, lymph node involvement, and surgical treatment modalities.
 
RESULTS. Over 80% of these patients presented following self-discovery of a breast mass, whereas routine mammography accounted for only 8%. Screen-detected tumours were smaller than self-discovered tumours (2.02 vs 2.35 cm, P<0.03), and mastectomy rates were lower in mammogram-screened patients than in self-discovered disease (35% vs 50%; P=0.03). In addition, self-detected tumours were significantly more likely to be associated with lymph node involvement than screen-detected tumours (38% vs 20%; P=0.007), confirming a prognostic difference. These uncontrolled data should not be interpreted as proving either the efficacy or the cost-effectiveness of breast screening.
 
CONCLUSION. The findings suggest a disturbingly low utilisation of mammography in Hong Kong patients, and raise the possibility of a more proactive public health approach to promote such screening for susceptible target groups.
 
Key words: Breast neoplasms; Breast selfexamination; Mammography; Mass screening; Mastectomy, segmental
 
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An audit on hysterectomy for benign diseases in public hospitals in Hong Kong

ABSTRACT
Hong Kong Med J 2007;13:187-93 | Number 3, June 2007
ORIGINAL ARTICLE
An audit on hysterectomy for benign diseases in public hospitals in Hong Kong
PL Leung, SW Tsang, PM Yuen
Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Kowloon, Hong Kong
 
 
OBJECTIVE. To assess the standard of hysterectomy in public hospitals in Hong Kong, so as to improve the quality of patient care and outcome.
 
DESIGN. Clinical audit.
 
SETTING. Twelve Hong Kong Hospital Authority public hospitals.
 
PATIENTS. All patients undergoing hysterectomy for benign gynaecological conditions during the period from 1 July 2002 to 31 December 2002 inclusive.
 
RESULTS. A total of 1330 patients were included for analysis: 934 (70.2%) having abdominal hysterectomies, 184 (13.8%) having laparoscopic hysterectomies, and 212 (15.9%) undergoing vaginal hysterectomies. Uterine fibroids constituted the commonest indication for abdominal (73.7%) and laparoscopic (61.4%) hysterectomies, while genital prolapse was the most common indication (96.2%) for vaginal hysterectomy. The majority of patients undergoing laparoscopic and vaginal hysterectomy (86.3% and 84.8% respectively) were given prophylactic antibiotics, in contrast to only 45.8% of those undergoing abdominal hysterectomy. In all, 85.8% of the abdominal and vaginal hysterectomies performed by trainees were supervised, while for trainees performing laparoscopic hysterectomy, all had specialists as their first assistant. The overall incidence of complications for vaginal hysterectomy was lower than that for both abdominal hysterectomy (P<0.001) and laparoscopic hysterectomy (P<0.05). Infectious morbidity was significantly higher in patients undergoing abdominal hysterectomy without prophylactic antibiotics.
 
CONCLUSION. The overall incidence of complications was lower for vaginal hysterectomies, as compared to both abdominal and laparoscopic hysterectomies, whereas the risk of urinary tract injury was significantly higher for laparoscopic hysterectomy. According to our audit, the level of supervision for the trainees was high. However, routine antibiotic prophylaxis should be more consistently used in the territory.
 
Key words: Audit; Hysterectomy
 
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Complicated parapneumonic effusion and empyema thoracis: microbiology and predictors of adverse outcomes

ABSTRACT
Hong Kong Med J 2007;13:178-86 | Number 3, June 2007
ORIGINAL ARTICLE
Complicated parapneumonic effusion and empyema thoracis: microbiology and predictors of adverse outcomes
KY Tsang, WS Leung, Veronica L Chan, Alsa WL Lin, CM Chu
Division of Infectious Disease, Department of Medicine and Geriatrics, United Christian Hospital, Kwun Tong, Hong Kong
 
 
OBJECTIVES. To describe the microbiological characteristics of a cohort of patients with complicated parapneumonic effusion and empyema thoracis, and to identify the potential risk factors for adverse outcomes, with particular reference to the choice of empirical antibiotics, intrapleural fibrinolytics, adherence to management guidelines, and input from pulmonologists.
 
DESIGN. Retrospective review.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. All patients with a diagnosis of complicated parapneumonic effusion/empyema thoracis admitted between January 2003 and June 2005.
 
MAIN OUTCOME MEASURES. Microbiological characteristics, mortality, and surgery-free survival.
 
RESULTS. There were 63 patients, with a mean age of 64 (standard deviation, 16) years and a male-to-female ratio of 45:18. The pleural fluid culture positivity rate was 68%; Streptococcus milleri (19%), Bacteroides (14%), Klebsiella pneumoniae (12%), and Peptostreptococcus (7%) were the most common organisms. Thirteen (21%) patients died during their index admission. Use of intrapleural fibrinolytics according to the guideline was associated with survival (P=0.001) while discordant initial antibiotic use was associated with mortality (P=0.002). Discordant initial antibiotic use was also independently associated with reduced surgery-free survival (P<0.001). Subgroup analysis showed that early intrapleural fibrinolytic use (within 4 days of diagnosis) was associated with decreased mortality (P<0.001), increased surgery-free survival (P=0.005), and shorter hospital stay (P=0.039).
 
CONCLUSION. Organisms identified from complicated parapneumonic effusion and empyema thoracis differ from those giving rise to community-acquired pneumonia. In these patients, adherence to guidelines, early concordant antibiotic treatment, intrapleural fibrinolytics, and input from a pulmonologist were associated with improved outcomes.
 
Key words: Empyema, pleural; Fibrinolytic agents; Guidelines; Pleural effusion; Pneumonia; Thoracic cavity
 
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Breast pathology in complications associated with polyacrylamide hydrogel (PAAG) mammoplasty

ABSTRACT
Hong Kong Med J 2007;13:137-40 | Number 2, April 2007
ORIGINAL ARTICLE
Breast pathology in complications associated with polyacrylamide hydrogel (PAAG) mammoplasty
KM Leung, GPS Yeoh, KW Chan
Diagnostix Pathology Laboratories Ltd, Canossa Hospital, 1 Old Peak Road, Hong Kong
 
 
OBJECTIVE. To study the tissue pathology of breast lesions associated with hydrophilic polyacrylamide gel injection augmentation mammoplasty.
 
DESIGN. Retrospective study.
 
SETTING. Private anatomical pathology practice, Hong Kong.
 
PATIENTS. Eight patients who underwent lumpectomy of the breast due to complications of hydrophilic polyacrylamide gel injection for augmentation mammoplasty.
 
MAIN OUTCOME MEASURES. Identification of hydrophilic polyacrylamide gel in breast tissue and associated pathological changes.
 
RESULTS. We reviewed the pathological changes in breast tissue associated with hydrophilic polyacrylamide gel injection in eight cases retrieved from our archive. Microscopically, the hydrophilic polyacrylamide gel appeared as pools of pale violet gelatinous material of variable size, between the interstices of connective tissue and fat cells. The larger pools were often surrounded by cellular reactions consisting of histiocytic cells and foreign body-type multinucleated giant cells. Inflammatory reaction featuring infiltration by lymphocytes and plasma cells in the adjacent breast tissue was observed in samples from four patients, and a sample from another patient showed acute inflammation with abscess formation. There was no evidence of abnormal cellular proliferation, atypia or malignant change in the stromal connective tissue or ductal-acinic epithelial components of the breast tissue.
 
CONCLUSIONS. Hydrophilic polyacrylamide gel injection for augmentation mammoplasty can give rise to a breast lump and inflammation. Pathologically, this complication is associated with fibrosis, foreign body reaction, and inflammation.
 
Key words: Acrylamides; Acrylic resins; Breast implants; Cosmetics; Injections
 
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The skin prick test results of 977 patients suffering from chronic rhinitis in Hong Kong

ABSTRACT
Hong Kong Med J 2007;13:131-6 | Number 2, April 2007
ORIGINAL ARTICLE
The skin prick test results of 977 patients suffering from chronic rhinitis in Hong Kong
APW Yuen, S Cheung, KC Tang, WK Ho, BYH Wong, ACS Cheung, ACW Ho
Department of Otorhinolaryngology, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong
 
 
OBJECTIVES. To evaluate the prevalence of aetiological allergens identifiable by skin prick test alone in patients suffering from chronic rhinitis in Hong Kong, and also compared the clinical history and symptoms of skin prick test-positive versus skin prick test-negative patients.
 
DESIGN. Prospective study.
 
SETTING. Otorhinolaryngology clinic in Queen Mary Hospital of Hong Kong.
 
PATIENTS. A total of 977 patients suffering from chronic rhinitis were recruited into the study. Skin prick test was performed with a panel of allergens including house dust mites, cockroach, cat, dog, moulds, and pollens.
 
MAIN OUTCOME MEASURES. Skin prick test results and their correlation with symptoms.
 
RESULTS. Of the 977 patients, 651 (67%) had positive skin prick test reactions. The commonest allergen was house dust mite which was positive in 63% of the 977 patients and 95% of those 651 skin prick test-positive patients. The other allergens were in order of cockroach (23%), cat (14%), dog (5%), pollen (4%), and mould (3%). Compared with skin prick test-negative patients, skin prick test-positive patients were more likely to have earlier age of onset of the chronic rhinitis, association with asthma, more severe symptom in the morning, more severe symptoms of itchy nose, sneezing, nasal discharge, itchy eye, and watery eye.
 
CONCLUSIONS. Identifiable aeroallergens could be detected in 67% chronic rhinitis patients by skin prick test alone. House dust mites were the most prevalent causative allergen. There were significant differences of patterns of clinical history and symptoms severity between skin prick test-positive and skin prick test-negative patients.
 
Key words: Allergens; Rhinitis, allergic, perennial
 
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