Acquired factor V inhibitor in a patient receiving venous-venous extracorporeal membrane oxygenation for Legionella pneumonia.

We report a rare complication of factor V deficiency in a patient having Legionella pneumonia. This patient also had other complications like severe acute respiratory distress syndrome, acute kidney injury, and septic shock that required venous-venous extracorporeal membrane oxygenation support. This is the first reported case of acquired factor V deficiency in a patient receiving extracorporeal membrane oxygenation for Legionella pneumonia. With the combined use of intravenous immunoglobulin, rituximab and plasma exchange, we achieved rapid clearance of the factor V inhibitor within 1 week so as to allow safe decannulation of extracorporeal membrane oxygenation.

Development of an automated model to predict the risk of elderly emergency medical admissions within a month following an index hospital visit: a Hong Kong experience.

OBJECTIVES: To develop an automated risk prediction model to identify elderly patients at high risk of emergency admission to medical wards within 28 days following an index hospital visit. METHODS: A retrospective data analysis of 41 hospitals and 48 specialist outpatient clinics in Hong Kong. The study subjects were elderly patients aged 65 years or above, who had index hospital visit(s) in the year of 2005, which included hospitalizations at medical wards and attendances at the accident and emergency departments or specialist outpatient clinics for medical conditions. Multiple logistic regression was used to estimate the risk of emergency medical admission in 28 days after an index hospital visit. Model validation was performed against the complete cohort in 2006. RESULTS: Over a million of episodes were included in the derivation cohort. A total of 14 predictor variables included patient socio-demographics, service utilization in the previous year, presence and number of chronic diseases and type of index episode. The model has a good discriminative ability with the area under receiver-operating characteristic curve at 0.819 and 0.824 for the derivation and validation cohorts, respectively. The model has a sensitivity of 70.3 per cent, specificity of 78.4 per cent, positive predictive value of 21.7 per cent and negative predictive value of 96.9 per cent. CONCLUSION: This simple, accurate and objective risk prediction model has been computerized into an automated screening tool to recruit high-risk elderly patients discharged from all public hospitals in Hong Kong into the Community Health Call Centre service with an aim to prevent avoidable hospitalizations.

Three-year experience of using venovenous extracorporeal membrane oxygenation for patients with severe respiratory failure.

OBJECTIVE: To present the 3-year experience of using venovenous extracorporeal membrane oxygenation for patients with severe respiratory failure in a single centre in Hong Kong. DESIGN: Case series. SETTING: A 19-bed Intensive Care Unit of a tertiary hospital in Hong Kong. PATIENTS: All patients who were managed with venovenous extracorporeal membrane oxygenation from 1 July 2010 to 30 June 2013 in the Intensive Care Unit. RESULTS: Overall, 31 patients (mean age, 42.2 years, standard deviation, 14.1 years; 21 males) received venovenous extracorporeal membrane oxygenation for the treatment of severe respiratory failure. Of these, 90.3% (28 patients) presented with pneumonia as the cause of the respiratory failure, and 22 of them had identifiable causes. A total of nine (29.0%) patients were diagnosed to have H1N1 infection. The median Murray score was 3.5 (interquartile range, 3.0-3.5); the median duration of venovenous extracorporeal membrane oxygenation support was 5.0 (2.8-8.6) days; and the median duration of mechanical ventilator support was 18.2 (7.8-27.9) days. The overall intensive care unit mortality was 19.4% (n=6). The overall in-hospital mortality and the 28-day mortality were both 22.6% (n=7). Among the 22 patients who had identifiable infective causes, those suffering from viral infection had lower intensive care unit and hospital mortality than those who had bacterial infection (8.3% vs 20.0%). All the H1N1 patients survived. Complications related to extracorporeal membrane oxygenation included severe bleeding (n=2; 6.5%) and mechanical complications of the circuits (n=3; 9.7%). CONCLUSIONS: Venovenous extracorporeal membrane oxygenation is an effective adjunctive therapy and can be used as a life-saving procedure for carefully selected patients with severe acute respiratory distress syndrome when the limits of standard therapy have been reached.

Uncommon cause of severe pneumonia: co-infection of influenza B and Streptococcus.

Influenza and pneumococcus co-infection can cause severe morbidity and mortality. Usually, this entails influenza A, while infection by influenza B is rarely serious. The literature describes influenza A epidemics leading to prolific loss of lives, notably the 1918 epidemic was blamed for the deaths of 40 to 50 million people. In this report, four patients were infected by influenza B during the influenza epidemic of 2011/12 in Hong Kong. All of them were previously healthy and had no chronic diseases; they were admitted to the hospital due to influenza-like symptoms. They rapidly deteriorated with multi-organ failure, and were subsequently diagnosed to be infected with influenza B and streptococci that gave rise to severe pneumonia. Three of them were infected with Streptococcus pneumoniae and one with Streptococcus pyogenes. All of them had leukopenia, septic shock, and acute kidney injury; two of whom died despite aggressive antibiotic treatment and organ support in the intensive care unit. According to the literature, this is the second case report of severe invasive pneumococcal pneumonia secondary to influenza B infection.

Isolation of Laribacter hongkongensis, a novel bacterium associated with gastroenteritis, from drinking water reservoirs in Hong Kong.

AIMS: Freshwater fish has been found to be the reservoir of Laribacter hongkongensis, a recently discovered bacterium associated with community-acquired gastroenteritis. However, little is known about the ecology of this bacterium in the aquatic environment. We carried out a surveillance study to investigate the presence of L. hongkongensis in water and freshwater fish from 10 drinking water reservoirs in Hong Kong. METHODS AND RESULTS: Using membrane filtration, L. hongkongensis was isolated from the waters of six reservoirs, with numbers ranging from 1 to 12 CFU l(-1). Higher recovery rates were observed in summer and during days of higher water and ambient temperatures. Of 27 freshwater fish collected from the reservoirs, L. hongkongensis was recovered from the intestines of two fish, a Goldfish and a Nile tilapia. Overall, 35 different pulsed-field gel electrophoresis patterns are found among the 59 isolates recovered from water and the two isolates from freshwater fish. CONCLUSIONS: The present report represents the first to demonstrate the presence of L. hongkongensis in natural water environments. SIGNIFICANCE AND IMPACT OF THE STUDY: Although it is unlikely that treated, drinking water is an important source of L. hongkongensis-associated gastroenteritis, one should be aware of the possibility of other contaminated water as a source of human infection.

Functional decline of the elderly in a nursing home.

INTRODUCTION: This study aims to determine if risk factors present on admission to the nursing home could be predictive of later functional decline and to determine the causes of decline. METHODS: This is a retrospective case-control study conducted in 2000 at a voluntary welfare nursing home. Functional decline was defined as deterioration in two or more of the five activities of daily living (ADLs), namely: mobility, toileting, bathing, dressing and feeding, from the time of admission to the study period. Potential risk factors for decline studied were: age, sex, marital status, number of medical diagnoses and medications, types of medical diagnoses, and the presence of dementia on admission to the home. Causes of decline were categorised as (A) Development of new illness, (B) Progression of chronic illness, or (C) Both of the above. RESULTS: 36 out of 103 residents had functional decline. On analysis, univariate and multivariable logistic regression models, adjusted for length of stay, yielded the same significant risk factors for decline, namely: age (p-value is 0.02) and dementia (p-value is 0.04). Majority of decline (78 percent) was due to progression of chronic illnesses, most commonly dementia (15 out of 36), eight percent were due to acute illness (stroke), and 14 percent were due to both. In January 2003, 18 out of the 36 residents who declined had died. CONCLUSIONS: Functional decline is common in the nursing home. More attention should be paid to the older residents and those with dementia, right from the point of admission.

Who are the residents of a nursing home in Singapore?

AIM OF STUDY: To describe the residents of a nursing home for the elderly in terms of their socio-demographic profile, mental and physical attributes, functional abilities and existing medical problems. METHOD: A random sample of 120 subjects was obtained from a total of 350 residents in a voluntary welfare nursing home. Two subjects were excluded as they did not satisfy inclusion criteria (age > or = 60 years). The subjects' biodata, social background, medical problems and functional status at the time of admission were obtained by a review of the case records. Each of the subjects was examined with attention to their general condition, hearing and vision, presence of postural hypotension, cognition and ability to perform basic activities of daily living (ADL). RESULTS: Results were available for 106 out of the 118 subjects as the rest were either discharged in the course of the study or had died. Single (36%), widowed (41%), female (71%) and age > or = 75 years (73%) consisted the majority. Most subjects (43%) were admitted because of both medical and social factors. Twenty-two percent appeared undernourished and of those who could be assessed, 14% had postural hypotension, 18% were hearing impaired and 53% had visual impairment. Fifty-two per cent suffered from mental problems while 46% and 40% had been diagnosed with hypertension and stroke respectively. Forty-eight percent had probable cognitive impairment (according to ECAQ scores) and 41% were very severely disabled (according to Barthel Index). Fifty-five percent were dependent in bathing, 50% dependent in dressing, 50% incontinent of urine (and requiring diapers), 48% were non-ambulant and 21% dependent in feeding. CONCLUSION: With a significant proportion of the population requiring nursing home care in the future, a closer review of the situation is needed. This study has identified malnutrition, urinary incontinence, falls, functional decline and impaired vision/hearing as issues that deserve greater attention and, where necessary, intervention. Whether implementing recognised effective interventions will truly benefit our nursing home residents would warrant more local studies.

Nursing home falls: a local perspective.

INTRODUCTION: This study aims to examine the demography of falls, factors that contribute to falls and fall risk factors in residents of a nursing home for the elderly in Singapore. MATERIALS AND METHODS: An 18-month follow-up study was carried out on 95 nursing home residents. Information on the subjects' potential risk factors for falls was obtained through a review of their casenotes and physical examination. At the end of the study period, the casenotes were reviewed for any documented fall, the circumstances surrounding each fall and whether complications resulted from the fall. The likely factors and events associated with each fall were categorised where possible. Logistic regression was performed to determine the risk factors for falls. Subjects who died or were discharged during the study were included in the analysis. RESULTS: Several subjects (72.6%) were > or = 75 years old, required assistance in activities of daily living (71.6%), cognitively impaired (52.6%), diagnosed with mental illness (49.5%) and non-ambulant (43.2%). A total of 63 falls contributed by 38 (40%) subjects were documented over 18 months, giving an incidence of 0.5 fall per bed year. Thirteen (20.6%) injuries resulted from the falls, of which 3 were fractures. Falls associated with both intrinsic and extrinsic factors were identified in 38.1% of falls. The most common intrinsic factors were gait disorders (31.7%) and confusion/difficult behaviour (31.7%). Contributory extrinsic factors include wheelchair/commode (22.2%) and bathroom-related (15.9%) incidents. Most falls occurred during ambulation (31.7%) and transfers (17.5%). On multivariate logistic regression, the only significant risk factors for falls were "need for ambulatory aids" (odds ratio, 24.4) and "cognitive impairment" (odds ratio, 8.1). CONCLUSION: The study confirms that falls are common amongst elderly in a local nursing home. Residents with gait instability and behavioural problems due to underlying dementia or mental illnesses are most at risk. Extrinsic factors, such as bathroom activities and the use of wheelchair/commodes, are contributory. Thus, falls reduction protocols in nursing homes should include behavioural measures, enhanced care practices and environmental modifications to be effective.

Early unplanned readmission of elderly in Singapore: a retrospective study.

STUDY OBJECTIVE: To study the incidence and profile of elderly patients requiring early unplanned readmission within 15 days of discharge from a regional hospital and the predictive factors for readmission. PATIENTS: All patients (n = 150) aged 65 years old and above who were readmitted within 15 days into the hospital's geriatric unit in the western region of Singapore over a period of 10 months were retrospectively studied. METHODOLOGY: Demographic data, information on patients' medical problems and social environment were gathered from the patients' medical, nursing and therapist records. A control group (n = 103) consisting of patients not readmitted over 15 days were gathered over the same period. RESULTS: The percentage of readmission over the period between 1 January 1999 and 31 October 1999 was (150/1632) 9.2% (95% CI, 7.8% to 10.7%). There were a total of 150 patients with an equal number of male and female patients. The patients had a mean of 4 medical problems. Cardiovascular disease was noted in 73% (95% CI, 65.5% to 80.2%) of the patients during the index admissions. They were noted to be ambulatory and were staying with their own families. Half of the patients were discharged from the index admission with no adjustment to their previous care system. The majority of patients (68.7%; 95% CI, 59.9% to 75.4%) required readmission because of medical problems. Fifty per cent of the patients admitted for a new medical complaint were secondary to sepsis. Thirty per cent (95% CI, 22.8% to 38.0%) of the study population had both medical and social issues. The main predictive factors noted when compared to a control group of 103 patients (using a stepwise logistic regression model) were number of medical problems (P = 0.0128; OR = 1.4; 95% CI, 1.1 to 1.9) and number of previous admissions (P = 0.005; OR = 1.6; 95% CI, 1.2 to 2.3). CONCLUSION: Unplanned readmissions are relatively common in elderly patients. They cannot be entirely prevented in view of multiple chronic illnesses. Further studies, looking at early detection of medical problems and prevention of nosocomial infections are warranted to decrease the problem of readmissions for this group of elderly.

A survey of the long term outcome of elderly stroke survivors and the needs of their carers.

A survey was conducted to assess the long term outcome of 60 elderly stroke survivors (mean age, 81.7 years). Of these patients, 48% died within one year of discharge and 79% of the mortality occurred in the first six months. Patients discharged to institutions after the initial stroke had a significantly higher risk of death in one year (relative risk=1.47) compared with those who were discharged home. For those who survived for a mean period of 18.6months, 72% (21/29) were institutionalised. This group had significantly worse functional status and mobility compared with those who were living at home. The caring of elderly stroke patients was considered a heavy burden for most carers at home or in institutions and the need for medical and social support was great.

Urinary incontinence: an ignored problem in elderly patients.

Urinary incontinence is a common problem among the elderly, especially those admitted to acute care hospitals. A study investigating this problem was conduced in the geriatric wards of the Tuen Mun Hospital, Tuen Mun, from 26 October 1995 to 9 November 1995. Fifty of 139 (36%) patients had urinary incontinence with a male to female ratio of 1:15. Patients with urinary incontinence were found more often to have mobility problems and a higher institutionalisation rate than did continent patients. Dementia and cerebrovascular accident were also found to be associated with this problem. Although it is a common problem, none had been evaluated or treated before. Most of the caregivers thought that urinary incontinence was a normal ageing process and used diapers to treat this problem.

The prevalence of diabetes mellitus and an assessment of methods of detection among a community of elderly Chinese in Hong Kong.

This study provides information on the prevalence of diabetes mellitus in a group of elderly Chinese subjects aged 60 and above living in the community in Hong Kong, and investigates the sensitivity of the urine sugar, random blood glucose, glycosylated haemoglobin, and fructosamine measurements compared to a glucose tolerance test in screening for diabetes mellitus in this population. Four hundred twenty-seven subjects aged 60 and above were studied. The National Diabetes Data Group Criteria were used for the diagnosis of diabetes. Those with a random blood glucose exceeding 12.5 mmol/l were considered diabetic, and all of these patients had glycosuria together with elevated total glycosylated haemoglobin and fructosamine concentrations. A diagnostic 75 g oral glucose tolerance test was performed on patients with one or more of the following abnormalities: glycosuria, random plasma blood glucose 7.8 mmol/l to 12.5 mmol/l, glycosylated haemoglobin 8.5%, and fructosamine 2.20 mmol/l. By these criteria, the prevalence of diabetes in this community was found to be 9.8%. An elevated random glucose greater than 11.1 mmol/l proved to be the only specific method of screening and glycosuria was found to be at least as good as fructosamine and HbA1. However, HbA1 is more sensitive than random glucose, glycosuria or fructosamine in detecting impaired glucose tolerance. On the basis of this study, a higher reference range for glycosylated haemoglobin for the elderly alone is also suggested (5.74-9.34%).