High Prevalence of Late-Onset Fabry Cardiomyopathy in a Cohort of 499 Non-Selective Patients with Left Ventricular Hypertrophy: The Asian Fabry Cardiomyopathy High-Risk Screening Study (ASIAN-FAME)

Left ventricular hypertrophy (LVH) caused by cardiac variant Fabry disease (FD) is typically late-onset and may mimic LVH caused by abnormal loading conditions. We aimed to determine the prevalence of FD in a non-selective patient population of everyday practice presenting with LVH, including those with hypertension and valve disease. We measured plasma alpha-galactosidase A activity using dried blood spot tests in 499 (age = 66 ± 13 years; 336 men) Hong Kong Chinese patients with LVH defined as maximal LV septal/posterior wall thickness ≥13 mm on echocardiography. Patients with low enzyme activity underwent mutation analysis of the GLA gene. Eight (age = 53−74 years; all men) unrelated patients (1.6%) had low plasma alpha-galactosidase A activity (0.57 ± 0.27 μmol/L wb/hr) and all were confirmed to have the GLA IVS4 + 919G > A mutation. FD patients presented with heart failure (n = 5), heart block (n = 2), ventricular tachycardia (n = 1), chest pain (n = 3), and/or murmur (n = 1). Uncontrolled hypertension (n = 4) and/or severe mitral/aortic valve pathology (n = 2) were frequent. Ethnic subgroups included Teochew (n = 5), Canton (n = 2), and Wenzhou (n = 1). Endomyocardial biopsy (n = 6) revealed hypertrophic myocytes with vacuolization and dense lamellar bodies. Late-onset IVS4 + 919G > A FD is prevalent among Chinese LVH patients, and should be considered as a cause of LVH in adult patients even when hypertension and/or valve pathology are present.

Screening for Fabry Disease in patients with unexplained left ventricular hypertrophy

Fabry Disease (FD) is a systemic disorder that can result in cardiovascular, renal, and neurovascular disease leading to reduced life expectancy. FD should be considered in the differential of all patients with unexplained left ventricular hypertrophy (LVH). We therefore performed a prospective screening study in Edmonton and Hong Kong using Dried Blood Spot (DBS) testing on patients with undiagnosed LVH. Participants found to have unexplained LVH on echocardiography were invited to participate and subsequently subjected to DBS testing. DBS testing was used to measure α-galactosidase (α-GAL) enzyme activity and for mutation analysis of the α-galactosidase (GLA) gene, both of which are required to make a diagnosis of FD. DBS testing was performed as a screening tool on patients (n = 266) in Edmonton and Hong Kong, allowing for detection of five patients with FD (2% prevalence of FD) and one patient with hydroxychloroquine-induced phenocopy. Left ventricular mass index (LVMI) by GLA genotype showed a higher LVMI in patients with IVS4 + 919G > A mutations compared to those without the mutation. Two patients were initiated on ERT and hydroxychloroquine was discontinued in the patient with a phenocopy of FD. Overall, we detected FD in 2% of our screening cohort using DBS testing as an effective and easy to administer screening tool in patients with unexplained LVH. Utilizing DBS testing to screen for FD in patients with otherwise undiagnosed LVH is clinically important due to the availability of effective therapies and the value of cascade screening in extended families.

Diagnosing Epiglottitis with Radiographs: Can we be More Objective?

Objective

The classical radiographic signs in acute epiglottitis are qualitative. The purpose of our study was to identify objective radiographic parameters to aid diagnosis of acute epiglottitis in Chinese adults.

Methods

A case-control study of Chinese adult patients attending the accident and emergency department (AED) who were subsequently diagnosed to have acute epiglottitis from 1st January 2009 to 31st December 2013 in a public hospital in Hong Kong. Controls were one-to-one age- and sex-matched patients who attended the AED during the study period for orthopaedic problems with cervical spine radiographs taken. Cases and controls were retrieved from the hospital computer system and their radiographs were interpreted by two specialist radiologists with various pharyngeal and laryngeal parameters, including the dimensions of the third cervical vertebral body, epiglottis, aryepiglottic fold, hypopharynx, retropharyngeal soft tissue and retrotracheal soft tissue, measured and analysed. Sensitivity, specificity, positive and negative likelihood ratios were calculated for each of the parameters.

Results

Twenty-six patients and 26 age- and sex-matched controls were included in the study. Epiglottis width of 5.5 mm or more was found to be 96.2% sensitive and 100% specific in diagnosing acute epiglottitis. Positive and negative likelihood ratios were infinity and 0.04 respectively. Aryepiglottic fold width of 5.9 mm or more was 92.3% sensitive and 80.8% specific. Positive and negative likelihood ratios were 4.80 and 0.10 respectively.

Conclusion

The identified objective radiographic parameters should aid in the diagnosis of acute epiglottitis in Chinese adults. (Hong Kong j. emerg.med. 2016;23:168-175)

A Prospective Clinical Trial Comparing Self-Administered Nitrous Oxide and Haematoma Block for Analgesia in Reducing Fracture of the Distal Radius in an Emergency Department

Objective

To compare the effectiveness and efficacy of self-administered nitrous oxide and haematoma block in pain relief during close reduction of fractured distal radius in adult patients.

Methods

This was a prospective clinical trial. All adult patients aged 18 years or above with fracture of the distal radius within 24 hours requiring close reduction in the Accident and Emergency Department of Kwong Wah Hospital were included. Patients with known contraindications were excluded. A consecutive series of patients were randomised into the two groups in alternating fashion. Pain perception (VAS score), procedure time, patient acceptance and complications were measured and monitored.

Results

A total of 67 patients (53 females and 14 males) with age ranging from 26 to 94 years were enrolled during the period from April 2008 to December 2008; 33 patients received Entonox and 34 received haematoma block. The average VAS score before reduction was 6.97 cm for the Entonox group and 6.76 cm for the haematoma block group (p=0.61). The average VAS score during reduction was 7.19 cm for the Entonox group and 2.80 cm for the haematoma block group (p<0.0001). For the difference of average VAS scores during and before reduction, there was 0.22 cm increase in the Entonox group and 3.95 cm decrease in the haematoma block group (p<0.0001). The relative change of mean VAS score was 3% increase in the Entonox group and 58% decrease in the haematoma block group (p<0.0001). The average procedure time was 6.29 min for the Entonox group and 6.44 min for the haematoma block group (p=1). In the Entonox group, 64% patients agreed to use the same analgesia method under similar circumstances whereas in the haematoma block group, it was 91% (p=0.009). There were no complications or failed reductions in both groups.

Conclusion

Haematoma block is a safe and effective analgesia in the reduction of fractured distal radius with less pain perception, more patient acceptance and similar procedure time compared with Entonox.

News Board for Emergency Incidents

In the past, intra-hospital communication during disaster incidents relied heavily on pagers, phones or direct verbal communication. Other communication channels may include facsimile transmission, email and “walkie-talkie”. There was often delay or inadequacy of information dissemination. This article introduces the “News Board for Emergency Incidents” recently launched in our hospital intranet as an efficient communication channel to convey up-to-date information to other hospital staff during major incidents. The background and process of development of this new communication modality is discussed. We also try to explore possible future development of such “news board” via intranet broadcast.

Differential attitudes of Chinese students toward people with disabilities: a cross-cultural perspective

The purpose of this study was to examine the attitudes of 338 Chinese secondary school students toward three major disability groups (people who are physically disabled, emotionally disturbed, and mentally retarded) using an adaptation of the American Scale of Attitudes toward Disabled Persons (SADP). We found that physically disabled persons were rated higher across the three subscales of the SADP compared to either emotionally disturbed and mentally retarded individuals, who were rated similarly low by the students. The lack of differentiation between the two mental handicapping conditions is at variance with contemporary western findings. The overall negative attitudes toward people with mental disabilities may have significant implications for community rehabilitation programming for this population.