Is it feasible to discuss an advance directive with a Chinese patient with advanced malignancy? A prospective cohort study

OBJECTIVES

Advance directives have been implemented for years in western countries, but the concept is new to Asian cultures. According to traditional Chinese culture, family members usually play a decisive role in a patient's treatment plan. Thus it may be hard to implement an advance directive despite its importance to the treatment of patients. The objectives of this study were to assess the feasibility of advance directive engagement and to explore significant contributing factors to achieving such a goal.

DESIGN

Prospective cohort study.

SETTING

Palliative Care Unit of Clinical Oncology, Tuen Mun Hospital, Hong Kong.

PATIENTS

The subjects of the investigation were adult patients diagnosed to have advanced malignancy and newly referred to the hospice service from 24 April 2009 to 30 July 2009. Data were collected from nursing assessment forms, locally designed advance directive forms, a checklist completed by oncologists, and details available in the electronic hospital record.

RESULTS

Of the 191 eligible patients, 120 (63%) had the advance directive, whereas 71 (37%) did not. In the Cox regression model, the patient having insight of a poor prognosis was the most significant factor facilitating advance directive engagement (P=0.001). Any family objection in the discussion of advance directives was also an important factor, though it did not reach statistical significance (P=0.082). Other factors like age, gender, education, religion, financial status, living environment, understanding the diagnosis, bereavement experience, type of cancer, nature of illness, courses of chemotherapy or radiotherapy received, main caregiver, in-house supporter, nurse-led clinic attendance, clinical psychologist consultation, and in-patient hospice nurse coordinator interview were all statistically insignificant.

CONCLUSIONS

Our study demonstrated that it was feasible to discuss an advance directive with Chinese patients with advanced malignancy. When patients have insight about their poor prognosis and family members have no objection, it may be appropriate to discuss an advance directive.

Chocolate: food for moods

INTRODUCTION

Chocolate is a popular food and its consumption has long been associated with enjoyment and pleasure. The effect of chocolate on mood too has long been recognised. Chocolate is thought to have interactions with neurotransmitters which contribute to mood modulation and appetite regulation. However, the evidence in chocolate and mood studies remains highly controversial. As more is known about the influence of chocolate on mood, the reasons for these effects appear increasingly complex and inter-related.

METHODS

We reviewed chocolate's properties and the principal hypotheses addressing its mood altering propensities.

RESULTS

The relationship between chocolate and mood are highly complex, combining psychopharmacological components, nutritional and sensory characteristics of the food. Individual and situational differences on chocolate consumption may also exert influence on mood and the mixed results in previous research indicate that the direction of the association remains unclear.

CONCLUSION

The association between chocolate consumption and emotions warrants further multi-prong investigations to substantiate chocolate's mood alterating propensity.

Sleep position and infant care practices in an urban community in Kuala Lumpur

Several modifiable risk factors for sudden infant death syndrome (SIDS) have been identified such as sleeping prone or on the side, sleeping on a soft surface, bed-sharing, no prenatal care and maternal ante-natal smoking. A cross-sectional survey of infant sleep and care practices was conducted among parents of babies aged below 8 months to determine the prevalence and predictors of non-supine sleep position and the prevalence of other high-risk infant care practices for SIDS. Of 263 infants, 24.7% were placed to sleep in the non-supine position and age of infants was a factor positively associated with this (adjusted odds ratio 1.275, 95% CI=1.085, 1.499). The most common modifiable risk factor was the presence of soft toys or bedding in the infants' bed or cot (89.4%). Results from this study indicate that although the predominant sleep position of Malaysian infants in this population is supine, the majority of infants were exposed to other care practices which have been shown to be associated with SIDS.

The relationship between clinically relevant depressive symptoms and episodes and duration of all cause hospitalization in Southern Chinese elderly

BACKGROUND

Identification of depression as an independent factor for increased hospital service utilization, or as part of other factors, is important for primary healthcare in possibly preventing use of hospitals. The objective of this study was to study the effects of having clinically relevant depressive symptoms in community dwelling elderly on all cause hospitalization in the elderly.

METHODS

We administered the validated Chinese version of Geriatric Depression Scale on 3770 men and women aged 65 years and over. Duration and episodes of hospitalization were assessed using 4-monthly telephone interviews and database from the Hospital Authority over a 4-year period. The associations between the presence of clinically relevant depressive symptoms and the number of hospitalizations and duration of hospitalization were studied by multiple Poisson regression analysis.

RESULTS

The presence of clinically relevant depressive symptoms was independently associated with increased episodes (RR: 1.29; CI: 1.16-1.43) and increased length of stay (RR: 1.18; CI: 1.10-1.25) for all cause hospitalization in those with and without chronic conditions at baseline.

LIMITATION

Our study relied on self report of chronic medical conditions. As a result, under-diagnosis of diseases and misclassification of disease status could not be excluded.

CONCLUSION

It was shown that clinically relevant depressive symptoms are independently associated with inpatient utilization over a 4-year period after adjustment for socioeconomic and health status in these elderly subjects. Identification and effective management of depression in primary care may be one way to reduce hospital service utilization in the elderly in China.

Self-perceived social status and health in older Hong Kong Chinese women compared with men

Economic and social factors are determinants of health, as are psychosocial factors. The present study compared self-perceived social status and its relation to health, health related quality of life and lifestyle in older women with men, adjusting for age, education level and maximum lifetime income. A cross-sectional study was conducted of 4,000 men and women aged 65 years and over in a community in the North Eastern part of Hong Kong, a Special Administrative Region in China. Participants were asked to rate their community status, education, income and occupation, on two ladders, each with ten rungs. The distributions of the two ladder scores differed, showing that although participants may not have been ranked highly in terms of money, education and job respectability, they may have ranked their community standing highly. Women and older participants tended to rank their community standing highly in spite of lower ratings in the objective measures. A social gradient in self-perceived social status, independent of objective socioeconomic measures, was noted for physical performance and health-related quality of life, rather than related to presence of specific chronic diseases or lifestyle. However, the different ratings of the two ladders suggested that mechanisms by which the gradient operates may differ between women and men. Further studies are needed to explore the health and psychosocial consequences of the gender difference in self-rated social status.

Prognostic factors in patients with acute liver failure undergoing live donor liver transplantation

Mortality from acute liver failure (ALF) is high. Live donor liver transplantation (LDLT) is the treatment of choice for ALF in Asia, because cadaveric donors are rare. We sought to review our results in ALF patients with undergoing LDLT at our center. One hundred two LDLTs were performed at our center from April 2002 to November 2007, 15 (14%) because of ALF. Mean (SEM; median, range) follow-up was 1,065 (189; 1400; 3-2046) days. Nine patients (60%) had acute exacerbation of chronic hepatitis B; and 6 (40%) had drug-induced liver injury. Age was 47 (3; 50; 27-65) years. Ten patients (67%) were men. At transplantation, laboratory values were included bilirubin, 449 (35) micromol/L; creatinine concentration, 182 (32) mmol/L. The international normalized ratio was 2.4 (0.2). The Model for End-Stage Liver Disease (MELD) score was 34 (2). Both inpatient and long-term mortality was 20% 3 of 15 patients died. The 5-year survival was 80%. Compared with survivors, patients who died had a significantly higher creatinine concentration 289 vs 155 micromol/L, international normalized ratio (3.4 vs 2.1), MELD score (47 vs 32). We conclude that despite being sick with median and mean MELD scores of 32 and 34, 80% of patients with ALF can achieve good long-term survival after LDLT.

Prognostic factors in patients with acute liver failure undergoing live donor liver transplantation

Mortality from acute liver failure (ALF) is high. Live donor liver transplantation (LDLT) is the treatment of choice for ALF in Asia, because cadaveric donors are rare. We sought to review our results in ALF patients with undergoing LDLT at our center. One hundred two LDLTs were performed at our center from April 2002 to November 2007, 15 (14%) because of ALF. Mean (SEM; median, range) follow-up was 1,065 (189; 1400; 3-2046) days. Nine patients (60%) had acute exacerbation of chronic hepatitis B; and 6 (40%) had drug-induced liver injury. Age was 47 (3; 50; 27-65) years. Ten patients (67%) were men. At transplantation, laboratory values were included bilirubin, 449 (35) micromol/L; creatinine concentration, 182 (32) mmol/L. The international normalized ratio was 2.4 (0.2). The Model for End-Stage Liver Disease (MELD) score was 34 (2). Both inpatient and long-term mortality was 20% 3 of 15 patients died. The 5-year survival was 80%. Compared with survivors, patients who died had a significantly higher creatinine concentration 289 vs 155 micromol/L, international normalized ratio (3.4 vs 2.1), MELD score (47 vs 32). We conclude that despite being sick with median and mean MELD scores of 32 and 34, 80% of patients with ALF can achieve good long-term survival after LDLT.

Reducing antimicrobial resistance through appropriate antibiotic usage in Singapore

Two alarming trends threaten the future utility of antimicrobial agents: rise of antimicrobial resistance and decline in development of new antibiotics. The continuing emergence and spread of antimicrobial-resistant microbes--a global public health issue--exacerbates the problem of paucity of new antimicrobial agents. Singapore's public sector hospitals currently have some of the highest rates of antimicrobial resistance worldwide, evolving with surprising speed over the past two decades. Because there was no systematic surveillance until fairly recently, this healthcare problem has not been emphasised. In contrast, it is difficult to assess the scale of antimicrobial resistance in the community in view of the lack of recent research, although indirect evidence suggests that this is also a source of concern. A panel comprising representatives from multiple professional healthcare societies was convened to address the issue of antimicrobial resistance in Singapore, focusing on the conservation of antibiotics against resistance. From a review of the medical literature, potentially successful strategies involve facilitating prudent and appropriate use of antimicrobial agents in tandem with other interventions in infection control. Presently, there is a lack of data on the appropriate use of antibiotics in Singapore. The recommendations of the panel are: The professions should look into ways and means to support systematic data collection on antibiotic use and appropriateness of use; The Ministry of Health should take a more active and positive role in regulating antibiotic usage; Hospitals should actively support effective antimicrobial stewardship programmes; Educators should coordinate programmes to give greater emphasis on appropriate antimicrobial prescription, and support good clinical practice; and, Local and regional branches of pharmaceutical companies should adopt the Pharmaceutical Research and Manufacturers of America's updated code of conduct on interactions with physicians as a step towards re-aligning the industry-physician relationship in the direction of educational and informational support.

Necrotizing fasciitis in rheumatic diseases

Necrotizing fasciitis is an uncommon but life-threatening complication in immunocompromised hosts. We reported four patients with rheumatic diseases complicated by necrotizing fasciitis and reviewed 14 others from literature search. Most patients were on corticosteroid treatment. Septic shock, disseminated intravascular coagulopathy and acute renal deterioration were common giving rise to an overall mortality rate of 27.8%. Septic arthritis may also complicate the condition. Statistical analysis on the series showed the lack of major surgical debridement as the only risk factor associated with increased mortality (RR 7.5, 95% CI 2.1-27.3, P = 0.01). Timely debridement of necrotic tissue is important for reducing mortality.

Effects of an education programme on family participation in the rehabilitation of children with developmental disability

The growth and development of children with developmental disability depend very much on the parents. The present study was designed to examine whether family-focused education could enhance parental skills, knowledge and competency. The enhancement would in turn result in greater parental participation in the rehabilitation process of these children. The parental needs of Chinese parents were reviewed for the formulation of the Family-Focused Education Programme, which was then implemented, and evaluated using a pre-test/post-test control group design. Forty parents were invited to participate in the study using a convenience sampling technique. The mean scores of these variables were in the direction of increasing after the programme, though repeated measures ANOVA did not indicate any statistically significant changes in parenting knowledge, attitude and stress. It was apparent that the Family-Focused Education Programme enhanced parental competence. Undoubtedly, the family-focused approach is crucial for enhancing parenting competency, and education is fundamental to enabling parents.

The elimination of a hydrogen atom in Na(H2O)n

By a systematic examination on Na(H2O)n, with n = 4-7, 9, 10, and 15, we demonstrate that a hydrogen loss reaction can be initiated by a single sodium atom with water molecules. This reaction is similar to the well-known size-dependent intracluster hydrogen loss in Mg+(H2O)n, which is isoelectronic to Na(H2O)n. However, with one less charge on Na(H2O)n than that on Mg+(H2O)n, the hydrogen loss for Na(H2O)n is characterized by a higher barrier and a more flexible solvation shell around the metal ion, although the reaction should be accessible, as the lowest barrier is around 8 kcal/mol. Interestingly, the hydroxide ion OH- produced in the process is stabilized by the solvation of H2O molecules and the formation of an ion pair Na+(H2O)4(H2O)n-l-4[OH-(H2O)l]. The activation barrier is reduced as the unpaired electron in Na(H2O)n moves to higher solvation shells with increasing cluster size, and the reaction is not switched off for larger clusters. This is in sharp contrast to the reaction for Mg+(H2O)n, in which the OH- ion is stabilized by direct coordination with Mg2+ and the reaction is switched off for n > 17, as the unpaired electron moved to higher solvation shells. Such a contrast illustrates the important link between microsolvation environment and chemical reactivity in solvation clusters.

Reflection on SARS precautions in a severe intellectual disabilities hospital in Hong Kong

BACKGROUND

Hong Kong went through a battle with a new respiratory disease, severe acute respiratory syndrome (SARS), from March to June 2003. All clinical settings, including rehabilitative and infirmary setting, have actively involved in fighting against the infection. The intent of this paper was to reflect on the SARS precautionary measures that had been taken in a severe intellectual disabilities hospital in Hong Kong.

METHODS

A review on six SARS precautionary measures were conducted. They were assessment of risk, formulation of operational guidelines, implementation of infection control measures, education and training of staff, conducting audits and carrying out environmental improvement work.

RESULTS

Patients were at risk of getting infected from carers, visitors, volunteers, and staff and patients of general hospitals. A SARS Quarantine Unit, isolation ward, was opened to isolate patients who might have had close contact with SARS patients during a stay in a general hospital or when they returned from home leave. Undoubtedly, both staff and relatives participated in preventing the patients from being infected. No day leave and home leave was reported and the number of hospitalization in general hospital was decreased during the critical period. Three infection control audits were conducted and improvement work was carried out subsequently.

CONCLUSION

The practice of grouping within a standard isolation room is recommended to continue in the future. Moreover, intensive infection control training for all staff is of highest importance to safeguard the health of both staff and patient.

Is dietary counselling effective in increasing dietary calcium, protein and energy intake in patients with osteoporotic fractures? A randomized controlled clinical trial

To determine the feasibility of increasing the calcium, protein and calorie intake of osteoporotic fracture patients by repeated dietary counselling delivered by a dietitian, a randomized controlled trial was conducted. Among 189 patients presenting with osteoporotic fractures to an Orthopaedics and Traumatology Department of a large regional hospital, 98 patients were randomized to the intervention group and 91 were randomized to the control group (with usual care). Intervention group received three sessions of dietary counselling with tailored made recommendations over a period of 4 months, while the control group only received dietary assessment and pamphlets on the prevention of osteoporosis. Almost all subjects in both intervention and control groups had calcium intake below the recommended level of 1000 mg at baseline. Half and 60% of subjects in both groups had total energy and protein intake below recommended levels respectively. The mean weights of control and intervention groups at baseline were 51.5 and 50.9 kg respectively, while the body mass index (BMI) were 22.6 (kg m(-2)) and 22.6 (kg m(-2)) respectively. After dietary intervention, significant increase of intake was seen in calcium intake (P = 0.0095 by t-test) in the intervention group. No significant increase was seen in protein or calorie intake. No significant change was observed in the body weight or BMI although there was a positive trend in the intervention group for all these parameters. We concluded that there was general malnutrition in Chinese elderly who presented with osteoporotic fractures. Dietary calcium could be increased by repeated professional dietary counselling. Future studies with longer duration and more objective clinical outcomes will be helpful to further demonstrate the long-term effects of dietary intervention on osteoporosis and other chronic diseases.

High incidence of clopidogrel-associated gastrointestinal bleeding in patients with previous peptic ulcer disease

BACKGROUND

In average-risk patients, the new anti-platelet agent, clopidogrel, causes less upper gastrointestinal adverse events than aspirin. However, there are no safety data on the use of clopidogrel in high-risk patients.

AIM

To evaluate the safety of clopidogrel in patients with peptic ulcer disease in a retrospective cohort longitudinal study.

METHODS

During the period from January 2000 to May 2002, 70 patients who were prescribed clopidogrel (75 mg/day) for a previous history of non-aspirin-related peptic ulcer disease or a history of aspirin-related gastrointestinal complications (dyspepsia or peptic ulcer) were recruited. The occurrence of ulcer complications (bleeding/perforation/obstruction) was the primary end-point.

RESULTS

After a median follow-up of 1 year, nine patients (12%) developed gastrointestinal bleeding and one had a perforated peptic ulcer. Clopidogrel-associated gastrointestinal bleeding was significantly more common in patients with a history of gastrointestinal bleeding than in those without (22% vs. 0%; P = 0.007; odds ratio, 1.3; 95% confidence interval, 1.1-1.5).

CONCLUSIONS

Clopidogrel is associated with a high incidence of upper gastrointestinal bleeding in high-risk patients. A previous history of gastrointestinal bleeding appears to be a predictor of adverse gastrointestinal events.

Sequential intravenous/oral antibiotic vs. continuous intravenous antibiotic in the treatment of pyogenic liver abscess

AIM

Pyogenic liver abscesses result in substantial morbidity and mortality. Antimicrobial regimens using sequential intravenous/oral therapy may reduce the length of hospital stay. In this retrospective analysis, the efficacy of continuous intravenous antibiotic therapy (group I) vs. sequential intravenous/oral antibiotic therapy (group II) was studied in patients with pyogenic liver abscess.

METHODS

One hundred and twelve consecutive patients (55 in group I and 57 in group II) with pyogenic liver abscess were analysed. Clinical response, length of hospital stay and relapse rates were examined.

RESULTS

Group II had a significantly shorter duration of intravenous antibiotic treatment (3.2 weeks vs. 5.9 weeks, P < 0.01) and a shorter length of hospital stay (28 days vs. 42 days, P < 0.01) when compared to group I. Oral antibiotics were prescribed for a median duration of 2.9 weeks in group II after discharge. No relapse occurred within 6 weeks after the completion of treatment in both groups. The cost of therapy was significantly lower in group II than in group I by 33%.

CONCLUSIONS

A sequential intravenous/oral antibiotic regime is a safe and effective treatment for pyogenic liver abscess. This reduces the cost of therapy and the length of hospital stay.

Clinical and endoscopic characteristics of non-Helicobacter pylori, non-NSAID duodenal ulcers: a long-term prospective study

BACKGROUND

The proportion of duodenal ulcers not associated with Helicobacter pylori infection or the use of non-steroidal anti-inflammatory drugs (NSAIDs) is increasing.

AIM

To identify the clinical and endoscopic characteristics of non-H. pylori, non-NSAID duodenal ulcers.

METHODS

Clinical and endoscopic data and H. pylori status were prospectively collected from consecutive patients who underwent upper endoscopy from 1997 to 1999. Patients with duodenal ulcers were identified, and those with non-H. pylori, non-NSAID duodenal ulcers were analysed further.

RESULTS

A total of 11 717 upper endoscopies were performed in 8344 patients. Of these, 1153 (14%) had duodenal ulcers. Of 599 patients with active ulcers and known H. pylori status, 104 (17%) had ulcers not associated with H. pylori or the use of NSAIDs, 393 (66%) had ulcers associated with H. pylori alone, 51 (8.5%) had ulcers associated with the use of NSAIDs alone and 51 (8.5%) had ulcers associated with both. Multivariate logistic regression analysis revealed that the presence of concomitant diseases (odds ratio=15.0; 95% confidence interval, 8.64-25.9; P < 0.001) and the absence of epigastric pain/discomfort (odds ratio=0.52; 95% confidence interval, 0.29-0.91; P=0.022) were independent predictors for non-H. pylori, non-NSAID duodenal ulcers.

CONCLUSIONS

Non-H. pylori, non-NSAID duodenal ulcers exhibit certain distinct clinical and endoscopic characteristics. The presence of concomitant diseases is an important predictive factor.

Repeated intestinal perforation caused by an incomplete form of Behçet's syndrome

Behçet's disease, as initially described, is a triad of recurrent oral and genital ulcers and relapsing uveitis. The incomplete form, in which there is no ocular involvement, has been described in Japan and Korea, but this is not commonly recognized in the southern Chinese. We reported herein a rare case of repeated intestinal perforations caused by an incomplete form of Behçet's syndrome in a southern Chinese man.

Novel mutations in ndh in isoniazid-resistant Mycobacterium tuberculosis isolates

Novel mutations in NADH dehydrogenase (ndh) were detected in 8 of 84 (9.5%) isoniazid (INH)-resistant isolates (T110A [n = 1], R268H [n = 7]), but not in 22 INH-susceptible isolates of Mycobacterium tuberculosis. Significantly, all eight isolates with mutations at ndh did not have mutations at katG, kasA, or the promoter regions of inhA or ahpC, except for one isolate. Mutations in ndh appear to be an additional molecular mechanism for isoniazid resistance in M. tuberculosis.

The generation of concentration gradients using electroosmotic flow in micro reactors allowing stereoselective chemical synthesis

The stereoselective control of chemical reactions has been achieved by applying electrical fields in a micro reactor generating controlled concentration gradients of the reagent streams. The chemistry based upon well-established Wittig synthesis was carried out in a micro reactor device fabricated in borosilicate glass using photolithographic and wet etching techniques. The selectivity of the cis (Z) to trans (E) isomeric ratio in the product synthesised was controlled by varying the applied voltages to the reagent reservoirs within the micro reactor. This subsequently altered the relative reagent concentrations within the device resulting in Z/E ratios in the range 0.57-5.21. By comparison, a traditional batch method based on the same reaction length, concentration, solvent and stoichiometry (i.e., 1.0:1.5:1.0 reagent ratios) gave a Z/E in the range 2.8-3.0. However, when the stoichiometric ratios were varied up to ten times as much, the Z/E ratios varied in accordance to the micro reactor i.e., when the aldehyde is in excess, the Z isomer predominates whereas when the aldehyde is in low concentrations, the E isomer is the more favourable form. Thus indicating that localised concentration gradients generated by careful flow control due to the diffusion limited non-turbulent mixing regime within a micro reactor, leads to the observed stereo selectivity for the cis and trans isomers.

The preparation of a series of nitrostilbene ester compounds using micro reactor technology

The synthesis of stilbene esters using Wittig chemistry has been used to illustrate the generic diversity micro reactors offer in terms of chemical control and rapid method development. The micro reactor consisted of a 'T' design based on channel geometries 200 microns wide and 100 microns deep, etched into borosilicate glass and sealed with a borosilicate top plate using a thermal bonding technique. The movement of the reagent and products was achieved using electroosmotic flow (EOF), assisted by the incorporation of micro porous silica frits within the micro-channels to allow accurate solution control. To optimise the operating conditions methyl 4-formylbenzoate, premixed with sodium methoxide, was reacted with 2-nitrobenzyl-triphenylphosphonium bromide in dry degassed MeOH using flow conditions for both reagents of 0.40 microL min-1 for 20 min. A product yield of 70% (2:1 reaction stoichiometry with the aldehyde in excess) was obtained representing a 10% increase compared with the traditional batch synthesis. To demonstrate the capability of micro reactors to perform atom efficient synthesis a series of experiments based on an injection methodology (optimised to 30 s) were performed in the micro reactor at 1:1 stoichiometry resulting in a yield of 59%. Finally, the capability of micro reactors to perform a series of analogue reactions was investigated. The yields for a further three aldehydes indicated that the technology will be suitable for the development of automated device to support the generation of combinatorial libraries and rapid high throughput synthetic methods.