Preliminary analysis of phosphorus flow in Hue Citadel.

Characteristics of waste and wastewater management can affect material flows. Our research investigates the management of waste and wastewater in urban areas of developing countries and its effects on phosphorus flow based on a case study in Hue Citadel, Hue, Vietnam. One hundred households were interviewed to gain insight into domestic waste and wastewater management together with secondary data collection. Next, a phosphorus flow model was developed to quantify the phosphorus input and output in the area. The results showed that almost all wastewater generated in Hue Citadel was eventually discharged into water bodies and to the ground/groundwater. This led to most of the phosphorus output flowing into water bodies (41.2 kg P/(ha year)) and ground/groundwater (25.3 kg P/(ha year)). Sewage from the sewer system was the largest source of phosphorus loading into water bodies, while effluent from on-site sanitation systems was responsible for a major portion of phosphorus into the ground/groundwater. This elevated phosphorus loading is a serious issue in considering surface water and groundwater protection.

Characterization of water pollution in drainage networks using continuous monitoring data in the Citadel area of Hue City, Vietnam.

In the Citadel area of Hue City, drainage systems that include canals and ponds are considerable sources of fecal contaminants to inundated water during the rainy season because canals and ponds receive untreated wastewater. It is important to investigate the characteristics of hydraulics and water pollution in canals and ponds. At the canals and ponds, water sampling was conducted during dry and wet weather periods in order to evaluate fecal contamination and to investigate changes in water pollution caused by runoff inflow. Inundated water was also collected from streets during heavy rainfall. At the canals and ponds, concentrations of Escherichia coli and total coliform exceeded the Vietnamese regulation values for surface water in 23 and 24 out of 27 samples (85 and 89%), respectively. The water samples were categorized based on the characteristics of water pollution using cluster analysis. In the rainy season, continuous monitoring was conducted at the canals and ponds using water depth and electrical conductivity (EC) sensors to investigate the dynamic relationship between water level and water pollution. It is suggested that in the canals, high EC meant water stagnation and low EC signified river water inflow. Therefore, EC might be a good indicator of water flow change in canals.

Development of single-stage nitrogen removal using anammox and partial nitritation (SNAP) and its treatment performances.

Single-stage Nitrogen removal using Anammox and Partial nitritation (SNAP) process was newly developed as an economical nitrogen removal process for ammonium rich wastewaters. The experimental studies for the evaluation of SNAP process were carried out using a novel biofilm reactor, in which hydrophilic net-type acryl fiber biomass carrier was applied. This SNAP reactor was operated under operational conditions of pH 7.5-7.7, 35 degrees C and DO 2-3 mg/L, and 60 to 80% of influent NH4-N was removed under loading rate of 0.48 kg-N/m3/d. Through the DNA analysis of the attached sludge, it was made clear that ammonium oxidizing bacteria (AOB) and anammox bacteria coexisted in the attach-immobilized sludge on the acryl fiber biomass carrier. Favorable conditions for the growth of anammox bacteria were created inside attach-immobilized nitrifying sludge. Two kinds of anammox bacteria and two kinds of AOB were detected in the SNAP sludge. Existence ratios of anammox and AOB were estimated to be 15% and 8.7%, respectively, based on the obtained clone numbers. This coexisting condition was confirmed by the FISH image of SNAP sludge and its confocal laser scanning microscope.

Bedside clinical methods useful as screening test for aspiration in elderly patients with recent and previous strokes.

INTRODUCTION: This study was undertaken to ascertain the usefulness of clinical screening tools for dysphagia in a heterogeneous group of older stroke patients. The usefulness of bedside clinical assessment tools for detecting dysphagia on different consistencies of feeds was also studied. MATERIALS AND METHODS: Fifty patients referred to a speech therapist for the assessment of possible dysphagia were recruited. The clinical tools studied included the water swallow test, the oxygen desaturation test and the combination of both tests (termed "clinical aspiration test"). The outcomes of the clinical assessments were compared with a fibreoptic endoscopic examination of swallowing (FEES) conducted at the same sitting. Fifty patients underwent an examination of their ability to swallow 50 mL of water in 10-mL aliquots. They underwent a FEES with different food consistencies by a speech therapist and oxygen saturation with pulse oximetry was monitored during the procedure. Oxygen desaturation of more than 2% was considered to be clinically significant. RESULTS: The water swallow test had a sensitivity of 79.4% and specificity of 62.5% for the detection of aspiration, with a positive predictive value (PPV) of 81.8% and a negative predictive value (NPV) of 58.8%. The oxygen desaturation test had a sensitivity of 55.9% and a specificity of 100% with PPV of 100% and NPV of 51.6%. When both tests were combined, a sensitivity of 94.1% and a specificity of 62.5% was attained, with PPV of 84.2% and NPV of 83.3%. Using the clinical assessment test, we were able to pick up 3 aspirators who would otherwise have been missed if they were assessed with the water swallow test using thin fluids alone. CONCLUSION: Simple clinical assessment tools can be used to screen for dysphagia in a heterogeneous group of older patients with stroke disease, and clinical testing using feeds of different consistencies should be considered.

Epidemiology of beta-haemolytic group G streptococcal bacteraemia in Singapore (1996 to 1998).

INTRODUCTION: Group G streptococcus (GGS) accounted for 8% to 44% of all bacteraemias due to beta-haemolytic streptococci according to various reports. The aims of this study were 1) to describe the epidemiology of GGS bacteraemia in Singapore for which local data are lacking and 2) to compare its frequency of isolation to the other Lancefield groups. PATIENTS AND METHODS: The study period was from 1 January 1996 to 30 June 1998. The laboratory records of 2 large acute care hospitals were examined. There was a total of 85 patients. The medical records of 52 patients were available for analysis. In addition, laboratory microbiological data from 1993 to 1999 were reviewed and the number of blood cultures that were positive for beta-haemolytic streptococci groups A, B, C and G was collated. RESULTS: The majority involved the elderly. The mean age was 67 years. The skin was the major portal of entry. Local conditions predisposing the skin to infection occurred in 40.4%. Co-morbidity included malignancies in 28.8% of patients, diabetes mellitus in 11.5% and liver disease in 9.6%. Mortality was 15.4% including fatal septic shock. Recurrent bacteraemia occurred in 5.8% of the patients. The majority (90.4%) were community-acquired infections. GGS, along with group B streptococcus (GBS), was the most common streptococcus among the beta-haemolytic streptococci causing bacteraemia in these 2 hospitals.

The impact of swallowing disorders in the elderly.

INTRODUCTION: Swallowing disorders are common in the elderly but its prevalence is often underestimated. They can result in increased morbidity and mortality. METHODS: This article summarises the findings of selected published papers in major international journals indexed on Medline on swallowing using the key words--swallowing, dysphagia, aged, geriatrics and deglutition. RESULTS: There are age-related changes in the oral, pharyngeal and oesophageal functions. In the elderly, central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors are common causes of swallowing dysfunction. Swallowing disorders in the elderly are associated with increased mortality and morbidity. Aspiration, dehydration, pneumonia, malnutrition, functional decline and institutionalisation are often encountered in the elderly with dysphagia. There is a choice of different interventions available to reduce morbidity and mortality arising from swallowing impairments, and improving their quality of life. CONCLUSION: The effective management of swallowing impairment in the elderly requires a multidisciplinary team approach.

Accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) in determining the risk of aspiration in acute stroke patients.

This prospective study was undertaken to determine the accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) for detecting aspiration in acute stroke patients. Fifty patients underwent an examination of their ability to swallow 50 ml of water in 10-ml aliquots. Later their oxygen saturation levels before and after swallowing 10 ml of water were measured using a pulse oximeter. Oxygen desaturation of more than 2%, was considered to be clinically significant. All patients then underwent a FEES assessment by a speech therapist and were followed up during their inpatient stay for evidence of aspiration pneumonia. The oxygen desaturation test had a sensitivity of 76.9% and specificity of 83.3% (chi2 = 18.154, p = 0.00002), while the 50-ml water swallow test had a sensitivity of 84.6% and specificity of 75.0% (chi2 = 18.001, p = 0.00002). However, when these two tests were combined into one test called "bedside aspiration," the sensitivity rose to 100% with a specificity of 70.8% (chi2 = 27.9, p = 0.000001). Five (10%) patients developed pneumonia during their inpatient stay. The relative risk (RR) of developing pneumonia, if there was evidence of aspiration on FEES, was 1.24 (1.03 < RR < 1.49). We conclude that the oxygen desaturation test combined with the 50-ml water swallow test is suitable as a screening test to identify all acute stroke patients at risk of aspiration for further evaluation and management.

Urinary retention in hospitalised older women.

INTRODUCTION: Information about urinary retention in women is scarce. We conducted a case-control study to identify the symptoms and risk factors associated with urinary retention in hospitalised older women. MATERIALS AND METHODS: Targeted history (especially lower urinary tract symptoms) and physical examination of 60 women (65 years or older) who had post-void residual urine volume (PRUV) (determined using a portable ultrasound Bladder Scan BVI-2500) of more than 100 mL were studied and compared with 60 controls. RESULTS: Symptoms of voiding difficulties had low positive predictive value (PPV) and negative predictive value (NPV), except for poor stream, which has a PPV of 100%. Only one-third of the patients with high PRUV had a palpable bladder. Associated with high PRUV were: 1) constipation [odds ratio (OR), 4.12; 95% confidence interval (CI), 1.90-8.91; P = 0.0004]; 2) urinary tract infection (UTI) (OR, 3.36; 95% CI, 1.58-7.12; P = 0.002); 3) impaired mobility (OR, 2.37; 95% CI, 1.12-4.97; P = 0.02); 4) past history of UTI (OR, 3.5; 95% CI, 1.34-9.14; P = 0.014); 5) past history of urinary retention (OR, 6.33; 95% CI, 1.72-23.33; P = 0.004); 6) stroke (OR, 2.5; 95% CI, 1.24-5.41; P = 0.017); 7) diabetes mellitus with microvascular complications (OR, 2.76; 95% CI, 1.08-7.04; P = 0.042). Applying logistic regression analysis, the three best predictive variables for high PRUV were constipation, UTI and past history of urinary retention. CONCLUSION: Symptoms (except for positive history of poor stream) and signs were unreliable in diagnosing urinary retention in hospitalised older women. Patients with the above risk factors should have their PRUV ascertained, which can be done reliably non-invasively. Early detection with appropriate intervention can potentially prevent the morbidity and mortality associated with urinary retention.

Wegener's granulomatosis in the elderly.

Wegener's granulomatosis classically involves the upper respiratory tract, lungs and kidneys. Rarely, it also affects the skin and heart. Cardiac involvement is uncommon in Wegener's granulomatosis and myocardial infarction is seldom highlighted. It can be a difficult diagnosis to make in the elderly who often have multiple co-existing illnesses. We present a case of a 75-year-old Chinese woman with interesting cardiac and dermatological manifestations of Wegener's granulomatosis.

Bedside assessment of swallowing: a useful screening tool for dysphagia in an acute geriatric ward.

AIM: Dysphagia is common in the elderly and is associated with increased morbidity and mortality. We undertook a prospective study to determine the usefulness of a simple bedside swallowing test in terms of (1) detecting previously undiagnosed dysphagia, (2) agreement of the doctor's assessment with that of the speech therapist, (3) impact on subsequent feeding modality, (4) predicting risk of subsequent pneumonia. METHOD: Patients in an acute geriatric ward who had no contra-indications to oral feeding were subjected to a bedside swallowing assessment by a geriatrician within 24 hours of admission. All patients found to be dysphagic were subsequently re-assessed by a speech therapist within 48 hours. In addition, every fifth patient deemed to have normal swallowing by the doctor was assessed by the speech therapist. RESULTS: Sixty-five patients were studied. The doctor's assessment was in very good agreement with the assessment of the speech therapist (kappa = 0.87). Patients found to have dysphagia using the doctor's assessment protocol had an increased risk of developing pneumonia during their hospitalization (relative risk R.R.: 9.9 confidence interval C.I.: 1.2-81.2). Cough on swallowing and delayed swallowing were both found to be associated with an increased risk of developing pneumonia during the period of hospitalization (R.R.: 4.2, C.I.: 1.2-14.4; R.R.: 5.3, C.I.: 1.1-26.3 respectively). CONCLUSION: A simple bedside swallowing test can be used as an effective screening tool in detecting hitherto undiagnosed dysphagia. The validity of this tool in the diagnosis of aspiration requires further investigation.

Swallowing impairment and feeding dependency in the hospitalised elderly.

A prospective study was carried out to determine the prevalence of swallowing impairment and feeding dependency in an acute geriatric medicine unit in Singapore and the co-morbidity associated with it. A total of 211 patients were assessed over a 3-month period. Only 7.1% of patients gave a history of swallowing impairment prior to hospitalisation. We found that 29.4% of patients on admission and 28.2% on discharge had swallowing impairment, with a mortality of 8.1%. The prevalence of feeding dependency, as defined by the need for feeding assistance or tube feeding, was 26.5% before admission and 27.8% on discharge. The mode of feeding between the time of admission and discharge was changed in 14.9% of patients in response to the evolving medical condition. Swallowing impairment was significantly associated with the presence of dehydration (RR = 2.82, CI = 1.74-4.57), chest infection on admission (RR = 2.85, CI = 1.85-4.41), development of nosocomial chest infection (RR = 6.75, CI = 2.60-17.5), discharge to institutional care (RR = 2.8, CI = 1.51-3.47) and increased mortality (RR = 3.77, CI = 1.45-9.70). We concluded that swallowing impairment and feeding dependency are common in the elderly admitted to an acute geriatric unit. As elderly patients seldom inform clinicians of any underlying swallowing impairment and in view of the increased morbidity and mortality associated with this disability, it is important to screen for swallowing impairment. The high prevalence of feeding dependency adds to the burden of care in the ill elderly.

Comparison of three methods of quantifying urethral resistance in men.

OBJECTIVES: To determine how well three methods of quantifying urethral resistance from pressure-flow plots compared in men. METHODS: The pressure-flow plots of 312 men who attended a Continence Clinic for evaluation of lower urinary tract symptoms were analyzed. The Abrams-Griffiths number (AG), detrusor-adjusted mean PURR [passive urethral resistance relation] factor (DAMPF), and group-specific urethral resistance factor (URA) were obtained for each plot. The correlation coefficients and simple regression equations were computed for AG versus DAMPF and AG versus URA. Using the provisional International Continence Society method for definition of obstruction to categorize the AG values as obstructed, equivocal, or unobstructed, we obtained the corresponding DAMPF and URA values for our study population. RESULTS: The Pearson correlation coefficient, r, for AG versus DAMPF and AG versus URA was 0.941 and 0.889, respectively. The corresponding regression equations obtained were AG = - 32.6 + (DAMPF)1.27 (95% confidence interval [CI] 1.22 to 1.32) and AG = - 16.4 + (URA) 1.67 (95% CI 1.58 to 1.77). The 5th to 95th percentiles of the DAMPF and URA for men who were obstructed (AG number more than 40) were 56 to 92 and 28 to 71, those for men who were equivocal (AG 20 to 40) were 35 to 62 and 17 to 38, and those for men who were unobstructed (AG less than 20) were 12 to 44 and 5 to 24, respectively. CONCLUSIONS: The DAMPF and URA were highly correlated to the AG in a linear fashion. Although these parameters were developed differently, they appeared to compare well. When using the DAMPF or URA to quantify urethral resistance, it was possible to estimate the corresponding AG value with reasonable confidence.

Use of the uroflow study in the diagnosis of bladder outlet obstruction in elderly men.

The uroflow and pressure-flow data of 67 men aged 65 years or more were compared. At best, the uroflow study applying the Liverpool nomogram (25th percentile) and Bristol nomogram (OSD) diagnosed bladder outlet obstruction with sensitivity of 62.5% and 62.5% and specificity of 48.8% and 74.4% respectively. Using the 50th percentile of the Liverpool nomogram as the cut-off resulted in a negative predictive value of 100.0% allowing about 10% of men to have this diagnosis ruled out. We conclude that the uroflow study is inaccurate in diagnosing bladder outlet obstruction in elderly men. However, it can be used to rule out this condition in the small subset of men with maximum flow rates above the 50th percentile of the Liverpool nomogram.

Prevention of falls in a geriatric ward.

Falls occurring in the hospital are significant events because of the injuries sustained, extended hospital stay and potential medicolegal implications. We conducted a 3-year study to determine the characteristics of fallers in a geriatric ward and assess the effectiveness of lectures and nursing assessments in the prevention of falls. In the first year of the study we found that the rate of falls was 9% of all patients admitted. About 85.7% of falls occurred at the bedside and 41.4% happened while getting in and out of bed. Most falls occurred between 4 pm and 8 pm and half of the fallers had no preceding symptoms. In the second year, a series of lectures and educational material were given to the same nursing staff and the prevalence of falls was reduced to 7% (P > 0.05). However, the implementation of a nursing assessment protocol in the third year of the study achieved a marked reduction in prevalence of falls to 5.9% from the initial 9% (Chi-square chi 2 = 4.19, P = 0.04). Thus, the vigorous administration of a nursing assessment protocol can reduce falls in a geriatric ward.

Bilateral lower limb oedema due to a distended urinary bladder.

A 91-year-old Chinese man developed bilateral lower limb oedema due to venous obstruction resulting from a distended urinary bladder. After the bladder was decompressed by urethral catheterisation, the bilateral lower limb oedema promptly subsided. Although a distended urinary bladder is a rare cause of bilateral lower limb oedema, it can be easily recognised by palpation of the lower abdomen and the relief of symptoms by urethral catheterisation is most rewarding.

Ticlopidine induced cholestatic jaundice.

Ticlopidine hydrochloride (Ticlid) has been increasingly used as an antiplatelet agent. Some studies showed that it has higher efficacy in reducing stroke recurrence when compared to conventional aspirin. Side effects like gastrointestinal disturbances and blood dyscrasias are common but ticlopidine-induced cholestatic jaundice has been reported only rarely. We present a case report on a patient who has ticlopidine-induced cholestatic jaundice.

The influence of age on isometric and isotonic rat detrusor contractions.

BACKGROUND: Reductions in detrusor shortening velocity and detrusor contractility have been observed in association with aging. The reasons for these changes are unclear. METHODS: We examined the isometric and isotonic responses of detrusor, taken from the bladder body, to adenosine 5'-triphosphate (ATP), noradrenaline (NA), serotonin, and acetylcholine (Ach) in vitro, using bladders from young (30 days) and old (365 days) Sprague-Dawley rats, to determine whether there were any significant age-related differences. RESULTS: Isometric contractions with ATP at doses of 10(-3) to 10(-2) molar concentrations produced greater contractile forces in old rats when compared to young rats (p = .0136 at 10(-2) mole of ATP). Isotonic contractions at similar concentrations also produced significant differences between the young and the old rats, the latter being faster (p = .0225). Isometric contraction with noradrenaline produced significant differences between young and old rats, the latter being stronger. This became apparent at 10(-4) molar concentration of noradrenaline (p = .0043). Isometric contractions with serotonin also produced significantly greater contractions in the old rats when compared to young rats. The differences became apparent at 10(-4) molar concentration of serotonin (p = .045). There were no age-related differences in isotonic and isometric contractile responses to acetylcholine in the doses used in our experimental setup. CONCLUSIONS: Age-related differences in isometric function were detected in response to ATP, NA, and serotonin. Differences in isotonic function were only found in response to ATP and Ach.

Is the bladder "an unreliable witness" in elderly males with persistent lower urinary tract symptoms?

AIM: We sought to study the usefulness of lower urinary tract symptoms and postvoid residual urine volume in the diagnosis of voiding dysfunction in elderly men. METHODS: The symptoms and postvoid residual urine volume of 126 men aged 65 years or older referred for urodynamic studies were obtained. Their accuracy in the diagnosis of detrusor instability, bladder outlet obstruction and impaired detrusor contractility was quantified. RESULTS: For the diagnosis of detrusor instability, urgency and urge incontinence with frequency and/or nocturia had a sensitivity of 73.0% and a specificity of 60.0%. For the diagnosis of bladder outlet obstruction, poor stream with frequency and/or nocturia had a sensitivity of 51.9% and a specificity of 71.6%. Using poor stream and residual urine volume of more than 50 ml occurring together, the sensitivity was 31.1% and specificity was 89.7%. For the diagnosis of impaired detrusor contractility, poor stream had a sensitivity of 44.8% and a specificity of 56.7%. With residual urine volume of more than 50 ml, a sensitivity of 96.6% and specificity of 80.4% was obtained. CONCLUSION: Based on our findings, we conclude that the bladder does appear to be an "unreliable witness" in elderly men for the diagnosis of bladder outlet obstruction, though this is less so with impaired detrusor contractility. No conclusion can be drawn for the detrusor instability as we did not use ambulatory urodynamic studies.

Bacteraemia in the elderly.

The aims of the study were to describe community-acquired and nosocomial bacteraemia in elderly patients and to determine the factors associated with increased mortality in these patients attending a tertiary hospital in Singapore. A consecutive series of 191 patients aged more than 60 years of age admitted in 1995 was studied retrospectively. All of them had positive blood culture results obtained from the Department of Pathology and the case notes were reviewed and entered into a standard clinical protocol. They were analysed for age, sex, place of origin, race, sites of infection, clinical parameters and bacteriology. The mean age of the study population was 75 years (SD = 8.9 years). Bacteraemia was acquired from the community in 57.5% of patients, 33% was nosocomial in origin and 9.5% acquired it in chronic long term care facilities. The common organisms cultured in community-acquired infections were Escherichia coli (26.1%), Klebsiella species (25.4%), Streptococcus species (11.1%), methicillin sensitive Staphylococcus aureus (7.6%) and Proteus mirabilis (4.8%). The common organisms cultured in nosocomial infections were Klebsiella species (19.8%), Enterobacter species (14.6%), E. coli (11.8%), Acinetobacter baumanii (9.2%), methicillin sensitive Staphylococcus aureus (7.9%) and methicillin-resistant Staphylococcus aureus (7.9%). Whilst most cases of bacteraemia were single organism cultures, 13.5% were polymicrobial. The common sources of bacteraemia were chest (27.5%), urinary tract (24.5%), skin (12.5), hepatic (8.8%), gut (4.3%), cardiovascular system (1%) and others (3.6%). In 12.5% of cases, the sources were multiple and in 5.3% of cases, the source could not be identified. Twenty-one per cent of patients with bacteraemia died. The following factors were associated with increased mortality rate: older age (median age of those that died was 78.5 years compared to survivors with a median age of 73 years, P = 0.011), patient's place of origin (patients in nursing home at higher risk of death, P = 0.04), patient's mobility status (immobile patients at higher risk, P = 0.00297), source of bacteraemia--respiratory infection at increased risk of death (P = 0.00009) but urinary tract infection had a better survival rate (P = 0.03935) and multiple sites of infection (patients with multiple sites of infection had higher risk, P = 0.00897). Methicillin-sensitive Staphylococcus aureus bacteraemia was associated with a mortality rate of 35.3%, followed by Klebsiella species 28.6%, Pseudomonas aeruginosa 28.6%, methicillin-resistant Staphylococcus aureus 25%, Proteus mirabilis 25% and E. coli 19.1%. Important clinical parameters which indicated a poor clinical outcome were: high pulse rate, hypotension, increased respiratory rate, low total white cell count, coagulopathy, hypoalbuminaemia and increased creatinine level.