Gastric carcinoma rarely presents as a perforation, but when it does, is perceived as advanced disease. The majority of such perforations are Stage III/IV disease. A T1 gastric carcinoma has never been reported to perforate spontaneously in English literature. We present a 56 year-old Chinese male who presented with a perforated gastric ulcer. Intra-operatively, there was no suspicion of malignancy. At operation, an open omental patch repair was performed. Post-operative endoscopy revealed a macroscopic Type 0~III tumour and from the ulcer edge biopsy was reported as adenocarcinoma. Subsequently, the patient underwent open subtotal gastrectomy and formal D2 lymphadenectomy. The final histopathology report confirms T1b N0 disease. The occurrence of a perforated early gastric cancer re-emphasises the need for vigilance, including intra-operative frozen section and/or biopsy, as well as routine post-operative endoscopy for all patients.
Adenocarcinoma ; Asian Continental Ancestry Group ; Biopsy ; Endoscopy ; Frozen Sections ; Gastrectomy ; Humans ; Lymph Node Excision ; Male ; Peritonitis ; Stomach Neoplasms ; Stomach Ulcer ; Ulcer

INTRODUCTION: Bystander cardiopulmonary resuscitation (B-CPR) is associated with improved out-of hospital cardiac arrest survival. Community-level interventions including dispatcher-assisted CPR (DA-CPR) and myResponder were implemented to increase B-CPR. We sought to assess whether these interventions increased B-CPR. METHODS: The Singapore out-of-hospital cardiac arrest registry captured cases that occurred between 2010 and 2017. Outcomes occurring in 3 time periods (Baseline, DA-CPR, and DA-CPR plus myResponder) were compared. Segmented regression of time-series data was conducted to investigate our intervention impact on the temporal changes in B-CPR. RESULTS: A total of 13,829 out-of-hospital cardiac arrest cases were included from April 2010 to December 2017. Higher B-CPR rates (24.8% versus 50.8% vs 64.4%) were observed across the 3 time periods. B-CPR rates showed an increasing but plateauing trend. DA-CPR implementation was significantly associated with an increased B-CPR (level odds ratio [OR] 2.26, 95% confidence interval [CI] 1.79-2.88; trend OR 1.03, 95% CI 1.01-1.04), while no positive change was detected with myResponder (level OR 0.95, 95% CI 0.82-1.11; trend OR 0.99, 95% CI 0.98-1.00). CONCLUSION B-CPR rates in Singapore have been increasing alongside the implementation of community-level interventions such as DA-CPR and myResponder. DA-CPR was associated with improved odds of receiving B-CPR over time while the impact of myResponder was less clear.

BACKGROUNDThe environmental sources associated with community-acquired or nosocomial legionellosis were not always detectable in the mainland of China and Hong Kong, China. The objective of this study was to illustrate the control measures implemented for nosocomial and community outbreaks of legionellosis, and to understand the environmental distribution of legionella in the water system in Hong Kong, China.

METHODSWe investigated the environmental sources of two cases of legionellosis acquired in the hospital and the community by extensive outbreak investigation and sampling of the potable water system using culture and genetic testing at the respective premises.

RESULTSThe diagnosis of nosocomial legionellosis was suspected in a patient presenting with nosocomial pneumonia not responsive to multiple beta-lactam antibiotics with subsequent confirmation by Legionella pneumophila serogroup 1 antigenuria. High counts of Legionella pneumophila were detected in the potable water supply of the 70-year-old hospital building. Another patient on continuous ambulatory peritoneal dialysis presenting with acute community-acquired pneumonia and severe diarrhoea was positive for Legionella pneumophila serogroup 1 by polymerase chain reaction (PCR) testing on both sputum and nasopharyngeal aspirate despite negative antigenuria. Paradoxically the source of the second case was traced to the water system of a newly commissioned office building complex. No further cases were detected after shock hyperchlorination with or without superheating of the water systems. Subsequent legionella counts were drastically reduced. Point-of-care infection control by off-boiled or sterile water for mouth care and installation of water filter for showers in the hospital wards for immunocompromised patients was instituted. Territory wide investigation of the community potable water supply showed that 22.1% of the household water supply was positive at a mean legionella count of 108.56 CFU/ml (range 0.10 to 639.30 CFU/ml).

CONCLUSIONSPotable water systems are open systems which are inevitably colonized by bacterial biofilms containing Legionella species. High bacterial counts related to human cases may occur with stagnation of flow in both old or newly commissioned buildings. Vigilance against legionellosis is important in healthcare settings with dense population of highly susceptible hosts.

Aged ; Aged, 80 and over ; Biofilms ; Community-Acquired Infections ; diagnosis ; epidemiology ; Female ; Hong Kong ; epidemiology ; Humans ; Legionellosis ; diagnosis ; epidemiology ; Male ; Water Microbiology

BACKGROUNDProactive infection control management is crucial in preventing the introduction of multiple drug resistant organisms in the healthcare setting. In Hong Kong, where vancomycin-resistant enterococci (VRE) endemicity is not yet established, contact tracing and screening, together with other infection control measures are essential in limiting intra- and inter-hospital transmission. The objective of this study was to illustrate the control measures used to eradicate a VRE outbreak in a hospital network in Hong Kong.

METHODSWe described an outbreak of VRE in a healthcare region in Hong Kong, involving a University affiliated hospital and a convalescent hospital of 1600 and 550 beds respectively. Computer-assisted analysis was utilized to facilitate contact tracing, followed by VRE screening using chromogenic agar. Multi-locus sequence typing (MLST) was performed to assess the clonality of the VRE strains isolated. A case-control study was conducted to identify the risk factors for nosocomial acquisition of VRE.

RESULTSBetween November 26 and December 17, 2011, 11 patients (1 exogenous case and 10 secondary cases) in two hospitals with VRE colonization were detected during our outbreak investigation and screening for 361 contact patients, resulting in a clinical attack rate of 2.8% (10/361). There were 8 males and 3 females with a median age of 78 years (range, 40 - 87 years). MLST confirmed sequence type ST414 in all isolates. Case-control analysis demonstrated that VRE positive cases had a significantly longer cumulative length of stay (P < 0.001), a higher proportion with chronic cerebral and cardiopulmonary conditions (P = 0.001), underlying malignancies (P < 0.001), and presence of urinary catheter (P < 0.001), wound or ulcer (P < 0.001), and a greater proportion of these patients were receiving β-lactam/β-lactamase inhibitors (P = 0.009), carbapenem group (P < 0.001), fluoroquinolones (P = 0.003), or vancomycin (P = 0.001) when compared with the controls.

CONCLUSIONExtensive contact tracing and screening with a "search-and-confine" strategy was a successful tool for outbreak control in our healthcare region.

Aged ; Aged, 80 and over ; Enterococcus faecium ; growth & development ; pathogenicity ; Female ; Gram-Positive Bacterial Infections ; epidemiology ; prevention & control ; Hong Kong ; epidemiology ; Humans ; Male ; Middle Aged ; Vancomycin Resistance

BACKGROUNDIdentification of hospitalized carbapenem-resistant Enterobacteriaceae (CRE)-positive patient is important in preventing nosocomial transmission. The objective of this study was to illustrate the implementation of proactive infection control measures in preventing nosocomial transmission of CRE in a healthcare region of over 3200 beds in Hong Kong between October 1, 2010 and December 31, 2011.

METHODSThe program included active surveillance culture in patients with history of medical tourism with hospitalization and surgical operation outside Hong Kong within 12 months before admission, and "added test" as an opportunistic CRE screening in all fecal specimens submitted to the laboratory. Outbreak investigation and contact tracing were conducted for CRE-positive patients. Serial quantitative culture was performed on CRE-positive patients and the duration of fecal carriage of CRE was analyzed.

RESULTSDuring the study period, a total of 6533 patients were screened for CRE, of which 76 patients were positive (10 from active surveillance culture, 65 from "added test", and 1 secondary case from contact tracing of 223 patients with no nosocomial outbreak), resulting in an overall rate of CRE fecal carriage of 1.2%. The median time of fecal carriage of CRE was 43 days (range, 13-119 days). Beta-lactam-beta-lactamase-inhibitors, cephalosporins, and fluoroquinolones were associated significantly with high fecal bacterial load when used 90 days before CRE detection, while use of cephalosporins, carbapenems, and fluoroquinolones after CRE detection are significantly associated with longer duration of carriage. The duration of fecal carriage of CRE also correlates significantly with the initial fecal bacterial load (Pearson correlation: 0.53; P = 0.02).

CONCLUSIONProactive infection control measures by enhanced surveillance program identify CRE-positive patients and data obtained are useful for the planning of and resource allocation for CRE control.

Anti-Bacterial Agents ; therapeutic use ; Carbapenems ; therapeutic use ; Cephalosporins ; therapeutic use ; Drug Resistance, Bacterial ; Enterobacteriaceae ; drug effects ; Enterobacteriaceae Infections ; prevention & control ; transmission ; Fluoroquinolones ; therapeutic use ; Humans ; Infection Control ; methods

It is largely unknown whether lower urinary tract symptoms (LUTS) or acute retention of urine (AROU) is linked to shorter life expectancy in men. We conducted a multicenter, retrospective database analysis of patients undergoing transurethral resection of prostate (TURP) to study their relationships. Multivariate Cox regression analysis and Kaplan-Meier analysis with stratification to age and indication of TURP were performed. We further performed an age- and sex-matched survival analysis with the general population using data from the Census and Statistics Department of the Hong Kong Special Administrative Region (Hong Kong, China). From January 2002 to December 2012, 3496 patients undergoing TURP were included in our study, with 1764 patients in the LUTS group and 1732 patients in the AROU group. Old age, ischemic heart disease, cerebrovascular accident, and AROU were risk factors of mortality. Patients aged <70 years (adjusted hazard ratio [HR]: 1.52, 95% confidence interval [CI]: 1.11-2.09, P = 0.010) and 70-80 years (adjusted HR: 1.39, 95% CI: 1.15-1.70, P = 0.001) in the AROU group had worse survival than those in the LUTS group, but such difference was not demonstrated in patients aged >80 years. Compared to the general population, younger patients in the LUTS group appeared to have better survival (<70 years, P = 0.091; 70-80 years, P = 0.011), but younger patients in the AROU group had worse survival (<70 years, P = 0.021; 70-80 years, P = 0.003). For patients aged >80 years, survival was similar with the general population in both the LUTS and AROU groups. In conclusion, AROU at young age was associated with mortality, while early detection and management of LUTS may improve survival.
Age Factors ; Aged ; Aged, 80 and over ; Databases, Factual ; Humans ; Kaplan-Meier Estimate ; Lower Urinary Tract Symptoms ; Male ; Middle Aged ; Prostate/surgery* ; Prostatic Hyperplasia/surgery* ; Retrospective Studies ; Risk Factors ; Survival Analysis ; Transurethral Resection of Prostate/methods* ; Urinary Retention/surgery*