Rex Pui Kin Lam

Objectives: To increase the uptake of the Surviving Sepsis Campaign Hour-1 Bundle, we implemented a novel sepsis care model (National Early Warning Score [NEWS]-1 care), in which the Hour-1 Bundle is objectively triggered by a high NEWS-2 (≥ 5). We aimed to determine the feasibility of a full-scale type 1 hybrid effectiveness-implementation trial of this model. Design: A pilot type 1 hybrid trial, comprising a stepped-wedge cluster randomized controlled trial and mixed-methods implementation evaluation with staff focus group interviews and an anonymous survey guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Setting: Four emergency departments in Hong Kong. Patients: Adult patients of 18 years or older with a clinical diagnosis of infection requiring hospitalization and a NEWS-2 greater than or equal to 5. Interventions: Implementation of the Hour-1 Bundle when NEWS-2 was greater than or equal to 5. Measurements and Main Results: The primary outcome was the feasibility of a full-scale hybrid trial, evaluated based on 14 progression criteria. Preliminary clinical effectiveness and safety were assessed, alongside implementation barriers and facilitators. During the implementation phase, compliance with lactate, blood culture, and antibiotics increased significantly. All progression criteria were met, except for suboptimal overall bundle compliance (56.1%). Exploratory intention-to-treat analysis (standard care group, n = 102; NEWS-1 group, n = 98) showed no significant between-group difference in 30-day all-cause mortality (standard care group, 3.9%; NEWS-1 group, 9.2%; absolute risk difference, 5.3%; 95% CI –1.6% to 12.1%); in-hospital, 90-day all-cause, or sepsis-related mortality; need for mechanical ventilation, renal replacement therapy, intensive care, or surgery; or ventilator-free days and adverse events. Implementation evaluation identified 15 barriers and 13 facilitators. Conclusions: The effectiveness of NEWS-1 care remained uncertain, though adverse events were rare. A full-scale hybrid stepped-wedge trial is feasible but requires a much larger sample size. Real-world implementation barriers and facilitators should be considered in sepsis management guidelines.

BACKGROUND Vital sign measurement is essential to assess a patient’s physiological status to guide clinical decisions on triage and resuscitation in the emergency department (ED). Manual measurement contributes to bottlenecks and delays in the triage and care processes when a surge in service demand or manpower shortage occurs. Remote photoplethysmography (rPPG) enables contactless vital sign estimation by analyzing changes in light reflected from the skin in smartphone-captured facial videos caused by pulsatile changes in tissue blood volume and light absorption. rPPG has the potential to automate vital sign measurement. However, its accuracy in the ED remains unclear. OBJECTIVE We aimed to compare the accuracy of rPPG–based contactless heart rate (HR) estimation with manual measurement in the ED and assess patient satisfaction and comfort with different measurement methods. METHODS This was a prospective cross-sectional study on a convenience sample of ambulatory adult patients in a tertiary ED in Hong Kong from October to November 2024. The reference standards were manual HR measurements by a research nurse using a standard hospital device. Simultaneously, 25-second facial videos were recorded with an iPhone for contactless HR estimation using a proprietary convolutional neural network algorithm. The accuracy of the contactless method was assessed using the intraclass correlation coefficient (ICC), mean absolute error (MAE), root-mean-square error (RMSE), and Bland–Altman plot, with ± 5 beats per minute (bpm) predefined as clinically acceptable levels of agreement. Patient satisfaction and comfort, rated on a 0-100 mm visual analog scale (VAS), were compared between the two methods using the Wilcoxon signed-rank test. RESULTS We analyzed 478 videos from 161 patients, including 97 women and 64 men. The mean patient age was 55.0 (SD 16.6) years, and 73.9% were Chinese (119/161) with Fitzpatrick skin types of 3 (61.5%, 99/161) and 4 (34.8%, 56/161). The contactless method had an ICC of 0.991 (95% CI 0.987-0.993), a MAE of 1.38 beats per minute (bpm), and a RMSE of 1.82 bpm. The Bland–Altman plot showed a bias of 0.54 bpm (95% CI –2.89 to 3.97 bpm), which falls within the predefined clinically acceptable levels of agreement. Patient satisfaction (contactless VAS 95.4 mm vs. manual VAS 90.3 mm, P<.001) and comfort (contactless VAS 98.0 mm vs. manual VAS 87.0 mm, P<.001) were significantly higher with the contactless method compared to manual measurement. CONCLUSIONS rPPG–based HR estimation from smartphone-captured facial videos is accurate in the ED. Further validation studies involving broader patient populations with a wider range of vital signs and skin colors are warranted. Future research should focus on extending the application of rPPG technology to other vital signs to fully realize its potential in automating vital sign measurements. CLINICALTRIAL ClinicalTrials.gov NCT06536647; https://clinicaltrials.gov/study/NCT06536647

Introduction: Neutropenic fever (NF) has a crude mortality rate of 3–18%. International guidelines recommend that all patients with NF receive ultrabroad-spectrum antibiotics (UBSAs) within 1 hour of emergency department (ED) registration. However, over 70% patients presenting to hospital with suspected NF (sNF) cannot access absolute neutrophil count (ANC) result within 1 hour, do not have NF and do not require UBSAs. In ED and hospitalised patients with sNF, we hypothesise that the ASTERIC protocol effectively and safely reduces the use of UBSAs compared with standard care alone. Methods and analysis: This pragmatic, parallel, multicentre, type 1, hybrid effectiveness-implementation, stepped-wedge, before-and-after, cluster randomised controlled trial aims to evaluate whether antibiotic prescribing can be safely reduced through implementing a multifaceted antibiotic stewardship intervention (ASTERIC) in adult patients with sNF presenting to EDs. The sNF was defined as a fever with a single oral temperature of ≥38.3°C (101°F) within 24 hours before ED registration or a temperature of ≥38.0°C (100.4°F) sustained over a 1-hour period, following last chemotherapy or targeted therapy within 6 weeks for any solid tumour, or in any period following therapies against leucaemia, lymphoma, myelodysplastic syndrome, aplastic anaemia, multiple myeloma or recipient of HSCT. The study will involve eight hospitals in Hong Kong with variable baseline practice. We will include 704 adult patients (352 patients in pre-implementation and post-implementation periods, respectively) with sNF (tympanic temperature ≥38.3°C) and 48 staff participants (6 staff participants in each hospital). Healthcare professionals will receive a multifaceted stewardship intervention consisting of risk assessment tools, fast-track ANCs, a decision tool for patient management and antibiotic use, supported by an educational package and staff interaction programmes (ASTERIC protocol). Patients’ blood ANC, and cancer therapy and chronic illness therapy scores will be measured. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) and Proctor conceptual frameworks will be followed for evaluation of implementation. The main outcome measures are the mean total dose of UBSAs prescribed in 7 days and serious adverse events at 30 days. Data analysis will incorporate intention-to-treat, per-protocol and as-treated analyses for service outcomes (effectiveness, safety, quality of life assessments and cost-effectiveness) and mixed methods for implementation outcomes, informed by the Theoretical Domains Framework. We expect that the study results will inform health policy with improvement in hospital services in treating stable sNF, evidenced by improved safe antibiotic stewardship, early antibiotic de-escalation and reduced costs and length of stay. Ethics and dissemination: The institutional review boards of all study sites approved this study. This study will establish the ASTERIC protocol safely improves antibiotic stewardship and clinical management in adult patients with sNF. We will disseminate the findings through peer-reviewed publications, conference presentations and educational activities. All patients with sNF will be influenced by the new protocol which is agreed at hospital level. Randomisation is at hospital level, not patient level. Patient consent is sought for follow-up and data access, not for treatment. Staff consent is sought for interviewing. Trial registration number: NCT06794320 .

Methamphetamine use is associated with frequent emergency department (ED) utilization, but factors associated with drug-related ED re-attendance are understudied. We aimed to characterize the pattern of 30-day drug-related ED re-attendance and evaluate the impact of the severity of acute toxicity and psychosocial interventions on such re-attendances. We conducted a secondary analysis of 815 episodes of acute methamphetamine toxicity reported to the Hong Kong Poison Control Centre from all local public EDs between January 1, 2010, and December 31, 2019. We defined the index attendance as the first ED presentation related to methamphetamine within the study period, and drug-related ED re-attendance as a presentation directly related to the acute toxicities or sequelae of drug misuse. The primary outcome was 30-day drug-related ED re-attendance after hospital discharge. We performed univariate and multivariable Cox regression analyses to identify factors associated with the primary outcome. Within 30 days of hospital discharge, 131 (16.1%) patients re-attended the ED for drug-related problems, with 119 re-attendances (90.8%) involving methamphetamine and 76 (58.0%) for psychiatric complaints. In multivariable Cox regression analysis, failed previous detoxification treatment (HR 1.61, 95% CI 1.08–2.39, P = 0.019) and a history of drug-induced psychosis (hazard ratio [HR] 1.76, 95% confidence interval [CI] 1.16–2.68, P = 0.008) remained significantly associated with the primary outcome. Drug-related ED re-attendance is common among methamphetamine users. Failed previous detoxification treatment and drug-induced psychosis are factors significantly associated with such re-attendances. The limited impact of the severity of acute toxicity and psychosocial interventions underscores the importance of primary prevention of methamphetamine misuse through public education and drug-control policy, and early multidisciplinary interventions before progression to drug-induced psychosis.

Aconitum spp. alkaloids, used in traditional Chinese medicine, are potent cardiotoxins and neurotoxins. Timely diagnosis of aconite poisoning remains challenging due to the long laboratory turnaround time. We aimed to derive and internally validate a diagnostic score for rapid recognition of acute Chinese medicine poisoning involving aconite using clinical parameters. We conducted a retrospective cross-sectional study on consecutive patients with laboratory-confirmed Chinese medicine poisoning reported to the Hong Kong Poison Control Centre between 1 July 2008 and 30 June 2021. The reference standard was the diagnosis of acute aconite poisoning by a clinical toxicologist and laboratory detection of aconitine or related alkaloids in the patients' urine, serum, or gastric lavage specimens. Univariate analyses, followed by multivariable logistic regression, were performed to identify independent predictors of laboratory-confirmed aconite poisoning. A scoring system was developed based on the regression coefficients of the independent predictors and internally validated using bootstrapping. We identified 542 eligible episodes, of which 179 involved aconite and 363 involved other herbs. The median patient age of the included episodes was 55 years (range 4-98 years). A clinical diagnostic score was developed based on the six independent predictors: hypotension (systolic blood pressure <90 mmHg in adults or < age-appropriate ranges in children, 3 points), herbal decoction or wine formulation (2 points), facial or oral numbness (2 points), ventricular tachycardia (1 point), limb numbness (1 point), and premature atrial or ventricular contractions (1 point). The score ranges from 0 to 10, with a higher score indicating a higher likelihood of aconite poisoning. At the cutoff point of ≥3, the sensitivity and negative predictive value of the score were 0.98 and 0.99, respectively. A higher specificity (0.92) and positive predictive value (0.84) could be achieved with a cutoff point at ≥4. The area under the receiver operating characteristic curve was 0.965 (95% CI: 0.950-0.980) during derivation and 0.965 (95% bias-corrected and accelerated CI: 0.947-0.977) during internal validation. The newly derived Clinical Aconite Poisoning Score is simple to use, but its real-time discriminatory performance in diverse populations with Chinese medicine poisoning in real-world settings and its impacts on clinical management are unknown. In the context of Chinese medicine poisoning, the Clinical Aconite Poisoning Score might be useful in early recognition of aconite poisoning before laboratory confirmation. Future prospective studies are warranted to externally validate its real-time discriminatory performance in real-world settings before clinical adoption.

Objective: Currently, there is no consensus among international guidelines on the management of patients with mild traumatic brain injuries (MTBIs) who are on direct oral anti‐coagulants (DOACs). Overuse of computed tomography (CT) scan of the brain results in unnecessary radiation exposure, longer waits and higher costs. The Haemorrhage Estimate Risk in Oral anticoagulation for Mild head trauma (HERO‐M) nomogram has been derived to assess the risk of post‐traumatic intracranial haemorrhage (ICH) in this group of patients in the emergency department (ED). This study aimed to externally validate this nomogram in Hong Kong and to identify an actionable cut‐off point, which was not defined in the original paper.Methods: This was a single‐centre retrospective cohort study that included adult ED patients presenting with MTBI and were on DOACs concurrently from 1 January 2022 to 31 December 2023. MTBI was defined as any closed trauma over the craniofacial region with a Glasgow Coma Scale of 14–15. The discriminatory performance of the HERO‐M nomogram was assessed using the area under the receiver operating characteristic curve (AUROC). Diagnostic metrics, including sensitivity and specificity, were evaluated at different cut‐off points.Results: Of the 180 patients included in the study, 23 (12.8%) had post‐traumatic ICH. The nomogram demonstrated good discriminatory performance in predicting post‐traumatic ICH with an AUROC of 0.87 (95% confidence interval [CI], 0.79–0.95). At the cut‐off point of ≥5, the sensitivity and specificity for ICH were 0.91 (95% CI 0.7–0.98) and 0.75 (95% CI 0.68–0.82), respectively.Conclusion: The HERO‐M nomogram has a high discriminatory performance, good sensitivity and reasonable specificity at the cut‐off point of ≥5 in identifying ED patients on DOACs who are at risk of ICH after MTBIs. It may help to supplement the current ED head injury guidelines on CT use.

Background: In resource‐limited settings where prehospital electrocardiogram (ECG) is not available, prehospital recognition of ST‐segment elevation myocardial infarction (STEMI) remains challenging. This study aimed to evaluate the accuracy of a structured prehospital questionnaire and develop a clinical diagnostic score for prehospital STEMI identification.Methods: We analyzed 324 adult patients with chest pain transported by ambulance in the Hong Kong West Cluster from 1 February 2018 to 12 August 2018. Participants' symptoms were systematically assessed by the ambulance crew using the standardized 5‐item prehospital chest pain (PHCP) questionnaire, which produced a composite score, and its diagnostic performance was evaluated. Univariate analysis followed by multivariable backward logistic regression was conducted to identify independent predictors of STEMI. A clinical diagnostic score, named the MANS score, was consequently developed based on the regression coefficients of these predictors and its discriminatory performance was compared with the PHCP score.Results: The PHCP score demonstrated suboptimal performance, with an area under the receiver operating characteristic curve (AUROC) of 0.63 (95% confidence interval [CI] 0.47–0.79). The MANS score (male sex, aspirin use, and nausea or vomiting and sweating) was derived from three independent predictors: male sex (1 point), aspirin use (−2 points), and the cooccurrence of nausea or vomiting and sweating (1 point). The score ranges from −2 to 2, with a higher score indicating a higher risk of STEMI. The MANS score achieved an AUROC of 0.85 (95% CI 0.79–0.91).Conclusions: While the PHCP questionnaire exhibited suboptimal diagnostic performance, the MANS score may help to identify STEMI in the absence of prehospital ECG. Further external validation is necessary to evaluate its generalizability.

Rapid identification of acute ischemic stroke (AIS) is challenging in both pre-hospital and hospital settings. We aimed to identify the most promising cell-free nucleic acids (cfNAs) as diagnostic biomarkers for IS within 72 h from symptom onset. We searched PubMed, Web of Science, EMBASE, and Cochrane Library for published articles that evaluated blood cfNAs in the early diagnosis of AIS until 10 May 2023. The diagnostic performances of individual cfNAs were pooled by random-effects meta-analysis based on the fold change of biomarkers’ level between AIS and non-AIS patients. Of 2955 records, 66 articles reporting 143 different cfNAs met the inclusion criteria. The median sample size was 110, and 21.4% of the studies performed validation. Among selected high-quality studies, miR-106b-5p, miR-124, miR-155, lncRNA H19, and cfDNA showed good diagnostic performance. Data from four studies on cfDNA involving 355 AIS patients and 97 controls were pooled in the meta-analysis, which showed a significant fold change between AIS and controls (pooled ratio 1.48, 95% confidence interval 1.23–1.79, p < 0.001). This review highlights that cfDNA, miR-106b-5p, miR-124, miR-155, and lncRNA H19 are the most promising biomarkers for AIS diagnosis, and further research is needed for verification.