Yat-Fung Shea

Prevention of Mortality and Pneumonia Among Nursing Home Older Adults by Dual Pneumococcal and Seasonal Influenza Vaccination During a Pandemic Caused by Novel Pandemic Influenza A (H1N1)

OBJECTIVE To evaluate the efficacy of dual vaccination of seasonal influenza and pneumococcus in nursing home older adults during a novel pandemic of influenza A (H1N1). SETTING Nine nursing homes in Hong Kong. PARTICIPANTS A total of 532 nursing home older adults were included in the study. MEASUREMENTS Efficacy of dual vaccination of seasonal influenza and pneumococcus in nursing home older adults during a novel pandemic influenza A (H1N1). DESIGN A prospective 12-month cohort study was conducted on older residents from December 2009 to November 2010. Participants were divided into 3 groups according to their choice of vaccination: received both seasonal influenza and 23-valent pneumococcal polysaccharide vaccine (PPV-TIV group), received seasonal influenza vaccine alone (TIV group), and those who refused both vaccinations (unvaccinated group). Those who had received vaccination for influenza A (H1N1) were excluded. Outcome measures included mortality from all causes, pneumonia, and vascular causes. RESULTS There were 246 in the PPV-TIV group, 211 in the TIV group, and 75 in the unvaccinated group. Baseline characteristics were similar among the groups. The 12-month mortality rates of the PPV-TIV, TIV alone group, and unvaccinated group were 17.1%, 27.0%, and 37.3% respectively (P < .001). Multivariate analysis demonstrated that, compared with vaccination of seasonal influenza alone, dual vaccination significantly reduced all-cause mortality (hazard ratio [HR] 0.54; 95% confidence interval [CI]: 0.35-0.84; P < .01), mortality from pneumonia (HR 0.60; 95% CI: 0.35-0.99; P < .05), and mortality from vascular causes (HR 0.24; 95% CI: 0.09-0.64; P < .01). CONCLUSIONS During an influenza pandemic or when the circulating influenza strain was not matched by the trivalent seasonal influenza vaccine, dual vaccination of influenza and pneumococcus provided additional protection to nursing home older adults in reducing mortality.

Efficacy of dual vaccination of pandemic H1N1 2009 influenza and seasonal influenza on institutionalized elderly: A one-year prospective cohort study

BACKGROUND The influenza A (H1N1) 2009 pandemic was declared by the WHO in April 2009. In Hong Kong, the vaccination program began in December 2009 in addition to the annual seasonal trivalent influenza vaccination program. The clinical efficacy of dual vaccination was unknown. METHOD From December 2009 to November 2010, a prospective 12-month cohort study on institutionalized elderly of nine nursing homes was conducted. Elderly persons who were followed up by the Hong Kong West Community Geriatric Assessment Team and had been vaccinated by the Department of Health were included. Outcome measures included all cause mortality, all cause hospitalization, hospitalization for fever on admission and hospitalization for pneumonia based on ICD-9-CM. RESULTS 711 elderly persons were included. 274 received both seasonal influenza vaccine and (H1N1) 2009 vaccine (H1N1-TIV), 368 received seasonal influenza vaccine only (TIV alone) and 69 received no vaccination (unvaccinated). Baseline characteristics were well matched between the groups, except there were fewer females in the TIV alone. The 12-month mortality rates of the H1N1-TIV, TIV alone and unvaccinated were 10.6%, 19.8% and 29%, respectively. Multivariate analysis demonstrated that dual vaccination in the institutionalized elderly significantly reduced all cause mortality by 54% (Hazard Ratio [HR] 0.46; 95% confidence interval [CI] 0.29-0.72; p<0.001) and 74% (HR 0.26; CI 0.13-0.49; p<0.001), compared with vaccination of seasonal vaccination alone and no vaccination, respectively. Dual vaccination also reduced all cause hospitalization, hospitalization for fever on admission and hospitalization for pneumonia compared with seasonal vaccination alone and the unvaccinated group. CONCLUSION Dual vaccination with both H1N1 and seasonal vaccinations provided additional protection to institutionalized elderly in reducing mortality and hospitalization.

Prevalence and Associated Comorbidities of Moderate to Severe Chronic Renal Impairment in Chinese Nursing Home Older Adults

OBJECTIVE To investigate the prevalence and associated comorbidities of Stage 3 (GFR 30-59 mL/min/1.73m(2)) and Stages 4 and 5 (GFR <30 mL/min/1.73m(2)) chronic kidney disease (CKD) among Chinese nursing home older adults. DESIGN Retrospective cross-sectional study. Glomerular filtration rate (GFR) was estimated by Modification of Diet in Renal Disease Study (Chinese-adjusted) equation and The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. SETTING Nine nursing homes in Hong Kong PARTICIPANTS Participants included 812 nursing home older adults (271 men and 571 women), mean age 86.0 ± 7.6. MEASUREMENTS Prevalence of Stage 3 (GFR 30-59 mL/min/1.73m(2)) and Stages 4 and 5 (GFR <30 mL/min/1.73m(2)) CKD. The comorbidities associated with renal impairment were also assessed. RESULTS There were 18.4% of nursing home older adults who had elevated serum creatinine levels above the normal limits. Using Modification of Diet in Renal Disease Study and CKD-EPI equations, 26.4% and 21.2% of them had Stage 3 CKD, whereas 6.8% and 4.4% had Stage 4-5 CKD, respectively. Diabetes mellitus, hypertension, congestive heart failure, and ischemic heart disease correlated significantly with moderate to severe renal impairment in Chinese nursing home older adults. CONCLUSION Stages 3 to 5 CKD are prevalent in Chinese nursing home older adults. Early identification of these patients facilitates drug prescription, renal management, and advance care planning.

Continuous use of antipsychotics and its association with mortality and hospitalization in institutionalized Chinese older adults: an 18-month prospective cohort study.

BACKGROUND Previous meta-analyses have suggested that antipsychotics are associated with increased mortality in dementia patients with behavioral and psychological symptoms (BPSD). Subsequent observational studies, however, have produced conflicting results. In view of this controversy and the lack of any suitable pharmacological alternative for BPSD, this study aimed to investigate the relationship between continuous use of antipsychotics and mortality as well as hospitalizations in Chinese older adults with BPSD residing in nursing homes. METHODS This was a prospective cohort study conducted in nursing homes in the Central & Western and Southern Districts of Hong Kong from July 2009 to December 2010. Older adults were stratified into the exposed group (current users of antipsychotics) and control group (non-users). Demographics, comorbidity according to the Charlson Comorbidity Index (CCI), Barthel Index (BI(20)), Abbreviated Mental Test (AMT), and vaccination status for pandemic Influenza A (H1N1) 2009, seasonal influenza and pneumococcus were collected at baseline. Subjects were followed up at 18 months. All-cause mortality and all-cause hospitalizations were recorded. RESULTS 599 older adults with dementia from nine nursing homes were recruited. The 18-month mortality rate for the exposed group was 24.1% while that for control group was 27.5% (P = 0.38). The exposed group also had a lower median rate of hospitalizations (56 (0-111) per 1000 person-months vs 111 (0-222) per 1000 person-months, median (interquartile range), p<0.001). CONCLUSIONS The continuous use of antipsychotics for BPSD does not increase mortality among Chinese older adults with dementia living in nursing homes. Furthermore, our results show that the use of antipsychotics can lead to decreased hospitalizations.

Functional Status of Older Nursing Home Residents Can Affect the Efficacy of Influenza Vaccination

BACKGROUND The efficacy of influenza vaccination in older nursing home residents is frequently overestimated due to frailty selection bias. Limited data exist to examine this issue. METHODS We conducted a prospective cohort study from December 2009 to November 2010 to evaluate the efficacy of influenza vaccination in old nursing home residents with respect to their functional status. Participants were stratified according to the Barthel Index (BI) into good functioning (GF; BI > 60), intermediate functioning (IF; BI = 5-60), and poor functioning (PF; BI = 0). Participants were vaccinated by monovalent H1N1 2009 and trivalent seasonal influenza vaccinations (H1N1-TIV), TIV alone, or remained unvaccinated by choice. The associations between all-cause mortality, vaccination efficacy, and functional status were examined. RESULTS A total of 711 older nursing home residents were enrolled (GF group: N = 230; IF group: N = 246; PF group: N = 235). At 12 months, H1N1-TIV recipients had the lowest all-cause mortality, whereas unvaccinated residents had the highest all-cause mortality in all three functional status groups. In the comparison between H1N1-TIV recipients and TIV alone recipients, the hazard ratios (HRs) of all-cause mortality were lower in the GF group and higher in the PF group (GF group: HR 0.30 [0.07-0.95], p < .05; IF group: HR 0.40 [0.18-0.86], p < .05; PF group: HR 0.53 [0.28-0.99], p < .05). The same observation was found in comparison between other vaccination statuses (H1N1-TIV vs unvaccinated and TIV alone vs unvaccinated). CONCLUSIONS Influenza vaccination was associated with reduced all-cause mortality in older nursing home residents with different functional statuses. Vaccine efficacy in reducing mortality declined with increasingly impaired functional status.

Sunitinib-induced hyperammonaemia in a patient with pancreatic neuroendocrine tumour

Sunitinib can improve progression‐free survival and overall survival in patients with advanced pancreatic neuroendocrine tumor (PNET). From clinical trial, most commonly reported adverse events of sunitinib were neutropenia (12%), diarrhea (10%), asthenia (7%), erythrodysesthesia (7%), hypertension (7%) and thrombocytopenia (6%).

Influence of education and age on the abbreviated mental test in Chinese nursing home older adults.

Communication barrier at the time of the test Yes/No Deafness _____ Depression _____ Dysphasia _____ Language barrier _____ Others: To the Editor: We thank Ms. Fortington and her coauthors for emphasizing the importance of foot care in older people with diabetes. They provide a timely reminder that clinicians should consider this issue with priority as we are now entering an era where structured and integrated diabetes care is demonstrating significant improvements in people with diabetes.1 In our position statement,2 we decided to rank only 8 domains of inquiry, although nutrition and hypertensionwere considered. Foot care was discussed in depth by the consensus group but fell outside of the initial 8 domains, and it would have been inappropriate to include it with the methodology we adopted. This does not mean we believed it was unimportant, but we took note of the data from the United States that showed that from 1996 to 2008, nontraumatic lower extremity amputation rates declined significantly in the US diabetic population in those subjects aged 40 years and older.3 We would like to draw the attention of Ms. Fortington and colleagues toour recentlypublishedEuropeanGuidelinesonDiabetes for Older People.4 In these guidelines, we have taken the opportunity tomake guideline statements on diabetes foot care and related issues such as falls, immobility, and peripheral vascular disease. Perhapswe believe that a position statement has a different purpose than a clinical guideline, but we respect the views expressed and find the comments very insightful and helpful. Nevertheless, as we have recently been tasked with leading a global initiative in diabetes care for older people by the International Association of Geriatrics and Gerontology, we can firmly state that foot care will be a key issue identified. We invite the team at the University of Groningen to work with us in this respect.

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.

Gabapentin-induced myoclonus in an elderly with end-stage renal failure

A 79-year-old woman, with end stage renal failure (ESRF) due to diabetic nephropathy, presented with generalized involuntary movements for 3 days. She had a history of hypertension, hyperlipidemia, and gouty arthritis. Gabapentin (GBP) 300 mg nocte was prescribed for her postherpetic neuralgia involving her right V1 dermatome. Ten hours later, she developed generalized involuntary jerky movements, and was also drowsy and unable to walk. She did not take further doses of GBP. On the following 2 days, her involuntary movements persisted but were decreasing in severity. She presented to us on the third day. She had a Glasgow coma scale of 15 and had high frequency multifocal myoclonus involving her neck, bilateral upper extremities, and trunk. Blood tests showed random glucose 8.1 mmol/L, urea 27.4 mmol/L, creatinine 531 mmol/L, adjusted calcium 2.15 mmol/L, phosphate 1.87 mmol/L, and normal liver function test. Computed tomography of the brain reviewed cerebral atrophy. Her medications include calcium supplements, frusemide, amlodipine, isosorbide mononitrate, sodium bicarbonate, and paracetamol. GBP level measured 67 hours later was 23 mmol/L (reference range 70e120 mmol/L). Clonazepam was prescribed but she was unable to tolerate it due to

A hidden cause of recurrent asthmatic attacks

cancer than individuals without the mutation. Thus, bilateral mastectomy is often the surgical procedure of choice. This strategy has been shown to improve breast cancer– specific survival and appears to be independent of age. The role of systemic and radiation therapy is similar in BRCAand non-BRCA-associated cancers. Existing guidelines for management of elderly adults with breast cancer can be applied.