Four-year overall survival update from the phase III HIMALAYA study of tremelimumab plus durvalumab in unresectable hepatocellular carcinoma

BACKGROUND

In the phase III HIMALAYA study (NCT03298451) in unresectable hepatocellular carcinoma (uHCC), STRIDE (Single Tremelimumab Regular Interval Durvalumab) significantly improved overall survival (OS) versus sorafenib; durvalumab monotherapy was noninferior to sorafenib for OS. Results reported herein are from a 4-year updated OS analysis of HIMALAYA.

PATIENTS AND METHODS

Participants with uHCC and no previous systemic treatment were randomized to STRIDE (n = 393), durvalumab (n = 389), or sorafenib (n = 389). The updated data cut-off was 23 January 2023. OS and serious adverse events (AEs) were assessed. Additionally, baseline characteristics and subsequent therapies were analyzed in long-term survivors (≥36 months beyond randomization).

RESULTS

For STRIDE, durvalumab, and sorafenib, median [95% confidence interval (CI)] follow-up was 49.12 months (46.95-50.17 months), 48.46 months (46.82-49.81 months), and 47.31 months (45.08-49.15 months), respectively. OS hazard ratio (95% CI) for STRIDE versus sorafenib was 0.78 (0.67-0.92). The 36-month OS rate for STRIDE was 30.7% versus 19.8% for sorafenib. The 48-month OS rate remained higher for STRIDE at 25.2%, versus 15.1% for sorafenib. The long-term OS benefit of STRIDE was observed across clinically relevant subgroups and was further improved in participants who achieved disease control. Long-term survivors with STRIDE (n = 103) included participants across clinically relevant subgroups, and 57.3% (59/103) had no reported subsequent anticancer therapy. No new serious treatment-related AEs occurred with STRIDE from the primary analysis (17.5%; 68/388). Durvalumab maintained OS noninferiority to sorafenib and no late-onset safety signals were identified.

CONCLUSIONS

These data represent the longest follow-up to date in phase III studies in uHCC. The unprecedented 3- and 4-year OS rates reinforce the sustained long-term OS benefit of STRIDE versus sorafenib. STRIDE maintained a tolerable yet differentiated safety profile from other current uHCC therapies. Results continue to support the long-term benefits of STRIDE in a diverse population, reflective of uHCC globally.

Hong Kong consensus recommendations on the management of pancreatic ductal adenocarcinoma

This project was undertaken to develop the first set of consensus statements regarding the management of pancreatic ductal adenocarcinoma (PDAC) in Hong Kong, with the goal of providing guidance to local clinicians. A multidisciplinary panel of experts discussed issues surrounding current PDAC management and reviewed evidence gathered in the local context to propose treatment recommendations. The experts used the Delphi approach to finalise management recommendations. Consensus was defined as ≥80% acceptance among all expert panel members. Thirty-nine consensus statements were established. These statements cover all aspects of PDAC management, including diagnosis, resectability criteria, treatment modalities according to resectability, personalised management based on molecular profiling, palliative care, and supportive care. This project fulfils the need for guidance regarding PDAC management in Hong Kong. To assist clinicians with treatment decisions based on varying levels of evidence and clinical experience, treatment options are listed in several consensus statements.

Applying motivational framework in medical education: a self-determination theory perspectives

BACKGROUND

The application of self-determination theory in explaining student achievement has been well-established in various contexts. However, its application to medical education, particularly in interprofessional education (IPE) remains underexplored. Understanding how students' motivation plays a role in students' engagement and achievement is essential to optimize efforts to improve learning and instruction.

OBJECTIVE

This two-stage study aims to contextualize the SDT framework to IPE through the adaptation of the Basic Psychological Need Satisfaction to IPE (Study 1) and to demonstrate how SDT can be applied in IPE by examining a model of SDT constructs (Study 2) in predicting outcomes (behavioral engagement, team effectiveness, collective dedication, goal achievement).

DESIGN

In Study 1 (n=996), we adapted and validated BPNS-IPE using confirmatory factor analysis and multiple linear regression using data from 996 IPE students (Chinese Medicine, Medicine, Nursing, and Pharmacy). In Study 2 (n=271), we implemented an IPE program where we integrated SDT approaches and examined the relationship of SDT constructs with IPE outcomes using multiple linear regression.

RESULTS

Our data supported the three-factor structure (autonomy, competence, and relatedness) of BPNS-IPE, meeting the required model fit. Autonomy predicted team effectiveness (F=51.290, p<.05, R²=.580); competence predicted behavioral engagement (F=55.181, p<.05, R²=.598); while relatedness predicted significantly four IPE outcomes: behavioral engagement (F=55.181, p<.01, R²=.598), team effectiveness (F=51.290, p<.01, R²=.580), collective dedication (F=49.858, p<.01, R²=.573), goal achievement (F=68.713, p<.01, R²=.649).

CONCLUSIONS

The SDT motivational framework can be adapted and applied in the IPE context to understand and enhance student motivation in medical education. Potential studies with the use of the scale are provided to guide researchers.

Risks and impacts of thromboembolism in patients with pancreatic cancer

INTRODUCTION

Patients with pancreatic cancer have a high risk of thromboembolism (TE), which may increase mortality. Most relevant studies have been conducted in Western populations. We investigated risk factors for TE in a predominantly Chinese population of patients with pancreatic cancer, along with effects of TE on overall survival.

METHODS

This retrospective cohort study included patients diagnosed with exocrine pancreatic cancer in Prince of Wales Hospital in Hong Kong between 2010 and 2015. Data regarding patient demographics, World Health Organization performance status, stage, treatment, TE-related information, and time of death (if applicable) were retrieved from electronic medical records. Univariate and multivariable logistic regression analyses were performed to identify risk factors for TE. Survival analyses were performed using Kaplan-Meier analysis and Cox proportional hazards regression.

RESULTS

In total, 365 patients were included in the study. The overall incidence of TE (14.8%) was lower than in Western populations. In univariate logistic regression analysis, stage IV disease and non-head pancreatic cancer were significantly associated with TE (both P=0.01). Multivariable logistic regression analysis showed that stage IV disease was a significant risk factor (odds ratio=1.08, 95% confidence interval [CI]=1.00-1.17; P=0.046). Median overall survival did not significantly differ between patients with and without TE (4.88 months vs 7.80 months, hazard ratio=1.08, 95% CI=0.80-1.49; P=0.58) and between patients with TE who received anticoagulation treatment or not (5.63 months vs 4.77 months, hazard ratio=0.72, 95% CI=0.40-1.29; P=0.27).

CONCLUSION

The incidence of TE was low in our Chinese cohort. Stage IV disease increased the risk of TE. Overall survival was not affected by TE or its treatment.

Recommendations for the use of next-generation sequencing in patients with metastatic cancer in the Asia-Pacific region: a report from the APODDC working group

INTRODUCTION

Next-generation sequencing (NGS) diagnostics have shown clinical utility in predicting survival benefits in patients with certain cancer types who are undergoing targeted drug therapies. Currently, there are no guidelines or recommendations for the use of NGS in patients with metastatic cancer from an Asian perspective. In this article, we present the Asia-Pacific Oncology Drug Development Consortium (APODDC) recommendations for the clinical use of NGS in metastatic cancers.

METHODS

The APODDC set up a group of experts in the field of clinical cancer genomics to (i) understand the current NGS landscape for metastatic cancers in the Asia-Pacific (APAC) region; (ii) discuss key challenges in the adoption of NGS testing in clinical practice; and (iii) adapt/modify the European Society for Medical Oncology guidelines for local use. Nine cancer types [breast cancer (BC), gastric cancer (GC), nasopharyngeal cancer (NPC), ovarian cancer (OC), prostate cancer, lung cancer, and colorectal cancer (CRC) as well as cholangiocarcinoma and hepatocellular carcinoma (HCC)] were identified, and the applicability of NGS was evaluated in daily practice and/or clinical research. Asian ethnicity, accessibility of NGS testing, reimbursement, and socioeconomic and local practice characteristics were taken into consideration.

RESULTS

The APODDC recommends NGS testing in metastatic non-small-cell lung cancer (NSCLC). Routine NGS testing is not recommended in metastatic BC, GC, and NPC as well as cholangiocarcinoma and HCC. The group suggested that patients with epithelial OC may be offered germline and/or somatic genetic testing for BReast CAncer gene 1 (BRCA1), BRCA2, and other OC susceptibility genes. Access to poly (ADP-ribose) polymerase inhibitors is required for NGS to be of clinical utility in prostate cancer. Allele-specific PCR or a small-panel multiplex-gene NGS was suggested to identify key alterations in CRC.

CONCLUSION

This document offers practical guidance on the clinical utility of NGS in specific cancer indications from an Asian perspective.

Virtual simulation and problem-based learning enhance perceived clinical and cultural competence of nursing students in Asia: A randomized controlled cross-over study

BACKGROUND

Both clinical and cultural competencies are of paramount importance in ensuring patients' safety and high-quality care. While problem-based learning (PBL) is a widely applied pedagogy in nursing education, an emerging technology-based pedagogy, virtual simulation provides a realistic clinical learning experience for students. It can be an effective solution for continuing clinical and cultural learning across countries in the era of the pandemic.

OBJECTIVES

This study aimed to compare the effectiveness of virtual simulation and PBL on the perceived clinical and cultural competence for nursing students.

DESIGN

A randomized controlled cross-over study design was used.

SETTINGS AND PARTICIPANTS

Sixty-one undergraduate and postgraduate nursing students from five Asian regions were selected for participation.

METHODS

Participants were randomized to receive either virtual simulation (group A) or PBL (group B) for one day, followed by another intervention on the second day. Three self-reported questionnaires were used: Clinical Competence Questionnaire (CCQ), Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals-Student Version (IAPCC-SV), and demographic questionnaire.

RESULTS

The results revealed that students in both arms had significant improvements in CCQ total score (A: d = 21.500, P < 0.001; B: d = 16.710, P = 0.001), nursing professional behavior (A: d = 8.233, P < 0.001; B: d = 6.323, P < 0.001), and advanced nursing skills (A: d = 2.533, P = 0.008; B: d = 2.129, P = 0.029) after two interventions. In addition, both arms demonstrated significant improvements in IAPCC-SV total score (A: d = 3.467, P = 0.037; B: d = 4.032, P = 0.010) and cultural skills (A: d = 0.767, P = 0.012; B: d = 1.000, P = 0.001). No significant differences were observed between the two arms.

CONCLUSIONS

The findings indicated that both virtual simulation and PBL were effective in promoting students' perceived clinical and cultural competence. As both education modes have their own uniqueness and effectiveness in both outcomes, the combination of both could enhance the variability of learning modalities. Notably, the use of virtual simulation first could engage students better in learning and achieve better educational outcomes.

Evaluating online learning engagement of nursing students

BACKGROUND

Previous studies suggest that increased learning satisfaction may encourage learning engagement in an online learning environment.

OBJECTIVES

To evaluate the level of learning engagement and its relationship with students' perceived learning satisfaction in an online clinical nursing elective course.

DESIGN

A prospective interventional study.

SETTINGS

A nursing course was converted to an online format because of the coronavirus disease COVID pandemic.

PARTICIPANTS

Part-time post-registration nursing undergraduates enrolled in an elective online clinical course.

METHODS

Related teaching and learning strategies were deployed in the course using the Community of Inquiry framework. All students who completed the course were invited to complete an online survey that included a validated Online Student Engagement questionnaire (OSE). Pearson's correlations were used to determine the association between perceived learning satisfaction and learning engagement. A logistic regression model was used to explore the associations of gender, age, working experience and perceived learning satisfaction with higher learning engagement.

RESULTS

The questionnaires were completed by 56 of 68 students (82%). The Pearson's correlation coefficient between the mean perceived learning satisfaction and OSE scores was 0.75 (p < .001). Twenty-five students (45%) were identified as highly engaged, using a cut-off of ≥3.5 for the mean OSE score. The mean perceived learning satisfaction (SD) score differed significantly between highly engaged and not highly engaged students [4.02 (0.49) vs. 3.27 (0.62), p < .001]. The logistic regression model showed that a greater perceived learning satisfaction [adjusted odds ratio (OR): 17.2, 95% C.I.: 3.46-86.0, p = .001] was associated with an increased likelihood of higher learning engagement, and >1 year of working experience (adjusted OR: 0.11, 95% C.I.: 0.01-0.89, p = .0039) was associated with a decreased likelihood of higher learning engagement.

CONCLUSIONS

The study findings suggest that perceived learning satisfaction predicts learning engagement among nursing students in this online learning course.

Registry to investigate the efficacy and safety of the VenaBlock© VeIn SEaling system for VaRicose veins in SingApore - Six months results of the RIVIERA trial

BACKGROUND

The Venablock^© Venous Closure System (Invamed, Ankara, Turkey) is a novel cyanoacrylate-based non-thermal non-tumescent embolization device to block refluxing truncal veins for chronic venous insufficiency and varicose veins. The aim was to prospectively evaluate the safety and 6 months efficacy of Venablock^© for the treatment of primary great saphenous vein (GSV) and small saphenous vein (SSV) incompetency in a multi-ethnic cohort from Singapore.

METHODS

This was a single arm, single investigator prospective study of 29 patients (39 limbs, 39 truncal veins) recruited over a 5-month period (August 2019 to February 2020), who were treated with the Venablock^© device at a tertiary vascular unit in Singapore. Patients with symptomatic varicose veins (C2-6) and had truncal reflux > 0.5 second on venous Duplex ultrasound were included. Follow-up occurred at 2 weeks, 3 and 6 months with dedicated quality of life questionnaires and a targeted Duplex ultrasound performed to check for continued venous occlusion.

RESULT

Mean age was 61.4 (±11.0) years and mean BMI was 26.2 (±5.7) kg/m². 11/29 (37.9%) were males. Most common CEAP class treated was 2 (12/29, 41.3%). Mean diameter of treated GSV was 5.7 (±2.0) mm, 4.8 (±1.7) mm and 4.2 (±1.3) mm for the proximal, mid and distal above knee segments respectively. Mean time from access puncture to sheath removal was 23.4 (±10.0) mins. Vein occlusion at 2 weeks, 3 and 6 months was 39/39 (100%), 39/39 (100%) and 36/37 (97.2%) respectively. 5/29 (17.2%) developed puncture site infections, of which 3/29 (7.7%) required formal surgical drainage. 3/29 (7.7%) developed phlebitis. At 6 months, revised Venous Clinical Severity Score improved from 5.2 (±3.5) to 2.1 (±2.9; p < .001); EuroQol-5 Dimension score, from 7.4 (±2.1) to 5.7 (±1.4; p < .001); Aberdeen Varicose Vein Questionnaire score, from 18.1 (±15.5) to 7.9 (±8.9; p = .007); and Chronic Venous Insufficiency Questionnaire, from 18.6 (±16.2) to 4.5 (±6.3; p < .001).

CONCLUSION

Venablock^© is a safe and efficacious option of treating truncal venous insufficiency in a multi-ethnic Asian cohort from Singapore in the short term. There is a significant improvement in QoL. Longer follow-up is required to assess the durability of this technique, in particular the higher puncture site infection rates observed compared to other glue-based therapies.

The effects of physical activity on overall survival among advanced cancer patients: a systematic review and meta-analysis

Background

The survival rates of advanced cancer patients remain low despite clinical therapy advancements. However, physical activity showed promising effects in improving cancer outcomes. This review aimed to systematically evaluate and synthesize the effects on overall mortality of post-diagnosis physical activity in advanced cancer patients.

Methods

A systematic search of six English databases (PubMed, EMBASE, CINAHL, PsycINFO, The Cochrane Central Register of Controlled Trials, and SPORTDiscus) was conducted from their inception up to 3 February 2021. The association of physical activity with survival was evaluated by combining study-specific hazard ratios with random-effects meta-analysis models.

Results

Eleven studies were identified. Compared with the reference group, higher-level physical activity was not significantly associated with a lower risk of earlier mortality in advanced cancer patients (InHR = − 0.18, 95% CI, − 0.36 to 0.01). When separated by study type, a higher level of physical activity in non-randomised trials was significantly associated with reduced mortality risk (InHR = − 0.25, 95% CI: − 0.44, − 0.06). However, in randomised trials, engaging in exercise was not significantly associated with a lower mortality risk compared with the control group (InHR = 0.08, 95%CI: − 0.17, 0.32).

Conclusions

Discrepancies were uncovered in the effect of physical activity on overall survival in randomised and non-randomised trials. In non-randomised trials, a higher level of physical activity was significantly associated with a lower risk of mortality, whereas no significant effect on survival was observed during exercise interventions compared to the control in randomised trials. Considering the wider benefits of physical activity, exercise can still be recommended to improve outcomes for advanced cancer patients. Nevertheless, it might be too late for advanced cancer patients to start exercising for survival improvements, based on findings from randomised controlled trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07988-1.

A comparison between Caucasian and Asian superficial venous anatomy and reflux patterns – Implications for potential precision endovenous ablation therapy

Objectives

The aim of this study is to investigate whether there are differences between predominantly Caucasians and Asians from two disparate cohorts around the globe, with regard to their pre-operative venous reflux patterns and truncal vein characteristics, which could potentially help clinicians tailor venous treatment for chronic venous insufficiency on a more individualised basis in different parts of the world.

Methods

A total of 200 lower limb chronic venous insufficiency duplex studies (127 Singaporean (predominantly Asian) patients) and 200 lower limb chronic venous insufficiency duplex scans (137 Americans predominantly Caucasians) were analysed and compared for differences in venous anatomy and reflux characteristics.

Results

Asian patients from Singapore presented with higher CEAP scores compared to the predominantly Caucasian cohort from the US (30% CEAP 4a or greater vs. 17.5%; p < 0.01). Singaporeans had more great saphenous vein reflux starting at the sapheno-femoral junction (86% vs. 73%; p < 0.01) and ending at the ankle (93% vs. 46%; p < 0.01). Vein diameters were generally larger in the US cohort of patients (median 5.7 mm vs. 2.9 mm; p < 0.01).

Conclusions

The predominantly Asian cohort from Singapore had smaller diameter truncal veins, longer segments of truncal vein reflux and present later with more advanced chronic venous insufficiency compared to their American counterparts. This information could help tailor endovenous ablation on a more individualised basis in the future.

The Efficacy of Emergency Medicine Ward for the Management of Patients with Mental Disorders

Objective

Patients with mental disorders are one of the target groups selected for management in the Emergency Medicine Ward (EMW) with the enrolment of psychiatric advanced practice nurses. This study aimed to determine whether the EMW can be efficiently used for the management of patients with mental disorders in terms of length of stay (LOS), admission rate, and re-attendance rate when compared with the medical ward.

Methods

This was a retrospective descriptive study. Patients with mental disorders were defined and recruited from the Princess Margaret Hospital during two selected study periods: pre-opening (pre-EMW) and post-opening (post-EMW) of the EMW. All emergency department records of patients with mental disorders within these two periods were reviewed and data of the selected samples were retrieved from different computer databases.

Results

The total number of patients with mental disorders was 565 in the pre-EMW period and 404 in the post-EMW period; 214 (37.9%) cases were admitted into the medical ward in the pre-EMW period while only 62 (15.3%) were admitted into the medical ward in the post-EMW period. The mean LOS in the pre-EMW period was 67.7 hours. For the post-EMW period, the mean LOS was 32.3 hours. The reduction in mean LOS was 35.4 hours, and 82% of the study patients treated in the EMW were discharged within 48 hours. Notably, 23.3% of the cases re-attended the emergency department after discharge from the medical ward, whereas only 8.8% of cases re-attended after discharge from the EMW.

Conclusion

Patients with mental disorders or related problems can be efficaciously managed in the EMW, as evidenced by a decrease in the length of stay, admission rate, and re-attendance rate.

Development and validation of algorithms for the detection of statin myopathy signals from electronic medical records

The purpose of this study was to develop and validate sensitive algorithms to detect hospitalized statin-induced myopathy (SIM) cases from electronic medical records (EMRs). We developed four algorithms on a training set of 31,211 patient records from a large tertiary hospital. We determined the performance of these algorithms against manually curated records. The best algorithm used a combination of elevated creatine kinase (>4× the upper limit of normal (ULN)), discharge summary, diagnosis, and absence of statin in discharge medications. This algorithm achieved a positive predictive value of 52-71% and a sensitivity of 72-78% on two validation sets of >30,000 records each. Using this algorithm, the incidence of SIM was estimated at 0.18%. This algorithm captured three times more rhabdomyolysis cases than spontaneous reports (95% vs. 30% of manually curated gold standard cases). Our results show the potential power of utilizing data and text mining of EMRs to enhance pharmacovigilance activities.

Randomized phase II study of axitinib versus placebo plus best supportive care in second-line treatment of advanced hepatocellular carcinoma

BACKGROUND

The efficacy and safety of axitinib, a potent and selective vascular endothelial growth factor receptors 1-3 inhibitor, combined with best supportive care (BSC) was evaluated in a global, randomized, placebo-controlled phase II trial in patients with locally advanced or metastatic hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Patients with HCC and Child-Pugh Class A who progressed on or were intolerant to one prior antiangiogenic therapy were stratified by tumour invasion (presence/absence of extrahepatic spread and/or vascular invasion) and region (Asian/non-Asian) and randomized (2:1) to axitinib/BSC (starting dose 5 mg twice-daily) or placebo/BSC. The primary end point was overall survival (OS).

RESULTS

The estimated hazard ratio for OS was 0.907 [95% confidence interval (CI) 0.646-1.274; one-sided stratified P = 0.287] for axitinib/BSC (n = 134) versus placebo/BSC (n = 68), with the median (95% CI) of 12.7 (10.2-14.9) versus 9.7 (5.9-11.8) months, respectively. Results of prespecified subgroup analyses in Asian versus non-Asian patients or presence versus absence of tumour invasion were consistent with the overall population. Improvements favouring axitinib/BSC (P < 0.01) were observed in secondary efficacy end point analyses [progression-free survival (PFS), time to tumour progression (TTP), and clinical benefit rate (CBR)], and were retained among Asian patients in the prespecified subgroup analyses. Overall response rate did not differ significantly between treatments and patient-reported outcomes favoured placebo/BSC. Most common all-causality adverse events with axitinib/BSC were diarrhoea (54%), hypertension (54%), and decreased appetite (47%). Baseline serum analyses identified potential new prognostic (interleukin-6, E-selectin, interleukin-8, angiopoietin-2, migration inhibitory factor, and c-MET) or predictive (E-selectin and stromal-derived factor-1) factors for survival.

CONCLUSIONS

Axitinib/BSC did not improve OS over placebo/BSC in the overall population or in stratification subgroups. However, axitinib/BSC resulted in significantly longer PFS and TTP and higher CBR, with acceptable toxicity in patients with advanced HCC.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01210495.

Efficacy and toxicity of intensity-modulated radiation therapy for prostate cancer in Chinese patients

OBJECTIVE

To report the treatment efficacy and toxicity profile of intensitymodulated radiation therapy in Chinese patients with clinically localised prostate cancer.

DESIGN

Historical cohort study.

SETTING

Oncology unit in a university teaching hospital in Hong Kong.

PATIENTS

Patients with clinically localised prostate cancer undergoing intensity-modulated radiation therapy in our institution between May 2001 and November 2009 were reviewed.

MAIN OUTCOME MEASURES

The 5-year biochemical failure–free survival, 5-year overall survival, as well as acute/late gastro-intestinal toxicities and genito-urinary toxicities.

RESULTS

A total of 182 patients were treated with prostate intensitymodulated radiation therapy with or without whole-pelvic radiotherapy. The median follow-up was 44 months. The median patient age was 72 years. Overall survival of the cohort was 92% after 5 years. The favourable, intermediate, and unfavourable risk category distributions of the National Comprehensive Cancer Network were 21 (12%), 42 (23%), and 119 (65%), respectively. The 5-year actuarial biochemical failure–free survival rates for patients in these categories were 95%, 82%, and 80%, respectively. Multivariate analysis identified early tumour stage, low pre-treatment prostate-specific antigen levels, and the use of adjuvant androgen deprivation as independent prognostic factors for better biochemical failure–free survival. Grade 2 and 3 late gastro-intestinal/genito-urinary toxicities occurred in 8%/3% and 4%/3% of the patients, respectively.

CONCLUSION

Intensity-modulated radiation therapy for prostate cancer is feasible and safe in the Chinese population. These data are consistent with the results of other series in Caucasian populations.

A correlation study between in-brace correction, compliance to spinal orthosis and health-related quality of life of patients with Adolescent Idiopathic Scoliosis

BACKGROUND

It has been proposed that in-brace correction is the best guideline for prediction of the results of brace treatment for patients with Adolescent Idiopathic Scoliosis (AIS). However, bracing may be a stressful experience for patients and bracing non-compliance could be psychologically related. The purpose of this study was to assess the correlation between brace compliance, in-brace correction and QoL of patients with AIS.

METHODS

Fifty-five patients with a diagnosis of AIS were recruited. All were female and aged 10 years or above when a brace was prescribed, none had undergone prior treatment, and all had a Risser sign of 0-2 and a Cobb angle of 25-40°. The patients were examined in three consecutive visits with 4 to 6 months between each visit. The Chinese translated Trunk Appearance Perception Scale (TAPS), the Chinese translated Brace Questionnaires (BrQ) and the Chinese translated SRS-22 Questionnaires were used in the study. The in-brace Cobb angle, vertebral rotation and trunk listing were also measured. Patients' compliance, in-brace correction and patients' QoL were assessed. To identify the relationship among these three areas, logistic regression model and generalized linear model were used.

RESULT

For the compliance measure, a significant difference (p = 0.008) was detected on TAPS mean score difference between Visit 1 and Visit 2 in the least compliant group (0-8 hours) and the most compliant group (17-23 hours). In addition, a significant difference (p = 0.000) was detected on BrQ mean score difference between Visit 2 and Visit 3 in the least compliant group (0-8 hours) and the most compliant group (17-23 hours). For the orthosis effectiveness measure, no significant difference was detected between the three groups of bracing hours (0-8 hours, 9-16 hours, 17-23 hours) on in-brace correction (below 40% and 40% or above). For the QoL measure, no significant difference was detected between the two different in-brace correction groups (below 40% and 40% or above) on QoL as reflected by the TAPS, BrQ and SRS-22r mean scores.

CONCLUSION

The results showed a positive relationship between patients' brace wear compliance and patients' QoL. Poor compliance would cause a lower QoL.

Anaemia and type 2 diabetes: implications from a retrospectively studied primary care case series

OBJECTIVES. To identify the prevalence of anaemia in Chinese type 2 diabetic patients managed in a primary care setting and to explore its associations with cardiovascular complications and kidney disease. DESIGN. Retrospective case series study. SETTING. General Out-patient Clinic of Hospital Authority, Hong Kong. PATIENTS. Chinese type 2 diabetic patients who had annual assessments between 1 January 2010 and 31 December 2011 were recruited. Their complete blood picture, serum creatinine, estimated glomerular filtration rate (calculated by Modification of Diet in Renal Disease method), haemoglobin A1c, and urine albumin-creatinine ratio were retrieved. Anaemia was defined as a haemoglobin level of <130 g/L in men and <120 g/L in women (World Health Organization criteria). Student's t test and analysis of variance were used to analyse continuous variables and the Chi squared test for categorical data. Pearson's correlation coefficient and multivariate logistic regression were used to examine associations between haemoglobin level and different variables including age, gender, serum creatinine level, estimated glomerular filtration rate, and urine albumin-creatinine ratio. All statistical tests were two-sided, and a P value of <0.05 was considered significant. RESULTS. Among 6325 Chinese type 2 diabetic patients fulfilling the inclusion criteria, 1441 were found to have anaemia with a period prevalence of 22.8%. The prevalence of anaemia increased significantly with deterioration of renal function. Compared with diabetic patients with normal haemoglobin levels, anaemic diabetic patients had a higher co-morbidity rate for stroke, ischaemic heart disease, hypertension, and chronic kidney disease (P<0.001). Independent predictors for haemoglobin level among diabetic patients were age, gender, serum creatinine level, estimated glomerular filtration rate, haemoglobin A1c, and urine albumin-creatinine ratio (P<0.001). Multivariate analysis showed that male gender, old age, increased serum creatinine level, decreased estimated glomerular filtration rate, elevated urine albumin-creatinine ratio, and co-morbidity with stroke or ischaemic heart disease were associated with greater odds for the presence of anaemia. CONCLUSION. Anaemia is common among Chinese type 2 diabetic patients, particularly those with impaired renal function or established cardiovascular disease. Early detection of anaemia and prompt referral to specialist care for optimal treatment, if associated with severe renal impairment or high-risk proteinuria at the primary care settings, is recommended.

A phase II study of concurrent cetuximab-cisplatin and intensity-modulated radiotherapy in locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

Based on our previous work on the clinical activity of cetuximab in recurrent nasopharyngeal carcinoma (NPC), we evaluated the feasibility of adding cetuximab to concurrent cisplatin and intensity-modulated radiotherapy (IMRT) in locoregionally advanced NPC.

PATIENTS AND METHODS

Patients with American Joint Committee on Cancer stage III-IVB NPC were given an initial dose of cetuximab (400 mg/m(2)) 7-10 days before receiving concurrent IMRT, weekly cisplatin (30 mg/m(2)/week) and cetuximab (250 mg/m(2)/week).

RESULTS

Thirty patients (median age of 45 years) with stage III (67%), IVA (30%) and IVB (3%) nonkeratinizing NPC were enrolled. Grade 3-4 oropharyngeal mucositis occurred in 26 (87%) patients and 10 (33%) patients required short-term nasogastric feeding. Grade 3 radiotherapy-related dermatitis occurred in six patients (20%) and three patients (10%) had grade 3 cetuximab-related acneiform rash. These grade 3-4 skin and mucosal toxic effects were manageable and reversible. At a median follow-up of 31.8 months [95% confidence interval (CI) 26.2-32.1 months], the 2-year progression-free survival was 86.5% (95% CI 74.3% to 98.8%).

CONCLUSIONS

Concurrent administration of cetuximab, weekly cisplatin and IMRT is a feasible strategy against locoregionally advanced NPC. Preliminary survival data compare favorably with historic data and further follow-up is warranted.

Secondary prevention of stroke: an evidence-based clinical audit in the primary care

OBJECTIVE

To audit secondary preventive care in non-acute stroke patients in a local General Outpatient Clinic of the Hospital Authority.

DESIGN

Comparison of two samples from a case series at different time-points.

SETTING

General Outpatient Clinic, Hong Kong.

PATIENTS

Non-acute stroke patients fulfilling the inclusion criteria and regularly followed up in a local General Outpatient Clinic during the audit cycle were recruited. Evidence-based audit criteria and performance standards were established after thorough literature review. A sample from this case series was compared retrospectively at two time-points. First-phase evaluation was performed in October 2009 and deficiencies were identified. After 9 months of active intervention, second-phase evaluation was performed in July 2010. Chi squared test and student's t test were used to compare the significance of relevant changes noted.

RESULTS

First-phase data showed marked deficiencies in proper assessment of cardiovascular risk factors. Satisfactory blood pressure, glucose and lipid control was evident only in 47% of the hypertensive, 45% of the diabetic, and 37% of the dyslipidaemic stroke patients, respectively. After 9 months of implementing changes, significant improvements were noted with respect to standard targets being achieved. In the second phase, more comprehensive tackling of cardiovascular risk factors was noted, with satisfactory blood pressure control in 73% of hypertensive patients, and adequate metabolic control in 62% diabetic patients (P<0.01 for both). Only 59% of the dyslipidaemic stroke patients had optimal lipid control, though their mean low-density lipoprotein concentration was significantly reduced (P<0.05).

CONCLUSION

This study provided a valuable lesson in identifying deficiencies in secondary prevention for stroke patients managed in a local primary care facility. Using a team approach intervention, quality assurance was promoted and a definite impact on patient care was demonstrated.

Sequential expression of putative stem cell markers in gastric carcinogenesis

BACKGROUND

Gastric carcinogenesis has been well documented in the step-wise histopathological model, known as Correa pathway. Several biomarkers including CD44, Musashi-1 and CD133 have been reported as putative stem cell (PSC) markers.

METHODS

We investigated expression of PSC markers CD44, Musashi-1 and CD133 in relation to gastric carcinogenesis and prognosis and chemoresponse. Immunohistochemistry staining was performed in gastric cancer (GC) clinical specimens representing different steps of the Correa pathway. Gastric cancer samples taken before and after neoadjuvant chemotherapy with docetaxel, cisplatin and capecitabine (DCX) were also evaluated for PSC marker expression.

RESULTS

We showed that the expression of three PSC markers was significantly elevated in GC relative to normal gastric mucosa (P<0.001 for each marker). Precancerous lesions, including intestinal metaplasia and dysplasia, demonstrated increased expression of CD44 and Musashi-1. CD133 was predominantly expressed along the border between intramucosal carcinoma and connective tissue at later stages. High CD44 and CD133 expression showed prognostic value for worse patient survival (P=0.014 and P=0.019, respectively). A small number of tumours with high expression of CD44 and CD133 showed pathological response to DCX-based neoadjuvant chemotherapy.

CONCLUSION

CD44 and Musashi-1 are frequently expressed in both premalignant gastric lesions and invasive GC, whereas CD133 expression is restricted mainly to neoplastic tissues.

Comparison of Chinese and Western rifapentines and improvement of bioavailability by prior taking of various meals

Bioavailability was measured by rifapentine (RPE) serum concentrations and by the urinary ratio between RPE and creatinine, in specimens obtained 4-50 h after 600 mg RPE preceded by food. The bioavailabilities of RPEs manufactured in China and by a Western manufacturer were similar after a standard English breakfast, and serum concentrations were also similar to those obtained in an earlier Italian study following a complex meal. Although absorption of RPE was unsatisfactory after lipid-rich biscuits or shortbread, absorption after egges and toast was excellent and was nearly as good after a fast-food sandwich. The urinary measure of bioavailability at 26 h appeared as efficient as peak serum estimations at 6, 8 and 26 h. Fast-food sandwiches are being taken before RPE in a current clinical trial of Chinese RPE in Hong Kong.

Multicenter phase II study of gemcitabine and oxaliplatin in advanced nasopharyngeal carcinoma--correlation with excision repair cross-complementing-1 polymorphisms

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a platinum-sensitive cancer and excision repair cross-complementing group 1 (ERCC1) polymorphisms have been shown to predict survival in several cancers following platinum therapy.

PATIENTS AND METHODS

This multicenter study evaluated the activity of oxaliplatin and prolonged infusion of gemcitabine ('GEMOX' regimen) in recurrent NPC. Baseline blood samples were genotyped for the presence of ERCC1-118 gene polymorphisms.

RESULTS

Forty-two patients were recruited, of whom most (61%) had metastatic disease. Of the 40 patients evaluated for response, the respective overall response and disease control rates were 56.1% and 90.2%. At a median follow-up of 14.8 months, the respective median overall survival and time to progression were 19.6 months [95% confidence interval (CI) = 12.8-22 months] and 9 months (95% CI = 7.3-10 months). Grade 3-4 toxic effects were uncommon. The distribution of ERCC1-118 genotypes from 29 patients was C/C (n = 17, 40.5%), C/T (n = 10, 23.8%) and T/T (n = 2, 4.8%). No differences in survival or response rates were found between genotypes.

CONCLUSIONS

GEMOX is active in the treatment of recurrent NPC. Detection of single-nucleotide gene polymorphisms from genomic DNA in peripheral blood is feasible in NPC and further studies are warranted.

A randomized study of aprepitant, ondansetron and dexamethasone for chemotherapy-induced nausea and vomiting in Chinese breast cancer patients receiving moderately emetogenic chemotherapy

OBJECTIVES

This is a single center, randomized, double-blind placebo-controlled study to evaluate the NK(1)-receptor antagonist, aprepitant, in Chinese breast cancer patients. The primary objective was to compare the efficacy of aprepitant-based antiemetic regimen and standard antiemetic regimen for the prevention of chemotherapy-induced nausea and vomiting (CINV) in patients who received moderately emetogenic chemotherapy. The secondary objective was to compare the patient-reported quality of life in these two groups of patients.

PATIENTS AND METHODS

Eligible breast cancer patients were chemotherapy-naive and treated with adjuvant AC chemotherapy (i.e. doxorubicin 60 mg/m(2) and cyclophosphamide 600 mg/m(2)). Patients were randomly assigned to either an aprepitant-based regimen (day 1, aprepitant 125 mg, ondansetron 8 mg, and dexamethasone 12 mg before chemotherapy and ondansetron 8 mg 8 h later; days 2 through 3, aprepitant 80 qd) or a control arm which consisted of standard regimen (day 1, ondansetron 8 mg and dexamethasone 20 mg before chemotherapy and ondansetron 8 mg 8 h later; days 2 through 3, ondansetron 8 mg bid). Data on nausea, vomiting, and use of rescue medication were collected with a self-report diary, patients quality of life were assessed by self-administered Functional Living Index-Emesis (FLIE).

RESULTS

Of 127 patients randomized, 124 were assessable. For CINV in Cycle 1 AC, there was no significant difference in the proportion of patients with reported complete response, complete protection, total control, 'no vomiting', 'no significant nausea' and 'no nausea'. The requirement of rescue medication appears to be lesser in patients treated with the aprepitant-based regimen compared to those with the standard regimen (11% vs. 20%; P = 0.06). Assessment of FLIE revealed that while there was no difference in the nausea domain and the total score between the two groups; however, patients receiving standard antiemetic regimen had significantly worse quality of life in the vomiting domain (mean score [SD] = 23.99 [30.79]) when compared with those who received the aprepitant-based regimen (mean score [SD] = 3.40 [13.18]) (P = 0.0002). Both treatments were generally well tolerated. Patients treated with the aprepitant-based regimen had a significantly lower incidence of neutropenia (53.2% vs. 35.5%, P = 0.0468), grade >or= 3 neutropenia (21.0% vs. 45.2, P = 0.0042) and delay in subsequent cycle of chemotherapy (8.1% vs. 27.4%, P = 0.0048).

CONCLUSION

The aprepitant regimen appears to reduce the requirement of rescue medication when compared with the control regimen for prevention of CINV in patients receiving both an anthracycline and cyclophosphamide, and is associated with a better quality of life during adjuvant AC chemotherapy.

Exploring ligand recognition and ion flow in comparative models of the human GABA type A receptor

We present two comparative models of the GABA(A) receptor. Model 1 is based on the 4-A resolution structure of the nicotinic acetylcholine receptor from Torpedo marmorata and represents the unliganded receptor. Two agonists, GABA and muscimol, two benzodiazepines, flunitrazepam and alprazolam, together with the general anaesthetic halothane, have been docked to this model. The ion flow is also explored in model 1 by evaluating the interaction energy of a chloride ion as it traverses the extracellular, transmembrane and intracellular domains of the protein. Model 2 differs from model 1 only in the extracellular domain and represents the liganded receptor. Comparison between the two models not only allows us to explore commonalities and differences with comparative models of the nicotinic acetylcholine receptor, but also suggests possible protein sub-domain interactions with the GABA(A) receptor not previously addressed.

Regulation of p53 and suppression of apoptosis by the soluble guanylyl cyclase/cGMP pathway in human ovarian cancer cells

Dysregulated apoptosis plays a critical role in the development of a number of aberrant cellular processes, including tumorigenesis and chemoresistance. However, the mechanisms that govern the normal apoptotic program are not completely understood. Soluble guanylyl cyclase (sGC) and cyclic guanosine monophosphate (cGMP) promote mammalian cell viability via an unknown mechanism and p53 status is a key determinant of cell fate in human ovarian cancer cells. Whether an interaction exists between these two determinants of cell fate is unknown. We hypothesized that basal sGC activity reduces p53 content and attenuates p53-dependent apoptosis in human ovarian cancer cells. Suppression of sGC activity with the specific inhibitor 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ) lowered cGMP content, and increased p53 protein content and induced apoptosis in three ovarian cancer cell lines, effects which were attenuated by the cGMP analog 8-Br-cGMP and by Atrial Natriuretic Factor, an activator of particulate guanylyl cyclase, which circumvent the inhibition of sGC. ODQ prolonged p53 half-life, induced phosphorylation of p53 on Ser15, and upregulated the p53-dependent gene products p21, murine double minute-2, and the proapoptotic, p53-responsive gene product Bax. ODQ activated caspase-3, and ODQ-induced apoptosis was inhibited by overexpression of X-linked inhibitor of apoptosis Protein. Pretreatment with the specific p53 inhibitor pifithrin or downregulation of p53 using a specific small inhibitory RNA significantly attenuated ODQ-induced apoptosis. Moreover, ODQ-induced upregulation of p21 and Bax and ODQ-induced apoptosis were significantly reduced in a p53 mutant cell line relative to the wild-type parental cell line. Thus, the current study establishes that basal sGC/cGMP activity regulates p53 protein stability, content, and function, possibly by altering p53 phosphorylation and stabilization, and promotes cell survival in part through regulation of caspase-3 and p53.

Unbinding pathways of an agonist and an antagonist from the 5-HT3 receptor

The binding sites of 5-HT3 and other Cys-loop receptors have been extensively studied, but there are no data on the entry and exit routes of ligands for these sites. Here we have used molecular dynamics simulations to predict the pathway for agonists and antagonists exiting from the 5-HT3 receptor binding site. The data suggest that the unbinding pathway follows a tunnel at the interface of two subunits, which is approximately 8 A long and terminates approximately 20 A above the membrane. The exit routes for an agonist (5-HT) and an antagonist (granisetron) were similar, with trajectories toward the membrane and outward from the ligand binding site. 5-HT appears to form many hydrogen bonds with residues in the unbinding pathway, and experiments show that mutating these residues significantly affects function. The location of the pathway is also supported by docking studies of granisetron, which show a potential binding site for granisetron on the unbinding route. We propose that leaving the binding pocket along this tunnel places the ligands close to the membrane and prevents their immediate reentry into the binding pocket. We anticipate similar exit pathways for other members of the Cys-loop receptor family.

Animal model for the pathogenesis of reactive amyloidosis

The pathogenesis of amyloidosis is not well understood. Here, Zafer Ali-Khan, Weihua Li and Sic L. Chan present a metazoan parasite mouse model of reactive amyloidosis, review the relationship between chronic inflammation and multiorgan AA amyloidosis and postulate how ubiquitin might function in the processing of serum amyloid A and in AA amyloid formation in the endosomes-lysosomes of activated murine reticuloendothetial cells.

Appropriateness of the use of parenteral nutrition in a local tertiary-care hospital

INTRODUCTION

Parenteral nutrition (PN) is an important supportive therapy for critically ill patients who have non-functioning gut. However, it is an expensive therapy and carries significant complications. The objective of our audit was to determine the appropriateness of prescription of PN in our hospital, based on the American Society for Parenteral and Enteral Nutrition (ASPEN) 2002 guidelines. In our hospital, the prescription of PN is managed by the Nutrition Support Team.

MATERIALS AND METHODS

A retrospective review of adult patients prescribed with PN in 2001 was undertaken. Data on patient demographics, underlying diagnoses, indications, duration and routes administration were collected. The use of PN was classified as "appropriate", "inappropriate" or "indeterminate" by the authors based on the above guidelines.

RESULTS

145 patients were prescribed PN in 2002. We were able to review the case notes for 137 patients. One patient received PN on 2 separate admissions. Of the 138 courses of PN (in 137 patients) reviewed, there were 88 males with the median age of 61 years (range, 16 to 91 years). 81.2% were surgical patients and of the remaining patients, 10.1% had haematological malignancies. The 2 most common indications were postoperative ileus (37.0%) and post-surgical complications (14.5%). The median duration of PN prescription was 9 days (range, 1 to 175 days). 109 (78.3%) courses of PN were classified as "appropriate", 22 (15.9%) courses as "inappropriate" and 7 (5.8%) courses as "indeterminate". Patients from the postoperative ileus group contributed to 10 (45.5%) patients with "inappropriate" indications; the main reason was premature initiation of PN. Of the patients considered to show "inappropriate" indications, 15 courses (68.1%) were prescribed for less than 7 days. PN was discontinued in 78% of courses due to satisfactory resumption of oral or enteral intake. The mean duration of PN use for patients with "inappropriate" indication was significantly shorter than for patients with "appropriate" indication (7.7 +/- 5.3 days versus 15.8 +/- 20.0 days, P = 0.002). 99.3% of PN courses were given via the central routes (with central vein cannulation or PICC). These lines were specifically inserted for PN in 60.14% of the cases.

CONCLUSION

Our audit showed that 15.9% of PN prescriptions were inappropriate according to the ASPEN guidelines. This was largely attributed to premature initiation of PN for postoperative ileus. We believe that these PN courses could have been avoided if these patients had been tried on naso-jejunal tube feeding, or oral nutrition with the use of prokinetics during the postoperative period.

Evidence for Nonadrenoceptor Responses to Imidazoline Derivatives in the Porcine Isolated Rectal Artery

High concentrations of phentolamine, efaroxan, and idazoxan were found to produce nonadrenoceptor contractions of the porcine isolated rectal artery previously exposed to U46619 and forskolin. These responses were insensitive to the putative imidazoline I(3) receptor antagonist KU-14R, unlike those previously reported in this preparation for oxymetazoline. The pharmacologic nature of this response and the obligate requirement for preconstriction suggests that these imidazoline derivatives modulate ion channel function through a novel nonadrenergic site.

Prevalence and predictors of default from tuberculosis treatment in Hong Kong

OBJECTIVE

To determine the prevalence and risk factors of default from tuberculosis treatment in Hong Kong.

DESIGN

Retrospective study.

SETTING

Data were obtained from programme forms completed by physicians in the Hong Kong Government Tuberculosis and Chest Service and from medical records from Hong Kong chest clinics.

PATIENTS

In all, 5917 patients registered for antituberculous drug therapy in 1996; medical records of 5757 patients were reviewed.

MAIN OUTCOME MEASURES

Patients who defaulted treatment were defined as those who had failed to collect medication for more than 2 consecutive months after the date of the last attendance during the course of treatment. Demographic and clinical characteristics, including history, treatment, and outcome, were compared between defaulters and non-defaulters, both among the whole group and among those with pulmonary disease.

RESULTS

There were 442 (8%) patients who defaulted from treatment. Forty-five percent of those who defaulted did so in the first 2 months of treatment. Key risk factors associated with non-compliance were a history of default, male sex, and a history of concomitant liver disease or lung cancer. Among patients with pulmonary tuberculosis (381 defaulters and 1537 non-defaulters), multiple drug resistance was also associated with default from treatment. Among defaulters with pulmonary disease, 39% were still bacteriologically positive at the time of default.

CONCLUSION

Default from treatment may be partially responsible for the persistent high rates of tuberculosis in Hong Kong in the past decade. Health professionals should ensure that all barriers to treatment be removed and that incentives be used to encourage treatment compliance.

Tuberculosis in Hong Kong-patient characteristics and treatment outcome

OBJECTIVES

To identify the general characteristics of patients with tuberculosis, and to evaluate their treatment outcomes.

DESIGN

Retrospective study.

SETTING

Tuberculosis and Chest Service, Department of Health, Hong Kong.

SUBJECTS AND METHODS

All patients with tuberculosis registered for treatment from 1 January 1996 to 31 December 1996 were included in the study. Information was extracted from their medical records at treatment commencement and at 12 and 24 months after treatment was instigated. Data gathered included demographic data, past treatment, site of disease, case category, treatment regimen, bacteriological status, and treatment outcome.

RESULTS

There were 5757 patients for analysis. Approximately one third of patients were aged 60 years or older, and 69.1% were male. Pulmonary disease alone occurred in 77.7% of patients, while both pulmonary and extrapulmonary diseases occurred in 8.6%. New patients comprised 84.6% of cases, and 16.3% had concomitant illnesses. There was excess risk of disease among patients who were male, elderly, or who had silicosis. Only 0.1% of patients were co-infected with human immunodeficiency virus infection. Among the 5757 cases evaluated, 1324 (23.0%) were new patients with a positive sputum smear, 299 (5.2%) were patients who were retreated with a positive sputum smear, and 4134 (71.8%) were new or retreatment patients with a negative sputum smear. The overall treatment completion rates at 12 and 24 months were 80.4% and 84.8%, respectively. Males and patients aged 60 years or older had lower treatment completion rates. Non-adherence, transfer to other services, and mortality among the elderly were key factors influencing treatment outcomes. Co-morbidity was associated with better case-holding, and this more than compensated for its effect on prolongation of treatment and mortality.

CONCLUSIONS

There was an excess risk of tuberculosis among male and elderly patients, who also had a less favourable outcome. Active screening of clearly identified risk groups may be appropriate but requires the completion of more in-depth studies and careful cost-effectiveness analyses. Further efforts with respect to case-holding are indicated to address treatment defaulting and transfer rates.

Extra-pulmonary and pulmonary tuberculosis in Hong Kong

OBJECTIVE

To compare the characteristics of patients with pulmonary and extra-pulmonary tuberculosis and to describe the organ involvement, diagnosis and treatment of extra-pulmonary tuberculosis.

MATERIALS AND METHODS

All patients with a diagnosis of tuberculosis treated by the Hong Kong Government Tuberculosis and Chest Service (Chest Service) in 1996 were studied.

RESULTS

Of the 5757 patients treated, 13.7% had extra-pulmonary tuberculosis alone and 8.6% had both extra-pulmonary tuberculosis and pulmonary tuberculosis. Extra-pulmonary tuberculosis was more common in women under 30 and over 75 years of age. Only six patients had human immunodeficiency virus (HIV) infection, of whom two had extra-pulmonary tuberculosis. The most common site of extra-pulmonary involvement was the pleura, followed by the lymph nodes. Miliary tuberculosis occurred in only 2.9%. Lymph node involvement occurred significantly higher in women, while pleural disease was significantly higher in men. The duration of treatment varied according to the site of disease, being shorter (6 months) for those with pleural disease only and >9 months for those with miliary, meningeal, gastrointestinal and genitourinary disease; 80.3% completed treatment at 12 months and 85.5% at 24 months. Of those who completed treatment, 1.4% had a relapse of disease at 24 months follow-up; there was no significant difference between those with pulmonary or extra-pulmonary disease.

CONCLUSION

In Hong Kong, extra-pulmonary tuberculosis is common, affecting 22.3% of TB patients, and is unrelated to HIV infection. There are sex differences in the organs most commonly affected. The rate of relapse of disease is low for those who completed treatment, irrespective of the site of involvement.

Tuberculosis in the elderly in Hong Kong

BACKGROUND

The rate of tuberculosis in Hong Kong has declined dramatically since the 1950s, but has remained high during the past decade, at around 110/100,000. The reason for the persistent high rate is not clear.

OBJECTIVES

To study the trend of tuberculosis in Hong Kong during the past decade (1989 to 1998) and the clinical characteristics of tuberculosis patients > or = 60 years of age, and compare them with those of the younger age groups.

METHODS

Notification rates of tuberculosis from 1989 to 1998 were obtained from the Hong Kong Government Tuberculosis and Chest Service (Chest Service), Department of Health, Hong Kong. In addition, all patients registered at the Chest Service for treatment of tuberculosis in 1996 were studied.

RESULTS

During the past decade, the notification rate of tuberculosis, which included both bacteriologically confirmed and clinically active but bacteriologically not confirmed cases, decreased in those under 60, remained unchanged in those between 60-69, and increased in those > or = 70 years of age. An increase in the rate of bacteriologically confirmed cases (sputum smear or culture positive for Mycobacterium tuberculosis) in the older age groups was observed during the same period. In 1989, 31.9% of tuberculosis cases were over the age of 60 years; this proportion increased to 45.4% in 1998. The increase in the number of cases in those > or = 60 years could almost account for the total increase in number of cases during the last decade. Patients in the older age groups had more advanced disease at the time of diagnosis, and a higher proportion had comorbid illnesses. They also had significantly higher mortality compared with the younger age groups.

CONCLUSION

The increasing longevity of the population and the high rate of tuberculosis in the elderly are important factors contributing to the persistent high rate of tuberculosis in Hong Kong in the past decade.

Exhaled nitric oxide: the effects of age, gender and body size

Since little is known of the effects of age, gender, and body size on exhaled nitric oxide (NO) production, we have conducted a prospective study to examine these factors in a healthy nonsmoking women (mean age +/- SD 47.7 +/- 15.8, range 20-79 years). Exhaled NO was measured by an automatic chemiluminescence analyzer (Sievers NO Analyser 280) at steady expiration. Men had significantly higher exhaled NO levels than women (p = 0.001). Although exhaled NO levels did not correlate with age (r = 0.12, p = 0.17), it correlated significantly with height (r = 0.23, p = 0.02), weight (r = 0.34, p

Perturbed endoplasmic reticulum function, synaptic apoptosis and the pathogenesis of Alzheimer's disease

Endoplasmic reticulum (ER) appears to be a focal point for alterations that result in neuronal dysfunction and death in Alzheimer's disease (AD). Aberrant proteolytic processing and/or trafficking of the beta-amyloid precursor protein (APP) in ER may promote neuronal degeneration by increasing the levels of the neurotoxic forms of beta-amyloid (A beta) and by decreasing the levels of the neuroprotective secreted form of APP (sAPP alpha). Some cases of AD are caused by mutations in the genes encoding presenilin 1 (PS1). When expressed in cultured neuronal cells and transgenic mice, PS1 mutations cause abnormalities in ER calcium homoeostasis, enhancing the calcium responses to stimuli that activate IP3- and ryanodine-sensitive ER calcium pools. Two major consequences of this disrupted ER calcium regulation are altered proteolytic processing of APP and increased vulnerability of neurons to apoptosis and excitotoxicity. The impact of PS1 mutations and aberrant APP processing is particularly great in synaptic terminals. Perturbed synaptic calcium homoeostasis promotes activation of apoptotic cascades involving production of Par-4 (prostate apoptosis response-4), mitochondrial dysfunction and caspase activation. A beta 42 (the 42-amino-acid form of A beta) induces membrane lipid peroxidation in synapses and dendrites resulting in impairment of membrane ion-motive ATPases and glucose and glutamate transporters. This disrupts synaptic ion and energy homoeostasis thereby promoting synaptic degeneration. In contrast, sAPP alpha activates signalling pathways that protect synapses against excitotoxicity and apoptosis. In the more common sporadic forms of AD, the initiating causes of the neurodegenerative cascade are less well defined, but probably involve increased levels of oxidative stress and impaired energy metabolism. Such alterations have been shown to disrupt neuronal calcium homoeostasis in experimental models, and may therefore feed into the same neurodegenerative cascade initiated by mutations in presenilins and APP. Perturbed synaptic ER calcium homoeostasis and consequent alterations in APP processing appear to be pivotal events in both sporadic and familial forms of AD.

Rifapentine and isoniazid in the continuation phase of a 6-month regimen. Final report at 5 years: prognostic value of various measures

SETTING

Clinical trial in 672 patients with newly diagnosed pulmonary tuberculosis in Hong Kong. After an initial 2 months of a four-drug intensive phase consisting of thrice-weekly streptomycin, isoniazid, rifampicin and pyrazinamide (SHRZ), a random allocation was made to a continuation phase of once-weekly 600 mg rifapentine + 15 mg/kg isoniazid (HRp1), HRp1 given in 2 of every 3 weeks (HRp1.2/3), or to thrice-weekly isoniazid + rifampicin (HR3), the standard treatment in Hong Kong.

OBJECTIVE

Final report evaluating adverse events (46 relapses and one failure) after 5 years and the prognostic influence of various factors.

METHODS

Kaplan-Meier analysis of adverse events and Cox proportional hazards analysis of prognostic factors.

RESULTS

The two rifapentine regimens, HRp1 and HRp1.2/3 had similar final rates of adverse events of 10.8% and 11.7%, respectively, compared to 4.2% for the HR3 regimen (P = 0.02 and 0.009, respectively). In the initial univariate proportional hazards analysis, adverse events were significantly related to the regimen, age, sex, pretreatment radiographic extent of disease and cavitation, and also to sputum culture at 2 months. In the final multivariate analysis, after step-wise removal of non-significant factors, adverse events were related only to the regimen, patients' sex and pretreatment radiographic extent of disease. Elderly male patients were more at risk of an adverse event, as were those with more severe disease. Adverse events occurred at life table rates of 9.0% in patients with drug-sensitive strains and in 8.9% of those with initially isoniazid-resistant organisms at 5 years.

CONCLUSIONS

The two rifapentine regimens were unsatisfactory because of their high incidence of adverse events. Isoniazid appeared not to contribute to preventing relapse. Further studies with increased rifapentine dosage are necessary.

Sex differences in tuberculosis in Hong Kong

SETTING

The Hong Kong Tuberculosis and Chest Service, Department of Health, Hong Kong.

OBJECTIVE

To examine sex differences in the rate and clinical manifestations of tuberculosis in Hong Kong.

DESIGN

Notification rates of tuberculosis during the past five decades were obtained from the Hong Kong Tuberculosis and Chest Service, Department of Health, Hong Kong. In addition, all patients registered with the Chest Service for treatment of tuberculosis in 1996 were studied.

RESULTS

The rate of tuberculosis during the past five decades was consistently higher in men than in women, irrespective of age group. The sex difference in rates was highest among those aged over 60 years. In 1996, a higher proportion of women had extra-pulmonary tuberculosis than men; the main site of involvement was the lymph nodes. More women completed treatment at 12 months and fewer women missed treatment appointments. A higher proportion of men had relapse pulmonary disease that was more extensive, a history of previous default from treatment and co-morbid illnesses.

CONCLUSION

There are sex differences in the rates and clinical manifestations of tuberculosis in Hong Kong. Study of sex differences is essential for targeting prevention programmes at groups at higher risk.

Contact examination for tuberculosis in Hong Kong is useful

SETTING

The tuberculosis programme of the Hong Kong Government Tuberculosis and Chest Service.

OBJECTIVE

To determine the outcome of examination of household contacts in Hong Kong.

DESIGN

A retrospective cohort study of all household contacts of 970 randomly selected index cases from a total of 5757 registered for treatment with the Chest Service.

RESULTS

Of 2678 household contacts (three/index case) identified, 90% were examined; 41 active cases were found, at a rate of 1720/100000 (95%CI 1238-2329). The rate was highest among two extremes of age, 3604/100000 (95%CI 990-3615) in children < or = 5 years and 3347/100000 (95%CI 1456-6489) in those >60 years of age. Contacts of index cases whose sputum smear and culture were positive had the highest rate of disease, 2904/100000 (95%CI 1669-4673); but contacts with negative bacteriology also had a high rate of 1478/100000 (95%CI 678-2789). Active cases identified through contact tracing could be source cases rather than secondary cases. Eight per cent of children aged < or = 5 years had positive tuberculin reactions; as BCG vaccination is given to all newborns, with 99% coverage in Hong Kong in the past 30 years, it was difficult to estimate the rate of infection in these children.

CONCLUSION

In Hong Kong, an area with an intermediate burden of tuberculosis, contact investigation is a very useful procedure for active case finding.

The Caenorhabditis elegans sex-determining protein FEM-2 and its human homologue, hFEM-2, are Ca2+/calmodulin-dependent protein kinase phosphatases that promote apoptosis

In Caenorhabditis elegans, fem-1, fem-2, and fem-3 play pivotal roles in sex determination. Recently, a mammalian homologue of the C. elegans sex-determining protein FEM-1, F1Aalpha, has been described. Although there is little evidence to link F1Aalpha to sex determination, F1Aalpha and FEM-1 both promote apoptosis in mammalian cells. Here we report the identification and characterization of a human homologue of the C. elegans sex-determining protein FEM-2, hFEM-2. Similar to FEM-2, hFEM-2 exhibited PP2C phosphatase activity and associated with FEM-3. hFEM-2 shows striking similarity (79% amino acid identity) to rat Ca(2+)/calmodulin (CaM)-dependent protein kinase phosphatase (rCaMKPase). hFEM-2 and FEM-2, but not PP2Calpha, were demonstrated to dephosphorylate CaM kinase II efficiently in vitro, suggesting that hFEM-2 and FEM-2 are specific phosphatases for CaM kinase. Furthermore, hFEM-2 and FEM-2 associated with F1Aalpha and FEM-1 respectively. Overexpression of hFEM-2, FEM-2, or rCaMKPase all mediated apoptosis in mammalian cells. The catalytically active, but not the inactive, forms of hFEM-2 induced caspase-dependent apoptosis, which was blocked by Bcl-XL or a dominant negative mutant of caspase-9. Taken together, our data suggest that hFEM-2 and rCaMKPase are mammalian homologues of FEM-2 and they are evolutionarily conserved CaM kinase phosphatases that may have a role in apoptosis signaling.

p38 MAP kinase mediates nitric oxide-induced apoptosis of neural progenitor cells

Neural progenitor cells (NPC) can proliferate, differentiate into neurons or glial cells, or undergo a form of programmed cell death called apoptosis. Although death of NPC occurs during development of the nervous system and in the adult, the underlying mechanisms are unknown. Here we show that nitric oxide (NO) can induce death of C17.2 NPC by a mechanism requiring activation of p38 MAP kinase, poly(ADP-ribose) polymerase, and caspase-3. Nitric oxide causes release of cytochrome c from mitochondria, and Bcl-2 protects the neural progenitor cells against nitric oxide-induced death, consistent with a pivotal role for mitochondrial changes in controlling the cell death process. Inhibition of p38 MAP kinase by SB203580 abolished NO-induced cell death, cytochrome c release, and activation of caspase-3, indicating that p38 activation serves as an upstream mediator in the cell death process. The anti-apoptotic protein Bcl-2 protected NPC against nitric oxide-induced apoptosis and suppressed activation of p38 MAP kinase. The ability of nitric oxide to trigger death of NPC by a mechanism involving p38 MAP kinase suggests that this diffusible gas may regulate NPC fate in physiological and pathological settings in which NO is produced.

Vasorelaxant response to isoprenaline, nitric oxide donor, calcitonin gene-related peptide and vasoactive intestinal peptide in aortic rings of adult C57BL/6J mice

The mouse and tissues from this species are increasingly used as experimental models because of the wide variety of gene deletions and overexpressions available in this species. Yet, very little is known about normal vascular responses in the mouse. We investigated the vasorelaxant responses on thoracic aortic rings from the adult male C57BL/6J mouse. Isoprenaline, acetylcholine, calcitonin gene-related peptide (CGRP), vasoactive intestinal peptide (VIP) and sodium nitroprusside all caused concentration-dependent relaxations in aortic rings possessing healthy endothelium and precontracted with phenylephrine. Maximum relaxations were 64.9+/-2.6%, 66.8+/-2.9%, 114.3+/-4.6%, 65.1+/-4.2% and 116.2+/-5.1% with -logEC(50) values of 6.76+/-0.14, 7.04+/-0.11, 8.53+/-0.14, 8.29+/-0.26 and 8.10+/-0.20 for isoprenaline, acetylcholine, CGRP, VIP and sodium nitroprusside, respectively. There were significantly smaller responses to isoprenaline, acetylcholine, CGRP and VIP when the endothelium was denuded. The maximum relaxations for isoprenaline, CGRP and acetylcholine were 48.3+/-5.1%, 99.6+/-4.4% and 5.7+/-1.6% with -logEC(50) values of 6.44+/-0.40 and 8.23+/-0.192, respectively, following endothelium removal. The response to VIP was completely dependent to endothelium. Without precontraction, isoprenaline, at the higher doses, caused small contractions. These experiments provide new information about vascular responses of five vasodilators in aortic rings of adult male C57BL/6J mice.

Clonidine-displacing substance reduces glucagon secretion from mouse pancreatic alpha-cells by K(ATP)-channel-independent inhibition of exocytosis

Clonidine-displacing substance (CDS) is a potent stimulator of insulin release from pancreatic beta-cells and has been suggested to constitute the endogenous ligand for the islet imidazoline-binding site. Here we have explored the effects of CDS on glucagon release from mouse pancreatic alpha-cells. CDS (5 U/ml) produced a 35% inhibition (P < 0.05) of glucagon release from intact islets. This effect was dose-dependent and half-maximal inhibition by CDS was observed at 0.03 U/ml. Inhibition of glucagon release was not associated with a change in whole-cell ATP-sensitive K(+)-channel activity in single alpha-cells. However, during intracellular application through the recording pipette, CDS produced a 36% (P < 0.05) decrease in the rate of exocytosis, measured as changes in cell capacitance. The inhibitory effect of CDS on exocytosis resulted from activation of the protein phosphatase calcineurin and was abolished by cyclosporin A. These data provide further evidence for a role of CDS as an endogenous ligand controlling islet hormone secretion.