Clinical features and prognostic factors of Klebsiella endophthalmitis-10-year experience in an endemic region.

AimsTo identify the clinical features and prognostic factors of endogenous endophthalmitis caused by Klebsiella pneumoniae.MethodsThis is a retrospective case series of all patients with Klebsiella endophthalmitis managed from January 2006 to December 2015 by Kowloon East Ophthalmic Service. Statistical analysis involved hypothesis testing on the SPSS 18.0 software (SPSS). A significance level of P<0.05 was taken.ResultsIn the 10-year period, K. pneumoniae accounted for 19 out of 39 cases of endogenous endophthalmitis (48.7%). The mean age of patients was 67.9 years. Bilateral involvement occurred in five patients (26.3%). More than half of the patients (10/19, 52.6%) had underlying diabetes mellitus. Most patients had concurrent liver abscess (18/19, 94.74%). Ten patients (52.6%) had disseminated intravascular coagulopathy. Eight patients (42.1%) were in shock. The overall mortality was 21.1% (4/19). Septic shock was associated with a significantly higher mortality (50.0 vs 0%, P=0.018). Among the 15 survivors, nine patients (60.0%) required evisceration and three patients (20.0%) had no light perception in an involved eye. Eyes with diffuse posterior involvement were less likely to have a final visual acuity of logMAR 0.30 or better than those with focal posterior involvement (4.76 vs 100% 4.76%, P=0.002). Patients with hypopyon were more likely to require evisceration (85.71 vs 25.00%, P=0.02).ConclusionsKlebsiella endophthalmitis is associated with a high incidence of diabetes mellitus and liver abscess. Prognosis remains poor. Universal ocular screening and systemic control in patients with Klebsiella sepsis are recommended.

Focal choroidal excavation-morphological features and clinical correlation.

PurposeTo describe and correlate the morphological and clinical features of focal choroidal excavation (FCE).MethodsThis is a consecutive case series from the review of the 4436 optical coherence tomography scans performed by Kowloon East Cluster Ophthalmic Service from 1 August 2014-31 January 2016. Statistical analysis was performed on SPSS 18.0 (SPSS, Chicago, IL, USA). A significance level of P<0.05 was taken.ResultsAll 16 patients with FCE had unilateral involvement. The mean age of diagnosis was 52.56±14.00. The mean greatest linear dimension (GLD) of FCE was 636.25±265.11 µm. The mean choroidal thickness was 183.63±52.39 µm. Fourteen FCEs (87.5%) were conforming and two were non-conforming (12.5%). In the eyes with FCE, concurrent macular pathology was present in four cases (25.0%). Tractional pathologies of macular pucker and macular scar corresponded to the two non-conforming FCEs in the series. Polypoidal choroidal vasculopathy (PCV) and lacquer crack had a close topographic relationship with the FCE. The mean GLD was significantly larger in eyes with concurrent macular pathology than those without (878.00 vs 555.67 µm, P=0.029). In the fellow eyes, concurrent macular pathology was present in 5 cases (31.3%): PCV in 3 cases and chronic central serous chorioretinopathy in 2 cases.ConclusionAs a significant proportion of FCE is associated with concurrent macular pathology in the involved or fellow eye, angiography for both eyes is recommended even for asymptomatic cases. The GLD of FCE may have clinical value in risk stratification.

The effects of CCR5 inhibition on regulatory T-cell recruitment to colorectal cancer.

BACKGROUND: Regulatory T cells (Treg) are enriched in human colorectal cancer (CRC) where they suppress anti-tumour immunity. The chemokine receptor CCR5 has been implicated in the recruitment of Treg from blood into CRC and tumour growth is delayed in CCR5-/- mice, associated with reduced tumour Treg infiltration. METHODS: Tissue and blood samples were obtained from patients undergoing resection of CRC. Tumour-infiltrating lymphocytes were phenotyped for chemokine receptors using flow cytometry. The presence of tissue chemokines was assessed. Standard chemotaxis and suppression assays were performed and the effects of CCR5 blockade were tested in murine tumour models. RESULTS: Functional CCR5 was highly expressed by human CRC infiltrating Treg and CCR5(high) Treg were more suppressive than their CCR5(low) Treg counterparts. Human CRC-Treg were more proliferative and activated than other T cells suggesting that local proliferation could provide an alternative explanation for the observed tumour Treg enrichment. Pharmacological inhibition of CCR5 failed to reduce tumour Treg infiltration in murine tumour models although it did result in delayed tumour growth. CONCLUSIONS: CCR5 inhibition does not mediate anti-tumour effects as a consequence of inhibiting Treg recruitment. Other mechanisms must be found to explain this effect. This has important implications for anti-CCR5 therapy in CRC.

Intraductal radiofrequency ablation of tumour ingrowth into an uncovered metal stent used for inoperable cholangiocarcinoma.

A 91-year-old woman diagnosed to have an inoperable cholangiocarcinoma had an uncovered metal stent inserted for palliative drainage. About 1.5 years later, tumour ingrowth into the metal stent caused cholangitis. Intraductal radiofrequency ablation was applied to create local coagulative tumour necrosis and the necrotic tissue was removed via a balloon catheter. A plastic stent was inserted to empirically treat any ensuing potential bile duct injury. The patient was discharged without complication with good palliative drainage. Intraductal radiofrequency ablation is a new technique for the treatment of metal stent occlusion due to tumour ingrowths. This is the first case report of this relatively safe and feasible new technique for the treatment of tumour ingrowth into a metal stent used as palliation for malignant biliary obstruction.

Patients newly diagnosed with ulcerative colitis receive earlier treatment in surgical clinics.

AIM: The diagnosis and treatment of ulcerative colitis (UC) is traditionally the realm of gastroenterologists. However, the symptoms of UC overlap with those of bowel cancer and patients may be initially referred to colorectal surgery clinics. The aims of this study were to define which specialty most frequently diagnoses UC and to determine if there were differences in management between the two specialities. METHOD: The demographics, presenting symptoms and clinical management of patients with newly diagnosed UC were determined and compared by speciality clinic of initial referral. Histopathology reports and clinic letters were reviewed to identify patients newly diagnosed with UC at a large university teaching hospital from January 2007 to January 2012. RESULTS: Patients were more commonly referred to colorectal surgeons (74 vs 41 patients) than gastroenterologists. Patients referred to gastroenterology were younger (36.0 vs 59.6 years, P < 0.01) but there were no significant differences in gender, presenting symptoms or disease extent. Rigid sigmoidoscopy ± biopsy was more commonly performed in colorectal clinic (93.2 vs 31.7%, P < 0.01). There was a significantly shorter delay in starting disease-specific treatment for those patients referred initially to colorectal surgery (13.8 vs 33.6 days, P = 0.01). Performing rigid sigmoidoscopy in clinic was associated with starting disease-specific treatment at this visit. CONCLUSION: Patients with first presentation UC are more commonly seen in colorectal surgery clinics where rigid sigmoidoscopy is more frequently undertaken, allowing earlier commencement of UC treatment.

The clinical characteristics of lupus related protein-losing enteropathy in Hong Kong Chinese population: 10 years of experience from a regional hospital.

OBJECTIVE: The aim of our study was to investigate systemic lupus erythematosus (SLE) related protein-losing enteropathy (PLE) in the following areas: clinical features, laboratory, endoscopic and imaging characteristics, treatment and outcome. METHOD: A retrospective analysis was performed. RESULTS: From 2001 to 2010, 48 patients had SLE related PLE and their clinical characteristics were: age 40.8 ± 14.3 years, male-to-female ratio 1:8.6, mean symptom duration 4.3 ± 3.4 weeks, initial presentation and concomitant activity of SLE in 21(43.8%) and 37 (77.1%) patients, <20% patients developed gastrointestinal (GI) symptoms, mean serum albumin level 24.4 ± 5 g/L. Thirty (62.5%) patients had diffuse non-erosive erythematous GI mucosa with chronic inflammatory cells in lamina propria. Protein leakage was at the small bowel in 15 (31.3%) patients, terminal ileum/caecum in 16 (33.3%) patients and ascending colon in 11 (22.9%) patients. Thirty (62.5%) patients responded initially well to a combination of prednisolone and azathioprine (AZA) and 33 (68.8%) patients were maintained well by the above therapy. Higher potent induction and maintenance therapy were required in patients with: proteinuria (p < 0.01), history of previous immunosuppressive therapy (p < 0.02) and requirement of higher potent induction therapy (p < 0.01). PLE as initial SLE presentation was associated with better prognosis. Four reversible adverse events were reported: one had AZA-induced pancreatitis, two developed AZA-induced hypoplastic anemia and one developed steroid psychosis. One patient developed shingles in the fourth month and responded to oral acyclovir. No thromboembolic events were reported and one patient died of SLE nephropathy. CONCLUSION: There appears to be increasing prevalence of SLE related PLE. A diagnosis can be made using 99m Tc-labeled HSA scintigraphy. PLE generally responds well to immunosuppressive therapy.

Nephrotoxicity, including acquired Fanconi's syndrome, caused by adefovir dipivoxil - is there a safe dose?

WHAT IS KNOWN AND OBJECTIVE: Adefovir dipivoxil (ADV) is an oral bioavailable prodrug of adefovir that possesses potent in vitro activity against hepadnaviruses, retroviruses and herpes viruses. ADV is excreted unchanged in the urine through glomerular filtration and tubular secretion and is known to be nephrotoxic at doses of 60mg daily and above. Thus, the long-term safety of ADV, particularly nephrotoxicity, is a major concern. Our objective is to comment on the nephrotoxcicity of low-dose (10mg daily) ADV through a case report. COMMENT: The clinical features of nephrotoxicity because of ADV are described. A case report of acquired Fanconi's syndrome in a chronic hepatitis B patient treated with ADV 10mg daily is used to illustrate several key aspects. WHAT IS NEW AND CONCLUSION: Adefovir dipivoxil can be nephrotoxic at conventional dosage and therefore, patients treated with long-term ADV should have regular monitoring of renal function, and calcium and phosphate levels.

HPV vaccination in Hong Kong: implications for medical education.

OBJECTIVE: To explore the experience and attitudes of physicians in clinics, and to facilitate physicians' promotion of HPV vaccination. DATA SOURCES: Primary data collected from conducting semi-structural in-depth interviews from May to June 2010 with 12 physicians in one district in Hong Kong to understand their experience of providing HPV vaccines, the difficulties in promoting HPV vaccines, and their attitudes towards HPV vaccination. STUDY DESIGN: Physicians identified 4 categories of factors related to their experiences of and attitudes to providing HPV vaccination: (a) background information on HPV vaccination provided by physicians, (b) factors influencing women to receive vaccination, (c) physicians' recommendations to the public on HPV vaccines, and (d) physicians' perspectives on HPV vaccine promotion. CONCLUSIONS: Our findings show that public knowledge on HPV and cervical cancer is insufficient and the role of government in vaccine promotion is unclear. Promotion strategies such as physicians' recommendation, financial assistance and health education provided by the government will influence HPV vaccination and its promotion.

Hepatocarcinogenesis of regenerative and dysplastic nodules in Chinese patients.

OBJECTIVES: To determine the development rate of hepatocellular carcinoma and survival of patients diagnosed to have regenerative, and low-grade and high-grade dysplastic liver nodules. DESIGN: Retrospective descriptive study. SETTING: Acute public hospital, Hong Kong. PATIENTS: Patients with non-malignant liver nodules confirmed by imaging-guided liver biopsy between January 1997 and December 2008. MAIN OUTCOME MEASURES: Rates of hepatocellular carcinoma development and survival. RESULTS: A total of 147 patients with non-malignant liver nodules were followed up over a median duration of 29 months. The initial histological diagnosis included regenerative nodules (n=74), low-grade dysplastic nodules (n=34), and high-grade dysplastic nodules (n=39). The respective cumulative hepatocellular carcinoma development rate during the first, second, third, and fourth year were 3%, 5%, 9% and 12% for simple regenerative nodules, 29%, 35%, 38% and 44% for low-grade dysplastic nodules, and 38%, 41%, 51% and 51% for high-grade dysplastic nodules. The hepatocellular carcinoma development rate was highest in those with high-grade dysplastic nodules. Multivariate analysis showed that histological dysplastic changes were associated with increased alpha-fetoprotein levels and advanced age, which were both independent predictors of hepatocellular carcinoma development. Histological dysplastic changes, male sex, advanced age, prolonged prothrombin time, and ultrasound appearances were independent predictors of mortality. CONCLUSION: The presence of dysplastic change in liver nodules increased the risk of hepatocellular carcinoma development and death.

Relapse of amoebic infection 10 years after the infection.

A 52-year-old man with schizophrenia, who had a history of amoebic liver abscess treated with combination antimicrobial agents, presented 10 years later with severe rectal bleeding. Diagnosis of amoebic colitis was confirmed by histological examination of endoscopic biopsy. Doctors treating patients with amoebic infection should be aware of the risk of eradication failure. Post-treatment stool testing, preferably by antigen testing or polymerase chain reaction, should be performed after antimicrobial treatment.

Ten-year review of epidemiology, clinical features, and treatment outcome of achalasia in a regional hospital in Hong Kong.

OBJECTIVE: To describe the epidemiology, clinical features, and treatment outcome of achalasia in Chinese patients. DESIGN: Retrospective study. SETTING: Major regional hospital, Hong Kong. PATIENTS: Clinical records of patients with the diagnosis of achalasia from July 1997 to June 2007 were reviewed. RESULTS: Thirty-two patients were diagnosed with achalasia during the study period. The mean age at diagnosis was 50 years (standard deviation, 20 years). The female-to-male ratio was 1.3:1. The main presenting symptoms were dysphagia (78%) and vomiting (50%). Nine laparoscopic and two open Heller's operations had been performed and 16 patients had undergone endoscopic dilatations. Four patients had botulinum toxin injection and four were taking calcium channel blocker (nifedipine) medications. Botulinum toxin injection and medical therapy had poor short- and long-term responses. Laparoscopic myotomy and pneumatic dilatation had comparable good short- and long-term responses. CONCLUSION: Achalasia affected all age-groups but there was a peak at middle age. Pneumatic dilatation and Heller's myotomy (open or laparoscopic approach) appeared able to maintain longer symptom responses than medical therapy and botulinum toxin injection.

Minichromosome maintenance proteins 2, 3 and 7 in medulloblastoma: overexpression and involvement in regulation of cell migration and invasion.

Minichromosome maintenance (MCM) proteins 2-7 are important in DNA replication licensing. Functional roles beyond licensing are speculated. In addition, significances in medulloblastoma (MB) remain unclear. In this study, we showed the frequent deregulation of MCM2 and MCM3 expression in 7 MB cell lines and 31 clinical samples. Moreover, DAOY and ONS76 and the clinical samples expressed elevated MCM7 transcripts with genomic gain of the gene. Immunopositivity restricted to tumor cells was found in 41, 37 and 53 out of 73 MB cases for MCM2, MCM3 and MCM7, respectively. High-MCM3 expression was associated with poor prognosis. Knockdowns of these MCMs significantly inhibited anchorage-dependent and -independent MB cell growth. The inhibition of MCM3 expression by small interfering RNA knockdown was related to G1 arrest with reduced cyclin A expression, whereas the MCM2- and MCM7-knocked-down cells arrested at G2/M with increased cyclin A expression. Interestingly, we demonstrated the links of these MCMs with cell migration and invasion using wound-healing and Transwell migration/invasion assays. Exogenous overexpression of MCM2, MCM3 and MCM7 increased anchorage-independent cell growth, and also cell migration and invasion capabilities in MB cells. The knockdown reduced the number of filopodial cells and the cells with intense stress fibers by blocking cdc42 and Rho activation. Taken together, deregulation of MCM2, MCM3 and MCM7 expression might be involved in MB tumorigenesis and we revealed undefined roles of these MCMs in control of MB cell migration and invasion.

Outcome of inoperable hepatocellular carcinoma patients receiving transarterial chemoembolisation: a real-life retrospective analysis in a Hong Kong regional hospital.

OBJECTIVE: To evaluate survival and prognostic factors in patients with advanced hepatocellular carcinoma treated by transarterial chemoembolisation in a real-life clinical practice setting. DESIGN: Retrospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: Patients with inoperable hepatocellular carcinoma diagnosed from January 1998 to December 2003 who received transarterial chemoembolisation. RESULTS: A total of 74 patients were identified, and had a median survival of 214 days. The cumulative survival rates at 1, 2, and 3 years were 28%, 12%, and 7%, respectively. By multivariate analysis, superselective cannulation performed in transarterial chemoembolisation (hazard ratio=0.47; 95% confidence interval, 0.23-0.95; P=0.034), embolisation with gelfoam (0.30; 0.11-0.80; P=0.017), and treatment intervals of more than 45 days (0.33; 0.15-0.72; P=0.006) were independent predictors of good survival. Child-Pugh grade B cirrhosis (hazard ratio=5.62; 95% confidence interval, 2.11-14.97; P=0.001), and high pre-treatment serum alpha-fetoprotein level (2.93; 1.50-5.73; P=0.002) were independent predictors of poor survival. CONCLUSIONS: In real-life clinical practice, survival of patients with inoperable hepatocellular carcinoma remains grave despite treatment. Patients with Child-Pugh grade A cirrhosis or with low pretreatment alpha-fetoprotein level are more suitable for this form of treatment. The procedure should be performed with superselective cannulation and embolisation with gelfoam.

Did the pattern of practice in the prescription of palliative radiotherapy for the treatment of uncomplicated bone metastases change between 1999 and 2005 at the rapid response radiotherapy program?

AIMS: Since 1999, randomised clinical trials and meta-analyses have reported equal efficacy of pain relief from single- and multiple-fraction radiotherapy for bone metastases. A number of factors, including limited radiotherapy resources, waiting times, and patient convenience, suggest single fraction to be the treatment of choice for patients. However, international patterns of practice indicate that multiple fractions are still commonly used. This study examined whether dose-fractionation schemes used for the treatment of bone metastases at the Rapid Response Radiotherapy Program (RRRP) at the Odette Cancer Centre have changed since 1999. MATERIALS AND METHODS: A retrospective review of the prospective RRRP database and hospital records were conducted for all patients treated with palliative radiotherapy for uncomplicated bone metastases at the RRRP in 1999 (or baseline), 2001, 2004 and from 1 January to 31 July 2005. Data were collected on patient demographics and clinical characteristics. RESULTS: Of the 693 patients, 65 and 35% were prescribed single fraction (predominantly single 8 Gy) and multiple fractions (predominantly 20 Gy/five fractions), respectively. The administration of single treatments generally increased over time, from 51% in 1999 to 66% in 2005 (P=0.0001). On the basis of multiple logistic regression analyses, patients were more likely to be prescribed single-fraction radiotherapy if they had prostate cancer, had a poorer performance status, were treated to the limbs, hips, shoulders, pelvis, ribs, scapula, sternum, or clavicle (compared with the spine), were treated by a radiation oncologist who had been trained in earlier years, and who were treated after 1999. CONCLUSIONS: Between 1999 and 2005, the use of single-fraction radiotherapy increased, corresponding to publications showing equal efficacy of pain relief between single and multiple fractions in the management of uncomplicated bone metastases. However, about a third of patients still received multiple fractions.