Occurrence and distribution of Meloidogyne spp. in fields rotated with sweetpotato and host range of a North Carolina population of Meloidogyne enterolobii

Root-knot nematodes (RKN, Meloidogyne spp.) are some of the most economically important and common plant parasitic nematodes in North Carolina (NC) cropping systems. Soil samples collected from fields planted with crops rotated with sweetpotato [Ipomoea batatas (L.) Lam.] in 39 NC counties in 2015-2018 were processed at the NC Nematode Assay Laboratory. The occurrence of second-stage juvenile (J2) RKN populations was examined based on collection year, month, county, and previous planted crop. The highest number of RKN positive samples originated from Cumberland (53%), Sampson (48%), and Johnston (48%) counties. The highest average RKN population density was detected in Sampson (147 J2/500 cm3 soil) and Nash (135 J2/500 cm3 soil) counties, while Wayne (7 J2/500 cm3 soil) and Greene (11 J2/500 cm3 soil) counties had the lowest average RKN population density. Meloidogyne enterolobii is a new invasive species that is impacting sweetpotato growers of NC. The host status of a NC population of M. enterolobii, the guava-root knot nematode, was determined by examining eggs per gram of fresh root (ER) and the final nematode egg population divided by the initial population egg count (reproductive factor, RF) in greenhouse experiments. This included eighteen vegetable, field, cover crops and weed species. The tomato 'Rutgers' was used as a susceptible control. Cabbage 'Stonehead', pepper 'Red bull', and watermelon 'Charleston gray' and 'Fascination' were hosts and had similar mean ER values to the positive control, ranging from 64 to 18,717. Among field crops, cotton, soybean 'P5018RX', and tobacco were hosts with ER values that ranged from 185 to 706. Members of the Poaceae family such as sweet corn (Zea mays) and sudangrass (Sorghum x drummondii) were non-hosts to M. enterolobii and the mean ER values ranged from 1.85 to 7. The peanut 'Tifguard' and winter wheat (Triticum aestivum) also had lower ER values than the vegetable hosts. Growers should consider planting less susceptible or non-hosts such as peanut, sudangrass, sweet corn, and winter wheat in 2-3 year crop rotations to lower populations of this invasive nematode.

Sensitivity of Meloidogyne incognita, Fusarium oxysporum f.sp. niveum, and Stagonosporopsis citrulli to succinate dehydrogenase inhibitors used for control of watermelon diseases

Watermelon is affected by diseases such as Fusarium wilt, gummy stem blight, and root-knot nematode. Succinate dehydrogenase inhibitors (SDHIs) with potential fungicide and nematicide activity provide the opportunity to control multiple diseases with one compound. In this study, we aimed to determine the sensitivity of Meloidogyne incognita race 4 (MI4), Fusarium oxysporum f.sp. niveum (FON), and Stagonosporopsis citrulli (SCIT), to existing SDHIs: benzovindiflupyr, fluopyram, cyclobutrifluram, and pydiflumetofen. All SDHIs had fungicidal activity against 19 SCIT isolates in mycelial growth assays, but isolates were most sensitive to pydiflumetofen (median EC50 = 0.41 µg/ml). Most of 50 FON isolates tested were sensitive to cyclobutrifluram for mycelial growth (median EC50 = 4.04 µg/ml) and conidial germination (median EC50 = 0.2 µg/ml) assays but were not sensitive to fluopyram. MI4 was most sensitive to cyclobutrifluram for egg hatch (mean EC50 = 0.0019 µg/ml) and J2 motility (mean EC50 = 1.16 µg/ml) assays but was not sensitive to pydiflumetofen. Significant positive correlations between the sensitivity of SCIT (mycelial growth) and FON (mycelial growth and conidial germination) for cyclobutrifluram and benzovindiflupyr (SCIT r=0.88, FON r =0.7, P< 0.0001) and cyclobutrifluram and pydiflumetofen (SCIT r=0.83, FON r =0.67 and 0.77, P< 0.0001) indicate a potential for cross-resistance between these SDHIs for these fungal pathogens. Overall, results suggest that cyclobutrifluram may be used for managing root-knot nematode, whereas it should be used judiciously for Fusarium wilt of watermelon and gummy stem blight due to the existence of insensitive isolates to the fungicide.

Pain management in community pharmacy: a survey of pharmacy customers

Introduction

Pain is one the few sensory and emotional experiences experienced by almost all humans. When pain is uncontrolled, prolonged or disabling, people are likely to seek help from healthcare professionals1. Community pharmacies are located in the centre of communities, providing easy access to highly trained healthcare professionals, and medicines, without an appointment. Consequently, many customer interactions within pharmacies may relate to pain, however current information on the utilisation of community pharmacies for pain management and the nature of interactions is limited.

Aim

To gain a greater understanding of how pharmacy customers use community pharmacies to manage pain.

Methods

A questionnaire survey was administered to customers in 14 community pharmacies situated within the East Midlands between 7th and 26th March 2022. Pharmacy customers were approached and invited to take part if they were aged 18 years or above and had capacity. Participants were asked information about their use of community pharmacy in general, and their use of community pharmacy in relation to pain and pain medicines. Responses were recorded electronically using the Qualtrics survey platform. Descriptive statistics were derived using Microsoft Excel. Ethical approval for the study was given by the School of Pharmacy Research Ethics Committee at the University of Nottingham (ref 2017-017er).

Results

Of the pharmacy customers approached, 2798 consented to taking part in the survey (response rate = 36.2%). Approximately two-thirds of participants were female (68.7%, n=1901), and around half were aged 50 years or older (51.8%, n=1434). The most common reason for visiting the pharmacy was to collect a prescription (42.5%, n=1159), followed by purchasing a non-medicinal product (34.4%, n=937). The third most common reason for visiting the pharmacy was to purchase a medicine (19.8%, n=540). The majority of customers reported purchasing a medicine for pain from the pharmacy counter in the past (84.8%, n=2277), approximately half had used a community pharmacy to get advice about a medicine for pain (55.4%, n=1468), and slightly fewer had used a community pharmacy for advice about a painful condition (41.9%, n=1076). Of those who had sought advice for a painful condition, most customers reported this being for a new painful condition (70.5%, n=759), with a third seeking advice for pain from a long-term problem (32.5%, n=350). Fewer customers had sought advice for long-term pain which had recently become worse (17.8%, n=191).

Discussion/Conclusion

A significant proportion of pharmacy customers participating in this survey reported purchasing a pain medicine from the pharmacy counter and/or seeking advice about a pain medicine or a painful condition. These results suggest community pharmacies play an important role in the management of pain and supporting the wider NHS. Whilst survey participation was substantial, the results may not reflect the use of community pharmacy throughout the UK. Further analysis of this survey and future work will help to inform how community pharmacies can develop their role in pain management to improve care and support other parts of the health service.

References

1. Thorstensson, C.A., Gooberman-Hill, R., Adamson, J. et al. Help-seeking behaviour among people living with chronic hip or knee pain in the community. BMC Musculoskelet Disord, 2009;10(1):153.

Membrane technology for pesticide removal from aquatic environment: Status quo and way forward

The noxious side effects of pesticides on human health and environment have prompted the search of effective and reliable treatment techniques for pesticide removal. The removal of pesticides can be accomplished through physical, chemical and biologicals. Physical approaches such as filtration and adsorption are prevailing pesticide removal strategies on account of their effectiveness and ease of operation. Membrane-based filtration technology has been recognized as a promising water and wastewater treatment approach that can be used for a wide range of organic micropollutants including pesticides. Nanofiltration (NF), reverse osmosis (RO) and forward osmosis (FO) have been increasingly explored for pesticide removal from aquatic environment owing to their versatility and high treatment efficiencies. This review looks into the remedial strategies of pesticides from aqueous environment using membrane-based processes. The potentials and applications of three prevailing membrane processes, namely NF, RO and FO for the treatment of pesticide-containing wastewater are discussed in terms of the development of advanced membranes, separation mechanisms and system design. The challenges in regards to the practical implementation of membrane-based processes for pesticide remediation are identified. The corresponding research directions and way forward are highlighted. An in depth understanding of the pesticide nature, water chemistry and the pesticide-membrane interactions is the key to achieving high pesticide removal efficiency. The integration of membrane technology and conventional removal technologies represents a new dimension and the future direction for the treatment of wastewater containing recalcitrant pesticides.

High-fidelity simulation training programme for final-year medical students: implications from the perceived learning outcomes

We designed a session of high-fidelity simulation training course for final-year medical students in their emergency medicine specialty clerkship. This was a new initiative with clearly defined learning outcomes. We aimed to evaluate the learning outcomes. Students completed an evaluation form at the end of the session focusing on their perceived learning outcomes. Thematic analysis was conducted for data processing. We collected responses from 149 students. In addition to the intended outcomes of the course, students gained unexpected learning outcomes from the training and some of them matched a few identified learning gaps between undergraduate medical education and their subsequent transition to early clinical practice that have been described in the literature. High-fidelity simulation training in medical school could be an effective tool to address some of the identified gaps in the transition between undergraduate medical education and postgraduate practice.

Depression and anxiety among university students in Hong Kong

INTRODUCTION

Entry into tertiary education is a critical juncture where adolescents proceed to adulthood. This study aimed to determine the prevalence of depression and anxiety, and factors associated with such symptoms, among university undergraduate students in Hong Kong.

METHODS

A cross-sectional questionnaire study was employed. A total of 1200 undergraduate students from eight University Grants Committee-funded universities were invited to complete three sets of questionnaires, including the 9-item patient health questionnaire for screening of depressive symptoms, the 7-item generalised anxiety disorder scale for screening of anxiety symptoms, and a socio-demographic questionnaire.

RESULTS

Among the valid responses (n=1119) analysed, 767 (68.5%) respondents indicated mild to severe depressive symptoms, which were associated with mild to severe anxiety symptoms. Several lifestyle and psychosocial variables, including regular exercise, self-confidence, satisfaction with academic performance, and optimism towards the future were inversely related with mild to severe depressive symptoms. A total of 599 (54.4%) respondents indicated mild to severe anxiety symptoms, which were associated with level of academic difficulty. Satisfaction with friendship, sleep quality, and self-confidence were inversely associated with mild to severe anxiety symptoms.

CONCLUSION

More than 50% of respondents expressed some degree of depressive and anxiety symptoms (68.5% and 54.4%, respectively). Approximately 9% of respondents exhibited moderately severe to severe depressive symptoms; 5.8% exhibited severe anxiety symptoms. Respondents reporting regular exercise, higher self-confidence, and better satisfaction with both friendship and academic performance had fewer depressive and anxiety symptoms.

Water transport properties of boron nitride nanosheets mixed matrix membranes for humic acid removal

Ultrafiltration grade polysulfone-based mixed matrix membranes (MMMs) incorporated with two-dimensional boron nitride nanosheet (BNNS) was prepared via phase inversion method. The amount of BN incorporated was varied and the influence on membrane morphology, contact angle, surface charge, as well as water permeability and humic acid rejection were investigated. Results revealed that the addition of BN to the membrane matrix resulted in profound increase in water permeability (almost tripled to that of neat PSf) and humic acid rejection due to the increase in pore size and surface negative charge. Beyond the morphological changes imparted by the inclusion of BNNS, we postulated that the presence of BNNS within the membrane matrix also contribute to the enhancement in flux and rejection based on surface-slip and selective interlayer transport. Despite the favourable augmentation of water transport and filtration performance, the MMMs suffered with fouling problem due to the entrapment of foulant within the enlarged pores and the membrane valleys. Its inherent adsorptive character could be a disadvantage when utilized as membrane filler.

A Study of Patients who Leave an Accident & Emergency Department against Medical Advice

Patients leaving an Accident & Emergency Department against medical advice are often considered a high-risk group. A prospective study was carried out in an Accident & Emergency Department (ED) to determine the characteristics of this distinct group of patients, their reasons for leaving against medical advice (AMA), and their subsequent outcome. Telephone or personal interview of patients by a clerk was attempted within 48 hours of the visit for all patients who left Against Medical Advice (AMA) based on a pre-set questionnaire. A follow-up call was used to ascertain health outcomes after the discharge. There were 210 AMA cases during the study period giving an incidence of 0.95%. Interview was successful in 186 (88.6%) patients. The mean age of the AMA group was around 36 years but there was no significant difference in sex. The major reasons for AMA included wanting to observe symptoms at home (78 of 186, 42 %), non-medical personal reason (64 of 186, 34%) and symptoms have abated (21 of 186, 11%). Eighteen (9.7%) patients left AMA because they wanted to seek treatment from other providers and among them three had private insurance coverage. Of the 5 (2.7%) patients who were dissatisfied with the management in ED, four disagreed with the diagnosis and treatment offered and the remaining one was unhappy with the attitude of the attending physician. About 12% (22) of patients returned within 48 hours for further treatment and 8 (36%) were admitted. The remaining 22% (40 of 186) sought further medical treatment from other sources. No formal patient complaint was received during the study period from this group.

Acute Confusion in a Middle-Aged Woman

This is a report of a previously healthy 47-year-old lady who presented to the Accident & Emergency Department (AED) with acute confusion. She was subsequently diagnosed to be suffering from acute disseminated encephalomyelitis (ADEM). We report this rare case to alert emergency physicians to consider acute disseminated encephalomyelitis when presented with a patient with acute confusion. The diagnosis, investigation, management will be discussed.

Can Bedside Ultrasonography of Internal Jugular Vein Replace Ultrasonography of Inferior Vena Cava for Volume Status Estimation?

Introduction

Estimation of haemodynamic status of acute and critically ill patients at Accident & Emergency (A&E) Departments is important. Measurement of inferior vena cava (IVC) diameter and collapsibility index by bedside ultrasound (USG) was known to correlate well with volume status of these patients. However, the value of similar estimation based on USG measurement of internal jugular vein (IJV) diameter was seldom studied. Whether USG measurement of IJV diameter can replace that of IVC diameter was unknown.

Methods

This was a cross-sectional study using a convenience sample of healthy volunteers among staff of a local A&E. The diameter of IJV and IVC (IJVD and IVCD) of the 51 participants were measured by bedside USG. The corresponding collapsibility index (CI) of IJV and IVC were then calculated. The correlation between IJVD and IVCD was assessed by the use of Bland-Altman plot.

Results

Median value of IVC-CI and of IJV-CI was 29.41% and 17.12% respectively. The mean of the difference of measurement of IJV-CI and IVC-CI was −11.10% (95% Confidence Interval: −15.27 to −6.92). The limits of agreement of the above difference were −40.77% and 18.58%. The range of these limits was too wide.

Conclusion

Because the range of limits of agreement between IJV-CI and IVC-CI were too wide, IJV-CI may not be used as an alternative to IVC-CI for the estimation of the volume status of normal adults.

Emergency Physicians' Preparedness for CBRNE Incidents in Hong Kong

Background

Recent terrorist attacks with biological and chemical weapons have caused much concern for the public. The purpose of this study was to assess emergency doctors' preparedness in handling Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) incidents.

Methods

This is a cross sectional survey of all emergency doctors working in public emergency departments (ED) in Hong Kong. Apart from the experience and confidence to handle these events, data on participants' willingness to participate in CBRNE incidents and training motivations were also analysed.

Results

Biological and radiological events were found to be the least commonly encountered. Few respondents reported they were confident to manage biological events (10.6% to 29.8%), despite 66% of respondents reported having prior training in CBRNE management.

Conclusions

This study demonstrates ED doctors' low confidence in managing specific CBRNE incidents. Current strengths identified include the good awareness of hospital emergency plans and high motivation to get more training.

The Diagnostic Value and Cost-Effectiveness of Creatine Kinase-MB, Myoglobin and Cardiac Troponin-T for Patients with Chest Pain in Emergency Department Observation Ward

Aim

To evaluate the diagnostic value and cost-effectiveness of creatine kinase-MB isomer, myoglobin and cardiac troponin-T for patients with chest pain in emergency department observation ward.

Method

A prospective study was carried out to include all patients presenting with chest pain of suspected cardiac origin and admitted to the observation ward. Electrocardiogram and blood tests for the three cardiac markers were performed at the time of consultation and six to eight hours after admission to the observation ward. Progress of the patients was followed up for 30-day survival or the condition reviewed up to six months and the final diagnoses were documented.

Result

A total of 480 patients were recruited. The incidence of acute myocardial infarction was 1.5%. No one died of cardiac cause within 30 days. Troponin was more accurate than creatine kinase for diagnosing acute myocardial infarction and it was cost-effective. Myoglobin was of no value.

Conclusion

Troponin is recommended as a diagnostic tool for evaluating patients with chest pain in observation ward.

Comparison of the GlideScope® with the Macintosh Laryngoscope in Endotracheal Intubation during Uninterrupted Mechanical Chest Compression: A Randomised Crossover Manikin Study

Background

The GlideScope® (GS) has been shown to improve the first-attempt success rate of endotracheal intubation during continuous mechanical chest compressions compared with the conventional Macintosh laryngoscope (ML) in inexperienced hands. Yet, its value for operators with experience of emergency airway management has remained uncertain. We set out to compare their performance in the hands of experienced operators in a manikin receiving continuous mechanical chest compressions delivered by LUCAS®.

Method

This was a randomised crossover study. Thirty-five emergency physicians and intensivists performed intubation using GS and ML in 3 different scenarios: (1) normal airway without chest compressions; (2) normal airway with uninterrupted mechanical chest compressions; and (3) normal airway with cervical spine (C-spine) immobilisation and uninterrupted mechanical chest compressions. The sequence of scenarios and devices used were randomised. The primary outcome was the first-attempt success rate of intubation. Other data including demographics, the time required for successful intubation, complications during intubation, the visual analog scale of perceived difficulty of intubation and the preference on devices in each scenario were also collected and analyzed.

Results

In scenario 1, the first-attempt success rate with both laryngoscopes was 100%. In scenario 2, there was a higher first-attempt success rate with ML but it was not statistically significant (GS 97.14% vs ML 100%, p=1.00). In scenario 3, one participant failed to intubate in the first attempt with each of the laryngoscopes (GS 97.14% vs ML 97.14%, p=0.754). More dental compression was noted with GS but the difference was not statistically significant (GS 42.86% vs ML 22.86%, p=0.126). Overall, the median time for intubation with GS was significantly longer in all 3 scenarios (Scenario 1: GS 18.5s; interquartile range [IQR] 13.8 -22.2s vs ML 11.2s, IQR 9.5-14.2s, p<0.001; Scenario 2: GS 18.7s, IQR 13.1-25.2s vs ML 13.4s, 10.3-15.8s, p<0.001; Scenario 3: GS 20.8s, IQR 16.5-29.2s vs ML 14.0s, IQR 10.5-18.0s, p<0.001). More participants preferred GS in scenario 3, while ML remained the device of choice in the other two scenarios. Conclusion: GS is not superior to ML in terms of the first-attempt success rate of intubation and it takes significantly longer to intubate for experienced operator. Yet more participants prefer its use when the C-spine motion is limited. Further studies are warranted to explore its role in trauma resuscitation. (Hong Kong j.emerg.med. 2016;23:159-167)

Emergency Medicine Ward as a Step down Unit for Selected Poisoned Patients after Intensive Care Unit Management: A Pilot Study

Introduction

Starting from the 1st July 2009, poisoned patients who fulfilled the emergency medicine ward (EMW) admission criteria were transferred to the EMW for subsequent care after intensive care unit (ICU) management. This study was undertaken to review the impact of such a strategy on the length of stay (ALOS).

Study design

This was a retrospective study on consecutive poisoned patients discharged from the ICU from the 1st July 2009 to 31st December 2010. Poisoned patients from the 1st January 2008 to 30th June 2009, who were discharged to the general medical ward or to other specialty wards were used as historical controls for comparison.

Method

Medical records of eligible cases were reviewed and data were collected using a standardized data collection form. Disease severity during the ICU stay was assessed using the Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The median ALOS and APACHE II scores of the 2 groups were compared.

Results

A total of 32 poisoned patients were transferred from the ICU to EMW during the study period, in which 28 patients were included as the study group. For the historical control group, 19 patients were identified for comparison. The study group had a significantly shorter median length of stay in the ICU (21.3 h vs. 36.0 h, p=0.013) and a significantly shorter median ALOS (28.8 h vs. 52.5 h, p=0.002) compared to the historical control group. All patients discharged to the EMW survived with no ICU re-admission.

Conclusion

The strategy of using the EMW as a step-down unit for selected poisoning cases after ICU discharge is feasible, safe and effective.

Clostridial Hepatic Gas Gangrene with Massive Intravascular Haemolysis and Acute Renal Failure: A Case Report and Literature Review

Clostridial hepatic gas gangrene is a rare but highly fatal disease. We report a complicated case of clostridial hepatic gas gangrene, presented with short history of fever, followed by severe back pain and systemic hypertension. Urgent contrast computed tomogram (CT) thorax and abdomen was performed to rule out aortic dissection. Instead, a gas-forming lesion was found in the liver, with multiple areas of hepatic venous gas. Also, CT showed poor renal contrast excretion, indicating acute renal failure. Unexpectedly, the patient developed cardiac arrest shortly after imaging and succumbed despite active resuscitation. Repeated biochemical tests showed gross hemolysis. Autopsy revealed generalised autolytic changes in internal organs with abundance of Gram positive bacilli. The overall picture was compatible with clostridial hepatic gas gangrene, with massive intravascular haemolysis and acute renal failure. Upon literature review, the importance of early diagnosis and aggressive management is highlighted.

Mechanical Cardiopulmonary Resuscitation Device in an Accident and Emergency Department: A Case Report and Literature Review

We present a case of resuscitation of a 38-year-old lady with ventricular fibrillation using the Lund University Cardiopulmonary Assist System (LUCAS), a mechanical cardiopulmonary resuscitation (CPR) device. Return of spontaneous circulation was obtained after prolonged resuscitation but the patient eventually succumbed nine days after admission to the coronary care unit. The role of mechanical CPR devices in resuscitation in the accident and emergency department is discussed.

ST Elevation is not Always Equivalent to Acute Myocardial Infarction: a Case of Brugada Syndrome

Acute myocardial infarction (AMI) is one of the most alerting situations in emergency department. Electrocardiogram (ECG) is one of the most important diagnostic tools and the decision about thrombolytic therapy is usually based upon ECG findings when clinically suspicious. However, ST segment elevation is not always equivalent to acute myocardial infarction. We present a rare syndrome whose ECG shows persistent ST elevation not related to AMI.

The Use of Patient Education Video in Improving Patient Satisfaction in the Accident and Emergency Department

Objective

To study the impact of patient education video in improving patient satisfaction in the accident and emergency department (AED).

Methods

This was a descriptive questionnaire study. A 20-minute patient education video in Cantonese was produced. The video was shown in the waiting hall from 9 am to 5 pm during the weekdays of a week in January 2008. All category 4 (semi-urgent) and category 5 (non-urgent) patients were invited to fill in an evaluation questionnaire after watching the video. The demographics of the patients were collected. There were two parts in the questionnaire. Part 1 contained four questions to test patients' knowledge retention after watching the video. These included questions on pharmacy location, triage system, use of patient identification slip and scope of the AED service. Part 2 contained six evaluation items (based on the 5-point Likert scale) to assess patients' opinion on the education video, understanding of the AED workflow and level of satisfaction after watching. Statistical analysis was performed to compare the knowledge retention scores and the Likert responses between different age and education level subgroups.

Results

Altogether 177 questionnaires were returned; 72 were excluded due to incomplete answers or absent patient gum label; and 105 completed questionnaires were analysed. Of the latter, 83 (79%) respondents scored 75% or more in the questions on knowledge retention, 79 (75%) respondents agreed that they understood the workflow of the AED better, 63 (60%) respondents thought that the video covered most frequently asked questions, and 69 (66%) respondents agreed that their level of satisfaction had improved after watching the video. There was no statistically significant difference on comparing the knowledge retention scores between different age and education level subgroups. Respondents more than 60 years old stated a better understanding about the location of consultation rooms after watching the video.

Conclusion

A patient education video is useful in providing information about operation and improving patient satisfaction in the accident and emergency department.

A Study on Trauma Documentation in Accident and Emergency Attendance Records

Aim

To study the adequacy of trauma documentation in accident and emergency (A&E) attendance records.

Method

We reviewed the A&E attendance records of major trauma requiring trauma-team care in the resuscitation room from January to June 1999 and July to December 2001. Thirty-eight items including the history, symptoms and signs of injury were scored with reference to the teaching of the Advanced Trauma Life Support course. The mean score and rate of documentation of each item were calculated. Additional items on biomechanics and environmental factors of injury were also examined. The performance of emergency medicine trainees and non-emergency medicine trainees was analysed.

Results

A total of 128 records were included, 46 and 82 records being from 1999 and 2001 respectively. The maximum documentation score was 38. The mean documentation score in 2001 was 23.27; and this was significantly better than 20.37 in 1999 (p < 0.05). The documentation rates of pre-hospital, biomechanics and environmental items were poor. Notably, 15 out of the 38 items were preformatted in the A&E records and 11 of these preformatted items had documentation rates of > 80%. Emergency medicine trainees had better scores in 2001 than in 1999. However, non-emergency medicine trainees did not show improvement in their documentation.

Conclusion

Trauma documentation has improved since 1999 for emergency medicine trainees. Preformatted charts may increase the rate of documentation. Information on pre-hospital care and injury mechanism was not well documented.

Over-Triage in Casevac Categorisation is Common in Hong Kong

Objective

To review the categorisation of patients who were transferred out from out-lying islands to urban hospitals utilising casualty evacuation (CASEVAC), and to search for possible patient characteristics which might have contributed to mis-categorisation during the ‘non-flying’ hours.

Methods

The medical records of 459 patients, who were transferred out in the year 2009 were reviewed. Correctness of categorisation was determined by 2 independent assessors according to the CASEVAC guidelines. The rates of mis-categorisation between ‘clinic hours’ and ‘AED hours’, and that between the ‘flying’ and ‘non-flying’ hours, were compared. The patients' demographic data and their presenting symptoms were collected and analysed using logistic regression models to identify factors contributing to mis-categorisation.

Results

The mis-categorisation rate was 60.1%. Among them, all were over-categorised. The over-categorisation rates between ‘clinic hours’ and ‘AED hours’, and between ‘flying’ and ‘non-flying’ hours, were not significantly different (p=0.07 and 0.09, respectively). Abnormal pulse rate was significantly associated with over-categorisation (p<0.01). Patients at extremes of age and psychiatric/drunk patients were significantly less likely to be over-categorised (p<0.05 and p<0.01, respectively). There was 20% disagreement between the two assessors when applying the existing CASEVACs guidelines (kappa score 0.58 or ‘moderate agreement’).

Conclusions

Over-triage in CASEVAC categorisation is common irrespective of the time of day. Revision of the current CASEVAC guidelines is recommended. (Hong Kong j.emerg.med. 2013; 20:327-336)

The Attitude of the Medical Students of the University of Hong Kong towards Emergency Medicine

Introduction

Understanding how medical students view the Specialty of Emergency Medicine is important. The knowledge helps the leaders in Emergency Medicine better plan the development of the specialty. In the medical literature, few studies primarily investigated this subject. Most were on the career choice of medical students. This study aimed at addressing this knowledge gap.

Methods

It was a cross-sectional questionnaire survey of the year 3 to 5 medical students studying at the Li Ka Shing Faculty of Medicine, the University of Hong Kong. The questionnaire measuring their attitude consisted of 16 items in 3 domains: overall merits of Emergency Medicine, the role and function of emergency physicians and the career prospect in Emergency Medicine. Descriptive statistics were used for data analysis. Their attitude was represented by an attitude score with 80 being most positive and 16 most negative.

Results

A total of 298 students participated in the survey. The response rate was 64.5%. The overall median attitude score was 59. Year 5 students had a statistically significant higher score. Emergency Medicine ranked third in their first specialty choice after qualification. There was no statistical relationship between a student's attitude score and the specialty choice.

Conclusion

The students' overall attitude towards Emergency Medicine was positive. Senior students held a more positive attitude. A student's specialty choice after qualification did not seem to relate to their attitude towards the specialty. (Hong Kong j.emerg.med. 2014;21:67-72)

A Study of Orotracheal Intubation in Emergency Departments of Five District Hospitals in Hong Kong

Objective

To study the success rates and complications of orotracheal intubation in emergency departments of five district hospitals in Hong Kong in order to identify ways for improvement.

Method

This was a prospective observational study. The emergency department doctors performing the intubation were asked to complete an intubation study form immediately after the procedure over a period of four months. Data collected included vital signs, experiences of intubators, method of intubation and complications.

Results

A total of 347 cases were collected and 93% of them were non-trauma cases. Fifty-two percent (52%) of the cases were in cardiac arrest before intubation. Rapid sequence intubation (RSI) was applied in 36% of the cases. Junior doctors first intubated about 72% of the patients. Successful intubation was achieved in 1 and 2 attempts in 70% and 89% of the cases respectively. In 10 cases (3%), secondary methods such as laryngeal mask airway, Combitube, Trachlight or cricothyroidotomy were needed. The overall complication rate was 7.8% and the complication rate in the RSI group was 15.3%. The complication rate was even higher (20%) if intubation without medication was used in non-cardiac arrest patients. Significant drop in blood pressure was the most common complication and it could be attributed to the use of midazolam as induction medication. The success rate was found to correlate with the experience of the first intubator (p<0.05) and the laryngeal view (p<0.001). The complication rate increased with repeated attempts (p<0.001) and was higher among junior doctors (p<0.05). Early use of elastic gum bougie was associated with lower complication and higher success rates.

Conclusion

Orotracheal intubation in the emergency department was associated with high complication rate. Many complications came from junior intubators. Hypotension was the most common complication. Potentially avoidable complications may be a result of failure to use RSI in non-cardiac arrest patients and failure to use bougie in cases of poor laryngeal view.

The Minimum Clinically Significant Difference in Visual Analogue Scale Pain Score in a Local Emergency Setting

Objectives

To determine whether the minimum clinically significant difference (MCSD) in visual analogue scale (VAS) pain score varies with age, gender, education level and cause of pain (trauma versus non-trauma) in Chinese patients.

Methods

This was a prospective descriptive study of local Chinese patients 15 years of age or older who presented with pain to the accident & emergency department. On presentation, patients were asked to indicate their current pain severity with a single mark through a standard 100–mm visual analogue scale. Then they would be offered an analgesic for pain-relief. After 30–45 minutes, the patients were asked to give a verbal categorical rating of their pain as ‘a lot better’, ‘a little better’, ‘much the same’, ‘a little worse’, or ‘much worse’ and to mark the level of pain on a VAS of the same type as used previously. The MCSD in VAS pain score was defined as the mean difference between the current and preceding scores when the subject reported ‘a little worse’ or ‘a little better’ in pain. Data were compared based on gender, age, education level, and traumatic versus non-traumatic causes of pain.

Results

186 patients were enrolled in the study, yielding 77 evaluable comparisons where pain was rated as ‘a little better’ or ‘a little worse’. Overall, the MCSD in VAS pain score in the group was 17 mm (95%CI 13.6 mm to 20.6 mm). There were statistically significant differences between the MCSD in VAS pain score between genders and causes of pain (trauma versus non-trauma).

Conclusions

The MCSD in VAS pain scores was found to be 17 mm. There was significant differences in MCSD in VAS pain score in different genders and between trauma and non-trauma cases.

A Prospective Epidemiological Study of Acute Poisoning in Hong Kong

Objective

To update our epidemiological knowledge of acute poisoning in Hong Kong.

Methods

A multi-centred prospective study was conducted for six months in six major accident and emergency departments in Hong Kong. A specially designed form was used to collect demographic data, type of poison involved, cause of poisoning, management, disposal as well as final outcome of the poisoned patients.

Results

A total of 1,467 patients (male: 588, female: 879) were included in the study. Most of them were young adults (32% were between 20 and 40 years old). Suicidal attempt (64%) was the most common cause of poisoning. Notably, 379 (26%) patients took more than one poison. Among the 2,007 counts of poison taken, sleeping pills (24%) and analgesics (18%) were the most commonly used drugs and paracetamol was the commonest single ingredient involved in poisoning. Most patients were treated with supportive measures, and about 40% and 15% of the patients were given gastrointestinal decontamination and specific antidotes respectively in their management, in which activated charcoal and N-acetylcysteine were the most common. Concerning disposal from the emergency department, 91% of the poisoned cases required in-patient management. Most patients had an uneventful recovery but 5 (0.3%) had significant disability and 21 (1.4%) died. Suicidal carbon monoxide poisoning was the leading cause of mortality in our study.

Conclusions

Most acute poisonings in Hong Kong were suicidal in nature and paracetamol was the commonest agent. Activated charcoal was the most commonly used decontamination method and most patients had an uneventful recovery.

Knowledge and Beliefs of Parents of Asthmatic Children Presenting to an Emergency Department

This is a survey on the knowledge and beliefs of 100 parents or guardians of asthmatic children presenting to the emergency department with an asthmatic attack and staying in the observation ward for treatment. The parents were asked to fill in a questionnaire on their knowledge and beliefs about asthma. Demographic data and data related to routine asthma care were also collected. The mean age of the children was 6.2± 3.2. The mean duration of asthma was 3.4 year (±2.6). In the preceding 6 months the mean attendance frequency at our accident and Energency department was 1.5±1.4. The majority of respondent (79%) agreed that asthma is caused by bronchoconstriction but only 42% understood that mucosal oedema is involved during an acute attack. Many people (82%) believed that asthma is just sensitive bronchus. Less than half (40%) believes asthma is a hereditary disease. It was a common belief that asthmatic attack can be precipitated by a change of weather (89%) and cold food/drink (77%). Over 75% agreed that carpet in the house is undesirable for an asthmatic child. The majority of parents (69%) disagreed that an asthmatic child should avoid physical exercise and only 13 would not allow the child to attend physical exercise class. Over half (54%) of the respondents believed that asthma could be cured. Only a minority (17%) believed that antibiotics are useful in shortening the attack. Thirty (30%) respondents also used alternative means of therapy for example crocodile meat. Parents' knowledge of preventive medication was inadequate. Understanding common beliefs among parents is beneficial in patient and parental education.

Validation of a 3-Item Screening Tool for Geriatric Depression in the Observation Unit of an Emergency Department

Introduction

The purpose of this study was to validate a new 3-item Emergency Department Depression Screening Instrument (ED-DSI) in screening for depression in elderly patients presenting to the emergency department (ED).

Methods

All Cantonese-speaking ED patients 65 years or older staying in the observation ward were included. Patients with a known diagnosis of dementia or depression and those with severe hearing problems were excluded. The doctor-in-charge would administer the 3-item ED-DSI which was adapted from the Geriatric Depression Scale (GDS). The research nurse who was blind to the answers of the initial screening then administered the 15-item GDS to the same patient. The 15-item GDS, which had been validated previously in the local population, was used as the reference standard.

Results

One hundred patients of whom 70 were female, were recruited. The mean age of the group was 75 years with a range from 65 to > 96 years. Using a cut-off score of 2, the new 3-item ED-DSI was shown to be as effective as the 15-item GDS (using a cut-off score of 8) in identifying depressed subjects. The sensitivity and specificity of the instrument were 90% and 74%, respectively.

Conclusions

The new 3-item ED-DSI for depression correlated well with the 15-item Geriatric Depression Scale. It can be used for screening of depression in elderly patients in a busy emergency department.

Sonographic Measurement of the Epiglottis in Normal Chinese Adults

Objectives

(1) To assess the normal range of thickness of the epiglottis by means of ultrasound measurement. (2) To evaluate inter-observer agreement in measuring the thickness of the epiglottis of normal individuals by ultrasound. (3) To assess the association between biological factors and the thickness of the epiglottis.

Methods

Fifty adult volunteers working at a local accident and emergency department were recruited. The thickness of the epiglottis was measured by means of ultrasound examination, which was performed twice by two emergency physicians at different time. The study subjects' age, sex, height and body weight were recorded.

Results

The mean thickness of the epiglottis was 0.236 cm and the standard deviation was 0.020. Male subjects had thicker epiglottis. Interobserver agreement of the two emergency physicians who performed the ultrasound scan was very good. Multiple regression models showed that sex and height were useful predictors of the thickness of the epiglottis.

Conclusions

Bedside ultrasound assessment of the epiglottis is an easy, rapid and reliable method to evaluate its thickness. Further studies are needed to evaluate the thickness of the epiglottis in patients with epiglottitis before it can be put into clinical use.

Liver Allograft Provides Immunoprotection for the Cardiac Allograft in Combined Heart-Liver Transplantation

When transplanted simultaneously, the liver allograft has been thought to have an immunoprotective role on other organs; however, detailed analyses in simultaneous heart-liver transplantation (SHLT) have not been done to date. We analyzed patient outcomes and incidence of immune-mediated injury in 22 consecutive SHLT versus 223 isolated heart transplantation (IHT) recipients between January 2004 and December 2013, by reviewing 3912 protocol- and indication-specific cardiac allograft biopsy specimens. Overall survival was similar (86.4%, 86.4%, and 69.1% for SHLT and 93.3%, 84.7%, and 70.0% for IHT at 1, 5, and 10 years; p = 0.83). Despite similar immunosuppression, the incidence of T cell-mediated rejection (TCMR) was lower in SHLT (31.8%) than in IHT (84.8%) (p < 0.0001). Although more SHLT patients had preexisting donor-specific HLA antibody (22.7% versus 8.1%; p = 0.04), the incidence of antibody-mediated rejection was not different in SHLT compared with IHT (4.5% versus 14.8%, p = 0.33). While the left ventricular ejection fraction was comparable in both groups at 5 years, the incidence and severity of cardiac allograft vasculopathy were reduced in the SHLT recipients (42.9% versus 66.8%, p = 0.03). Simultaneously transplanted liver allograft was associated with reduced risk of TCMR (odds ratio [OR] 0.003, 95% confidence interval [CI] 0-0.02; p < 0.0001), antibody-mediated rejection (OR 0.04, 95% CI 0-0.46; p = 0.004), and cardiac allograft vasculopathy (OR 0.26, 95% CI 0.07-0.84; p = 0.02), after adjusting for other risk factors. These data suggest that the incidence of alloimmune injury in the heart allograft is reduced in SHLT recipients.

Quantitative characterization of chitosan in the skin by Fourier-transform infrared spectroscopic imaging and ninhydrin assay: application in transdermal sciences

The chitosan has been used as the primary excipient in transdermal particulate dosage form design. Its distribution pattern across the epidermis and dermis is not easily accessible through chemical assay and limited to radiolabelled molecules via quantitative autoradiography. This study explored Fourier-transform infrared spectroscopy imaging technique with built-in microscope as the means to examine chitosan molecular distribution over epidermis and dermis with the aid of histology operation. Fourier-transform infrared spectroscopy skin imaging was conducted using chitosan of varying molecular weights, deacetylation degrees, particle sizes and zeta potentials, obtained via microwave ligation of polymer chains at solution state. Both skin permeation and retention characteristics of chitosan increased with the use of smaller chitosan molecules with reduced acetyl content and size, and increased positive charge density. The ratio of epidermal to dermal chitosan content decreased with the use of these chitosan molecules as their accumulation in dermis (3.90% to 18.22%) was raised to a greater extent than epidermis (0.62% to 1.92%). A larger dermal chitosan accumulation nonetheless did not promote the transdermal polymer passage more than the epidermal chitosan. A small increase in epidermal chitosan content apparently could fluidize the stratum corneum and was more essential to dictate molecular permeation into dermis and systemic circulation. The histology technique aided Fourier-transform infrared spectroscopy imaging approach introduces a new dimension to the mechanistic aspect of chitosan in transdermal delivery.

A hindbrain segmental scaffold specifying neuronal location in the adult goldfish, Carassius auratus

The vertebrate hindbrain develops as a series of well-defined neuroepithelial segments or rhombomeres. While rhombomeres are visible in all vertebrate embryos, generally there is not any visible segmental anatomy in the brains of adults. Teleost fish are exceptional in retaining a rhombomeric pattern of reticulospinal neurons through embryonic, larval, and adult periods. We use this feature to map more precisely the segmental imprint in the reticular and motor basal hindbrain of adult goldfish. Analysis of serial sections cut in three planes and computer reconstructions of retrogradely labeled reticulospinal neurons yielded a segmental framework compatible with previous reports and more amenable to correlation with surrounding neuronal features. Cranial nerve motoneurons and octavolateral efferent neurons were aligned to the reticulospinal scaffold by mapping neurons immunopositive for choline acetyltransferase or retrogradely labeled from cranial nerve roots. The mapping corresponded well with the known ontogeny of these neurons and helps confirm the segmental territories defined by reticulospinal anatomy. Because both the reticulospinal and the motoneuronal segmental patterns persist in the hindbrain of adult goldfish, we hypothesize that a permanent "hindbrain framework" may be a general property that is retained in adult vertebrates. The establishment of a relationship between individual segments and neuronal phenotypes provides a convenient method for future studies that combine form, physiology, and function in adult vertebrates.

Colon-specific delivery of 5-fluorouracil from zinc pectinate pellets through in situ intracapsular ethylcellulose-pectin plug formation

Conventional fluid-bed and immersion film coating of hydrophilic zinc pectinate pellets by hydrophobic ethylcellulose is met with fast drug release. This study explored in situ intracapsular pellet coating for colon-specific delivery of 5-fluorouracil (5-FU). The solid coating powder constituted ethylcellulose and pectin in weight ratios of 11:0 to 2:9. Its weight ratio to pellets varied between 2:3 and 3:2. Pectin was used as excipient of core pellets and coating powder in view of its potential use in colon cancer treatment. Delayed 5-FU release and core pectin dissolution were attainable when the weight ratio of solid coating powder to pellets was kept at 3:2, and weight ratio of ethylcellulose and pectin in coating powder was kept at 8:3 with particle size of ethylcellulose reduced to 22 μm. In situ intracapsular wetting of pectin coat by dissolution medium resulted in the formation of ethylcellulose plug interconnecting with pellets through the binding action of pectin. Less than 25% of drug was released at the upper gastrointestinal tract. The majority of drug was released upon prolonged dissolution and in response to colonic enzyme pectinase, which digested core pellets.

Vitexin and isovitexin from the Leaves of Ficus deltoidea with in-vivo α-glucosidase inhibition

ETHNOPHARMACOLOGICAL RELEVANCE

The leaves of Ficus deltoidea are used as a traditional medicine by diabetes patients in Malaysia.

AIM OF THE STUDY

The objective of the study is to identify and evaluate bioactive constituents with in vivo α-glucosidase inhibition.

MATERIALS AND METHODS

The partitioned extracts, subfractions and pure bioactive constituents were subjected to α-glucosidase inhibition assay. The identified bioactive constituents were administered orally to sucrose loaded normoglycemic mice and induced diabetic rats. The postprandial blood glucose levels were monitored at 30 min interval. Acute toxicity was evaluated in both normoglycemic mice and induced diabetic rats.

RESULTS

Bioactivity guided fractionation led to the isolation of both vitexin (1) and isovitexin (2). Oral administration of 1mg/kg of either vitexin (1) or isovitexin (2) significantly (p<0.05) reduced the postprandial blood glucose level in sucrose loaded normoglycemic mice at 30 min. The percentage of postprandial blood glucose reduction was highest in sucrose loaded induced diabetic rats administered orally with 200mg/kg of vitexin (1) or 100mg/kg of isovitexin (2). Both vitexin (1) and isovitexin (2) did not exert any signs of toxicity at the highest dose of 2g/kg administered orally to normoglycemic mice and induced diabetic rats.

CONCLUSION

Both the C-glycosyl bioflavonoids, namely, vitexin (1) and isovitexin (2) exhibited in vivo α-glucosidase inhibition.

Serotonin syndrome following overdose of a non-prescription slimming product containing sibutramine: a case report

INTRODUCTION

Non-prescription slimming products are popular and can be easily purchased from the Internet. However, adulteration of these products with undeclared substances including prescription drugs is not uncommon. We report a case of serotonin syndrome after an overdose of a non-prescription product containing sibutramine.

CASE REPORT

A 21-year-old woman presented with somnolence, sinus tachycardia, generalised increase in tone, hyper-reflexia and clonus more prominent in the lower limbs after an intentional overdose of a non-prescription slimming product obtained from the Internet. The product was later found to contain sibutramine and other substances such as animal thyroid tissues, caffeine and phenolphthalein. Quantitative analysis of patient's serum on presentation revealed a sibutramine concentration of 112 ng/mL, which far exceeded the reported peak serum concentration after a single oral dose of 15 mg (the maximum daily recommended dose). No other culpable agent was identified. The overall clinical presentation was compatible with serotonin syndrome associated with sibutramine overdose. The patient made a full recovery after supportive management.

DISCUSSION AND CONCLUSION

This case highlighted the health threat posed by non-prescription slimming products sold over the Internet. Sibutramine overdose can result in serotonin syndrome, as in overdose of other serotonergic agents. Early recognition and timely supportive treatment are essential to ensure a good clinical outcome.