The last defence? Surgical aspects of gouty arthritis of hand and wrist

ABSTRACT
Hong Kong Med J 2011;17:480–6 | Number 6, December 2011
REVIEW ARTICLE
The last defence? Surgical aspects of gouty arthritis of hand and wrist
Chris YK Tang, Boris Fung
Department of Orthopaedics and Traumatology, University of Hong Kong Medical Centre, Queen Mary Hospital, Pokfulam Road, Hong Kong
 
 
OBJECTIVE. To review the epidemiology, pathophysiology, clinical manifestations, diagnosis, and treatment of gouty arthritis of the hand and wrist, with a focus on the surgical aspects.
 
DATA SOURCES AND EXTRACTION. Electronic databases including MEDLINE, PubMed, and the Cochrane library were searched with the key words of "gouty arthritis", "hand", "wrist", and "surgical".
 
STUDY SELECTION. A total of 55 articles were selected for inclusion in this review.
 
DATA SYNTHESIS. There is no existing study for the overall prevalence of gout in Asia, though one study showed that it was 3.1% in Taiwan. Its pathophysiology entails hyperuricaemia, trauma, lower temperatures, and previous diseases. Gouty arthritis of hand and wrist presents as acute wrist pain, subcutaneous or peritendinous tophi, tenosynovitis, entrapment neuropathy, tendon rupture, or even bone destruction. Demonstration of negatively birefringent crystals in the absence of organisms and a normal white cell count in synovial fluid confirm the diagnosis. Medical treatment including non-steroidal anti-inflammatory drugs, colchicines, allopurinol, uricosuric agents, and lifestyle modifications remain the mainstay of treatment. Surgical treatment options for tophaceous gout involve decompression by aspiration, incision and drainage, tenosynovectomy, shaving procedures, and complex surgical approach.
 
CONCLUSION. While medical treatment remains the mainstay of treatment for gouty arthritis of the hand and wrist, 5% of patients may not respond. In this group, surgery is often performed in advanced stages, but yields less-than-satisfactory outcomes. Gouty arthritis is difficult to treat when it starts to cause stiffness and deformities. Although more studies are needed to evaluate the outcomes, the authors suggest that one possible solution is pre-emptive surgery.
 
Key words: Anti-inflammatory agents, non-steroidal; Antirheumatic agents; Gout/surgery; Prevalence
 
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Quality of care of nurse-led and allied health personnel-led primary care clinics

ABSTRACT
Hong Kong Med J 2011;17:217–30 | Number 3, June 2011
REVIEW ARTICLE
Quality of care of nurse-led and allied health personnel-led primary care clinics
WY Chin, Cindy LK Lam, SV Lo
Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
 
 
OBJECTIVES. To review the literature regarding quality of care of nurse-led and allied health personnel-led primary care clinics with specific attention to the quality indicators for fall prevention, continence care, pulmonary rehabilitation, mental health, pharmaceutical care, and wound care services.
 
DATA SOURCES. Literature search from 1990 to 2010 including Ovid Medline, Cochrane Database, RAND (Research and Development) Corporation Health Database, the ACOVE (Assessing the Care of Vulnerable Elders) project and clinical guidelines from the United Kingdom, Australia, Canada, and the United States. Study selection This review was limited to studies involving adult, primary care patients. Where available, evidence from systematic reviews and meta-analyses were used to synthesise findings.
 
DATA EXTRACTION. Combinations of the following terms (and related terms) were used to identify studies: primary care, clinic, allied-health, nurse-led, fall prevention, continence care, incontinence, chronic obstructive pulmonary disorder, pulmonary disease, respiratory rehabilitation, mental health, mental wellbeing, depression, anxiety, wound care, leg ulcer, venous ulcer, dressings clinic, wound clinic, medication review, pharmacistled, pharmaceutical care.
 
DATA SYNTHESIS. A total of 21 international guidelines and 33 studies were selected for data synthesis. Despite a lack of consistent outcomes data, it is apparent that certain aspects of organisational structure and clinical care processes are important though not necessarily sufficient indicators of quality of care, because they themselves can influence care outcomes. Seven key factors were identified which seem important determinants of the quality of care provided by nurse– and allied health personnel-led clinics.
 
CONCLUSION. Delivery of primary health care by nurse and allied health personnel-led teams is a well-established model, internationally. Evidence from the literature provides benchmarks for standards of good practice. Knowledge of factors influencing quality of care can assist the planning, implementation, evaluation, and further expansion of such programmes, locally.
 
Key words: Allied health-personnel; Health services needs and demand; Nurse practitioners; Primary health care; Quality of life
 
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Measuring and preventing potentially avoidable hospital readmissions: a review of the literature

ABSTRACT
Hong Kong Med J 2010;16:383–9 | Number 5, October 2010
REVIEW ARTICLE
Measuring and preventing potentially avoidable hospital readmissions: a review of the literature
Carrie HK Yam, Eliza LY Wong, Frank WK Chan, Fiona YY Wong, Michael CM Leung, EK Yeoh
School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
 
 
OBJECTIVE. To review literature identifying key components for measuring avoidable readmissions, their prevalence, risk factors, and interventions that can reduce potentially avoidable readmissions.
 
DATA SOURCES AND EXTRACTION. Literature search using Medline, PubMed and the Cochrane Library up to June 2010, using the terms "avoidable", "preventable", "unplanned", "unnecessary", "readmission", and "rehospitalization".
 
STUDY SELECTION. A total of 48 original papers and review articles were selected for inclusion in this review.
 
DATA SYNTHESIS. Although hospital readmission seemed to be a term commonly used as an outcome indicator in many studies, it is difficult to make valid comparison of results from different studies. This is because the definitions of terms, methods of data collection, and approaches to data analysis differ greatly. The following criteria for studying hospital readmissions have been recommended: (a) identify hospital admissions and define relevant terms, (b) establish a clinical diagnosis for a readmission; (c) establish the purpose for a readmission, (d) set a discharge-to-readmission timeframe, and (e) identify the sources of information for assessing readmissions. Studies to identify avoidable readmissions usually involve medical records and chart reviews by clinicians using the classification scheme developed by the authors. The proportion of all readmissions assessed as preventable varies from 9 to 59% depending on the population of patients studied, duration of follow-up, type and methodology of the study and case-mix- related factors. A number of studies classified risk factors for readmission into four categories: patient, social, clinical, and system factors. Home-based interventions, intensive education/ counselling, multidisciplinary care approaches, and telephone follow-up were the main types of interventions to address potentially avoidable readmissions.
 
CONCLUSIONS. A standard instrument to identify avoidable readmission is important in enabling valid comparisons within the system and at different timelines, so as to permit robust evaluation of interventions. The assessment of preventable risk factors for readmissions also provides a basis for designing and implementing intervention programmes.
 
Key words: Outcome and process assessment (health care); Patient readmission; Prevalence; Risk factors
 
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Neuroimaging techniques in epilepsy

ABSTRACT
Hong Kong Med J 2010;16:292–8 | Number 4, August 2010
REVIEW ARTICLE
Neuroimaging techniques in epilepsy
Vincent Lai, Henry KF Mak, Ada WY Yung, WY Ho, KN Hung
Department of Radiology, Tuen Mun Hospital, Hong Kong
 
 
OBJECTIVE. To review state-of-the-art neuroimaging modalities in epilepsy and their clinical applications.
 
DATA SOURCES AND STUDY SELECTION. PubMed literature searches to March 2010, using the following key words: 'epilepsy', 'positron emission tomography (PET)', 'single photon emission computed tomography (SPECT)', 'MR volumetry', 'diffusion tensor imaging', and 'functional MR imaging'.
 
DATA EXTRACTION. All articles including neuroimaging techniques in epilepsy were included in the review.
 
DATA SYNTHESIS. High-field magnetic resonance imaging is fundamental for high-resolution structural imaging. Functional radionuclide imaging (positron emission tomography/single-photon emission computed tomography) can provide additional information to improve overall accuracy, and show good results with high concordance rates in temporal lobe epilepsy. Magnetic resonance spectroscopy is a useful adjunct consistently demonstrating changing metabolites in the epileptogenic region. Magnetic resonance volumetric imaging shows excellent sensitivity and specificity for temporal lobe epilepsy but thus far it has been inconsistent for extratemporal epilepsy. Diffusion tensor imaging with tractography allows visualisation of specific tracts such as connections with the language and visual cortex to enhance preoperative evaluation. Functional magnetic resonance imaging using blood oxygen level-dependent activation techniques is mainly used in presurgical planning for the high-sensitivity mapping of the eloquent cortex. Both contrast-bolus and arterial spin labelling magnetic resonance perfusion imaging show good correlation with clinical lateralisation of seizure disorder.
 
CONCLUSION. Structural imaging is essential in localisation and lateralisation of the seizure focus. Functional radionuclide imaging or advanced magnetic resonance imaging techniques can provide complementary information when an epileptogenic substrate is not identified or in the presence of non-concordant clinical and structural findings.
 
Key words: Fluorodeoxyglucose F18; Magnetic resonance imaging; Magnetic resonance spectroscopy; Positron-emission tomography; Tomography, emissioncomputed, single-photon
 
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Antibiotic prophylaxis after total joint replacements

ABSTRACT
Hong Kong Med J 2009;15:458-62 | Number 6, December 2009
REVIEW ARTICLE
Antibiotic prophylaxis after total joint replacements
Evelyn E Kuong, FY Ng, CH Yan, Christian XS Fang, Peter KY Chiu
Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
 
 
OBJECTIVES. To review the latest evidence on antibiotic prophylaxis for patients with total joint replacements to prevent prosthesis infections.
 
DATA SOURCES. Literature search of Medline and PubMed until June 2009.
 
STUDY SELECTION. Studies of patients with total joint replacements from around the world, studies concerning antibiotic prophylaxis, as well as chemoprophylaxis guidelines from orthopaedic associations were searched.
 
DATA EXTRACTION. Literature review, original articles, case reports, best practice guidelines.
 
DATA SYNTHESIS. With the rising incidence of patients with total joint replacements, subsequent deep infection of the implants is a rare but dreaded complication which has immense physiological, psychological, financial, and social implications. Guidelines from urologists, gastroenterologists, and dental surgeons attempt to identify high-risk patients who may be more susceptible to prosthetic joint infections. These patients are provided with prophylactic antibiotics before any invasive procedure that may cause bacterial seeding to prosthetic joints. Most orthopaedic associations around the world adopt a similar policy to provide prophylaxis to cover any anticipated chance of bacteraemia. The American Association of Orthopaedic Surgeons adopts the most cautious approach in which all patients with total joint replacements who undergo any procedure that breaches a mucosal surface receive prophylactic antibiotics.
 
CONCLUSION. The guidelines from the American Association of Orthopaedic Surgeons seem to have an all-encompassing policy when it comes to providing prophylactic antibiotics. Nonetheless, physicians must still exercise their judgement and customise the treatment to each patient. The benefits of prophylactic antibiotics must be balanced against the risks of drug side-effects and the emergence of antibiotic resistance.
 
Key words: Antibiotic prophylaxis; Endoscopy; Infection; Replacement, arthroplasty; Surgical procedure, operative
 
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Renal replacement therapy in critically ill patients

ABSTRACT
Hong Kong Med J 2009;15:122-9 | Number 2, April 2009
REVIEW ARTICLE
Renal replacement therapy in critically ill patients
Anne KH Leung, WW Yan
Department of Anaesthesia and Operation Theatre Service, Queen Elizabeth Hospital, Hong Kong
 
 
OBJECTIVE. To provide updated information (including on treatment) in relation to renal replacement therapy in critically ill patients.
 
DATA SOURCES AND STUDY SELECTION. Literature search of Medline and PubMed till June 2008.
 
DATA EXTRACTION. Original studies, literature review, and book chapters.
 
DATA SYNTHESIS. The prevalence of acute renal failure in critically ill patients remains high and mortality is up to 60%. Both the practice of renal replacement therapy (continuous against intermittent, haemofiltration against haemodialysis) and patient outcomes vary widely between studies. To better understand this heterogeneous group of patients, a unified classification of acute renal failure proposed by the Acute Dialysis Quality Initiative allows better understanding of the epidemiology and outcome of this disease. Similar to patients with chronic renal failure, there exists a direct relationship between the dose of dialysis and survival; 35 mL/kg/h is the accepted norm. However, this traditional practice is being challenged by recent trials. Although the use of citrate as anticoagulant in renal replacement therapy can prolong circuit patency and decrease bleeding risk, its use is limited by the complex set up and metabolic problems.
 
CONCLUSIONS. The RIFLE classification allows an accurate description of the epidemiology and outcome of critically ill patients with acute renal failure. The well-accepted continuous renal replacement therapy dose of 35 mL/kg/h in critically ill patients needs further verification from ongoing clinical trials. The complex set-up and the use of citrate anticoagulant has limited the use of such dialysis, which can nevertheless be overcome with the support of pharmaceutical companies.
 
Key words: Critical illness; Kidney failure, acute; Renal dialysis; Renal replacement therapy; Treatment outcome
 
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A review of necrotising fasciitis in the extremities

ABSTRACT
Hong Kong Med J 2009;15:44-52 | Number 1, February 2009
REVIEW ARTICLE
A review of necrotising fasciitis in the extremities
Jason PY Cheung, Boris Fung, WM Tang, WY Ip
Department of Orthopaedics and Traumatology, University of Hong Kong Medical Centre, Queen Mary Hospital, Pokfulam, Hong Kong
 
 
OBJECTIVE. To review currently available evidence on the epidemiology and methods of management for necrotising fasciitis, with particular reference to Hong Kong.
 
DATA SOURCES AND STUDY SELECTION. Medline, PubMed, and Cochrane Library searches of local and internationally published English language journals, from 1990 to July 2008 using the terms 'necrotising fasciitis', 'Hong Kong', 'diagnosis', 'epidemiology', 'vibrio', 'streptococci', 'clostridia', and 'management'.
 
DATA EXTRACTION. All articles involving necrotising fasciitis in Hong Kong were included in the review.
 
DATA SYNTHESIS. The incidence of necrotising fasciitis in Hong Kong and around the world has been increasing. This rapidly progressive infection is a major cause of concern, due to its high morbidity and mortality. Up to 93% of affected patients at our hospital were admitted to the Intensive Care Unit and many still died from septic complications, such as pneumonia and multi-organ failure. Radical debridements in the form of amputations and disarticulations were considered vital in 46% of the patients. Early recognition and treatment remain the most important factors influencing survival. Yet, early diagnosis of the condition is difficult due to its similarities with many other soft tissue disorders such as cellulitis. Repeated surgical debridement or incisional drainage continues to be essential for the survival of sufferers from necrotising fasciitis. Many authorities have reported that carrying out the first fasciotomy and radical debridement within 24 hours of symptom onset was associated with significantly improved survival, which also emphasises the importance of early diagnosis.
 
CONCLUSION. Clinicians must adopt a high index of suspicion for necrotising fasciitis. Empirical antibiotics must be started early and repeated physical examinations should be performed, while maintaining a low threshold for tissue biopsy and surgery. The timing of the first fasciotomy and radical debridement within a window of 24 hours from symptom onset is associated with significantly improved survival.
 
Key words: Clostridium; Epidemiology; Fasciitis, necrotizing; Streptococcus; Vibrio
 
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Characterisation of brain disorders and evaluation of therapy by functional and molecular magnetic resonance techniques

ABSTRACT
Hong Kong Med J 2008;14:469-78 | Number 6, December 2008
REVIEW ARTICLE
Characterisation of brain disorders and evaluation of therapy by functional and molecular magnetic resonance techniques
YX Wang, Wynnie WM Lam
Department of Diagnostic Radiology and Organ Imaging, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVES. To review advanced functional and molecular magnetic resonance techniques that are currently clinically useful or with potential clinical use in the near future.
 
DATA SOURCES AND EXTRACTION. Literature search of Medline to December 2007 was conducted. Key words search terms were: 'magnetic resonance imaging' 'magnetic resonance spectroscopy' 'brain' 'functional' 'perfusion' 'diffusion' 'diffusion tensor' 'magnetic transfer' 'molecular imaging' 'superparamagnetic iron oxide' Relevant original papers and review articles were retrieved.
 
STUDY SELECTION. A total of 83 original papers and review articles were systematically analysed.
 
DATA SYNTHESIS. The introduction of modern neuroimaging modalities in recent years has revolutionised investigation of the normal and diseased brain. Among others, magnetic resonance has emerged as the pre-eminent imaging modality, which can produce both high-resolution anatomical images and maps that reflect a variety of physiological parameters relevant to functional assessment and tissue characterisation. Magnetic resonance imaging techniques are now capable of visualising physiological and diseased processes at cellular and molecular levels, including cerebral blood flow, capillary perfusion and permeability, blood oxygenation level dependent neuronal activation, microscopical motion of water (water diffusion), integrity of axonal fibres, and the molecular transfer of magnetisation within tissues. Magnetic resonance cell trafficking can evaluate the macrophage activity in areas of brain inflammation. Magnetic resonance cell-labelling strategies can be used to monitor the seeding and migration of embryonic stem cells. Magnetic resonance spectroscopy allows the detection of various metabolites that pertain to different biochemical processes in brain tissues. Such metabolites/spectra include: N-acetyl aspartate used as a neuronal marker, choline as a cell membrane metabolism marker, myo-inositol as a glial marker in proton spectrum, and phosphorous whose spectrum provides an in-vivo assessment of the bio-energetic status of tissues. Besides characterisation of brain disorders, magnetic resonance imaging and spectroscopy can improve the planning and monitoring of therapy and contribute to the development of new therapies.
 
CONCLUSION. Advances in neuroimaging have made a great leap in the morphological, metabolic, and functional assessment of the neurological diseases, enabling better diagnosis and management of patients.
 
Key words: Brain; Diffusion; Magnetic resonance imaging; Magnetic resonance spectroscopy; Perfusion
 
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Aspects of general medicine

ABSTRACT
Hong Kong Med J 2008;14:385-90 | Number 5, October 2008
REVIEW ARTICLE
Aspects of general medicine
Cyrus R Kumana
Department of Medicine, Queen Mary Hospital, Pokfulam Road, Hong Kong
 
 
Horizons in Medicine is a series produced annually by the Royal College of Physicians. Volume 19 is based on their Advanced Medicine Conference held in 2007 and offers updates on a wide range of topics in clinical medicine. This 'review of reviews' covers developments described in a selection of chapters. The chapters summarised include: Contemporary management of acute myocardial infarction; Imported infectious disease emergencies; New therapies in the management of type 2 diabetes; Stress and adrenal insufficiency; Making sense of a 'funny thyroid function test'; Myeloproliferative disorders: management and molecular pathogenesis; Drug allergies; Osteoporosis; Rheumatoid arthritis; Understanding migraine from bench to bedside.
 
Key words: Review
 
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Occupational repetitive strain injuries in Hong Kong

ABSTRACT
Hong Kong Med J 2008;14:296-302 | Number 4, August 2008
REVIEW ARTICLE
Occupational repetitive strain injuries in Hong Kong
Jason PY Cheung, Boris Fung, WY Ip, SP Chow
Department of Orthopaedics and Traumatology, University of Hong Kong Medical Centre, Queen Mary Hospital, Pokfulam Road, Hong Kong
 
 
OBJECTIVE. To review currently available evidence on the epidemiology and management of occupational repetitive strain injuries with particular reference to Hong Kong.
 
DATA SOURCES AND STUDY SELECTION. Medline, PubMed and Cochrane Library searches of local and internationally published English journals from 1990 to 2007 regarding repetitive strain injuries.
 
DATA EXTRACTION. All articles involving occupational repetitive strain injuries in Hong Kong were included in this review.
 
DATA SYNTHESIS. There were 16 articles contributing data on the impact of repetitive strain injuries both in Hong Kong and around the world. There were seven articles dealing with the problem of computer station set-ups and methods for improving the workstation environments.
 
CONCLUSION. Currently there were significant data on the impact of repetitive strain injuries in Hong Kong. The data took the form of compensation claims, days away from work, and cost of medical consultations. Other articles described proper workplace adjustments to help prevent repetitive strain injuries. However, there were no figures in the current literature showing the impact of these adjustments in reducing the incidence of repetitive strain injuries. More research could help to delineate the relationship between different types of interventions and occupational repetitive strain injuries.
 
Key words: Chronic disease; Cumulative trauma disorders; Occupations; Primary health care; Recurrence; Workplace
 
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