The first pilot study of expanded newborn screening for inborn errors of metabolism and survey of related knowledge and opinions of health care professionals in Hong Kong.

INTRODUCTION: Newborn screening is important for early diagnosis and effective treatment of inborn errors of metabolism (IEM). In response to a 2008 coroners' report of a 14-year-old boy who died of an undiagnosed IEM, the OPathPaed service model was proposed. In the present study, we investigated the feasibility of the OPathPaed model for delivering expanded newborn screening in Hong Kong. In addition, health care professionals were surveyed on their knowledge and opinions of newborn screening for IEM. METHODS: The present prospective study involving three regional hospitals was conducted in phases, from 1 October 2012 to 31 August 2014. The 10 steps of the OPathPaed model were evaluated: parental education, consent, sampling, sample dispatch, dried blood spot preparation and testing, reporting, recall and counselling, confirmation test, treatment and monitoring, and cost-benefit analysis. A fully automated online extraction system for dried blood spot analysis was also evaluated. A questionnaire was distributed to 430 health care professionals by convenience sampling. RESULTS: In total, 2440 neonates were recruited for newborn screening; no true-positive cases were found. Completed questionnaires were received from 210 respondents. Health care professionals supported implementation of an expanded newborn screening for IEM. In addition, there is a substantial need of more education for health care professionals. The majority of respondents supported implementing the expanded newborn screening for IEM immediately or within 3 years. CONCLUSION: The feasibility of OPathPaed model has been confirmed. It is significant and timely that when this pilot study was completed, a government-led initiative to study the feasibility of newborn screening for IEM in the public health care system on a larger scale was announced in the Hong Kong Special Administrative Region Chief Executive Policy Address of 2015.

Prospective assessment of the Hong Kong Hospital Authority universal Down syndrome screening programme.

OBJECTIVE: To evaluate the performance of the locally developed universal Down syndrome screening programme. DESIGN: Population-based cohort study in the period July 2010 to June 2011 inclusive. SETTING: Four Hong Kong Hospital Authority Departments of Obstetrics and Gynaecology and a central university-based laboratory for maternal serum processing and risk determination. PARTICIPANTS: Women were offered either a first-trimester combined test (nuchal translucency, free beta human chorionic gonadotropin, and pregnancy-associated plasma protein-A) or nuchal-translucency-only test, or a second-trimester double test (alpha-fetoprotein and total human chorionic gonadotropin) for detection of Down syndrome according to their gestational age. Those with a trisomy 21 term risk of 1:250 or higher were offered a diagnostic test. RESULTS: A total of 16 205 pregnancies were screened of which 13 331 (82.3%) had a first-trimester combined test, 125 (0.8%) had a nuchal-translucency test only, and 2749 (17.0%) had a second-trimester double test. There were 38 pregnancies affected by Down syndrome. The first-trimester screening tests had a 91.2% (31/34) detection rate with a screen-positive rate of 5.1% (690/13 456). The second-trimester test had a 100% (4/4) detection rate with a screen-positive rate of 6.3% (172/2749). There were seven (0.9%) pregnancies that miscarried following an invasive diagnostic test. There were two Down syndrome-affected live births, both with an estimated first-trimester trisomy 21 term risk lower than 1:250. CONCLUSION: The universal screening programme offered at the four units was effective and achieved the expected detection rates and low false-positive rates, and to maintain these, the current emphasis on training, quality control, and regular auditing must continue.

Parental attitudes on expanded newborn screening in Hong Kong.

OBJECTIVES: Classical inborn errors of metabolism (IEM) affect about 1 in 4000 in Hong Kong. Despite the widespread implementation of expanded newborn screening in most countries, Hong Kong only screen for three conditions and the awareness of public has not been evaluated. This is the first study to examine the parental knowledge and attitudes towards expanded newborn screening in Hong Kong. METHODS: A cross-sectional survey was conducted in the Princess Margaret Hospital. Parents with babies born from 1st July to 31st October 2010 were randomly recruited. Fifteen questions relating to the knowledge of newborn screening and biochemical genetic disorders, preferences about the features of newborn screening, the economic values, and attitudes toward false positive results were asked. RESULTS: In total, 172 subjects were interviewed by phone (overall response rate 97.2%). There were 87.8% parents who had never heard of expanded newborn screening; 99.4% demanded more parental education; 83.5% thought the programme should be implemented immediately; 97.7% supported population screening, even though the diseases are incurable; 93.9% accepted the possibility of false positive and false negative results; 70.4% preferred a voluntary basis; 83.2% believed that the programme should be fully government funded as basic primary care; 98.8% agreed that Hong Kong should follow mainland China's policy on expanded newborn screening; 98.2% required pre-test counseling; and 96.4% required an explicit parental consent before blood sampling. CONCLUSIONS: The response from parents overwhelmingly favoured having expanded newborn screening in Hong Kong. Parental tolerance was high. Parents valued the parental autonomy with informed consent and pre-test counseling the most. The success of any screening programme requires the public participation and this study is the first to prove the parental call for an expanded newborn screening in Hong Kong.

Evaluation of family-centred practices in the early intervention programmes for infants and young children in Singapore with Measure of Processes of Care for Service Providers and Measure of Beliefs about Participation in Family-Centred Service.

BACKGROUND: The primary purpose of this study was to report on an evaluation of the perceptions and beliefs of service providers towards family-centred practices in 11 early intervention programmes for infants and young children in Singapore. METHODS: The Measure of Processes of Care for Service Providers (MPOC-SP) and Measure of Beliefs about Participation in Family-Centred Service (MBP-FCS) were administered to 213 service providers made up of teachers, therapists, psychologists and social workers providing centre-based therapy to children with special needs who were below the age of 6 years. RESULTS: Exploratory factor analyses were performed with both scales. Nineteen of the 27 MPOC-SP items were retained and supported the original four-factor structure model. The exploratory factor analyses on MBP-FCS provided a less satisfactory outcome. Fourteen of the 28 items were retained and these loaded onto four factors. The two factors relating to Beliefs about benefits of FCS and Beliefs about the absence of negative outcomes from FCS failed to emerge as separate factors. Further multiple regressions indicated that more direct work with families and positive self-efficacy in implementing FCS contributed significantly to explaining service providers' positive perception towards family-centred practice in service delivery. CONCLUSIONS: This is the first time MPOC-SP and MBP-FCS were administered to a population in an Asian context. While MBP-FCS would benefit from further development work on its construct, MPOC-SP offered important insights into service providers' perspectives about family-centred practices that would have useful implications for professional and service development.

Determinants of insulin responsiveness in young women: Impact of polycystic ovarian syndrome, nitric oxide, and vitamin D.

BACKGROUND: Polycystic ovary syndrome (PCOS) is associated with incremental risk of atherosclerosis and possibly of cardiovascular events. Insulin resistance (IR) occurs frequently in PCOS subjects, which might be one of the mechanisms involved in engendering such risk. We sought to evaluate whether the impact of other factors potentially associated both with PCOS and with IR might differentially modulate degree of IR in women with and without PCOS. METHODS AND RESULTS: We measured body mass index (BMI), hs-CRP, plasma concentrations of asymmetric dimethylarginine (ADMA), vitamin D (25(OH)D3) levels and platelet responsiveness to nitric oxide donor sodium nitroprusside (NO responsiveness) in 47 young women (n=27 with PCOS and n=20 weight-matched controls) without metabolic syndrome, hypertension or overt cardiovascular disease. We performed univariate and multivariate regression analyses to establish correlates of the quantitative insulin-sensitivity check index (QUICKI), as a marker of IR. On univariate analysis, plasma 25(OH)D3 levels and low NO responsiveness tended to be direct correlates with QUICKI in the entire subject group. BMI, hs-CRP, and ADMA levels were significant inverse correlates of QUICKI in PCOS subjects, but not in subjects without PCOS. On multivariate analysis, NO responsiveness, and 25(OH)D3 levels, but not PCOS per se were significant correlates of QUICKI. CONCLUSIONS: In the entire cohort of young women, low NO responsiveness and vitamin D deficiency are associated with low QUICKI, while elevated ADMA, inflammatory activation and obesity are selectively associated with low QUICKI in PCOS subjects; this may contribute to the increased cardiovascular risk associated with this syndrome.

Leiomyosarcoma of ovarian vein compression as a cause of hydronephrosis.

We present a case of leiomyosarcoma of the right ovarian vein with MRI findings. The patient was a 52-year-old woman who had suffered from right flank pain for one week. Abdominal ultrasound and excretory urography revealed hydronephrosis of the right kidney. Ureteroscopy showed external compression at the right upper third of the ureter. CT and MRI of the abdomen revealed a retroperitoneal mass with compression of the right ureter. The retroperitoneal mass proved on histology to be a leiomyosarcoma arising from the right ovarian vein.

Off-midline retroperitoneal choriocarcinoma presenting as neurologic symptoms.

A 28-year-old woman suffered from frequent headaches. She had a history of a dilatation and curettage for hydatidiform moles. This admission showed markedly elevated levels of human chorionic gonadotropin (hCG) and lactate dehydrogenase. Brain MRI showed a hemorrhagic mass in the left temporal area, with rapid growth. Histology of tumors obtained from multiple areas including retroperitoneum was consistent with choriocarcinoma.

Re-emergence of late presentations of fetal haemoglobin Bart's disease in Hong Kong.

OBJECTIVES: To compare early and late presentations of fetal haemoglobin Bart's disease in the Kowloon West Cluster in Hong Kong, and to find reasons for the re-emergence of late presentations. DESIGN: Case series with internal comparisons. SETTING: Two tertiary obstetric units in Hong Kong. PATIENTS: All cases with confirmed diagnosis of fetal haemoglobin Bart's disease from 1 January 2000 to 31 December 2009. PRIMARY OUTCOME: antenatal care in the current pregnancy. SECONDARY OUTCOMES: clinical presentations, ultrasound features, and pregnancy outcomes. RESULTS: A total of 59 cases (46 early presentations and 13 late presentations) of fetal haemoglobin Bart's disease were identified during the study period. All the late presentations were identified from year 2003 onwards. Late presentations were significantly associated with non-eligible obstetric patients (69% vs 11%; P<0.001), non-booked status at our antenatal service (62% vs 0%; P<0.001), and unavailability of partner's mean corpuscular volume status (23% vs 0%; P=0.009). Mothers presenting late were more likely to have symptoms or signs (85% vs 0%; P<0.001) and to suffer from gestational hypertensive disorder (54% vs 0%; P<0.001). Ultrasound features of these pregnancies included cardiomegaly (94%), placentomegaly (98%), and hydrops fetalis (77%). All pregnancies presenting early were either legally terminated or miscarried. The perinatal mortality in late presentations was 85%. CONCLUSION: The re-emergence of late presentations of fetal haemoglobin Bart's disease after 2003 was related to influx of non-eligible obstetric patients without proper antenatal screening and diagnosis of thalassaemia. Maternal low mean corpuscular volume and characteristic prenatal ultrasound features such as cardiomegaly, placentomegaly, and hydrops fetalis are useful for detecting affected pregnancies in this group of patients. Better education of both patients and doctors is necessary to explain the importance of early diagnosis of the disease and the seriousness of complications due to late presentations, so as to reduce undesirable maternal and perinatal outcomes.

Epithelioid leiomyosarcoma of the uterus: computed tomography findings.

Uterine epithelioid leiomyosarcoma is a rare neoplasm. There have been no previous reports describing computed tomography (CT) findings for this tumor. A 31-year-old woman presented with a heterogeneous enhancing mass, with internal septa, in the uterus, which was shown on CT images. Histological diagnosis was compatible with epithelioid leiomyosarcoma.

Visual input to the efferent control system of a fly's "gyroscope".

Dipterous insects (the true flies) have a sophisticated pair of equilibrium organs called halteres that evolved from hind wings. The halteres are sensitive to Coriolis forces that result from angular rotations of the body and mediate corrective reflexes during flight. Like the aerodynamically functional fore wings, the halteres beat during flight and are equipped with their own set of control muscles. It is shown that motoneurons innervating muscles of the haltere receive strong excitatory input from directionally sensitive visual interneurons. Visually guided flight maneuvers of flies may be mediated in part by efferent modulation of hard-wired equilibrium reflexes.

Intracranial epidermoid cyst with hemorrhage: MR imaging findings.

We present a case of a 28-year-old woman with a cerebellopontine angle and prepontine cistern epidermoid cyst with unusual signal intensity. She presented with cranial nerve neuropathy and unsteady gait. MR imaging showed a tumor mass with central area of hemorrhage and a focal area of heterogeneous signal intensity with spotty enhancement, which correlated histologically to old blood in a cystic lumen and granulation of a cystic wall, with a large area of hemorrhage and mild vascularity.

Posterior epidural migration of a sequestrated lumbar disk fragment: MR imaging findings.

We present a 75-year-old man who, for 2 weeks, had progressive pain in both of his thighs when standing straight. MR imaging showed a sequestrated disk fragment, which had a signal intensity similar to that of a herniated disk with a rim enhancement in the posterior epidural space and a ruptured outermost annulus of the intervertebral disk at L2-3. Awareness of these MR imaging findings can help in the diagnosis of posterior epidural disk migration.

Endometrial stromal sarcoma mimicking submucosal myoma protruding to the vagina: MRI findings.

A 46-year-old woman complained of persistent abnormal vaginal bleeding over ten days. Her intrauterine device had been removed two years before. Soon after, she suffered from menorrhagia and metrorrhagia. An incidental finding of severe anemia was also noted. In this admission, our initial T2-weighted magnetic resonance imaging (MRI) revealed a well-demarcated mass predominantly in the uterine cavity. The mass was depicted by an isointense signal relative to the myometrium on T1-weighted images, high signal intensity on T2-weighted images, and slightly heterogeneous enhancement on post-contrast images. The patient refused surgery. After two years, follow-up MRI showed a pedunculated mass protruding into the upper third of the vagina with a stalk connecting to the posterior wall of the uterine cavity, simulating submucosal myoma. Histological diagnosis was compatible with low-grade endometrial stromal sarcoma.

Position-specific central projections of mechanosensory neurons on the haltere of the blow fly, Calliphora vicina.

The halteres of Dipteran insects play an important role in flight control. They are complex mechanosensory devices equipped with approximately 400 campaniform sensilla, cuticular strain gauges, which are organized into five fields at the base of each haltere. Despite the important role of these mechanosensory structures in flight, the central organization of the sensory afferents originating from the different field campaniforms has not been determined. We show here that in the blow fly, Calliphora vicina, sensory afferents from the campaniform fields project to the thorax in a region-specific manner. Afferents from different fields have different projection profiles and in addition, the projection pattern of afferents from different regions of the same field may show further variation. However, central target regions of these afferents are not exclusive to particular sensory fields because cells from different fields can possess similar projection profiles. Convergence of afferent projections is not limited to axons from the haltere fields, but is also observed between afferents originating from the haltere fields and those from serially homologous fields on the radial vein of the wing. Although we have not determined the specific cellular targets of the haltere sensory cells, the afferents of a dorsal field could make potential contact with at least one identified wing steering motoneuron that is known to be important in turning maneuvers. Our results, thus, provide the anatomical basis for studying how mechanosensory information encoded by the complex fields on the base of the haltere is mapped onto different functional regions within the CNS.

Expression and localization of the renin-angiotensin system in the rat pancreas.

The possibility of an intrinsic renin-angiotensin system (RAS) in the pancreas has been raised by previous studies in which immunohistochemical examination showed the presence of angiotensin II and its receptor subtypes, type 1 (AT1) and type 2 (AT2). In the present study, gene expression of several key RAS components was investigated by reverse-transcription PCR. mRNA expression for angiotensinogen, renin and angiotensin II receptor subtypes, AT1a, AT1b and AT2 was shown. The presence of angiotensinogen protein, the mandatory component for an intrinsic RAS, was demonstrated by Western blotting and localized by immunohistochemistry to the epithelia and endothelia of pancreatic ducts and blood vessels respectively. Immunoblot analysis detected a predominant protein band of about 60 kDa in the pancreas. This was consistent with the predicted value for angiotensinogen as reported in other tissues. Together with previous findings, the present study shows that the rat pancreas expresses the major RAS component genes, notably angiotensinogen and renin, required for intracellular formation of angiotensin II. The data support the notion of an intrinsic RAS in the rat pancreas which may play a role in the regulation of pancreatic functions.

Regulated expression of pancreatic renin-angiotensin system in experimental pancreatitis.

Our previous studies have provided evidence for the existence of an intrinsic renin-angiotensin system (RAS) in the rat pancreas, which may play a role in the regulation of pancreatic microcirculation and ductal secretion. Such a pancreatic RAS has recently shown to be activated by chronic hypoxia. The activation of a local RAS in the pancreas by chronic hypoxia and its significance of changes may be important for the physiological and pathophysiological aspects of the pancreas. In the present study, the regulation of experimentally induced acute pancreatitis on the expression of local RAS in the pancreas was investigated using Western blot, semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemical approaches. Results from Western blot demonstrated that experimentally induced pancreatitis caused significantly increased expression of the pancreatic RAS component proteins. In keeping with the protein level, RT-PCR analysis also revealed the enhanced expression of pancreatic RAS genes, notably the angiotensinogen in experimental pancreatitis. Immunohistochemical results further demonstrated that increased immunoreactivity for RAS in experimental pancreatitis was predominantly localized to the endothelia and epithelia of pancreatic vasculature and ductal system respectively. The data indicate that experimental pancreatitis may elicit activation of a local RAS in the pancreas. Such an activation of pancreatic RAS and its significance of differential changes in individual RAS components could play a role in the pathophysiology of acute pancreatitis

Activation of local renin-angiotensin system by chronic hypoxia in rat pancreas.

Previous studies have provided evidence that several key elements of renin-angiotensin system (RAS) are present in the rat pancreas, notably angiotensinogen, which is mandatory for intracellular generation of physiologically active angiotensin II. The data support the existence of an intrinsic RAS, which may be important for pancreatic blood flow and ductal anion secretion. In the present study, the effect of chronic hypoxia on the expression of RAS components, particularly at the levels of its precursor angiotensinogen and its receptor subtypes AT(1) and AT(2), were investigated in the rat pancreas. Results from western blot and semi-quantitative reverse-transcription polymerase chain reaction (RT-PCR) analyses unequivocally showed that chronic hypoxia caused a marked increase in angiotensinogen both at the protein and gene levels when compared with that in the normoxic pancreas. However, results from RT-PCR showed that there was a differential effect of chronic hypoxia on the expression of AT(1) and AT(2) receptor subtypes, which exhibited subtype-specific changes in gene expression. For AT(1), chronic hypoxia did not cause a significant change in mRNA expression for AT(1a) but a significant increase in mRNA expression for AT(1b). For AT(2), chronic hypoxia caused a marked increase in its mRNA expression. The increased expression of RAS component genes by chronic hypoxia and its significance of changes may be important for physiological and pathophysiological aspects of the pancreas.

Determination of 8-oxoguanine in individual cell nucleus of gamma-irradiated mammalian cells.

8-Oxoguanine, through its ability to mispair bases other than cytosine, is assumed to be one of the most potent premutagenic lesions in nuclear DNA damaged by reactive oxygen radicals. In this study, we examine whether the presence of residual 8-oxoguanine can be detected in mammalian cells after exposure to ionizing radiation. MOLT-4 human leukemia cells and CHO-K1 Chinese hamster cells were acutely irradiated in vitro with 0, 0.2, 0.4, 0.6 and 1.0 Gy gamma radiation at room temperature. The amounts of 8-oxoguanine and total DNA in the cell nucleus were detected by fluorescein-isothiocyanate (FITC)-labeled avidin, which binds specifically and directly to 8-oxoguanine, and propidium iodide, respectively. The intensity ratios between these two fluorescent dyes were then taken as indices to measure the content of 8-oxoguanine within individual cells. We found an apparent dose-dependent increase in the amount of 8-oxoguanine accumulated in cells of both lines. Moreover, the content of 8-oxoguanine decreased from 2 to 20 h after irradiation in CHO-K1 cells, which may reflect the time-dependent repair processes at the 8-oxoguanine lesions. This novel approach may provide a sensitive tool for in situ measurement of 8-oxoguanine in cells or even in the human body after exposure to ionizing radiation.

High incidence of BCL-6 gene rearrangement in diffuse large B-cell lymphoma of primary gastric origin.

The incidence of BCL-6 gene rearrangement was studied in 39 Hong Kong Chinese patients with diffuse large B-cell lymphoma. The primary site of involvement was nodal in 18 cases and gastric in 21 cases. Clonal BCL-6 gene rearrangement was found in 17% of the patients with primary nodal and 48% with primary gastric lymphoma (p = 0.05). The clinical characteristics and treatment outcome of the 21 patients with primary gastric lymphoma were analyzed according to the BCL-6 status. Significantly more patients in the germline BCL-6 gene group had advanced stage (II, III and IV) of disease. Complete remission rate following primary therapy appeared to be higher for the positive rearrangement group (70% versus 36%), but it was not statistically significant. Those with a rearranged BCL-6 gene also appeared to have better survival at 5 years (58% versus 36%) but the difference was also not statistically significant. On the other hand, patients being classified as low risk according to the International Prognostic Index had significantly better survival at 5 years (89% versus 9%, p = 0.0001). We concluded that BCL-6 gene rearrangement was more commonly found in diffuse large B-cell lymphoma of primary gastric origin than its nodal counterpart and it may be playing a more important role in the pathogenesis of gastric large B-cell lymphoma. There was a trend that the BCL-6 gene rearrangement was associated with a more favorable outcome in patients with gastric large B-cell lymphoma but the difference was not statistically significant.

Mutation of the 5' noncoding region of the BCL-6 gene in low-grade gastric lymphoma of the mucosa-associated lymphoid tissue.

BCL-6 gene rearrangement and hypermutations were investigated in four Hong Kong Chinese patients with low-grade gastric lymphoma of the mucosa-associated lymphoid tissue (MALToma). The former was studied by Southern analysis and the latter by the technique of polymerase chain reaction and denaturing gradient gel electrophoresis. BCL-6 gene rearrangement was not detectable in any of the four cases. However, mutations at both the E1.11 and E1.12 segments of the 5' noncoding region of the BCL-6 gene were found in two patients. This preliminary observation suggests that the mutations of the 5' noncoding region of the BCL-6 gene rather than gene rearrangement may be playing a more important role in the tumorigenesis of low-grade gastric MALToma. Further confirmation of this finding by studying a larger number of patients will be required.