Multicentre study of hospitalised patients with sports- and recreational cycling-related traumatic brain injury in Hong Kong.

INTRODUCTION: Cycling is associated with a greater risk of traumatic brain injury (TBI) than other recreational activities. This study aimed to investigate the epidemiology of sports-related TBI in Hong Kong and to examine predictors for recreational cycling-induced intracranial haemorrhage. METHODS: This retrospective multicentre study included patients diagnosed with sports-related TBI in public hospitals in Hong Kong from 2015 to 2019. Computed tomography scans were reviewed by an independent assessor. The primary endpoint was traumatic intracranial haemorrhage. The secondary endpoint was an unfavourable Glasgow Outcome Scale (GOS) score at discharge from hospital. RESULTS: In total, 720 patients were hospitalised with sports-related TBI. The most common sport was cycling (59.2%). The crude incidence of cycling-related TBI was 1.1 per 100 000 population. Cyclists were more likely to exhibit intracranial haemorrhage and an unfavourable GOS score, compared with patients who had TBI because of other sports. Although 47% of cyclists had intracranial haemorrhage, only 15% wore a helmet. In multivariate analysis, significant predictors for intracranial haemorrhage were age ≥60 years, antiplatelet medication, moderate or severe TBI, and skull fracture. Among 426 cyclists, 375 (88%) had mild TBI, and helmet wearing was protective against intracranial haemorrhage, regardless of age, antiplatelet medication intake, and mechanism of injury. Of 426 cyclists, 31 (7.3%) had unfavourable outcomes on discharge from hospital. CONCLUSIONS: The incidence of sports-related TBI is low in Hong Kong. Although cycling-related head injuries carried greater risks of intracranial haemorrhage and unfavourable outcomes compared with other sports, most cyclists experienced good recovery. Helmet wearing among recreational cyclists with mild TBI was protective against intracranial haemorrhage and skull fracture.

Transnasal penetrating intracranial injury with a chopstick.

We report the first case of a transnasal penetrating intracranial injury in Hong Kong by a chopstick. A 49-year-old man attempted suicide by inserting a wooden chopstick into his left nose and then pulled it out. The chopstick caused a transnasal penetrating brain injury, confirmed by contrast magnetic resonance imaging of the brain. He was managed conservatively. Later he developed meningitis without a brain abscess and was prescribed antibiotics for 6 weeks. He enjoyed a good neurological recovery. This case illustrates that clinician should have a high index of suspicion for penetrating intracranial injury due to a nasally inserted foreign body, even though it had already been removed. In such cases moreover, brain magnetic resonance imaging is the imaging modality of choice, as it can delineate the path of penetration far better than plain computed tomography.

Angioplasty and stenting for intracranial atherosclerotic stenosis: position statement of the Hong Kong Society of Interventional and Therapeutic Neuroradiology.

As a means of preventing secondary ischaemic stroke, angioplasty and stenting are considered potentially beneficial for patients with severe intracranial atherosclerotic stenosis. However, the role of stenting has been challenged since the publication of the first randomised controlled trial on Stenting versus Aggressive Medical Management for Preventing Recurrent stroke in Intracranial arterial Stenosis (SAMMPRIS). This indicated that aggressive medical management was superior to stenting using Wingspan to prevent recurrent stroke, because stenting has a high peri-procedural stroke and death rate. In this paper, we review the management of intracranial atherosclerosis, revisit the skepticism on stenting, and state our position on the topic in the form of recommendations. These are based on the prevalence of the disease in Hong Kong, the high risk of recurrent stroke despite medical therapy in the presence of haemodynamic intracranial stenosis without sufficient collaterals, an analysis of the weak points of SAMMPRIS, and results of clinical studies in Hong Kong.

Universal newborn hearing screening in Singapore: the need, implementation and challenges.

With about 1 in 1000 born with severe to profound hearing loss and about 5 in 1000 with lesser degrees of loss, congenital deafness is the commonest major birth defect. It is the recommended standard that hearing loss in newborns be detected by 3 months of age and intervention implemented by 6 months of age. Delayed detection and intervention may affect speech, language and psychosocial development, resulting in poor academic achievements. Universal newborn hearing screening (UNHS) is the only effective way of detecting all babies with hearing loss, within the recommended time frame. A survey in Singapore revealed that traditional childhood hearing screening programmes resulted in late detection (mean age, 20.8 months; range, 0 to 86 months) and late intervention (mean age, 42.4 months; range, 1 to 120 months). Increasingly, UNHS is becoming standard medical care in developed countries. In Singapore, UNHS has been implemented in all hospitals with obstetric services. Although a screening rate of more than 99% has been achieved in public hospitals, private hospitals have a screening rate of only about 77%. Parents' awareness and acceptance of early detection is still lacking, and this needs to be addressed by appropriate public education. Support from obstetricians and paediatricians will significantly contribute towards this objective. Effective programme management is essential; this includes the use of data management systems, the maintenance of a team of experienced screeners, and efficient coordination between screening and diagnostic services. Early detection of childhood deafness, together with early and effective intervention, maximises the chances of successful integration into mainstream education and society.

Outcome analysis of intraventricular thrombolytic therapy for intraventricular haemorrhage.

OBJECTIVES: To evaluate the outcome of intraventricular thrombolytic therapy for intraventricular haemorrhage and to formulate a safe and effective regimen. DESIGN: Retrospective study. SETTING: Regional neurosurgical centre, Hong Kong. PATIENTS: Twenty-nine consecutive adult patients who presented from November 1995 to November 1998 with non-traumatic intraventricular haemorrhage (Graeb score, > or =7) with no active rebleeding risks from vascular abnormalities. INTERVENTIONS: Fourteen consecutive patients received intraventricular streptokinase via the external ventricular drainage, and 15 consecutive patients received intraventricular urokinase treatment. MAIN OUTCOME MEASURES: Patient demographics, Glasgow coma scale score, Graeb score, mortality rate, shunt rate, fever response, infection rate, catheter blockage rate, and local and systemic bleeding tendency. RESULT: The mean age of the 16 men and 13 women was 59 years (range, 14-76 years). The median Graeb score for cases of intraventricular haemorrhage was 10 (range, 7-12). There was no significant difference in terms of the Graeb score distribution, total dosage, and duration of treatment between the streptokinase and urokinase groups. More cases of fever were observed in the streptokinase group, which could be due to its antigenicity. The infection rate of the central nervous system was 3%, and the shunt rate was 24%. The overall 1-month postoperative mortality was 10%, which was related to a low preoperative Glasgow coma scale score (< or =4). No local rebleeding, systemic coagulopathy, or catheter blockage occurred. CONCLUSIONS: Intraventricular thrombolytic therapy is a safe and effective method of managing intraventricular haemorrhage. We suggest instilling 20 000 units urokinase intra-operatively, followed by 20 000 units daily for about 3 days, except in cases of vascular abnormality, bleeding tendency, and trauma.

Tuberculous meningitis with spinal tuberculous arachnoiditis.

This report is of a 36-year-old woman who initially presented with confusion and fever. Subsequent investigations showed tuberculous meningitis with acute hydrocephalus. Ventriculoperitoneal shunt was performed and anti-tuberculosis therapy was given. The patient was later noticed to have weakness of both lower limbs and urinary retention. Magnetic resonance imaging of the thoracic spine showed radiological features of tuberculous arachnoiditis with cord compression. Decompressive laminectomy was performed and high-dose systemic corticosteroid was given. A high level of awareness is required when diagnosing tuberculous arachnoiditis and the importance of high-dose corticosteroid in the treatment regimen is emphasised.

Brain tuberculoma in Hong Kong.

We report two cases of brain tuberculoma occurring in patients residing in Hong Kong. Both patients presented with headache and had space-occupying lesions evident on computed tomography scans of the brain. The patients had no history of tuberculosis and no symptoms of concurrent extracranial tuberculosis were evident. The diagnosis of tuberculoma was made at the time of surgical excision. Delayed diagnosis of brain tuberculoma is likely to occur in industrialised countries where tuberculosis is rare. In Hong Kong, however, with a constant influx of foreign domestic workers from endemic regions, a high index of suspicion should be maintained. Imaging studies support, but do not confirm, the diagnosis of brain tuberculoma. We recommend obtaining a definitive histological diagnosis, with computed tomography-guided stereotactic biopsy, before starting antituberculous therapy. Surgical excision is necessary in patients with raised intracranial pressure secondary to the lesion, who are not responding to medical therapy.

Odontogenic subperiosteal abscess of orbit: a case report.

Subperiosteal abscess of orbit is an uncommon but serious complication of orbital infection. We report a case of a 78 year old gentleman who presented with bilateral periorbital oedema and proptosis. Computerised tomography of orbit revealed bilateral dilated superior ophthalmic veins. Bilateral carotid-cavernous fistula was initially suspected. Serial imaging showed an increasing bilateral subperiosteal lesion of the orbit. Fine needle aspiration confirmed subperiosteal abscess. A high level of awareness is necessary in diagnosing subperiosteal abscess.

Symptoms of depression in elderly Korean immigrants: narration and the healing process.

This paper explores ways in which depressive symptoms are expressed by elderly Korean immigrants in the USA. Depressed elderly Korean immigrants in the Washington DC area were interviewed in depth to explore their conceptualizations of depression in terms of explanatory models and semantic networks. The expressions of depressive symptoms were influenced by linguistic and psycho-socio-cultural factors, therapeutic behaviors, and efficacy of treatment. The data were interpreted in terms of traditional Korean medical principles, cosmological, socio-cultural, and religious influences, and an individual's family structural changes and acculturation. Findings indicate the construction of somatization among Korean elders is more complex than is generally reported: in most cases, a dynamic, holistic blend of processes appears to operate simultaneously, instead of as somatization in isolation. Informants placed different degrees of emphasis on psychologization or somatization, or the two combined. The roles of personality, value orientation, intellect, emotion, economic status, degree of acculturation, degree of dependence on children, living situation (with or not with children), and self-will or self-confidence are important influences on the depression symptoms in the psychologization-somatization continuum. The more self-directed the informants are, the more they psychologize; the more other-directed, the more they seem to somatize. Names and symptoms of depression (a Western concept) and popular illnesses (traditional Korean concepts) were used interchangeably by the informants. When informants were asked to explain the signs and symptoms of depression and sadness, some described symptoms similar to the criteria of major depression in DSM-III (American Psychiatric Association), while others gave different symptoms and ways of expressing them. Some informants believed that symptoms and signs of depression can be concealed from others if one chooses to do so. Many felt that manifestations of depression can be controlled by willpower, personality, and self-care.

Self-care strategy of elderly Korean immigrants in the Washington DC Metropolitan Area.

The elderly Korean immigrants in the Greater Washington, DC Metropolitan Area use emotional self-care practices to counteract sad and depressive experiences. They tend not to use professional medical help and/or prescription medicine. Their choice of a self-care mental health strategy is a function of several sociocultural and historical factors: the Korean concept of self, life-long caring role, concepts of a morally exemplary emotional life, religious and cosmological beliefs, beliefs about depression and mental illness, systematic and holistic medical principles, political and social upheavals in Korea. Additional factors include the challenge of transition and immigration to a new culture and country, the USA, with its lack of available resources for the immigrants, such as time with their adult children, lower socioeconomic status, language facility, and transportation. Specific self-prescribed self-care strategies for depression include cognitive strategies, religious strategies, physical strategies, social strategies, and artistic strategies.

Prevalence of depression and somatic symptoms among Korean elderly immigrants.

Forty-one Korean immigrants in Washington, D.C. (of the United States) metropolitan area over age 60 were interviewed using the Diagnostic Interview Schedule (Korean version) with additional questions about culture-specific somatic symptoms identified in previous research with Korean populations. The lifetime and current prevalence were 29.27 percent and 14.63 percent, respectively, for major depression; 9.76 percent and 2.44 percent for generalized anxiety disorder; and 9.76 percent and 7.32 percent for somatization disorder. The lifetime and current rates of co-occurrence of major depression and somatization disorder were 25 percent and 33.33 percent. Subjects who met criteria for depression were more likely to experience culture-specific Korean somatic symptoms than subjects who did not meet those criteria.

Hwabyung: the construction of a Korean popular illness among Korean elderly immigrant women in the United States.

The cultural construction of Hwabyung, a Korean culture-bound syndrome, is explored among a sample of 20 elderly Korean immigrant women in the United States. Hwabyung results when distressed emotions associated with the specifically Korean way of perceiving and reacting to intolerable and tragic life situations cause bodily symptoms by interfering with the harmony of "Ki" (vital energy). Korean elderly immigrants report a broad range of symptoms associated with Hwabyung; they less frequently report the epigastric mass, which had been considered the cardinal symptom by cosmopolitan and traditional medical writers. Hwabyung is treated holistically with psychosocial support from family, spiritual comfort, home and popular remedies, traditional Korean medicine, and biomedical treatments. Hwabyung provides a way of conceptualizing and resolving emotional distress through somatization among Korean elderly immigrant women.

The practice of traditional Korean medicine in Washington, D.C.

Therapeutic relationships between Korean immigrants and their hanui, traditional Korean professional physicians, and the role adaptation of these physicians in the United States are discussed. The professional practices of four hanui who work in the Washington, D.C., area are examined through case studies. Research methods included semi-structured interviews, participant observation, key informant interviews, and examination of documentary materials. In hanbang, the traditional Korean medical care system, illness is related to a disturbed state of ki, the cosmological vital energy. Symptoms are often interpreted in terms of a psychosocial base. Pathophysiology is usually illustrated in functional and holistic terms. Treatment modalities include acupuncture, herbal medicines, moxabustion, and cupping. Improvement is evaluated by the quality of pulse, the disappearance of symptoms, restoration of the appetite and of a healthy look and voice, and the return of the ability to function in everyday life. The therapeutic relationship between hanui and their clients is genuine, spontaneous, and harmonious. Clients actively enter into the clinical process by negotiating with hanui about treatment decisions. Hanui practicing in the United States modify their practices to meet their immigrant clients' expectations in relation to the impact of Western biomedicine. They may use some biomedical diagnostic techniques, offer traditional medicines in tablet form, and explain symptoms and treatment with reference to some biomedical terms. Koreans use both hanbang and Western biomedical treatments. However, clients who receive both types of therapy may experience conflicts because of the lack of cooperation between hanui and biomedical physicians.

Structural and functional maturation of rat gastrointestinal barrier with thyroxine.

It has been noted that the closure of the intestinal barrier to immunoglobulins is a normal maturational process in the rat. It has also been noted that the microvillus membrane (MVM) of newborn animals differs from adult MVM. The purpose of this study is to document whether thyroid hormone can induce closure in vivo in the rat and to relate this effect of thyroxine to the structural and functional maturation of the intestinal MVM. To assess closure, 2-wk-old rats were fed a rat immunoglobulin G (IgG), and serum antibody binding activity was measured 4 h later. The antibody binding activity of treated animals (T) was 1.5-2 times less than that of controls (C) (P less than 0.001), indicating that thyroxine stimulates closure. The MVM similarly showed signs of maturation. Structural maturation was demonstrated by the lower fluidity of the thyroid-treated animals' membranes. Under the influence of thyroxine, the number of receptors on the MVM for IgG had decreased [2.8 X 10(-7) M (C) vs. 1.7 X 10(-7) M (T)], while the Ka remained the same, demonstrating the functional maturation of the MVM. In conclusion, thyroid hormone can induce both structural and functional maturation of the intestinal MVM and can enhance the intestinal mucosal barrier by decreasing the penetration of antibodies.

Development of gastrointestinal surface. VIII. Lectin identification of carbohydrate differences.

Binding of microvillus membranes (MVM) from newborn and adult rats by concanavalin A (Con A), Ulex europaeus (UEA I), Dolichos bifluorus (DBA), and Triticum vulgaris (WGA) was examined to determine the availability of carbohydrate-containing sites for these lectins on the intestinal surface during development. Consistent patterns of differences in the reaction of MVM with these lectins were found. Con A and UEA had much higher reactivities to MVM of adult than newborn rats. 125I-labeled-UEA gel overlay experiments revealed the abundance of UEA-binding sites in MVM of adult rat in contrast to the two binding sites in MVM of a newborn rat. DBA bound only to MVM of the adults, and very few binding sites were found in immature MVM. In contrast to these lectins, WGA binding was much higher in MVM of the newborns and decreased with maturation. Additional experiments on the age dependence of UEA and DBA reactivities revealed that the most striking changes occur in animals from 2 to 4 wk of age. In MVM from 2-wk-old rats, there were only 13.9% and less than 0.2% of the adult binding capacities for UEA and DBA, respectively. By the time the animals were 4 wk old, the binding capacity for UEA had attained close to the level of the adults, whereas for DBA it reached 71.3% of the adult value. These results provide definite evidence of changes in the intestinal surface during perinatal development.

Development of gastrointestinal mucosal barrier. VII. In utero maturation of microvillus surface by cortisone.

When studying mucosal barrier function of developing animals, we noted that intestinal microvillus membranes (MVM) of newborn animals differ in their fluidity and binding characteristics to lectins compared with adult MVM. To further investigate these differences and determine whether maturation of the microvillus surface could be accelerated in utero, pregnant rats were given intraperitoneal cortisone beginning on the 17th day of gestation. Control and cortisone-treated animals were allowed to deliver normally, and the small intestines from newborns were used to isolate MVM. Microvillus membrane surface characteristics were evaluated by employing an 125I-labeled fucose-specific lectin, Ulex europeus (UEA). Changes in MVM proteins were monitored by disaccharidase activities and sodium dodecyl sulfate-polyacrylamide electrophoresis. MVM fluidity was accessed using a 5-doxyl stearic acid label and electron-spin-resonance spectroscopy. Results from these studies indicate that the birth weights of newborn rats exposed to cortisone in utero were significantly reduced; sucrase activity was prematurely induced and specific activities of lactase and maltase were enhanced in the intestines of the cortisone-treated newborns as contrasted with control animals. Furthermore, binding of 125I-UEA to MVM was greatly increased in treated animals. MVM fluidity decreased (P less than 0.001) compared with control animals and resembled the structural characteristics of more mature MVM. These results suggest that cortisone exposure in utero accelerate maturation of the microvillus surface of enterocytes.

The effect of short-term starvation on mucosal barrier function in the newborn rabbit.

The compromised human newborn frequently presents with overwhelming feeding problems which lead to inadequate intake. These problems may affect the development of the small intestine, especially mucosal barrier function, leading to increased infections and susceptibility to allergens. To study this, an animal model was established using neonatal rabbits deprived of nutrients from birth until 72 h. Mucosal barrier function was compared in deprived and control (naturally fed 72-h-old animals) rabbits by measuring immunoreactive bovine serum albumin in serum 4 h after intragastric infusion of crystalline bovine serum albumin (200 mg/100 g body weight). Trypsin activity was measured in rinse fluid obtained from the small intestine. Representative sections of jejunum from control and experimental animals were formalin fixed and stained with hematoxylin and eosin for morphologic comparison. Following the bovine serum albumin feeding, a significantly increased serum immunoreactive bovine serum albumin and significantly decreased trypsin-like activity of the small intestinal rinse fluid was noted in starved animals compared to controls. In addition, the enterocytes of malnourished animals were more cuboidal and contained fewer and smaller supranuclear granules on microscopic examination than the enterocytes of controls. This study suggests that short-term starvation in newborns affects mucosal barrier function. Acute starvation may place newborns at increased risk for infections and allergic disease.