Illness Management in Older Lesbian, Gay, Bisexual, and Transgender Couples: A Review

More openly sexually and gender diverse people are aging into later life across the world as generational transitions occur. People identifying many different ways beyond cisgender and heterosexual are diverse with respect to many other characteristics and sociopolitical locations across the globe and may thus experience a wide array of health journeys both individually and as partners in intimate relationships. In this review article, we summarize the major contributions of and ongoing gaps in existing studies about such couples’ experiences of chronic disease management in later life. We focus on three key groups of findings from prior research about the health of older sexually and/or gender diverse couples: care practices, unmet needs, and diverse resources. We outline priorities for future research within and across these topic areas and in varied locations, with unique recommendations for scholars in both academic and clinical settings. These recommendations support greater integration of such populations, topics, and needs in existing discourse on aging and late life. Likewise, recommendations from this review illuminate potential best practices for engaging and serving these elders in both academic and applied settings.

Attitudes about Organ and Tissue Donation among the General Public and Blood Donors in Hong Kong

Context

The cadaveric organ and tissue donation rate in Hong Kong is not satisfactory; 1 million blood donors are registered and more than 300 000 are active. However, the current attitudes toward organ and tissue donation in the general public and blood donors of Hong Kong are unknown.

Methods

Random general public (n = 1018) and blood donors (n = 1227) of Chinese origin, with age ranging from 16 to 60 years, were interviewed using a standard verified questionnaire that examines attitudes and knowledge of organ and tissue donation.

Results

The mean age of the general public and blood donors were 32.6 and 28.9 years, respectively. Of the general public, 44.4% were men and among blood donors, 60% were men. About 56% of both groups thought that organ donation is an obligation of citizens. Blood donors were more aware than the general public about the types of organs that can be donated. When compared with the general public, a significantly higher percentage of blood donors were willing to donate their organs (81% vs 53%), had heard about organ donation cards (98.3% vs 89.5%), and had signed the cards (49.9% vs 22.6%). About 70% of both groups who had signed a card were carrying it. Thirty-nine percent of the general public and 17% of blood donors had not decided whether they would donate. For blood donors, 49.7% were willing to donate their relatives' organs, compared with 41.8% of the general public. Most individuals in both groups would not object to their relatives' decision to donate. About two thirds of individuals in both groups disagreed with the concept of an opt-out law, though only 20% of the general public and 14.4% of blood donors would refuse donation if an opt-out law were in practice.

Conclusions

This study shows that blood donors have better knowledge of organ donation and are more willing to donate their organs and sign an organ donation card than the general public. However, a substantial proportion of blood donors have not signed a donor card. It would be useful to design promotion programs to facilitate blood donors' participation in organ donation.

BAG3-related myofibrillar myopathy in a Chinese family

In contrast to the usual slow disease progression in myofibrillar myopathies, patients with Bag3opathy often have a rapidly progressive and more severe phenotype with a worse prognosis. We describe a Chinese patient, born to non-consanguineous parents, who first presented at age 6 with clumsy walking and difficult climbing staircase. With a history of restrictive lung disease previously diagnosed as asthma, she progressed rapidly with proximal myopathy, rigid spine and bilateral tightening of the Achilles tendons requiring surgical elongation. Hypertrophic cardiomyopathy with restrictive physiology was shown by echocardiogram. Moreover, prolonged QT interval was also noted in the patient. Family history was unremarkable yet her father was incidentally found to have prolonged QT interval. Mutation analysis with genomic DNA of the proband showed heterozygous de novo known mutation c.626C>T (p.Pro209Leu) and a germline variation c.772C>T (p.Arg258Trp) in BAG3. Her father was found to be a carrier of c.772C>T. Muscle biopsy findings were suggestive of myofibrillar myopathy on light microscopy and ultrastructural studies. To our knowledge, this is the first Chinese case of Bag3opathy so far reported.

The HBS1L-MYB intergenic region on chromosome 6q23 is a quantitative trait locus controlling fetal haemoglobin level in carriers of beta-thalassaemia

BACKGROUND

Fetal haemoglobin (HbF) level modifies the clinical severity of HBB disorders. Intergenic variants of HBS1L-MYB on chromosome 6q23 have recently been shown to be a major quantitative trait locus (QTL) influencing HbF levels in normal Caucasian adults.

METHODS

A unique and well-characterised cohort of 238 Chinese subjects with beta-thalassaemia trait was used to conduct a single-nucleotide polymorphism (SNP) association study for HbF level.

RESULTS

Within this locus, 29 trait-associated SNPs in a non-coding 56 kb segment were identified. They were divided into five linkage disequilibrium (LD) blocks in the Chinese participants.

CONCLUSIONS

The data independently validate for the first time the significance of the HBS1L-MYB intergenic region in regulating HbF expression in a separate ethnic group that has a high prevalence of beta-thalassaemia. Functional studies to unravel the biological significance of this region in regulating HbF production is clearly indicated, which may lead to new strategies to modify the disease course of severe HBB disorders.

Risk factors for injury to married women from domestic violence in Hong Kong

OBJECTIVE

To examine risk factors for injury to married women from domestic violence in Hong Kong.

DESIGN

Case control study.

SETTING

Regional public hospital, Hong Kong.

PATIENTS

All married women aged 18 to 60 years who attended an accident and emergency department for treatment of a domestic violence injury from January 2004 to June 2005.

MAIN OUTCOME MEASURES

Social and health characteristics of abused women and their husbands.

RESULTS

A total of 293 cases were compared to 313 controls. Eight predictive variables were found to be significant by univariate analysis: woman who is a new immigrant (P = 0.003), woman with no job (P = 0.019), husband with low educational level (P < 0.001), presence of extramarital affairs (P < 0.001), husband's unemployment (P < 0.001), husband's alcohol abuse (P < 0.001), husband's illicit drug abuse (P = 0.032), husband's mental illness (P < 0.001). Five factors were found to be significant in a logistic regression analysis: husband with a low educational level (nil to primary) [adjusted odds ratio = 2.78; 95% confidence interval, 1.149-6.727], husband unemployed (adjusted odds ratio = 9.031; 95% confidence interval, 5.163-15.796), presence of extramarital affairs (adjusted odds ratio = 5.218; 95% confidence interval, 2.899-9.395), husband's alcohol abuse (adjusted odds ratio = 6.089; 95% confidence interval, 3.460-10.716), husband's mental illness (adjusted odds ratio = 9.443; 95% confidence interval, 2.351-37.926).

CONCLUSIONS

Several significant risk factors have been identified for injury incurred during domestic violence to married women in Hong Kong. It provides information useful for developing local preventive strategies.

Platelet Na,K-adenosine triphosphatase as a tissue marker of hyperthyroidism

Platelet Na(+),K(+)-adenosine triphosphatase (ATPase) activity was measured in 34 (15 males, 19 females) healthy subjects, 89 (35 males, 54 females) hyperthyroid patients, and 34 (7 males, 27 females) treated hyperthyroid patients to assess the potential of this measurement as a tissue marker and diagnostic test for hyperthyroidism. Platelet Na(+),K(+)-ATPase activity was measured in platelet lysates by the rate of release of phosphate from adenosine triphosphate (ATP) in the presence and absence of ouabain. Platelet Na(+),K(+)-ATPase activity (median and range) in the hyperthyroid group (271, 169 to 821 pmol/h/g protein) was significantly higher compared with the healthy group (125, 74 to 185 micromol/h/g protein, P <.001 by Mann-Whitney U test). The treated hyperthyroid group had slightly, but significantly higher, free triiodothyronine (FT3) and free thyroxine (FT4), as well as platelet Na(+),K(+)-ATPase activity (147, 98 to 246 micromol/h/g protein, P <.05). If a platelet Na(+),K(+)-ATPase activity of 190 micromol/h/g protein was used as a cut off value, the specificity and sensitivity were 90% and 93%, respectively. We conclude that platelet Na(+),K(+)-ATPase may be a useful tissue marker of hyperthyroidism.

Haemoglobin H disease due to (--SEA) alpha-globin gene deletion and alpha2-codon 30 (DeltaGAG) mutation: a family study

A Chinese family in which two siblings suffer from haemogloblin (Hb) H disease due to (--SEA) alpha-globin gene deletion and alpha2-codon 30 (DeltaGAG) mutation is described. Both siblings are transfusion-independent and have survived to adulthood. In contrast to previous report of hydrops fetalis associated with zeta-alpha-thal-1 and alpha2-codon 30 (DeltaGAG) mutation, the zeta-globin genes are intact in the two siblings, which most probably alleviates the gamma-chain excess and protects the fetus from severe anaemia. Correlation of genotype with phenotype in Hb H disease is important for genetic counselling, especially in the antenatal setting.

Clinical phenotype of triplicated alpha-globin genes and heterozygosity for beta0-thalassemia in Chinese subjects

The presence of extra copies of alpha-globin gene has been shown to worsen the degree of anemia in beta-thalassemia heterozygotes. We describe the clinical phenotype of eight Chinese subjects with heterozygosity for both triplicated alpha-globin gene and a beta0-thalassemia allele. They were identified through genotyping of beta-thalassemia intermedia and major patients, and through community-based thalassemia screening program in Hong Kong. Standard molecular techniques were used in the determination of genotype. All subjects in this series showed five copies of alpha-globin genes (alphaalphaalpha/alphaalpha) in association with a beta0-thalassemia allele. Although genotypically identical, six subjects showed a beta-thalassemia intermedia phenotype while two were clinically indistinguishable from beta-thalassemia minor, implying the presence of genetic modifying factors that remained undefined. Triplication of alpha-globin gene and heterozygosity for beta0-thalassemia accounted for 15% of beta-thalassemia intermedia patients at our locality and was associated with a mild clinical phenotype. This genotype was not found among beta-thalassemia major patients. They presented in adulthood and were usually not transfusion dependent. When compared with simple beta-thalassemia heterozygotes, they showed obvious red cell abnormalities (hypochromasia, anisopoikilocytosis, circulating normoblasts), lower hemoglobin (Hb) and higher HbF levels. The presence of triplicated alpha-globin genes should always be considered in apparent beta-thalassemia carriers who were more symptomatic than expected, so that unnecessary investigations for the cause of anemia could be avoided. Finally, triplication of alpha-globin genes should be looked for in families with children affected by beta-thalassemia intermedia in which only one parent showed a picture of beta-thalassemia on Hb analysis.

Attitudes about organ and tissue donation among the general public and blood donors in Hong Kong

CONTEXT

The cadaveric organ and tissue donation rate in Hong Kong is not satisfactory; 1 million blood donors are registered and more than 300,000 are active. However, the current attitudes toward organ and tissue donation in the general public and blood donors of Hong Kong are unknown.

METHODS

Random general public (n = 1018) and blood donors (n = 1227) of Chinese origin, with age ranging from 16 to 60 years, were interviewed using a standard verified questionnaire that examines attitudes and knowledge of organ and tissue donation.

RESULTS

The mean age of the general public and blood donors were 32.6 and 28.9 years, respectively. Of the general public, 44.4% were men and among blood donors, 60% were men. About 56% of both groups thought that organ donation is an obligation of citizens. Blood donors were more aware than the general public about the types of organs that can be donated. When compared with the general public, a significantly higher percentage of blood donors were willing to donate their organs (81% vs 53%), had heard about organ donation cards (98.3% vs 89.5%), and had signed the cards (49.9% vs 22.6%). About 70% of both groups who had signed a card were carrying it. Thirty-nine percent of the general public and 17% of blood donors had not decided whether they would donate. For blood donors, 49.7% were willing to donate their relatives' organs, compared with 41.8% of the general public. Most individuals in both groups would not object to their relatives' decision to donate. About two thirds of individuals in both groups disagreed with the concept of an opt-out law, though only 20% of the general public and 14.4% of blood donors would refuse donation if an opt-out law were in practice.

CONCLUSIONS

This study shows that blood donors have better knowledge of organ donation and are more willing to donate their organs and sign an organ donation card than the general public. However, a substantial proportion of blood donors have not signed a donor card. It would be useful to design promotion programs to facilitate blood donors' participation in organ donation.

Should we screen for globin gene mutations in blood samples with mean corpuscular volume (MCV) greater than 80 fL in areas with a high prevalence of thalassaemia?

AIMS

To investigate whether it is worthwhile, in areas where thalassaemia is common, to screen for globin gene mutations in subjects with a mean corpuscular volume (MCV) above 80 fL, especially in partners of known thalassaemia carriers.

METHODS

Blood samples from 95 subjects with MCV between 80 and 85 fL were screened for the presence of alpha globin gene mutations and the haemoglobin (Hb) E mutation.

RESULTS

Thirty four subjects harboured globin gene mutations. Of these, 31 had deletions of one alpha globin gene, one had Hb Constant Spring, and three had Hb E mutations.

CONCLUSION

Based on the above figures and known prevalence rates of thalassaemia carriers, it would seem worthwhile to screen for globin gene mutations in partners of known thalassaemia carriers, regardless of MCV, to identify pregnancies at risk of Hb H disease or Hb E/beta thalassaemia.

Diagnosis of concurrent hemoglobin H disease and heterozygous beta-thalassemia

Definitive diagnosis of concurrent hemoglobin (Hb) H disease and heterozygous beta-thalassemia cannot be made from Hb analysis alone, but necessitates genotype analysis and family study. Interactions between alpha- and beta-thalassemia must be considered when investigating moderate to severe hypochromic microcytic anemia of uncertain cause in adult patients from areas with a high prevalence of globin gene mutations.

Outcome of 235 renal transplant recipients followed up at ministry of health hospitals in the State of Johor

Retrospective analysis was done on 235 recipients, 133 males and 102 females, who were transplanted between 25th September 1979 and 25th June 1999. 85.1% were Chinese, 7.7% were Indians and 7.2% Malays. 23% (54) were living related renal transplants (LRRT) all except 5 done at Hospital Kuala Lumpur. 60% (141) were living unrelated donor renal transplants (LURT) done in India. 17% (40) were cadaveric transplants (CADT) (all done in China except 2 at Hospital Kuala Lumpur and one in London). 97% (228) were first transplants. Primary renal disease was unknown in 69.4%, 17% (40) glomerulonephritis, 5.5% diabetic nephropathy and 8.1% 19 others. All were on prednisolone, 93.2% were on azathioprine and 96.6% were on cyclosporin A. The acute rejection rate was 23.4% (55 episodes). Patient survival was 88% at five years and patients alive with functioning graft was 84% at 5 years. LRRT had significantly better survival compared to LURT. 34 grafts were lost to chronic allograft nephropathy. 46 recipients died (33 died with functioning graft).

Haemoglobin Q-Thailand and hereditary spherocytosis in a Chinese family

A Chinese family with concurrent hereditary spherocytosis (HS) and haemoglobin (Hb) Q-Thailand is described. The Hb Q-Thailand mutation was found on the remaining alpha1 globin gene on a chromosome 16 containing the (-alpha 4.2) deletion. Active haemolysis in members of this family is segregated with the HS phenotype, and the Hb Q-Thailand in the heterozygous state does not seem to show any modulating effect on HS.

Effects of knee joint angles and fatigue on the neuromuscular control of vastus medialis oblique and vastus lateralis muscle in humans

The effects of different knee joint angles and fatigue on the neuromuscular control of the vastus medialis oblique (VMO) and vastus lateralis (VL) muscles were investigated in 17 (11 men, 6 women) young subjects. The electromyogram (EMG) activities and the force generation capacities were monitored before and after a fatigue protocol at three different knee joint angles, 90 degrees, 150 degrees, 175 degrees of knee extension, on three occasions. In response to randomly triggered light signals, the subjects performed three isometric maximal voluntary contraction (IMVC) that lasted for 4 to 8 s. This was then followed by the fatigue protocol which consisted of six bursts of contractions fixed at 30 s on and 10 s off. Immediately after the exercise to fatigue, the subjects performed another three IMVC in response to the light signals. Repeated measures ANOVA were performed to examine the effects of fatigue at these three positions on the electromechanical delay (EMD), median frequency (fmed), peak force (Fpeak) and root mean square (rms)-EMG:Fpeak quotient of VMO and VL. The results revealed a significant effect of the three knee joint angles on the EMD before the fatigue (P < 0.05). The fatigue protocol induced a significant decrease in Fpeak at all the three positions (P < 0.01). However, the fatigue induced a significant decrease of fmed at only 90 degrees and 150 degrees of knee extension (P < 0.01). This occurred in parallel with the lengthening of EMD at these two joint angles (P < 0.01 and P < 0.05). The effects of fatigue on the fmed and EMD were not significant between VMO and VL at all three angles. The insignificant difference in fmed and EMD between VMO and VL at the three knee positions before and after fatigue indicated that no preferential onset activation between VMO and VL had occurred.

Recurrent and novel mutations of GCDH gene in Chinese glutaric acidemia type I families

Glutaric acidemia type I is caused by mutations of the glutaryl-CoA dehydrogenase (GCDH) gene resulting in loss of GCDH enzyme activity. Patients present with progressive dystonia and lesions in basal ganglia. Dietary treatment, when instituted from the early neonatal period, markedly reduces dystonia and morbidity. Early diagnosis and prenatal diagnosis will be facilitated by knowledge of locally prevalent GCDH mutations. Several common GCDH mutations have been found in different ethnic groups. GCDH mutations were studied in 5 Chinese glutaric acidemia type I families. We detected two novel recurrent mutations (A219T and IVS10-2A>C) which were found in two unrelated families. An asymptomatic carrier of IVS10-2A>C was also found on screening of 120 individuals. Other mutations were identified, including two other novel (R386G & IVS3+1G>A) and two known mutations (G178R & R355H). Fibroblasts from patients carrying the novel mutations were confirmed to be deficient for GCDH activity. This is the first report of GCDH mutations describing recurrent mutations in Chinese patients. The carrier rate of IVS10-2A>C may be particularly high in Chinese.

beta-thalassemia intermedia caused by compound heterozygosity for Hb Malay (beta codon 19 AAC-->AGC; asn-->Ser) and codons 41/42 (-CTTT) beta(0)-thalassemia mutation

We report a case of beta-thalassemia intermedia caused by compound heterozygosity for hemoglobin (Hb) Malay and codon 41/42 (-CTTT) beta(0)-thalassemia mutation in a 38-year-old Chinese woman. This patient has long-standing anemia with a baseline Hb level of around 70 g/L. She worked as a full-time cashier and had not required regular blood transfusions. Nevertheless, she had splenomegaly necessitating splenectomy, cholelithiasis, and iron overload. This case illustrates the varied phenotypic expression associated with compound heterozygosity for Hb Malay and other beta-thalassemia mutations. Since Hb Malay migrates as Hb A on electrophoresis and chromatography, this variant Hb mutation ought to be included in the differential diagnosis for beta-thalassemia major or intermedia patients of Southeast Asian descent who are reported to have Hb A on the basis of Hb analysis. The possible presence of this mutation should also be considered in appropriate cases for genetic counseling in couples at risk of conceiving fetuses with beta-thalassemia major or intermedia.

Recurrent upper gastrointestinal bleeding due to the Dieulafoy's lesion

Dieulafoy's lesion of the gastrointestinal tract, an abnormally dilated artery that penetrates through the mucosa, has been diagnosed more frequently in recent years. Bleeding occurs when the vessel ruptures. Despite widespread awareness of this entity, it remains a diagnostic challenge for gastroenterologists because of its small size and hidden location. Several different diagnostic methods and treatments have been introduced throughout the years. Endoscopy plays a major role in diagnosis and therapy. In this case report, the patient was successfully treated endoscopically using epinephrine injection and heater probe thermoco-agulation. The characteristics of the Dieulafoy's lesion, its current diagnosis, treatment, and complications are discussed.

Outcome of 85 lupus nephritis patients treated with intravenous cyclophosphamide: a single centre 10 year experience

Retrospective analysis was done on 85 patients (76 female, 9 male) with lupus nephritis who started intravenous cyclophosphamide between 1/1/1989 and 31/12/1998. The initial renal biopsy (World Health Organisation) classification was III (4.7%), IV (89.4%) and V (5.9%). Average serum creatinine at time of biopsy was 0.12 +/- 0.12 mmol/l. Median duration of nephritis before biopsy was 2 months (range 0-133). Median duration of follow-up from time of biopsy to outcome (death or end-stage renal failure) was 3.3 years (range 0.3-11.8). Nineteen patients died. The calculated proportion alive at 5 years was 75% and at 10 years 64%. The calculated proportion alive with renal function was 74% and 54% at 5 and 10 years respectively. Fifty-two patients completed cyclophosphamide therapy at the end of the study. There were ten episodes of herpes zoster, the most common infection seen. No malignancy was reported.

Presence of donor- and recipient-derived DNA in cell-free urine samples of renal transplantation recipients: urinary DNA chimerism

BACKGROUND

Previous studies have indicated that microchimerism is present in body tissues, peripheral blood, and plasma of recipients after organ transplantation. We hypothesize that donor-derived DNA may also be present in cell-free urine of renal transplant recipients and that the concentrations of urine DNA may be correlated with graft rejection.

METHODS

Thirty-one female patients who had renal transplantation were enrolled in the study. In women with male organ donors, the SRY gene on the Y chromosome was used as a marker for donor-derived DNA. Real-time quantitative PCR for the SRY and beta-globin genes was carried out on cell-free urinary DNA from these patients. Serial urine samples from a female renal transplant recipient undergoing an acute rejection episode were also collected and analyzed with the beta-globin quantitative PCR system.

RESULTS

SRY sequences were detected in the urine of 14 of 17 female patients with male organ donors. None of the 14 patients with female organ donors had detectable SRY sequences in urinary DNA. The median fractional concentration of donor-derived DNA was 8.7% (interquartile range, 1.9-26.4%). During the acute rejection episode, urinary concentrations of the beta-globin gene were markedly increased, with the concentrations returning rapidly to normal following antirejection treatment.

CONCLUSIONS

Our results demonstrate that urinary DNA chimerism is present following renal transplantation. The measurement of urinary DNA using quantitative PCR may be useful for the diagnosis and monitoring of graft rejection.

In utero treatment of fetal complete heart block with terbutaline. A case report

BACKGROUND

Isolated fetal complete heart block is an uncommon finding, with a mortality rate of 20-30%. Various treatment modalities have been reported, with no consistent success.

CASE

Fetal complete heart bock was diagnosed in a 30-year-old woman at 29 weeks' gestation. She had an elevated antinuclear antibody and anti-SSA antibody titer. Fetal cardiac decompensation was detected at 32 weeks. After a trial of intravenous isoproterenol without significant side effects, she was treated with oral terbutaline. An increase in the fetal ventricular rate and complete resolution of hydrops fetalis occurred. A male infant was delivered by cesarean section, at term, and underwent cardiac pacemaker implantation at 4 days of age.

CONCLUSION

The treatment of fetal complete heart block is controversial. Premature delivery with cardiac pacing is associated with high morbidity and mortality. We report prenatal treatment with oral sympathomimetic medication, which allowed delivery to be delayed until term, with a successful outcome.

Tetrahydropalmatine poisoning: diagnoses of nine adult overdoses based on toxicology screens by HPLC with diode-array detection and gas chromatography-mass spectrometry

BACKGROUND

Tetrahydropalmatine (THP) is a neuroactive alkaloid with analgesic and hypnotic action. Its analysis is important because cases of human poisonings have emerged as a result of unregulated use of some proprietary biopharmaceuticals containing purified THP.

METHODS

We established analytical parameters for HPLC with diode-array detection (HPLC-DAD) and gas chromatography-mass spectrometry (GC-MS) for the detection of THP in serum and urine. Nine acutely THP-poisoned adults were thus screened over 16 months.

RESULTS

All patients recovered quickly after mild neurological disturbance. In general, THP was metabolized rapidly and excreted as polar metabolites in urine. Serum THP was measured in five cases and found to be <0.1-1.2 mg/L (<0.3-3.4 micromol/L). Paired analyses of urine with and without glucuronidase treatment clarified the disposition of THP. Our GC-MS method with trimethylsilane derivatization identified O-desmethyl metabolites. With a uniform solid-phase extraction, the HPLC-DAD procedure detected intact glucuronide metabolites.

CONCLUSION

Intact glucuronide metabolites of THP are sensitive markers for THP exposures. Our methods and findings provide practical tools and information for surveillance of intoxication caused by excessive THP intake.

Myelodysplastic syndrome with myelofibrosis and basophilia: detection of trisomy 8 in basophils by fluorescence in-situ hybridization

We report a case of myelodysplastic syndrome (MDS) with myelofibrosis and pulmonary tuberculosis who had marked basophilia in the peripheral blood. A clonal karyotypic abnormality characterized by trisomy 8 was demonstrated by cytogenetic analysis. By correlation of cell morphology with results of fluorescence in situ hybridization using a chromosome 8 probe, we demonstrated that the basophils were not reactive but belonged to the neoplastic MDS clone.

Sodium and potassium intakes and blood pressure in Chinese adults in Hong Kong: A comparison with southern China

The ranges of sodium and potassium intake and their relationship to blood pressure were studied in 126 healthy Chinese subjects (42 men, 84 women) aged between 20 and 65 years living in Hong Kong. An average of three blood pressure measurements and one to three 24-hour urinary sodium and potassium outputs were used to characterize an individual's blood pressure, and sodium and potassium intake, respectively. The average sodium and potassium intakes were 145 and 40 mmol/day in men and 135 and 41 mmol/day in women. When compared with subjects of similar age in southern China, Chinese in Hong Kong excreted 20% less sodium but 40% more potassium and had a lower systolic blood pressure (113 vs 118 mmHg in men, 106 vs 112 mmHg in women). It should be remembered that the Hong Kong subjects were heavier and were under more urban stress, both of which would be expected to be associated with higher blood pressure. The findings from this pilot study are compatible with a positive association between sodium intake and blood pressure and/or an inverse association between potassium intake and blood pressure.

Intraperitoneal pulse calcitriol in the treatment of secondary hyperparathyroidism in patients on continuous ambulatory peritoneal dialysis

OBJECTIVE

To determine whether it is practicable to use intraperitoneal calcitriol to treat continuous ambulatory peritoneal dialysis (CAPD) patients with secondary hyperparathyroidism and whether this form of therapy is effective and safe.

DESIGN

A prospective, nonrandomized study.

SETTING

Division of Nephrology, Tertiary Hospital.

METHOD

Eight patients from our CAPD population were recruited (5 F, 3 M), aged 24 to 63 years (mean 38.9 +/- 7.6 yr). They had been on CAPD for 8 to 84 months (mean 47.6 +/- 24.6 months). All the patients had bone biopsy-proven secondary hyperparathyroidism with 2 patients showing mixed lesions. The CAPD system was changed to the twin-bag system (Ultrabag, Baxter Healthcare, McGaw Park, IL, U.S.A.) in all 8 patients, who were taught to inject the calcitriol directly through the short transfer set and the Tenckhoff catheter into the peritoneal cavity, twice per week before bedtime. Calcium carbonate or calcium acetate was used as the main phosphate binder. Intact parathyroid hormone level (iPTH), serum ionized calcium (iCa), serum phosphate, and serum total alkaline phosphatase (alk. phos.) levels were measured at baseline and then every 4 weeks. The mean duration of follow-up was 10.5 months +/- 1.9 months.

RESULTS

There was a significant drop of iPTH level from the pretreatment level of 100.6 +/- 35.8 pmol/L to a level of 63.8 +/- 48.7 pmol/L at 24 weeks (p = 0.036). The lowest level of iPTH attained was 43.4 +/- 27.0 pmol/L at 48 weeks. Serum total alk. phos. also dropped from 232.4 +/- 83.3 IU/L pretreatment to 147.9 +/- 52.0 IU/L at 24 weeks (p = 0.017). The decrease in alk. phos. level paralleled the decrease in iPTH level. The mean serum iCa level did not show any significant rise throughout the study period. The maximum dose of calcitriol used was 6.6 +/- 1.5 microg/week and the average dose of calcitriol was 5.4 +/- 1.2 microg/week. One patient did not respond satisfactorily and she subsequently had a parathyroidectomy. Two episodes of peritonitis occurred during the study period, giving a peritonitis rate of one episode per 42 patient-months. There was no significant change in the urea clearance tests or the peritoneal equilibration tests before and after the study.

CONCLUSION

Intraperitoneal calcitriol is practicable, effective, and safe in the treatment of secondary hyperparathyroidism in CAPD patients.

EGF stimulates an increase in actin nucleation and filament number at the leading edge of the lamellipod in mammary adenocarcinoma cells

Stimulation of metastatic MTLn3 cells with EGF causes the rapid extension of lamellipods, which contain a zone of F-actin at the leading edge. In order to establish the mechanism for accumulation of F-actin at the leading edge and its relationship to lamellipod extension in response to EGF, we have studied the kinetics and location of EGF-induced actin nucleation activity in MTLn3 cells and characterized the actin dynamics at the leading edge by measuring the changes at the pointed and barbed ends of actin filaments upon EGF stimulation of MTLn3 cells. The major result of this study is that stimulation of MTLn3 cells with EGF causes a transient increase in actin nucleation activity resulting from the appearance of free barbed ends very close to the leading edge of extending lamellipods. In addition, cytochalasin D causes a significant decrease in the total F-actin content in EGF-stimulated cells, indicating that both actin polymerization and depolymerization are stimulated by EGF. Pointed end incorporation of rhodamine-labeled actin by the EGF stimulated cells is 2.12+/−0.47 times higher than that of control cells. Since EGF stimulation causes an increase in both barbed and pointed end incorporation of rhodamine-labeled actin in the same location, the EGF-stimulated nucleation sites are more likely due either to severing of pre-existing filaments or de novo nucleation of filaments at the leading edge thereby creating new barbed and pointed ends. The timing and location of EGF-induced actin nucleation activity in MTLn3 cells can account for the observed accumulation of F-actin at the leading edge and demonstrate that this F-actin rich zone is the primary actin polymerization zone after stimulation.

Biochemical investigation of young hospitalized Chinese children: results over a 7-year period

During the seven years from January 1989 to December 1995, we investigated 2,269 Chinese infants and young children for metabolic disorders in Hong Kong. These young patients, all aged under 4 years and originated from southern China, were ill with no apparent cause and had clinical manifestations suggestive of inherited metabolic diseases. A spot urine and a plasma sample were obtained from each patient for biochemical analysis, including urinary organic acid identification and plasma amino acid analysis. Six cases of mucopolysaccharidosis, four multiple carboxylase deficiency, three 2-methylacetoacetyl CoA thiolase deficiency, two methymalonic aciduria, one glutaric aciduria type I, one glutaric aciduria type II, one a-oxoglutaric aciduria, and one case of orotic aciduria were detected. There were also single suspected cases of medium-chain acyl-CoA dehydrogenase deficiency and isovaleric aciduria. No primary amino acid disorder, such as phenylketouria and maple syrup urine disease, has been detected. Our results suggest that a different pattern of inherited metabolic diseases exists in the southern Chinese when compared with the Chinese in other regions of China.

Epidemiology of poisoning in the New Territories south of Hong Kong

Little is known about the incidence and pattern of poisonings in Hong Kong. Hence, adults (subjects aged > or = 15 years) and children (subjects aged < or = 14 years) hospitalized in the Princess Margaret Hospital in 1994 with ICD codes of 960-977 (medicinal poisonings) or 980-989 (non-medicinal poisonings) were studied. This is the main general hospital with a 24-hour emergency department for the 0.68 million people living in the New Territories South. Sex and age specific rates per 100,000 population were calculated. The incidence of poisoning in 1994 was 113.5/100,000. The incidence was higher in males than in females (130.0 vs 96.4/100,000). Poisoning was more common in adults than in children (128.8 vs 44.9/100,000). Subjects with medicinal poisonings were predominantly young females and hypnotics/sedatives were the main agents involved. In contrast, males aged 35-64 years predominated in non-medicinal poisonings, which were mostly related to alcohol. In children, medicinal poisonings were more common than non-medicinal poisonings (24.9 vs 20.2/100,000). All of the nine deaths were adults.

Uniform solid-phase extraction procedure for toxicological drug screening in serum and urine by HPLC with photodiode-array detection

In this HPLC-diode-array detection method for toxicological drug screening, a mixed-mode solid-phase extraction procedure is optimized for isolation of a broad range of drugs from serum and urine. Basic, neutral, and weakly acidic drugs are uniformly recovered. The extract from the solid-phase cartridge is readily injected to a reversed-phase HPLC column for separation by gradient elution. Unknown drugs and metabolites in urine and serum samples from acute drug poisoning cases are rapidly identified by matching their retention times and ultraviolet spectra with hundreds of reference compounds in the library. Urine metabolites of common toxicants from various medications and drugs of abuse are recorded, with their changes of retention times and ultraviolet spectra as related to their metabolic transformations. Glucuronide conjugates of common benzodiazepines, tricyclic antidepressants, and beta-blockers are examined directly without chemical or enzymatic hydrolysis. The system is reliable for diverse clinical investigations of drug overdoses, drug-induced psychoses, and substance abuse.

The production of interleukin-1 alpha immunoreactivity by human oviductal cells in a coculture system

PURPOSE

The aim of this study was to determine the concentration of interleukin-1 alpha in human embryo culture medium with or without oviductal cell coculture and to correlate the interleukin-1 alpha levels with pregnancy.

METHODS

Culture media from 32 in vitro fertilization and embryo transfer cycles were assayed for interleukin-1 alpha by immunoassay technique. Human embryos were cultured in Earles' balanced salt solution supplemented with 15% preovulatory serum (sEBSS) in 16 of these cycles, while embryos in the rest of the cycles were cocultured with human oviductal cells in sEBSS.

RESULTS

Both sEBSS and spent sEBSS after embryo culture contained low or undetectable levels of interleukin-1 alpha in the pregnant and nonpregnant cycles. On the other hand, oviductal cells significantly increased the amount of interleukin-1 alpha immunoreactivity in the conventional culture medium or coculture medium (P < 0.001, Mann-Whitney rank sum test). The concentrations of interleukin-1 alpha in the spent sEBSS after oviductal cell culture and after coculture with human embryos were 1.5 +/- 1.0 and 1.3 +/- 0.9 pg/ml, respectively. There was no difference in the interleukin-1 alpha concentration between the pregnant and the nonpregnant coculture cycles.

CONCLUSIONS

These data showed that human oviductal cells produced interleukin-1 alpha immunoreactivity in a coculture system. However, this production could not be used as a marker for successful embryo implantation.

An estimate of the incidence of pesticide poisoning in Hong Kong

The exact incidence of vegetable-borne and other types of acute pesticide poisoning among the 6.2 million population of Hong Kong is difficult to determine. Vegetable-borne pesticide poisoning is notifiable and, in 1992, 47 outbreaks of such poisoning (all caused by methamidophos) affected about 329 persons. No similar figures are available for non-vegetable-borne pesticide poisoning, but we calculated it based on our experience at the Prince of Wales Hospital (PWH) and on reports to our territory-wide Drug and Poisons Information Bureau (DPIB). The PWH serves the 1.2 million population in the New Territories East, where much of the remaining farmland in Hong Kong is situated. Extrapolating from our regional data to the whole of Hong Kong, we estimate that, in subjects aged > or = 15 y between 1988 and 1991, the annual incidence of non-vegetable-borne acute pesticide poisoning from parasuicides, non-farming accidents and work-related accidents was 59, 4 and 1, respectively. Between 1988 and 1992, 5 pediatric cases of non-vegetable-borne pesticide poisoning were reported to the DPIB annually. In the New Territories East, 80% of the acute pesticide poisoning deaths were due to 24% paraquat solution. In Hong Kong, acute pesticide poisoning is relatively uncommon. By maintaining a close surveillance of imported vegetables for excessive methamidophos residues, replacing high concentration paraquat with less toxic formulations, and placing pesticides out of reach of children, much of this morbidity and mortality associated with acute pesticide poisoning can be prevented.

The metabolic syndrome in Hong Kong Chinese. The interrelationships among its components analyzed by structural equation modeling

OBJECTIVE

To examine the pattern of the metabolic syndrome in Chinese and the causal relationships among its components, including aging, obesity, hyperglycemia, hypertension, hypertriglyceridemia, and hyperinsulinemia in these subjects.

RESEARCH DESIGN AND METHODS

Based on a 75-g oral glucose tolerance test, the World Health Organization criteria were used for the diagnosis of glucose intolerance in a population-based study involving 1.513 Chinese subjects in two work sites. Demographic data including age, family history of diabetes, BMI, waist-to-hip ratio (WHR), and sitting blood pressure (BP) were documented. Fasting plasma glucose, triglyceride (TG) and insulin concentrations, and spot urinary albumin concentration (Ualb) were also measured. Structural equation modeling incorporating factor analysis and path analysis was performed to examine the causal relationships among these variables and their interactions.

RESULTS

Subjects who were treated with antidiabetic and/or antihypertensive drugs or who had a plasma creatinine level > or = 150 mumol/l were excluded (n = 52). The prevalence of diabetes and impaired glucose tolerance (IGT) were 3.9% (n = 34) and 7.2% (n = 63) in men (n = 881) and 3.1% (n = 18) and 6.7% (n = 39) in women (n = 580), respectively. In both groups, glucose intolerance was associated with increasing age, higher BMI, WHR, BP, Ualb, serum TG, and insulin levels as well as higher prevalence rates of positive family history of diabetes. Structural equation modeling showed that age was a significant determinant for both BMI and WHR. Age and obesity accounted for most of the variance of BP, Ualb, plasma glucose, insulin and TG levels either directly or indirectly. Plasma glucose was determined by a positive family history of diabetes, age, and BMI while TG was dependent on BMI and WHR. Serum insulin was mainly determined by a positive family history of diabetes, obesity, plasma glucose, and TG levels. Apart from age and obesity, BP was also determined by serum insulin, both of which had causal effects on Ualb.

CONCLUSIONS

This model emphasizes the centrality of aging and obesity as well as a positive family history of diabetes as major determinants of the components of the metabolic syndrome. These components in turn had causal effects upon one another. Apart from a familial tendency, a central neurohormonal mechanism may account for these abnormalities mediated primarily through obesity and in close association with aging.

Use of a plasma salicylate assay service in a medical unit in Hong Kong: a follow-up study

We have previously showed that routine screening of all patients with acute poisoning for salicylates in Hong Kong is unnecessary. We suggested that plasma measurements should be restricted to those suspected of having ingested salicylates. Our results and suggestion have since been presented and discussed in our medical unit meetings. The impact of our suggestion on the use of our plasma salicylate assay service was determined in this follow-up study of 196 patients presenting between October 1994 and April 1995. In 24 patients (12%), ingestion of salicylates was suspected, and of these, 3 (12.5%) had detectable plasma salicylate concentrations (> or = 0.3 mmol/L). The incidence in those who had taken identifiable drugs, unidentifiable drugs but nature known, and topical medicaments was 20%, 0% and 29%, respectively. Urinary alkalinization was necessary in the only patient with moderate to severe symptoms. In 172 patients (88%), ingestion of salicylates was not suspected; 3 (1.7%) had plasma salicylate concentrations of 0.47-2.05 mmol/L but mild symptoms only. We confirmed that routine screening for salicylates in all patients with acute poisoning was unnecessary. Despite our suggestion, 88% of plasma salicylate measurements in this follow-up study (76% in January 1992-June 1993) involved patients not suspected of having ingested salicylates.

Factors responsible for continuing morbidity after paracetamol poisoning in Chinese patients in Hong Kong

To determine those factors responsible for continuing prevalence of liver damage after paracetamol poisoning, 222 Chinese patients presenting to the Prince of Wales Hospital, Hong Kong from 1988 to 1993 were studied. Of the 27 patients with plasma paracetamol concentrations above the recommended "treatment line", 13 developed liver damage. Time elapsed between ingestion and treatment with intravenous N-acetylcysteine (NAC) was the most important prognostic factor. Failure to give NAC appropriately (50%) and late presentation (23%) were the main reasons for the continuing morbidity. Liver damage in some of the remaining patients (30%) could have been prevented if NAC was started in the Emergency Department within 8-15 hours of ingestion. Liver damage after paracetamol poisoning remains common (5.9%) in Hong Kong because of the failure to give NAC appropriately or late presentation. We hope to improve patient management by repeatedly emphasising the importance of adherence to the standard protocols and having the toxic plasma level results phoned directly to the duty registrars.

Comparison of the HbH inclusion test and a PCR test in routine screening for alpha thalassaemia in Hong Kong

AIM

To compare the haemoglobin (Hb) H inclusion test with a polymerase chain reaction (PCR) test in routine screening for alpha thalassaemia.

METHODS

Ninety nine peripheral blood samples from Chinese patients with mean corpuscular volume below 80 fl were screened for alpha thalassaemia using the HbH inclusion test and by PCR utilising primers bridging the common deletion breakpoint of the South East Asian (--SEA/) deletion.

RESULTS

The HbH inclusion test was positive in 78 (79%) patients, 73 (93.7%) of whom carried the (--SEA/) deletion on analysis of their DNA by PCR, as did one patient with a negative HbH inclusion test.

CONCLUSIONS

These results suggest that in areas with a high prevalence of the (--SEA/) deletion, such as Hong Kong, the HbH inclusion test can be replaced by PCR as the investigation of choice in screening for alpha thalassaemia.

Clinical experience with holmium:YAG laser lithotripsy of ureteral calculi

BACKGROUND AND OBJECTIVE

We recently acquired a holmium:YAG laser with wavelength of 2.1 microns. We would like to report our success in using this machine for laser lithotripsy.

STUDY DESIGN/PATIENTS AND METHODS

Forty-seven ureteroscopic laser lithotripsies were performed in 44 patients (three bilateral stones) over a 6 month period. Four stones were in the upper ureter, six in the middle ureter, and 37 in the lower ureter. The holmium laser beam was delivered via a 400 micron flexible quartz fiber through a 7 Fr rigid ureteroscope during the procedure. The stone size varied from 4 to 21 mm.

RESULTS

The success rate was 91%. Most of the stones were fragmented to less than 2 mm in size. Larger fragments were removed with a Dormia basket (six cases) for stone clearance. Endoscopic laser ureterotomy was performed in two patients with stricture below the stone. One patient required conversion to open ureterolithotomy, and three required subsequent Extracorporeal Shock Wave Lithotripsy. A low complication rate was observed.

CONCLUSION

The pulsed holmium:YAG laser is safe and effective for use in ureteroscopic laser lithotripsy.

Unrestricted availability of a plasma paracetamol assay service resulting in an increased number of inappropriate requests

Previously, prior approval from the on-call chemical pathologist was required in our hospital for plasma paracetamol measurements. However, since May 1992, there have been no restrictions on ordering this assay. We have assessed the consequences of this policy change by comparing the number and appropriateness of requests for plasma paracetamol measurements in Chinese patients admitted to our hospital with acute poisoning over two six-month periods (July-December) in 1991 and 1993. Requests were considered appropriate if paracetamol ingestion was suspected or unknown drugs were ingested. The number of patients having plasma paracetamol concentrations assayed increased from 51 in 1991 to 141 in 1993 (176%). The corresponding increase in the number of Chinese patients admitted to two of our eight general wards with poisoning was estimated to be 93%. The proportion of 'appropriate' plasma paracetamol measurements dropped from 55% in 1991 to 21% in 1993. Eight patients had plasma paracetamol concentrations above the recommended treatment line; they were all from the group in whom the requests were appropriate. Three of the 135 patients in the group with 'inappropriate' requests were found to have slightly elevated but far from toxic plasma paracetamol concentrations. Unrestricted availability of plasma paracetamol measurements resulted in an increase in the number of inappropriate requests.

Poisoning due to Chinese proprietary medicines

1. To determine the toxic potentials of those Chinese proprietary medicines (CPM) which are commonly used for self-poisoning by adults in Hong Kong, all patients admitted to four of the eight general medical wards at the Prince of Wales Hospital between January 1988 and December 1993 were retrospectively studied. 2. There were 54 women and 17 men with their age ranging from 15 to 86 years. Twenty-three subjects (32%) also took alcohol, chemicals or drugs. Of the 51 subjects (72%) who had taken topical medicaments, 22 had no symptoms while 28 had minor features of gastrointestinal irritation (n = 26), mild (n = 2) or severe (n = 1) salicylate poisoning. Of the 17 subjects (24%) who had taken CPM tablets/capsules, nine had mild symptoms including nausea/vomiting and drowsiness. The three remaining patients (4%) who had ingested liquid CPM preparations were asymptomatic. Elevated plasma salicylate or paracetamol concentrations (> 0.1 mmol l-1) were found in some patients who had taken topical medicaments and CPM tablets/capsules, respectively. All the 71 patients completely recovered. 3. Most of the CPM used for self-poisoning in Hong Kong were of low to moderate toxicity except for those containing wintergreen oil (methyl salicylate).

Renal failure is uncommon in Chinese patients with paracetamol (acetaminophen) poisoning

The reported incidence of renal failure in unselected patients with paracetamol poisoning is about 1-2%. Since the introduction of antidotal therapy for paracetamol poisoning in 1973, renal failure is now mainly seen in those admitted too late for effective therapy and is usually associated with liver damage. To determine the incidence of renal failure in Chinese patients with paracetamol poisoning, a retrospective survey was conducted of 224 patients admitted to the Prince of Wales Hospital, Hong Kong, with paracetamol poisoning from January 1988 to January 1994. Of the 28 patients at risk (plasma paracetamol concentrations above the recommended treatment line), 13 developed liver damage which was severe in 5. One patient with severe liver damage developed a transient increase in plasma creatinine concentration from 90 to 116 umol/L. All 28 patients completely recovered. Renal failure was uncommon in Chinese subjects (0.4%), and this was probably related to a lower incidence of liver damage which may be due to less chronic alcoholism as well as ethnic differences in paracetamol metabolism resulting in an inherent reduced susceptibility to its liver and renal toxicity.