Search

Background: Few data are available about the effectiveness of nonpharmaceutical interventions for preventing influenza virus transmission.Objective: To investigate whether hand hygiene and use of facemasks prevents household transmission of influenza.Design: Cluster randomized, controlled trial. Randomization was computer generated; allocation was concealed from treating physicians and clinics and implemented by study nurses at the time of the initial household visit. Participants and personnel administering the interventions were not blinded to group assignment. (ClinicalTrials.gov registration number: NCT00425893)Setting: Households in Hong Kong.Patients: 407 people presenting to outpatient clinics with influenza-like illness who were positive for influenza A or B virus by rapid testing (index patients) and 794 household members (contacts) in 259 households.Intervention: Lifestyle education (control) (134 households), hand hygiene (136 households), or surgical facemasks plus hand hygiene (137 households) for all household members.Measurements: Influenza virus infection in contacts, as confirmed by reverse-transcription polymerase chain reaction (RT-PCR) or diagnosed clinically after 7 days.Results: Sixty (8%) contacts in the 259 households had RT-PCR-confirmed influenza virus infection in the 7 days after intervention. Hand hygiene with or without facemasks seemed to reduce influenza transmission, but the differences compared with the control group were not significant. In 154 households in which interventions were implemented within 36 hours of symptom onset in the index patient, transmission of RT-PCR-confirmed infection seemed reduced, an effect attributable to fewer infections among participants using facemasks plus hand hygiene (adjusted odds ratio, 0.33 [95% CI, 0.13 to 0.87]). Adherence to interventions varied.Limitation: The delay from index patient symptom onset to intervention and variable adherence may have mitigated intervention effectiveness.Conclusion: Hand hygiene and facemasks seemed to prevent household transmission of influenza virus when implemented within 36 hours of index patient symptom onset. These findings suggest that nonpharmaceutical interventions are important for mitigation of pandemic and interpandemic influenza.Primary Funding Source: Centers for Disease Control and Prevention. [ABSTRACT FROM AUTHOR]

BACKGROUND: The variable-stiffness colonoscope incorporates different degrees of stiffness of the insertion tube, which can be adjusted during the examination. Whether its use can lead to reduced procedure-related pain and sedative use is unknown. OBJECTIVE: Our purpose was to compare the use of 3 types of colonoscope with different shaft stiffnesses in relation to procedure-related pain and sedative consumption. DESIGN: Prospective randomized trial. SETTING: Endoscopy unit of a university-affilitated hospital. PATIENTS: Consecutive patients undergoing ambulatory colonoscopy. INTERVENTIONS: Random assignment was made of patients into 3 groups to receive colonoscopic examinations by one of the 3 types of colonoscope: conventional standard adult size, 1.3-m; 1.6-m; and the new variable-stiffness adult size, full-length (1.6-m) colonoscope. A mixture of propofol and afentanil, delivered by a patient-controlled syringe pump, was used for sedation in all groups. MAIN OUTCOME MEASURES: Outcome measures included dose of patient-controlled sedation consumed, pain score, cecal intubation rate, cecal intubation time, requirement of abdominal pressure and change of patients' positions during colonoscopy, and endoscopists and patients' satisfaction scores according to a visual analog scale. RESULTS: A total of 335 patients were randomized. Patients in group 3 used significantly less propofol (in milligrams per kilograms, mean [SD]) compared with the other 2 groups (group 1: 1.00 [0.75], group 2: 0.93 [0.62], and group 3: 0.75 [0.65]; P = .02; 1-way analysis of variance). The mean (SD) pain score was also lower in group 3. LIMITATIONS: The endoscopists were not blinded. CONCLUSION: The use of the new variable-stiffness adult-size colonoscope significantly reduced procedure-related pain and doses of sedative medications during colonoscopy. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the diagnostic performance of a deep learning system for automated detection of atrial fibrillation (AF) in photoplethysmographic (PPG) pulse waveforms., Methods: We trained a deep convolutional neural network (DCNN) to detect AF in 17 s PPG waveforms using a training data set of 149 048 PPG waveforms constructed from several publicly available PPG databases. The DCNN was validated using an independent test data set of 3039 smartphone-acquired PPG waveforms from adults at high risk of AF at a general outpatient clinic against ECG tracings reviewed by two cardiologists. Six established AF detectors based on handcrafted features were evaluated on the same test data set for performance comparison., Results: In the validation data set (3039 PPG waveforms) consisting of three sequential PPG waveforms from 1013 participants (mean (SD) age, 68.4 (12.2) years; 46.8% men), the prevalence of AF was 2.8%. The area under the receiver operating characteristic curve (AUC) of the DCNN for AF detection was 0.997 (95% CI 0.996 to 0.999) and was significantly higher than all the other AF detectors (AUC range: 0.924-0.985). The sensitivity of the DCNN was 95.2% (95% CI 88.3% to 98.7%), specificity was 99.0% (95% CI 98.6% to 99.3%), positive predictive value (PPV) was 72.7% (95% CI 65.1% to 79.3%) and negative predictive value (NPV) was 99.9% (95% CI 99.7% to 100%) using a single 17 s PPG waveform. Using the three sequential PPG waveforms in combination (<1 min in total), the sensitivity was 100.0% (95% CI 87.7% to 100%), specificity was 99.6% (95% CI 99.0% to 99.9%), PPV was 87.5% (95% CI 72.5% to 94.9%) and NPV was 100% (95% CI 99.4% to 100%)., Conclusions: In this evaluation of PPG waveforms from adults screened for AF in a real-world primary care setting, the DCNN had high sensitivity, specificity, PPV and NPV for detecting AF, outperforming other state-of-the-art methods based on handcrafted features., Competing Interests: Competing interests: M-ZP and YCP are employees of Cardiio and have an ownership stake in the company, which holds intellectual property rights to the new algorithm tested in this work., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To evaluate the diagnostic performance of a UK National Institute for Health and Care Excellence-recommended automatic oscillometric blood pressure (BP) measurement device incorporated with an atrial fibrillation (AF) detection algorithm (Microlife WatchBP Home A) for real-world AF screening in a primary healthcare setting., Setting: Primary healthcare setting in Hong Kong., Interventions: This was a prospective AF screening study carried out between 1 September 2014 and 14 January 2015. The Microlife device was evaluated for AF detection and compared with a reference standard of lead-I ECG., Primary Outcome Measures: Diagnostic performance of Microlife for AF detection., Results: 5969 patients (mean age: 67.2±11.0 years; 53.9% female) were recruited. The mean CHA 2 DS 2 -VASc ( C : congestive heart failure [1 point]; H : hypertension [1 point]; A 2 : age 65-74 years [1 point] and age ≥75 years [2 points]; D : diabetes mellitus [1 point]; S : prior stroke or transient ischemic attack [2 points]; VA : vascular disease [1 point]; and Sc : sex category [female] [1 point])score was 2.8±1.3. AF was diagnosed in 72 patients (1.21%) and confirmed by a 12-lead ECG. The Microlife device correctly identified AF in 58 patients and produced 79 false-positives. The corresponding sensitivity and specificity for AF detection were 80.6% (95% CI 69.5 to 88.9) and 98.7% (95% CI 98.3 to 98.9), respectively. Among patients with a false-positive by the Microlife device, 30.4% had sinus rhythm, 35.4% had sinus arrhythmia and 29.1% exhibited premature atrial complexes. With the low prevalence of AF in this population, the positive and negative predictive values of Microlife device for AF detection were 42.4% (95% CI 34.0 to 51.2) and 99.8% (95% CI 99.6 to 99.9), respectively. The overall diagnostic performance of Microlife device to detect AF as determined by area under the curves was 0.90 (95% CI 0.89 to 0.90)., Conclusions: In the primary care setting, Microlife WatchBP Home was an effective means to screen for AF, with a reasonable sensitivity of 80.6% and a high negative predictive value of 99.8%, in addition to its routine function of BP measurement. In a younger patient population aged <65 years with a lower prevalence of AF, Microlife WatchBP Home A demonstrated a similar diagnostic accuracy., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: In Hong Kong, the prevalence of atherosclerotic cardiovascular disease has increased markedly over the past few decades, and further increases are expected. In 2008, the Hong Kong Cardiovascular Task Force released a consensus statement on preventing cardiovascular disease in the Hong Kong population. The present article provides an update on these recommendations., Participants: A multidisciplinary group of clinicians comprising the Hong Kong Cardiovascular Task Force-10 cardiologists, an endocrinologist, and a family physician-met in September 2014 and June 2015 in Hong Kong., Evidence: Guidelines from the American College of Cardiology/American Heart Association, the European Society of Hypertension/European Society of Cardiology, and the Eighth Joint National Committee for the Management of High Blood Pressure were reviewed., Consensus Process: Group members reviewed the 2008 Consensus Statement and relevant international guidelines. At the meetings, each topical recommendation of the 2008 Statement was assessed against the pooled recommendations on that topic from the international guidelines. A final recommendation on each topic was generated by consensus after discussion., Conclusions: It is recommended that a formal risk scoring system should be used for risk assessment of all adults aged 40 years or older who have at least one cardiovascular risk factor. Individuals can be classified as having a low, moderate, or high risk of developing atherosclerotic cardiovascular disease, and appropriate interventions selected accordingly. Recommended lifestyle modifications include adopting a healthy eating pattern; maintaining a low body mass index; quitting smoking; and undertaking regular, moderate-intensity physical activity. Pharmacological interventions should be selected as appropriate after lifestyle modification.

Background: Diagnosing atrial fibrillation (AF) before ischemic stroke occurs is a priority for stroke prevention in AF. Smartphone camera-based photoplethysmographic (PPG) pulse waveform measurement discriminates between different heart rhythms, but its ability to diagnose AF in real-world situations has not been adequately investigated. We sought to assess the diagnostic performance of a standalone smartphone PPG application, Cardiio Rhythm, for AF screening in primary care setting., Methods and Results: Patients with hypertension, with diabetes mellitus, and/or aged ≥65 years were recruited. A single-lead ECG was recorded by using the AliveCor heart monitor with tracings reviewed subsequently by 2 cardiologists to provide the reference standard. PPG measurements were performed by using the Cardiio Rhythm smartphone application. AF was diagnosed in 28 (2.76%) of 1013 participants. The diagnostic sensitivity of the Cardiio Rhythm for AF detection was 92.9% (95% CI] 77-99%) and was higher than that of the AliveCor automated algorithm (71.4% [95% CI 51-87%]). The specificities of Cardiio Rhythm and the AliveCor automated algorithm were comparable (97.7% [95% CI: 97-99%] versus 99.4% [95% CI 99-100%]). The positive predictive value of the Cardiio Rhythm was lower than that of the AliveCor automated algorithm (53.1% [95% CI 38-67%] versus 76.9% [95% CI 56-91%]); both had a very high negative predictive value (99.8% [95% CI 99-100%] versus 99.2% [95% CI 98-100%])., Conclusions: The Cardiio Rhythm smartphone PPG application provides an accurate and reliable means to detect AF in patients at risk of developing AF and has the potential to enable population-based screening for AF., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: The pandemic potential of avian influenza A/H5N1 should not be overlooked, and the continued development of vaccines against these highly pathogenic viruses is a public health priority., Methods: This open-label extension booster study followed a Phase III study of 1206 adults who had received two 3.75 μg doses of primary AS03A-adjuvanted or non-adjuvanted H5N1 split-virus vaccine (A/Vietnam/1194/2004; clade 1) (NCT00449670). The aim of the extension study was to evaluate different timings for heterologous AS03A-adjuvanted booster vaccination (A/Indonesia/5/2005; clade 2.1) given at Month 6, 12, or 36 post-primary vaccination. Immunogenicity was assessed 21 days after each booster vaccination and the persistence of immune responses against the primary vaccine strain (A/Vietnam) and the booster strain (A/Indonesia) was evaluated up to Month 48 post-primary vaccination. Reactogenicity and safety were also assessed., Results: After booster vaccination given at Month 6, HI antibody responses to primary vaccine, and booster vaccine strains were markedly higher with one dose of AS03A-H5N1 booster vaccine in the AS03A-adjuvanted primary vaccine group compared with two doses of booster vaccine in the non-adjuvanted primary vaccine group. HI antibody responses were robust against the primary and booster vaccine strains 21 days after boosting at Month 12 or 36. At Month 48, in subjects boosted at Month 6, 12, or 36, HI antibody titers of ≥1:40 against the booster strain persisted in 39.2%, 61.2%, and 95.6% of subjects, respectively. Neutralizing antibody responses and cell-mediated immune responses also showed that AS03A-H5N1 heterologous booster vaccination elicited robust immune responses within 21 days of boosting at Month 6, 12, or 36 post-primary vaccination. The booster vaccine was well tolerated, and no safety concerns were raised., Conclusions: In Asian adults primed with two doses of AS03A-adjuvanted H5N1 pandemic influenza vaccine, strong cross-clade anamnestic antibody responses were observed after one dose of AS03A-H5N1 heterologous booster vaccine given at Month 6, 12, or 36 after priming, suggesting that AS03A-adjuvanted H5N1 vaccines may provide highly flexible prime-boost schedules. Although immunogenicity decreased with time, vaccinated populations could potentially be protected for up to three years after vaccination, which is likely to far exceed the peak of the a pandemic.

Objective: To examine whether the inverse care law operates in a screening program for diabetic retinopathy (DR) based on fee for service in Hong Kong., Design: Randomized controlled trial., Participants: All those with type 1 or 2 diabetes from 2 clinics were recruited., Intervention: Diabetic retinopathy screening with a small copayment versus free access in a publicly funded family medicine service., Main Outcome Measures: Uptake of screening and severity of DR detected. Association between these outcome variables and independent variables were determined using multivariate logistic regression models and reported as odds ratios (ORs)., Results: After randomization, 1387 subjects in the free group and 1379 subjects in the pay group were eligible for screening, and 94.9% (1316/1387) and 92.6% (1277/1379), respectively, agreed to participate in the study. The offer of screening was accepted by 94.8% (1247/1316) in the free group and 91.2% (1164/1277) in the pay group, and the final uptake ratios were 88.5% (1165/1316) and 82.4% (1052/1277), respectively (Pearson chi = 19.74, P<0.001). Being in the pay group was associated with a lower uptake of screening than being in the free group (OR, 0.59; confidence interval [CI], 0.47-0.74) and a lower detection rate of DR (OR, 0.73; CI, 0.60-0.90) after adjustment for potential confounding factors. Subjects with higher socioeconomic status were more likely to attend screening and had a lower prevalence of DR detected., Conclusions: The inverse care law seems to operate in a preventive intervention when a relatively small copayment is applied. There is a case for making effective preventive services free of charge., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To present Hong Kong'Äìspecific data from a large Asian population (also involving Thailand, Singapore, and Taiwan) on safety and manufacturing consistency across four AS03(A)-adjuvanted H5N1 vaccine formulations in terms of immune response against the A/Vietnam/1194/2004 strain. Immunogenicity against the heterologous A/Indonesia/05/2005 strain was also assessed. NCT Number: 00449670., Design: Prospective, observer-blind study., Setting: Out-patient clinic of a tertiary hospital in Hong Kong., Participants: A total of 360 subjects aged 18 to 60 years were randomised into six groups to receive two doses (21 days apart) of the study vaccine., Interventions: One of the four adjuvanted formulations (3.75 microgram H5N1 haemagglutinin [HA]+AS03(A)) of the vaccine (H5N1-AS03(A)) or one of the two non-adjuvanted (3.75 microgram H5N1 [HA]) formulations of the vaccine (H5N1-DIL)., Main Outcome Measures: Blood samples collected before vaccination and 21 days after each vaccine dose were analysed using haemagglutination-inhibition and neutralisation assays. Solicited, unsolicited, and serious adverse events were recorded., Results: Manufacturing consistency across all four vaccine formulations was demonstrated. After two doses, the AS03(A)-adjuvanted prepandemic influenza vaccine demonstrated high seroprotection rates against the A/Vietnam/1194/2004 strain (95.8%) and good immunogenicity against the heterologous A/Indonesia/05/2005 strain (45.7%), as compared to the non-adjuvanted vaccine (4.6% and 1.5%, respectively). The seroconversion rates induced by the adjuvanted formulations in terms of viral neutralising antibodies against the two strains were much higher than those induced by the non-adjuvanted formulations. There were no safety concerns for any of the adjuvanted vaccine formulations., Conclusions: The AS03(A)-adjuvanted H5N1 prepandemic influenza vaccine demonstrated good immunogenicity and an acceptable safety profile in Hong Kong.

Background: A single-nucleotide polymorphism (SNP), rs2268388, in the acetyl-coenzyme A carboxylase beta (ACACB) gene is associated with susceptibility to type 2 diabetic nephropathy (T2DN) in Japanese and European-American populations. Whether this association also exists in Chinese patients is unclear. Attempts at replication in small Singaporean and Korean samples were not significant., Methods: Eight ACACB SNPs were genotyped in 595 subjects with type 2 diabetes mellitus born in Hong Kong or southern China, 295 with advanced T2DN and 300 with long-standing diabetes lacking nephropathy. Association analyses were focused primarily on SNP rs2268388 and secondarily on flanking SNPs and haplotypes., Results: Adjusting for age, gender and diabetes duration, ACACB SNP rs2268388 was significantly associated with advanced T2DN (odds ratio = 2.39; recessive model; P = 0.0129)., Conclusion: These results in the Chinese replicate the association between T2DN and rs2268388, as seen in Japanese and European Americans. The ACACB gene and attendant alterations in fatty acid oxidation may play important roles in susceptibility to T2DN. Targeting this pathway may provide novel treatment options for the prevention of diabetic nephropathy.

Background: A single administration of laninamivir octanoate, a long-acting neuraminidase inhibitor, against influenza infection has been proven effective in nonclinical studies. This study evaluated the clinical efficacy of laninamivir octanoate for the treatment of adult influenza patients., Methods: A double-blind, randomized controlled trial examined whether laninamivir octanoate was noninferior to oseltamivir. A total of 1003 patients aged ≥ 20 years with febrile influenza symptoms for no more than 36 h were randomized to receive either 40 mg of laninamivir octanoate, 20 mg of laninamivir octanoate, or oseltamivir. Laninamivir octanoate was inhaled once on day 1, and oseltamivir (75 mg) was administered orally twice daily for 5 days. The primary end point was the time to illness alleviation., Results: A total of 996 patients were included in the primary analysis (40-mg laninamivir octanoate, n = 334; 20-mg laninamivir octanoate, n = 326; and oseltamivir, n = 336). The median time to illness alleviation in the 40-mg laninamivir octanoate, 20-mg laninamivir octanoate, and oseltamivir groups was 73.0, 85.8, and 73.6 h, respectively. The difference between laninamivir octanoate and oseltamivir was -0.6 h (95% confidence interval, -9.9 to 6.9 h) for the 40-mg group and 12.2 h (95% confidence interval, -1.5 to 17.2 h) for the 20-mg group. The upper limits of the 95% confidence intervals were less than the prespecified noninferiority margin (18 h). The proportion of patients shedding virus at day 3 was significantly lower in the 40-mg laninamivir octanoate group than in the oseltamivir group (P = .006)., Conclusions: A single inhalation of laninamivir octanoate is effective for the treatment of seasonal influenza, including that caused by oseltamivir-resistant virus, in adults., Clinical Trials Registration: NCT00803595.

Background: Despite World Health Organization recommendations, the rate of 23-valent pneumococcal (PPV) and influenza (TIV) vaccination among elderly persons in Hong Kong, China, is exceptionally low because of doubts about effectiveness of vaccination. The efficacy of dual vaccination remains unknown., Methods: From 3 December 2007 to 30 June 2008, we conducted a prospective cohort study by recruiting outpatients aged ≥65 years with chronic illness to participate in a PPV and TIV vaccination program. All were observed until 31 March 2009. The outcome of subjects, including the rates of death, hospitalization, pneumonia, ischemic stroke, acute myocardial infarction, and coronary and intensive care admissions, were determined., Results: Of the 36,636 subjects recruited, 7292 received both PPV and TIV, 2076 received TIV vaccine alone, 1875 received PPV alone, and 25,393 were unvaccinated, with a duration of follow-up of 45,834 person-years. Baseline characteristics were well matched between the groups, except that there were fewer male patients in the PPV and TIV group and fewer cases of comorbid chronic obstructive pulmonary disease among unvaccinated persons. At week 64 from commencement of the study, dual-vaccinees experienced fewer deaths (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.55-0.77]; P<.001) and fewer cases of pneumonia (HR, 0.57; 95% CI, 0.51-0.64; P<.001), ischemic stroke (HR, 0.67; 95% CI, 0.54-0.83; P<.001), and acute myocardial infarction (HR, 0.52; 95% CI, 0.38-0.71; P<.001), compared with unvaccinated subjects. Dual vaccination resulted in fewer coronary (HR, 0.59; 95% CI, 0.44-0.79; P<.001) and intensive care admissions (HR, 0.45; 95% CI, 0.22-0.94; P=.03), compared with among unvaccinated subjects., Conclusions: Dual vaccination with PPV and TIV is effective in protecting elderly persons with chronic illness from developing complications from respiratory, cardiovascular, and cerebrovascular diseases, thereby reducing hospitalization, coronary or intensive care admissions, and death.

The immunogenicity and lot-to-lot consistency of an AS03-adjuvanted H5N1 vaccine were evaluated in 1206 Asian adults, randomised to receive two doses of adjuvanted (3.75 microg haemagglutinin) or diluent-mixed vaccines, 21 days apart. Post-Dose 2, 96.0% of vaccinees in the H5N1-AS03 group demonstrated a four-fold increase in neutralising antibody titres against the vaccine strain A/Vietnam/1194/2004 and 91.4% against strain A/Indonesia/05/2005. Haemagglutination-inhibiting antibodies (titre > or = 1:40) against A/Vietnam/1194/2004 and A/Indonesia/05/2005 strains were observed in 94.3% and 50.2% of subjects, respectively. Lot-to-lot consistency of the AS03-adjuvanted vaccine combinations was demonstrated. The AS03-adjuvanted vaccine was well tolerated, induced a high frequency of immune responses to the vaccine strain, allowed antigen sparing and promoted cross-clade immunity. These characteristics make it suitable for presumptive use if an H5N1 pandemic were considered to be imminent.

Objectives: Aberrant activation of the Wnt/beta-catenin signaling pathway is common in human cancers, including cervical cancer. The secreted frizzled-related proteins (SFRPs) function as Wnt antagonists and play important implications in carcinogenesis. Recently, we have shown that SFRP1 and SFRP2 are frequently downregulated through promoter hypermethylation. However, the function of SFRP1 and SFRP2 in cervical cancer remains unclear., Methods: To improve our understanding of the role of SFRP1 and SFRP2 in cervical cancer cells, we use overexpression or shRNA approach in cervical cancer cell lines., Results: Restoration of the expression of SFRP1 and SFRP2 attenuated Wnt signaling in CaSki cells, decreased abnormal accumulation of free beta-catenin in the nucleus, and suppressed cancer cell growth. In addition, different statuses of beta-catenin accumulation in the cytoplasm of CaSki or HeLa3rd cells were observed, suggesting that different Wnt pathways are executed. Furthermore, we demonstrated that SFRP1 and SFRP2 enhance the expression of the epithelial marker E-cadherin, through inhibition of the expression of SLUG, TWIST and SNAIL, three transcription factors involved in the epithelial mesenchymal transition (EMT) program. Finally, in a xenograft animal model, we showed that SFRP1 suppresses tumorigenicity of cancer cells in vivo., Conclusions: Taken together, these data strongly suggest that epigenetic silencing of SFRP genes leads to oncogenic activation of the Wnt pathway and contributes to cervical cancer progression through the EMT program.

Objectives: To examine the presentation, workup, and surgical complications of substernal goitre., Design: Retrospective study., Setting: Regional hospital, Hong Kong., Patients: Twenty-four mostly elderly patients (mean age, 60.1 years) who underwent thyroidectomy for substernal goitres between 2000 and 2003 (substernal goitres were defined as those having either a caudal mass transgressing the fourth thoracic vertebra or having more than 50% of their overall mass residing within the thorax)., Main Outcome Measures: Symptoms, histopathological diagnoses, morbidities, and complications., Results: Dyspnoea was the most common symptom (n=8, 33%). Three (12.5%) patients presented with acute airway obstruction; however, 13 (54.2%) were asymptomatic apart from the presence of cervical masses. Computed tomographic scans were performed on all but two patients. Malignancy was present in 12.6% of patients, or 16.8% if occult papillary carcinoma is included. Partial or full sternotomies were performed in two (8.3%) patients. Complications included recurrent laryngeal nerve injury (n=1, 2.7% of nerves at risk), transient hypoparathyroidism (n=2, 13.3% of patients at risk), haematoma (n=1, 2.7%), pneumonia (n=1, 2.7%), and wound infection (n=1, 2.7%). There was no operative mortality or permanent hypoparathyroidism. The complication rate was significantly lower in the asymptomatic patients (P=0.033 by Fisher's exact test); clinicopathological parameters were otherwise statistically comparable between the two groups., Conclusions: There is rarely any mortality in thyroidectomy for substernal goitre, and the morbidity is also very low, especially in asymptomatic patients. In the absence of contra-indications, substernal goitre should be treated with early surgery rather than having it run the risk of acute airway distress or cancer.

We report a rare case of transomental small-bowel herniation in a 91-year-old lady who presented with central abdominal pain and mild distension. Urgent abdominal computed tomography (CT) showed a segment of dilated ileum with features suggestive of strangulation. Emergency exploration revealed a segment of congested small-bowel loop herniated through a defect over the greater omentum. Reduction of the bowel loops and division of the omental defect was performed without the need for bowel resection. The patient made an uneventful recovery. We discuss the value of CT scan and highlight the importance of recognizing this rare cause of small-bowel obstruction.

Objective: To evaluate the clinical efficacy and outcomes of percutaneous cholecystostomy as an alternative treatment option for elderly and critically ill patients who have acute cholecystitis., Patients and Methods: The medical records of patients who underwent emergency percutaneous cholecystostomy at the North District Hospital, Hong Kong from September 1999 to July 2002 were reviewed. Indications for the procedure, patient demographics, and other clinical details were recorded., Results: A total of 25 patients (10 male, 15 female) with a median age of 81 years (range, 39-97 years) presented with acute cholecystitis and underwent percutaneous cholecystostomy with ultrasound guidance. Two patients required emergency cholecystectomy on day 1 after the procedures because of deteriorating conditions. The rest of the patients clinically improved after drainage. There was no major periprocedural complication, and four patients had their catheter accidentally dislodged but did not require re-insertion. There were five in-patient mortalities, although the majority of these deaths were from unrelated illness. Subsequently, only six patients underwent elective cholecystectomy, one open and five laparoscopic. Two patients were offered percutaneous endoscopic cholecystolithotripsy, one defaulted and the other could not tolerate the procedure. Eleven patients declined further intervention due to the high surgical risks, three of these patients developed biliary symptoms, one had acute cholecystitis, and the other two had cholangitis. The rest of patients had no symptoms related to the gallstones. The median follow-up period was 81 weeks (range, 27-162 weeks)., Conclusion: Percutaneous cholecystostomy is a viable treatment option for elderly and critically ill patients presenting with acute cholecystitis. It has a high success rate with minimal procedure-related complications. Elective cholecystostomy is the treatment of choice for low-risk patients after the initial acute cholecystitis.

Background: Transoral removal and sialoadenectomy are the two main modalities of treatment for submandibular stones. However, missed ductal stones are not uncommon, and there is a risk of lingual or hypoglossal nerve injury. We attempted to avoid these complications by using an endoscopic technique., Methods: The case notes of the patients who had undergone endoscopic removal of submandibular stones were studied retrospectively. The procedure was performed under general anesthesia. The submandibular orifice was incised by carbon dioxide laser, and a 3.1-mm rigid scope was inserted under direct vision with normal saline irrigation after dilatation. The stones were either broken down by laser or removed with a Dormia basket or forceps., Results: A total of 13 patients underwent the procedure. The duration of median follow-up was 15 months. In 11 patients, the stones were identified and removed. No stone was found in two patients (15.4%). There were no false negatives, since no stones were discovered subsequently in these two patients. One, two, three, and four stones were present inside the ducts in seven patients (54.6%), one patient (7.7%), two patients (15.4%), and one patient (7.7%), respectively. The symptoms subsided completely in 11 patients within 4 weeks after the procedure. Persistent swelling occurred in two patients. In one of them, no residual stone was revealed by CT scan. The other patient had a large calculus that was only partially fragmented by laser lithotripsy at the initial operation. No lingual nerve or hypoglossal nerve injury was detected in any patient., Conclusion: Sialoendoscopy is a safe and efficacious treatment for submandibular ductal stones. It reduces the incidence of missed stones, and nerve injury, as well as the need for sialoadenectomy.

Background: The present study was undertaken to evaluate the efficacy of acupuncture anaesthesia in inguinal hernia repair., Methods: Twelve patients with non-recurrent inguinal hernia had Lichtenstein mesh repair under acupuncture anaesthesia. Selected acupuncture loci were stimulated with fine needles connected to low frequency current. Supplementary local anaesthetic was given when required., Results: Four (33%) patients reported satisfactory analgesic effect throughout the operation without need for additional medication, eight (67%) patients experienced mild discomfort during the operation requiring 1-4 mL of 1% lignocaine injection. Blood pressure and heart rate were stable during the procedure. All patients were able to sit up and resume their diet immediately post-operatively. All but one patient were discharged on day one after the procedure, with no early or late complications reported. Most patients were satisfied with the analgesic effect of acupuncture anaesthesia., Conclusions: Acupuncture anaesthesia is a feasible anaesthetic option. It reduces the amount of local anaesthetic required, and thus the associated potential complications. It is effective in pain relief and inhibiting gastrointestinal upset. Postoperative recovery was rapid and complication free.

The responses to oxidative stress induced by chronic exercise (8-wk treadmill running) or acute exercise (treadmill running to exhaustion) were investigated in the brain, liver, heart, kidney, and muscles of rats. Various biomarkers of oxidative stress were measured, namely, lipid peroxidation [malondialdehyde (MDA)], protein oxidation (protein carbonyl levels and glutamine synthetase activity), oxidative DNA damage (8-hydroxy-2'-deoxyguanosine), and endogenous antioxidants (ascorbic acid, alpha-tocopherol, glutathione, ubiquinone, ubiquinol, and cysteine). The predominant changes are in MDA, ascorbic acid, glutathione, cysteine, and cystine. The mitochondrial fraction of brain and liver showed oxidative changes as assayed by MDA similar to those of the tissue homogenate. Our results show that the responses of the brain to oxidative stress by acute or chronic exercise are quite different from those in the liver, heart, fast muscle, and slow muscle; oxidative stress by acute or chronic exercise elicits different responses depending on the organ tissue type and its endogenous antioxidant levels.

We have proposed a cooperative quinolone-DNA binding model for the inhibition of DNA gyrase. The essential feature of the model is that bound gyrase induces a specific quinolone binding site in the relaxed DNA substrate in the presence of ATP. The binding affinity and specificity are derived from two unique and equally important functional features: the specific conformation of the proposed single-stranded DNA pocket induced by the enzyme and the unique self-association phenomenon (from which the cooperativity is derived) of the drug molecules to fit the binding pocket with a high degree of flexibility. Supporting evidence for and implications of this model are provided.