[Efficacy and safety of fourth-generation CD19 CAR-T expressing IL7 and CCL19 along with PD-1 monoclonal antibody for relapsed or refractory large B-cell lymphoma]

Objective: This study systematically explore the efficacy and safety of fourth-generation chimeric antigen receptor T-cells (CAR-T), which express interleukin 7 (IL7) and chemokine C-C motif ligand 19 (CCL19) and target CD19, in relapsed or refractory large B-cell lymphoma. Methods: Our center applied autologous 7×19 CAR-T combined with tirelizumab to treat 11 patients with relapsed or refractory large B-cell lymphoma. The efficacy and adverse effects were explored. Results: All 11 enrolled patients completed autologous 7×19 CAR-T preparation and infusion. Nine patients completed the scheduled six sessions of tirolizumab treatment, one completed four sessions, and one completed one session. Furthermore, five cases (45.5%) achieved complete remission, and three cases (27.3%) achieved partial remission with an objective remission rate of 72.7%. Two cases were evaluated for disease progression, and one died two months after reinfusion because of uncontrollable disease. The median follow-up time was 31 (2-34) months, with a median overall survival not achieved and a median progression-free survival of 28 (1-34) months. Two patients with partial remission achieved complete remission at the 9th and 12th months of follow-up. Therefore, the best complete remission rate was 63.6%. Cytokine-release syndrome and immune effector cell-associated neurotoxicity syndrome were controllable, and no immune-related adverse reactions occurred. Conclusion: Autologous 7×19 CAR-T combined with tirelizumab for treating relapsed or refractory large B-cell lymphoma achieved good efficacy with controllable adverse reactions.

[Impact of orthotopic liver transplantation on serum lipid level and growing development in patients with homozygous or compound heterozygous familial hypercholesterolemia]

Objective: To investigate the impact of orthotopic liver transplantation on serum lipid and growing development in patients with homozygous (HoFH) or compound heterozygotes (cHeFH) familial hypercholesterolemia. Methods: Patients who were treated in Peking Union Medical College Hospital from August 2019 to August 2021, entered the rare disease database and underwent liver transplantation, were included in this single center retrospective cohort study. The height for age Z score (HAZ) and length for age Z score (WAZ) at birth, at the time of transplantation and one year after transplantation were calculated respectively by collecting demographic characteristics, clinical manifestations, echocardiography, lipid-lowering treatment, blood lipid level data and donor characteristics data of liver transplantation. The serum cholesterol level and growing development changes before and after liver transplantation were evaluated. Results: A total of five patients with HoFH or cHeFH, including two females, were included in this study. The median age was 10 years (6-22 years). The median follow up duration was 28 months (24-33 months). All HoFH or cHeFH patients in this study received the maximum daily dosage of the lipid-lowering drug combined with low salt and low-fat diet control treatment for at least 3 months before orthotopic liver transplantation. The average level of total cholesterol (TC) decreased by 27% compared with that before treatment, the level of low-density lipoprotein cholesterol (LDL-C) decreased by 21% after 3 months treatment. There was no intervention of lipid-lowering therapy after operation. One month after liver transplantation, the average levels of TC and LDL-C further decreased rapidly by 68% and 76% respectively. One year after liver transplantation, the level of LDL-C decreased from (17.1±1.6)mmol/L without any intervention before transplantation to (3.0±0.7)mmol/L, and remained stable thereafter. In addition, compared with no intervention before liver transplantation, the serum triglyceride (TG) level decreased after the maximum daily dosage of the lipid-lowering drug and low salt and low-fat diet control for 3 months ((1.88±0.27) mmol/L vs. (1.12±0.55)mmol/L, P=0.031), and the HDL-C level also decreased significantly ((1.95±0.49)mmol/L vs. (0.95±0.30)mmol/L, P=0.006) at the same time period. TG and HDL-C remained stable after liver transplantation during the 24-month follow-up period (P>0.05). One and two years after liver transplantation, there was no significant difference in height and weight, malnutrition and growth retardation between the patients in this cohort and Chinese children of the same age. Conclusion: Early liver transplantation is a feasible and effective treatment option for HoFH or cHeFH patients with extremely high serum low-density lipoprotein cholesterol levels.

[Clinical features and treatment outcome of patients with non-Hodgkin lymphoma-associated hemophagocytic lymphohistiocytosis]

Objective: To investigate the clinical features and effect of prognostic factors in patients with different pathological types of non-Hodgkin lymphoma-associated hemophagocytic lymphohistiocytosis. Methods: We collected and analyzed the clinical data of 89 patients with non-Hodgkin lymphoma-associated hemophagocytic lymphohistiocytosis who were treated at Huadong Hospital from March 2013 to May 2020. The data were analyzed via log-rank and Cox multivariate analyses. Results: The median overall survival time of the 89 cases was 10.2 months. Patients with B-cell lymphoma-associated hemophagocytic lymphohistiocytosis did not reach the median overall survival time. The median overall survival times of T-cell lymphoma-associated hemophagocytic lymphohistiocytosis and NK-cell lymphoma-associated hemophagocytic lymphohistiocytosis were 10.2 and 3.0 months, respectively. The pathological type of non-Hodgkin lymphoma (OS: P=0041, PFS: P=0.015) , ECOG score ≥ 3 (OS: P=0.031, PFS: P=0.030) , hematopoietic stem cell transplantation (OS: P=0.005, PFS: P=0.040) , lymphadenopathy (OS: P=0.007, PFS: P=0.012) , and splenomegaly (OS: P=0.276, PFS: P=0.324) were related to the overall survival and progression-free survival of patients with non-Hodgkin lymphoma-associated hemophagocytic lymphohistiocytosis. Splenectomy could improve the prognosis of patients with lymphoma-associated hemophagocytic lymphohistiocytosis, especially T-cell lymphoma-associated hemophagocytic lymphohistiocytosis. Conclusion: The clinical characteristics of patients with different pathological types of non-Hodgkin lymphoma-associated hemophagocytic lymphohistiocytosis were similar but were different in the overall survival rate and the effect of prognostic factors. We suggested that patients with non-Hodgkin lymphoma-associated hemophagocytic lymphohistiocytosis should receive more than combined chemotherapy. To improve the prognosis and survival rate of patients, those with B-cell lymphoma-associated hemophagocytic lymphohistiocytosis and NK-cell lymphoma-associated hemophagocytic lymphohistiocytosis promptly require hematopoietic stem cell transplantation. Moreover, patients with T-cell lymphoma-associated hemophagocytic lymphohistiocytosis should consider splenectomy.

[Performance of high-risk HPV typing test in early diagnosis of cervical cancer]

Objective: To evaluate the performance of High-risk HPV typing detection in cervical cancer screening. Methods: A total of 3 231 women were recruited as the subjects of cervical cancer screening from Jiyuan city of Henan provinces from June to July 2017. All women underwent HPV DNA test. The women with cytological examination ≥ASCUS or cytological examination negative and HPV 16/18 positive underwent colposcopy biopsy and pathological examination. Pathological diagnosis was used as the gold standard. Sensitivity, specificity, positive predictive value (PPV), negative predictive value(NPV) as well as corresponding 95% confidence interval (CI) of HR-HPV and HPV 16/18 were calculated. Results: The mean age of 3 231 subjects selected in this study was 46.84±10.00 (21-64) years old. 524 subjects had the positive results of HR-HPV, including 91 of HPV16 and 15 of HPV18. Pathological test result CIN2+ was the gold standard. The sensitivity and specificity of HR-HPV for cervical precancer lesions screening were 93.75 (95%CI: 79.85-98.27) and 84.56% (95%CI: 83.26-85.77), respectively. To compared with HR-HPV, HPV16/18 had low sensitivity (65.63%, 95%CI: 48.31-79.59)and higher specificity (97.44%, 95%CI: 96.83-97.93). After age stratification by age 30 and 45, the sensitivity of HPV 16/18 was same with HR-HPV (100%, 95%CI: 34.24-100.00), the specificity of HPV 16/18 was higher than HR-HPV (98.71%, 95%CI: 96.27-99.56 vs 84.48%, 95%CI: 79.27-88.58) in<30 age group.The sensitivity of HR-HPVin 30-45 and ≥45 age group were higher than HPV16/18 (85.71%, 95%CI: 48.69-97.43 vs 71.43%, 95%CI: 35.89-91.78, 95.65%, 95%CI: 79.01-99.23 vs 60.87%, 95%CI: 40.79-77.84), but the specificity werelower than HPV16/18 (86.89%, 95%CI: 84.58-88.90 vs 98.51%, 95%CI: 97.51-99.11、83.49%, 95%CI: 81.81-85.04 vs 96.80%, 95%CI: 95.94-97.48). Conclusions: HR-HPV detection has relatively high sensitivity and specificity in cervical cancer screening. For >30 years old women, HR-HPV is more recommended in cervical cancer screening. Therefore, HR-HPV detection is an effective method for cervical cancer screening.

Effects of Bi incorporation on recombination processes in wurtzite GaBiAs nanowires

The effects of Bi incorporation on the recombination process in wurtzite (WZ) GaBiAs nanowires are studied by employing micro-photoluminescence (μ-PL) and time-resolved PL spectroscopies. It is shown that at low temperatures (T < 75 K) Bi-induced localization effects cause trapping of excitons within band-tail states, which prolongs their lifetime and suppresses surface nonradiative recombination (SNR). With increasing temperature, the trapped excitons become delocalized and their lifetime rapidly shortens due to facilitated SNR. Furthermore, Bi incorporation in the GaBiAs NW is found to have a minor influence on the surface states responsible for SNR.

[Evaluation the triage performance of p16/Ki-67 dual staining for HR-HPV positive women]

Objective: This study aimed to evaluate the clinical performance of p16/Ki-67 dual staining for triage high risk HPV (HR-HPV) infected women. Method: Target objects were women who infected HR-HPV and received colposcopy examination between April and December of 2016 at the Second Affiliated Hospital of Zhengzhou University. Gynecologists collected the cervical exfoliated cells from eligible women for p16/Ki-67 dual staining, LBC testing and HPV DNA testing. Histology diagnosis were used as gold standard. Sensitivities, specificities, positive predictive values (PPVs), negative predictive values (NPVs) of p16/Ki-67 dual staining, LBC testing and HPV16/18 testing for triage of HR-HPV positive population were calculated and compared. Results: A total of 295 HR-HPV infected women were selected, and the mean age was (44.29±11.48) years old. Positive rates of p16/Ki-67 dual staining, HPV16/18 testing and LBC testing were 70.17% (207), 56.95% (168) and 85.76% (253), respectively. When CIN2+as the endpoint, among the three triage methods, sensitivity of p16/Ki-67 dual staining was 90.00% (95%CI: 85.06%-93.43%), higher than the value of HPV 16/18 testing, but lower than the value of LBC testing. Specificity, PPV and NPV of p16/Ki-67 dual staining were the highest [71.58% (95%CI: 61.81%-79.67%), 86.96% (95%CI:81.69%-90.88%) and 77.27% (95%CI: 67.49%-84.78%)]. When detection for CIN3+, sensitivity of p16/Ki-67 dual staining was 92.90% (95%CI: 87.74%-95.99%), lower than the value of LBC testing, but higher than the value of HPV16/18 testing. Specificity of p16/Ki-67 dual staining was 55.00% (95%CI: 46.74%-63.00%), lower than the value of HPV16/18 testing, but higher than the value of LBC testing. PPV of p16/Ki-67 dual staining was 69.57% (95%CI: 62.99%-75.43%), lower than the value of HPV 16/18 testing, but higher than the value of LBC testing. NPV of p16/Ki-67 dual staining was 87.50% (95%CI: 78.99%-92.87%), higher than value of HPV 16/18 testing, but lower than the value of LBC testing. Conclusion: p16/Ki-67 dual staining has better clinical effects than HPV 16/18 testing and LBC testing for triage women with HR-HPV infection.

[Joint effect of smoking and diabetes on stroke]

Objective: To explore the interaction of smoking and diabetes on stroke. Methods: In this case-control study, a face to face questionnaire survey was conducted. Logistic regression models were used to analyze the relationship between smoking or diabetes and stroke. The indicators of interaction were calculated according to the Bootstrap method in this study. Results: A total of 918 cases and 918 healthy controls, who participated in the chronic disease risk factor survey in Xuzhou in 2013, were included in this study. Logistic regression analysis found that cigarette smoking was associated with stroke (OR=1.63, 95%CI: 1.33-2.00), and diabetes was also associated with stroke (OR=2.75, 95%CI: 2.03-3.73) after adjusting confounders. Compared with those without diabetes and smoking habit, the odds ratio of stroke in those with diabetes and smoking habits was 8.94 (95%CI:3.77-21.19). Diabetes and smoking combined interaction index was 3.65 (95%CI: 1.68-7.94), the relative excess risk was 5.77 (95%CI: 0.49-11.04), the attributable proportion was 0.65 (95%CI: 0.42-0.87). Conclusion: The results suggest that there are additive interactions between smoking and diabetes on stroke.

[The clinical characteristics of pediatric external auditory canal keratosis obturans]

Objective: To analyze the clinical characteristics of pediatric external auditory canalkeratosis obturans(KO). Method: Retrospective analyze the clinical data of twenty-three patients were diagnosed with external auditory canal cholesteatoma(EACC). Their chief complaint, the course of the disease, clinical characteristics,CT manifestations,surgical procedure and prognosis were retrospectively analyzed. The clinical characteristics between EACC and KO were compared.Result: Twenty cases(22 ears) were eventually diagnosed as KO. Among them, 2 cases were bilaterally involved. In the remaining unilateral cases, right ear was involved in 11 cases and left ear in 7 cases. All patients complained otalgia(100%). Purulent otorrhea was found in 17 ears(77.3%), and hearing loss withpurulent otorrhea in 3 ears(13.6%). Otoscopic examination found 17 ear with granulation(77.3%).CT scan found deformation of the osseous ear canal and displacement of the tympanic membrane because of compression in 18 ears(81.8%), and the bony canal was absorpt because of pression in 7 cases(38.9%).All patients underwent otoendoscopic operation,and tympanic membrane perforation was found in 4 cases.Postoperative pathologic examination results were keratin epithelial. Conclusion: EACC is easily confused with KO. KO should be considered in the following circumstances: patient who complained of ear pain, ear granulation with purulent discharge, or circinate deformation of the osseous ear canal and displacement of the tympanic membrane in CT scan.

In-situ medical simulation for pre-implementation testing of clinical service in a regional hospital in Hong Kong

The implementation of a new clinical service is associated with anxiety and challenges that may prevent smooth and safe execution of the service. Unexpected issues may not be apparent until the actual clinical service commences. We present a novel approach to test the new clinical setting before actual implementation of our endovascular aortic repair service. In-situ simulation at the new clinical location would enable identification of potential process and system issues prior to implementation of the service. After preliminary planning, a simulation test utilising a case scenario with actual simulation of the entire care process was carried out to identify any logistic, equipment, settings or clinical workflow issues, and to trial a contingency plan for a surgical complication. All patient care including anaesthetic, surgical, and nursing procedures and processes were simulated and tested. Overall, 17 vital process and system issues were identified during the simulation as potential clinical concerns. They included difficult patient positioning, draping pattern, unsatisfactory equipment setup, inadequate critical surgical instruments, blood products logistics, and inadequate nursing support during crisis. In-situ simulation provides an innovative method to identify critical deficiencies and unexpected issues before implementation of a new clinical service. Life-threatening and serious practical issues can be identified and corrected before formal service commences. This article describes our experience with the use of simulation in pre-implementation testing of a clinical process or service. We found the method useful and would recommend it to others.

Intravenous lignocaine infusion facilitates acute rehabilitation after laparoscopic colectomy in the Chinese patients

INTRODUCTION

Intravenous infusion of lignocaine has emerged in recent years as a feasible, cost-effective, and safe method to provide postoperative analgesia. There is, however, no literature about this perioperative pain control modality in Chinese patients. This study aimed to determine whether perioperative intravenous lignocaine safely reduces postoperative pain, shortens postoperative ileus, and reduces the length of hospital stay in laparoscopic colorectal surgery.

METHODS

Between September 2012 and May 2015, 16 patients who underwent elective laparoscopic resection of colorectal cancer and received a 1% lignocaine infusion for 24 hours postoperatively were studied. After surgery, categorical pain scores were obtained immediately, followed by hourly pain scores at rest. Pain scores at rest and with mobilisation, and patient satisfaction score were documented on postoperative day 1. Return of bowel function was measured by time of first flatus and bowel opening. The patient's rehabilitation was assessed by time taken to tolerate diet, full mobilisation, and length of hospital stay.

RESULTS

The median (interquartile range) self-reported pain scores at 2 hours and 6 hours after surgery were 1.5 (0-4) and 2 (0-3), respectively. The median pain scores at rest and mobilisation on postoperative day 1 were 1 (0-2.5) and 2 (2.5-5), respectively, with a median satisfaction score of 7.5 (7-9). The median times to first flatus and first bowel opening were 21 (18-35) hours and 3 (1-3) days, respectively. No patient had postoperative ileus. The median times to tolerating diet and mobilisation were 1 (1-1) day and 2 (2-3) days, respectively. The median postoperative stay was 6 (5-8) days.

CONCLUSIONS

Intravenous lignocaine is a safe and effective postoperative analgesic in a Chinese population. It enhances the rehabilitation process for patients following laparoscopic resection of colorectal cancer.

A Study of the Reliability and Concurrent Validity of the Chinese Version of the Pain Medication Attitude Questionnaire (ChPMAQ) in a Sample of Chinese Patients with Chronic Pain

OBJECTIVES

The Pain Medication Attitude Questionnaire (PMAQ) was designed to assess concerns about pain medication among patients with chronic nonmalignant pain. The instrument has been demonstrated to be a reliable measure with good psychometric properties, yet its validity among Chinese has not been evaluated. This study aimed to translate the English-language version of the PMAQ into Chinese (ChPMAQ) and to evaluate its reliability and concurrent validity.

METHODS

A total of 201 Chinese patients with chronic pain attending two multidisciplinary pain clinics in Hong Kong completed the ChPMAQ, the Chronic Pain Grade (CPG) questionnaire, the mental health subscale of the SF-12 (QoL-Mental), and questions assessing sociodemographic and pain characteristics.

RESULTS

Our results showed that the seven ChPMAQ scales possessed good internal consistency. Except for the correlation between Withdrawal and Mistrust (r = 0.13), all ChPMAQ scales were significantly correlated with each other (all p < 0.01). The scales also correlated with two concurrent criterion measures, QoL-Mental and Pain Disability, in a predictable direction. Results of hierarchical multiple regression analyses showed that the ChPMAQ scales predicted concurrent QoL-Mental (F(7,190) = 2.75, p < 0.05) and pain disability (F(7,188) = 3.00, p < 0.01). Need (std β = -0.23, p<0.05) and Side effects (std β = 0.27, p < 0.01) emerged as independent predictors of concurrent QoL-Mental and pain disability, respectively.

CONCLUSION

Despite the current preliminary findings for the reliability and concurrent validity of the ChPMAQ, more research is needed to substantiate the reliability, validity and other psychometric properties of the instrument.

Quantitative description of collagen fibre network on trabecular bone surfaces based on AFM imaging

The collagen fibre network is an important part of extracellular matrix (ECM) on trabecular bone surface. The geometry features of the network can provide us insights into its physical and physiological properties. However, previous researches have not focused on the geometry and the quantitative description of the collagen fibre network on trabecular bone surface. In this study,we developed a procedure to quantitatively describe the network and verified the validity of the procedure. The experiment proceeds as follow. Atomic force microscopy (AFM) was used to acquire submicron resolution images of the trabecular surface. Then, an image analysing procedure was built to extract important parameters, including, fibre orientation, fibre density, fibre width, fibre crossing numbers, the number of holes formed by fibre s, and the area of holes from AFM images. In order to verify the validity of the parameters extracted by image analysing methods, we adopted two other methods, which are statistical geometry model and computer simulation, to calculate those same parameters and check the consistency of the three methods' results. Statistical tests indicate that there is no significant difference between three groups. We conclude that, (a) the ECM on trabecular surface mainly consists of random collagen fibre network with oriented fibres; (b) our method based on image analysing can be used to characterize quantitative geometry features of the collagen fibre network effectively. This method may provide a basis for quantitative investigating the architecture and function of collagen fibre network.

Incidence and risk factors for traumatic intraocular pressure elevation and traumatic glaucoma after open-globe injury

PURPOSE

To examine traumatic intraocular pressure (IOP) elevation and glaucoma after open-globe injury.

DESIGN

Retrospective, observational case series.

METHODS

Review of patients with open-globe repair at the University of Washington from May 1997 through July 2010. Traumatic IOP elevation and glaucoma were defined respectively as intraocular pressure (IOP) ≥22 mm Hg at >1 visit or need for glaucoma medication, and long-term (at least 3 months) glaucoma medication use or glaucoma surgery.

RESULTS

We included 515 eyes (515 patients). The mean follow-up was 12.6±20.1 months. One hundred twenty eyes (23.3%) developed traumatic IOP elevation, of which 32 (6.2%) developed glaucoma; six eyes (1.2%) required glaucoma surgery. The mean time to development of traumatic IOP elevation was 1.5±3.4 months (range 1 day to 2 years). Kaplan-Meier 6- and 12-month estimates for development of traumatic IOP elevation were 27.2 and 32.4%, respectively, and for development of traumatic glaucoma were 7.1 and 11.0%, respectively. Multivariate regression revealed associations between traumatic IOP elevation and older age, and traumatic glaucoma and prior penetrating keratoplasty, initial vitreous hemorrhage, Zone II injury, and penetrating keratoplasty after open-globe repair. Traumatic glaucoma was controlled (IOP <22 mm Hg) in 78.1% of eyes at final follow-up, with mean IOP of 18.2 mm Hg on 1.7 medications.

CONCLUSIONS

Traumatic IOP elevation and glaucoma were common after visually salvageable open-globe injury. Most cases developed within 6 months, although longer follow-up remains important for case detection. Penetrating keratoplasty before or after repair, and vitreous hemorrhage were notable risk factors.

The fear-avoidance model of chronic pain: assessing the role of neuroticism and negative affect in pain catastrophizing using structural equation modeling

BACKGROUND

Previous research on the fear-avoidance model (FAM) of chronic pain suggests that the personality traits of neuroticism and negative affect (NA) influence pain catastrophizing. However, the mechanisms of their influence on pain catastrophizing remain unclear.

PURPOSE

This study examined four possible models of relationships between neuroticism, NA, and pain catastrophizing within the FAM framework using structural equation modeling.

METHOD

A total of 401 patients with chronic musculoskeletal pain completed measures of neuroticism, NA, three core FAM components (pain catastrophizing, pain-related fear, and pain anxiety), and adjustment outcomes (pain-related disability and depression).

RESULTS

Regression analyses refuted the possibility that neuroticism and NA moderated each other's effect on pain catastrophic thoughts (p > 0.05). Results of structural equation modeling (SEM) evidenced superior data-model fit for the collapsed models in which neuroticism and NA were two secondary traits underlying a latent construct, negative emotion (disability: comparative fit index (CFI) = 0.93; depression: CFI = 0.91).

CONCLUSION

The results offer preliminary evidence that patients presenting with more neurotic symptom and heightened NA probably elicit more catastrophic thoughts about pain.

Pain management programme for Chinese patients: a 10-year outcome review

OBJECTIVES

To review the clinical and social benefits of a pain management programme in Hong Kong.

DESIGN

Prospective cohort study.

SETTING

Tertiary out-patient clinic, Hong Kong.

PARTICIPANTS

Patients with chronic non-cancer pain and prolonged (mean, 46 months) psychosocial disability who joined the Comprehensive Outpatient Pain Engagement programme between 2002 and 2012.

INTERVENTION

A structured 6-week out-patient pain rehabilitation course designed to improve function and reduce disability, regardless of the cause or severity of pain.

MAIN OUTCOME MEASURES

Social outcomes included return-to-work rate, hospital admissions, and out-patient visits. Physical outcomes included tolerance to sitting and standing. Psychological constructs such as mood, catastrophisation, self-efficacy, quality of life, and perceived performances were used. Each measure was taken before and 1 year after the programme.

RESULTS

There was significant increase in return-to-work rate 1 year after commencement of the programme (35% after vs 17% before the programme; odds ratio=3.01), reduction in medical utilisation, and improvement in all physical and psychological measures. Pain intensity, psychological distress, and history of work-related injuries were not related to the likelihood of return to work. Shorter duration of pain and higher physical functioning score in 36-Item Short-Form Health Survey were prognostic indicators.

CONCLUSIONS

Patients with chronic pain who joined the Comprehensive Outpatient Pain Engagement programme showed significant functional improvement despite the long history of pain.

A longitudinal analysis on pain treatment satisfaction among Chinese patients with chronic pain: predictors and association with medical adherence, disability, and quality of life

BACKGROUND

Patient satisfaction research in chronic pain treatment is scarce internationally and is nonexistent in Chinese communities like Hong Kong. This longitudinal study examined the relationships between medical adherence, pain treatment satisfaction, disability, and quality of life (QoL) in a sample of Chinese patients with chronic pain.

METHODS

A total of 178 patients with chronic pain were assessed at baseline, 3 and 6 months following baseline. Medical adherence and pain treatment satisfaction were assessed by the Participant Compliance Reporting Scale and the Pain Treatment Satisfaction Scale (PTSS), respectively. QoL, depression, pain catastrophizing, and pain-related fear were assessed using SF-12, the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D), the Pain Catastrophizing Scale, and the Tampa Scale for Kinesiophobia, respectively. Linear mixed effects models (LME) were fitted to identify predictors of pain treatment satisfaction, medical adherence, and QoL.

RESULTS

Results of univariate LME analyses showed significant quadratic time effects on four PTSS scores and significant associations between disability grade and PTSS scores (all p < 0.05). Medical adherence was not significantly associated with satisfaction regarding pain medication (model 1). Satisfaction with medication characteristics emerged as an independent predictor of medical adherence (model 2: std β = -0.11, p < 0.05) after controlling for sociodemographic and pain variables. Neither medical adherence nor pain treatment satisfaction predicted QoL outcomes (models 3 and 4).

CONCLUSIONS

Distinct trajectories in pain treatment satisfaction were displayed in the current sample of Chinese patients with different disability grading chronic pain. Within pain treatment, only medication characteristics significantly impacted patients' medical adherence.

Multiplanar 3D ultrasound imaging to assess the anatomy of the upper airway and measure the subglottic and tracheal diameters in adults

OBJECTIVE

To evaluate the feasibility of using three-dimensional (3D) ultrasound to assess the anatomy of the airway.

METHODS

11 young volunteers were recruited for 3D ultrasound and MRI of the airway. 3D ultrasound data were obtained from the level of the true vocal cords, cricoid cartilage and upper trachea. Multiplanar 3D ultrasound images were rendered and compared visually with corresponding MRI and cadaver anatomical sections. The anteroposterior (AP) and transverse diameter of the subglottic space and transverse diameter of the upper trachea were also measured in the 3D ultrasound and MR images and compared.

RESULTS

The airway anatomy was clearly delineated in the multiplanar 3D ultrasound images. It was also possible to identify the cricothyroid junction, and a simple method to measure the AP diameter of the subglottic space using this landmark is described. We were also able to accurately measure the transverse diameter of the upper trachea, but the transverse diameter of the subglottic space was overestimated using ultrasound. There was a strong correlation for the AP diameter measurement (r=0.94, p<0.05) and moderate correlation for the transverse diameter measurement (r=0.82, p=0.002) of the subglottic space, and a strong correlation for the transverse diameter measurement (r=0.91, p<0.05) of the upper trachea, in the ultrasound and MR images.

CONCLUSION

The anatomy of the adult airway can be assessed using 3D ultrasound. It can also be used to accurately measure the AP diameter of the subglottic space and the transverse diameter of the upper trachea.

ADVANCES IN KNOWLEDGE

This is the first report to describe the use of 3D ultrasound to evaluate the anatomy of the upper airway and accurately measure the AP diameter of the subglottic space and the transverse diameter of the upper trachea.

Assessing depression in patients with chronic pain: a comparison of three rating scales

BACKGROUND

Considerable evidence has suggested depression is significantly more prevalent in patients with chronic pain. A number of studies exclusively based on Western samples have evaluated the effectiveness of depression rating scales in assessing depression in the chronic pain context. The objective of this cross-sectional study was to compare within a Chinese chronic pain sample three depression rating scales commonly used in identifying depression.

METHODS

A total of 366 Chinese patients with chronic pain attending either an orthopedic specialist clinic (n=185) or a multidisciplinary pain clinic (n=181) in Hong Kong completed a structured interview using CIS-R and two depression rating scales, the Beck Depression Inventory (BDI standard and short form) and the Center for Epidemiological Studies-Depression (CES-D). Patient scores on the BDI and CES-D were then assessed against their responses on the CIS-R to determine their effectiveness.

RESULTS

The prevalence of depression was 20.2% and 57.8% in the Orthopedics and Pain Clinic sample respectively. Results of ROC analyses showed that all the three measures performed well at predicting depression with AUC ≥ 0.89 and high sensitivity and specificity.

CONCLUSIONS

Our findings suggest that the three depression measures assessed have good predictive validity in the Chinese chronic pain context, and they could be used as screening or diagnostic measures of depression in Chinese chronic pain patients. The decision of using a specific measure and a specific cutoff score should be based on study aim and setting.

Validation study of the Chinese Identification Pain Questionnaire for neuropathic pain

OBJECTIVES

For diagnosing neuropathic pain, a simple 6-item patient-completed identification pain questionnaire has been validated among Caucasians. We aimed to study the validity and reliability of this questionnaire among Hong Kong Chinese patients.

DESIGN

Questionnaire survey.

SETTING

Two pain clinics and two neurology clinics in Hong Kong.

PATIENTS

Patients with either neuropathic pain or nociceptive pain were recruited randomly from the four clinics. The patients completed the questionnaire themselves and the diagnosis of neuropathic pain and nociceptive pain was made by the pain specialists. We determined the optimal cutoff, positive and negative predictive values, sensitivity, specificity, the area under the receiver operating characteristic curve, and test-retest reliability of the translated version.

RESULTS

Among the 92 participants, 60 (65%) had neuropathic pain and 32 (35%) had nociceptive pain. At an optimal cutoff score of 3 or higher, the positive predictive value was 87% while the negative predictive value was 55%, and it correctly classified 71% of cases. The specificity and sensitivity were 81% and 65%, respectively. The area under the curve was 0.78 (P<0.001). Test-retest reliability in the 10 randomly selected patients showed a good intraclass correlation of 0.72.

CONCLUSION

The Chinese Identification Pain Questionnaire is a valid and reliable scale that may be used as an initial diagnostic tool for neuropathic pain among Hong Kong Chinese patients.

Decreased expression of heparin-binding epidermal growth factor-like growth factor as a newly identified pathogenic mechanism of antiphospholipid-mediated defective placentation

OBJECTIVE

Heparin-binding epidermal growth factor-like growth factor (HB-EGF) plays a role in blastocyst implantation and is down-regulated in preeclampsia and in hypertensive pregnancy disorders associated with defective extravillous trophoblast invasion. Defective placentation and severe preeclampsia are also features of the antiphospholipid syndrome (APS). The purpose of this study was to investigate whether abnormal HB-EGF expression plays a pathogenic role in antiphospholipid antibody (aPL)-mediated defective placentation.

METHODS

HB-EGF expression in placental tissue was evaluated by Western blotting and messenger RNA analysis in normal and APS placentae. Polyclonal IgG fractions or monoclonal beta(2)-glycoprotein I-dependent aPL and their respective controls were investigated for the following 4 features: their binding to human trophoblast monolayers, as determined by cell enzyme-linked immunosorbent assay (ELISA); their effect on HB-EGF expression by Western blotting in trophoblast cell extracts as well as by ELISA as a protein secreted in the culture supernatants; their inhibitory effect on in vitro trophoblast invasiveness, as evaluated by Matrigel assay; and their inhibitory effect on matrix metalloproteinase (MMP) levels, as measured by gelatin zymography. Experiments were also performed in the presence of serial concentrations of heparin or recombinant HB-EGF.

RESULTS

Placental APS tissue displayed reduced expression of HB-EGF. Polyclonal and monoclonal aPL bound to trophoblast monolayers and significantly reduced the in vitro synthesis and secretion of HB-EGF. Heparin inhibited aPL binding and restored HB-EGF expression in a dose-dependent manner. Addition of recombinant HB-EGF reduced the in vitro aPL-induced inhibition of Matrigel invasiveness as well as MMP-2 levels.

CONCLUSION

These preliminary findings suggest that the reduction of aPL-mediated HB-EGF represents an additional mechanism that is responsible for the defective placentation associated with APS and that heparin protects from aPL-induced damage by inhibiting antibody binding.

Some antiphospholipid antibodies bind to various serine proteases in hemostasis and tip the balance toward hypercoagulant states

The body has an elaborate system that maintains blood circulation and rapidly stops bleeding when vessels are damaged. Abnormalities that disrupt this balance may lead to thrombosis. While β2-glycoprotein I is generally accepted as the major antigen for antiphospholipid antibodies in the antiphospholipid syndrome, our accumulated studies show that some antiphospholipid antibodies bind homologous enzymatic domains of several serine proteases involved in hemostasis and fibrinolysis. Functionally, some of the protease-reactive antiphospholipid antibodies hinder anticoagulant regulation and resolution of clots, thus tip the balance toward thrombosis. Intriguingly, several serine protease-reactive antiphospholipid antibodies also react with β2-glycoprotein I, and interactions between antiphospholipid antibodies and antigens are cross-inhibited, indicating that these antiphospholipid antibodies recognize conformational epitope(s) on β2-glycoprotein I and target serine proteases. Viewed as a whole, these results extend previous reports that antiphospholipid antibodies bind to various hemostasis factors, and provide a new perspective about some antiphospholipid antibodies in terms of their binding specificities and related functional properties in promoting thrombosis.

Involvement of Cyr61 in growth, migration, and metastasis of prostate cancer cells

Cyr61 has been reported to participate in the development and progression of various cancers; however, its role in prostate cancer (PCa) still remains poorly understood. In this study, we explored the function of Cyr61 in a series of malignant PCa cell lines, including LnCap, Du145, and PC3. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and crystal violet assays demonstrated that Cyr61 was essential for the proliferation of PCa cells. Soft agar assay and xenograft analysis showed that downregulation of Cyr61 suppressed the tumorigenicity of Du145 cells both in vitro and in vivo. Either silencing the cellular Cyr61 by RNA interference or neutralising the endogenous Cyr61 by antibody inhibited the migration of Du145 cells. In contrast, purified protein of Cyr61 promoted the migration of LnCap cells in a dose-dependent manner. These results suggested that Cyr61 was involved in the migration of PCa cells. We also observed the accumulation of mature focal adhesion complexes associated with the impaired migration through Cyr61 downregulation. Also, further studies showed that Cyr61 regulated the level of activated Rac1 as well as its downstream targets, including phosphorylated JNK, E-cadherin, and p27^kip1, which are key molecules involved in cell growth, migration, and invasion. The in vivo mouse tail vein injection experiment revealed that Cyr61 affected the metastatic capacity of Du145 cells, suggesting that Cyr61 was required for prostate tumour metastasis. Altogether, our results demonstrated that Cyr61 played an important role in the tumorigenicity and metastasis of PCa cells, which will benefit the development of therapeutic strategy for PCas.

Some antiphospholipid antibodies bind to hemostasis and fibrinolysis proteases and promote thrombosis

It is generally accepted that the major autoantigen for antiphospholipid antibodies (aPL) is β2glycoprotein I (β2GPI). Interestingly, some aPL bind to β2GPI and the homologous enzymatic domains of several proteases involved in hemostasis and fibrinolysis, and correspondingly hinder anticoagulant regulation and resolution of clots. These findings are consistent with several early findings of aPL and provide a new perspective about some aPL in terms of their binding specificities and related functional properties in promoting thrombosis. In addition, homologous enzymatic domains of the involved proteases share conformation epitope(s) with β2GPI, thus providing a possible structural basis for some non-mutually exclusive mechanisms of aPL-mediated thrombosis.

Controlled release of insulin from PLGA nanoparticles embedded within PVA hydrogels

A simple and versatile delivery platform for peptide and protein based on physically cross-linked poly (vinyl alcohol) (PVA) hydrogels containing insulin-loaded poly (lactic-co-glycolic acid) (PLGA) nanoparticles was successfully fabricated. The particle morphology and size were characterized by SEM and laser light scattering method, respectively. Results showed that these particles had a mean diameter of 615 nm with a narrow size distribution and homogeneous particle production. The protein encapsulation efficiency was 72.6%. When insulin-loaded PLGA nanoparticles were administered intraperitoneally as a single dose (20 U/kg) to streptozotocin-induced diabetic mouse, blood glucose levels of these mice decreased and it could be sustained at such levels over 24 h. In vitro release further indicated that entrapment of the nanoparticles into the PVA hydrogels causes a reduction in both the release rate and the total amount of insulin released, which suggesting that PLGA nanoparticles entrapped into the PVA hydrogels showed more suitable controlled release kinetics for protein delivery.

Clinical experience with a chronic pain management programme in Hong Kong Chinese patients

OBJECTIVE

To describe experience with a chronic pain management programme in Hong Kong Chinese patients.

DESIGN

Prospective study.

SETTING

Regional hospital, Hong Kong.

PARTICIPANTS

Patients with chronic pain who participated in the first six Comprehensive Out-patient Pain Engagement programmes between 2002 and 2005.

INTERVENTION

Comprehensive Out-patient Pain Engagement is a 14-day structured, multidisciplinary out-patient programme conducted over 6 weeks. It includes pain education, cognitive re-conceptualisation, training in communication skills and coping strategies, graded physical exercises and functional activities training. It aims to improve patient function and quality of life, despite persistent pain.

MAIN OUTCOME MEASURES

Changes in scores from baseline values after joining the programme, with respect to several assessment tools. These included the following: visual analogue pain scale, Pain Catastrophizing Scale, Patient Self-efficacy Questionnaire, Canadian Occupational Performance Measure, Medical Outcome Survey-Short Form 36 Questionnaire, and duration of physical tolerances, medication utilisation, and work status records.

RESULTS

Forty-five patients were available for analysis. After the Comprehensive Out-patient Pain Engagement programme, improvements in Medical Outcome Survey-Short Form 36 Questionnaire (role physical and vitality), Pain Catastrophizing Scale, Patient Self-efficacy Questionnaire, and Canadian Occupational Performance Measure were demonstrated (P<0.05). The duration of standing and sitting tolerances increased (P<0.05). An improvement in employment rate was also evident (P=0.01).

CONCLUSION

The initial results of our management programme in Chinese patients with chronic pain are encouraging. This type of programme should be promoted more widely in this group of patients, as it appears to improve physical function, psychological well-being, and productivity.

Molecular basis for the cross-reactive idiotypes on human anti-IgG autoantibodies (rheumatoid factors)

High titres of anti-IgG autoantibodies (rheumatoid factors, RF) are characteristic of patients with rheumatoid arthritis, Sjögren's syndrome, and mixed cryoglobulinaemia, and may contribute to immune complex formation and tissue damage. The monoclonal RFs from cryoglobulinaemia patients frequently display cross-reactive idiotypes. The genetic basis for the cross-reactive idiotypes on RF autoantibodies has not been determined. To clarify structural and genetic relationships among RFs from unrelated subjects, a series of anti-peptide antibodies have been generated that define primary sequence-dependent idiotypes on RF heavy and light chains. Multiple monoclonal and polyclonal RFs from unrelated individuals have been probed by Western blotting with the anti-idiotypic reagents. The results show that sequences in the kappa light chain variable region represent a common structural element among RF autoantibodies. This hypothesis is confirmed by the cloning and sequencing of the conserved germline variable region gene which encodes human RF kappa chains.

Attitudes towards day-case surgery in Hong Kong Chinese patients

OBJECTIVE

To evaluate attitudes of Chinese patients towards day-case surgery.

DESIGN

Prospective cross-sectional questionnaire survey.

SETTING

District public hospital, Hong Kong.

PATIENTS

Two hundred patients attending a preanaesthetic assessment clinic between 1 January and 30 June 2004 were invited to participate.

MAIN OUTCOME MEASURES

Demographic profiles, understanding and attitudes towards day-case surgery, preference for day-case surgery before and after the experience, postoperative adverse effects, and patient satisfaction.

RESULTS

The mean age of the patients was 28 (standard deviation, 19) years. In all 200 respondents completing the survey, 180 preferred day-case surgery. Important reasons for this view were: shorter duration of hospitalisation, dislike of hospital environments, belief that hospitals are highly infectious, need to look after their families, desire to return to work early, and doctors' advice. Small home environments and belief that day-case surgery was unsafe were not important. Respondents who did not prefer day-case surgery stressed the importance of better care available for hospital in-patients, concerns about surgical complications, postoperative nausea and vomiting, and doctors' advice. Only 11% patients complained of postoperative adverse effects. Demographic characteristics and previous day-case surgery experience did not have any effect on patient preferences. However, experiencing a postoperative adverse effect significantly affected the preference (P=0.005) and satisfaction (P=0.001) of respondents for day-case surgery.

CONCLUSION

Local Chinese patients attending our institution have a high preference for day-case surgery. Postoperative adverse effects might influence the respondents' satisfaction and preference after their surgical experience.

Postoperative outcome in Chinese patients having primary total knee arthroplasty under general anaesthesia/intravenous patient-controlled analgesia compared to spinal-epidural anaesthesia/analgesia

OBJECTIVE

To compare postoperative outcomes in patients having primary total knee arthroplasty receiving general or regional anaesthesia.

DESIGN

Randomised prospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Patients having primary total knee replacement were randomised to either general anaesthesia followed by postoperative intravenous patient-controlled analgesia with morphine, or combined spinal-epidural anaesthesia followed by postoperative epidural infusion of bupivacaine 0.1% with fentanyl 2 microg/mL.

MAIN OUTCOME MEASURES

Visual analogue scale pain scores, perioperative blood loss, time to first meal and ambulation, and prevalence of postoperative complications.

RESULTS

Sixty consecutive patients were enrolled in this study. Postoperative median pain scores were consistently lower at 1 (P<0.0001), 6 (P=0.08), 12 (P=0.003), 24 (P=0.14), and 48 hours (P=0.007) in those given regional anaesthesia. Although there was a trend towards fewer complications in the latter group, there were no statistically significant differences between the two groups with respect to the incidence of postoperative blood loss, haemodynamic instability, pruritus, nausea, vomiting, urinary retention, or other surgical/medical complications. Postoperatively, patients given regional anaesthesia also resumed meals earlier (P<0.0001), and showed a trend towards earlier ambulation and hospital discharge.

CONCLUSION

Chinese patients undergoing total knee arthroplasty with regional anaesthesia/regionally delivered analgesia enjoyed better postoperative pain relief and resumed meals earlier than those receiving general anaesthesia/intravenous patient-controlled analgesia. The former also showed trends towards less adverse effects, postoperative complications, earlier ambulation, and earlier hospital discharge.

Human monoclonal IgG anticardiolipin antibodies induce nitric oxide synthase expression

OBJECTIVE

Antiphospholipid antibodies are associated with increased risk of thrombosis, particularly as in antiphospholipid syndrome. This study aims to determine the acute effects of anticardiolipin antibodies on nitric oxide production and vascular function.

METHODS

Ex vivo aortic rings from male Sprague Dawley rats were incubated with IgG monoclonal anticardiolipin antibody (IS4) or a non-specific IgG control. In organ baths, response to phenylephrine and acetlycholine was determined alone and with nitro-L-arginine methyl ester (L-NAME), 1,400 W, D-arginine, L-arginine, sodium nitroprusside and cardiolipin. In vivo antibodies were injected into anaesthetised, spontaneously breathing male Sprague Dawley rats. Haemodynamic variables and serum nitric oxide were measured. Immunohistochemistry for iNOS and eNOS was performed in kidney vessels.

RESULTS

Phenylepherine contraction was decreased in the IS4 group compared to controls (p < 0.001). L-NAME, 1,400 W and cardiolipin, abolished this effect. L-Arginine caused significant relaxation in the IS4 group (p = 0.005). Mean arterial pressure in rats injected with IS4 was reduced compared to IgG and saline controls (p < 0.001). NO in plasma increased significantly after IS4 administration (p < 0.001). Immunohistochemistry showed increased iNOS expression in kidney arteries in the IS4 group, with no change in eNOS.

CONCLUSION

Anticardiolipin antibodies induce NO production acutely via increased expression of iNOS in both ex vivo and in vivo models.

Antiphospholipid antibodies are associated with enhanced oxidative stress, decreased plasma nitric oxide and paraoxonase activity in an experimental mouse model

OBJECTIVE

Oxidative stress contributes to atherosclerosis, and evidence of enhanced oxidative stress exists in antiphospholipid syndrome (APS). In a non-lupus murine model, we evaluated whether anticardiolipin (aCL) antibodies could affect the oxidant/antioxidant balance as an early biochemical step of APS.

METHODS

Hybridomas producing human and murine aCL and anti-beta(2)-glycoprotein I (abeta2-GPI) monoclonal antibodies were injected into three groups of five female BALB/c severe combined immunodeficiency (SCID) mice. Corresponding hybridomas secreting non-antiphospholipid antibodies of the same isotype were employed as controls. Sera and organs were collected after 30 days. Paraoxonase (PON) activity, peroxynitrite, superoxide, nitric oxide (NO) and nitrotyrosine were measured in plasma. Expression of endothelial nitric oxide synthase and inducible nitric oxide synthase (iNOS) was assessed by western blot and immunohistochemistry.

RESULTS

PON activity and NO (sum of nitrate and nitrite) levels were reduced in the human aCL IgG group (P<0.002 and P<0.04, respectively), whilst peroxynitrite and superoxide and expression of total antioxidant capacity of plasma were increased (P<0.01). PON and NO were decreased in the murine abeta2-GPI IgG and IgM aCL groups (P<0.03 and P<0.05, respectively). Nitrotyrosine was elevated in the human aCL IgG group (P<0.03). Western blotting showed reduced iNOS expression in the hearts of the IgG aCL group, confirmed by immunostaining. PON inversely correlated with IgG aCL titres (P<0.001), superoxide (P<0.008) and peroxynitrite levels (P<0.0009). Peroxynitrite and total IgG aCL were independent predictors of PON (P<0.0009 and P<0.02, respectively). Superoxide was the only independent predictor of NO (P<0.008) and of nitrotyrosine (P<0.002).

CONCLUSION

aCL antibodies are associated with the decreased PON activity and reduced NO that may occur in the preclinical phase of APS.

A prospective evaluation of health-related quality of life in Hong Kong Chinese patients with chronic non-cancer pain

OBJECTIVE

To evaluate the health-related quality of life in Hong Kong Chinese patients with chronic non-cancer pain.

DESIGN

Prospective cross-sectional survey.

SETTING

Regional public hospitals, Hong Kong.

PATIENTS

Patients attending out-patient pain management clinics between 1 July 2002 and 28 February 2003 were approached to complete a set of standardised questionnaires.

MAIN OUTCOME MEASURES

Demographic profiles, treatment modality, litigation, compensation, social welfare status, Hospital Anxiety Depression Scale, and Medical Outcomes Survey short-form health survey (SF36).

RESULTS

Data from 166 patients were analysed. The median numeric pain rating score was 6 (interquartile range, 2-10). Work-related injury occurred in 34.3% of patients, while another 34% were involved in pain-related litigation and 32% were receiving disability or unemployment benefit. Sixty-four percent of patients were managed by three or more disciplines, while 54.8% were also receiving complimentary alternative medical treatment, mainly traditional Chinese medicine (49.7%). The Hospital Anxiety Depression Score indicated clinical anxiety or depression in 71.1% of patients. All SF36 subscale scores were lower than the local population norm. Unemployed patients had higher depression scores (P = 0.005), while students or retirees had lower physical functioning scores (P = 0.004). Patients who were single had higher role emotion scores than those who were married or separated/widowed (P = 0.011). Logistic regression analysis showed that younger age (odds ratio = 0.95), being married (6.62), work-related injury (15.63) or higher general scores (1.03) were more likely to be associated with litigation. Social welfare benefit was associated with unemployment (3.39) and a lower level of physical functioning (0.98).

CONCLUSION

There was a high prevalence of clinical anxiety, depression, and severe impairment in the health-related quality of life in Hong Kong Chinese patients with chronic non-cancer pain. Specific factors affected the health-related quality of life, likelihood of litigation, and social benefit.

Patient-controlled epidural analgesia in a parturient with hypertrophic obstructive cardiomyopathy

We describe the use of patient-controlled epidural analgesia (PCEA) using fentanyl in the management of a labouring parturient with hypertrophic obstructive cardiomyopathy (HOCM). With non-invasive monitoring, PCEA was started in the early first stage of labour with a bolus dose of fentanyl 20 microg, lockout 5 min and 4-h maximum dose of 500 microg. Analgesia was satisfactory during the early first stage but was poor subsequently, despite a total fentanyl consumption of 760 microg during the 6-h labour. The maternal cardiovascular condition was stable throughout labour and delivery and the baby was born in good condition without subsequent respiratory depression. Opioid-based PCEA is an alternative to systemic analgesia in labouring parturients with HOCM. However, although its use avoids the potential adverse effects of sympathetic block associated with conventional epidural analgesia, our regimen had limited analgesic efficacy in the latter stage of labour.

Data management using the personal digital assistant in an acute pain service

Handheld personal digital assistants (PDA) are increasingly being used by physicians for a variety of information and data management purposes. We evaluated a PDA-based data management system for our acute pain service. A structured questionnaire survey was conducted to assess staff experience and attitude towards the paper system before the introduction of the PDA, and three months after introduction of the PDA system. We compared the time taken to conduct the acute pain round before and after the implementation of the PDA. The time saved in data management and the amount of paper saved were estimated. Data from 177 patients with a total of 635 acute pain follow-up visits were entered over a three-month period. User satisfaction, ease of access to drug reference and clinical guidelines were similar between the two systems. The respondents found that the PDA was easy to use but less so than the paper system (P = 0.007), in particular, when accessing a patient's cumulative data (P = 0.007). There was no missed follow-up or data entry with the use of PDA. The time taken to attend follow-up visits was similar for the two systems (Paper: 8.8 +/- 3.2 compared to PDA: 7.0 +/- 2.0 minutes, P = 0.151). The estimated annual amount of paper and time saved in data management was 650 sheets and 130 man-hours respectively. Our experience with the use of the PDA in APS was satisfactory. The PDA system can potentially reduce time and paper use and missed data entry and patient follow-up.

Out-patient chronic pain service in Hong Kong: prospective study

OBJECTIVE

To examine the profile and referral pattern of patients attending an out-patient pain management service in Hong Kong.

DESIGN

Prospective cross-sectional survey.

SETTING

Regional public hospitals, Hong Kong.

PATIENTS

All patients attending out-patient pain management clinics in the New Territories East public hospitals between 1 September and 31 December 2002.

MAIN OUTCOME MEASURES

Demographic profiles, referring specialty, pain diagnosis, pain sites, duration and severity of pain, treatment modality, litigation, compensation, and social welfare status. Data were collected using a standardised questionnaire.

RESULTS

Two hundred and forty-eight patients were interviewed. Most patients (70%) were middle-aged, with 21% over 60 years. Seventy-nine percent of patients were referred to the clinics either from orthopaedic surgeons (64.1%), general and other surgeons (14.9%), or general practitioners (3.6%). The median (range) duration of pain was 2.3 (0.08-26.7) years. The most common pain diagnoses were musculoskeletal back pain (46.4%) and neuropathic pain (27.8%). A total of 11.3% of the patients had two pain diagnoses, while 40.7% complained of pain in more than one location. Pain in the limbs was the most frequent complaint followed by the head, neck, and back. Approximately 38% of patients had tried four or more treatment modalities. Oral medication was the most common method (86.7%) of pain-relief treatment. More than half of the patients had also tried physiotherapy and traditional Chinese medicine. Approximately 37% of the patients were unemployed, while 31% were receiving social security subsidy. Eighty-six patients had pain associated with a work-related injury, and of these patients, 80% were involved in compensation claims.

CONCLUSIONS

The profile of patients referred to the pain management clinics was complex. Patients were mainly referred from specialists. The economic implication in this group of patients is likely to be significant as many patients utilised multiple treatment modalities, were unemployed and on social welfare benefits, and were involved in compensation and litigation proceedings.

Status of obstetric epidural analgesia services in Hong Kong public hospitals: postal questionnaire survey

OBJECTIVE

To examine the status of obstetric epidural analgesia services in Hong Kong public hospitals in 2001, and to compare findings with those from a similar survey conducted in 1995.

DESIGN

Postal questionnaire survey.

SETTING

Hospital Authority hospitals in Hong Kong offering an obstetric and delivery service.

PARTICIPANTS

Chiefs of Service of departments of anaesthesia and coordinators of obstetric anaesthesia and analgesia service.

MAIN OUTCOME MEASURES

The availability of an obstetric epidural analgesia service, specialist staff allocation to the service, existence of clinical protocols, rate of epidural analgesia, techniques of epidural administration, obstetric outcome or mode of delivery, and the incidence of adverse events associated with the use of epidural analgesia.

RESULTS

Between 1 January and 31 December 2001, all eight Hospital Authority hospitals with an obstetric service provided epidural analgesia for labour pain relief, but only six (75%) offered a 24-hour service. A dedicated anaesthetist provided obstetric anaesthesia and analgesia during office hours in all units, but after hours in only three. This level of service provision compared favourably with that available in 1995, when only 82% of public maternity units provided epidural analgesia and only 36% offered a 24-hour service. The median epidural analgesia rate was 15% (range, 8%-20%) compared with 10% in 1995. The incidence of adverse events and complications was very low. Formal written protocols for the conduct of epidural analgesia for labour were used in six units. All units used mixtures of local anaesthetic combined with opioid, administered as intermittent boluses, continuous epidural infusion, or patient-controlled epidural analgesia.

CONCLUSIONS

Although there has been progress and improvement in the provision of obstetric epidural analgesia services in our public hospitals, the rate is still relatively low and the provision of services after hours is limited. Further progress will likely be hindered by current or future cutbacks in public hospital budgets.

Hong Kong Chinese teachers' attitudes towards life-sustaining treatment in the dying patients

OBJECTIVE

To evaluate the attitudes of Hong Kong Chinese teachers towards life-sustaining treatment in the dying patients.

DESIGN

Prospective structured questionnaire survey.

SETTING

Hong Kong Institute of Education.

SUBJECTS AND METHODS

All teaching staff at the Hong Kong Institute of Education were sent the survey questionnaire. The questionnaire gathered demographic data, information on experience of 'life and death' decision-making, and views on life-sustaining treatment decisions. Respondents were also requested to respond to statements on life-sustaining treatment using a 5-point Likert Scale (1 representing strong disagreement and 5 representing strong agreement).

RESULTS

A total of 436 questionnaires were sent to teaching staff at the Hong Kong Institute of Education. The response rate was 27.8%. More than half (65.8%) of the respondents were aged between 30 and 49 years. There was an equal proportion of men and women among respondents. The respondents agreed with statements supporting end-of-life decisions (mean aggregate score, 3.13; standard deviation, 1.24; P<0.0001), and disagreed with statements against such decisions (mean aggregate score, 2.81; standard deviation, 1.22; P<0.0001). If the patient is competent, half of the respondents agreed that the patient alone should make the decision, while 27.2% believed that it should be a joint decision made by the patient, the family, and the doctor. Conversely, if the patient is incompetent, 52.6% agreed that it should be a joint decision made by the family and the doctor. There was strong support for advanced directives, whereby decisions in relation to life-sustaining treatment were legally recorded in advance (mean score, 3.62; P=0.0001).

CONCLUSION

The teachers in this survey appear to support the practice of withdrawing and withholding life-sustaining treatment in the dying patients when medical treatment is considered futile. Although patient autonomy in decision-making was supported by the greatest number of respondents, joint decision-making by the patient, family members, and doctors was also favoured by a substantial group. There was strong support for the use of advanced directives with respect to life-sustaining treatment.

The effect of an alveolar recruitment strategy on oxygenation during laparascopic cholecystectomy

This prospective randomized controlled trial examined the effect of an "alveolar recruitment strategy" (ARS) in healthy patients having laparoscopic cholecystectomy. Twenty-four consecutive ASA 1 or 2 patients were randomly allocated to an ARS or control group. All patients were manually ventilated to a maximal airway pressure of 25 to 30 cmH2O or a tidal volume of 10 ml/kg during induction of general anaesthesia. After intubation, the control group was ventilated with standardized mechanical ventilation settings. The ARS group was manually ventilated to an airway pressure of 40 cmH2O for 10 breaths over one minute, followed by mechanical ventilation with similar standardized settings plus 5 cmH2O positive end-expiratory pressure. Blood pressure, heart rate, arterial oxygen and carbon dioxide tension (PaO2 and PaCO2) was measured pre-induction, 20 minutes post induction but before abdominal insufflation, 20 minutes after abdominal insufflation, and 20 minutes after arrival in the recovery room. Demographic and operation data were similar. The ARS group pre-insufflation PaO2 [30.16 (9.43)] was higher than the control group [22.19 (9.08)] (P = 0.047). There was a significant difference in PaO2 between the ARS [23.94 (4.87)] and control [17.26 (3.93)] groups during the post-insufflation period (P = 0.001). There were no significant differences in PaO2 between the groups during baseline and recovery periods. No adverse effects were reported. ARS improved arterial oxygenation intraoperatively in healthy patients having laparoscopic cholecystectomy, without clinical cardiovascular compromise or respiratory complication. We conclude that this alveolar recruitment strategy is a useful method of increasing arterial oxygenation.

The effect of intra-operative video on patient anxiety

We conducted a randomised controlled study to evaluate whether watching video compact discs intra-operatively using a liquid crystal display (LCD) unit decreased anxiety. Forty-four patients undergoing elective surgery under regional anaesthesia were assigned to either the LCD or control group. Anxiety was measured using the Chinese version of the State-Trait Anxiety Inventory (STAI) and visual analogue score (VAS). The mean (SD) anxiety trait scores were 46.15 (6.28) and 46.40 (7.32) in the control and LCD groups, respectively. The state anxiety of the LCD group [35.50 (7.96)] measured immediately postoperatively was significantly lower than the control group [41.50 (9.02); p = 0.03]. The median (range) reduction in VAS anxiety score was not significantly greater in the LCD group [20 (20 to 80) mm] compared with the control group [12.5 (70 to 60) mm]. Watching video intra-operatively reduces patient anxiety as measured by the STAI.

Acute pain services in Hong Kong: facilities, volume, and quality

Acute pain services in public hospitals in Hong Kong were studied. Audit data on the volume and quality of acute pain services were collected prospectively from 1997 to 1999, and data on related facilities were collected in 2000. About 20% of patients undergoing a major operation received an acute pain service; of these, 78.6% were satisfied with the treatment provided. In 2000, 86% (18/21) of hospitals providing anaesthetic services were running an acute pain service. Staffing was better in hospitals providing a high volume of acute pain services, ranging from a full-time specialist anaesthesiologist assisted by a half-time trainee to a half-time specialist assisted by a full- or half-time trainee. However, only four hospitals were staffed with pain nurses. In total, 57% of patients received intravenous patient-controlled analgesia and 32% epidural analgesia. The mean duration of acute pain service treatment was 3.1 days. Currently anaesthesiologist-based acute pain services take care of a limited number of patients. To expand the coverage, there should be a move towards an anaesthesiologist-led, pain nurse-based, acute pain service. The present shortage of pain nurses should be addressed.

Recall of preoperative anaesthesia information in Hong Kong Chinese patients

OBJECTIVE

To evaluate the ability of patients to recall information provided during a preoperative visit.

DESIGN

Qualitative study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Sixty patients scheduled for elective surgery under general anaesthesia or central neuro-axial block.

MAIN OUTCOME MEASURES

Satisfactory recall of preoperative information, defined as the ability to remember at least 75% of adverse effects described.

RESULTS

Fifty-nine (98.3%) patients were satisfied with the preoperative information. Forty-two (70%) patients rated anaesthetic complications as important. At the interview on the day of the operation, 57 (95%) patients had satisfactory recall of the information provided. Eighty-five percent of patients remembered that the information was provided by an anaesthesiologist. After the operation, of those who experienced adverse effects, 48 (96%) patients remembered being told to anticipate the adverse anaesthetic event. Univariate analysis found that age, sex, education level, occupation, and the modality of anaesthesia did not affect patient recall of preoperative information on the day of surgery or 1 day postsurgery. CONCLUSION. There was satisfactory recall of preoperative information by the majority of patients in the study. Most patients expressed satisfaction with the information provided.

Tracheobronchial injury secondary to blunt chest trauma: diagnosis and management

Tracheobronchial injury is an uncommon complication in blunt chest trauma. The typical clinical features include haemoptysis, dyspneoa, and air leak. Tracheobronchial injury occurs after high energy impact and is commonly associated with injuries of other vital organs. If tracheobronchial injury is undetected and left untreated, it may cause persistent air leak which can render ventilation difficult and inefficient. Diagnosis of tracheobronchial injury should be made and confirmed by flexible bronchoscopy. The essence of airway management is to bypass the lesion by means of endobronchial intubation to the healthy bronchus with a single-lumen or double-lumen endotracheal tube. Such manoeuvres can also facilitate surgical access if thoracotomy is indicated. Taking into account the size of the lesion and the resulting respiratory status, surgical reconstruction of the injured airway is often necessary. More severe injury may even require lobectomy or pneumonectomy. Late complications of untreated tracheobronchial injury include bronchial stenosis, recurrent pneumonia and bronchiectasis. Prompt diagnosis and treatment generally lead to good functional recovery.

The application of clinical simulation in crisis management training

Since it was first introduced more than 30 years ago, clinical simulation has become a popular tool for medical training, particularly in crisis management. The modern high-fidelity patient simulator consists of a whole-body mannequin with integrated electronic patient monitoring; it is controlled by computers capable of simulating numerous clinical scenarios and patient characteristics, and reacting to various interventions appropriately. Simulator training is theoretically superior to conventional training in management of rare crisis situations, as it allows unlimited practice in a safe yet familiar environment. Training in clinical skills can be developed, together with competency in crisis management behaviours such as leadership and communication skills. Although there is evidence demonstrating the popularity, reliability, and validity of simulator training, its superiority over conventional training has not been proven, and research in this area is required.