Faecal microbiota transplantation for treatment of recurrent or refractory Clostridioides difficile infection in Hong Kong

INTRODUCTION

Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated infection globally, causing significant morbidity and mortality. Faecal microbiota transplantation (FMT) has emerged as a promising option for recurrent and refractory CDI. This study aimed to assess the safety, efficacy, and feasibility of FMT for CDI in Hong Kong.

METHODS

We conducted a single-centre, retrospective study for all consecutive cases of recurrent or refractory CDI who underwent FMT from 2013 to 2018. Clinical demographics, outcome, and safety parameters were collected.

RESULTS

A total of 24 patients with recurrent or refractory CDI (median age 70 years, interquartile range=45.0-78.3 years; 67% male) were included. Over 80% had been recently hospitalised or were long-term care facility residents. Faecal microbiota transplantation was delivered by feeding tube in 11 (45.8%), oesophagogastroduodenoscopy in eight (33.3%), and colonoscopy in six (25%) of the patients. Resolution of diarrhoea without relapse within 8 weeks was achieved in 21 out of 24 patients (87.5%) after FMT. No deaths occurred within 30 days. The FMT was well tolerated and no serious adverse events attributable to FMT were reported.

CONCLUSION

Our results confirm that FMT is a safe, efficacious, and feasible intervention for patients with refractory or recurrent CDI in Hong Kong. Given the increasing disease burden and the lack of effective alternatives in Hong Kong for difficult-to-treat cases of CDI, we recommend that a territory-wide FMT service be established to address increasing demand for this treatment.

Skin squames contribute to ammonia and volatile fatty acid production from bacteria colonizing in air-cooling units with odor complaints

One of the most notable Indoor Air Quality problems is odor emission. This study investigated the potential contribution of skin squames to the production of ammonia (NH₃ ) and volatile organic acids (VFAs) by 7 bacteria isolated from air-cooling (AC) units with complaints of urine and body odors. Our previous study showed that keratinolytic activity is higher in AC units with odor complaints than those without. In the offices where these units are located, the most likely source of keratins is from human skin squames. Most bacteria can produce NH₃ and VFAs in the skin squame culture. Some correlations between the levels of NH₃ , NH4+, VFAs, and keratinolytic activity were found. The odor production pathway with skin squames was proposed. Staphylococcus haemolyticus was abundant in the AC units with odor problems and had a high level of keratinolytic activity in addition to odor production. For long-term odor control, it is important to reduce the level of skin squames entering the AC units.

Alternatives to colonoscopy for population-wide colorectal cancer screening

Colorectal cancer is one of the top three cancers in the world in terms of incidence. Colonoscopy, which many regard as the gold standard in diagnosis of colonic polyps and neoplasm, is costly, invasive and labour-intensive, and deemed an unsuitable population-wide index screening tool. Alternative modalities, including guaiac and immunohistochemical faecal occult blood tests, computed tomographic colonography, colon capsule endoscopy, flexible sigmoidoscopy, and double-contrast barium enema are available. The procedures, test characteristics, and their implications are reviewed. Immunohistochemical faecal occult blood testing appears to be the most suitable population-wide screening test for an average-risk population, with flexible sigmoidoscopy as an alternative. More evidence is needed to determine the role of computed tomographic colonography and colon capsule endoscopy in colorectal cancer screening.

Pipeline embolisation device for wide-necked internal carotid artery aneurysms in a hospital in Hong Kong: preliminary experience

OBJECTIVE. To review our hospital's experience with the pipeline embolisation device to reconstruct wide-necked intracranial aneurysms. DESIGN. Descriptive case series. SETTING. A regional neurosurgical centre in Hong Kong. PATIENTS. Patients presented with wide-necked intracranial internal carotid artery aneurysms who underwent pipeline embolisation device reconstruction between October 2008 and June 2009. RESULTS. There were 13 wide-necked internal carotid artery aneurysms (in nine patients) treated by pipeline embolisation device reconstruction. Eleven aneurysms were de-novo; two were recurrent. The complete occlusion rate was 66% (8/13) at the first angiographic follow-up and 69% (9/13) at the second follow-up. One patient developed in-stent stenosis and in another there was distal migration of the stent. There was no added neurological deficit in any patient. CONCLUSION. In our series, the clinical results from using the pipeline embolisation device for the treatment of non-ruptured internal carotid artery aneurysms appeared encouraging. However, larger studies with longer follow-up duration are warranted to assess the complications and durability of the device for reconstructing internal carotid artery aneurysms.

Improved treatment results for childhood acute myeloid leukemia in Taiwan

To improve treatment results for children with de novo acute myeloid leukemia (AML), we introduced a novel protocol, Taiwan Pediatric Oncology Group-AML-97A, for AML other than acute promyelocytic leukemia (APL), for which modified conventional protocols were used. From January 1, 1997, to December 31, 2002, 141 children younger than 17 years old with de novo AML were enrolled. In total, 117 patients with non-APL AML were treated with induction therapy of idarubicin and cytarabine (Ara-C), postremission therapy with high-dose Ara-C - containing regimens for four monthly courses, and moderate-dose therapy with idarubicin and Ara-C for four monthly courses. The first 19 patients with APL were treated with all-trans retinoic acid, idarubicin and Ara-C, with the remaining five patients receiving all-trans retinoic acid and idarubicin, followed by maintenance therapy for 2 years. Stem cell transplantation was performed in 29 patients in first remission with a similar outcome as chemotherapy alone. The remission rate in the AML-97A study was 90%, the 5-year survival 51 +/- 5.3% (s.e.) and the 5-year event-free survival 50 +/- 4.8%; for APL, these were 100%, 86 +/- 7.0, and 75 +/- 9.8%. For the whole group, the 5-year survival was 57 +/- 4.7% and the 5-year event-free survival 54 +/- 4.4%. The AML-97A regimen was well tolerated.

Effect of laboratory acclimation on food and water consumption of pregnant sheep after fetal catheterization

The objectives of this study were to determine 1) the time required for food and water consumption of late-gestation pregnant sheep to stabilize after a 6- to 7-h shipment by truck and 2) whether the duration of laboratory acclimation altered food and/or water consumption of pregnant sheep after fetal and maternal vascular catheterization. We used a semi-quantitative scale and a retrospective study design to determine food and water consumption as a function of acclimation time in post-shipping and post-surgery animals. These animals had been in our research facility for 2, 3, 4, and 5 or more days prior to surgical catheterization of the fetus and mother. We used a quantitative scale and a prospective study design to determine food and water consumption in post-surgery animals that had been in the laboratory for either 2 or > or = 7 days at the time of surgery. We used two- and three-factor repeated measures analyses of variance to determine the statistical significance of any differences. Although food and water consumption in post-shipping animals were significantly (p < 0.001) lower on day 1 than other days, we attributed this difference to the fact that "day 1" was shorter than 24 hours because the animals arrived in the laboratory at noon. Further, the post-surgery decrease and subsequent recovery in food and water consumption did not depend on the duration of the acclimation prior to surgery. We conclude that differences in pre-surgery, post-transportation acclimation periods ranging from 48 hours to > or = 7 days do not affect post-operative recovery from fetal surgery in sheep.

Aggressive thoracic actinomycosis complicated by vertebral osteomyelitis and epidural abscess leading to spinal cord compression

STUDY DESIGN

Report of a successfully diagnosed and treated case of spinal cord compression due to epidural actinomycosis.

OBJECTIVE

To illustrate that proper use of imaging strategy can greatly facilitate diagnosis and management of this rare condition.

SUMMARY OF BACKGROUND DATA

Spinal actinomycosis causing epidural abscess and significant spinal cord compression is an uncommon condition. Although diagnosis is difficult, favorable results are widely reported when specific therapy is instituted.

METHODS

A 32-year-old Chinese man had extensive dorsal thoracic soft tissue swelling and lower limb weakness. Collapse of the T5 vertebral body was found on plain radiographs with mediastinal infiltrates on chest radiograph. It took magnetic resonance imaging (MRI) to fully delineate the epidural abscess and dorsal muscular abscesses, which were not depicted by computed tomographic (CT) scan. Diagnosis was made by examination of CT-guided aspirate and tissue recovered during surgery by a microbiologist. The patient received high-dose intravenous penicillin and prompt spinal decompression once diagnosis of actinomycosis was confirmed.

RESULTS

The dorsal muscular abscesses and upper thoracic epidural abscess resolved rapidly after intravenous antibiotics and surgical drainage. This was well documented by follow-up MRI and the full recovery of motor power and lower limb sensation in the patient.

CONCLUSIONS

High clinical suspicion and proper use of imaging data led to timely diagnosis of this rare case of mediastinal, epidural, and intramuscular thoracic actinomycosis. Specific antibiotic therapy and timely, well-targeted surgical intervention greatly improve the outcome of this condition.

Isolated femoral mononeuropathy to the vastus lateralis: EMG and MRI findings

A 16-year-old female track athlete experienced sudden onset of right anterolateral thigh pain, initially thought to be cramping. After 2 months of continued postexercise pain she sought medical evaluation. A 3-cm thigh circumference discrepancy was noted on physical exam. She was referred for electromyography (EMG) and magnetic resonance imaging (MRI) studies. Femoral and screening nerve conduction studies were normal. Needle EMG revealed acute neuropathic changes confined to the right vastus lateralis only. These findings were confirmed by MRI, including short T1 inversion recovery (STIR) sequences. All other medical work-up was normal, including lumbar and pelvic MRI, and complete serologic studies. This case represents a unique presentation of an idiopathic femoral mononeuropathy isolated to the vastus lateralis only, which has not been previously reported. The highly unusual anatomical presentation of this case illustrates the emerging complementary usefulness of EMG and MRI in delineating neuromuscular pathology.

Computed tomography of the normal temporomandibular joint

A study was made in two parts, retrospective (I) and prospective (II), on two samples of 36 and 17 individuals, respectively, who had temporal bone CT studies for reasons unrelated to TMJ pain and dysfunction. Groups I and II had no radiographic signs of TMJ disease and Group II had neither radiographic nor clinical signs of TMJ disease. Both groups were considered to have normal joints. Joint morphometrics for the two groups (I/II) were as follows; transverse condylar dimensions were 18.5/18.1 mm. Condylar angulation averaged 24 degrees/25 degrees and intercondylar distance averaged 83/83 mm while extra condylar distance averaged 118/118 mm. The condyle in the sagittal plane showed a smooth and rounded form with anterior-superior joint space averaging 1.9/1.7 mm while the central-superior joint space averaged 2.3/2.2 mm. The medial-horizontal joint space averaged 3.9/3.7 mm. The slope of the central portion of the articular eminence averaged 60 degrees/60 degrees in the sagittal plane.

Threonine as a carbon source for Escherichia coli

Threonine can be used aerobically as the sole source of carbon and energy by mutants of Escherichia coli K-12. The pathway used involves the conversion of threonine via threonine dehydrogenase to aminoketobutyric acid, which is further metabolized by aminoketobutyric acid ligase, forming acetyl coenzyme A and glycine. A strain devoid of serine transhydroxymethylase uses this pathway and excretes glycine as a waste product. Aminoketobutyric acid ligase activity was demonstrated after passage of crude extracts through Sephadex G100.

Pseudomembranous enterocolitis. Resurgence related to newer antibiotic therapy

Six patients with pseudomembranous entercolitis were seen at one institution over a six-month period. Clindamycin therapy preceded the diagnosis in all six patients and possibly caused the disease in five cases. Common clinical features included diarrhea, abdominal pain, fever, leukocytosis, radiographic findings of large bowel dilatation with mucosal thickening and a characteristic sigmoidoscopic or gross pathologic demonstration of discrete yellow-white plaques on an otherwise normal mucosa. Complications included toxic megacolon and sigmoid colon perforation. Two of the six patients died. The literature since 1970 is tabulated to clarify the clinical and pathological features of pseudomembranous enterocolitis associated with newer antibiotic therapy. Lincomycin and clindamycin are strongly implicated in the recent resurgence of this formerly rare variety of colitis.