A paradigm shift in the provision of improved critical care in the emergency department.

With Hong Kong's ageing population, advancement of medical technologies and hospital congestion, it is not uncommon for emergency physicians to encounter complicated critically ill patients in daily practice. It becomes a fundamental role of emergency physicians to initiate timely diagnostic and therapeutic interventions to save a patient's life and improve their prognosis. It is the reason a critical care service has been developed in emergency departments worldwide over the last decade. This article shares how emergency department intensivists can contribute to this novel model of care with some illustrative cases. Advanced airway and peri-intubation management, difficult mechanical ventilation, treatment of shock, circulatory arrest, and metabolic disturbances can be safely and efficiently handled in the current emergency department setting. Obstacles, barriers, and the road ahead will be discussed.

Assessing the factor structure of the Chinese conformity to masculine norms inventory.

The purpose of the present study was to examine the factor structure and assess the reliability of the Chinese Conformity to Masculine Norms Inventory-46 (CCMNI-46). Using a cohort of 254 Hong Kong-born Chinese males, scale reliability determination involved the internal consistencies of the entire instrument. Ages of respondents ranged from 18 to 81 years (M = 38.05; SD = 17.3). Confirmatory factor analysis provided support for the psychometric properties of the CCMNI-46, thus confirming the multidimensional structure of the CMNI-46 and the replicability of the CMNI using a Hong Kong Chinese sample. All items loaded onto the corresponding factor with the exception of one item from the emotional control subscale. The overall reliability of the CCMNI-46 was lower than previous Western studies and may well reflect the subtle diversity of masculinity across cultures. The findings offered psychometric support for use of the CCMNI-46 in research and practice regarding Hong Kong Chinese masculinity. The CCMNI-46 provides a useful template for the operationalization of masculine norms in Chinese society.

Factors associated with utilisation of traditional Chinese medicine among Hong Kong Chinese.

The present study explored factors associated with belief in, and utilisation of, traditional Chinese medicine (TCM), as well as factors associated with trust in TCM practitioners (TCMPs) among Hong Kong Chinese individuals. Data were collected using a structured questionnaire. A sample of 300 Hong Kong Chinese aged between 18 and 90 years old were recruited. The study used a number of outcome variables including demographic variables, health status, as measured by the SF-12, attitude towards TCM and Western medicine as measured by the Chinese-Western Medical Beliefs Scale, traditional Chinese values as measured by the Chinese Values Scale and trust in physicians. Findings revealed an association between age, gender and education level, with older age, being female and lower educational attainment all being predictive of TCM utilisation. Utilisation norms was predictive of trust in practitioners, indicating that frequent use of TCM lead to higher levels of trust in TCMP. Chinese values were differentially associated with use of and belief in TCM. Confucian obligation was predictive of belief in TCM and utilisation of TCM, while tolerance and harmony was not associated with belief and use of TCM. Younger respondents tended to score higher in tolerance and harmony, while older respondents scored higher in Confucian obligation, which goes some way to explain these differing trends in Chinese values and associations with TCM as older respondents were much more likely to utilise TCM than their younger counterparts.

Patupilone in patients with pretreated metastatic/locally recurrent colorectal cancer: results of the Phase II CINATRA trial.

BACKGROUND: Phase I trials of the microtubule stabilising agent patupilone showed encouraging tumour control and response rates in patients with metastatic colorectal cancer. METHODS: Patients with metastatic or locally recurrent colorectal cancer who had progressed following treatment with oxaliplatin, irinotecan and fluoropyrimidines were treated with patupilone (8 mg/m(2) IV every 3 weeks) in combination with dexamethasone or prednisolone. RESULTS: The trial was closed early after 29 patients had been enrolled due to concerns about toxicity. 20 patients (71.4 %) experienced at least one grade 3-5 toxicity, most commonly diarrhoea (14 patients), dehydration (7 patients) and lethargy (6 patients). The 12 week progression-free survival rate was 16.7 % (95 % CI 6.1 %-36.5 %) in the 24 patients with a 12 week scan available or who had died prior to the 12 week scan. No complete or partial responses were seen by 12 weeks. The median progression-free survival was 2.6 months (95 % CI 2.3-2.9) and median overall survival was 6.1 months (95 % CI 3.7-8.4). CONCLUSION: Patupilone given at a dose of 8 mg/m(2) IV over 20 min every 3 weeks was associated with high levels of toxicity and no significant evidence of efficacy in patients with pre-treated colorectal cancer.

Targeted drug therapies and cancer.

With the progress of research in molecular biology and greater understanding of cell signalling systems emerge an increasing array of potential targets for the therapy of cancer. While traditional chemotherapy aims to elicit tumour cell death, it also produces undesirable side effects on physiologically proliferating cells. By isolating cell surface receptors which link specific intracellular secondary messenger pathways, researchers are increasingly able to define the biological network which drives cellular function. Of importance are routes involved in malignant transformation, proliferation, survival and angiogenesis. Thus targeted therapy is directed to specific differential growth processes particular to malignant tumours. The principle mode of action generally involves the "lock-and-key" mechanism and identifying the "Achilles' heel" for drug action. Various targeted agents have been studied and many have translated into significant clinical benefit. This chapter will describe some examples which illustrate the role of this approach in gastrointestinal cancers.

A clinical specimen collection and transport medium for molecular diagnostic and genomic applications.

Pathogen detection and genetic characterization has dramatically changed in recent years. Clinical laboratories are transitioning from traditional culture and primer-specific sequencing to more robust and rapid nucleic acid testing such as real-time PCR and meta-genomic characterization, respectively. Specimen collection is the first step in any downstream molecular diagnostic procedure. PrimeStore Molecular Transport Medium (MTM) is an optimized blend of nucleic acid stabilizing reagents that includes a non-specific internal positive control that can be amplified using real-time RT-PCR for tracking the integrity of a specimen from the point of collection to detection. PrimeStore MTM is shown here to effectively kill pathogens, including highly pathogenic H5 influenza virus, inactivate nucleases and to protect and preserve released RNA at ambient temperature for up to 30 days for downstream real-time and traditional RT-PCR detection and genetic characterization. PrimeStore MTM is also compatible with a variety of commercial extraction kits. PrimeStore is suited for routine clinical specimens and has added utility for field collection in remote areas, triage centres, border crossings and during pandemics where cold-chain, transport, and dissemination of potentially infectious pathogens are a concern.

Effects of early-life stress on peripheral and central mitochondria in male mice across ages.

Exposure to early-life stress (ES) increases the vulnerability to develop metabolic diseases as well as cognitive dysfunction, but the specific biological underpinning of the ES-induced programming is unknown. Metabolic and cognitive disorders are often comorbid, suggesting possible converging underlying pathways. Mitochondrial dysfunction is implicated in both metabolic diseases and cognitive dysfunction and chronic stress impairs mitochondrial functioning. However, if and how mitochondria are impacted by ES and whether they are implicated in the ES-induced programming remains to be determined. ES was applied by providing mice with limited nesting and bedding material from postnatal day (P)2-P9, and metabolic parameters, cognitive functions and multiple aspects of mitochondria biology (i.e. mitochondrial electron transport chain (ETC) complex activity, mitochondrial DNA copy number, expression of genes relevant for mitochondrial function, and the antioxidant capacity) were studied in muscle, hypothalamus and hippocampus at P9 and late adulthood (10-12 months of age). We show that ES altered bodyweight (gain), adiposity and glucose levels at P9, but not in late adulthood. At this age, however, ES exposure led to cognitive impairments. ES affected peripheral and central mitochondria in an age-dependent manner. At P9, both muscle and hypothalamic ETC activity were affected by ES, while in hippocampus, ES altered the expression of genes involved in fission and antioxidant defence. In adulthood, alterations in ETC complex activity were observed in the hypothalamus specifically, whereas in muscle and hippocampus ES affected the expression of genes involved in mitophagy and fission, respectively. Our study demonstrates that ES affects peripheral and central mitochondria biology throughout life, thereby uncovering a converging mechanism that might contribute to the ES-induced vulnerability for both metabolic diseases and cognitive dysfunction, which could serve as a novel target for intervention.

Knowledge and Perceptions of Child Protection and Mandatory Reporting: A Survey of Nurses in Hong Kong.

In the absence of a mandatory reporting (MR) structure, it is unclear how nurses perceive or exercise their role in child protection. This study examined knowledge and perceptions of child protection and MR among nurses working in Hong Kong. This cross-sectional web-based survey used the Child Abuse Report Intention Scale to measure nurses' child protection knowledge and attitudes, and their perceived norms, control, and intention to report suspected maltreatment. Nurses also indicated if they support MR and to provide an explanation for their preference. Quantitative data were described and analyzed using bivariate and regression analyses. Open-ended responses were analyzed using directed content analysis. A convenient sample of 91 nurses working in Hong Kong completed the survey. The majority (86%) were female with a mean of 9.5 years of nursing experience; their mean knowledge score was 6.64 out of 13 (range 2-10). Compared with other maltreatment types, sexual abuse was perceived to be most severe and most likely to be reported. Perceived severity and attitudes toward child maltreatment was significantly associated with nurses' intention to report. Over half (58%) supported MR; those against MR expressed concerns about lack of support from management. Although nurses working in Hong Kong still hold polarized views about MR, findings point to the importance of creating a supportive reporting culture, and designing training programs that focus on changing perceptions about child protection in order to improve their tendency to report.

The first nocturnal home haemodialysis patient in Hong Kong.

We report our experience of the first use of nocturnal home haemodialysis in Hong Kong. The patient, a 40-year-old man with end-stage renal failure, was recruited into the Nocturnal Home Haemodialysis Programme at Princess Margaret Hospital in 2006. He received haemodialysis at home on alternate nights (3.5 sessions per week) for 5.5 to 6 hours per session. After 1 year of nocturnal home haemodialysis, his recombinant human erythropoietin requirement had been reduced by more than 50%. His serum phosphate level decreased by 35% and calcium phosphate product by 34%. After nocturnal home haemodialysis, his blood pressure control has been excellent and he was able to cease taking anti-hypertensive medications soon after commencing nocturnal home haemodialysis. Regression of his left ventricular hypertrophy has also been noted, with a 39% decrease in his left ventricular mass index. The haemodialysis adequacy index, weekly single-pool Kt/V, increased by 59% after switching to nocturnal home haemodialysis and his quality-of-life indices also showed significant improvement. Nocturnal home haemodialysis holds promise as an alternative dialytic therapy for patients on chronic haemodialysis in Hong Kong.

Nab-paclitaxel in combination with gemcitabine for the treatment of metastatic pancreas cancer: the South Wales experience.

The prognosis of pancreatic cancer remains very poor, with a 5-year survival rate of around 3%. There has been little impact from various chemotherapy regimens on improving outcome for several decades. Gemcitabine has been the mainstay chemotherapy for around two decades with little improvement in overall survival (OS) for patients with advanced disease. However, more recently, there has been a paradigm shift in treatment options for these patients. Reported in 2011, combination therapy with FOLFIRINOX (oxaliplatin, irinotecan, leucovorin, and fluorouracil) showed a long awaited but modest improvement in survival, but is reserved only for a small proportion of very fit patients due to concerns over its toxicities. In 2013, the landmark phase III international study MPACT demonstrated an improvement in OS with the combination of nab-paclitaxel and gemcitabine (GEMBRAX) for the treatment of patients more akin to the real-world population. In the United Kingdom (UK), it was first made widely available on the National Health Service (NHS) in Wales in September 2014 and only recently received a final positive appraisal by NICE (National Institute of Clinical Excellence) for England in 2017. In this paper, we present our data on the use of this treatment for patients in South Wales and compare real-life practical experience with the MPACT data and reflecting the impact of this paradigm shift.

Cotton rat model for testing vaccines and antivirals against respiratory syncytial virus.

Respiratory syncytial virus is the leading cause of pneumonia and bronchiolitis in infants and is a serious health risk for elderly and immunocompromised individuals. No vaccine has yet been approved to prevent respiratory syncytial virus infection and the only available treatment is immunoprophylaxis of severe respiratory syncytial virus disease in high-risk infants with Palivizumab (Synagis®). The development of respiratory syncytial virus vaccine has been hampered by the phenomenon of enhanced respiratory syncytial virus disease observed during trials of a formalin-inactivated respiratory syncytial virus in 1960s. A search for effective respiratory syncytial virus therapeutics has been complicated by the fact that some of the most advanced respiratory syncytial virus antivirals, while highly effective in a prophylactic setting, had not demonstrated clinical efficacy when given after infection. A number of respiratory syncytial virus vaccines and antivirals are currently under development, including several vaccines proposed for maternal immunization. The cotton rat Sigmodon hispidus is an animal model of respiratory syncytial virus infection with demonstrated translational value. Special cohort scenarios, such as infection under conditions of immunosuppression and maternal immunization have been modeled in the cotton rat and are summarized here. In this review, we focus on the recent use of the cotton rat model for testing respiratory syncytial virus vaccine and therapeutic candidates in preclinical setting, including the use of special cohort models. An overview of published studies spanning the period of the last three years is provided. The emphasis, where possible, is made on candidates in the latest stages of preclinical development or currently in clinical trials.

Improving ability of RSV microneutralization assay to detect G-specific and cross-reactive neutralizing antibodies through immortalized cell line selection.

Respiratory syncytial virus (RSV) is a significant cause of bronchiolitis and pneumonia. Protection against RSV is associated with neutralizing antibodies against the fusion (F) and attachment (G) glycoproteins. Several RSV vaccine candidates are in development, but their immunogenicity is hard to compare due to the little-understood differences between multiple RSV neutralizing antibody assays used. Existing assays utilize primarily Vero or HEp-2 cells, but their ability to detect G-neutralizing antibodies or antibodies against specific RSV strains is unclear. In this work, we developed an RSV microneutralization assay (MNA) using unmodified RSV and immortalized cell line derived from human airway epithelial cells (A549). Performance of A549-, HEp-2- and Vero-based MNA was compared under the same assay conditions (fixed amount of virus and cells) with regards to detection of neutralizing antibodies against RSV A or B viruses, G-reactive neutralizing antibodies, and effect of complement. Our results indicate that A549 cells yield the highest MNA titers, particularly in the RSV A/A2 MNA, are least susceptible to complement-enhancing effect of neutralizing titer readout and are superior to Vero or HEp-2 MNA at recognizing G-reactive neutralizing antibodies when no complement is used. Vero cells, however, can be more consistent at recognizing neutralizing antibodies against multiple RSV strains. The choice of substrate cells thus affects the outcome of MNA, as some immortalized cells better support detection of broader range of neutralizing antibodies, while others facilitate detection of G-targeting neutralizing antibodies, a long-thought prerogative of primary airway epithelial cells.

Minimal change disease following exposure to mercury-containing skin lightening cream.

A 34-year-old woman developed nephrotic syndrome after using a skin lightening cream that contained an extremely high level of mercury. Blood and urine mercury levels were elevated and a renal biopsy revealed minimal change disease. Membranous nephropathy was excluded using immunofluorescence and electron microscopy. Her proteinuria remitted 9 months after she stopped using the cosmetic cream. This is the first reported case in the English literature of proven minimal change disease secondary to mercury exposure. It is important that mercury poisoning due to cosmetic cream is considered in the differential diagnoses for any woman who presents with nephrotic syndrome.

Clopidogrel-induced hepatotoxicity after percutaneous coronary stenting.

Clopidogrel, an adenosine diphosphate receptor blocker, is widely used as an adjunctive antiplatelet therapy in acute coronary syndrome and percutaneous coronary stenting. The occurrence of hepatotoxicity is rare. We describe the occurrence of symptomatic liver disease in a 74-year-old man 5 weeks following commencement of therapy with clopidogrel. The reported cases of clopidogrel-induced hepatotoxicity are reviewed and the clinical significance of this event are discussed.

Single-tube nested PCR in the diagnosis of tuberculosis.

AIMS: To evaluate the usefulness of a single-tube nested polymerase chain reaction (PCR) assay in the diagnosis of tuberculosis in 1497 pulmonary and 536 extrapulmonary specimens. METHODS: A single-tube nested PCR, utilising two sets of primers with different melting temperatures (88 degrees C for external primers; 70 degrees C for internal primers) to augment sensitivity and specificity without increasing the risk of amplicon contamination, was evaluated. Specimens were initially tested for the repetitive IS6110 sequences and if negative, retested for the universal 38 kilodalton sequence and for inhibitors. dUTP/Uracil-N-glycosylase and Instagene treatment were used to minimise contamination and the effect of inhibitors, respectively. RESULTS: Using culture as the gold standard, the overall sensitivity of the assay was 89% for pulmonary and 42% for extrapulmonary specimens. Sensitivity varied greatly with respect to sample type (92% for follow up specimens from a chest hospital and 70% for non-follow up specimens from a general hospital). The smear positivity rates were 15% for extrapulmonary specimens, and 69% and 45%, respectively, for follow up and non-follow up specimens from pulmonary sites. Specificity was 99.7%. Inhibitors were present more frequently in extrapulmonary than in pulmonary specimens (13.4% v 2.7%). CONCLUSION: Despite the high sensitivity of the PCR assay for the diagnosis of tuberculosis in pulmonary specimens, it was less effective in the extrapulmonary samples. This is probably because of the lower bacterial load in extrapulmonary specimens, the presence of more inhibitors adversely affecting the PCR assay and the higher volume of specimens used for culture.

Construction of plasmids, estimation of plasmid stability, and use of stable plasmids for the production of poly(3-hydroxybutyric acid) by recombinant Escherichia coli.

Plasmids containing the Alcaligenes eutrophus poly(3-hydroxybutyric acid) (PHB) biosynthetic genes were constructed for the production of PHB in Escherichia coli and plasmid stability was investigated by repeated subculturing without antibiotic pressure. Both pSYL101 (high copy) and pSYL102 (medium copy) were unstable during the subcultures. Higher instability was observed when cells were accumulating PHB. Segregational instability was aggravated by the faster growth of plasmid-free cells and by appearance of non-dividing cells harboring large amount of PHB during the fed-batch culture. Two derivatives, pSYL103 and pSYL104, were then developed by cloning the parB locus of plasmid R1 into pSYL102 and pSYL101, respectively. They showed 100% stability even during PHB synthesis and accumulation over 110 generations. All four plasmids were structurally stable. The final cell mass, PHB concentration, and PHB per dry cell weight (P/X, w/w, %) of 101.4 g l-1, 81.2 g l-1, and 80.1%, respectively, were obtained in 39 h by high cell density culture of XL1-Blue (pSYL104). The final PHB concentration was lower using XL1-Blue (pSYL103), which suggested that high gene dosage was required for the synthesis and accumulation of PHB to a high concentration in E. coli.

Capillary zone electrophoretic resolution of recombinant human bone morphogenetic protein 2 glycoforms. An investigation into the separation mechanisms for an exquisite separation.

Recombinant human bone morphogenetic protein 2 (rhBMP-2) is a disulfide-linked homodimeric glycoprotein (M(r) = 30,000) which induces bone formation in vivo in several animal model systems. In this paper, we report the separation of a homogeneous rhBMP-2 sample into nine peaks by capillary zone electrophoresis (CZE), using a simple, pH 2.5, phosphate buffer containing no additives. The nine peaks have been identified to be glycoforms of rhBMP-2 [designated as (rhBMP-2)2-(GlcNAc)4(ManZ), where Z varies from 10 to 18]. The difference between any adjacent pair of peaks is only one mannose residue (M(r) = 162). The ability of CZE to resolve rhBMP-2 glycoforms having the same charge and differing only 0.5% in molecular mass, without resorting to chemical complexation, is both unexpected and intriguing. Possible mechanisms explaining how the additional mannose can affect the mobility of rhBMP-2 glycoforms were explored. Zeta potentials of various glycoforms were calculated from their mobilities and interpreted in light of diffuse double layer parameters. Our results suggest that CZE employing a low-pH buffer, where proteins are highly charged, may be uniquely suitable for complex protein glycoform analysis.

Treatment of chronic osteomyelitis of the lower extremities with debridement and microvascular muscle transfer.

Of our 55 patients treated for lower extremity osteomyelitis, 91% underwent debridement and microvascular muscle flap coverage with eradication of their infections and restoration of ambulation. This series of patients helps to solidly establish the efficacy of this approach to the treatment of osteomyelitis.

Tibialis anterior turnover flap coverage of exposed tibia in a severely burned patient.

A case report of a longitudinally split tibialis anterior turnover flap reconstruction of an exposed tibia in a burn patient is presented here. The patient had sustained deep partial- and full-thickness burns to 70 per cent of his total body surface area (TBSA), resulting in an exposed left patella and upper two-thirds of the left tibia. Although full thickness loss of skin occurred on the left lower leg, no muscle trauma was sustained. Reconstruction was therefore deemed possible using local muscle tissue to provide transposed flap coverage. A gastrocnemius muscle flap was used to cover the exposed patella and superior aspect of the tibia. A portion of the tibialis anterior muscle was split longitudinally and turned over medially to cover the remaining exposed tibia. The advantages offered by this infrequently used flap include technical simplicity, reliability, minimal donor site dysfunction and the allowance of future use of the soleus flap. The tibialis anterior turnover flap may therefore have wide applicability for reconstruction of the severely burned lower extremity.

Pulp plasty after toe-to-hand transplantation.

Pulp plasty is a simple procedure that is used to debulk the bulbous-appearing pulp of a transplanted digit after toe-to-hand transplantation. A retrospective review of the effect of pulp plasty on the appearance and function of the debulked digit was conducted of 82 digits on 51 patients. Pulp plasty was performed on average of 14 months after toe-to-hand transplantation; the average follow-up interval was 20 months. Subjective improvement in appearance and function was reported in 67.1 and 63.4 percent, respectively, of the debulked digits. Painful scarring was rare, and hypersensitivity was not reported. Sensation was not affected adversely by pulp plasty. The procedure was considered to be worthwhile in 87.8 percent of the cases. Pulp plasty is a simple and effective procedure after toe-to-hand transplantation that enhances the appearance and function of the transplanted digit. Patient satisfaction with the procedure is high.