Hong Kong Society of Clinical Blood Management recommendations for implementation of patient blood management

Patient blood management (PBM) is a patient-centred, multidisciplinary approach to optimise red cell mass, minimise blood loss, and manage tolerance to anaemia in an effort to improve patient outcomes. Well-implemented PBM improves patient outcomes and reduces demand for blood products. The multidisciplinary approach of PBM can often allow patients to avoid blood transfusions, which are associated with less favourable clinical outcomes. In Hong Kong, there has been increasing demand for blood in the ageing population, and there are simultaneous blood safety and donor issues that are adversely affecting the blood supply. To address these challenges, the Hong Kong Society of Clinical Blood Management recommends implementation of a PBM programme in Hong Kong, including strategies such as optimising red blood cell mass, improving anaemia management, minimising blood loss, and rationalising the use of blood and blood products.

An expression study of hormone receptors in spontaneously developed, carcinogen-induced and hormone-induced mammary tumors in female Noble rats

The Noble (Nb) rat model has been used in the study of hormonal carcinogenesis of mammary and prostate glands, as this rat strain is susceptible to tumor induction in these glands by hormonal treatments. Recently, we demonstrated that this rat strain can develop spontaneously mammary tumors at high incidence in aged animals and also show high sensitivity to chemical carcinogens (DMBA and MNU) and combined treatments with sex hormones in mammary tumor induction. In the present study, we examined and compared the expression of hormone receptors [including estrogen receptors (ERalpha and ERbeta), androgen receptor (AR), progesterone receptor (PR), prolactin receptor (PRLR)] and prolactin (PRL) by immunohistochemistry, Western blotting and RT-PCR in spontaneous mammary tumors, and mammary tumors induced by sex hormones (T+E2 and T+DES for 8-10 months) and DMBA in Nb rat model. Immunohistochemistry and Western blotting showed that both the spontaneously developed and hormone-induced carcinomas exhibited strong immunoreactivity of ERalpha, ERbeta, AR, PR and PRLR, while the spontaneous fibroadenomas showed weak to moderate immunoreactivity of ERalpha and PRLR, whereas the DMBA-induced carcinomas exhibited weak to moderate immunoreactivity of ERalpha, AR, PR and PRLR, and sporadic weak ERbeta immunoreactivity. RT-PCR analyses showed that mRNA expression pattern of these markers resembled that of proteins. In addition, weak mRNA expression of PRL was detected in spontaneous carcinomas and carcinomas induced by DMBA and hormones, suggesting that PRL could be produced locally within the tumors. The results showed that the expression status of hormone receptors and PRL was different in spontaneous mammary tumors and tumors induced by carcinogen or hormones, suggesting that the extent of involvement of steroid hormones and their receptors in the spontaneous, carcinogen- or hormone-induced mammary carcinogenesis might be different.

Recommendations are needed for adolescent and adult pertussis immunisation: rationale and strategies for consideration

Pertussis vaccination of infants has dramatically reduced disease, complications and deaths in infancy and early childhood. But there is still a major public health challenge--to deal with the morbidity and economic burden of illness in older children, adolescents and adults. Furthermore, it is these groups that form a major source of infection for non-immunised and partially immunised infants who are at high risk of severe complications. Adult-type acellular pertussis vaccine confers safe and effective protection against pertussis. There are several strategies to consider for immunising older individuals. Universal vaccination of all age groups would be the best available strategy for protecting individuals. It would also reduce the potential for transmitting the disease to other susceptibles, particularly infants. However, such a policy may be difficult both logistically and economically at this time. More easily achievable as a first step would be a strategy of universal adolescent booster vaccination combined with a programme targeted at adults most likely to have contact with very young babies including healthcare and childcare workers, parents and close family contacts. There is also potential for offering vaccination to adults (and their carers and close contacts) whose medical conditions or advanced age may place them at increased risk of more severe pertussis disease. Specific details of immunisation programmes must be made on a country by country basis depending on local circumstances.

Sharing Pacific-Rim experiences in disasters: summary and action plan

INTRODUCTION

The discussions in this theme provided an opportunity to address the unique hazards facing the Pacific Rim.

METHODS

Details of the methods used are provided in the preceding paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. Since the findings from the Theme 3 and Theme 7 groups were similar, the chairs of both groups presided over one workshop that resulted in the generation of a set of action plans that then were reported to the collective group of all delegates.

RESULTS

The main points developed during the presentations and discussion included: (1) communication, (2) coordination, (3) advance planning and risk assessment, and (4) resources and knowledge.

DISCUSSION

Action plans were summarized in the following ideas: (1) plan disaster responses including the different types, identification of hazards, focusing training based on experiences, and provision of public education; (2) improve coordination and control; (3) maintain communications, assuming infrastructure breakdown; (4) maximize mitigation through standardized evaluations, the creation of a legal framework, and recognition of advocacy and public participation; and (5) provide resources and knowledge through access to existing therapies, the media, and increasing and decentralizing hospital inventories.

CONCLUSIONS

The problems in the Asia-Pacific rim are little different from those encountered elsewhere in the world. They should be addressed in common with the rest of the world.

Reversal of TNF-alpha resistance by hyperthermia: role of mitochondria

The aim of this study is to examine the effect of hyperthermia on tumour necrosis factor-alpha (TNF-alpha) resistance in L929-11E cells. L929-11E is a TNF-alpha resistant variant derived from L929 cells, a commonly used model for TNF-alpha study. Based on the results from flow cytometry and Western blotting, hyperthermia (43 degrees C, 3 h) was found to induce apoptosis, mitochondrial potential (delta psi(m)) depolarization and release of cytochrome c in L929-11E cells. Similar responses were found in L929 cells when treated with TNF-alpha. Heating at 43 degrees C for 1 h did not significantly damage the mitochondria of L929-11E cells but partially reversed their resistance to TNF-alpha. When L929-11E cells were sequentially treated with heating (43 degrees C, 1 h) and TNF-alpha, a more severe damage in mitochondria was observed. Taken together, our results indicate (1) hyperthermia induced apoptosis in L929-11E cells via mitochondrial damages in a way very similar to the action of TNF-alpha in L929 cells, (2) hyperthermia could be used to overcome TNF-alpha resistance by altering mitochondrial activities and (3) L929-11E and its parental cells provide a useful model in elucidating the signalling linkage between TNF-alpha receptor and mitochondria.

Obstructive sleep apnea syndrome in obese Singapore children

We set out to determine the prevalence of obstructive sleep apnea syndrome (OSAS) among obese Singapore school children and identify risk factors for OSAS. This study was designed as a prospective study in three phases. Parents completed a questionnaire with regards to sleep and daytime symptoms in Phase 1. Children suspected to have OSAS based on the questionnaire and all with a percent ideal body weight (IBW) >/=180 were called for clinic visits in Phase 2. All whose percent IBW >/=180 and those in whom the physicians strongly suspected OSAS were subjected to a polysomnogram in phase 3. The children were recruited from the School Health Nutritional Clinic for obese children. The investigations were carried out at Tan Tock Seng Hospital. In all, 3,671 children were screened with the questionnaire. Of these, 146 were selected to undergo polysomnography. Twenty-six had abnormal sleep studies with apnea/hypoxia indices (AHIs) >5/hr. The significant clinical feature which correlated with OSAS was sleep sitting up (P = 0.005). The risk is higher in morbidly obese (IBW >/=180), with a prevalence of 13.3% (8/60), than in less obese children (IBW <180). One in eight (12.5%) of these children was asymptomatic and would have been missed based on the questionnaire. Presence of adenotonsillar hypertrophy led to increased risk of OSAS. The prevalence of OSAS was 0.7% (26/3,671) among the obese schoolchildren in Singapore, which is similar to the prevalence reported by others. Using discriminant analysis, the estimated prevalence increased to 5.7%. In the morbidly obese (IBW >/=180), the prevalence rate is higher at 13.3%.

Complicated varicella zoster infection in 8 paediatric patients and review of literature

BACKGROUND

This is a study of complicated varicella zoster infection in paediatric patients.

AIM

To find out the number of patients with such complications, the types of complications and their outcome.

METHOD

This involved a retrospective review of the case records of 8 patients who presented to our unit over a 12-month period (Jan-Dec 96). All patients were previously well without any underlying immunodeficiency. Varicella zoster (VZ) infection was confirmed by VZ immunofluorescence from vesicular fluid.

RESULTS

CMS complications accounted for 6 of the 8 cases. Of these, 3 presented with encephalitis, 2 with cerebella ataxia and 1 with aseptic meningitis and cerebella ataxia. Of the non-CNS cases, 1 presented with glomerulonephritis with superimposed staphylococcus infection of skin ulcers; the other had disseminated VZ infection with haemorrhagic vesicles, hepatitis, ileus with mesenteric adenitis and disseminated intravascular coagulation.

OUTCOME

The patient with disseminated VZ infection and multiple organ involvement died 5 days after a stormy course. One patient with encephalitis who had status epilepticus for 2 hours had behavioural problems and poor memory. The remaining 6 patients had no sequelae.

CONCLUSION

VZ infection usually a minor illness, can result in serious life-threatening complications in previously healthy patients.

Lungs in thalassaemia major patients receiving regular transfusion

Progressive tissue iron deposition from multiple blood transfusions is common in beta-thalassaemia and pulmonary iron deposition may result in parenchymal damage. The objectives of this study were to: 1) determine the predominant pulmonary dysfunction in patients with thalassaemia major; and 2) demonstrate that parenchymal disease, if present, is at the level of the alveolocapillary membrane. Fourteen thalassaemia major patients (13 nonsmokers) receiving regular blood transfusion and without any history of chronic respiratory disease were recruited. Pulmonary function tests and echocardiography were performed before the scheduled transfusions. Three patients with the most restricted lung function were selected for high resolution computerized tomography (CT) of the lungs. One patient had an obstructive pattern with a forced expiratory volume in one second as percentage of forced vital capacity (FEV1/FVC) of 71%. Four patients demonstrated a restrictive pattern, as defined by total lung capacity (TLC) less than 80% predicted with normal FEV1/FVC%. Twelve patients had pulmonary transfer factors for carbon monoxide (TL,CO) below 80% pred, even after correction for the anaemia, indicating parenchymal disease. Eight of these 12 patients had alveolocapillary membrane defect, as demonstrated by a gas transfer factor of the pulmonary membrane (Tm) less than 80% pred. Mean resting arterial oxygen saturation was 95 +/- 2 (range 92-98) %. Eleven patients had oxygen desaturation of 5% or more during exercise on a bicycle ergometer, consistent with interstitial lung disease. There was no clinical or echocardiographic evidence of heart failure. Percentage predicted TLC was inversely correlated with age (r = -0.547; p = 0.043). Both percentage predicted TLC and TL,CO were not correlated with iron burden or desferoxamine ratio. High resolution CT in the three selected patients showed no evidence of pulmonary fibrosis. We conclude that thalassaemia major patients have a predominant restrictive lung dysfunction with pulmonary parenchymal disease and alveolocapillary membrane block. The restrictive and interstitial lung disease could not be accounted for by iron loading or pulmonary fibrosis in our patients.

Etiology of acute severe lower respiratory tract infection in hospital-based patients

Acute respiratory infections are common childhood illnesses. Most are mild and self-limiting. Five percent are lower respiratory tract diseases and are potentially serious. A prospective study was conducted to ascertain the etiology of community-acquired severe lower respiratory tract infections (LRTI) in hospital based patients. Mycoplasma was the most frequently identified agent (33%). This was followed by viruses (28%) and bacteria (15%). Twenty-four percent of children had no identified causative agent.

ECG abnormalities in Kawasaki disease and their value in predicting coronary artery aneurysms

ECG abnormalities suggestive of carditis were encountered in 20 of 25 patients (80%) with Kawasaki Disease. The commonest abnormalities were raised S-T segments (11 patients), increased Q/R ratio (11 patients) and prolonged corrected Q-T interval (7 patients). Six patients had coronary artery dilatation and all resolved on subsequent 2-D Echocardiography. These six patients all had ECG changes of carditis. Such changes were present in 74% of patients with normal coronary arteries. The differences were not significant. A similar comparison between the two groups using the modified Asai scoring system failed to show the usefulness of this scoring system in predicting the risk of coronary artery involvement in our patients.

Clinical features and haematological indices of bacterial infections in young infants

The clinical features and haematologic indices of 100 young infants aged 3 months and below, admitted with suspected bacterial infections, were analysed. Fever, lethargy, hepatomegaly, poor feeding and irritability were the commonest features for suspecting a bacterial infection in these infants. However, the features significantly associated with bacterial infections were respiratory distress and cyanosis. Of the haematologic indices commonly associated with bacterial infections, only C-reactive protein and erythrocyte sedimentation rate were significantly predictive compared to leukocyte counts, absolute neutrophil counts and nitro-blue tetrazolium tests. When used in combination, a raised C-reactive protein with erythrocyte sedimentation rate, a raised erythrocyte sedimentation rate with abnormal leukocyte counts and a raised C-reactive protein with abnormal leukocyte counts were significantly associated with bacterial infections.

Normal boron excretion levels and borates related gastroenteritis cases in Singapore

Urinary borates calculated as boric acid were found to span 0 to 54 microgramme per ml urine for both Singaporean adults (population size: 507) and children (population size: 162). The normal dietary boron intake could account for the urinary boric acid levels observed. Of the hundred and fifty-three children who suffered from gastroenteritis in Singapore over the period from Jan to May 1989, two were found to have urinary boric acid exceeding 54 micrograms per ml urine. One of them was said to have consumed fish balls, bean curds and noodles prior to the onset of illness. These food items were among those likely to have added borates. Unfortunately, the dietary intake prior to the onset of illness of the other child was not recorded. Of the hundred and twelve adults affected by gastroenteritis in Dec 1988 in the Tiong Bahru area, one was found to have boric acid level of 117 micrograms per ml urine, indicative of added borates in the diet. The present study showed that borates related gastroenteritis incidents in Singapore over the time-period of our study at least, were few and far in between. With the on-going surveillance for the presence of added borates in both locally manufactured and imported food and the continued tight control over the importation and sale of borates, future incidents are likely to be minimal.

Margosa oil poisoning as a cause of toxic encephalopathy

Margosa Oil is an extract of the seed of the Neem tree and is widely used as a traditional medicine by Indians in India, Sri Lanka, Burma, Thailand, Malaysia and Indonesia. Used mainly for external applications, it is often administered orally to neonates and infants regularly in small amounts. Margosa Oil causes toxic encephalopathy particularly in infants and young children. The usual features are vomiting, drowsiness, tachypnea and recurrent generalised seizures. Leucocytosis and metabolic acidosis are significant laboratory findings. Management is aimed primarily towards the control of convulsions although supportive management is equally important. Prognosis is usually good but fatalities and neurological deficits have been reported. We report here two infants with Margosa Oil poisoning presenting with encephalopathy.

Acute glomerulonephritis--changing patterns in Singapore children

This study compared the pattern of acute glomerulonephritis (AGN), a disease known to be influenced by socioeconomic and environmental factors, in children 12 years and under, for the years 1971 and 1985. All children admitted to the four major paediatric departments with haematuria and at least two of the following (oedema, hypertension or oliguria) had an initial diagnosis of AGN. A sample population from one unit from 1980 to 1984 showed that over 70% of these children had evidence of a post-streptococcal aetiology. In 1971, 411 children were admitted with AGN, as compared with only 58 in 1985. The age-sex-race standardized rates for 1971 and 1985 were 0.632 and 0.023/1,000 children 12 years and under, respectively (P less than 0.001). The mean age of presentation was lower in 1971. Over this period, Singapore saw a threefold rise in the gross national product, accompanied by rapid urbanization. On analysis of the housing pattern, only 31% of the children lived in high-rise apartments in 1971, in contrast with 86% in 1985 (P less than 0.001). The majority of non-apartment dwellers had homes in rural districts. From an epidemiological perspective, factors which could have led to the highly significant decline in prevalence of AGN in Singapore children included improvement in the socioeconomic status and health care system, and urbanization of the country.

Percutaneous balloon pulmonary valvuloplasty--the Singapore General Hospital experience

Percutaneous balloon pulmonary valvuloplasty was performed in ten children aged 4 months to 9 years (mean age = 3.9 years). Their weights ranged from 5.6 to 38 kg (mean = 16.1 kg). Seven had typical pulmonary valve stenosis, two had pulmonary atresia and previous surgical valvotomy and one had dysplastic pulmonary valve. In patients with typical pulmonary valve stenosis, significant reductions in the right ventricular systolic pressure and pulmonary systolic pressure gradients were observed immediately after balloon dilatation. Follow-up evaluation by Doppler echocardiography at six months to two years showed further reduction in pulmonary gradients in five, and in the other two, the gradients remained low. Reduction in right ventricular pressure was less in patients with pulmonary atresia and previous surgical valvotomy and patients with dysplastic pulmonary valve. Balloon pulmonary valvuloplasty is a safe and effective procedure for the relief of typical pulmonary valve stenosis. In patients with pulmonary atresia and previous surgical valvotomy, balloon valvuloplasty can be an effective palliation for decompressing the right ventricle and improving pulmonary blood flow.

Balloon atrial septostomy under two dimensional echocardiographic visualisation

From May 1988 to January 1989, we performed balloon atrial septostomy under Two Dimensional Echocardiographic visualisation on 8 patients at the bedside in the intensive care unit, in the Singapore General Hospital. Their ages ranged from 3 to 45 days (median = 7 days). Their weights ranged from 1.6 to 4.0 kg (mean +/- 2sd = 3.2 + 1.6). Five patients had transposition of the great arteries, 1 had tricuspid atresia and 2 with pulmonary atresia/stenosis. There were no complications related to the procedure. The advantage of Two Dimensional Echocardiographic imaging compared to fluoroscopy are 1) excellent visualisation of cardiac structures, 2) it can be performed safely at the bedside without transporting patient to the cardiac catheter laboratory, 3) Immediate detection of cardiac complications and 4) no radiation exposure. Balloon atrial septostomy done using Two Dimensional Echocardiographic visualisation is acceptable and safe. It is the method of choice in our department.

Danazol for treatment of refractory autoimmune hemolytic anaemia

Autoimmune hemolytic anemia (AHA) is uncommon in childhood. A female child presented with severe and chronic clinical course. She was refractory to steroid and the response to splenectomy was poor. She showed excellent remission of hematological condition with Danazol. Danazol may be the drug of choice for refractory autoimmune hemolytic anemia.

Bacterial meningitis--a four year survey in a paediatrics unit

The aim of this prospective survey was to study the clinical profile, the incidence among the various age groups, the bacteriology, sequelae and mortality in patients, with bacterial meningitis. Patients included in the study were 36 cases of bacterial meningitis admitted to the Paediatric Unit, Tan Tock Seng Hospital, Singapore, between the period January 1984 to December 1987. Of the total number of patients, 36% were in the neonatal age group. Positive bacterial cultures were obtained in 45% of cases in both the cerebrospinal fluid and blood. The incidence of neurological sequelae was about 10%. 14% of the patients died and the majority of deaths were patients in the neonatal age group. Among the patients studied, was one who had recurrent episodes of bacterial meningitis.

Acute appendicitis in Singapore children--some clinical aspects

This retrospective study of 132 patients less than 12 years of age with Appendectomy done for Acute Appendicitis showed histological confirmation in 106 patients (80.3%) and a "negative appendix" rate of 19.7%. The appendix was perforated in 31 patients (23.5%). In those patients with confirmed Acute Appendicitis, males predominate (1.7 males: 1 female) and the peak incidence was in those 9 years of age or more. Abdominal pain was present in all patients except a 13 month old infant. Abdominal tenderness was also elicited in all patients except one. Fever was present in 83 patients (78.3%), vomiting in 82 patients (77.4%) and diarrhoea in 19 patients (17.9%). There were 2 deaths in this review, giving a mortality rate of 1.9%. Postoperative complications include wound infection (13.2%), pelvic abscess (0.9%), ileus (0.9%) and adhesion obstruction (0.9%).

Acute gastroenteritis in children--aetiology and comparison of two modes of treatment

287 patients with Acute Gastroenteritis were studied. Rotavirus accounted for 29.7% and bacterial aetiology for 9.3% of the cases. In the early infant age group (0-6 months), bacterial aetiology (28.8%) was commoner than Rotavirus aetiology (7.7%). In the older age groups, Rotavirus was more common than bacteria as a cause for Gastroenteritis.

Infections in children with acute lymphoblastic leukaemia

Infective and febrile episodes were studied in 28 patients with childhood acute lymphoblastic leukaemia. Most of the infections were referrable to the respiratory tract. Organisms commonly cultured were Gram positive bacteria. The incidence of febrile episodes were generally low but was higher during induction and remission.