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Timothy H Rainer

Publications and source records attributed to Timothy H Rainer.

At least 19 recordsLinked to original sources
PubMed2006

Prospective comparison of three predictive rules for assessing severity of community-acquired pneumonia in Hong Kong.

BACKGROUND: Community-acquired pneumonia (CAP) is a leading infectious cause of death throughout the world, including Hong Kong. AIM: To compare the ability of three validated prediction rules for CAP to predict mortality in Hong Kong: the 20 variable Pneumonia Severity Index (PSI), the 6-point CURB65 scale adopted by the British Thoracic Society and the simpler CRB65. METHODS: A prospective observational study of 1016 consecutive inpatients with CAP (583 men, mean (SD) age 72 (17) years) was performed in a university hospital in the New Territories of Hong Kong in 2004. The patients were classified into three risk groups (low, intermediate and high) according to each rule. The ability of the three rules to predict 30 day mortality was compared. RESULTS: The overall mortality and intensive care unit (ICU) admission rates were 8.6% and 4.0%, respectively. PSI, CURB65 and CRB65 performed similarly, and the areas under the receiver operating characteristic (ROC) curve were 0.736 (95% CI 0.687 to 0.736), 0.733 (95% CI 0.679 to 0.787) and 0.694 (95% CI 0.634 to 0.753), respectively. All three rules had high negative predictive values but relatively low positive predictive values at all cut-off points. Larger proportions of patients were identified as low risk by PSI (47.2%) and CURB65 (43.3%) than by CRB65 (12.6%). CONCLUSION: All three predictive rules have a similar performance in predicting the severity of CAP, but CURB65 is more suitable than the other two for use in the emergency department because of its simplicity of application and ability to identify low-risk patients.

Adolescent↗
PubMed2006

Outcome of traumatic extradural haematoma in Hong Kong.

AIM: Traumatic extradural haematoma (EDH) is a neurosurgical emergency and timely surgical intervention for significant EDH is the gold standard. This study aims to determine the incidence and mortality of consecutive patients with traumatic EDH admitted to the Emergency Department (ED) of Prince of Wales Hospital (PWH), a University Hospital Trauma Centre in Hong Kong. PATIENTS AND METHODS: Retrospective analysis of prospectively collected data for all consecutive trauma cases admitted through the ED during 2001-2004. EDH was diagnosed by CT in all cases. Both primary and delayed onset EDH were included, as were patients with combined EDH and other intracranial lesions (e.g. subdural haematoma). Age, sex, cause of injury, associated intracranial lesions, skull fracture, Glasgow Coma Scale, pupil reactivity, treatment, length of stay and clinical outcome were determined. RESULTS: Two thousand and two hundred and eight patients were in the trauma registry for 2001-2004. Total 1080 head injured patients; 89 patients had traumatic EDH, mean of 1.9 patients per month. Seventy (79%) patients were male, with a mean age of 37.7 years. Fifty (56%) patients were from road traffic crashes, 27 (30%) sustained falls, 10 (11%) had direct head trauma. On admission, 62 (70%) patients were GCS 13-15, 9 (10%) GCS 9-12 and 18 (20%) GCS 3-8. Sixty-six (74%) patients had a skull fracture. Thirty (34%) patients underwent neurosurgical operation. Overall, nine patients (10%) died; eight patients were GCS<8; five had bilateral fixed and dilated pupils; one had a single fixed and dilated pupil. Four patients died after neurosurgical operation, three of whom had fixed dilated pupils and were GCS 3 prior to surgery. Median length of hospital stay for survivors was 10.4 days. CONCLUSION: Survival from traumatic EDH was 90% (80/89) and 91% (73/80) of survivors had a Glasgow Outcome Score of 4 or 5 (good or moderate). The combination of bilateral fixed dilated pupils and GCS 3 suggests severe primary brain injury. Emergency evacuation of intracranial haematomas is unlikely to improve the outcome for these patients. Even in an urban environment with short prehospital times and rapid access to neurosurgery, outcome in patients who are GCS 3 following EDH is likely to be poor.

Accidental Falls↗
PubMed2006

Five year analysis of Jockey Club horse-related injuries presenting to a trauma centre in Hong Kong.

BACKGROUND: Professional horse riding-related injuries have not been studied before in Hong Kong, although horse racing takes place very regularly in the territory. In addition, the equestrian events of the 2008 Beijing Olympic Games will come to Hong Kong. This study analysed the pattern of horse-related injury among patients who presented to a trauma centre in a teaching hospital in Hong Kong. METHODS: Information from the trauma centre database was analysed retrospectively. The database includes trauma patients who had sustained potentially severe injuries that warranted initial assessment and resuscitation in a trauma resuscitation room (triage category 1 or 2). Data analysed included demographic variables, causes and mechanisms of injury, anatomical injuries, anatomical and physiological trauma scores, and patient outcome. RESULTS: Between January 2001 and June 2005, 2312 trauma patients were entered into the database. Thirty-six (1.6%) patients had sustained horse-related injuries (mean age 34 years, range 17-54; male to female ratio 32:4), all whilst at work in the Jockey Club. Twenty-two patients were injured between midnight and 09:00 h. This group stayed in the resuscitation room for longer prior to admission compared with patients presenting between 09:00h and midnight (median time 127 min (interquartile range [IQR] 57-183) versus 58 min (IQR 43-83), p=0.06). Twenty-five patients fell from horseback, whilst 11 were kicked by the horse. Twenty patients had a single injury and 16 patients had multiple injuries. Eighteen patients had injuries to the thorax, abdomen, thoracolumbar spine or pelvis. Eleven patients had head, face and cervical spine injuries and 11 had limb injuries. Twenty-five patients were admitted, including four admitted to the intensive care unit (ICU). Ten patients required surgery. Median (standard deviation [S.D.]) probability of survival was 0.996 (0.052) and median revised trauma score (RTS) (S.D.) was 7.841 (0.624). There were no fatalities. Potentially serious horse-related injuries presented once every 6 weeks. CONCLUSION: Most injuries are minor and affect the trunk but occur out of hours. Helmets, face shields and body protectors should be worn when riding or handling horses.

Accidents, Occupational↗
PubMed2006

Comparison of plasma beta-globin DNA and S-100 protein concentrations in acute stroke.

BACKGROUND: This study aimed to compare changes in plasma beta-globin DNA and serum S100 protein to diagnose stroke and for predicting mortality and morbidity. METHODS: Patients with stroke-like symptoms presenting to the emergency department of a Hong Kong hospital were recruited. Plasma DNA was analyzed for the beta-globin gene with fluorescent-based PCR. S100 concentrations were determined using ELISA. Primary outcomes were diagnosis of stroke, mortality, and modified Rankin Score (mRS) after 6 months. RESULTS: One hundred ninety-seven consecutive patients recruited, 118 (60%) ischemic stroke, 35 (18%) hemorrhage and 44 (22%) with no acute neuroimaging changes. Serum S100 and plasma DNA were increased in 126 (p<0.0010) and 36 (p=0.21) stroke patients respectively vs. controls. Median plasma DNA was higher in hemorrhagic stroke than those without (1725 vs. 1050 kilogenome-equivalents/l, p=0.0104). Median plasma DNA was higher in mRS>2 vs. mRS 2 patients vs. mRS<or=2 (0.152 vs. 0.131 microg/l, p=0.0003). The odds ratio (OR) of discriminating hemorrhagic from non-hemorrhagic stroke with DNA was 4.24 (95% CI 1.88-9.56); S100 and DNA together give an OR of 16.55. CONCLUSION: For stroke diagnosis, S100 performs better than DNA; DNA is a better marker for hemorrhage. For diagnosis of hemorrhagic stroke, combined S100 and DNA performs better than either alone. Plasma DNA and serum S100 predict morbidity and mortality in stroke.

Adult↗
PubMed2006

Plasma beta-globin DNA as a prognostic marker in chest pain patients.

BACKGROUND: Acute coronary syndrome may involve cell death and the release of nucleic acids into the circulation. We thus investigated whether plasma DNA concentrations are increased and determined its prognostic significance in patients with ACS. METHODS: Real-time polymerase chain reaction was used to quantitatively measure the beta-globin gene from blood samples taken from patients presenting to an emergency department with chest pain of probable cardiac cause. RESULTS: Samples from 58 patients with chest pain, and from 21 age- and sex-matched healthy control subjects were analysed. Compared with the control group, median plasma DNA concentrations were increased 1.5-fold in patients with minor cardiac injury, were increased further in patients with STEA and STEMI, and were the highest in those patients who died within 2 years (P=0.0005; post-hoc Dunn's, P<0.05). Median plasma DNA concentrations were higher in patients who later developed heart failure (1060 vs. 500 kGE/l; P=0.0095); higher in patients who later reinfarcted (1000 vs. 530 kGE/l; P=0.0298); higher in patients who had a cardiac arrest in that admission (1350 vs. 525 kGE/l; P=0.04); and were higher in patients who were readmitted within 6 months of discharge (725 vs. 475 kGE/l; P=0.04). CONCLUSION: Plasma DNA is a potential marker for post-ACS complications.

Adult↗
PubMed2006

Primary spontaneous pneumothorax: 1-year recurrence rate after simple aspiration.

OBJECTIVES: Recurrence rate is an important factor to consider when choosing the modality of treatment for primary spontaneous pneumothorax. The recurrence rate after simple aspiration has only been previously reported in several relatively small studies. The objectives of this study was to investigate the 1-year recurrence rate of primary spontaneous pneumothorax after treatment by simple aspiration and the potential risk factors for recurrence. METHODS: A retrospective cohort study was performed over a 2-year period on 91 consecutive patients with primary spontaneous pneumothorax who were treated with simple aspiration. The setting was an emergency department of a 1400-bed university teaching hospital in Hong Kong. Recurrence within 1 year and associated risk factors were assessed by telephone follow-up interviews. The factors evaluated were age, sex, side of pneumothorax, previous and present smoking history, history of previous pneumothorax, size of pneumothorax at initial assessment, volume of air aspirated, and final outcome. RESULTS: The overall 1-year recurrence rate was 15.7% [95% confidence interval (CI), 8.9-25.0%]. The recurrence rate for patients who had successful simple aspiration was 17.6% (95% CI, 8.0-32.1%). In patients who had successful aspiration, the median size of pneumothorax at initial presentation for those with recurrence was 17.5% (95% CI, 12.0-23.0%), compared with 25.0% (95% CI, 22.7-30.6%) for those without recurrence (P = 0.044). CONCLUSIONS: The 1-year recurrence rate after successful simple aspiration for primary spontaneous pneumothorax in Chinese patients in Hong Kong is not high. Recurrence within 1 year appears to be associated with smaller initial size of pneumothorax.

Adult↗
PubMed2006

Primary trauma diversion: initial experience in Hong Kong.

BACKGROUND: Trauma is a leading cause of death and loss of workdays in Hong Kong. Reports have suggested that timely provision of care in dedicated trauma centers can improve outcomes. Until recently, ambulances were required to take trauma patients to the nearest hospital's emergency department. This paper reports on the initial experience of primary trauma diversion from scene to a dedicated trauma center in Hong Kong. METHODS: This prospective study involved the establishment of primary trauma diversion in the area served by Alice Ho Nethersole Hospital (AHNH), a general hospital in the New Territories. Trauma patients who fulfilled diversion criteria were taken directly to the Prince of Wales Hospital (PWH) in Shatin, a university teaching hospital and trauma center for the area. Data were collected to determine the change in time to definitive care for trauma patients and an impact analysis on PWH services was performed. RESULTS: There were 60 patients who underwent primary trauma diversion and 35 patients underwent secondary diversion after initial treatment at AHNH. This represented two extra trauma patients per week at PWH. Median Injury Severity Score (ISS) was 9 and 52% of patients had been involved in a traffic crash. Of eligible patients, 76% (69 out of 91) diverted correctly according to protocol. Primary trauma diversion patients reached definitive care 97 minutes faster than patients undergoing secondary diversion. CONCLUSION: Primary trauma diversion is feasible in Hong Kong and means that patients reach definitive care 97 minutes faster than going to the nearest hospital. Primary trauma diversion protocols should be extended throughout Hong Kong.

Adult↗
PubMed2006

Topographic patterns of small subcortical infarcts associated with MCA stenosis: a diffusion-weighted MRI study.

BACKGROUND AND PURPOSE: Small subcortical infarcts (SSI, maximum lesion diameter < or =2.0 cm) are usually considered as infarcts caused by small vessel disease. However, SSI can also be associated with large artery occlusive disease such as middle cerebral artery (MCA) stenosis. We performed a prospective study to investigate the relationship between MCA stenosis and SSI distribution and further to investigate the mechanism of SSI caused by MCA stenosis. METHODS: Magnetic resonance angiography (MRA) and diffusion-weighed MRI (DWI) of consecutive acute ischemic stroke patients with recent SSI were studied. The distribution of acute infarcts on DWI was categorized as cortical infarct (CI), border zone infarct (BI), or perforating artery infarct (PAI). RESULTS: Totally, 93 cases were recruited, among which 12 had single SSI with MCA stenosis (group 1) and 26 patients had multiple SSI with MCA stenosis (group 2), while 55 patients without MCA stenosis had single SSI (group 3). For patients with single SSI and MCA stenosis, 6 had BI and 6 had PAI; for patients with multiple SSI and MCA stenosis, 25 had BI, 4 had PAI and 9 had CI (compared with group 1: P= .001); for patients with single SSI but without MCA stenosis, 20 had BI and 35 had PAI (compared with group 1: P= .58). CONCLUSION: Multiple acute infarcts along the border zone are the commonest pattern in small infarcts with MCA stenosis, especially among those with multiple acute infarcts. Our data suggest that hemodynamic compromise and artery-to-artery embolism may be both important factors for infarcts in patients with MCA stenosis.

Aged↗
PubMed2006

Circulating nucleic acids and critical illness.

This article reviews some of the early work that has been performed to investigate the potential roles of circulating nucleic acids as prediction markers in acute illness and injury. Circulating DNA and RNA concentrations are elevated early in patients with trauma, stroke and ACS, and are generally highest in patients with a high risk of death. Circulating nucleic acids may be useful markers for the evaluation and risk-stratification of such patients.

Biomarkers↗
PubMed2005

Plasma DNA as a prognostic marker for stroke patients with negative neuroimaging within the first 24 h of symptom onset.

Modern neuroimaging safely and reliably diagnoses stroke and provides information for outcome prediction. However, some patients with clinical stroke have no detectable abnormality on neuroimaging and other patients are not fit for such investigations. Therefore, we evaluated the potential of plasma DNA and serum S100 protein concentrations to predict post-stroke mortality and morbidity in patients with negative neuroimaging results. Patients with stroke-like symptoms but negative neuroimaging results were recruited. Both plasma and serum were collected from each patient for plasma DNA and serum S100 analysis. The primary outcome measures were 6-month mortality and morbidity using the post-stroke modified Rankin score (mRS). Forty-four patients were recruited to the study. Seventeen (39%) patients were classified as post-stroke mRS grades 3-6. The median plasma DNA concentration of this group of patients was significantly higher than that of patients with post-stroke mRS grades 0-2. Median serum S100 protein concentrations did not show significant differences between the two groups. Plasma DNA concentrations > 800 kilogenome-equivalent/l have a sensitivity of 42% and a specificity of 100% for predicting 6-month post-stroke mRS (grades 0-2), with an area under the receiver operator characteristic (ROC) curve of 0.742. By comparison, serum S100 protein concentrations > 0.09 microg/l have a sensitivity of 48% and specificity of 75% for predicting 6-month post-stroke mRS (grades 0-2), and the area under the curve is 0.542. Plasma DNA concentration predicts post-stroke morbidity and mortality in patients with negative neuroimaging, and may be more effective than S100 protein measurement.

Aged↗
PubMed2005

Reduced time on the spinal board-effects of guidelines and education for emergency department staff.

AIM: Prehospital spinal immobilisation is usually accomplished with a spinal board. Prolonged immobilisation on spinal boards in the emergency department (ED) can be detrimental. This study aimed to reduce the time spent by patients on spinal boards using a staff education program. METHODS: Observational study in a trauma centre ED seeing 180,000ED attendances per year. The length of time immobilised on spinal board was recorded by the trauma nurse coordinator. Guidelines on removal of spinal boards were issued after recording period 1 (January-June 2001) and reinforced several times. The post-training period (period 2) extended from May to October 2003. Medians were compared using Mann-Whitney U-test (non-parametric data); chi-square test was used for categorical data. RESULTS: There were 122 eligible patients in period 1 and 104 eligible patients in period 2. Median time to removal from the spinal board was reduced by 18.5 min from 50 to 31.5 min (Mann-Whitney U-test, p<0.0001, 95% CI for difference in medians 13-29 min). In period 1, 44 of 122 patients (36%) were removed from the spinal board before leaving the ED, compared to 78 of 104 patients (75%) in period 2 (p<0.0001, chi-square test). CONCLUSION: The introduction of guidelines, reinforced by ED staff education, can significantly reduce the time patients spend on spinal boards after trauma and can increase the proportion of patients who can be removed from the board before leaving the ED.

Education, Continuing↗
PubMed2005

Randomized double-blind trial comparing oral paracetamol and oral nonsteroidal antiinflammatory drugs for treating pain after musculoskeletal injury.

STUDY OBJECTIVE: We investigate the efficacy and safety of oral paracetamol compared with oral nonsteroidal antiinflammatory drugs or combination therapy in relieving pain after blunt limb injury in an emergency department (ED). METHODS: This was a double-blind, randomized, controlled study in an ED of a university hospital in the New Territories of Hong Kong. Three hundred adult patients with painful isolated limb injuries were enrolled. Primary outcome measures were pain relief at rest and with limb movement, adverse events, and patient satisfaction. RESULTS: There was no statistical difference in the mean reduction in pain score between any of the combinations at any point, although combination therapy was the first to reach a clinically significant reduction in pain score (<13 mm), and diclofenac-paracetamol combinations consistently produced a greater reduction in mean pain score than either nonsteroidal antiinflammatory drugs or paracetamol alone. All combinations appeared to be safe, although more patients receiving diclofenac-paracetamol combination complained of abdominal pain. The median patient satisfaction scores were poor. CONCLUSION: In the doses, frequencies, and routes of administration used for this study, any analgesic benefit of oral paracetamol-nonsteroidal antiinflammatory drug combinations over single nonsteroidal antiinflammatory drugs or paracetamol treatment is small and of doubtful clinical significance. Nonsteroidal antiinflammatory drugs, paracetamol, and diclofenac-paracetamol combinations appeared equally safe in the management of musculoskeletal pain.

Acetaminophen↗
PubMed2005

Anaphylaxis presentations to an emergency department in Hong Kong: incidence and predictors of biphasic reactions.

We describe the epidemiology, clinical features and management of anaphylaxis in a population in Hong Kong, including the features associated with progression to biphasic reactions and the nature of these reactions. A retrospective review was undertaken of patients of all age groups, presenting consecutively to the resuscitation room of a large Hong Kong emergency department with the diagnosis of anaphylaxis, from March 1999 to February 2003. There were 282 patients included. Median age was 28 years, with 59% male. A precipitant was identified in 89%, with 19% of patients claiming a known allergy to the precipitant. Seafood was responsible for 71% of all food-related reactions. More patients reacted to nonsteroidal anti-inflammatory drugs rather than antibiotics. Cutaneous features were present in 79%, and 12% presented with hypotension. Ninety-five percent received H1 antagonist, and 67% received epinephrine. Biphasic reactions were reported in 15 (5.3%) cases with 20% of these patients having unstable vital signs. The mean time from treatment to onset of biphasic reaction was 8 h (range 1-23). Patients with respiratory features on initial presentation were less likely to develop biphasic reactions. It is concluded that prolonged observation of patients with anaphylaxis is important, because of the risk of biphasic reactions. Better education could prevent recurrent anaphylaxis.

Adolescent↗
PubMed2004

A clinical prediction rule for diagnosing severe acute respiratory syndrome in the emergency department.

BACKGROUND: Accurate, objective models of triage for patients with suspected severe acute respiratory syndrome (SARS) could assess risks and improve decisions about isolation and inpatient treatment. OBJECTIVE: To develop and validate a clinical prediction rule for identifying patients with SARS in an emergency department setting. DESIGN: Retrospective analysis using a 2-step coefficient-based multivariable logistic regression scoring method with internal validation by bootstrapping. SETTING: 2 hospitals in Hong Kong. PARTICIPANTS: 1274 consecutive patients from 1 hospital and 1375 consecutive patients from another hospital. MEASUREMENTS: Points were assigned on the basis of history, physical examination, and simple investigations obtained at presentation. The outcome measure was a final diagnosis of SARS, as confirmed by World Health Organization laboratory criteria. RESULTS: Predictors for SARS on the basis of history (step 1) included previous contact with a patient with SARS and the presence of fever, myalgia, and malaise. Age 65 years and older and younger than 18 years and the presence of sputum, abdominal pain, sore throat, and rhinorrhea were inversely related to having SARS. In step 2, haziness or pneumonic consolidation on chest radiographs and low lymphocyte and platelet counts, in addition to a positive contact history and fever were associated with a higher probability of SARS. A high neutrophil count, the extremes of age, and sputum production were associated with a lower probability of SARS. In the derivation sample, the observed incidence of SARS was 4.4% for those assigned to the low-risk group (in steps 1 or 2); in the high-risk group, incidence of SARS was 21.0% for quartile 1, 39.5% for quartile 2, 61.2% for quartile 3, and 79.7% for quartile 4. This prediction rule achieved an optimism-corrected sensitivity of 0.90, a specificity of 0.62, and an area under the receiver-operating characteristic curve of 0.85. LIMITATIONS: The prediction rule may not apply to isolated cases occurring during an interepidemic period. Generalizability of the findings should be confirmed in other SARS-affected countries and should be prospectively validated if SARS returns. CONCLUSIONS: Our findings suggest that a simple model that uses clinical data at the time of presentation to an emergency department during an acute outbreak predicted the incidence of SARS and provided good diagnostic utility.

Adult↗
PubMed2004

The spectrum of severe acute respiratory syndrome-associated coronavirus infection.

BACKGROUND: Whether subclinical or atypical presentations of severe acute respiratory syndrome (SARS) occur and whether clinical judgment is accurate in detecting SARS are unknown. OBJECTIVES: To describe the spectrum of SARS coronavirus infection in a large outbreak and to compare diagnoses based on clinical judgment with the SARS coronavirus test. DESIGN: Secondary analysis of prospectively collected clinical data and archived serum. SETTING: A SARS screening clinic of a university hospital in the New Territories of Hong Kong. PATIENTS: 1221 patients attending the clinic between 12 March 2003 and 12 May 2003. MEASUREMENTS: SARS coronavirus serology. RESULTS: 145 of 553 (26%) patients had serologic evidence of SARS coronavirus infection. Of 910 patients who were managed without hospitalization, only 6 had serologic evidence of SARS. Five of the six patients had normal chest radiographs, and four had symptoms such as myalgia, chills, coughing, and feeling feverish. With the SARS coronavirus serologic test as the gold standard, the clinical diagnosis of probable SARS at hospitalization had a sensitivity of 0.96 (95% CI, 0.91 to 0.98) and a specificity of 0.96 (CI, 0.92 to 0.97). LIMITATIONS: Follow-up serologic samples were not obtained from almost half of the patients because they declined further testing. Some people living in the community who were infected but who had minor or no symptoms might not have visited the clinic. CONCLUSIONS: There is little evidence of widespread subclinical or mild forms of SARS coronavirus infection. Clinical diagnoses during the outbreak were reasonable and resulted in appropriate triaging.

Adolescent↗