Trauma team activation criteria and outcomes of geriatric trauma: 10 year single centre cohort study.

BACKGROUND: With the aging population, the number of older patients with multiple injuries is increasing. The aim of this study was to understand the patterns and outcomes of older patients admitted to a major trauma centre in Hong Kong from 2006 to 2015, and investigate the performance of the trauma team activation (TTA) criteria for these elderly patients. METHODS: This was a retrospective cohort study from a university hospital major trauma centre in Hong Kong from 2006 to 2015. Patients aged 55 or above who entered the trauma registry were included. Patients were divided into those aged 55-70, and above 70. To test the performance of the TTA criteria, we defined injured patients with severe outcomes as those having any of the following: death within 30 days; the need for surgery; or the need for intensive care unit (ICU) care. RESULTS: 2218 patients were included over the 10 year period. The 30-day mortality was 7.5% for aged 55-70 and 17.7% for those aged above 70. The sensitivity of TTA criteria for identifying severe outcomes for those aged 55 or above was 35.6%, with 91.6% specificity. The under-triage rate was 59% for age 55-70, and 69.1% for those aged above 70. CONCLUSION: There is a need to consider alternative TTA criteria for our geriatric trauma population, and to more clearly define the process and standards of care in Hong Kong.

Brief Report: Progression of Atherosclerosis in HIV-Infected Individuals-Prospective Data From an Asian Cohort.

BACKGROUND: The magnitude and risk factors of progression of atherosclerosis in Asian HIV-infected individuals were unknown. This study aimed to evaluate: (1) the rate of progression of atherosclerosis in HIV-infected individuals, and (2) metabolic and inflammatory parameters that may predict atherosclerosis progression in HIV-infected individuals in an Asian cohort. SETTING: A prospective, longitudinal study was performed among adults attending an HIV Metabolic clinic in Hong Kong. METHODS: Carotid intima media thickness (cIMT) was measured at baseline and 24 months. Body composition, metabolic, and inflammatory biomarkers [including homeostasis model assessment of insulin resistance, LDL (low-density lipoprotein) cholesterol particle size, high-sensitive C reactive protein, adiponectin] associated with cIMT change were analyzed; their predictive performances were estimated using receiver operating characteristic analyses. RESULTS: Sixty-one HIV-infected individuals (mean ± SD age 49.8 ± 11.4 years, 89% men, 97% Chinese, diabetes 39%, hypertension 30%, and dyslipidemia 85%) were recruited. Annual rate of change of cIMT was +0.0075 (0.0000-0.0163) mm/yr, and 19% developed new plaque at 24 months. Two patients died during the study period, 1 because of sudden cardiac death. Using receiver operating characteristic analyses, combination of lower limb fat percentage, LDL cholesterol subclass pattern B, and lower adiponectin level, but not Framingham score, predicted greater cIMT progression in HIV-infected individuals. CONCLUSIONS: Asian HIV-infected individuals had atherosclerosis progression. Limb fat percentage, LDL cholesterol particle size, and adiponectin level may identify at-risk Asian HIV-infected individuals for early intervention.

Anti-inflammatory effects of adjunctive macrolide treatment in adults hospitalized with influenza: A randomized controlled trial.

INTRODUCTION: - Macrolides can ameliorate inflammation in respiratory diseases, providing clinical benefits. Data in influenza is lacking. METHOD: - A randomized, open-label, multicenter trial among adults hospitalized for laboratory-confirmed influenza was conducted. Study treatments of oseltamivir and azithromycin (500 mg/day), or oseltamivir alone, both for 5 days, were allocated at 1:1 ratio. The primary outcome was plasma cytokine/chemokine concentration change over time (Day 0-10); secondary outcomes were viral load and symptom score changes. Generalized Estimating Equation (GEE) models were used to analyze longitudinal data. RESULTS: - Fifty patients were randomized to the oseltamivir-azithromycin or oseltamivir groups, with comparable baseline characteristics (age, 57 ± 18 years; A/H3N2, 70%), complications (72%), and viral load. Pro-inflammatory cytokines IL-6 (GEE: ß -0.037, 95%CI-0.067,-0.007, P = 0.016; reduction from baseline -83.4% vs -59.5%), CXCL8/IL-8 (ß -0.018, 95%CI-0.037,0.000, P = 0.056; -80.5% vs -58.0%), IL-17 (ß -0.064, 95%CI-0.117,-0.012, P = 0.015; -74.0% vs -34.3%), CXCL9/MIG (ß -0.010, 95%CI-0.020,0.000, P = 0.043; -71.3% vs -56.0%), sTNFR-1, IL-18, and CRP declined faster in the oseltamivir-azithromycin group. There was a trend toward faster symptom resolution (ß -0.463, 95%CI-1.297,0.371). Viral RNA decline (P = 0.777) and culture-negativity rates were unaffected. Additional ex vivo studies confirmed reduced induction of IL-6 (P = 0.017) and CXCL8/IL-8 (P = 0.005) with azithromycin. CONCLUSION: - We found significant anti-inflammatory effects with adjunctive macrolide treatment in adults with severe influenza infections. Virus control was unimpaired. Clinical benefits of a macrolide-containing regimen deserve further study. [ClinicalTrials.gov NCT01779570].

HMGB1/RAGE Signaling and Pro-Inflammatory Cytokine Responses in Non-HIV Adults with Active Pulmonary Tuberculosis.

BACKGROUND: We aimed to study the pathogenic roles of High-Mobility Group Box 1 (HMGB1) / Receptor-for-Advanced-Glycation-End-products (RAGE) signaling and pro-inflammatory cytokines in patients with active pulmonary tuberculosis (PTB). METHODS: A prospective study was conducted among non-HIV adults newly-diagnosed with active PTB at two acute-care hospitals (n = 80); age-and-sex matched asymptomatic individuals (tested for latent TB) were used for comparison (n = 45). Plasma concentrations of 8 cytokines/chemokines, HMGB1, soluble-RAGE, and transmembrane-RAGE expressed on monocytes/dendritic cells, were measured. Gene expression (mRNA) of HMGB1, RAGE, and inflammasome-NALP3 was quantified. Patients' PBMCs were stimulated with recombinant-HMGB1 and MTB-antigen (lipoarabinomannan) for cytokine induction ex vivo. RESULTS: In active PTB, plasma IL-8/CXCL8 [median(IQR), 6.0(3.6-15.1) vs 3.6(3.6-3.6) pg/ml, P<0.001] and IL-6 were elevated, which significantly correlated with mycobacterial load, extent of lung consolidation (rs +0.509, P<0.001), severity-score (rs +0.317, P = 0.004), and fever and hospitalization durations (rs +0.407, P<0.001). IL-18 and sTNFR1 also increased. Plasma IL-8/CXCL8 (adjusted OR 1.12, 95%CI 1.02-1.23 per unit increase, P = 0.021) and HMGB1 (adjusted OR 1.42 per unit increase, 95%CI 1.08-1.87, P = 0.012) concentrations were independent predictors for respiratory failure, as well as for ICU admission/death. Gene expression of HMGB1, RAGE, and inflammasome-NALP3 were upregulated (1.2-2.8 fold). Transmembrane-RAGE was increased, whereas the decoy soluble-RAGE was significantly depleted. RAGE and HMGB1 gene expressions positively correlated with cytokine levels (IL-8/CXCL8, IL-6, sTNFR1) and clinico-/radiographical severity (e.g. extent of consolidation rs +0.240, P = 0.034). Ex vivo, recombinant-HMGB1 potentiated cytokine release (e.g. TNF-α) when combined with lipoarabinomannan. CONCLUSION: In patients with active PTB, HMGB1/RAGE signaling and pro-inflammatory cytokines may play important roles in pathogenesis and disease manifestations. Our clinico-immunological data can provide basis for the development of new strategies for disease monitoring, management and control.

High morbidity and mortality of Clostridium difficile infection and its associations with ribotype 002 in Hong Kong.

OBJECTIVES: We aim to study the disease burden, risk factors and severity of Clostridium difficile infection (CDI) in Hong Kong. METHODS: We conducted a prospective, case-control study in three acute-care hospitals in Hong Kong. Adult inpatients who developed CDI diarrhoea confirmed by PCR (n = 139) were compared with the non-CDI controls (n = 114). Ribotyping of isolates and antimicrobial susceptibility testing were performed. RESULTS: The estimated crude annual incidence of CDI was 23-33/100,000 population, and 133-207/100,000 population among those aged ≥65 years. The mean age of CDI patients was 71.5. Nursing home care, recent hospitalization, antibiotics exposure (adjusted OR 3.0, 95% CI 1.3-7.1) and proton-pump inhibitors use (adjusted OR 2.2, 95% CI 1.2-3.9) were risk factors. Severe CDI occurred in 41.7%. Overall mortality was 16.5% (among severe CDI, 26.5%). The commonest ribotypes were 002 (22.8%), 014 (14.1%), 012 and 046; ribotype 027 was absent. Ribotype 002 was associated with fluoroquinolone resistance and higher mortality (47.6% vs. 12.7%; adjusted HR 2.8, 95% CI 1.1-7.0). CONCLUSIONS: Our findings show high morbidity and mortality of CDI in the older adults, and identify ribotype 002 as a possible virulent strain causing serious infections in this cohort.

High Viral Load and Respiratory Failure in Adults Hospitalized for Respiratory Syncytial Virus Infections.

A prospective study among adults hospitalized for polymerase chain reaction-confirmed respiratory syncytial virus infections (n = 123) showed frequent occurrence of lower respiratory-tract complications causing respiratory insufficiency (52.8%), requirement for assisted ventilation (16.3%), and intensive care unit admission/death (12.2%). High viral RNA concentration was detected at time of hospitalization, including in patients who presented later than 2 days of illness (day 1-2, 7.29 ± 1.47; day 3-4, 7.28 ± 1.41; day 5-8, 6.66 ± 1.87 log10 copies/mL). RNA concentration was independently associated with risk of complications and respiratory insufficiency (adjusted odds ratio 1.40 per log10 copies/mL increase, 95% confidence interval, 1.03-1.90; P = .034). Our data indicate the need and provide a basis for clinical research on antiviral therapy in this population.

Neuraminidase inhibitors, superinfection and corticosteroids affect survival of influenza patients.

We aimed to study factors influencing outcomes of adults hospitalised for seasonal and pandemic influenza.  Individual-patient data from three Asian cohorts (Hong Kong, Singapore and Beijing; N=2649) were analysed. Adults hospitalised for laboratory-confirmed influenza (prospectively diagnosed) during 2008-2011 were studied. The primary outcome measure was 30-day survival. Multivariate Cox regression models (time-fixed and time-dependent) were used. Patients had high morbidity (respiratory/nonrespiratory complications in 68.4%, respiratory failure in 48.6%, pneumonia in 40.8% and bacterial superinfections in 10.8%) and mortality (5.9% at 30 days and 6.9% at 60 days). 75.2% received neuraminidase inhibitors (NAI) (73.8% received oseltamivir and 1.4% received peramivir/zanamivir; 44.5% of patients received NAI ≤2 days and 65.5% ≤5 days after onset of illness); 23.1% received systemic corticosteroids. There were fewer deaths among NAI-treated patients (5.3% versus 7.6%; p=0.032). NAI treatment was independently associated with survival (adjusted hazard ratio (HR) 0.28, 95% CI 0.19-0.43), adjusted for treatment-propensity score and patient characteristics. Superinfections increased (adjusted HR 2.18, 95% CI 1.52-3.11) and chronic statin use decreased (adjusted HR 0.44, 95% CI 0.23-0.84) death risks. Best survival was shown when treatment started within ≤2 days (adjusted HR 0.20, 95% CI 0.12-0.32), but there was benefit with treatment within 3-5 days (adjusted HR 0.35, 95% CI 0.21-0.58). Time-dependent analysis showed consistent results of NAI treatment (adjusted HR 0.39, 95% CI 0.27-0.57). Corticosteroids increased superinfection (9.7% versus 2.7%) and deaths when controlled for indications (adjusted HR 1.73, 95% CI 1.14-2.62). Early NAI treatment was associated with shorter length of stay in a subanalysis. NAI treatment may improve survival of hospitalised influenza patients; benefit is greatest from, but not limited to, treatment started within 2 days of illness. Superinfections and corticosteroids increase mortality. Antiviral and non-antiviral management strategies should be considered.

Development of a quality assessment tool for systematic reviews of observational studies (QATSO) of HIV prevalence in men having sex with men and associated risk behaviours.

BACKGROUND: Systematic reviews based on the critical appraisal of observational and analytic studies on HIV prevalence and risk factors for HIV transmission among men having sex with men are very useful for health care decisions and planning. Such appraisal is particularly difficult, however, as the quality assessment tools available for use with observational and analytic studies are poorly established. METHODS: We reviewed the existing quality assessment tools for systematic reviews of observational studies and developed a concise quality assessment checklist to help standardise decisions regarding the quality of studies, with careful consideration of issues such as external and internal validity. RESULTS: A pilot version of the checklist was developed based on epidemiological principles, reviews of study designs, and existing checklists for the assessment of observational studies. The Quality Assessment Tool for Systematic Reviews of Observational Studies (QATSO) Score consists of five items: External validity (1 item), reporting (2 items), bias (1 item) and confounding factors (1 item). Expert opinions were sought and it was tested on manuscripts that fulfil the inclusion criteria of a systematic review. Like all assessment scales, QATSO may oversimplify and generalise information yet it is inclusive, simple and practical to use, and allows comparability between papers. CONCLUSION: A specific tool that allows researchers to appraise and guide study quality of observational studies is developed and can be modified for similar studies in the future.

An audit of risk factors for wound infection in patients undergoing coronary artery bypass grafting or valve replacement.

OBJECTIVES: To investigate the epidemiology of surgical site infection in cardiac surgery patients operated on in 2006. DESIGN: Retrospective study of a case-control sample. SETTING: Cardiac surgery unit of a university teaching hospital in Hong Kong. PATIENTS: Cardiac surgery patients with surgical site infection were matched by procedure type, sex, and year of surgery with non-infected patients. MAIN OUTCOME MEASURES: Identification of risk factors for surgical site infection. RESULTS: The infected and non-infected cardiac surgery patients did not differ in age, sex, or smoking history; however, patients with surgical site infection were significantly heavier (mean body mass index, 26.6 vs 23.9 kg/m2, P < 0.046). Almost 41% of the subjects had a history of diabetes mellitus, there being a significantly greater proportion among infected than non-infected patients (53.1% vs 28.1%, P < 0.042). All 37 of the patients without a diagnosis of diabetes had normal (ie < 8 mmol/L) preoperative glucose levels, but 99% of them yielded evidence of subsequent glycaemic dysfunction during or after surgery. Overall, 50% of the patients had a blood transfusion during the operation, with infected patients significantly more likely to have been transfused than the non-infected ones (65.6% vs 34.4%, P < 0.008). CONCLUSIONS: There appears to be a relationship between surgical site infection in cardiac surgery patients and pre-existing (diagnosed and covert) diabetes mellitus and blood transfusion. Future studies should consider these factors in relation to surgical site infections, both in the wider surgical population and from a risk-minimisation perspective.

Bone mineral status and its relation with dietary estimates of net endogenous acid production in Hong Kong Chinese adolescents.

Diet composition influences net endogenous acid production (NEAP), which may affect bone health. No studies are available to relate dietary estimate of NEAP to bone health in Chinese adolescents. This study examined the association of dietary estimates of NEAP with bone mineral status in Hong Kong Chinese adolescents. Baseline data on 171 boys and 180 girls aged 10-12 years from the Hong Kong Adolescent Bone Health Cohort Study were presented. Weight, height, Tanner stage and dietary intakes by FFQ were collected. NEAP was estimated from diet using Frassetto's method. Bone area (BA), bone mineral content (BMC) and bone mineral apparent density (BMAD) of total hip, lumbar (L1-L4) spine and whole body were estimated by dual-energy X-ray absorptiometry (DXA). No significant association was observed between BMC or BMAD and energy-adjusted NEAP or other nutrients. BA was significantly and positively associated with BMC at all sites in both sexes. Weight was significantly and positively associated with BMC in hip and spine in both sexes. Height was negatively correlated with hip BMC for boys and whole body BMC for girls. Pubertal stage was significantly and positively associated with BMC in all sites in both sexes. Weight and height contributed most of the variability in BMAD at different sites. The results suggest that anthropometric characteristics and pubertal stage are more influential than dietary NEAP in determining bone mineral status of Hong Kong Chinese adolescents. However, the methodological weaknesses regarding the use of DXA and FFQ in the present sample require attention.

Balance control in adolescents with idiopathic scoliosis and disturbed somatosensory function.

STUDY DESIGN: A cross-sectional study of the balance control in adolescents with idiopathic scoliosis. OBJECTIVE.: To investigate the relationship among somatosensory function, balance control, and adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Balance control requires the contribution of somatosensory, visual, and vestibular inputs. Previous studies have shown that abnormal somatosensory evoked potentials (SSEPs) were associated with AIS. METHODS: A total of 105 girls with AIS and 57 normal girls aged 11-14 years entered the study, and were evaluated with bilateral tibial nerve evoked cerebral SSEPs and standing balance control under reduced or conflicting sensory conditions (i.e., the sensory organization test). One-way analysis of variance was conducted to evaluate the effects of scoliosis and somatosensory function tested by SSEPs on the performance of sensory organization test. RESULTS: There were 15 patients with AIS who had abnormal SSEPs. Postural sway was measured on all subjects under normal, reduced, or conflicting somatosensory, visual, and vestibular conditions. One-way analysis of variance indicated no significant effect of spinal deformity or SSEPs on the balance control when there was an increased reliance on the somatosensory, visual, and vestibular systems during stance (P > 0.05). However, in the patients with abnormal SSEPs, a significant effect was found when subjects had to rely on somatosensory input for their balance control (P = 0.023). The effect of scoliosis by itself was not found to be significant (P = 1.0). CONCLUSIONS: The finding of significantly larger difference in bilateral SSEP latencies in patients with AIS indicated the association of abnormal SSEPs with AIS. The finding of a significant effect of SSEPs on the balance control further indicated the presence of abnormal somatosensory function in a subgroup of patients with AIS.

Association of osteopenia with curve severity in adolescent idiopathic scoliosis: a study of 919 girls.

Generalized osteopenia and spinal deformity occur concomitantly in adolescent idiopathic scoliosis (AIS) during the peripubertal period. No large-scale study has been performed to reveal the link between scoliotic deformity and bone-mineral status in AIS. In a cross-sectional study, the extent of scoliotic-curve severity in relation to bone-mineral status was examined for 619 AIS girls and compared with those of 300 healthy non-AIS counterparts aged 11-16 years. Curve severity was categorized into a moderate (10-39 degrees) and a severe group (> or = 40 degrees) based on Cobb angle. Anthropometric parameters, bone mineral-density (BMD) and bone mineral-content (BMC) of lumbar spine, proximal femur and distal tibia were determined by dual-energy X-ray absorptiometry and peripheral QCT. Differences in anthropometric parameters and bone mass among control and the AIS-moderate and AIS-severe groups were tested by one-way ANOVA. Association between Cobb angle and bone mass was determined by univariate and multivariate analyses. Mean Cobb angle of the moderate and severe groups were 25+/-6.3 degrees and 50.2+/-11.3 degrees, respectively. Arm span and leg length among the moderate and severe AIS subjects were almost all longer than for the controls from age 13 years. Age-adjusted arm span and leg length were significantly correlated with curve severity (p < 0.015). Starting from age 13 years, most axial and peripheral BMD and BMC of the moderate or severe AIS group was significantly lower than for the controls (p < 0.029). Age-adjusted Cobb angle was inversely correlated with BMD and BMC of the distal tibia and lumbar spine among AIS subjects (p < or = 0.042). The proportion of osteopenic AIS girls in the severe group was significantly higher than that in the moderate group (p < or = 0.033). Multivariate analysis indicated that Cobb angle was inversely and independently associated with axial and peripheral BMD and BMC (p < or = 0.042). To conclude, curve severity was an inverse and independent associated factor on bone mineral mass of AIS during peripuberty. The study implied that prevention of osteopenia could be as important as controlling spinal progression in the management of AIS.

Generalized low bone mass of girls with adolescent idiopathic scoliosis is related to inadequate calcium intake and weight bearing physical activity in peripubertal period.

Generalized low bone mass has been well documented in patients with adolescent idiopathic scoliosis (AIS). However, studies linking calcium-intake (CA), weight-bearing physical-activity (PA) and bone mass of AIS are lacking. We aimed to study the relationship between CA, PA and bone mass in AIS girls and compared to those of healthy non-AIS controls during the peripubertal period. Newly diagnosed AIS girls (n=596) aged 11-16 years with Cobb angle >/=10 degrees were recruited to compare with age-matched healthy girls (n=302) in a cross-sectional study. Anthropometric parameters, pubertal status, CA and PA were assessed. Areal bone mass of lumbar spine and femoral neck, and volumetric bone mass of distal radius and tibia were determined by dual-energy X-ray absorptiometry and peripheral quantitative computed tomography, respectively. The results showed that weight and body mass index (BMI) of AIS were lower than the controls (P<0.05). Corrected height and arm span of AIS were longer than those of controls from 13 years onwards (P<0.02). Median CA of AIS was <410 mg/day across the ages and did not differ from the controls (P=0.063). Median PA of AIS (1.6 h/day) was lower than the controls (1.8 h/day) (P=0.025). Bone mass of AIS was on average 6.5% lower than controls across the ages (P<0.05). CA and PA were significantly correlated with bone mass of AIS (P<0.04). Multivariate analysis showed that AIS in girls was associated with lower bone mass, and that both CA and PA were independent predictors of bone mass in AIS. In conclusion, AIS girls were found to have lower body weight and BMI, longer segmental lengths and generalized low bone mass. Inadequate calcium intake and weight-bearing physical activity were significantly associated with low bone mass in AIS girls during the peripubertal period. The importance of preventing generalized osteopenia in the control of AIS progression during the peripubertal period warrants further study.