Methods and clinical outcomes of in situ fenestration for aortic arch revascularization during thoracic endovascular aortic repair.

OBJECTIVE: Despite endovascular advances in fenestrated and branched devices, thoracic endovascular aortic repair (TEVAR) for arch pathologies remains challenging. The aim of this study was to provide a contemporary review on the current evidence for in situ fenestration during TEVAR and to evaluate its short- and mid-term clinical outcome in the management of arch pathology. METHODS: A systematic literature review on in situ fenestration of thoracic aortic stent-graft from January 2003 to September 2018 was performed under the instruction of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. RESULTS: Our initial search yielded 169 studies, of which 21 articles were relevant to the topic and were finally included. One hundred and forty-five in situ fenestration procedures in 99 patients were reviewed, involving 25 innominate arteries (17%), 33 left common carotid arteries (23%) and 87 left subclavian arteries (60%). Twelve patients (12/99, 12%) had two-vessel fenestration and three-vessel fenestration was performed in 17 patients (17/99, 17%). Technical success was achieved in 136 arteries (136/145, 93%). Talent/Valiant with monofilament twill woven polyester fabric was the most common (50/99, 51%) stent-graft used for fenestration. Three methods reported for in situ fenestration were needle, laser and radiofrequency. Needle was the most frequently used device for fenestration, which was performed in 60 patients (60/99, 61%). Three patients (3/99, 3%) died with 30 days, none were in situ fenestration TEVAR procedure-related. Perioperative complications including one (1%) retrograde type A aortic dissection, two (2%) type II endoleaks, and three (3%) strokes were reported. The pooled estimate for overall technical success, perioperative mortality and stroke was 88.3% (95% CI, 78.6%-93.9%), 5.9% (95% CI, 2.5%-13.4%) and 9.5% (95% CI, 4.1%-20.6%), respectively. Four patients (4/96, 4%) died during follow-up, none were aortic-related. All the fenestration bridging stents were reportedly patent, with only 1 (1/96, 1%) asymptomatic left subclavian stent stenosis. Two patients (2/96, 2%) with type II endoleak from left subclavian artery required secondary intervention. CONCLUSION: In situ fenestration appeared to be a feasible and effective method to extend proximal landing zone during TEVAR. It had an acceptable short-term result with high technical success and low fenestration related morbidity. Long-term durability data were lacking, and there was no high level evidence to recommend the routine use of in situ fenestration TEVAR for the management of arch pathology.

Percutaneous mechanical thrombectomy in the treatment of acute iliofemoral deep vein thrombosis: a systematic review.

BACKGROUND: Conventional treatment of deep vein thrombosis (DVT) of the lower extremities by anticoagulation alone has been proven to be insufficient to prevent recurrence and post-thrombotic syndrome (PTS). Early restoration of venous patency and preservation of valvular function by endovascular surgery has been advocated. The aim of this study was to review the efficacy and safety of percutaneous mechanical thrombectomy (PMT) against catheter-directed thrombolysis (CDT) in the treatment of acute iliofemoral DVT. METHODS: Three hundred sixty-nine articles were identified through screening of the PubMed, EMBASE, and Cochrane databases from January 2006 to December 2016. RESULTS: Fifteen retrospective studies and one prospective registry, totalling 1170 patients, were recruited for qualitative synthesis. The venous patency rate ranged from 75% to 100% with mean follow-up of 12.3 months. The rates of PTS and recurrent DVT were less than 17% and 15%, respectively. The overall mortality rate was 0.26%. Compared with CDT, PMT was shown to reduce PTS at 1 year (Villalta score: 2.1 ± 3.0 in the PMT group and 5.1 ± 4.1 in the CDT group, P=0.03) and bleeding complications (packed cells transfused: 0.2 ± 0.3 units in the pharmacomechanical thrombectomy group and 1.2 ± 0.7 units in the CDT group, P<0.05). CONCLUSION: Percutaneous mechanical thrombectomy is a safe and effective treatment for acute iliofemoral DVT in terms of restoration of venous patency, prevention of DVT recurrence, and PTS. Compared with CDT alone, PMT offers a lower risk of PTS and bleeding complications.

Ontogeny of human IgE-expressing B cells and plasma cells.

BACKGROUND: IgE-expressing (IgE+ ) plasma cells (PCs) provide a continuous source of allergen-specific IgE that is central to allergic responses. The extreme sparsity of IgE+ cells in vivo has confined their study almost entirely to mouse models. OBJECTIVE: To characterize the development pathway of human IgE+ PCs and to determine the ontogeny of human IgE+ PCs. METHODS: To generate human IgE+ cells, we cultured tonsil B cells with IL-4 and anti-CD40. Using FACS and RT-PCR, we examined the phenotype of generated IgE+ cells, the capacity of tonsil B-cell subsets to generate IgE+ PCs and the class switching pathways involved. RESULTS: We have identified three phenotypic stages of IgE+ PC development pathway, namely (i) IgE+ germinal centre (GC)-like B cells, (ii) IgE+ PC-like 'plasmablasts' and (iii) IgE+ PCs. The same phenotypic stages were also observed for IgG1+ cells. Total tonsil B cells give rise to IgE+ PCs by direct and sequential switching, whereas the isolated GC B-cell fraction, the main source of IgE+ PCs, generates IgE+ PCs by sequential switching. PC differentiation of IgE+ cells is accompanied by the down-regulation of surface expression of the short form of membrane IgE (mIgES ), which is homologous to mouse mIgE, and the up-regulation of the long form of mIgE (mIgEL ), which is associated with an enhanced B-cell survival and expressed in humans, but not in mice. CONCLUSION: Generation of IgE+ PCs from tonsil GC B cells occurs mainly via sequential switching from IgG. The mIgEL /mIgES ratio may be implicated in survival of IgE+ B cells during PC differentiation and allergic disease.

Haemodynamic Variations of Flow to Renal Arteries in Custom-Made and Pivot Branch Fenestrated Endografting.

OBJECTIVE: This study aimed to investigate variation of blood flow to renal arteries in custom-made and pivot branch (p-branch) fenestrated endografting, using a computational fluid dynamics (CFD) technique. METHODS: Idealised models of custom-made and p-branch fenestrated grafting were constructed on a basis of a 26 mm stent graft. The custom-made fenestration was designed with a 6 mm diameter, while the 5 mm depth renal p-branch was created with a 6 mm inner and 15 mm outer fenestration. Two configurations (option A and option B) were constructed with different locations of p-branches. Option A had both renal p-branches at the same level, whereas option B contained two staggered p-branches at lower positions. The longitudinal stent orientation in both custom-made and p-branch models was represented by a takeoff angle (ToA) between the renal stent and distal stent graft centreline, varying from 55° to 125°. Computational simulations were performed with realistic boundary conditions governing the blood flow. RESULTS: In both custom-made and p-branch fenestrated models, the flow rate and wall shear stress (WSS) were generally higher and recirculation zones were smaller when the renal stent faced caudally. In custom-made models, the highest flow rate (0.390 L/min) was detected at 70° ToA and maximum WSS on vessel segment (16.8 Pa) was attained at 55° ToA. In p-branch models, option A and option B displayed no haemodynamic differences when having the same ToA. The highest flow rate (0.378 L/min) and maximum WSS on vessel segment (16.7 Pa) were both calculated at 55° ToA. The largest and smallest recirculation zones occurred at 90° and 55° ToA respectively in both custom-made and p-branch models. Custom-made fenestrated models exhibited consistently higher flow rate and shear stress and smaller recirculation zones in renal arteries than p-branch models at the same ToA. CONCLUSIONS: Navigating the renal stents towards caudal orientation can achieve better haemodynamic outcomes in both fenestrated devices. Custom-made fenestrated stent grafts are the preferred choice for elective patients. Further clinical evidence is required to validate the computational simulations.

Surgical management of carotid body tumor - Is Shamblin classification sufficient to predict surgical outcome?

Background The study aims to conduct a review of the surgical management of carotid body tumor. Methods Consecutive patients with CBT who received surgical interventions from January 1994 to January 2014 at our institution were reviewed. Clinical, operative, pathological and follow up information were reported. Results Twenty patients (four males; median age was 36) with 21 CBT operations were recorded during the period. One patient undertook sequential operations for bilateral CBTs. Patients had 19 neck mass, 1 incidental finding and 1 facial nerve palsy. Six CBTs (28.6%) were Shamblin class I, ten (47.6%) were class II and five (23.8%) were class III. Nine CBTs had preoperative conjunctive embolization. Two operations required internal carotid artery resection and reconstruction. Four patients received subtotal resections, while 17 achieved complete resection. Complications included two major strokes, three hoarse voice and two Horner's syndrome. Shamblin class was significant predictor of operative time, blood loss, and whether complete resection accomplished, but could not predict postoperative complication. With median follow up period of 94 months, there was no tumor recurrence found in those had complete resection. Conclusions This small cohort showed that Shamblin class was significant in predicting technical difficulties but could not predict occurrence of complications.

Temporal dynamics of visual working memory.

The involvement of the human cerebellum in working memory has been well established in the last decade. However, the cerebro-cerebellar network for visual working memory is not as well defined. Our previous fMRI study showed superior and inferior cerebellar activations during a block design visual working memory task, but specific cerebellar contributions to cognitive processes in encoding, maintenance and retrieval have not yet been established. The current study examined cerebellar contributions to each of the components of visual working memory and presence of cerebellar hemispheric laterality was investigated. 40 young adults performed a Sternberg visual working memory task during fMRI scanning using a parametric paradigm. The contrast between high and low memory load during each phase was examined. We found that the most prominent activation was observed in vermal lobule VIIIb and bilateral lobule VI during encoding. Using a quantitative laterality index, we found that left-lateralized activation of lobule VIIIa was present in the encoding phase. In the maintenance phase, there was bilateral lobule VI and right-lateralized lobule VIIb activity. Changes in activation in right lobule VIIIa were present during the retrieval phase. The current results provide evidence that superior and inferior cerebellum contributes to visual working memory, with a tendency for left-lateralized activations in the inferior cerebellum during encoding and right-lateralized lobule VIIb activations during maintenance. The results of the study are in agreement with Baddeley's multi-component working memory model, but also suggest that stored visual representations are additionally supported by maintenance mechanisms that may employ verbal coding.

Evidence for Endovascular Simulation Training: A Systematic Review.

BACKGROUND: Simulation training in endovascular surgery provides opportunities for trainees to practice and learn from non-patient based experience. Several types of endovascular simulators are available commercially. Previous studies on endovascular simulation training can be categorized into trials in which only a simulator was used when measuring performance metrics or "trials within simulation"; patient specific procedure rehearsals; and randomized, controlled trials (RCTs) or translational studies. OBJECTIVES: To examine whether endovascular simulation training can improve surgeon techniques and patient outcomes in real clinical settings. METHODS: A literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All searches were done via PubMed and Embase. Review articles, and papers that were not related to endovascular surgery and not within the scope of interest were excluded. References of review articles were further screened according to the exclusion criteria. RESULTS: In total, 909 records were identified and 290 duplicates were removed. Thirty-one were included in the qualitative analysis. Twenty-three were trials within simulation and most of them found statistically significant improvements in procedure time, fluoroscopy time, and contrast volume. Five were patient specific procedure rehearsals and showed that simulation significantly affected the fluoroscopy angle and improved performance metrics. Three were RCTs and revealed mainly positive results on a Global Rating Scale and procedure specific rating scale. CONCLUSIONS: Contemporary evidence shows that performance metrics within endovascular simulations improve with simulation training. Successful translation to in vivo situations is observed in patient specific procedure rehearsals and RCTs on real procedures. However, there is no level I evidence to show that predictive validity of simulation can definitively improve patient outcomes. Current literature supports the idea that there is a beneficial role of simulation in endovascular training. Future studies are needed to confirm the efficacy of simulation in endovascular surgical training and to see if simulation is superior to traditional training in the operating theatre.

Persistent Intraluminal Pressure After Endovascular Stent Grafting for Type B Aortic Dissection.

OBJECTIVES: Despite technically successful thoracic endovascular stent graft repair (TEVAR) in patients with Stanford Type B aortic dissection (TBAD), long-term follow up studies have shown that the false lumen may continue to dilate. The aim of this study was to analyze the possible mechanisms leading to such changes from a hemodynamic perspective. METHODS: Twenty-eight ex vivo fresh porcine TBAD models (Mo A: 10; Model B: 12; Model C: 6) were established to simulate three clinical situations: Model A with patent false lumen (pre-TEVAR); Model B with distal re-entry only (post-TEVAR), and Model C with thrombus filling in the false lumen and a distal re-entry (chronic stage of post-TEVAR). Synchronous pressure waveforms were taken from both the true and the false lumen. True lumen and false lumen pressure differences were calculated for each model as four indices: systolic index (SI), diastolic index (DI), mean pressure index (MPI) and area under curve index (AUCI). These indices were compared between the three models. RESULTS: False lumen pressure and corresponding pressure-accumulating effects were significantly higher in Model A than in Model C: SI (99.9% vs. 189.4%; p < .001); MPI and AUCI (99.5% vs. 128.2%; 99.5% vs. 128%; p < .001). The SI, MPI, and AUCI were significantly higher in Model B compared with Model C. The differences between the four indices were not significant between Model A and B. The false lumen area under curve (AUC) in Model C was merely lowered by 20% compared with its true lumen (67.5 mmHg vs. 85.2 mmHg). CONCLUSION: The false lumen pressure remained unchanged in the non-thrombosed segment with patent blood flow after the primary entry tear sealed. Intraluminal pressure reduction in the thrombosed false lumen was significant. However, nearly 80% of the pressure remained in the thrombosed false lumen. If this high intra-thrombus pressure persists, it may contribute to delayed aneurysmal formation after endovascular treatment.

Effectiveness of proximal intra-operative salvage Palmaz stent placement for endoleak during endovascular aneurysm repair.

INTRODUCTION: The use of a proximal Palmaz stent is a well-recognised technique to treat proximal endoleak in endovascular aortic repair. This study aimed to report the effectiveness and safety of an intra-operative Palmaz stent for immediate type 1a endoleak in Hong Kong patients. METHODS: This case series was conducted at a tertiary hospital in Hong Kong. In a cohort of 494 patients who underwent infrarenal endovascular aortic repair from July 1999 to September 2015, 12 (2.4%) received an intra-operative proximal Palmaz stent for type 1a endoleak. Immediate and subsequent proximal endoleak on follow-up image was documented. RESULTS: Morphological review of the pre-repair aneurysm neck showed five conical, one funnel, five cylindrical and one undetermined short neck, with a median neck angle of 61 degrees (range, 19-109 degrees). Stent grafts used included seven Cook Zenith, one Cook Aorto-Uni-Iliac device, three Metronic Endurant, and one TriVascular Ovation. Eleven Palmaz stents were placed successfully as intended, but one of them was accidentally placed too low. Of the 12 type 1a endoleaks, postoperative imaging revealed immediate resolution of eight whilst four had improved. After a median follow-up of 16 (range, 1-59) months, none of the subsequent imaging showed a type 1a endoleak. The mean size of the aneurysm sac reduced from 7.4 cm preoperatively to 7.3 cm at 1 month, 6.9 cm at 6 months, 7.1 cm at 1 year, and 6.1 cm at 2 years postoperatively. None of these patients required aortic reintervention or had device-related early- or mid-term mortality. One patient required delayed iliac re-interventions for an occluded limb at 10 days post-surgery. CONCLUSION: In our cohort, Palmaz stenting was effective and safe in securing proximal sealing and fixation.

Intrinsic properties of germinal center-derived B cells promote their enhanced class switching to IgE.

BACKGROUND: Research on the origins and development of human IgE-expressing (IgE(+) ) cells is required for understanding the pathogenesis of allergy and asthma. These studies have been thwarted by the rarity of IgE(+) cells in vivo and the low frequency of class switch recombination (CSR) to IgE ex vivo. To determine the main source of IgE(+) cells, we investigated the relation between the phenotypic composition of tonsil B cells and the CSR to IgE ex vivo. METHODS: Human tonsil B cells were analyzed by flow cytometry (FACS) and cultured with IL-4 and anti-CD40 to induce CSR to IgE. Naïve, germinal center (GC), early GC (eGC), and memory tonsil B cells were isolated by FACS, and their capacities for IL-4 and anti-CD40 signaling, cell proliferation, and de novo class switching to IgE were analyzed by RT-PCR and FACS. RESULTS: B cells from different tonsils exhibited varying capacities for CSR to IgE ex vivo. This was correlated with the percentage of eGC B cells in the tonsil at the outset of the culture. Despite relatively poor cell viability, eGC and GC B-cell cultures produced the highest yields of IgE(+) cells compared to naïve and memory B-cell cultures. The main factors accounting for this result were the strength of IL-4R and CD40 signaling and relative rates of cell proliferation. CONCLUSIONS: This study shows that the maturation state of tonsil B cells determines their capacity to undergo class switching to IgE ex vivo, with the GC-derived B cells yielding the highest percentage of IgE(+) cells.

Clinical profile, morbidity and outcome of adult patients with psoriasis at a district hospital in Northern Malaysia.

INTRODUCTION: Psoriasis is a common, chronic, relapsing, immune-mediated inflammatory disease. Our objective is to review the clinical profile, co-morbidities, and outcome of patients with psoriasis. METHODS: This is a cross-sectional study of outpatient psoriasis patients attending the dermatology clinic, Hospital Sultan Abdul Halim (HSAH) between January 2012 and June 2014. Data collection was based on Malaysian Psoriasis Registry. RESULTS: Among 296 patients with psoriasis, Malays were the most common 175 (59.1%), followed by Indians 82 (27.7%), Chinese 37 (12.5%) and others 2 (0.6%). Male to female ratio was 1.2:1. More than half (54.7%) of the patients had early onset disease (age 40 or less). Only 26 patients (8.8%) have positive family history. The most common clinical presentation was chronic plaque psoriasis (89.9%), followed by erythrodermic psoriasis (4.7%), guttate psoriasis (3.0%) and pustular psoriasis (1.7%). Twenty eight percent had nail involvement while arthropathy was seen only in 14.7%. Common triggers were sunlight (46.0%), stress (31.1%), trauma (5.4%), food (4.0%), pregnancy (4.0%), and upper respiratory tract infections (2.7%). Co-morbidities observed include ischaemic heart disease (7.1%), hypertension (26.7%), dyslipidemia (17.6%), and diabetes mellitus (22.0%). All patients were on topical medications. About 6.8% of the patients were treated with phototherapy. One third of patients (35.5%) were given systemic therapy. Out of these, 84 patients (80.0%) were on methotrexate while only 16 (15.2%) on acitretin. None was on cyclosporine or biologic. In term of disease severity, 41.7% of patients had BSA >10% and 31.4% patients had DLQI > 10. CONCLUSION: Our patients show a similar clinical profile and outcome as our Malaysian psoriasis population. However they tend to have a more severe disease. There is a need for a more effective targeted therapy for a better outcome.

Building pharmacogenetics into a pharmacovigilance program in Singapore: using serious skin rash as a pilot study.

To study the possible genetic associations with adverse drug reactions (ADR), the Singapore Health Sciences Authority (HSA) has piloted a program to collect DNA and phenotype data of ADR cases as part of its pharmacovigilance program. Between 2009 and 2012, HSA screened 158 cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). To assess the association between HLA-B*1502 and carbamazepine (CBZ)-induced SJS/TEN, 13 cases and 26 drug-tolerant controls were analyzed. All 13 CBZ-SJS/TEN cases and 3/26 controls were HLA-B*1502 positive (odds ratio 181, 95% confidence interval: 8.7-3785, P=6.9 × 10(-8)). Discussions of the finding with the Ministry of Health and an expert panel led to the decision to make HLA-B*1502 testing the standard of care prior to first use of CBZ in Asians and to subsidize the genotyping test at public hospitals. This program illustrates the role of a regulatory authority in advancing the use of pharmacogenetics for drug safety.

Generalised involuntary limb twitching after ingestion of Mesobuthus martensii Karsch (Quanxie) powder.

Mesobuthus martensii Karsch, commonly known as the Chinese scorpion or Manchurian scorpion, has been used in traditional Chinese medicine as Quanxie to treat chronic pain, tetanus, tremors, convulsion, and paralysis for more than a thousand years. We report a case of poisoning after ingestion of a teaspoon of Quanxie powder. The patient presented with chest pain, dizziness, diaphoresis, generalised involuntary limb twitching, and hypertonia around 15 minutes post-ingestion. The patient recovered uneventfully after supportive management. Intravenous diazepam appeared to be effective in alleviating limb twitching. Failure to accurately measure the dose and to boil before consumption may have contributed to his clinical toxicities.

Custom-made fenestrated stent grafts to preserve accessory renal arteries in patients with abdominal aortic aneurysms.

Accessory renal arteries are common and may contribute significantly to renal perfusion. With the current endovascular design and technology, it is possible to preserve accessory renal arteries during endovascular aneurysm repair (EVAR). We report two patients with custom-made EVAR devices to preserve accessory renal arteries with good mid- and long-term clinical and radiological results. Conventional EVAR would have occluded their origins. As a result of customized fenestrations in commercially available stentgrafts, the patency of large accessory renal arteries can be maintained, whilst securing a proximal seal.

A pilot study on low-density lipoprotein receptor-related protein-1 in Chinese patients with abdominal aortic aneurysm.

OBJECTIVE: There are no published data on the expression of low-density lipoprotein receptor-related protein 1 (LRP1) in human aortic tissues with abdominal aortic aneurysm (AAA), although some researchers have suggested that LRP1 may be a crucial regulator in the pathogenesis of AAA. The aim of this pilot study is to investigate LRP1 expression in aortic tissues from Chinese patients with AAA compared with normal control tissues. MATERIALS AND METHODS: This study used human abdominal aortic tissues with or without AAA as a research model. Aneurysmal abdominal aortas were collected from Chinese patients with AAA (n = 12) during open surgical aneurysmal repair at our institution, and normal control non-aneurysmal abdominal aortas were collected from Chinese healthy organ donors (n = 12) during organ transplantation. Protein expression of LRP1 was analyzed by western blotting and immunohistochemistry. RESULTS: LRP1 protein expression was significantly lower in AAA (mean LRP1AAA/LRP1(Normal Control) = 0.51 ± 0.28) than in normal control aortic tissues (mean LRP1(Normal Control)/LRP1(Normal Control) = 1 ± 0.18) in our small sample cohort (p < .001). No significant correlation was shown between LRP1 protein expression and the size of AAA (p > .05). CONCLUSIONS: Our pilot result suggests that a reduction in LRP1 protein expression may be associated with aneurysm progression.

Successful endovascular management of giant splenic artery aneurysms.

Giant pseudoaneurysms of the splenic artery, with a diameter of 5 cm or more, are rare surgical emergencies, and conventional open surgery usually involves splenectomy. The aim of this study is to report two cases from our institution and to review the world's literature on successful endovascular treatment of patients with giant splenic artery pseudoaneurysms. A retrospective review of a prospectively entered departmental computerized database was performed for the two patients from our institution. Articles were searched electronically from PubMed and Medline, using the terms 'giant splenic artery', 'endovascular' and 'embolization'; and relevant cases were reviewed from the world's literature. We hereby report two patients with giant splenic artery pseudoaneurysms who were treated successfully with endovascular procedures. In addition to the two patients from our institution, there were five patients with giant splenic artery pseudoaneurysms in the published literature who underwent successful endovascular management. The first patient of our series had the largest pseudoaneursym size of 7.2 × 8.1 cm, which is the largest documented pseudoaneursym in the current literature. We report two cases of giant splenic artery pseudoaneurysm with one being the largest pseudoaneurysm treated with endovascular technique in the current literature. Endovascular coil embolization of main trunk of splenic artery is less invasive than open surgical treatment for giant splenic artery pseudoaneurysm, and circumvents the problem of difficult exposure, especially in those patients with significant co-morbidity.

Chinese herbal medicine-induced anticholinergic poisoning in Hong Kong.

OBJECTIVE: To study the epidemiology, causes, and clinical course of Chinese herbal medicine-induced anticholinergic poisoning in Hong Kong. DESIGN: Case series. SETTING: Hong Kong. PATIENTS: All case histories of Chinese herbal medicine-induced anticholinergic poisoning (with laboratory confirmation) recorded by the Hong Kong Poison Information Centre over a 93-month period were accessed for analysis. RESULTS: During the relevant period, 22 clusters of Chinese herbal medicine-induced anticholinergic poisoning involving 32 patients were retrieved. The commonest clinical features were mydriasis (n=32, 100%) and confusion (n=24, 75%). No gastro-intestinal decontamination was performed. None of these patients underwent intubation, defibrillation, cardioversion, pacing, fluid resuscitation, inotropic support or dialysis. Of the 32 patients, 17 (53%) were treated with physostigmine because of confusion, three of whom had previously received intravenous benzodiazepines. No patient could be effectively treated with benzodiazepines alone. There was no mortality, and all the patients were discharged within 3 days. None of them re-attended the emergency department within 1 week of discharge. The commonest cause was the substitution of flos campsis (Campsis grandiflora) by the flower of the Datura species (7 clusters [32%] in 10 patients). CONCLUSION: Mydriasis and confusion were the commonest clinical features of Chinese herbal medicine-induced anticholinergic poisoning in Hong Kong. Physostigmine was frequently used in the treatment; benzodiazepines appeared ineffective. The commonest cause was the substitution of flos campsis (Campsis grandiflora) by the flower of the Datura species.