Sodium ramping reduces hypotension and symptoms during haemodialysis

ABSTRACT
Hong Kong Med J 2006;12:10-4 | Number 1, February 2006
ORIGINAL ARTICLE
Sodium ramping reduces hypotension and symptoms during haemodialysis
HL Tang, SH Wong, KH Chu, W Lee, A Cheuk, CMK Tang, ILL Kong, KS Fung, WK Tsang, HWH Chan, KL Tong
Division of Nephrology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Laichikok, Hong Kong
 
 
OBJECTIVES. To evaluate the effectiveness of sodium ramping (profiling) in reducing hypotensive episodes and symptoms during haemodialysis.
 
DESIGN. Prospective study.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. Thirteen patients who experienced frequent episodes of hypotension and/or symptoms such as cramps, dizziness, chest pain, nausea, vomiting, and headache during haemodialysis in the preceding 4 weeks.
 
INTERVENTIONS. Each patient was switched from standard haemodialysis with a constant dialysate sodium concentration of 135 to 140 mmol/L to a ramped sodium haemodialysis for a period of 4 weeks. During this time the dialysate sodium concentration was ramped linearly downwards from 150 mmol/L at the beginning of dialysis to 140 mmol/L at the end of dialysis.
 
MAIN OUTCOME MEASURES. Intradialytic hypotensive episodes, intradialytic symptoms, nursing interventions, systolic and diastolic blood pressures, and interdialytic weight gain.
 
RESULTS. A total of 248 haemodialysis sessions undertaken by 13 patients were analysed. Switching from constant sodium haemodialysis to ramped sodium haemodialysis resulted in a significant reduction in the number of intradialytic hypotensive episodes from 5.8 (standard deviation, 6.4) to 2.2 (3.3) [P<0.05], the total number of intradialytic symptoms from 7.1 (3.4) to 0.9 (1.3) [P<0.01], and nursing interventions from 11.3 (6.3) to 1.7 (3.9) [P<0.01]. Post-dialysis systolic and diastolic blood pressures were higher during ramped sodium haemodialysis compared with constant sodium haemodialysis (systolic blood pressure, 139 [standard deviation, 23] vs 133 [22] mm Hg, P<0.001; diastolic blood pressure, 77 [11] vs 74 [13] mm Hg, P<0.01), and there was a trend towards a smaller drop in blood pressure after dialysis. The interdialytic weight gain with sodium ramping haemodialysis was greater compared with constant sodium haemodialysis (3.1 [standard deviation, 1.0] vs 2.7 [1.1] kg, P<0.001).
 
CONCLUSION. Sodium ramping during haemodialysis effectively reduces hypotensive episodes and intradialytic symptoms. Post-dialysis blood pressure is better maintained. A side-effect of sodium ramping is a greater interdialytic weight gain.
 
Key words: Blood pressure; Hemodialysis solutions; Kidney failure, chronic; Renal dialysis; Sodium
 
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Prevalence of workplace violence against nurses in Hong Kong

ABSTRACT
Hong Kong Med J 2006;12:6-9 | Number 1, February 2006
ORIGINAL ARTICLE
Prevalence of workplace violence against nurses in Hong Kong
RPW Kwok, YK Law, KE Li, YC Ng, MH Cheung, VKP Fung, KTT Kwok, JMK Tong, PF Yen, WC Leung
Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong
 
 
OBJECTIVES. To determine the prevalence and nature of workplace violence against nurses, and how nurses deal with such aggression; and to identify the risk factors related to violence in the hospital environment.
 
DESIGN. Cross-sectional questionnaire study.
 
SETTING. University teaching hospital, Hong Kong.
 
PARTICIPANTS. All nursing staff in the hospital, except nurses who were unable to read Chinese or who did not have patient contact (eg those worked in administrative positions), were invited to complete a questionnaire.
 
MAIN OUTCOME MEASURES. Demographic data of the respondents, incidence of and risk factors contributing to workplace violence.
 
RESULTS. A total of 420 nurses returned the completed questionnaire (response rate, 25%). Three hundred and twenty (76%; 95% confidence interval, 72-80%) nurses reported abuse of any kind—verbal abuse, 73%; bullying, 45%; physical abuse, 18%; and sexual harassment, 12%. Most (82%) nurses who experienced verbal abuse tended to confide in friends, family members, or colleagues. Some (42%) ignored the incident. Risk factors for workplace violence included: working in male wards and in certain specialties such as the Accident and Emergency Department, Community Nursing Service, and the Orthopaedics and Traumatology Department.
 
CONCLUSION. Workplace violence against nurses is a significant problem in Hong Kong. Further large-scale studies should be conducted to more closely examine the problem.
 
Key words: Nursing staff, hospital; Occupational health; Questionnaires; Violence; Workplace
 
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Barriers to participation in a phase II cardiac rehabilitation programme

ABSTRACT
Hong Kong Med J 2005;11:472-5 | Number 6, December 2005
ORIGINAL ARTICLE
Barriers to participation in a phase II cardiac rehabilitation programme
YMW Mak, WK Chan, CSS Yue
Division of Cardiology, Department of Medicine and Geriatrics, United Christian Hospital, Kwun Tong, Hong Kong
 
 
OBJECTIVES. To identify barriers to participation in a phase II cardiac rehabilitation programme and measures that may enhance participation.
 
DESIGN. Prospective study.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. Cardiac patients recruited for a phase I cardiac rehabilitation programme from July 2002 to January 2003.
 
MAIN OUTCOME MEASURES. Reasons for not participating in a phase II cardiac rehabilitation programme.
 
RESULTS. Of the 193 patients recruited for a phase I cardiac rehabilitation programme, 152 (79%) patients, with a mean age of 70.3 years (standard deviation, 11.9 years), did not proceed to phase II programme. Eleven (7%) deaths occurred before commencement of phase II and 74 (49%) patients were considered physically unfit. Reasons for the latter included fractures, pain, or degenerative changes in the lower limbs (24%), and co-morbidities such as cerebrovascular accident (19%), chronic renal failure (11%), congestive heart failure (9%), and unstable angina (8%). Phase II rehabilitation was postponed until after completion of scheduled cardiac interventions in 13% of patients. Failure of physicians to arrange the pre-phase II exercise stress test as per protocol was reported in 7% of patients. Other reasons were reported: work or time conflicts (16%), non-compliance with cardiac treatment (5%), financial constraints (4%), self-exercise (3%), fear after exercise stress testing (3%), and patients returning to their original cardiologists for treatment (3%).
 
CONCLUSIONS. A significant (79%) proportion of patients did not proceed to a phase II cardiac rehabilitation programme for a variety of reasons. These included physical unfitness, work or time conflicts, and need to attend scheduled cardiac interventions. Further studies are required to determine how to overcome obstacles to cardiac rehabilitation.
 
Key words: Cardiovascular diseases; Motivation; Patient dropouts; Patient participation
 
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An active surveillance study of vancomycin-resistant Enterococcus in Queen Elizabeth Hospital, Hong Kong

ABSTRACT
Hong Kong Med J 2005;11:463-71 | Number 6, December 2005
ORIGINAL ARTICLE
An active surveillance study of vancomycin-resistant Enterococcus in Queen Elizabeth Hospital, Hong Kong
VWM Chuang, DNC Tsang, JKS Lam, RKW Lam, WH Ng
Department of Pathology, Queen Elizabeth Hospital, 30 Gascoigne Road, Hong Kong
 
 
OBJECTIVE. To assess the rate of faecal vancomycin-resistant Enterococcus colonisation in high-risk patients in a regional hospital.
 
DESIGN. Prospective observational surveillance study.
 
SETTING. Queen Elizabeth Hospital, Hong Kong.
 
PATIENTS. From September 2001 to December 2002, stool samples from patients in the intensive care unit and patients in whom Clostridium difficile testing was requested were used for study using a broth enrichment method.
 
MAIN OUTCOME MEASURES. Number of faecal vancomycin-resistant Enterococcus colonisation.
 
RESULTS. A total of 2414 cultures from 1792 patients were tested for vancomycin-resistant Enterococcus using a broth enrichment method. Only one (0.06%) patient was found to harbour a vancomycin-resistant Enterococcus faecalis in the gastro-intestinal tract. Surveillance cultures from contacts of the case revealed another six with vancomycin-resistant Enterococcus faecalis. Vancomycin-resistant Enterococcus faecalis was also later reported from a clinical specimen (catheterized urine) of another patient. They were all epidemiologically linked to the index case. Mean inhibitory concentrations of vancomycin and teicoplanin were determined to be higher than 256 and 0.5 ug/mL, respectively by E-test for all the vancomycin-resistant Enterococcus isolates. Polymerase chain reaction analysis confirmed the presence of vanB genes and the result was in line with the phenotype. Pulsed-field gel electrophoresis confirmed a monoclonal vancomycin-resistant Enterococcus outbreak. Strict infection control measures recommended by the Centers for Disease Control and Prevention were followed and the outbreak was successfully controlled.
 
CONCLUSION. Vancomycin-resistant Enterococcus colonisation is rare, but present among high-risk patients in our hospital. A routine surveillance programme should be implemented that will enable early case detection and prompt initiation of infection control measures to prevent the emergence of an endemic situation.
 
Key words: Clostridium infections; Cross infection; Enterococcus; Feces/microbiology; Vancomycin resistance
 
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Cerebrospinal fluid to serum glucose ratio in non-hypoglycorrhachic neurological conditions

ABSTRACT
Hong Kong Med J 2005;11:457-62 | Number 6, December 2005
ORIGINAL ARTICLE
Cerebrospinal fluid to serum glucose ratio in non-hypoglycorrhachic neurological conditions
W Mak, TS Cheng, KH Chan, RTF Cheung, SL Ho
Department of Medicine, University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong
 
 
OBJECTIVES. To explore the relevance of cerebrospinal fluid to serum glucose ratio in non-hypoglycorrhachic conditions.
 
DESIGN. Retrospective observational study.
 
SETTING. Neurology ward, university teaching hospital, Hong Kong.
 
PATIENTS. Adult patients with conditions unrelated to hypoglycorrhachia who underwent lumbar puncture.
 
MAIN OUTCOME MEASURES. Cerebrospinal fluid and simultaneous serum glucose concentrations, and their ratio to each other.
 
RESULTS. Between September 1998 and August 2003, 170 cerebrospinal fluid and serum glucose samples were collected from 138 patients. Mean cerebrospinal fluid to serum glucose ratio was 0.61 (standard deviation, 0.142; range, 0.21-1.00). With the exception of cerebrospinal fluid protein level, laboratory parameters were similar among different diseases. The glucose ratio was lower than 0.6 in 43% and lower than 0.5 in 19% of samples. Cases with a low glucose ratio appeared to have higher serum glucose concentrations (significant among groups with different glucose ratios, P<0.001). The mean glucose ratio (0.65) was also significantly higher in patients with serum glucose concentration of lower than 7.8 mmol/L compared with those with serum glucose concentration between 7.8 and 11.1 mmol/L (mean, 0.46), or higher than 11.1 mmol/L (mean, 0.46) [P<0.001]. There was a strong negative correlation between the glucose ratio and serum glucose concentration (r= –0.704, P<0.001).
 
CONCLUSION. A lowered cerebrospinal fluid to serum glucose ratio is often seen in the absence of an appropriate disorder, especially when simultaneous serum glucose concentration is elevated. This may be explained by the saturation kinetics of glucose transportation in hyperglycaemia, and the time lag for cerebrospinal fluid and glucose to equilibrate when the blood level fluctuates.
 
Key words: Blood glucose; Cerebrospinal fluid; Glucose/cerebrospinal fluid; Spinal puncture
 
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Temozolomide in the treatment of recurrent malignant glioma in Chinese patients

ABSTRACT
Hong Kong Med J 2005;11:452-6 | Number 6, December 2005
ORIGINAL ARTICLE
Temozolomide in the treatment of recurrent malignant glioma in Chinese patients
DTM Chan, WS Poon, YL Chan, HK Ng
Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVE. To determine the anti-tumour efficacy and safety profile of temozolomide in local Chinese patients with recurrent malignant glioma.
 
DESIGN. Open-label trial.
 
SETTING. University teaching hospital, Hong Kong.
 
PATIENTS. Twenty-two patients had been enrolled in the study since 2001. Patients had to show unequivocal evidence of tumour recurrence or progression on gadolinium-enhanced magnetic resonance imaging after failing conventional radiotherapy and surgery for initial disease. Histology reviewed by a neuropathologist was required to show anaplastic glioma (anaplastic astrocytoma, anaplastic oligodendroglioma, or mixed anaplastic oligoastrocytoma) or glioblastoma multiforme.
 
INTERVENTIONS. Patients were treated with temozolomide (200 mg/m2 per day for the first 5 days of a 28-day cycle for four cycles) and monitored clinically every month and radiologically (gadolinium magnetic resonance imaging) at 6 months.
 
MAIN OUTCOME MEASURES. Six-month progression-free survival and objective response rate.
 
RESULTS. Twenty-two patients with recurrent malignant glioma were recruited between January 2001 and July 2004. Progression-free survival at 6 months was 54.5%. The mean progression-free survival for all patients was 7.2 months. The objective response rate, determined by gadolinium magnetic resonance imaging, was 9% for patients demonstrating a complete or partial response and a further 45% for patients demonstrating stable disease. Temozolomide was well tolerated orally with minimal adverse events.
 
CONCLUSION. Preliminary results showed that temozolomide had an acceptable safety profile and anti-tumour activity in recurrent malignant glioma in local Chinese population. The results were comparable with those of western studies.
 
Key words: Astrocytoma; Brain neoplasms; Disease-free survival; Glioblastoma; Neoplasm recurrence
 
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Fractures associated with non-accidental injury--an orthopaedic perspective in a local regional hospital

ABSTRACT
Hong Kong Med J 2005;11:445-51 | Number 6, December 2005
ORIGINAL ARTICLE
Fractures associated with non-accidental injury--an orthopaedic perspective in a local regional hospital
CM Fong, HM Cheung, PY Lau
Paediatric Orthopaedic Team, Department of Orthopaedics and Traumatology, United Christian Hospital, Kwun Tong, Hong Kong
 
 
OBJECTIVES. To identify the potential risk factors for fractures due to non-accidental injury in children, and to alert clinicians and health care workers to the diagnosis of child abuse.
 
DESIGN. Retrospective review.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. Children who were admitted to the hospital with a clinical diagnosis of child abuse with associated fracture(s) between January 1996 and April 2004.
 
MAIN OUTCOME MEASURES. Demographic data, site of fractures, and investigations performed.
 
RESULTS. Of the 377 children presented with non-accidental injuries, 29 (15 male, 14 female) had bone fractures. The mean age of the 29 children at the time of injury was 5 years and 5 months. Of the nine records showing pregnancy, seven were unplanned. Approximately 75% of the families were living in public housing estates, and 28% were receiving social security subsidy. Over half (52%) of the abused children were aged 3 years or less. A total of 78 fractures were documented with a mean of 2.7 fractures per child. The most common sites of fracture were the forearm (29%), followed by the ribs (24%). Most long bone fractures occurred in those aged 3 years or less. Fractures were detected by skeletal survey and bone scan for 90% of the children.
 
CONCLUSION. A number of potential risk factors were identified in children with fractures associated with non-accidental injury. They included age younger than 3 years, lower socio-economic status, presentation with long bone fracture, and unplanned pregnancy. Bone scan and skeletal survey are mutually complementary, and both should be performed in cases of suspected child abuse. Subsequent management requires cooperation of multi-disciplinary health care professionals.
 
Key words: Child; Child abuse; Fractures/etiology
 
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Epidemiological study of diabetic retinopathy in a primary care setting in Hong Kong

ABSTRACT
Hong Kong Med J 2005;11:438-44 | Number 6, December 2005
ORIGINAL ARTICLE
Epidemiological study of diabetic retinopathy in a primary care setting in Hong Kong
TKW Tam, CM Lau, LCY Tsang, KK Ng, KS Ho, TC Lai
Professional Development and Quality Assurance, Department of Health, 2/F Ngautaukok Jockey Club Clinic, 60 Ting On Street, Hong Kong
 
 
OBJECTIVES. To estimate the prevalence and risk factors of diabetic retinopathy in type 2 diabetic patients, and to investigate the difference in retinopathy progression in patients with normal fundi or established retinopathy at baseline and the risk factors implicated in the progression.
 
DESIGN. Retrospective community-based study.
 
SETTING. Ten primary care clinics in Hong Kong.
 
PATIENTS. Type 2 diabetic patients; subsidiary analysis included subjects with more than one screening event.
 
MAIN OUTCOME MEASURES. Patient demographics, baseline prevalence, and risk factors of diabetic retinopathy; progression of retinopathy in patients with normal fundi and established retinopathy at baseline, and the associated risk factors.
 
RESULTS. A total of 6165 patients were recruited from January 1998 to May 2004. Primary analysis included 4423 patients with good-quality retinal photographs. The mean age of the patients was 60.36 years (standard deviation, 10.80 years; range, 28-94 years), the mean duration of diabetes was 4.71 years (standard deviation, 4.67 years; range, 0.1-40.6 years), and the mean level of glycated haemoglobin was 7.47% (standard deviation, 1.44%). The prevalence of retinopathy at baseline was 28.4%. Subsidiary analysis showed progression to sight-threatening retinopathy was more common in the group with baseline retinopathy than that without (7.9% vs 0.7%), and occurred at a faster rate (mean, 1.5 [range, 0.5-3.0] vs 2.0 [1.0-4.2] years). Logistic regression revealed that the level of glycated haemoglobin was positively associated with both the onset (P<0.001) and progression of retinopathy (P=0.03).
 
CONCLUSION. Optimal glycaemic control is important for reducing sight-threatening retinopathy. Close observation is required for patients with established retinopathy as progression occurs more rapidly.
 
Key words: Diabetic retinopathy; Disease progression; Prevalence; Primary health care; Risk factors
 
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A community-based study of the prevalence of constipation in young children and the role of dietary fibre

ABSTRACT
Hong Kong Med J 2005;11:431-6 | Number 6, December 2005
ORIGINAL ARTICLE
A community-based study of the prevalence of constipation in young children and the role of dietary fibre
KS Ip, WTK Lee, JSH Chan, BWY Young
Department of Paediatrics and Adolescent Medicine, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
 
 
OBJECTIVES. To study the prevalence of constipation in young children, and to explore its association with dietary fibre intake.
 
DESIGN. Cross-sectional community-based study.
 
SETTING. Three kindergartens randomly selected from the eastern district of Hong Kong.
 
PARTICIPANTS. Between October 2003 and January 2004, parents of children aged 3 to 5 years completed a specially designed questionnaire and a 3-day dietary record form, which were used to collect information on bowel function and dietary intake. Children with constipation were identified based on Rome criteria. Children with normal bowel habits served as a comparison group.
 
MAIN OUTCOME MEASURES. Dietary intake of energy, protein, and dietary fibre.
 
RESULTS. Of 778 children recruited, 561 complete sets of data were successfully obtained from the participating kindergartens. One hundred and sixty-six (29.6%) children were found to be constipated. The incidence of a family history of constipation was significantly higher in the constipated group (14%) than in the non-constipated group (7%) [P=0.013]. Mean dietary fibre consumption was 4.1 g/d (standard deviation, 2.3 g/d) in all children corresponding to 45.5% (standard deviation, 24.9%) of the daily recommendation. Constipated children (mean, 40.7%; standard deviation, 20.5%) had a significantly lower dietary fibre intake of the daily recommendation than the non-constipated group (mean, 47.5%; standard deviation, 26.2%) [P=0.017].
 
CONCLUSION. Up to 30% of preschool children in the eastern district had constipation. A family history of constipation was related to its occurrence in the studied children. Dietary fibre intake was insufficient in all children and even lower in those who were constipated.
 
Key words: Child; Constipation; Dietary fiber; Prevalence
 
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Child behaviour and parenting stress in Hong Kong families

ABSTRACT
Hong Kong Med J 2005;11:373-80 | Number 5, October 2005
ORIGINAL ARTICLE
Child behaviour and parenting stress in Hong Kong families
C Leung, S Leung, R Chan, K Tso, F Ip
Family Health Service, Department of Health, Wu Chung House, 213 Queen's Road East, Wanchai, Hong Kong
 
 
OBJECTIVES. To examine parent perception of child behaviour problems and parenting stress in Hong Kong, and to assess the extent to which they are related to socio-demographic factors and the availability of social support.
 
DESIGN. Cross-sectional survey by using a questionnaire.
 
SETTING. Maternal and Child Health Centres, Hong Kong.
 
PARTICIPANTS. Parents of children aged 4 years who were registered with Maternal and Child Health Centres and were living in Hong Kong between September 2002 and February 2003.
 
MAIN OUTCOME MEASURES. Child behaviour problems and parenting stress.
 
RESULTS. A total of 1009 questionnaires were returned giving a participation rate of 67.0%. About one tenth of parents were experiencing difficulties with their children's behaviour. Parenting stress and children's behaviour problems were associated with presence or absence of social support. Parenting stress was also associated with household income.
 
CONCLUSIONS. The prevalence of child behaviour problems in Hong Kong is comparable with international figures. Intervention programmes should be targeted at parents who experience difficulties with their children's behaviour and parenting.
 
Key words: Child behavior; Child health services; Parenting; Social support
 
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