ADHD Drug Prescribing Trend Is Increasing Among Children and Adolescents in Hong Kong

OBJECTIVE

To investigate the prevalence of ADHD medication prescribing of school-aged children in Hong Kong (HK) from 2001 to 2013 and to compare with other countries.

METHOD

Using the Hong Kong Hospital Authority Clinical Data Analysis and Reporting System, we investigated the epidemiology and prevalence of ADHD medication prescribing.

RESULTS

The prevalence of children on ADHD medication increased 14 times throughout the study period-0.072% in 2001 (95% confidence interval [CI] = [0.068%, 0.077%]) to 1.027% (95% CI = [1.008%, 1.047%]) in 2013. Prevalence in females increased at a faster rate than in males. The prescribing trend in kindergarten children (3- to 5-year-old) was relatively steady from 2001 to 2008-0.025% (95% CI = [0.019%, 0.033%]) in 2001-until a marked increase from 2009 to 2013-0.121% (95% CI = [0.105%, 0.139%]) in 2013.

CONCLUSION

The prevalence of ADHD medication prescribing in Hong Kong is increasing but remains lower than most Western countries. However, the prevalence of ADHD medication prescribing for kindergarten children should be monitored to ensure appropriate use.

Development of an electronic emergency department-based geo-information injury surveillance system in Hong Kong

OBJECTIVES

To describe the experience in the development of an electronic emergency department (ED)-based injury surveillance (IS) system in Hong Kong using data-mining and geo-spatial information technology (IT) for a Safe Community setup.

METHODS

This paper described the phased development of an emergency department-based IS system based on World Health Organization (WHO) injury surveillance Guideline to support safety promotion and injury prevention in a Safe Community in Hong Kong starting 2002.

RESULTS

The initial ED data-based only collected data on name, sex, age, address, eight general categories of injury types (traffic, domestic, common assault, indecent assault, batter, industrial, self-harm and sports) and disposal from ED. Phase 1--manual data collection on International Classification of External Causes of Injury pre-event data; Phase 2--manual form was converted to electronic format using web-based data mining technology with built in data quality monitoring mechanism; Phase 3--integration of injury surveillance-data with in-patient hospital information; and Phase 4--geo-spatial information and body mapping were introduced to geo-code exact place of injury in an electronic map and site of injury on body map.

CONCLUSION

It was feasible to develop a geo-spatial IS system at busy ED to collect valuable information for safety promotion and injury prevention at Safe Community setting. The keys for successful development and implementation involves engagement of all stakeholders at design and implementation of the system with injury prevention as ultimate goal, detail workflow planning at front end, support from the management, building on exiting system and appropriate utilisation of modern technology.

Neonatal infections in Asia

OBJECTIVE

To study the epidemiology (including incidence, antibiotic sensitivity and mortality) of neonatal unit infections in countries in Asia.

METHODS

One year prospective study of neonatal infections in eight neonatal units in Asia.

RESULTS

There were 453 episodes of sepsis affecting 394 babies. Mortality from neonatal sepsis was 10.4%, with an incidence of 0.69 deaths/1000 live births. Group B streptococcus was the most common early-onset organism causing 38% of episodes of early-onset (<48 h old) sepsis, with a rate of 0.51 episodes per 1000 live births and a mortality of 22%. Gram-negative bacillary early-onset sepsis occurred at a rate of 0.15 episodes per 1000 live births with a mortality of 12%. There were 406 episodes of late-onset sepsis. The incidence was high at 11.6 per 1000 live births, and mortality was 8.9%. Coagulase-negative staphylococcus caused 34.1% of episodes, whereas Staphylococcus aureus caused only 5.4%. Gram-negative bacilli caused 189 episodes (46.6%). Only 44% of Gram-negative bacilli were sensitive to both gentamicin and a third-generation cephalosporin, whereas 30% were resistant to both antibiotics. Meningitis occurred in 17.2% of episodes of late sepsis, with a mortality of 20%.

CONCLUSIONS

The incidence of late-onset sepsis was higher in Asia than in resource-rich countries, but the organisms isolated and mortality were similar. Over half of all Gram-negative bacilli were antibiotic resistant.

Clinical characteristics of nosocomial norovirus outbreaks in Hong Kong

Norovirus outbreaks occur worldwide every year and have become more frequent over the last few years. There were extensive outbreaks in Hong Kong from May to July 2006 and our aim was to describe nosocomial outbreaks from 1 May 2006 to 31 July 2006 in this retrospective observational study. A total of 38 confirmed norovirus outbreaks involving 218 patients were identified. Most of these patients were elderly with a mean age of 74.5 years (range: 3 months to 97 years); 62% of them were either totally or partially dependent for help with daily activities, 83.9% had underlying chronic medical problems and 56% had limited mobility. In all, 97.2% of individuals presented with diarrhoea and only 46.3% of them had vomiting. The median duration for diarrhoea was 3 days and the longest 24 days. The median duration of vomiting was one day and the longest 15 days. Fever occurred in one-third of all cases. Reverse transcriptase-polymerase chain reaction was positive for norovirus in 72.6% cases. We conclude that nosocomial norovirus infection often involves frail elderly patients with limited mobility and that these patients may have more prolonged symptoms.

Carnitine-acylcarnitine translocase deficiency in three neonates presenting with rapid deterioration and cardiac arrest

We report on three Chinese neonates with carnitine-acylcarnitine translocase deficiency. They presented within the first 48 hours of life. Two neonates were found in cardiac arrest; one of them survived after resuscitation. The third neonate suddenly developed cardiorespiratory insufficiency and succumbed eventually. The clustering of three cases in 5 years suggests that carnitine-acylcarnitine translocase deficiency is not rare in our Chinese population. We advocate that investigation for metabolic diseases including carnitine-acylcarnitine translocase deficiency should be performed in cases of sudden infant death and unexplained abrupt clinical deterioration in the early neonatal period. Non-ketotic hypoglycaemia is an early clue. The mainstay of initial treatment is glucose infusion at a rate greater than 7 mg/kg/minute, which inhibits beta-oxidation of fatty acids (the defective enzymatic steps in carnitine-acylcarnitine translocase deficiency) and thus prevents the accumulation of toxic long-chain acylcarnitines.

Chorioamnionitis with or without funisitis increases the risk of hypotension in very low birthweight infants on the first postnatal day but not later

OBJECTIVE

To evaluate the relation between chorioamnionitis and hypotension in very low birthweight infants.

METHODS

Retrospective cohort study in infants with a birth weight of <1500 g born between January 2002 and September 2004. The placentas were examined for evidence of chorioamnionitis and funisitis. Hypotension was defined by the use of vasopressors.

RESULTS

Of 105 infants, 37 (35%) were chorioamnionitis positive. The onset of hypotension had a skewed distribution: day 1 for 30 episodes and scattered from day 2 to day 19 for the remaining 22. Of the 30 infants who developed hypotension on day 1, 17 (57%) were chorioamnionitis positive. The mean maturity of the chorioamnionitis positive group was 27.91 weeks, marginally less than the mean maturity of 29.05 weeks of the chorioamnionitis negative group (p = 0.05). After adjustment of the effects for confounding variables (birth weight, gestation, surfactant therapy, mechanical ventilation on day 1, high frequency oscillatory ventilation, patent ductus arteriosus), chorioamnionitis was the significant factor in line with hypotension developing on day 1 (adjusted odds ratio 5.14, 95% confidence interval 1.51 to 17.50). There was no evidence that hypotension developing after day 1 was associated with chorioamnionitis.

CONCLUSIONS

There is a strong association between chorioamnionitis and hypotension developing on day 1 in very low birthweight infants.

BiliCheck transcutaneous bilirubinometer: a screening tool for neonatal jaundice in the Chinese population

OBJECTIVE

To verify the usefulness of the BiliCheck transcutaneous bilirubin meter as a screening device for neonatal jaundice in a Chinese population compared with the Minolta bilirubin meter.

DESIGN

A prospective correlation study that compared transcutaneous bilirubin measurements with serum bilirubin levels.

SETTING

Obstetric ward and a neonatal unit of a regional hospital in Hong Kong.

PATIENTS

Neonates with gestation above 32 weeks with neonatal jaundice who were admitted between April 2001 and February 2002.

MAIN OUTCOME MEASURES

Transcutaneous measurements of serum bilirubin obtained from the forehead and the sternum with two instruments: BiliCheck and Minolta Airshields JM 102.

RESULTS

A total of 77 term and six near-term babies (gestation, 32-37 weeks) were recruited. The mean age at the time of data collection was 3.96 days (range, 2-9 days). The correlations between serum bilirubin and transcutaneous bilirubin measurements of the two devices at the two sites were high, with a coefficient of 0.718 (95% confidence interval, 0.610-0.800; n=100) for forehead measurements, and 0.814 (95% confidence interval, 0.740-0.870; n=99) for sternum using the Minolta Airshields JM 102; and a coefficient of 0.757 (95% confidence interval, 0.657-0.827; n=98) for forehead measurements, and 0.794 (95% confidence interval, 0.700-0.862; n=92) for sternum using the BiliCheck. For BiliCheck, a cut-off point of 250 micromol/L at the forehead and 260 micromol/L at the sternum had a specificity of 61.9% and 70.0%, respectively with a sensitivity of 100% for the detection of serum bilirubin concentrations of 250 micromol/L or higher. This level is commonly used as the level for initiation of treatment such as phototherapy.

CONCLUSION

BiliCheck is a useful screening tool for neonatal jaundice in the Chinese population and is comparable with the Minolta Airshields JM 102.

Limbs Anthropometry of Singleton Chinese Newborns of 28–42 Weeks’ Gestation

Abnormalities of limbs are important features of some syndromes recognizable at birth. The purpose of this study was to establish normal standards of limbs including arm length, arm circumference, upper arm length, lower arm length, leg length, thigh circumference, upper leg length, and lower leg length. 10,226 infants (5,422 males, 4,804 females) with gestation 28-42 weeks from 12 hospitals were included. The LMS method using maximum penalized likelihood was used to perform model fitting of the anthropometric centiles for these parameters. This study provided the first set of references for the limbs of the infants by gestation and gender. Racial differences were found when comparing with other populations. The parameters are useful for evaluation of morphologic disorders involving the limbs.

Trunk anthropometry of Hong Kong Chinese infants

BACKGROUND

Disturbed growth of the trunk may result in abnormal sternocostal relationship and a variety of pectus deformities.

AIMS

The purposes of this study were to establish norms of trunk anthropometry for dysmorphology identification in the newborns and to evaluate chest circumference as a predictor for low birth weight for outborn infants where weighing scales were unavailable.

STUDY DESIGN AND SUBJECTS

A total of 10,339 Chinese infants (5478 males, 4861 females) with gestation 24-42 weeks from 12 hospitals were included. The anthropometric measurements analyzed included chest circumference, inter-nipple distance, sternal length and abdominal circumference.

OUTCOME MEASURES

The LMS method using maximum penalized likelihood was used to perform model fitting of the anthropometric centiles for these physical parameters.

RESULTS

References tables of the four physical parameters for newborns were constructed. Chest circumference showed the highest correlation with birth weight (male: r = 0.866, female: r = 0.883). The cut-off points for chest circumference of 295 (male) and 299 mm (female) were the best predictor for low birth weight. There were also racial differences in these parameters. When compared with French infants, Chinese newborns had smaller chest circumference.

CONCLUSION

These physical parameters provide useful references and aid dysmorphology diagnosis in newborns of ethnic Chinese origin.

Normative Data of Penile Length for Term Chinese Newborns

Careful examination and assessment of penile length in the newborn is important because micropenis is associated with hypothalamic disorders. This prospective cross-sectional study was designed to establish the norm of penile length for term Hong Kong Chinese newborns. 4,628 full-term healthy male newborns were enrolled in the study. Penile length was measured from pubic ramus to the tip of the glans penis by placing the end of a straight edge ruler against the pubic ramus. A gestation-associated graph of 3rd, 10th, 25th, 50th, 75th, 90th and 97th centiles for the penile length was created. The penile length was significantly correlated with gestational age, birth weight and body length. When compared with published data for other populations, Hong Kong newborns have significantly shorter penile length. The norm of the penile length is useful in diagnostic and therapeutics for the ethnic Chinese male newborns.

Fetal growth velocities in Hong Kong Chinese infants

Few studies have investigated the velocities of fetal growth. The aim of the present study was to determine the pattern of 'fetal' growth velocities in a Chinese population. The gestation-specific measurements of the body weight, body length and head circumference in a representative sample of 5,045 male and 4,484 female newborns delivered between 26 and 42 weeks of gestation at 12 hospitals in Hong Kong were obtained. Peak growth velocity occurred before 30 weeks of gestation for head circumference, at week 30 for length and at week 30 for weight. When compared with data obtained from a French population, a significant difference in the growth velocity for body weight was observed below 32 weeks between French and Chinese infants, suggesting an ethnic difference in fetal growth of this parameter.

Post-SARS infection control in the hospital and clinic

The recent severe acute respiratory syndrome (SARS) outbreak has almost mandated a re-evaluation of infection control practices in hospitals, clinics, schools and domestic environments, especially for patients with respiratory tract symptoms. Triage, early case detection followed by prompt isolation and quarantine are major preventive measures. Respiratory tract infections are the most common childhood illnesses and paediatric SARS poses special problems in diagnosis because of its non-specific presentation. The main lessons learnt from the outbreak were: (1) despite well established guidelines on infection control precautions, poor understanding of underlying principles and deficiencies in compliance are common among healthcare professionals, especially during emergencies; (2) even a slight lapse can be fatal; and (3) over-protection can be counterproductive. Hence it is important to: (1) be protected to protect others; (2) be vigilant and prepared for emerging infections; (3) be proficient and scrupulous in infection control measures; (4) be apposite and practical on personal protective equipments to ensure sustainability; and (5) be dutiful and prompt in informing of potential threats and work closely with others.

Rapid assessment of a helpdesk service supporting severe acute respiratory syndrome patients and their relatives

BACKGROUND

To contain severe acute respiratory syndrome, the Hong Kong Hospital Authority set a policy that stipulated there should be no visitors to hospital wards. A helpdesk service was established with the goal of providing immediate emotional and communication support to relatives while severe acute respiratory syndrome patients were isolated during the acute phase of the illness.

AIM

This study describes the results of a rapid assessment of the effectiveness of a helpdesk service designed to meet the immediate needs of relatives of severe acute respiratory syndrome patients in Hong Kong.

DESIGN

Survey.

METHOD

Eighty-three respondents, representing about 46.3% of relatives (179), attending the helpdesk on the day of the study were recruited. Service evaluation data was collected using a self-administered questionnaire completed by respondents.

RESULTS

Nearly 100% of respondents who used the service found the delivery service with on-site counselling useful for alleviating their anxiety. However, about half of these relatives complained of insufficient information regarding the patient's condition and progress. The majority of respondents were satisfied with the service. In describing the most important traits of the service providers, caring and enthusiasm were mentioned most frequently by respondents who stated that they were very satisfied with the service.

CONCLUSION

The results support the value of the service, and demonstrate that the service is effective in meeting relatives' immediate needs. These needs include information, aid in fulfilling their role as caretaker for the patient (delivering prepared soup) and psychological support. The results suggest that facilitation of visitation of patients by relatives via video conferencing and education of the public on the nature and course of severe acute respiratory syndrome to reduce the social stigma of having a potentially life-threatening disease should be introduced in Hong Kong.

RELEVANCE TO CLINICAL PRACTICE

The results highlight important attributes that helpers (nurses) should have in order to alleviate the suffering of severe acute respiratory syndrome patients and their relatives.

Jervell-Lange Nielsen syndrome in a Pakistani family

Congenital long QT syndrome is a rare hereditary disease that is related to the dysfunction of ion channels in cardiac cells. We report on a very rare case of its autosomal recessive form--the Jervell-Lange Nielsen syndrome--in a Pakistani family, which was diagnosed after the incidental finding of bradycardia in a newborn baby girl. We discuss the range of presentations in neonates; the importance of strong suspicion of the syndrome and family screening; the use of the diagnostic criteria and genetic tests; and the different management strategies.

Consensus statement on iodine deficiency disorders in Hong Kong

This article reviews the available data on the study of iodine deficiency disorders in Hong Kong and to discuss the approach towards preventing such disorders in Hong Kong. The importance of iodine and iodine deficiency disorders is described, and the available data on the dietary iodine intake and urinary iodine concentration in different populations of Hong Kong are summarised and discussed. Dietary iodine insufficiency among pregnant women in Hong Kong is associated with maternal goitrogenesis and hypothyroxinaemia as well as neonatal hypothyroidism. Borderline iodine deficiency exists in the expectant mothers in Hong Kong. Women of reproductive age, and pregnant and lactating women should be made aware and educated to have an adequate iodine intake, such as iodised salt, as an interim measure. A steering group involving all stakeholders should be formed to advise on the strategy of ensuring adequate iodine intake, including universal iodisation of salt in Hong Kong. Continuous surveillance of iodine status in the Hong Kong population is necessary.

A case of partial trisomy 13 presenting with hyperinsulinaemic hypoglycaemia

We report on a newborn baby with partial trisomy 13 who presented with multiple dysmorphic features and hyperinsulinaemic hypoglycaemia. Cytogenetic study on peripheral blood lymphocytes showed 47,XY,+mar in all cells analysed; fluorescent in situ hybridisation showed that the marker was solely derived from chromosome 13. The final karyotype was 47,XY,+del(13)(q14q32). Milk formula through a nasogastric drip and intravenous glucose infusion were given to prevent further hypoglycaemia. However, the baby developed occasional episodes of hypoglycaemia during bolus feeding. Hence, diazoxide was given, at a dosage of 10 mg/kg per day from day 24. Thereafter, no hypoglycaemic episodes were detected. Subsequent follow-up revealed satisfactory growth, global developmental delay, and left divergent squint.

Unintentional residential child injury surveillance in Hong Kong

OBJECTIVES

To provide an overall pattern of morbidity in unintentional residential childhood injuries (URCI) in Hong Kong.

METHODOLOGY

A cross-sectional telephone survey of caregivers of children aged under 16-years and adolescents suffering from URCI and admitted to three selected local Accident and Emergency Departments.

RESULTS

Falls, cuts and scalds were the most common external causes of URCI observed, while boys predominated in the sample population. Most of the observed URCI were of moderate to mild severity. Children of new immigrant mothers were more likely to receive first aid immediately after the incidents. Parents were aware of potentially injurious behaviour and intervened on occasion, but most resorted to verbal warnings only.

CONCLUSIONS

Prevalence of falls among observed URCI offers evidence in support of the hypothesis that the high population density in Hong Kong plays an integral role in understanding mechanisms of morbidity. Parents show concern about URCI but often lack substantial action that modifies injury risk. Considering the local injury differentials, an active prevention effort such as behavioural intervention and education for parents may be useful.

Sitosterolaemia and xanthomatosis in a child

A 4-year-old boy presented with multiple tuberous xanthomata and a fasting plasma sterol concentration of 18.3 mmol/L, consisting primarily of cholesterol. Two months after changing from an unrestricted diet to a cholesterol-lowering diet, the plasma sterol concentration decreased to 4 mmol/L. Fasting plasma cholesterol levels for his father and mother were 7.3 mmol/L and 6.0 mmol/L, respectively. The degree and rapidity of the child's response to dietary control, together with the fasting cholesterol results of both parents suggested a diagnosis of sitosterolaemia. Gas chromatography and mass spectrometry of the patient's plasma sterol levels showed that the percentage of beta-sitosterol was raised at 12.76%, as was campesterol (6.26%), and stigmasterol (0.71%), confirming the diagnosis of sitosterolaemia. The addition of cholestyramine 4 g/day to a low sterol diet maintained the plasma sterol concentration at 4 to 5 mmol/L, and gradual regression of the xanthoma was observed. These findings indicate that a diagnosis of sitosterolaemia, a treatable cause of premature atherosclerosis, should be considered in children with severe hypercholesterolaemia whose plasma cholesterol level is highly responsive to dietary manipulation.

Updated gestational age specific birth weight, crown-heel length, and head circumference of Chinese newborns

OBJECTIVE

To construct gestation specific standards of birth weight, crown-heel length, and head circumference of Chinese infants.

DESIGN

A prospective cross sectional population study.

METHODS

The birth weight, crown-heel length, and head circumference were prospectively measured using standard equipment in newborns delivered at 24-42 weeks gestation in the maternity units of 10 public hospitals and two private hospitals in Hong Kong. The findings were used to construct gestation specific standards of these variables. The LMS method using maximum penalised likelihood was used to perform model fitting. The results were compared with those obtained from a cohort of infants born in the same locality between 1982 and 1986.

RESULTS

From October 1998 to September 2000, a total of 10 032 infants were measured, representing 9.6% of the total deliveries in Hong Kong during that period. An extra 307 infants with gestation < or = 35 weeks were recruited from October 2000 to June 2001. Each of the three variables showed a normal distribution at each gestational week. Gestation specific reference standards for each variable were constructed for male and female infants separately. Comparison with the 1982-1986 cohort showed a significant secular trend to increased birth weight. The trend was small, but significant, for crown-heel length and head circumference.

CONCLUSION

These growth standards will provide useful references for the care of newborns of ethnic Chinese origin. These standards, especially that for birth weight, should be updated regularly.

Gaucher disease with pulmonary involvement in a 6-year-old girl: report of resolution of radiographic abnormalities on increasing dose of imiglucerase

We report resolution of ground-glass appearance in high-resolution computed tomography of chest in a 6-year-old girl who had Gaucher disease with pulmonary involvement. This radiographic abnormality, which developed during the course of enzyme replacement therapy at doses between 20 to 60 U/kg/2 weeks, resolved when the dose was increased to 100 U/kg/2 weeks. This case illustrates the importance of trial of escalating dosage in the face of failure of response at lower doses.

An international comparison of childhood injuries in Hong Kong

OBJECTIVES

This study describes 7813 childhood injuries in Shatin, Hong Kong. Supplementary analyses include developmental specificity of external causes and comparison with international childhood injury data.

METHODS

Children aged 0-15 attending the accident and emergency (A&E) department of the Prince of Wales Hospital in Hong Kong were recruited for the study. Attendance records of participants from the A&E department were analyzed. Details concerning the injury, including the International Classification of Diseases, ninth revision, external cause of injury (E code), nature of injury (N code), abbreviated injury scale, and injury severity scale constitute core measurements, along with participants' age, gender, and respective A&E procedural data.

RESULTS

Males (65.7%) and fall related injuries (44.2%) predominate, while contusion (34.6%) is the prevailing nature of injury. Two age external cause dimensions are derived from a correspondence analysis. Children 0-1 years old are associated with falls, poisoning, scalds, and machinery related injury. Adolescents aged 12-15 are associated with motor related injury, animal related injury, and cuts/piercings. In comparison with international data, unintentional child injuries in Hong Kong comprised more falls but fewer poisonings and burns.

CONCLUSION

A large proportion of falls, along with low proportion of poisonings and burns, are characteristics of childhood injury profile in Hong Kong. From the results of age external cause correspondence analysis, prevention strategies for different external cause should be developmentally specific.

Survival of a 30-week baby with congenital myotonic dystrophy initially ventilated for 55 days

In previous reports, duration of initial ventilation exceeding 1 month almost always predicts non-survival of babies with congenital myotonic dystrophy. However, a baby with this condition survived beyond infancy after 55 days' ventilation. We describe this case in detail, explain why the baby survived and highlight the importance of individualized assessment, in addition to applying general prognostic terms described in the literature.

Hepatitis C virus antibody in multiply transfused Chinese with thalassaemia major

Thirty-four of 99 multiply transfused Chinese (49 females, 50 males) with thalassaemia major were positive for antibody to hepatitis C virus. There was no sex predominance in seropositivity with 18 females and 16 males positive. The mean (+/- SD) age and units of blood transfused were significantly higher in the seropositive patients (167 +/- 48 months, 206 +/- 82 units respectively) than the seronegative patients (113 +/- 56 months, 124 +/- 80 units respectively). The seropositive patients had higher mean (+/- SD) serum alanine aminotransferase, aspartate aminotransferase and ferritin concentrations (91 +/- 82 IU/L, 67 +/- 38 IU/L, 4797 +/- 2522 ng/ml respectively) than the seronegative patients (38 +/- 29 IU/L, 48 +/- 28 IU/L, 3620 +/- 2140 ng/ml respectively). Serum ferritin had an independent and significant effect on serum alanine aminotransferase in addition to that of seropositivity to hepatitis C virus.

Changing epidemiology of measles in Hong Kong from 1961 to 1990--impact of a measles vaccination program

With the use of measles vaccine since 1967, Hong Kong has experienced a low incidence of measles until a major outbreak in 1988. A shift in the distribution of susceptible children to older age groups was suddenly accelerated in the 1988 outbreak. The attack rate increased by 18.9-fold for children greater than 10 years old, while that for those in the best-protected age group of 1-4 years was only 2.2-fold. Of the cases during that outbreak, 56.3% would have been considered preventable with the present vaccination regimen, and vaccine failures accounted for only 20.4% of the cases. Present control strategies aim at increasing the coverage rate rather than introducing a two-dose regimen, which may be necessary when vaccine failures account for a larger proportion of measles cases.

Chronic granulomatous disease: a different pattern in Hong Kong?

From July 1988 to December 1989, six boys with chronic granulomatous disease were diagnosed in our institutions. Their clinical features were reviewed in order to delineate the pattern of infections which seems to have both similarities and differences when compared with published reports of Caucasian patients. The most striking differences was the lack of skin sepsis and chronic lymphadenitis in our six patients. Gram-negative organisms were the commonest pathogens while Staphylococci sp. were not isolated. Clinical features which should alert one to the diagnosis were also highlighted. Prophylactic co-trimoxazole was effective in reducing the frequency of bacterial infections. Early diagnosis is not only essential for optimal patient management but also for genetic counselling for the extended family.

[Hypoplastic left heart syndrome due to aortic and mitral atresias: report of one case]

A three-day-old female infant was transferred to the Pediatric Intensive Care Unit with chief presenting problems of progressive change of cyanosis and respiratory distress. Physical examination revealed tachypnea, acrocyanosis, hepatomegaly, undetectable pulse of extremities and oozing over the place of venous puncture. Chest roentgenograms revealed slight cardiomegaly; other X-rays were within normal limits. Complete electrocardiograms showed right axis deviation and right ventricular hypertrophy. Because of an impression of neonatal sepsis, the patient was put in an incubator with oxygen and antibiotics were given. Persistent anuria appeared associated with sighs of cardiac and renal failure; the ventilator was applied; dopamine and lasix were also given. Unfortunately, the cyanosis worsened progressive. Despite several attempts at resuscitations, the infant expired eight hours later. Pathology disclosed the heart size as normal; hypoplasia of ascending aorta as 0.4 cm in diameter; a PDA with 1 cm in diameter; a diminutive bean-sized left ventricle; hypertrophy of right ventricle and atresias of aortic and mitral valves. There was no evidence of septicemia.

Typhoid fever in Hong Kong children

Experience with typhoid fever in 111 children over a 5-year period was reviewed. There were 66 boys and 45 girls, ranging in age from 1 to 11.5 years. The symptoms of typhoid fever were quite non-specific. Fever was the most common presenting symptom (in 98.3%). Other common presenting features were diarrhoea (25.7%), constipation (22%), vomiting (21.1%), cough (25%), abdominal pain (27.5%), headache (9.2%), epistaxis, meningism and convulsions. Rose spots were detected in 20% of cases, occurring mainly during the first 2 weeks of illness. Significant Widal reactions were present in 84.7% of cases. Blood and stool cultures were positive in 57% and 44% of cases, respectively. Peripheral blood white cell counts were not found to be of great diagnostic value. Chloramphenicol remained the drug of choice in the treatment of typhoid fever. It was more effective than ampicillin or co-trimoxazole. Complications were uncommon, occurring in only two patients. There were two deaths; both were admitted late and in moribund state. Early diagnosis and treatment is vital in typhoid fever and, as the presenting features are non-specific, a high index of suspicion is required.

High prevalence of hepatitis B surface antigenaemia in nephrotic syndrome in Hong Kong

Of 61 boys and girls with relapsing or steroid-resistant nephrotic syndrome admitted for renal biopsy, 22 had persistent hepatitis B virus surface antigenaemia despite normal liver function and an absence of previous transfusion. The prevalence of hepatitis B virus surface antigenaemia amongst nephrotic patients is significantly higher than that of the general population. Membranous nephropathy remains the commonest glomerulopathy associated with hepatitis B virus antigenaemia, and boys predominate.

Acute viral hepatitis: aetiology and evolution

Over a period of three and a half years, 348 consecutive children with acute hepatitis were studied. There were 205 boys and 143 girls aged from 3 months to 12 years old. The most common type was hepatitis A, of which there were 281 cases, 81% of the total; there were 41 in the under 4 years old age group (63% of that group), 99 in the 5-8 year old age group (87% of that group) and 141 in the 8-12 year old age group (83% of that group). Hepatitis B occurred in 29 (8% of the total), and non-A, non-B hepatitis occurred in 35 (10%). All the children with hepatitis A and all but one with hepatitis B recovered. There were three deaths from fulminant hepatitis, one in the group with hepatitis B and two with non-A, non-B. Clearance of the hepatitis B surface antigen was fast, by six months 26 patients having cleared the antigen and 21 (77%) being positive for hepatitis B surface antibody. One patient became a carrier of hepatitis B surface antigen.

Diagnostic value of the Widal test in childhood typhoid fever

The usefulness of the Widal test in diagnosing childhood typhoid fever in endemic areas was investigated. The test was done on 150 children with other febrile illnesses and 98 bacteriologically proved cases of typhoid fever. Of the 150 children with nontyphoidal fever, only one had an H agglutinin titer of 1:50. Using an H or O agglutinin titer of 1:50 or more as a criterion for diagnosis, a positive Widal test was found in 88% of typhoid fever cases on the first occasion on which the test was done. If the test was repeated at least 94% of the typhoid cases had a significant result. The Widal test is a useful diagnostic test in children in endemic areas, provided interpretation of the test is made against background information relating to agglutinin levels in normal children in the region.

The clinico-pathologic features of hepatitis B virus-associated glomerulonephritis

The frequency of hepatitis B surface antigen (HBsAg) was studied in the sera of 311 patients with various forms of primary glomerulonephritis and 43 patients with lupus nephritis. HBs antigenaemia was detected in 69 of the 311 patients (22 per cent) with primary glomerulonephritis and this prevalence of HBsAg carrier was significantly higher than that in the general population (p less than 0.001). These patients had no clinical or biochemical findings to suggest acute or chronic liver disease. A higher HBs antigenaemia carrier rate was not observed in patients with lupus nephritis. Three glomerulopathological entities, membranous nephropathy, IgA nephropathy, and mesangial proliferative glomerulonephritis, were found to be associated with a higher prevalence of HBs antigenaemia compared with the general population (p less than 0.001). Glomerular deposits of HBsAg and/or hepatitis core antigen (HBcAg) were detected in 41, 61, and 60 per cent of renal biopsy specimens from patients with membranous nephropathy, IgA nephropathy, and mesangial proliferative glomerulonephritis associated with persistent HBs antigenaemia respectively. During the mean study period of 40 months (range 12-180), 14 per cent of these patients with hepatitis-associated glomerulonephritis developed progressive renal failure, although none required maintenance dialysis. Our study suggests that hepatitis B virus antigenaemia may play a significant role in the development of specific forms of glomerulonephritis and that these hepatitis B virus-associated glomerulonephritides can run an indolent but relentless progressive clinical course.

A prospective study on the intrauterine growth of Hong Kong Chinese babies

A prospective study on the birth weight, crown-heel length and head circumference of 8,445 singleton Chinese newborn infants born between 27 and 42 weeks of gestation was conducted in three major regional maternity units in Hong Kong over a 3 1/2-year period. The data were used to construct centile charts for the intrauterine growth of each physical measurement. By careful gestational assessment of the infants, primary exclusion of pregnancies complicated by abnormal fetal or maternal conditions that might have affected fetal growth together with infants of doubtful maturity, these curves depict more accurately the prenatal growth of Chinese infants than those previously published in studies on similar populations of infants. Chinese infants, as shown by the findings of the present study, are similar in their mean weight to Japanese infants and American infants in Denver but are lighter than British and Australian infants, as well as American infants born at sea level.

Loperamide associated necrotising enterocolitis

Two cases of necrotising enterocolitis (NEC) occurring in infants beyond the neonatal period were reported. They did not have any predisposing factors to NEC but both had paralytic ileus after loperamide therapy for their mild diarrhoea prior to the onset of NEC. The possible role of loperamide in the pathogenesis of NEC was discussed.

Membranous glomerulonephritis in Hong Kong

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