Incidence and progression of diabetic retinopathy in Hong Kong Chinese with type 2 diabetes mellitus.

OBJECTIVE: We conducted a cohort study to determine the incidence and progression of diabetic retinopathy (DR) in a Chinese population with type 2 diabetes mellitus in a district hospital in Hong Kong, and to identify the risk factors associated with the development and progression of DR over 4 years. RESEARCH DESIGN AND METHODS: A total of 413 type 2 diabetic patients who followed up in our diabetic clinic and had a diabetic complication screening performed in 2001 were studied. The final analysis included 354 subjects (85.7%) after a mean follow-up period of 4.2 years. The severity of DR was graded according to the modified Early Treatment Diabetic Retinopathy Study (ETDRS). The relationship between clinical variables and DR development and progression was determined. RESULTS: The baseline prevalence of DR was 39.2%. On 4-year follow-up, the incidence of DR was 20.3% (43 of 212). In those with baseline DR, 34.7% (42 of 121) progressed by >or=2 steps in ETDRS. On multivariate analysis, a high baseline glycosylated hemoglobin (HbA(1c)) was the only predictor of DR development, while macroalbuminuria and high mean HbA(1c) predicted progression. Regression of DR, defined by a >or=2-step decrement in ETDRS, occurred in 13.2% (12 of 91) of subjects and was associated with lower baseline HbA(1c) and absence of albuminuria. CONCLUSION: The incidence of DR in our study was similar to--but progression of DR was higher than--those reported in Caucasians. More frequent retinal screening should be offered to those with baseline DR, high HbA(1c), or albuminuria. Good glycemic control is important in order to prevent the development and progression of DR, and can lead to regression of DR.

Multiple eyelid defects in cutaneous Langerhans cell histiocytosis.

Langerhans cell histiocytosis is a disorder characterized by the proliferation of histiocytes of the mononuclear phagocyte system. Cutaneous Langerhans cell histiocytosis can develop as a solitary lesion or more frequently as part of a multisystem disease. This report describes a case of cutaneous Langerhans cell histiocytosis affecting the eyelids, resulting in a coloboma-like defect. The clinical features and management are discussed.

Evaluation of scanning resolution on retinal nerve fiber layer measurement using optical coherence tomography in normal and glaucomatous eyes.

PURPOSE: To evaluate the effect of varying the scanning resolution of optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) measurement on diagnostic sensitivity and functional correlation in glaucoma. PATIENTS AND METHODS: 314 eyes from 182 subjects including 107 normal eyes, 83 glaucoma suspect eyes, and 124 glaucoma eyes were included in this cross-sectional study. Standard automated perimetry and OCT measurement of RNFL thickness were performed. Each individual underwent two scanning protocols: (1) fast RNFL thickness (3.4) scan (with resolution of 256 scan points) and (2) RNFL thickness (3.4) scan (with resolution of 512 scan points). RNFL thickness was compared among the groups. Diagnostic sensitivity was evaluated with Receiver Operating Characteristic (ROC) Curve. Relationship between RNFL thickness and visual field mean deviation was examined using linear regression analysis. RESULTS: Measured RNFL thickness using fast RNFL thickness (3.4) scan was significantly higher compared with RNFL thickness (3.4) scan in average, superior, nasal and inferior RNFL in all diagnostic groups. Comparing normal and glaucoma groups, RNFL thickness (3.4) scan produced the largest area under the ROC curve (0.912) based on average RNFL thickness. A stronger correlation between average RNFL and visual field mean deviation was found in RNFL thickness (3.4) scan (R = 0.75, R = 0.56). CONCLUSIONS: Higher resolution RNFL scan provides better diagnostic sensitivity in glaucoma detection and a stronger correlation with visual function.

Modified lateral orbitotomy for intact removal of orbital dumbbell dermoid cyst.

: We describe a modified lateral orbitotomy for intact removal of a dumbbell dermoid cyst involving the frontozygomatic suture. The clinical features and surgical treatment of the case are discussed.

Septic metastatic endophthalmitis complicating Klebsiella pneumoniae liver abscess in a non-diabetic Chinese man.

Septic metastatic endophthalmitis is a rare but serious disease. Endophthalmitis arising from Klebsiella pneumoniae liver abscess has been reported with diabetes mellitus as a major associated condition, but is rarely seen in patients without diabetes. A non-diabetic patient with liver abscess complained of right eye discomfort and floaters 3 days after admission. Both blood and liver aspirate cultured Klebsiella pneumoniae. The patient was treated initially with systemic and subconjunctival antibiotics followed by intravitreal antibiotics with successful visual salvation. Previous reports from the literature showed poor visual outcome despite treatment and delayed recognition was often the cause. Clinicians should be alert to endophthalmitis whenever a patient with Klebsiella pneumoniae liver abscess complains of ocular symptoms. Urgent ophthalmological assessment should be sought.

Pilot study of in-situ thermal treatment for the remediation of pentachlorophenol-contaminated aquifers.

A field pilot study of a steam injection method for the treatment of pentachlorophenol (PCP)-contaminated soil and groundwater has shown potential advantages over the traditional pump-and-treatment method. Low-pressure steam was injected 10 m below the ground surface. The ground water temperature was raised to 118 degrees C over a period of 3 months. Five soil and groundwater sampling events were performed during the pilot test. Results of sample analysis showed that the PCP concentrations in deep aquifer soil decreased dramatically whereas those in shallow aquifer soil increased. It was concluded that raising the groundwater temperature caused PCP in deep aquifer soil to be desorbed, and as the hot, deep groundwater circulated upward, it brought the desorbed PCP to the shallow aquifer. By using steam injection, PCP can be desorbed from soil and moved upward to the ground surface so that it can be removed more easily through pump-and-treatment.

A prospective study of elective stenting in unprotected left main coronary disease.

The standard treatment of left main coronary artery (LMCA) disease has been bypass surgery (CABG). Recent reports suggested that stenting of LMCA disease might be feasible. From January 1995 to April 1998, we carried out a prospective study of elective stenting of unprotected LMCA disease to evaluate its immediate and long-term results. Of 61 consecutive patients with unprotected LMCA disease, 6 were excluded. Acute procedural success was 100% for the remaining 55 patients, without any complications such as stent thrombosis, myocardial infarction, CABG, or death. During a mean follow-up of 16.1+/-9.6 months, 11 patients (20%) had symptomatic recurrence, between 2 to 6 months after their procedure. Seven patients underwent CABG, two had repeat intervention, one continued with medical therapy, and one died before planned angiography. There was no late sudden death. Forty-four patients (80%) remained asymptomatic. We conclude that elective stenting may be a safe alternative to CABG in unprotected LMCA disease.

Adrenal extramedullary haemopoiesis: diagnosis by a non-invasive method.

Bilateral adrenal masses were discovered incidentally in a patient with beta-thalassaemia intermedia. Endocrine investigations showed that the adrenal lesion was hormonally inactive. Extramedullary haemopoiesis involving the adrenal glands was suggested by the presence of reticuloendothelial tissue as demonstrated by bone marrow scintigraphy using Technetium Tc-99m nanocolloid. This report illustrates the use of non-invasive functional imaging techniques in the management of adrenal 'incidentalomas', which in this case turned out to be a rare presentation of extramedullary haemopoiesis.

High performance liquid chromatographic analysis of a novel aminoalkylpyridine anticonvulsant 2-(4-chlorophenyl)amino-2-(4-pyridyl)ethane.

A simple, rapid and specific high performance liquid chromatographic (HPLC) method for the quantitation of 2-(4-chlorophenyl)amino-2-(4-pyridyl)ethane (AAP-Cl) and identification of its putative metabolite, 2-(4-chlorophenyl)amino-2-(4-pyridyl)ethanol (beta-AA) in rat blood and urine has been developed. AAP-Cl, beta-AA and an appropriate internal standard were extracted from rat biofluids by a solid phase extraction technique using C18 cartridges prior to the HPLC analysis. The extractibility was 92% for AAP-Cl and 98% for beta-AA. The HPLC analysis employed a symmetrical or standard reversed-phase HPLC column (Apex ODS, 5 microm, 25 cm x 0.46 cm) for blood or urine analysis, a mobile phase of water methanol acetonitrile (40:30:30) containing 20 microl 100 ml(-1) diethylamine at a flow rate of 1 ml min(-1), and UV detection at 254 nm. The limit of detection was 100 ng ml(-1) for both analytes in both blood and urine. The calibration curves for AAP-Cl in rat biofluids were shown to be linear in both low and high concentration ranges (blood: 0-1 and 1-10 microg ml(-1); urine: 0-10 and 10-100 microg ml(-1)) with intra- and inter-day coefficients of variation of no more than 18% for blood and 14% for urine. The method developed was successfully applied to a preliminary analysis of intact AAP-Cl in both blood and urine obtained from rats dosed with AAP-Cl.

Endothelium-dependent dilation of the coronary arteries in syndrome X: effects of the cold pressor test.

The coronary flow reserve is abnormal in syndrome X, but the response to the cold pressor test, which in normals produces flow-mediated endothelium-dependent epicardial coronary dilation, has not been studied. In this study, in 12 patients with typical syndrome X and angiographically normal coronary arteries, the response to the cold pressor test was abnormal with a mean fall in diameter (10 +/- 8%) in 6 patients, no change in 1, and a minimal increase (4 +/- 2%) in 5 patients (normal increase 12 +/- 1%). The coronary blood flow fell slightly during the cold pressor test, and the coronary vascular resistance increased significantly (from 2.4 +/- 1.1 to 3.2 +/- 1.7 mm Hg/cm.s-1.mm2; p = 0.05), both abnormal responses. This study confirms that in syndrome X patients there is coronary endothelial dysfunction which is apparent in response to physiological stimuli induced by the cold pressor test.

Effects of soup preloads on gastric emptying and fullness ratings following an egg sandwich meal.

To identify the source of inhibitory signals from the stomach or intestine that lead to satiation, the effects of 300-g tomato soup preloads on the gastric emptying of a solid meal and on hunger and fullness ratings were examined. Subjects were nine healthy women who each ingested an egg sandwich: 1) with no soup, 2) immediately after the soup, and 3) 20 min after the soup. Emptying of the sandwich was measured using radionuclide scintigraphy. Soup significantly prolonged the lag phase (period before significant emptying occurred, p < 0.05), and the half-emptying time (p < 0.01) of the sandwich, but only when ingested immediately before the sandwich. Thus, soup affected the emptying of the sandwich when the volume of soup in the stomach was at a maximum. Passage of soup into the duodenum over a 20-min period had no effect on emptying of the sandwich. Despite the different gastric/postgastric distributions of the soup and the sandwich in the two preload conditions, fullness ratings were not different.

Cholescintigraphy in the diagnosis of acute cholecystitis: morphine augmentation is superior to delayed imaging.

Morphine-augmented radionuclide hepatobiliary imaging has been used as an alternative to delayed imaging for the diagnosis of acute cholecystitis. Previous studies have indicated that the morphine-augmentation is as useful as, or more useful than, delayed imaging. A careful comparison of the efficacy of the two techniques appears warranted because: (1) most early studies did not compare the efficacy of the two techniques in a single report using comparable patient populations; (2) the reported efficacy of morphine-augmentation is based primarily on study designs which excluded cases of early gallbladder visualization without morphine, while most delayed imaging protocols included these cases; and (3) there were concerns about the potential consequences of a false-negative morphine examination. This study compared the efficacy of morphine-augmentation with delayed imaging in those cases in which the gallbladder was not visualized during the first hour of study. Of 306 consecutive patients who were scanned to rule out acute cholecystitis, the gallbladder was visualized within 1 hr in 215 cases. In the remaining 91 cases, 46 patients had delayed imaging (17 true-positive, 10 true-negative, 19 false-positive and 0 false-negative), and 45 had morphine-augmentation (24 true-positive, 15 true-negative, 4 false-positive and 2 false-negative). The data indicate that delayed imaging has a significantly lower specificity and positive-predictive value for acute cholecystitis than morphine-augmentation and a slightly higher (statistically insignificant) sensitivity and negative-predictive value. These results appear to be supported by a reanalysis of the data that has already been reported in the literature.

Percutaneous treatment of post catheterization massive retroperitoneal hemorrhage.

We describe a patient on anticoagulant therapy with massive retroperitoneal and intraperitoneal bleeding complicating femoral catheterization. Balloon tamponade of the actively bleeding femoral artery was effective in sealing off the leakage after failed surgical exploration.

The impact of thrombolytic therapy on hospital mortality from acute myocardial infarction in the Chinese in Hong Kong.

Thrombolytic therapy using recombinant-tissue plasminogen activator, urokinase and streptokinase for acute myocardial infarction was instituted in the coronary care unit of the Prince of Wales Hospital in Hong Kong in 1988. To evaluate its impact on hospital mortality of acute myocardial infarction, the database of 465 patients (mean age 65.2 +/- 12.6 yr) admitted into the coronary care unit in the period between 1985-1990 was collected prospectively and their clinical course reviewed. Three hundred and thirty-five patients were males and 130 were females. Patients in the prethrombolytic era (1985-87) and the thrombolytic era (1988-90) were matched for age, proportion of females and clinical severity. One hundred and two patients (39.5%) received thrombolytic therapy. The overall hospital mortality (18.6%) in the thrombolytic era and that for each sex (18.2% in the males; 19.5% in the females) were significantly lower than those of prethrombolytic era (27.1%, 23.4% and 37.7%, respectively). No death was due to bleeding complication. The benefit of thrombolytic therapies in the Chinese was confirmed. More effort is needed to popularize this concept in the Chinese communities, to shorten the prehospital delay of patients and to extend its utilisation to the elderly patients.

Recombinant tissue plasminogen activator in acute myocardial infarction in the Chinese in Hong Kong.

Eighty-nine consecutive Chinese patients (69 males, 20 females) with acute myocardial infarction treated by 100 mg recombinant tissue plasminogen activator (7 intracoronarily, 82 intravenously) at 3.7 +/- 1.0 h after onset, and intravenous heparin or dipyridamole therapy started at 3 h, were studied prospectively. Their mean age was 59.6 +/- 10.6 yr. Forty-six patients (51.7%) had anterior and 39 patients (43.8%) had inferior infarcts. Clinical evidence of reperfusion were seen in 63 patients (70.8%), while new complications included hypotension (5.6%), heart failure (6.7%), cardiac arrhythmias (76.4%) majority of which are related to reperfusion and self-remitting, haematoma around vascular access sites (23.6%), melaena (3.3%) and cerebral infarction (2.2%). Maximal changes in coagulation profiles were seen at 3 h, including a decrease in fibrinogen by 64.2% and an increase in fibrin degradation products by 47 times. The changes in haemostatic variables were not related to body weight or bleeding complications. Nine patients (10.1%) had recurrence of angina and 6 patients (6.9%) died due to pump failure and reinfarction. Angiogram at 14 days confirmed TIMI 2 or 3 patency of infarct-related arteries in 63 out of 73 (86.3%) patients, with a mean global ejection fraction of 52.5 +/- 12.4%. Nearly all survivors could maintain class I-II functional status after discharge. The safety and promise of recombinant tissue plasminogen activator for acute myocardial infarction in the Chinese were confirmed.

Recombinant tissue-plasminogen activator (rt-PA) in acute myocardial infarction in the Chinese in Hong Kong.

Eighty-nine consecutive Chinese patients (69 males, 20 females) with acute myocardial infarction treated by 100 mg recombinant tissue-plasminogen activator (rt-PA) (7 intracoronarily, 82 intravenously) at 3.7 +/- 1.0 hours after onset, and intravenous heparin or dipyridamole therapy started at 3 hours, were studied prospectively. Their mean age was 59.6 +/- 10.6 years. Forty-six patients (51.7%) had anterior and 39 patients (43.8%) had inferior infarcts. Clinical evidence of reperfusion was seen in 63 patients (72.8%), while new complications included hypotension (5.6%), heart failure (6.7%), cardiac arrhythmias (76.4%), hematoma around vascular access sites (23.6%), melena (2.2%) and cerebral infarction (2.2%). Maximal changes in coagulation profiles were seen at 3 hours, including a decrease in fibrinogen (by 64.2%), an increase in FDP by 11.7 times and D-dimers by 4.4 times. Nine patients (10.1%) had recurrence of angina and 6 patients (6.9%) died due to pump failure (5) and reinfarction (1). Angiogram at 14 days confirmed TIMI (2 or 3) patency of infarct related arteries in 62/81 (76.5%) patients, with a mean global ejection fraction of 52.5 +/- 12.4%. Nearly all survivors could maintain class I-II functional status after discharge. The safety and promises of rt-PA for acute myocardial infarction in the Chinese were confirmed.

Infective endocarditis caused by Streptococcus suis serotype 2.

Infective endocarditis caused by Streptococcus suis serotype 2 is not uncommon in pigs but is rare in human beings. We describe the case of a pig-farmer with endocarditis due to S. suis serotype 2 and in whom prolapse of the mitral valve was the predisposing cardiac lesion. Streptococcus suis, a possible cause of infective endocarditis in endemic areas, may be confused with other group D streptococci. In suspected cases a history of contact with pigs or raw pork should be sought.