Smartphone electrocardiogram for QT interval monitoring in Coronavirus Disease 2019 (COVID-19) patients treated with Hydroxychloroquine.

INTRODUCTION: The global pandemic of Corona Virus Disease 2019 (COVID-19) has led to the re-purposing of medications, such as hydroxychloroquine and lopinavir-ritonavir in the treatment of the earlier phase of COVID-19 before the recognized benefit of steroids and antiviral. We aim to explore the corrected QT (QTc) interval and 'torsadogenic' potential of hydroxychloroquine and lopinavir-ritonavir utilising a combination of smartphone electrocardiogram and 12-lead electrocardiogram monitoring. MATERIALS AND METHODS: Between 16-April-2020 to 30-April- 2020, patients with suspected or confirmed for COVID-19 indicated for in-patient treatment with hydroxychloroquine with or without lopinavir-ritonavir to the Sarawak General Hospital were monitored with KardiaMobile smartphone electrocardiogram (AliveCor®, Mountain View, CA) or standard 12-lead electrocardiogram. The baseline and serial QTc intervals were monitored till the last dose of medications or until the normalization of the QTc interval. RESULTS: Thirty patients were treated with hydroxychloroquine, and 20 (66.7%) patients received a combination of hydroxychloroquine and lopinavir-ritonavir therapy. The maximum QTc interval was significantly prolonged compared to baseline (434.6±28.2msec vs. 458.6±47.1msec, p=0.001). The maximum QTc interval (456.1±45.7msec vs. 464.6±45.2msec, p=0.635) and the delta QTc (32.6±38.5msec vs. 26.3±35.8msec, p=0.658) were not significantly different between patients on hydroxychloroquine or a combination of hydroxychloroquine and lopinavir-ritonavir. Five (16.7%) patients had QTc of 500msec or more. Four (13.3%) patients required discontinuation of hydroxychloroquine and 3 (10.0%) patients required discontinuation of lopinavirritonavir due to QTc prolongation. However, no torsade de pointes was observed. CONCLUSIONS: QTc monitoring using smartphone electrocardiogram was feasible in COVID-19 patients treated with hydroxychloroquine with or without lopinavir-ritonavir. The usage of hydroxychloroquine and lopinavir-ritonavir resulted in QTc prolongation, but no torsade de pointes or arrhythmogenic death was observed.

Multi-disciplinary Psychiatric Case Management Model in Hong Kong: Service Coverage and Risk Stratification.

INTRODUCTION: Community mental health services in Hong Kong follow a multi-disciplinary case management model. We investigated whether at-risk patients received higher intensity care and whether risk stratification concorded between personalised care programmes and integrated community centres of mental wellness. METHODS: Records of all patients in North Lantau and Mongkok districts who received case management services (from personalised care programmes and/or integrated community centres of mental wellness) between 1 April 2014 and 30 June 2015 were reviewed. Patients' levels of risk, demographic data, and clinical characteristics were analysed. RESULTS: Identified at-risk patients received high-intensity care from personalised care programmes and integrated community centres of mental wellness. Case management was coordinated between the Hospital Authority and non-government organisations. However, risk stratification did not correlate with assessment rating scores of psychopathology or psychosocial functioning. Assessment rating scales appear unsuitable to provide any optimal cut-off scores for risk stratification. CONCLUSIONS: Risk stratification should be a structured clinical judgement based on comprehensive and accurate information of protective and risk factors, rather than relying on cut-off scores of assessment rating scales.

Contrasting Some Differences in Managing Advanced Unresectable Hepatocellular Carcinoma Between the East and the West.

Hepatocellular carcinoma (HCC) is a common malignancy worldwide, although its aetiologies vary significantly between the East and the West. About a half of HCC cases present with advanced unresectable HCC at the time of diagnosis, leading to a worse prognosis. Over the past 20 years, the treatment paradigm for advanced unresectable HCC has shifted from an entirely palliative approach to a multidisciplinary treatment, with continuous reassessment and possible repeat treatment attributed to the advent of novel and improved local, regional and systemic therapeutic options, contributed by both the East and the West. An individualised treatment plan should be determined for each patient, as there can be substantial differences in the decision-making and treatment response to the same treatment for different patients and different patient populations. This review provides a summary of the recent advances in management and compares Eastern and Western strategies for HCC.

Hepatitis B Vaccination in Patients Receiving Oral Antiviral Therapy Without Hepatitis B Immunoglobulin After Liver Transplant.

Our study aimed to determine if a double-dose pre-S containing hepatitis B virus (HBV) vaccination (Sci-B-Vac) could elicit an adequate and sustainable immune response in HBV patients who developed spontaneous hepatitis B surface antibody (anti-HBs) response after liver transplant. PATIENTS AND METHODS: All patients who received transplants for HBV-related disease for >1 year with normal graft function and hepatitis B surface antigen seronegativity were evaluated. They received a 40-µg HBV vaccine if they were responders in our previous vaccine trial, if anti-HBs was positive for >1 year after liver transplant (LT), or if a peak anti-HBs at any time point after LT was >100 mIU/mL. Primary endpoint was the development of anti-HBs ≥ 10 mIU/mL from previous negative value or a 1-log increase from baseline. RESULTS: A total of 86 patients were recruited; 5 were responders from a previous trial; 45 patients had detectable anti-HBs >1 year after LT, and 36 patients had an anti-HBs >100 mIU/mL. All (5/5, 100%) previous responders responded to booster vaccination. For the remaining 81 patients, 10 of 81 (12.3%) responded. CONCLUSION: All previous responders responded to booster vaccination, implying durability and memory of HBV immune response, which is an important prerequisite for definitive host immunity for HBV. In patients who had spontaneous anti-HBs production after LT, a single vaccination can induce response in 12.3% of patients.

Geriatric Nutritional Risk Index, a Simplified Nutritional Screening Index, Is a Strong Predictor of Handgrip Strength in Renal Transplant Recipients.

BACKGROUND: The Geriatric Nutritional Risk Index (GNRI) is a useful predictor of prognosis in older patients and those receiving hemodialysis. However, the predictive value of the GNRI in renal transplant recipients (RTRs) is unclear. In this study we investigated the correlation between the GNRI and muscle function, as indicated by handgrip strength (HGS). METHODS: A cross-sectional study was performed on 42 RTRs (50% women), with a mean age of 49.0 ± 10.8 years. The GNRI was derived from patients' body weight and serum albumin level by using the following equation: GNRI = [14.89 × albumin (g/dL)] + [41.7 × (body weight/ideal body weight)]. HGS was evaluated in dominant arms; HGS measurement was repeated 3 times, and the highest value was used. Multivariable stepwise regression analyses were performed to obtain adjusted correlates, and the significance levels for entry and remaining were set at 0.1. RESULTS: The mean values of the GNRI and HGS were 105.0 ± 5.4 and 29.0 ± 9.4, respectively. The GNRI was positively correlated with HGS (r = 0.36, P = .02). Linear and stepwise multivariable adjustment analyses revealed that the homeostatic model assessment of insulin resistance (HOMA-IR) and GNRI were independent determinants of HGS (ßHOMA-IR = 0.53 and ßGNRI = 0.43, adjusted R2 = 0.45) after adjustment for age, sex, total muscle mass, and C-reactive protein level as covariates. CONCLUSION: This study has shown that the GNRI is a favorable predictor of muscle function in RTRs.

Randomized clinical trial of hepatic resection versus radiofrequency ablation for early-stage hepatocellular carcinoma.

BACKGROUND: Hepatic resection and radiofrequency ablation (RFA) are treatment options for early-stage hepatocellular carcinoma (HCC). Whether tumour recurrence and long-term survival favour either treatment has not been established. This randomized trial aimed to test the hypothesis that RFA is superior to hepatic resection in terms of lower tumour recurrence rate and better long-term survival. METHODS: Patients with early-stage HCC (solitary tumour no larger than 5 cm; or no more than 3 tumours, each 3 cm or smaller) were randomized into hepatic resection and RFA groups. Demographic and clinical characteristics, and short- and long-term outcome measures were compared between groups. Primary and secondary outcome measures were overall tumour recurrence and survival respectively. RESULTS: Clinicopathological data were similar in the two groups, which each contained 109 patients. The RFA group had a shorter treatment duration, less blood loss and shorter hospital stay than the resection group. Mortality and morbidity rates were similar in the two groups. The overall tumour recurrence rate was similar in the resection and RFA groups (71·3 versus 81·7 per cent respectively). The 1-, 3-, 5- and 10-year overall survival rates were 94·5, 80·6, 66·5 and 47·6 per cent respectively in the resection group, compared with 95·4, 82·3, 66·4 and 41·8 per cent in the RFA group (P = 0·531). Corresponding disease-free survival rates were 74·1, 50·9, 41·5 and 31·9 per cent in the resection group, and 70·6, 46·6, 33·6 and 18·6 per cent in the RFA group (P = 0·072). CONCLUSION: RFA for early-stage HCC is not superior to hepatic resection, in terms of tumour recurrence, overall survival and disease-free survival. Registration number: HKUCTR-10 (http://www.hkuctr.com).

Reduced sleep duration mediates decreases in striatal D2/D3 receptor availability in cocaine abusers.

Neuroimaging studies have documented reduced striatal dopamine D2/D3 receptor (D2/D3R) availability in cocaine abusers, which has been associated with impaired prefrontal activity and vulnerability for relapse. However, the mechanism(s) underlying the decreases in D2/D3R remain poorly understood. Recent studies have shown that sleep deprivation is associated with a downregulation of striatal D2/D3R in healthy volunteers. As cocaine abusers have disrupted sleep patterns, here we investigated whether reduced sleep duration mediates the relationship between cocaine abuse and low striatal D2/D3R availability. We used positron emission tomography with [(11)C]raclopride to measure striatal D2/D3R availability in 24 active cocaine abusers and 21 matched healthy controls, and interviewed them about their daily sleep patterns. Compared with controls, cocaine abusers had shorter sleep duration, went to bed later and reported longer periods of sleep disturbances. In addition, cocaine abusers had reduced striatal D2/D3R availability. Sleep duration predicted striatal D2/D3R availability and statistically mediated the relationship between cocaine abuse and striatal D2/D3R availability. These findings suggest that impaired sleep patterns contribute to the low striatal D2/D3R availability in cocaine abusers. As sleep impairments are similarly observed in other types of substance abusers (for example, alcohol and methamphetamine), this mechanism may also underlie reductions in D2/D3R availability in these groups. The current findings have clinical implications suggesting that interventions to improve sleep patterns in cocaine abusers undergoing detoxification might be beneficial in improving their clinical outcomes.

Case Report of Relay Liver Transplantation With Graft Infected With Hepatitis B Virus.

Reuse of liver graft for transplantation is extremely uncommon. We report the 1st case of reuse of liver graft from a recipient who had hepatitis B virus (HBV) infection, 11 years after the 1st transplantation. Our relay liver transplantation challenged conventional thinking because of late reuse of graft in the presence of HBV infection. Moreover, both the 1st and the 2nd donors were of advanced age. The key questions were whether the liver graft could be reused safely, especially in the setting of HBV infection, and technical concerns during organ procurement and implantation. The absence of HBV replication was confirmed with negative hepatitis B surface antigen and undetectable serum HBV DNA in the 2nd donor. Based on our experience in managing HBV infection after liver transplantation, we were confident that the adequately suppressed HBV infection in the donor would not jeopardize graft function and that the graft would be able to withstand another ischemia-perfusion injury to continue to function well in our recipient.

Incidence and phenotype of inflammatory bowel disease based on results from the Asia-pacific Crohn's and colitis epidemiology study.

BACKGROUND & AIMS: Inflammatory bowel diseases (IBD) are becoming more common in Asia, but epidemiologic data are lacking. The Asia-Pacific Crohn's and Colitis Epidemiology Study aimed to determine the incidence and phenotype of IBD in 8 countries across Asia and in Australia. METHODS: We performed a prospective, population-based study of IBD incidence in predefined catchment areas, collecting data for 1 year, starting on April 1, 2011. New cases were ascertained from multiple overlapping sources and entered into a Web-based database. Cases were confirmed using standard criteria. Local endoscopy, pathology, and pharmacy records were searched to ensure completeness of case capture. RESULTS: We identified 419 new cases of IBD (232 of ulcerative colitis [UC], 166 of Crohn's disease [CD], and 21 IBD-undetermined). The crude annual overall incidence values per 100,000 individuals were 1.37 for IBD in Asia (95% confidence interval: 1.25-1.51; 0.76 for UC, 0.54 for CD, and 0.07 for IBD-undetermined) and 23.67 in Australia (95% confidence interval: 18.46-29.85; 7.33 for UC, 14.00 for CD, and 2.33 for IBD-undetermined). China had the highest incidence of IBD in Asia (3.44 per 100,000 individuals). The ratios of UC to CD were 2.0 in Asia and 0.5 in Australia. Median time from symptom onset to diagnosis was 5.5 months (interquartile range, 1.4-15 months). Complicated CD (stricturing, penetrating, or perianal disease) was more common in Asia than Australia (52% vs 24%; P = .001), and a family history of IBD was less common in Asia (3% vs 17%; P < .001). CONCLUSIONS: We performed a large-scale population-based study and found that although the incidence of IBD varies throughout Asia, it is still lower than in the West. IBD can be as severe or more severe in Asia than in the West. The emergence of IBD in Asia will result in the need for specific health care resources, and offers a unique opportunity to study etiologic factors in developing nations.

Trigger thumbs in children: results of surgical release.

OBJECTIVE. To evaluate results from surgical release of trigger thumbs in children in a regional hospital cluster in Hong Kong. DESIGN. Descriptive case series. SETTING. A regional hospital cluster, Hong Kong. PATIENTS. Data from 1993 to 2009 on 180 children with 209 trigger thumbs were collected. Analyses into gender, predominance of thumb, age of onset, associated abnormalities and family history, symptoms and signs, surgical outcomes, and postoperative complications were carried out retrospectively. RESULTS. There were 92 girls and 88 boys having trigger thumbs (1.05:1). In all, 29 (16%) of the children presented with bilateral trigger thumbs, while the right thumb was singly involved in 81 (45%) and the left thumb in 70 (39%) of the children. The mean age of onset was 19 months; only 20% were diagnosed before the age of 1 year. Only nine (5%) of the children were associated with congenital diseases and none had a positive family history of trigger thumb. Flexion deformity was the major presenting feature, other than triggering or pain. A nodule and flexion deformity were very commonly observed during physical examination. More than 95% of the operated thumbs with transverse incision acquired a good range of movement with a scarcely apparent scar. A residual flexion deformity was evident in only 4%, mostly in children who underwent surgical release under the age of 1 year. CONCLUSION. Surgical release is recommended for children with trigger thumbs aged more than 1 year, which attains satisfactory results with minimal complications.

Factors affecting mortality in Hong Kong patients with upper limb necrotising fasciitis.

OBJECTIVE: To identify predictive factors for mortality of patients with upper limb necrotising fasciitis. DESIGN: Retrospective study. SETTING: Six hospitals in Hong Kong. PATIENTS: Clinical records of 29 patients treated in the hospitals were traced and analysed. MAIN OUTCOME MEASURES: Possible predictive factors for mortality as evaluated by application of Fisher's test. RESULTS: Overall mortality was 28%. Digital infections conferred a lower mortality, but progressive necrosis necessitated amputation. Vibrio vulnificus was the commonest organism identified in association with marine injury and in patients with cirrhosis. Prognostic indicators with decreasing significance include deranged renal and liver function, thrombocytopaenia, proximal involvement (elbow or above) initially, and presence of hypotension upon admission. CONCLUSION: With a P value of less than 0.05, deranged renal and liver function, thrombocytopaenia, initial proximal involvement, and hypotension on admission were predictors of mortality in necrotising fasciitis affecting the upper limbs. The ALERTS (Abnormal Liver function, Extent of infection, Renal impairment, Thrombocytopenia, and Shock) score with a cutoff of 3 appeared to predict mortality.

Endoscopic carpal tunnel release: experience of surgical outcome in a Chinese population.

OBJECTIVE: To review the outcomes of endoscopic carpal tunnel release in a Hong Kong public hospital and identify any predictive factors. DESIGN: Retrospective study. SETTING: Regional hospital with a hand surgery service, Hong Kong. PATIENTS: Between January 2001 and December 2007, records of 145 patients (160 carpal tunnel syndromes) having endoscopic release were reviewed. Five major symptom domains (pain, numbness, nocturnal awakening, weakness, and clumsiness) before and after the operation were scrutinised. Functional status was assessed by grading key pinch and hand grip, as well as complications. INTERVENTION: Endoscopic carpal tunnel release using the modified Chow's extrabursal technique under intravenous anaesthesia. RESULTS: After the 160 procedures performed, 124 (78%) and 132 (83%) of them revealed improvement in terms of numbness and nocturnal awakening, respectively. Also, there were significant improvements in terms of average functional grading of pinch power and grip power. No serious complications due to the surgery were encountered. CONCLUSIONS: Experience using the Chow's two-portal endoscopic technique for the treatment of carpal tunnel syndrome in the Chinese population was encouraging. It was a safe and effective method for treating carpal tunnel syndrome. We advocate endoscopic surgical intervention for patients with refractory relief of symptoms following conservative management.

Casting versus percutaneous pinning for extra-articular fractures of the distal radius in an elderly Chinese population: a prospective randomised controlled trial.

We carried out a prospective randomised controlled clinical trial to compare the functional and radiological outcomes of casting with percutaneous pinning in treating extra-articular distal radial fracture in an elderly Chinese population. Sixty patients were randomly allocated by sealed envelopes to either a 'Cast' group (n = 30) or a 'K-wire' group (n = 30). All patients were available for final follow-up assessment. The radiological outcomes in terms of dorsal angulation, radial inclination and radial length were statistically significantly better in the K-wire group, whereas the Mayo wrist score and quality of life, healing rate, healing time, and complications were similar. The functional outcomes and quality of life were not affected by the treatments. Both treatments had a very low rate of complication and high healing rates.

Haemodynamic instability secondary to minimally displaced pubic rami fractures: a report of two cases.

We report 2 patients with haemodynamic instability secondary to minimally displaced pubic rami fractures following a fall. Both complained of pain and swelling in the abdomen and groin, and had abdominal distension and bruising in the abdomen, groin, and perineum. All these may be early signs of severe vascular injury and should be treated promptly. Both patients were treated with embolisation of the injured vessels using emergency angiography.