Factitious thyrotoxicosis and herbal dietary supplement for weight reduction.

This article describes three patients who developed factitious thyrotoxicosis, as well as other adverse effects, after taking herbal dietary supplements for weight reduction. All products were found to contain undeclared animal thyroid tissue and western pharmaceuticals causing the adverse effects. Adulteration is concealed addition of undeclared drugs, or other substances with therapeutic effects, to a health product. Consumption of such products, and the concealed components unwittingly, is obviously dangerous. Multiple adulterants in one product are often seen. Untoward adverse effect or drug interaction could occur. Overdose subsequent to poor standardization of the adulterants is another concern. Health care professionals must therefore be aware of the potential dangers posed by adulterated dietary supplements.

Hazards posed by a banned drug--phenformin is still hanging around.

The Hospital Authority Toxicology Reference Laboratory confirmed six cases of phenformin use, with or without complications, from July 2005 to November 2006. Two of the patients presented with potentially fatal phenformin-induced lactic acidosis. Phenformin was found (or suspected to be) adulterating Chinese proprietary medicine in five of the six cases. We report these six cases to highlight the underrecognised hazards posed by phenformin, a banned drug in Hong Kong.

Analogues of erectile dysfunction drugs: an under-recognised threat.

OBJECTIVES: To investigate the problem of drug analogue adulteration in male erectile dysfunction health products. DESIGN: Survey of over-the-counter male erectile dysfunction health products available in convenience stores and pharmacies in Hong Kong. SETTING: Tertiary referral centre for clinical toxicology analysis in Hong Kong. MAIN OUTCOME MEASURES: The pattern and extent of adulteration of male erectile dysfunction health products with sildenafil, tadalafil, and vardenafil as well as their structurally modified analogues. RESULTS: Of 26 products studied, one (4%) was found to contain undeclared sildenafil, while 14 (54%) contained drug analogues of different kinds. The latter included acetildenafil, hydroxyacetildenafil, hydroxyhomosildenafil, and piperidenafil. The first three were analogues of sildenafil and the last was an analogue of vardenafil. One young patient presented with ataxia after taking an acetildenafil-containing product. CONCLUSIONS: The positive rate of concealed drug analogues in male erectile dysfunction health products is alarmingly high. Such analogues are difficult to detect by ordinary laboratory methods, and might be used in an attempt to evade regulatory inspection. Without going through the stringent drug testing process, the adverse effects of these chemicals remain largely unknown and unpredictable. Effective surveillance system and control measures are needed urgently. The medical profession and the public should be alerted to this under-recognised threat.

Methemoglobinemia after ingestion of Chinese herbal medicine in a 9-day-old infant.

Traditional Chinese Medicine has long been popular among Chinese people, but it is always difficult for physicians to ascertain the nature and use of different ingredients involved. We report case of a 9-day-old infant who ingested home-made herbal medicine and developed cyanosis with methemoglobinemia. He responded to a single dose of methylene blue therapy. The suspected causative agent identified in the herbal medicine was sulfamethazine. This is the first reported case of methemoglobinemia related to the use of Chinese herbal medicine in the newborn period.

Aconite poisoning in camouflage.

The Toxicology Reference Laboratory has confirmed 10 cases of aconite poisoning from March 2004 to May 2006. In four of these 10 cases, the aconite herb was not listed in the written prescription. We report these four cases to highlight the problem of 'hidden' aconite poisoning.

Acute renal failure associated with prolonged intake of slimming pills containing anthraquinones.

Chinese herbal medicine preparations are widely available and often regarded by the public as natural and safe remedies for a variety of medical conditions. Nephropathy caused by Chinese herbs has previously been reported, usually involving the use of aristolochic acids. We report a 23-year-old woman who developed acute renal failure following prolonged use of a proprietary Chinese herbal slimming pill that contained anthraquinone derivatives, extracted from Rhizoma Rhei (rhubarb). The renal injury was probably aggravated by the concomitant intake of a non-steroidal anti-inflammatory drug, diclofenac. Renal pathology was that of hypocellular interstitial fibrosis. Spontaneous renal recovery occurred upon cessation of the slimming pills, but mild interstitial fibrosis and tubular atrophy was still evident histologically 4 months later. Although a causal relationship between the use of an anthraquinone-containing herbal agent and renal injury remains to be proven, phytotherapy-associated interstitial nephropathy should be considered in patients who present with unexplained renal failure.

Individual allergens as risk factors for asthma and bronchial hyperresponsiveness in Chinese children.

The role of allergen sensitization in the development of asthma in the Chinese is not clear. This study aims to determine the relationship of sensitization to individual allergens, and the development of asthma and bronchial hyperresponsiveness (BHR) in schoolchildren from three Chinese cities: Hong Kong, Beijing and Guangzhou. Community-based random samples of 10-yr-old schoolchildren from three Chinese cities were recruited for study using the International Study of Asthma and Allergies in Childhood (ISAAC) Phase II protocol. Subjects were studied by parental questionnaires (n=10,902), skin-prick tests (n=3,479), and methacholine challenge tests (n=608). The prevalence rates of wheeze in the past 12 months (Hong Kong, 5.8%; Beijing, 3.8%; Guangzhou, 3.4%) and atopy (Hong Kong, 41.2%; Beijing, 23.9%; Guangzhou, 30.8%) were highest in schoolchildren from Hong Kong. Multivariate logistic regression analyses revealed that sensitization to Dermatophagoides pteronyssinus (odds ratio (OR)=4.48; 95% confidence interval (CI): 3.02-6.66), cat (2.59; 1.67-4.03), Dermatophagoides farinae (2.41; 1.65-3.51) and mixed grass pollen (2.85; 1.24-6.50) were significantly associated with current wheeze. Atopy, defined as having > or = 1 positive skin-prick tests, was not an independent risk factor for current wheeze in children from any of the three cities. Furthermore, atopy (OR=2.53; 95% CI: 1.07-5.97), sensitization to cat (3.01; 1.39-6.52) and D. farinae (3.67; 1.93-6.97) were significantly associated with BHR. The authors confirmed that sensitization to house dust mite and cat was significantly associated with current wheeze and bronchial hyperresponsiveness in Chinese schoolchildren. However, the difference in the prevalence rate of atopic sensitization cannot explain the higher prevalence of childhood asthma in Hong Kong, when compared with those children from Beijing and Guangzhou.

Snoezelen for dementia.

BACKGROUND: Snoezelen, multi-sensory stimulation, provides sensory stimuli to stimulate the primary senses of sight, hearing, touch, taste and smell, through the use of lighting effects, tactile surfaces, meditative music and the odour of relaxing essential oils (Pinkney 1997). The clinical application of snoezelen has been extended from the field of learning disability to dementia care over the past decade. The rationale for its use lies in providing a sensory environment that places fewer demands on intellectual abilities but capitalizes on the residual sensorimotor abilities of people with dementia (e.g. Buettner 1999, Hope 1998). Practitioners are keen to use snoezelen in dementia care, and some encouraging results have been documented in the area of promoting adaptive behaviours (e.g. Baker, Long 1992, Spaull 1998). However, the clinical application of snoezelen often varies in form, nature, principles and procedures. Such variations not only make examination of the therapeutic values of Snoezelen difficult, but also impede the clinical development of snoezelen in dementia care. A systematic review of evidence for the efficacy of snoezelen in the care of people with dementia is therefore needed to inform future clinical applications and research directions. OBJECTIVES: This review aims to examine the clinical efficacy of snoezelen for older people with dementia. SEARCH STRATEGY: "Snoezelen", "multi-sensory", "dement*", "Alzheimer*", "randomized control/single control/double control" were used as keywords to search seven electronic databases (e.g. MEDLINE, PsyLIT). The list of trials was compared with those identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group. SELECTION CRITERIA: All RCTs in which Snoezelen or multi-sensory programmes were used as an intervention for people with dementia were included in the review. Trial data included in the review were restricted to those involving people aged over 60 years suffering from any type of dementia, except one subject of Baker's study was aged below 60 years. DATA COLLECTION AND ANALYSIS: Only two RCTs fulfill the inclusion criteria for this systematic review. Two reviewers independently extracted the data from these two inclusion studies. Quantitative synthesis of the comparable data from the two trials was performed. MAIN RESULTS: Two trials were included. Both Baker (and Kragt examined the short-term values of snoezelen on the behaviours of people with dementia. Although the pooled results were insignificant, the trend was in the direction of favouring treatment (hence a negative value of the SMD). The standardized mean difference (SMD) was -1.22, with a 95% confidence interval (CI) (-4.08, 1.64). Kragt's result, weighted 47%, was significant in favour of treatment, with a SMD of -2.77 and a 95% CI (-4.24, -1.29). During the snoezelen session, Kragt's subjects presented significantly fewer apathetic behaviours (t=-8.22, p<0.01), fewer restless behaviours (t=-3.00, p=0.01), fewer repetitive behaviours (t=-.822, p<0.01), and fewer disturbances (t=-4.91, p<0.01). Baker's result was slightly not in favour of the treatment, with a SMD of 0.16 and a 95% CI (-0.41, 0.73). The control subjects touched objects/equipment more appropriately within the activity sessions than the subjects who participated in snoezelen sessions (F(1,47)=5.96, p=.001). Kragt did not examine the carryover and long-term effects of snoezelen, so only Baker's results were analysed. Baker used the Behavioural and Mood Disturbance scale (BMD), the REHAB, the CAPE and MMSE to assess patients mood, behaviour and cognition after (but not immediately after) four treatment sessions and eight treatment sessions. Some assessments were carried at home, some at day hospital. There were many subscores and mostly there were no differences between treatment and control. The following significant differences were found with benefit in favour of snoezelen compared with control after four sessions: apathy ezelen compared with control after four sessions: apathy score of the BRS (CAPE) (MD -3.00, 95%CIs -5.87 to -0.13, P=0.04), after eight sessions: mood score of the BRS (CAPE) (MD -2.60, 95%CIs -4.92 to -0.28, P=0.03), total score of the BRS (CAPE) (MD -6.92, 95%CIs -13.13 to -0.7, P=0.03), speech skills of the REHAB (MD 1.46, 95%CIs 0.01 to 2.82, P=0.03), psychomotor subscore of the cognitive assessment scale of CAPE (MD -3.12, 95%CIs -5.31 to -0.93, P<0.01). REVIEWER'S CONCLUSIONS: Two trials were reviewed. Although both studies examined the short-term values of snoezelen on people with dementia, it is not feasible to draw a firm conclusion at this stage, for two main reasons. Firstly, very limited data were available for analysis, thus limiting data inference and generalization. Secondly, different methodology and control conditions were adopted in the two trials. Such variations not only require a careful interpretation of results but also make the comparison of results across studies less valid. Hence, there is an urgent need for more systematic and scientific research studies to examine the clinical value of snoezelen for people with dementia. To our knowledge, there are four RCTs currently in progress. It is hoped that the data and results of these trials will enrich the systematic review of snoezelen for dementia in the next update.

Absorption of lidocaine during aspiration anesthesia of the airway.

STUDY OBJECTIVE: To determine the optimal solution to use when anesthetizing the airway by aspiration of lidocaine. DESIGN: Randomized, double-blind clinical study. SETTING: University hospital. PATIENTS: 96 adult ASA physical status 1,II, and III patients, scheduled for diagnostic flexible bronchoscopy. INTERVENTIONS: Patients were randomized to receive one of 5 solutions of lidocaine: Group A (n = 16): 1% lidocaine, 0.2 mL. kg(-1); Group B (n = 16): 1.5% 0.2 mL. kg(-1); Group C (n = 32): 2% 0.2 mL. kg(-1); Group D (n = 16): 1% 0.3 mL. kg(-1), and Group E (n = 16): 2% 0.3 mL. kg(-1). Fiberoptic bronchoscopy was performed after the airway was anesthetized with this aspiration technique, using the assigned lidocaine solution. The scope was manipulated in the trachea to test for anesthesia. MEASUREMENTS AND MAIN RESULTS: Successful airway anesthesia was determined by tolerance to bronchoscopy without sustained coughing, and also by the number of lidocaine supplements, if any, that were given via the bronchoscope. Arterial plasma concentrations of lidocaine were measured in 33 patients from Groups C, D, and E. All solutions provided equally effective anesthesia of the airway. All patients tolerated endoscopy through the vocal cords, and 94 patients required no supplementary anesthesia, or only one dose of lidocaine, during bronchoscopy to the carina. The highest peak plasma concentrations of lidocaine were 5.02 and 6.28 microg. mL. No patient had signs of toxicity. CONCLUSIONS: This technique produced anesthesia of the airway to the carina, safely, suitable for awake intubation, in 94 of 95 patients. The use of 1% lidocaine, 0.2 to 0.3 mL. kg(-1), so that the volume is 10 to 20 mL, is recommended.

Phenytoin poisoning after using Chinese proprietary medicines.

We report a case of poisoning resulting from the use of Chinese proprietary medicines (CPM) containing anticonvulsants phenytoin, carbamazepine and valproate. The manufacturer's information leaflets did not mention any of these prescription drugs. As a consequence, the patient was admitted comatose due to severe phenytoin poisoning. We are not aware of any reported case of severe poisoning due to CPM adulterated with anticonvulsants and this is possibly the first case.

Evaluation of the efficacy of a hospital-based asthma education programme in patients of low socioeconomic status in Hong Kong.

BACKGROUND: Good asthma control requires optimal medical treatment in conjunction with appropriate self-management. In the West, the effectiveness of patient education on improving self-management has been well documented. However, data amongst Asian populations are lacking. We performed a pilot study to evaluate the efficacy of a hospital based education programme aimed at improving self-management skills and reducing morbidity in a Chinese population with low socioeconomic status and education level. METHODS: Our asthma education programme was a low-cost programme conducted in essence by specialist respiratory nurses. Patients attending our asthma clinic were instructed during a two-hour educational session on the pathophysiology of asthma, its potential triggers, the appropriate use of medications including proper inhaler techniques, and the self-management of their disease. These instructions were reinforced by video sessions at subsequent outpatient clinic attendance when patients' inhaler and peak flow techniques were checked by the same nurses and their self-management plan re-examined by the attending physicians. Asthma knowledge, inhaler technique, FEV1 and peak expiratory flow (PEF), and patients' self-rating of their asthma were determined at baseline, 6 months and 1 year after the intervention. Morbidity was assessed by the numbers of hospitalizations, unscheduled visits to family physicians and accident and emergency department attendance, courses of oral steroid used and days off work or school at baseline and 1 year. RESULTS: Two hundred and thirty patients were recruited for the study, 83% completing the entire assessment period. The group demonstrated significant improvements in lung function: the mean FEV1 +/- SD increased from 63.6 +/- 20.6% of predicted values at baseline to 68.5 +/- 22.3% at 6 months and 68.6 +/- 22.8% at 1 year (P < 0.05), and the mean PEF +/- SD increased from 64.6 +/- 23.0% of predicted values at baseline to 75.4 +/- 27.0% at 6 months and 76.8 +/- 24.5% at 1 year(P < 0.001). There were also significant improvements in inhaler technique (P < 0.01), asthma knowledge (P < 0.001), patients' self-rating of their asthma (P < 0.05), and reductions in the numbers of hospitalizations (P < 0.01), visits to family physicians (P < 0.001) and accident and emergency department attendance (P < 0.001) during the study period. Patients with moderate to severe asthma as defined by an FEV1 of < 80% of predicted values were most likely to benefit from the programme. CONCLUSIONS: We conclude that patient education is likely to be an essential component in the holistic approach to the management of asthma even amongst Asian populations of low socioeconomic status and education level. Further studies using randomised controlled trials are necessary to consolidate our findings.

Comparison of oral ciprofloxacin and amoxycillin in treating infective exacerbations of bronchiectasis in Hong Kong.

A randomised double-blind controlled clinical trial was conducted to compare oral ciprofloxacin (500 mg b.d.) and amoxycillin (1 g t.d.s.) in the treatment of infective exacerbations of bronchiectasis. The commonest organism isolated from sputum was Pseudomonas aeruginosa, which accounted for 34% of all positive sputum cultures. Other Pseudomonas species and Haemophilus influenzae, accounted for 19%, respectively. Ciprofloxacin produced better clinical response, a higher sputum to serum antibiotic level (mean of 0.65 in the ciprofloxacin group vs. 0.18 in amoxycillin group, p = 0.0001), broader spectrum of antibacterial activity and less side-effect. It was also better tolerated by patients. The findings suggest that ciprofloxacin is an effective treatment of infective exacerbations of bronchiectasis.

Air-driven nebulised high-dose salbutamol in severe chronic obstructive airways disease: is it safe?

The increasing use of air-driven nebulised bronchodilators by patients with airflow obstruction has raised concern about the safety of this practice. We have investigated the effects of 10 mg salbutamol, nebulised in air, on blood gas tensions, heart rate and plasma potassium (K+), when administered alone to 9 patients with severe chronic obstructive airway disease and then in combination with a therapeutic dose of oral sustained-release theophylline to 5 of them on 2 separate occasions. No significant reductions in PaO2 were observed with either treatments. Heart rate increased significantly from 77.8 +/- 3.7 beats/min (mean +/- s.e.m.) at baseline to a peak of 87.1 +/- 4.4 beats/min at 45 min (p less than 0.001) with salbutamol alone and there was a similar trend of increase after combined therapy. K+ decreased significantly from a baseline of 4.0 +/- 0.3 to a minimum of 3.6 +/- 0.2 mmol/l at 90 min (p less than 0.001) with combined therapy but did not change significantly with single therapy. No subject developed any significant cardiac arrhythmias on either occasion. Although the number of subjects studied is small, our data suggest that air-driven nebulised high-dose salbutamol may be safe in the treatment of severe chronic obstructive airway disease but when combined with oral theophylline, a significant fall in plasma potassium may occur. This could be of clinical significance in hypokalaemic patients. When combination treatment is used, monitoring of plasma potassium is recommended.

Frank rectal bleeding: a prospective study of causes in patients over the age of 40.

In order to determine the frequency of tumours in patients presenting with frank rectal bleeding, a prospective study was carried out in 337 patients over the age of 40 attending our Proctology Clinic. After making a clinical diagnosis, flexible sigmoidoscopy followed by barium enema was performed. Excluding 7 digitally palpable rectal cancers, there were 30 cancers (9.1%), 34 polyps (10.3%), 7 proctocolitis (2.1%) and 25 diverticula (7.6%) detected, giving a total diagnostic yield of 29.1%. A clinical diagnosis of bleeding sources other than haemorrhoids was made in 80% of the cancers. Flexible sigmoidoscopy detected 93.3% of the cancers and 88.2% of the polyps. Barium enema diagnosed the remaining cancers and polyps but there was a false-positive rate of 3.8%. From our results, we conclude that patients with frank rectal bleeding should be screened routinely for left-colon cancer irrespective of the clinical diagnosis. The flexible sigmoidoscope is a quick and useful tool. However, barium enema should be recommended to individuals with strong clinical suspicion of rectal bleeding other than haemorrhoids.