Leung-Wing Chu

Risk Factors for Early Emergency Hospital Readmission in Elderly Medical Patients

Background: Early emergency readmissions is a common and important problem in the elderly patient. Identification of the risk factors for early emergency readmissions is needed to prevent this occurring. Objective: The aim of this study was to study the risk factors for early emergency readmission in the elderly medical patient. Methods: A case-control study (sex- and age-matched) was conducted from March to December 1996. 380 elderly (age 65 years or over) medical patients with emergency hospital readmission (within 28 days) and 380 matched controls were recruited from an acute university general hospital in Hong Kong. Potential risk factors which included demographic, socio-economic, principal medical diseases, comorbid diseases, dysphagia, physical functional status and mental status were studied. Results: In bivariate analyses for the risk factors of early emergency readmission, institutional carer, previous visiting nurse service, adverse drug reaction, chronic obstructive pulmonary disease, end-stage renal failure, mobility being chair- or bed-bound, dysphagia, use of a nasogastric tube feeding, urinary incontinence and bowel incontinence were significant. Readmission cases had higher mean number of comorbid diseases, lower mean Barthel Index, higher mean number of impairments in Activities of Daily Living (ADL) tasks and lower mean Abbreviated Mental Test score than controls. In multivariate logistic regression model, the number of ADL impairments (OR = 1.13, 95% CI = 1.08–1.19), no income (OR = 2.28, 95% CI = 1.19–4.37), adverse drug reaction (OR = 4.19, 95% CI = 1.56–11.2), advanced malignancy (OR = 2.45, 95% CI = 1.37–4.37), congestive heart failure (OR = 1.63, 95% CI = 1.05–2.53), chronic obstructive airways disease (OR = 2.1, 95% CI = 1.47–3.02), end-stage renal failure (OR = 5.48, 95% CI = 1.69–17.75), dysphagia (OR = 3.9, 95% CI = 1.5–10.11) and the number of comorbid diseases (OR = 1.3, 95% CI = 1.13–1.49) were significant risk factors for early emergency readmissions. Living in a private old aged home was associated with a lower risk of readmissions (OR = 0.53, 95% CI = 0.36–0.93). Conclusions: Definite medical, functional and socio-economic factors were found to be risk factors for early emergency readmissions in the elderly medical patient. A multiple risk factors intervention approach should be considered in designing future prevention strategies.

Effects of cognitive function and depressive mood on the quality of life in Chinese Alzheimer's disease patients in Hong Kong

Aim:  In view of the paucity of data on the quality of life (QOL) in Chinese Alzheimers disease (AD) patients, we investigated the effects of cognitive function and depressive mood on QOL among our Chinese AD patients in Hong Kong, using the Cantonese Chinese version of Quality of Life in Alzheimers disease (QOL‐AD).

Prevalence of anemia in Chinese nursing home older adults: Implication of age and renal impairment

Aim:  There is little data regarding the prevalence and associated comorbidities of anemia in Chinese nursing home older adults. The objective of this study was to investigate the prevalence and associated comorbidities of anemia in Chinese nursing home older adults.

Impact of (18)FDG PET and (11)C-PIB PET brain imaging on the diagnosis of Alzheimer's disease and other dementias in a regional memory clinic in Hong Kong.

OBJECTIVE This study investigated the improvement in the accuracy of diagnosis of dementia subtypes among Chinese dementia patients who underwent [18F]-2-fluoro-2-deoxy-D-glucose positron emission tomography ((18)FDG PET) with or without carbon 11-labelled Pittsburgh compound B ((11)C-PIB). METHODS This case series was performed in the Memory Clinic at Queen Mary Hospital, Hong Kong. We reviewed 109 subjects (56.9% were female) who received PET with or without (11)C-PIB between January 2007 and December 2014. Data including age, sex, education level, Mini-Mental State Examination score, Clinical Dementia Rating scale score, neuroimaging report, and pre-/post-imaging clinical diagnoses were collected from medical records. The agreement between the initial and post-PET with or without (11)C-PIB dementia diagnosis was analysed by the Cohens kappa statistics. RESULTS The overall accuracy of initial clinical diagnosis of dementia subtype was 63.7%, and diagnosis was subsequently changed in 36.3% of subjects following PET with or without (11)C-PIB. The rate of accurate initial clinical diagnosis (compared with the final post-imaging diagnosis) was 81.5%, 44.4%, 14.3%, 28.6%, 55.6% and 0% for Alzheimers disease, dementia with Lewy bodies, frontotemporal dementia, vascular dementia, other dementia, and mixed dementia, respectively. The agreement between the initial and final post-imaging dementia subtype diagnosis was only fair, with a Cohens kappa of 0.25 (95% confidence interval, 0.05-0.45). For the 21 subjects who underwent (11)C-PIB PET imaging, 19% (n=4) of those with Alzheimers disease (PIB positive) were initially diagnosed with non-Alzheimers disease dementia. CONCLUSIONS In this study, PET with or without (11)C-PIB brain imaging helped improve the accuracy of diagnosis of dementia subtype in 36% of our patients with underlying Alzheimers disease, dementia with Lewy bodies, vascular dementia, and frontotemporal dementia.

Amyloid beta 1–42 and tau in the cerebrospinal fluid of renal failure patients for the diagnosis of Alzheimer′s disease

Cerebrospinal fluid (CSF) Aβ42, total tau and phosphorylated tau (p-tau) are well-defined diagnostic markers for Alzheimer’s disease (AD). There has been no previous report of the use of these markers in the diagnosis of AD in patients with chronic kidney disease (CKD). We would like to report our preliminary findings on these biomarkers in three patients with renal failure. One patient with a clinical diagnosis of AD showed elevated CSF tau, p-tau 181, and decreased Aβ42 levels, within a similar range as in local Chinese AD patients without renal impairment. The other two delirious patients, who did not have a clinical diagnosis of AD, showed normal CSF biomarkers. We found that the diagnosis of AD with CSF biomarkers appears to be useful in renal failure patients. But our results need to be confirmed in a larger study, comparing these CSF biomarkers in AD vs. non-AD patients with concomitant CKD.

A COMPARISON OF CLINICAL PRESENTATION AND NATURAL CLINICAL COURSE OF BIOMARKER-SUPPORTED ALZHEIMER’S DISEASE AND LEWY BODY DEMENTIA IN HONG KONG

quantify the metabolites implicated in selected pathways of interest; i.e. the tryptophan and tyrosine pathway, the TCA cycle and purine and pyrimidine metabolism. Results: Untargeted profiling revealed alterations in amino acid metabolism and acylcarnitine metabolism, implying disrupted energy production in mitochondria in AD. Subsequent targeted multiple pathway analysis was focused on energy metabolism and confirmed significant differences in several amino acid-related pathways in both plasma and CSF. In both biofluids, tryptophan and lysine pathways were significantly altered and levels of several long chain acylcarnitines were higher in AD compared to control subjects. In plasma, additional differences were found for purine and pyrimidine metabolism and a number of amino acid pathways, including tyrosine. CSF-specific differences were observed between the two subject groups for fructose and mannose metabolism, as well as glycolysis and pyruvate metabolism. Following the ongoing comprehensive quantification of metabolites from the altered pathways, we will further report associations with CSF biomarkers of amyloid pathology and taurelated neurodegeneration, and with clinical disease progression. Conclusions: Several amino acid and core energy metabolism-related pathways were significantly altered in plasma and/or CSF in patients with early clinical AD compared to control subjects. These observed systemic and central nervous system alterations suggest energy metabolism to be part of the AD pathophysiology.

A descriptive study of Lewy body dementia with functional imaging support in a Chinese population: a preliminary study

INTRODUCTION Lewy body dementia includes dementia with Lewy bodies and Parkinsons disease dementia. There have been limited clinical studies among Chinese patients with Lewy body dementia. This study aimed to review the presenting clinical features and identify risk factors for complications including falls, dysphagia, aspiration pneumonia, pressure sores, and mortality in Chinese patients with Lewy body dementia. We also wished to identify any difference in clinical features of patients with Lewy body dementia with and without an Alzheimers disease pattern of functional imaging. METHODS We retrospectively reviewed 23 patients with Lewy body dementia supported by functional imaging. Baseline demographics, presenting clinical and behavioural and psychological symptoms of dementia, functional and cognitive assessment scores, and complications during follow-up were reviewed. Patients with Lewy body dementia were further classified as having an Alzheimers disease imaging pattern if functional imaging demonstrated bilateral temporoparietal hypometabolism or hypoperfusion with or without precuneus and posterior cingulate gyrus hypometabolism or hypoperfusion. RESULTS The pre-imaging accuracy of clinical diagnosis was 52%. In 83% of patients, behavioural and psychological symptoms of dementia were evident. Falls, dysphagia, aspiration pneumonia, pressure sores, and death occurred in 70%, 52%, 26%, 26%, and 30% of patients, respectively with corresponding event rates per person-years of 0.32, 0.17, 0.18, 0.08, and 0.10. Patients with aspiration pneumonia compared with those without were more likely to have dysphagia (100% vs 35%; P=0.01). Deceased patients with Lewy body dementia, compared with alive patients, had a higher (median [interquartile range]) presenting Clinical Dementia Rating score (1 [1-2] vs 0.5 [0.5-1.0]; P=0.01), lower mean (± standard deviation) baseline Barthel index (13 ± 7 vs 18 ± 4; P=0.04), and were more likely to be prescribed levodopa (86% vs 31%; P=0.03). Patients with Lewy body dementia with an Alzheimers disease pattern of functional imaging, compared with those without the pattern, were younger at presentation (mean ± standard deviation, 73 ± 6 vs 80 ± 6 years; P=0.02) and had a lower Mini-Mental State Examination score at 1 year (15 ± 8 vs 22 ± 6; P=0.05). CONCLUSIONS Falls, dysphagia, aspiration pneumonia, and pressure sores were common among patients with Lewy body dementia. Those with an Alzheimers disease pattern of functional imaging had a younger age of onset and lower 1-year Mini-Mental State Examination score.

GENETIC VARIANTS OF MICRORNAS AND INSIGHTS INTO AMNESTIC MILD COGNITIVE IMPAIRMENT

imputation in the 103,067 individuals using a “cosmopolitan” reference panel of the full set of the 1000 Genomes project genotypes to generate genotypic probabilities for variants not directly assayed. The Apoe4 allele was imputed with an r1⁄40.92. EMR diagnoses of dementia, Alzheimer’s disease(AD), MCI and subjective memory complaints (SMC) were collected from 1996-2015. APOE allele frequencies were examined across all cognitive impairment phenotypes versus controls by racial/ethnic groups. We examined the association between E4 (3/4 and 4/4) and phenotypes with odds ratios (OR). Results: The mean age of the sample at collection was 62 years. E4 was present in 22% controls, 32%Dementia, 41% AD, 32%MCI and 31% SMC for Europeans (Table 1). AD risk was 2.5-fold increased among those with an E4 allele versus without, and dementia, MCI, and SMC risk were all 1.7 fold increased in those with E4 versus those without in Europeans; findings were similar across all racial/ethnic minority groups (Table 1). Conclusions: This is one of the largest efforts to date evaluating E4 and EMR records of subjective memory complaints and diagnoses of dementia andMCI phenotypes. EMR phenotypes and subjective memory complaints in this diverse cohort are increased for those with E4, suggesting future applications for identifying those at increased AD risk harnessing large-scale electronic data combined with biospecimens.

A lucky and reversible cause of 'ischaemic bowel'.

An 81-year-old man was admitted with an infective exacerbation of chronic obstructive pulmonary disease. He also had clinical and radiological features suggestive of ileus. On day 6 after admission, he developed generalised abdominal pain. Urgent computed tomography of the abdomen showed presence of portovenous gas and dilated small bowel with pneumatosis intestinalis and whirl sign. Emergency laparotomy was performed, which showed a 7-mm perforated ulcer over the first part of the duodenum and small bowel volvulus. Omental patch repair and reduction of small bowel volvulus were performed. No bowel resection was required. The patient had a favourable outcome. Clinicians should suspect small bowel volvulus as a cause of ischaemic bowel. Presence of portovenous gas and pneumatosis intestinalis are normally considered to be signs of frank ischaemic bowel. The absence of bowel ischaemia at laparotomy in this patient shows that this is not necessarily the case and prompt surgical treatment could potentially save the bowels and lives of these patients.