Malignancies after kidney transplantation: Hong Kong renal registry

Manystudies have shown that kidney transplant recipients have a higher incidence of cancers when compared with general population. However, most data on the posttransplant malignancies (PTM) are derived from Western literature and large population-based studies are rare. There is also lack of information about the posttransplant cancer-specific mortality rate. We conducted a population-based study of 4895 kidney transplants between 1972 and 2011, with data from the Hong Kong Renal Registry. Patterns of cancer incidence and mortality in our kidney transplant recipients were compared with those of the general population using standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) respectively. With 40 246 person-years of follow-up, 299 PTM was diagnosed. The SIR of all cancers was 2.94 (female 3.58 and male 2.58). Non-Hodgkin lymphoma (NHL), kidney, and bladder cancers had the highest SIRs. The overall SMR was 2.3 (female 3.4 and male 1.7) and the highest SMR was NHL. The patterns of PTM differ among countries. Increases in cancer incidence can now translate into similar increases in cancer mortality. NHL is important in our kidney transplant recipients. Strategies in cancer screening in selected patient groups are needed to improve transplant outcomes.

Dettol poisoning and the need for airway intervention

OBJECTIVES. To (1) characterise the clinical features of Dettol poisoning on a territory-wide basis, (2) assess the need for airway intervention after such poisoning and its time frame after ingestion, and (3) identify predictors for such an intervention. DESIGN. Case series. SETTING. Sixteen accident and emergency departments in Hong Kong. PATIENTS. Patients with Dettol ingestion who presented within 48 hours of ingestion from July 2005 to June 2009, derived from the database of the Hong Kong Poison Information Centre. RESULTS. In all, 213 patient records were identified, of which 36 were excluded based on pre-defined criteria and 177 were analysed. Among the latter, the median age was 32 (range, 2-95) years and the male-to-female ratio was 1:2.7 (48:129). Intentional ingestion constituted the majority (95%) of cases. The most common symptoms were related to the local irritative/corrosive effects on the aero-digestive tract, such as gastro-intestinal upset and localised throat pain. Airway intervention was required in 14 (8%) patients. All interventions were performed within 12 hours of Dettol ingestion and three cases involved re-intubation after extubation. Univariate analysis showed that a Glasgow Coma Scale score of <8, older age, a larger amount ingested, lip swelling, lung crackles, and wheezing were all associated with airway intervention. In the multivariate analysis using forward stepwise logistic regression, only coma (Glasgow Coma Scale score of <8) remained statistically significant. CONCLUSIONS. Delayed airway obstruction (>12 hours after Dettol ingestion) is unlikely. For those who are intubated, careful assessment of airway adequacy before extubation is strongly recommended to avoid extubation failure and subsequent re-intubation. Patients in coma (Glasgow Coma Scale score of <8) should prompt airway intervention.

Chronic total occlusion intervention: a novel antegrade guidewire probing technique

We reported a case of successful recanalization of a left anterior descending (LAD) artery chronic total occlusion (CTO) with 'integrate guidewire probing technique.' After we mistakenly deployed a stent at the proximal LAD from left main (LM) into a diagonal branch across the mid LAD, this mid LAD CTO became further jailed under the stent. Antegrade wiring of this CTO lesion became exceptionally difficult. After several unsuccessful attempts with different guidewires and interventional techniques, we placed a retrograde microcatheter into the CTO lesion with its tip just situated at the stent strut. An antegrade guidewire supported by another microcatheter was targeted at the tip of the retrograde microcatheter and successfully crossed the CTO lesion. The LAD was successfully recanalized. This technique appeared to be feasible and safe to facilitate antegrade wire crossing of the CTO lesion.

Stretching and migration of DNA by solvent elasticity in an oscillatory flow

A model with solution viscoelasticity is proposed to explain the ratchetlike stretching of DNA by a symmetric ac electric field in polymer solutions. In this model, DNA is stretched by the interaction between the fluid elasticity and the oscillatory flow induced by DNA. Predictions of the model are confirmed by DNA stretching experiments performed in various polymer solutions and the corresponding rheological measurements of the solutions. In particular, experiments have verified that a net migration of stretched DNA in polymer solutions can be induced by a zero-mean asymmetric ac electric field. This last finding cannot be explained by other existing models.

Mercury exposure: the experience of the Hong Kong Poison Information Centre

OBJECTIVES

To review the characteristics of the consultation about the management of mercury exposure and identify the controversial issues on the clinical management of individuals with a history of mercury exposure.

DESIGN

Descriptive case series.

SETTING

Hong Kong Poison Information Centre, Hong Kong.

PARTICIPANTS

Persons consulting the Hong Kong Poison Information Centre about individuals with possible or definitive mercury exposure.

MAIN OUTCOME MEASURES

Characteristics of the consultations, including: the demographics of affected individuals, source and reason for the consultation, tissue mercury levels, the source of mercury exposure, specific intervention if any, and clinical outcomes.

RESULTS

Forty-one consultations were analysed. Most consultations were from the public sector. Reasons of the consultation were very variable. Individuals with abnormal tissue mercury levels were uncommon. There was only one case of acute mercury poisoning. The majority of identified individuals were not subjected to specific interventions. Chelation therapy was given to three patients, but in one of them it was considered to be contra-indicated.

CONCLUSION

The management of mercury exposure is highly variable. Recommendations were made on the approach to an individual with potential mercury exposure or poisoning.

Effects of glial release and somatic receptors on bursting in synchronized neuronal networks

A model is constructed to study the phenomenon of bursting in cultured neuronal networks by considering the effects of glial release and the extrasynaptic receptors on neurons. In the frequently observed situations of synchronized bursting, the whole neuronal network can be described by a mean-field model. In this model, the dynamics of the synchronized network in the presence of glia is represented by an effective two-compartment neuron with stimulations on both the dendrite and soma. Numerical simulations of this model show that most of the experimental observations in bursting, in particular the high plateau and the slow repolarization, can be reproduced. Our findings suggest that the effects of glia release and extrasynaptic receptors, which are usually neglected in neuronal models, can become important in intense network activities. Furthermore, simulations of the model are also performed for the case of glia-suppressed cultures to compare with recent experimental results.

Frequency enhancement in coupled noisy excitable elements

Oscillatory dynamics of coupled excitable FitzHugh-Nagumo elements in the presence of noise is investigated as a function of the coupling strength g. For two such coupled elements, their frequencies are enhanced and will synchronize at a frequency higher than the uncoupled frequencies of each element. As g increases, there is an unexpected peak in the frequency enhancement before reaching synchronization. The results can be understood with an analytic model based on the excitation across a potential barrier whose height is controlled by g. Simulation results of a coupled square lattice can quantitatively reproduce the unexpected peak in the variation of the beating rates observed in cultured cardiac cells experiments.

Prognostic value of adenosine stress myocardial perfusion by cardiac magnetic resonance imaging in patients with known or suspected coronary artery disease

BACKGROUND

Cardiac magnetic resonance imaging (CMR) has been intensely researched in recent years, and its high diagnostic accuracy for myocardial ischemia has been demonstrated. However, its prognostic information is very limited.

AIM

We sought to assess the value of adenosine stress myocardial perfusion by CMR in predicting cardiac events in patients with known or suspected coronary artery disease (CAD).

DESIGN

Retrospective study.

METHODS

From January 2003 to December 2008, we retrospectively reviewed consecutive patients with or without history of CAD referred for evaluation of suspected myocardial ischemia who had undergone adenosine stress CMR in our hospital. End points were cardiac death or non-fatal myocardial infarction (MI).

RESULTS

After a mean follow-up of 3.2 ± 1.6 years in 203 patients, 15 (7.4%) cardiac events occurred. The 4-year event-free survival was 96.2% for patients with normal stress CMR perfusion and 71.5% for those with abnormal stress CMR perfusion. Univariate analysis showed that both adenosine-induced reversible perfusion defect and delayed gadolinium enhancement by CMR were significant predictors of cardiac events [Hazard ratio (HR) 9.31; 95% Confidence Interval (95% CI) 3.18-27.3; and HR 9.24; 95% CI 3.27-26.08; P < 0.001, respectively). By multivariate analysis, adenosine-induced reversible perfusion defect remained an independent predictor of cardiac events (HR 7.77; 95% CI 2.50-24.18; P < 0.001). In a stepwise multivariate model (Cox regression), an abnormal stress CMR perfusion result had significant incremental predictive value over clinical risk factors and resting regional wall motion abnormality (RWMA) (P < 0.001).

CONCLUSION

In patients with known or suspected CAD, adenosine stress CMR could be used to identify patients at high risk for subsequent cardiac death or nonfatal MI. A normal CMR perfusion was associated with a very low long-term event rate and excellent long-term prognosis. In addition, stress CMR perfusion provided important incremental prognostic information over clinical risk factors and RWMA.

Granular jet impingement on a fixed target

In this work discrete element modeling (DEM) was applied to the flow of granular jets against a target. The resulting sheetlike or conelike formations under different conditions are described and explained by means of kinetic analysis. A qualitative and quantitative comparison with experimental results [Cheng, Phys. Rev. Lett. 93, 188001 (2007)] provides interesting insights in the theoretical treatment of the head-on collision of granular jets. Results presented in this paper provide a theoretical description of this type of physical system. However, there still exist obstacles in obtaining quantitative results.

Excitation transport and trapping on spectrally disordered lattices

It is widely assumed that the decay of fluorescence in photosynthetic systems can be described as a sum of exponential components and that the amplitude of each component is directly related to the absorption cross-section of the antenna pigments coupled to the fluorescing species. We present exact calculations of excited state decay in two-dimensional regular lattices of different geometries containing multiple spectral forms of antenna pigments. We illustrate by these calculations that there is no simple relation between the decay amplitudes (and resulting time-resolved excitation spectra) and the steady-state absorption spectra. Only in the limit that the electronic excitations reach a rapid equilibrium among all antenna spectral forms does the excitation spectrum depend uniquely on the spectral features of the array. Using the simulations in conjunction with our recent fluorescence studies, we examine excitation transport and trapping dynamics in photosystem I and the limitations imposed by the finite time resolution in single photon counting experiments. In particular, we show that rising components, associated with excitation transfer among different spectral forms, with lifetimes <20 ps would be undetected in a typical photon counting experiment.

In vivo study of novel nanofibrous intra-luminal guidance channels to promote nerve regeneration

A novel nanofibrous construct for promoting peripheral nerve repair was fabricated and tested in a rat sciatic nerve defect model. The conduit is made out of bilayered nanofibrous membranes with the nanofibers longitudinally aligned in the lumen and randomly oriented on the outer surface. The intra-luminal guidance channel is made out of aligned nanofibrous yarns. In addition, biomolecules such as laminin and nerve growth factor were incorporated in the nanofibrous nerve construct to determine their efficacy in in vivo nerve regeneration. Muscle reinnervation, withdrawal reflex latency, histological, axon density and electrophysiology tests were carried out to compare the efficacy of nanofibrous constructs with an autograft. Our study showed mixed results when comparing the artificial constructs with an autograft. In some cases, the nanofibrous conduit with aligned nanofibrous yarn as an intra-luminal guidance channel performs better than the autograft in muscle reinnervation and withdrawal reflex latency tests. However, the axon density count is highest in the autograft at mid-graft. Functional recovery was improved with the use of the nerve construct which suggested that this nerve implant has the potential for clinical usage in reconstructing peripheral nerve defects.

The epidemiology and clinical manifestations of human immunodeficiency virus-associated tuberculosis in Hong Kong

OBJECTIVE

To evaluate the epidemiology and clinical manifestations of human immunodeficiency virus-associated tuberculosis in Hong Kong.

DESIGN

Retrospective study.

SETTING

Tuberculosis and Chest Service and Special Preventive Programme, Public Health Services Branch, Centre for Health Protection, Department of Health, Hong Kong Special Administrative Region.

PATIENTS

Cases reported to the TB/HIV Registry jointly kept by the Tuberculosis and Chest Service and Special Preventive Programme from 1996 to 2006 were reviewed. The Registry includes cases of human immunodeficiency virus-associated tuberculosis diagnosed in the two services, and cases referred from regional hospitals under the Hong Kong Hospital Authority and the private sector.

RESULTS

Tuberculosis has become an increasingly important acquired immunodeficiency syndrome-defining illness in Hong Kong, and overtook Pneumocystis jiroveci pneumonia for the first time as the most common primary acquired immunodeficiency syndrome-defining illness in 2005 (accounting for 39% and 31% of all such illnesses, respectively in that year). The presentation of human immunodeficiency virus-associated tuberculosis is often atypical. In these patients moreover, there was a slightly higher rate of multidrug-resistant tuberculosis (2%) than in the general population (range, 0.7-1.5%).

CONCLUSIONS

Programmes for the provider-initiated human immunodeficiency virus testing policy to reduce diagnostic delays should continue and be enhanced. Continual surveillance of both conditions is imperative, especially in view of a possible link between human immunodeficiency virus and multidrug-resistant tuberculosis.

Zero-refractoriness spirals in phase-coupled excitable media

Effects of excitability and coupling strength on plane and spiral waves in two-dimensional excitable lattices modeled by phase-coupled elements are investigated. The corresponding phase diagrams for stable plane waves and spiral waves are obtained by simulations. The parameters capable of supporting stable spiral waves are sorted out together with the spiral rotation frequencies. This discrete model corresponds to an excitable medium with zero refractoriness and in the continuum limit supports zero-core spiral waves. The associated wave propagating behaviors are also discussed analytically and verified.

Laboratory bioefficacy of nine commercial formulations of temephos against larvae of Aedes aegypti (L.), Aedes albopictus Skuse and Culex quinquefasciatus Say

The bioefficacy of nine commercial formulations of temephos against Aedes aegypti, Aedes albopictus and Culex quinquefasciatus larvae were evaluated in the laboratory. WHO larval bioassay with operational dosage of temephos at 1 mg/L was performed. The larval mortality was recorded every 5 minutes until complete mortality was achieved. All formulations of temephos exhibited various toxicity level against Ae. aegypti, Ae. albopictus and Cx. quinquefasciatus. Generally, larvae of Cx. quinquefasciatus was susceptible to all formulations of temephos, followed by Ae. aegypti and Ae. albopictus.

Star fruit intoxication successfully treated by charcoal haemoperfusion and intensive haemofiltration

We report on a case of an elderly woman with chronic renal impairment, secondary to diabetic nephropathy, who developed a deep coma and seizure shortly after consumption of star fruit. She was managed in the intensive care unit, and her consciousness level improved dramatically after an 8-hour charcoal haemoperfusion and 30 hours of continuous haemofiltration. There were no long-term neurological or renal sequelae 9 months later. Early recognition of this condition, intensive dialytic therapy and supportive measures, as well as early initiation of charcoal haemoperfusion may improve the management of this potentially treatable condition.

Diluted povidone-iodine versus saline for dressing metal-skin interfaces in external fixation

PURPOSE

To compare infection rates associated with 2 dressing solutions for metal-skin interfaces.

METHODS

60 patients who underwent distraction osteogenesis with external fixators were equally randomised into 2 dressing solution groups (diluted povidone-iodine vs. saline). Fixations were attained using either rigid stainless steel 5-mm diameter half pins or smooth stainless steel 1.8-mm diameter wires. Half-pin fixation had one metal-skin interface, whereas wire fixation had 2 interfaces. Patients were followed up every 2 weeks for 6 months.

RESULTS

Of all 788 metal-skin interfaces, 143 (18%) were infected: 72 (19%) of 371 in the diluted povidone-iodine group and 71 (17%) of 417 in the saline group. Dressing solution and patient age did not significantly affect infection rates. Half-pin fixation was more likely to become infected than wire fixation (25% vs 15%).

CONCLUSION

Saline is as effective as diluted povidone-iodine as a dressing solution for metal-skin interfaces of external fixators. Saline is recommended in view of its easy availability and lower costs.

Sibutramine-induced acute myocardial infarction in a young lady

INTRODUCTION

Sibutramine is an amphetamine-like drug used for its weight reducing effect. Sibutramine-induced acute coronary syndrome has rarely been reported. We report a case of myocardial infarction associated with the use of sibutramine.

CASE REPORT

A 37-year-old woman presented to an Emergency Department (ED) with intermittent retrosternal chest pain, nausea, and sweating for 3 days. She reported taking one sibutramine tablet each day for 3 days. Blood pressure was 128/89 mm Hg and pulse 66 beats/min. An electrocardiogram revealed ST elevation over the inferior leads and ST depression over leads AVR and V1, the other leads were normal. Serum troponin T was 0.65 microg/L, and sibutramine was identified in her urine. Echocardiography revealed mild hypokinesia over the inferior wall without evidence of acute aortic dissection. The ST segment changes resolved spontaneously within 24 h of cardiac care unit (CCU) admission, a coronary angiogram performed 1 week later was unremarkable, and echocardiography performed 4 weeks after the event showed normal resting regional wall motion.

DISCUSSION

Seventeen medications containing sibutramine as an active ingredient were registered in Hong Kong in 2007. Sibutramine was introduced in the United States in 1997 and in Australia, United Kingdom, and Italy in 2001. Hypertension, tachycardia, dry mouth, and headache are the most commonly reported adverse reactions. Cardiovascular toxicities include tachycardia, palpitation, hypertension, and tachyarrhythmia.

CONCLUSIONS

We postulate that the myocardial infarction was the result of coronary vasospasm associated with the therapeutic use of sibutramine-containing slimming pills.

Synchronization phenomena in mixed media of passive, excitable, and oscillatory cells

We study collective phenomena in highly heterogeneous cardiac cell culture and its models. A cardiac culture is a mixture of passive (fibroblasts), oscillatory (pacemakers), and excitable (myocytes) cells. There is also heterogeneity within each type of cell as well. Results of in vitro experiments are modelled by Luo-Rudy and FitzHugh-Nagumo systems. For oscillatory and excitable media, we focus on the transitions from fully incoherent behavior to partially coherent behavior and then to global synchronization as the coupling strength is increased. These regimes are characterized qualitatively by spatiotemporal diagrams and quantitatively by profiles of dependence of individual frequencies on coupling. We find that synchronization clusters are determined by concentric and spiral waves. These waves arising due to the heterogeneity of medium push covered cells to oscillate in synchrony. We are also interested in the influence of passive and excitable elements on the oscillatory characteristics of low- and high-dimensional ensembles of cardiac cells. The mixture of initially silent excitable and passive cells shows the transitions to oscillatory behavior. In the media of oscillatory and passive or excitable cells, the effect of oscillation death is observed.

Risk factors for multidrug-resistant tuberculosis in Hong Kong

SETTING

Previous anti-tuberculosis treatment is a widely reported risk factor for multidrug-resistant tuberculosis (MDR-TB), whereas other risk factors are less well described. In Hong Kong, the clinical characteristics of MDR-TB have not been systematically evaluated.

OBJECTIVE

To explore the risk factors for MDR-TB in Hong Kong.

DESIGN

MDR-TB patients treated between 1999 and 2003 were compared with non-MDR-TB patients by stratification of previous anti-tuberculosis treatment.

RESULTS

One hundred and fifty-six MDR-TB patients, including 93 with and 63 without a previous history of anti-tuberculosis treatment, were identified. Among the 322 non-MDR-TB controls, respectively 192 and 130 patients did and did not have a previous history of anti-tuberculosis treatment. Using logistic regression analysis, non-permanent residents (OR 6.85, 95%CI 1.38-34.09), frequent travel (OR 2.48, 95%CI 1.07-5.74) and younger age were found to be independent predictors of MDR-TB in previously treated patients, whereas living on financial assistance just failed to reach statistical significance (OR 2.75, 95%CI 0.98-7.68, P=0.05). In the treatment-naïve group, despite significant differences in baseline characteristics among MDR-TB and non-MDR-TB patients, no independent predictor variables could be identified.

CONCLUSION

In Hong Kong, non-permanent residents, frequent travel and young age were independent predictors of MDR-TB among previously treated patients.

Isolated tumor cells and circulating CK20 mRNA in pN0 colorectal cancer patients

Micrometastases in lymph nodes and blood may provide important prognostic information. In this study, cytokeratin 20 (CK20) positive cells in lymph nodes and circulating CK20 mRNA were studied using 57 paraffin-embedded lymph node specimens and blood from 24 patients with pN0 colorectal cancer (CRC), respectively. Results showed that 29 out of 56 (52%) lymph node specimens had CK20-positive cells (range: 1-35). Follow-up of the patients for 12 months indicated that 4 patients (7%) had CRC metastases to liver, lung, and bone. In addition, 8 out of 24 (33%) samples had at least 2-fold circulating CK20 mRNA expression higher than the pooled normal sample. This study provides evidence that CK20-positive cells were found in the lymph nodes and differentially expressed circulating CK20 mRNA was also detected in the blood from patients with pN0 CRC. Long-term follow-up is necessary to study their prognostic use in patients with non-metastatic CRC.