Medical informatics--the state of the art in the Hospital Authority

Since its inception in 1990, the Hospital Authority (HA) has strongly supported the development and implementation of information systems both to improve the delivery of care and to make better information available to managers. This paper summarizes the progress to date and discusses current and future developments. Following the first two phases of the HA information technology strategy the basic infrastructural elements were laid in place. These included the foundation administrative and financial systems and databases; establishment of a wide area network linking all hospitals and clinics together; laboratory, radiology and pharmacy systems with access to results in the ward. A major push into clinical systems began in 1994 with the clinical management system (CMS), which established a clinical workstation for use in both ward and ambulatory settings. The CMS is now running at all major hospitals, and provides single logon access to almost all the electronically collected clinical data in the HA. The next phase of development is focussed on further support for clinical activities in the CMS. Key elements include the longitudinal electronic patient record (ePR), clinical order entry, generic support for clinical reports, broadening the scope to include allied health and the rehabilitative phase, clinical decision support, an improved clinical documentation framework, sharing of clinical information with other health care providers and a comprehensive data repository for analysis and reporting purposes.     

Health care concerns and guidelines for adults with Down syndrome

Down syndrome (DS) is the most common cause of mental retardation in North America, yet little information is available on the natural history of DS in adults. We report on significant medical problems of adults with DS (DS adults) residing in a British Columbia provincial residential center, Woodlands, over the 12-year period from 1981 through 1992. Prospective, yearly health care reviews on 38 DS adults are summarized according to age. Group 1 consists of 18 middle-aged DS adults less than 50 years old, and group 2 comprises 20 elderly DS adults 50 years and older. Significant health problems in all DS adults include untreated congenital heart anomalies (15. 8%), acquired cardiac disease (15.8%), pulmonary hypertension (7.8%), recurrent respiratory infections/aspiration leading to chronic pulmonary interstitial changes (30%), complications from presenile dementia/Alzheimer-type disease (42%), adult-onset epilepsy (36.8%), osteoarthritic degeneration of the spine (31.6%), osteoporosis with resultant fractures of the long bones (55%) or vertebral bodies (30%), and untreated atlantooccipital instability (7.9%). Acquired sensory deficits are significant problems including loss of vision due to early onset of adult cataracts (50%), recurrent keratitis (21%) or keratoconus (15.8%), and significant hearing loss (25%). Behavioral problems (50%), loss of cognitive abilities, and onset of symptoms of Alzheimer disease (group 1: 5.5%; group 2: 75%) pose ongoing challenges for care. In conclusion, the quality of life for adults with DS can be improved by routine, systematic health care screening to identify treatable diseases that may be missed because of poor communication or confusion due to Alzheimer disease.     

Attributes of quiet stance in the chronic spinal cat

Standing is a dynamic task that requires antigravity support of the body mass and active regulation of the position of the body center of mass. This study examined the extent to which the chronic spinal cat can maintain postural orientation during stance and adapt to changes in stance distance (fore-hindpaw separation). Intact cats adapt to changes in stance distance by maintaining a constant horizontal orientation of the trunk and changing orientation of the limbs, while keeping intralimb geometry constant and aligning the ground reaction forces closely with the limb axes. Postural adaptation was compared in four cats before and after spinalization at the T(6) level, in terms of the forces exerted by each paw against the support, body geometry (kinematics) and electromyographic (EMG) activity recorded from chronic, indwelling electrodes, as well as the computed net torques in the fore and hindlimbs. Five fore-hindpaw distances spanning the preferred distance were tested before spinalization, with a total range of 20 cm from the shortest to the longest stance. After spinalization, the cats were trained on a daily basis to stand on the force platform, and all four cats were able to support their full body weight. Three of the four cats could adapt to changes in stance distance, but the range was smaller and biased toward the shorter distances. The fourth cat could stand only at one stance distance, which was 8 cm shorter than the preferred distance before spinalization. All cats shifted their center of pressure closer to the forelimbs after spinalization, but the amount of shift could largely be accounted for by the weight loss in the hindquarters. The three cats that could adapt to changes in stance distance used a similar strategy as the intact cat by constraining the trunk and changing orientation of the limb axes in close relation with the forces exerted by each limb. However, different postures in the fore- and hindlimbs were adopted, particularly at the scapula (more extended) and pelvis (tipped more anteriorly). Other changes from control included a redistribution of net extensor torque across the joints of the forelimb and of the hindlimb. We concluded that the general form of body axis orientation is relatively conserved in the spinal cat, suggesting that the lumbosacral spinal circuitry includes rudimentary set points for hindlimb geometry. Both mechanical and neural elements can contribute toward maintaining body geometry through stiffness regulation and spinal reflexes.     

Effect of stance width on multidirectional postural responses

The effect of stance width on postural responses to 12 different directions of surface translations was examined. Postural responses were characterized by recording 11 lower limb and trunk muscles, body kinematics, and forces exerted under each foot of 7 healthy subjects while they were subjected to horizontal surface translations in 12 different, randomly presented directions. A quasi-static approach of force analysis was done, examining force integrals in three different epochs (background, passive, and active periods). The latency and amplitude of muscle responses were quantified for each direction, and muscle tuning curves were used to determine the spatial activation patterns for each muscle. The results demonstrate that the horizontal force constraint exerted at the ground was lessened in the wide, compared with narrow, stance for humans, a similar finding to that reported by Macpherson for cats. Despite more trunk displacement in narrow stance, there were no significant changes in body center of mass (CoM) displacement due to large changes in center of pressure (CoP), especially in response to lateral translations. Electromyographic (EMG) magnitude decreased for all directions in wide stance, particularly for the more proximal muscles, whereas latencies remained the same from narrow to wide stance. Equilibrium control in narrow stance was more of an active postural strategy that included regulating the loading/unloading of the limbs and the direction of horizontal force vectors. In wide stance, equilibrium control relied more on an increase in passive stiffness resulting from changes in limb geometry. The selective latency modulation of the proximal muscles with translation direction suggests that the trunk was being actively controlled in all directions. The similar EMG latencies for both narrow and wide stance, with modulation of only the muscle activation magnitude as stance width changed, suggest that the same postural synergy was only slightly modified for a change in stance width. Nevertheless, the magnitude of the trunk displacement, as well as of CoP displacement, was modified based on the degree of passive stiffness in the musculoskeletal system, which increased with stance width. The change from a more passive to an active horizontal force constraint, to larger EMG magnitudes especially in the trunk muscles and larger trunk and CoP excursions in narrow stance are consistent with a more effortful response for equilibrium control in narrow stance to perturbations in all directions.     

Differential sensitivities of severe acute respiratory syndrome (SARS) coronavirus spike polypeptide enzyme-linked immunosorbent assay (ELISA) and SARS coronavirus nucleocapsid protein ELISA for serodiagnosis of SARS coronavirus pneumonia

The use of recombinant severe acute respiratory syndrome-coronavirus (SARS-CoV) nucleocapsid protein (N) enzyme-linked immunosorbent assay (ELISA)-based antibody and antigen tests for diagnosis of SARS-CoV infections have been widely reported. However, no recombinant SARS-CoV spike protein (S)-based ELISA is currently available. In this article, we describe the problems and solutions of setting up the recombinant SARS-CoV S-based ELISA for antibody detection. The SARS-CoV S-based immunoglobulin M (IgM) and IgG ELISAs were evaluated and compared with the corresponding N-based ELISA for serodiagnosis of SARS-CoV pneumonia, using sera from 148 healthy blood donors who donated blood 3 years ago as controls and 95 SARS-CoV pneumonia patients in Hong Kong. Results obtained by the recombinant S (rS)-based IgG ELISA using the regenerated S prepared by dialysis with decreasing concentrations of urea or direct addition of different coating buffers, followed by addition of different regeneration buffer, identified 4 M urea and 1 M sarcosine for plate coating and no regeneration buffer as the most optimal conditions for antibody detection. The specificities of the S-based ELISA for IgG and IgM detection were 98.6% and 93.9%, with corresponding sensitivities of 58.9% and 74.7%, respectively. The sensitivity of the rN IgG ELISA (94.7%) is significantly higher than that of the rS IgG ELISA (P < 0.001), whereas the sensitivity of the rS IgM ELISA is significantly higher than that of the rN IgM ELISA (55.2%) (P < 0.01). An ELISA for detection of IgM against S and N could be more sensitive than one that detects IgM against N alone for serodiagnosis of SARS-CoV pneumonia.     

Phacoemulsification and implantation of posterior chamber intraocular lens in eyes with quiescent proliferative diabetic retinopathy

A phacoemulsification procedure, combined with an in-the-bag lens implantation, was performed on ten eyes that once had proliferative diabetic retinopathy (PDR). The ten eyes were in eight patients who had a 20-plus year history of either type I or type II diabetes mellitus. All eyes had reached the quiescent state of diabetic retinopathy 2–13 years before the cataract surgery through either argon laser pan retinal photocoagulation and/or pars plana vitrectomy. Nine of ten eyes remained completely free of retinal neovascularization and rubeosis iridis, with follow-up periods between 1.5 and 5 years. One eye has been lost to recurrent vitreous hemorrhages and an inoperable retinal detachment.Presented in part at the XVth Meeting of the Club Jules Gonin, Copenhagen, 10–15 August 1986     

Diet Quality and Cognitive Performance in Australian Adults Aged 55–85 Years: A Cross-Sectional Analysis of the Hunter Community Study Cohort

There is a lack of evidence to determine if diet quality is associated with cognitive performance in older adults. Therefore, the aim of this study was to examine whether diet quality is associated with cognitive performance among older adults. A cross-sectional, secondary analysis of baseline data from the Hunter Community Study (HCS), comparing diet quality, measured using the Australian Recommended Food Score (ARFS), along with validated cognitive performance instruments the Audio Recorded Cognitive Screen (ARCS) and the Mini-Mental State Examination (MMSE) were undertaken in adults aged 55–85 years, living in Newcastle, NSW, Australia. Adjusted linear regression analyses showed that, compared with the lowest ARFS quintile, those in the highest quintile had an ARCS score 5.883 units greater (p < 0.001; R² = 0.0098). Furthermore, when quintiles of ARFS score were tested against each ARCS sub-scale score, statistically significant associations were observed with the greatest effect for the Memory (β = 4.055; p = 0.001; R² = 0.0065) and Attention (β = 4.136; p = 0.002; R² = 0.0047) domains. No statistically significant associations were observed between quintiles of ARFS and MMSE score in the adjusted linear regression analyses. In conclusion, a positive association was observed between diet quality and cognitive performance within this sample of older Australian adults. Further investigation of the above association over time, when follow-up data becomes available, in longitudinal analysis is recommended.     

Territorywide Study of Early Coronavirus Disease Outbreak,Hong Kong,China

Initial cases of coronavirus disease in Hong Kong were imported from mainland China. A dramatic increase in case numbers was seen in February 2020. Most case-patients had no recent travel history, suggesting the presence of transmission chains in the local community. We collected demographic, clinical, and epidemiologic data from 50 patients, who accounted for 53.8% of total reported case-patients as of February 28, 2020. We performed whole-genome sequencing to determine phylogenetic relationship and transmission dynamics of severe acute respiratory syndrome coronavirus 2 infections. By using phylogenetic analysis, we attributed the community outbreak to 2 lineages; 1 harbored a common mutation, Orf3a-G251V, and accounted for 88.0% of the cases in our study. The estimated time to the most recent common ancestor of local coronavirus disease outbreak was December 24, 2019, with an evolutionary rate of 3.04 × 10⁻³ substitutions/site/year. The reproduction number was 1.84, indicating ongoing community spread.     

Regional anaesthesia for orthopaedic procedures

Regional anaesthetic techniques are fundamental in the anaesthetic care of orthopaedic patients. They may be used as the primary anaesthetic technique or to provide postoperative pain relief. Compared to general anaesthesia alone, regional techniques can provide superior perioperative analgesia, fewer systemic drug adverse effects such as nausea, vomiting and confusion, and earlier mobilization which can reduce nosocomial complications and facilitate expedited hospital discharge. Disadvantages include block failure, nerve injury, unrecognised injury to the anaesthetised limb, prolonged motor blockade and local anaesthetic toxicity. Preoperative assessment should identify contraindications, document pre-existing neurological deficits, and clarify surgical and perioperative aims. Informed consent should be obtained after a clear explanation of the procedure, its risks, and potential complications. Serious and long-term neurological complications are rare and may be reduced by an awake regional technique, sonographic guidance, regular aspiration and by ensuring low pressure injections. Postoperative follow-up is essential and suspicious neurological findings should be detected, investigated, and managed in an early and timely manner.