Doris M.W. Tse

Viral loads in clinical specimens and SARS manifestations.

The number of anatomical sites with detectable viral loads by RT-qPCR appeared to correlate with death risk.

Viral replication in the nasopharynx is associated with diarrhea in patients with severe acute respiratory syndrome

Abstract The role of severe acute respiratory syndrome (SARS) coronavirus as an enteric pathogen was investigated in a cohort of 142 patients with SARS who were treated with a standard treatment protocol. Data from daily hematological, biochemical, radiological, and microbiological investigations were prospectively collected, and the correlation of these findings with diarrhea was retrospectively analyzed. Sixty-nine patients (48.6%) developed diarrhea at a mean (± standard deviation [SD]) of 7.6 ± 2.6 days after the onset of symptoms. The diarrhea was most severe at a mean (±SD) of 8.8 ± 2.4 days after onset, with a maximum frequency of 24 episodes per day (median, 5 episodes; range, 3–24 episodes). A higher mean virus load in nasopharyngeal specimens obtained on day 10 after the onset of symptoms was significantly associated with the occurrence of diarrhea (3.1 log10 vs. 1.8 log10 copies/mL; P = .01) and mortality (6.2 vs. 1.7 log10 copies/mL; P < .01). However, diarrhea was not associated with mortality. The lung and the gastrointestinal tract may react differently to SARS coronavirus infection. Additional investigation of the role of SARS coronavirus in the pathogenesis of diarrhea in patients with SARS should be conducted.

Initial viral load and the outcomes of SARS

Background: Severe acute respiratory syndrome (SARS) is caused by a novel coronavirus. It may progress to respiratory failure, and a significant proportion of patients die. Preliminary data suggest that a high viral load of the SARS coronavirus is associated with adverse outcomes in the intensive care unit, but the relation of viral load to survival is unclear. Methods: We prospectively studied an inception cohort of 133 patients with virologically confirmed SARS who were admitted to 2 general acute care hospitals in Hong Kong from Mar. 24 to May 4, 2003. The patients were followed until death or for a minimum of 90 days. We used Cox proportional hazard modelling to analyze potential predictors of survival recorded at the time of presentation, including viral load from nasopharyngeal specimens (measured by quantitative reverse transcriptase polymerase chain reaction [PCR] of the SARS-associated coronavirus). Results: Thirty-two patients (24.1%) met the criteria for acute respiratory distress syndrome, and 24 patients (18.0%) died. The following baseline factors were independently associated with worse survival: older age (61–80 years) (adjusted hazard ratio [HR] 5.24, 95% confidence interval [CI] 2.03–13.53), presence of an active comorbid condition (adjusted HR 3.36, 95% CI 1.44–7.82) and higher initial viral load of SARS coronavirus, according to quantitative PCR of nasopharyngeal specimens (adjusted HR 1.21 per log10 increase in number of RNA copies per millilitre, 95% CI 1.06–1.39). Interpretation: We found preliminary evidence that higher initial viral load is independently associated with worse prognosis in SARS. Mortality data for patients with SARS should be interpreted in light of age, comorbidity and viral load. These considerations will be important in future studies of SARS.

Living and dying with dignity in Chinese society: perspectives of older palliative care patients in Hong Kong.

BACKGROUNDnthe empirical Dignity Model has profoundly influenced the provision of palliative care for older terminally ill patients in the West, as it provides practical guidance and intervention strategies for promoting dignity and reducing distress at the end-of-life.nnnOBJECTIVEnto examine the concept of living and dying with dignity in the Chinese context, and explore the generalisability of the Dignity Model to older terminal patients in Hong Kong.nnnMETHODSnusing qualitative interviews, the concept of dignity was explored among 16 older Chinese palliative care patients with terminal cancer. Framework analysis with both deductive and inductive methods was employed.nnnRESULTSnthe three major categories of themes of the Dignity Model were broadly supported. However, the subtheme of death anxiety was not supported, while two subthemes of generativity/legacy and resilience/fighting spirit manifested differently in the Chinese context. Furthermore, four new emergent themes have been identified. They include enduring pain, moral transcendence, spiritual surrender and transgenerational unity.nnnCONCLUSIONnthese findings highlight both a cultural and a familial dimension in the construct of dignity, underline the paramount importance of cultural awareness and competence for working with ethnically diverse groups, and call for a culturally sensitive and family oriented approach to palliative care interventions with older Chinese terminal patients.

Comparing noncancer and cancer deaths in Hong Kong: a retrospective review.

This retrospective study aimed to compare noncancer deaths with cancer deaths in the following: 1) utilization of the public health care system in the last six months of life; 2) end-of-life care received; and 3) documentation of the advance care planning (ACP) process. The following sample was recruited from the deaths in 2006 in four public hospitals for analysis: 656 noncancer deaths consisting of 239 deaths from chronic renal failure (CRF), 242 deaths from chronic obstructive pulmonary disease (COPD) and 175 deaths from congestive heart failure (CHF), and 183 cancer deaths. Only 1.4% of noncancer patients received palliative care, compared with 79.2% of cancer patients. As compared with cancer, the noncancer patients were older (79.1±9.5 vs. 71.1±12.4 years, P<0.001) and had more comorbid conditions (2.3±1.4 vs. 1.6±1.4, P<0.001). Utilization of public health care was more intensive in noncancer patients, with more intensive care unit admissions, more ward admissions, more bed days occupied, and more clinic attendances. Within the last two weeks of life, the noncancer patients had more invasive interventions initiated, fewer symptoms documented, less analgesics and sedatives prescribed, less do-not-resuscitate orders in place, and more cardiopulomonary resuscitation performed. Dyspnea, edema, pain, and fatigue were among the most documented symptoms in both cancer and noncancer patients. A higher proportion of ACP discussions were first documented within three days before death in COPD and CHF patients as compared with CRF and cancer patients. There is a need to develop palliative care for noncancer patients in Hong Kong.

The Blessings and the Curses of Filial Piety on Dignity at the End-of-Life: Lived Experience of Hong Kong Chinese Adult Children Caregivers

This study critically examines the evolving nature of filial piety and the role that it plays in the contemporary experience of “living and dying with dignity” among Hong Kong Chinese families facing the end of life. Meaning-oriented interviews were conducted with a purposive sample of 15 adult-children caregivers, ages 30 to 62, to elicit their narratives and stories in caring for a dying elderly parent. Qualitative content analysis reveals that although traditional filial beliefs provided motivation for family caregiving, the regrets of unfulfilled filial responsibilities create emotional distance between parents and adult children, which acts as a cultural barrier for reconciliation and contentment at lifes final margin. These findings underscore the importance of intergenerational dynamics and interactions in the transformation of filial attitudes and behaviors, highlighting the importance of reciprocal relationships (versus authority relationship), mutual support (versus complete obedience), compassionate duty (versus obligatory duty), emotional connection (versus task fulfillment), and appreciation and forgiveness (versus guilt and shame) in the promotion of dignity at the end of life. Policy and clinical implications are discussed.

Dignity amidst liminality: Healing within suffering among Chinese terminal cancer patients

This study critically examines the concepts of dignity and liminality at the end-of-life, in an effort to better understand the processes of healing within suffering among Chinese terminal cancer patients receiving palliative care services in Hong Kong. Meaning-oriented interviews were conducted with 18 Chinese terminal patients, aged 44 to 98, to elicit the narratives and stories of their illness experience. All interviews were analyzed using grounded theory and supplemented by ethnographic observations and field notes. Two major themes and eight subprocesses of healing adopted by patients to achieve and maintain dignity were identified: (a) personal autonomy, which encompasses the need to (i) regain control over living environments, (ii) maintain self-sufficiency despite institutional care, (ii) make informed care decisions to reduce sense of burden, and (iv) engage in future planning to create a lasting legacy; and (b) family connectedness, which encompasses the need to (i) maintain close ties with family members to express appreciation, (ii) achieve reconciliation, (iii) fulfill family obligations, and (iv) establish a continuing bond that transcends generations. Implications of these themes for advanced care planning and life review interventions were discussed with the goal of enhancing patient autonomy and family connectedness, and thereby providing structure and meaning for Chinese terminal patients and their families at the end of life.

The Quintessence of Traditional Chinese Medicine: Syndrome and Its Distribution among Advanced Cancer Patients with Constipation

Constipation is a common problem in advanced cancer patients; however, specific clinical guidelines on traditional Chinese medicine (TCM) syndrome (Zhang) are not yet available. In this cross-sectional study, the TCM syndromes distribution and their common symptoms and signs among 225 constipated advanced cancer patients were determined. Results showed that 127 patients (56.4%) and 7 patients (3.1%) were in deficient and excessive patterns, respectively, while 91 patients (40.4%) were in deficiency-excess complex. The distributions of the five syndromes were: Qi deficiency (93.3%), Qi stagnation (40.0%), blood (Yin) deficiency (28.9%), Yang deficiency (22.2%), and excess heat (5.8%). Furthermore, age, functional status, and level of blood haemoglobin were factors related to the type of TCM syndrome. A TCM prescription with the functions on replenishing the Deficiency, redirecting the flow of Qi stagnation and moistening the dryness caused by the blood (Yin) deficiency can be made for the treatment of advance cancer patients with constipation. Robust trials are urgently needed for further justifying its efficacy and safety in evidence-based approaches.

Experience of a Renal Palliative Care Program in a Hong Kong Center: Characteristics of Patients Who Prefer Palliative Care to Dialysis

Background A renal palliative care (RPC) program was developed in a local center as an option for patients with end-stage renal disease (ESRD) who may not benefit from dialysis or who do not prefer dialysis. The model involved collaboration between the palliative care and renal teams, and the RPC program was introduced as an option in the advance care planning (ACP) interview during which treatment benefits, burdens, predicted prognosis and the patients preferences were discussed. Patients who preferred palliative care to dialysis were recruited into the RPC program. An interdisciplinary team approach was adopted and the Renal Palliative Clinic comprised the core component among the full spectrum of services. Methods This was a retrospective study of the characteristics of ESRD patients who were interviewed for ACP between August 2007 and the end of 2008 and who preferred palliative care to dialysis. Results A total of 96 ESRD patients were interviewed for ACP during this period, among which 36 patients opted for dialysis while 60 patients chose RPC. In both groups, around 97% of patients were mentally competent and involved in ACP. The patients who chose RPC, as compared with the patients who opted for dialysis, were older (74.1 ± 8.7 years vs. 56.3 ± 10.0 years, p Conclusion The RPC program, introduced as an option in ACP, was appropriate in meeting the preferences and needs of a significant proportion of ESRD patients and their families.

Optic neuritis in Hong Kong: a 1-year follow-up study

To investigate the etiology and prevalence of optic neuritis in a Chinese population. This was a single centre prospective cohort study. Consecutive patients with either a first or recurrent attack of optic neuritis from November 2010 to December 2011 were recruited from a district hospital in Hong Kong Special Administrative Region, China. All patients underwent serology testing for NMO (neuromyelitis optica) IgG; oligoclonal bands from lumbar puncture; computer tomography and contrast magnetic resonance imaging (MRI) of the brain and orbit as well as visual field; and optical coherence tomography testing. Patients were followed up for 1xa0year after the initial attack. 30 optic neuritis subjects were recruited. 73.3xa0% (22/30) remain as clinical isolated syndrome (CIS) after 1-year follow-up. 10xa0% (3/30) patients developed multiple sclerosis. 10xa0% (3/30) were diagnosed with NMO and 6.7xa0% (2/30) with NMO-spectrum disorder. The majority of acute unilateral optic neuritis in Chinese was CIS in origin although a fraction does progress to develop MS or NMO-related disorders. Clinicians should be aware of the associations and offer appropriate systemic workups.