End-of-life practices in Hong Kong intensive care units: results from the Ethicus-2 study.

INTRODUCTION: The need for end-of-life care is common in intensive care units (ICUs). Although guidelines exist, little is known about actual end-of-life care practices in Hong Kong ICUs. The study aim was to provide a detailed description of these practices. METHODS: This prospective, multicentre observational sub-analysis of the Ethicus-2 study explored end-of-life practices in eight participating Hong Kong ICUs. Consecutive adult ICU patients admitted during a 6-month period with life-sustaining treatment (LST) limitation or death were included. Follow-up continued until death or 2 months from the initial decision to limit LST. RESULTS: Of 4922 screened patients, 548 (11.1%) had LST limitation (withholding or withdrawal) or died (failed cardiopulmonary resuscitation/brain death). Life-sustaining treatment limitation occurred in 455 (83.0%) patients: 353 (77.6%) had decisions to withhold LST and 102 (22.4%) had decisions to withdraw LST. Of those who died without LST limitation, 80 (86.0%) had failed cardiopulmonary resuscitation and 13 (14.0%) were declared brain dead. Discussions of LST limitation were initiated by ICU physicians in most (86.2%) cases. Shared decision-making between ICU physicians and families was the predominant model; only 6.0% of patients retained decision-making capacity. Primary medical reasons for LST limitation were unresponsiveness to maximal therapy (49.2%) and multiorgan failure (17.1%). The most important consideration for decision-making was the patient's best interest (81.5%). CONCLUSION: Life-sustaining treatment limitations are common in Hong Kong ICUs; shared decision-making between physicians and families in the patient's best interest is the predominant model. Loss of decision-making capacity is common at the end of life. Patients should be encouraged to communicate end-of-life treatment preferences to family members/surrogates, or through advance directives.

Breast-to-brain metastasis is exacerbated with chemotherapy through blood-cerebrospinal fluid barrier and induces Alzheimer's-like pathology.

Control of breast-to-brain metastasis remains an urgent unmet clinical need. While chemotherapies are essential in reducing systemic tumor burden, they have been shown to promote non-brain metastatic invasiveness and drug-driven neurocognitive deficits through the formation of neurofibrillary tangles (NFT), independently. Now, in this study, we investigated the effect of chemotherapy on brain metastatic progression and promoting tumor-mediated NFT. Results show chemotherapies increase brain-barrier permeability and facilitate enhanced tumor infiltration, particularly through the blood-cerebrospinal fluid barrier (BCSFB). This is attributed to increased expression of matrix metalloproteinase 9 (MMP9) which, in turn, mediates loss of Claudin-6 within the choroid plexus cells of the BCSFB. Importantly, increased MMP9 activity in the choroid epithelium following chemotherapy results in cleavage and release of Tau from breast cancer cells. This cleaved Tau forms tumor-derived NFT that further destabilize the BCSFB. Our results underline for the first time the importance of the BCSFB as a vulnerable point of entry for brain-seeking tumor cells post-chemotherapy and indicate that tumor cells themselves contribute to Alzheimer's-like tauopathy.

Admission triage tool for adult intensive care unit admission in Hong Kong during the COVID-19 outbreak.

Intensive care is expensive, and the numbers of intensive care unit (ICU) beds and trained specialist medical staff able to provide services in Hong Kong are limited. The most recent increase in coronavirus disease 2019 (COVID-19) infections over July to August 2020 resulted in more than 100 new cases per day for a prolonged period. The increased numbers of critically ill patients requiring ICU admission posed a capacity challenge to ICUs across the territory, and it may be reasonably anticipated that should a substantially larger outbreak occur, ICU services will be overwhelmed. Therefore, a transparent and fair prioritisation process for decisions regarding patient ICU admission is urgently required. This triage tool is built on the foundation of the existing guidelines and framework for admission, discharge, and triage that inform routine clinical practice in Hospital Authority ICUs, with the aim of achieving the greatest benefit for the greatest number of patients from the available ICU resources. This COVID-19 Crisis Triage Tool is expected to provide structured guidance to frontline doctors on how to make triage decisions should ICU resources become overwhelmed by patients requiring ICU care, particularly during the current COVID-19 pandemic. The triage tool takes the form of a detailed decision aid algorithm based on a combination of established prognostic scores, and it should increase objectivity and transparency in triage decision making and enhance decision-making consistency between doctors within and across ICUs in Hong Kong. However, it remains an aid rather than a complete substitute for the carefully considered judgement of an experienced intensive care clinician.

Nonclinical Characterization of the Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitor Roxadustat, a Novel Treatment of Anemia of Chronic Kidney Disease.

Anemia of chronic kidney disease (CKD) is a multifactorial disorder caused by impaired erythropoietin (EPO) production and altered iron homeostasis associated with inflammation. Hypoxia-inducible factor (HIF) is a transcription factor that stimulates erythropoiesis via a coordinated response involving increased EPO production and enhanced iron availability for Hb synthesis. HIF degradation is regulated by HIF-prolyl hydroxylase (HIF-PH) enzymes. We hypothesized that roxadustat, an orally available small-molecule inhibitor of HIF-PH, would increase EPO production and promote erythropoiesis in animal models of anemia. In cells, roxadustat increased both HIF-1α and HIF-2α proteins, leading to an increase in EPO production, even in the presence of EPO-suppressing inflammatory cytokines. Roxadustat administered intermittently to healthy rats and cynomolgus monkeys increased circulating EPO levels, reticulocytes, blood Hb, and hematocrit in a dose-dependent manner. Roxadustat corrected anemia in a rat model of CKD after five-sixth nephrectomy and in a rat model of anemia of inflammation with impaired iron metabolism induced by peptidoglycan-polysaccharide (PG-PS). In the PG-PS model, roxadustat significantly decreased hepatic expression of hepcidin, a hormone responsible for iron sequestration and functional iron deficiency, and increased expression of two genes involved in duodenal iron absorption: divalent metal transporter 1 and duodenal cytochrome b. In conclusion, by activating the HIF pathway, roxadustat increased EPO production, elevated Hb, corrected anemia, and improved iron homeostasis. The coordinated erythropoietic response stimulated by roxadustat, involving both EPO production and mobilization of iron stores, makes this compound a promising treatment of anemia of CKD and anemia associated with functional iron deficiency. SIGNIFICANCE STATEMENT: Roxadustat is a novel orally available small-molecule inhibitor of HIF prolyl hydroxylase enzymes that reversibly stabilizes HIF-α, thus activating transcription of HIF-dependent genes, including EPO and regulators of iron homeostasis. Activation of the HIF pathway by roxadustat induces erythropoiesis in healthy rats and monkeys and corrects experimentally induced anemia in rats. The coordinated erythropoietic response that increases EPO production and mobilizes iron stores makes roxadustat a promising treatment for anemia of chronic kidney disease and anemia associated with functional iron deficiency.

Guidance on the management of familial hypercholesterolaemia in Hong Kong: an expert panel consensus viewpoin.

In 2016, meetings of groups of physicians and paediatricians with a special interest in lipid disorders and familial hypercholesterolaemia were held to discuss several domains of management of familial hypercholesterolaemia in adults and children in Hong Kong. After reviewing the evidence and guidelines for the diagnosis, screening, and management of familial hypercholesterolaemia, consensus was reached on the following aspects: clinical features, diagnostic criteria, screening in adults, screening in children, management in relation to target plasma low-density lipoprotein cholesterol levels, detection of atherosclerosis, lifestyle and behaviour modification, and pharmacotherapy.

Radiofrequency ablation compared with laparoscopic adrenalectomy for aldosterone-producing adenoma.

BACKGROUND: Radiofrequency ablation (RFA) is an emerging treatment for primary aldosteronism owing to aldosterone-producing adenoma. Whether RFA could be an alternative treatment to laparoscopic adrenalectomy is unknown. METHODS: This was a retrospective comparative study in patients with aldosterone-producing adenoma undergoing either laparoscopic adrenalectomy or CT-guided percutaneous RFA between 2004 and 2012. Short-term outcomes and long-term resolution rates of primary aldosteronism (normalized aldosterone to renin ratio), hypokalaemia and hypertension (BP lower than 140/90 mmHg without antihypertensive medical therapy) were evaluated. RESULTS: Some 63 patients were included, 27 in the laparoscopic adrenalectomy group and 36 in the RFA group. RFA was associated with shorter duration of operation (median 12 versus 124 min; P < 0·001), shorter hospital stay (2 versus 4 days; P < 0·001), lower analgesic requirements (13 of 36 versus 23 of 27 patients; P < 0·001) and earlier resumption of work (median 4 versus 14 days; P = 0·006). Morbidity rates were similar in the two groups. With median follow-up of 5·7 (range 1·9-10·6) years, resolution of primary aldosteronism was seen in 33 of 36 patients treated with RFA and all 27 patients who had laparoscopic adrenalectomy (P = 0·180). Hypertension was resolved less frequently after treatment with RFA compared with laparoscopic adrenalectomy (13 of 36 versus 19 of 27 patients; P = 0·007). Hypokalaemia was resolved in all patients. CONCLUSION: For patients with aldosterone-producing adenoma the efficacy of resolution of primary aldosteronism and hypertension was inferior after treatment with RFA compared with laparoscopic adrenalectomy.

Comparative efficacy, safety, and cardiovascular outcomes with once-weekly subcutaneous semaglutide in the treatment of type 2 diabetes: Insights from the SUSTAIN 1-7 trials.

In individuals with type 2 diabetes, glycaemic control and cardiovascular risk factor management reduces the likelihood of late-stage diabetic complications. Guidelines recommend treatment goals targeting HbA1c, body weight, blood pressure, and low-density lipoprotein cholesterol. Development of new treatments for type 2 diabetes requires an understanding of their mechanism and efficacy, as well as their relative effects compared to other treatment choices, plus demonstration of cardiovascular safety. Subcutaneous semaglutide is a glucagon-like peptide-1 receptor agonist currently approved in several countries for once-weekly treatment of type 2 diabetes. Semaglutide works via the incretin pathway, stimulating insulin and inhibiting glucagon secretion from the pancreatic islets, leading to lower blood glucose levels. Semaglutide also decreases energy intake by reducing appetite and food cravings, and lowering relative preference for fatty, energy-dense foods. Semaglutide was evaluated in the SUSTAIN clinical trial programme in over 8000 patients across the spectrum of type 2 diabetes. This review details the efficacy and safety profile of semaglutide in the SUSTAIN 1-5 and 7 trials, and its cardiovascular safety profile in the SUSTAIN 6 trial. Semaglutide consistently demonstrated superior and sustained glycemic control and weight loss vs. all comparators evaluated. In SUSTAIN 6, involving patients at high risk of cardiovascular disease, semaglutide significantly decreased the occurrence of cardiovascular events compared with placebo/standard of care (hazard ratio 0.74, P < 0.001 for non-inferiority). Through a comprehensive phase 3 clinical trial program, we have a detailed understanding of semaglutide's efficacy, safety, cardiovascular effects and comparative role in the treatment of type 2 diabetes.

Posttraumatic Stress after Treatment in an Intensive Care Unit.

OBJECTIVE: To study posttraumatic stress in patients after treatment in an intensive care unit (ICU). METHODS: This prospective cohort study included 136 adult patients with critical medical and surgical problems who were discharged from the ICU of the Caritas Medical Centre, Hong Kong. Their occurrence of posttraumatic stress disorder (PTSD), anxiety, and depression after ICU treatment were measured using the Impact of Event Scale-Revised and Hospital Anxiety and Depression Scale. Patient ICU experience was measured using the ICU Memory Tool. Multivariable analyses were conducted to examine the predictors of PTSD symptoms, anxiety, and depression. RESULTS: Symptoms of PTSD, anxiety, and depression were reported in 10% to 17% of patients. Symptom severity was associated with less factual memory, more vivid memory of feelings about and more delusional memory of the ICU experience, low emotional support, and high perceived life threat. CONCLUSIONS: Symptoms of posttraumatic stress, anxiety, and depression may occur after ICU treatment. Early identification and appropriate intervention for PTSD are important for rehabilitation.

Hospital waste generation during an outbreak of severe acute respiratory syndrome in Taiwan.

During the SARS outbreak in Taiwan, the number of ambulatory patients and inpatients treated at one medical center decreased by 40%-70% because of the increasing number of SARS patients. At the peak of the epidemic, the amount of hospital infectious waste had increased from a norm of 0.85 kg per patient-day to 2.7 kg per patient-day. However, the hospital was able to return the generation of waste to normal levels within 10 days.

Memory is relevant in the symmetric phase of the minority game.

Minority game is a simple-mined econophysical model capturing the cooperative behavior among selfish players. Previous investigations, which were based on numerical simulations up to about 100 players for a certain parameter alpha in the range 0.1 < approximately alpha < approximately 1, suggested that memory is irrelevant to the cooperative behavior of the minority game in the so-called symmetric phase. Here using a large scale numerical simulation up to about 3000 players in the parameter range 0.01 < approximately alpha < approximately 1, we show that the mean variance of the attendance in the minority game actually depends on the memory in the symmetric phase. We explain such dependence in the framework of crowd-anticrowd theory. Our findings conclude that one should not overlook the feedback mechanism buried under the correlation in the history time series in the study of minority game.

Laparoscopic adjustable gastric banding for the treatment of morbidly obese patients: early outcome in a Chinese cohort.

OBJECTIVE: To evaluate the efficacy of laparoscopic adjustable gastric banding in the management of morbid obesity in a cohort of Chinese patients. DESIGN. Cohort study. SETTING: University teaching hospital, Hong Kong. PATIENTS: From August 2002 to September 2003, 10 patients (6 male, 4 female) with a median age of 34 years (range, 23-48 years) underwent laparoscopic adjustable gastric banding to treat morbid obesity. Considerable co-existing diseases were present in 90% of the cases. We instituted a team approach that allowed every patient to see our dietitian, physician, psychiatrist (if necessary), and surgeon prior to deciding on the procedure to be used. MAIN OUTCOME MEASURES: Excessive body weight loss, quality-of-life score (SF36), and co-morbidities improvement. RESULTS: The 10 patients had a median weight of 127 kg (range, 115-196 kg) and median body mass index of 47 kg/m(2) (range, 38-67 kg/m(2)). The operation was successful in all patients with a median operating time of 110 minutes (range, 75-240 minutes). The median hospital stay was 3 days (range, 3-4 days) and three of the patients required overnight observation in the intensive care unit because of severe sleep apnoea and asthma. The median follow-up period was 12 months (range, 1-18 months). The mean weight loss at 6, 12, and 18 months was 19.3, 22.4, and 25.9 kg, respectively. Mean percentage of excessive weight loss at 6, 12, and 18 months was 34.9%, 36.5%, and 40.5%, respectively. Unsatisfactory weight loss (<20 kg) occurred in three patients because of poor dietary compliance and non-follow-up. Surgery also considerably improved the patients' co-morbidities (hypertension, diabetes, and obstructive sleep apnoea) and the quality of life. CONCLUSION: In the short term, laparoscopic adjustable gastric banding is certainly an effective procedure for morbid obesity, which results in a substantial weight loss and improvement of co-existing morbidities. Longer follow-up will show whether this weight loss is maintainable.

Time-dependent changes induced by azidothymidine in erythroid progenitor colonies in immunodeficient mice.

The effect of azidothymidine (AZT) on erythropoiesis in C57BL/6 mice made immunodeficient by infection with LP-BM5 murine leukemia virus (MuLV) was examined. Earlier work from our laboratory indicated that long-term treatment of LP-BM5 MuLV-infected mice with AZT induced peripheral anemia but increased the number of splenic and bone marrow erythroid burst-forming units (BFUe). In contrast, other workers have demonstrated that short-term intensive AZT treatment decreases bone marrow BFUe of normal mice. The purpose of the present study was to determine the effects of short-term oral AZT treatment in immune deficient animals. LP-BM5 MuLV-infected and normal mice were given 0, 1, and 2.5 mg/ml of AZT in their drinking water. Mice were killed after 2, 4, 8, 15, and 30 days of AZT treatment. The hematocrits of all AZT-treated mice decreased in a dose- and time-dependent fashion. AZT treatment decreased the absolute numbers of circulating reticulocytes in both normal and infected mice after 4 days of treatment. In contrast, the percentage of bone marrow early erythroblasts was increased in both normal and infected animals after 4 days of treatment. AZT at both doses decreased the number of BFUe per femur in both infected and normal mice after 2, 4, and 8 days. However, after 15 days the number of bone marrow BFUe increased. In spleen, the numbers of BFUe were increased only with high-dose AZT in both normal and infected mice at all time points, although the increases were more dramatic in infected mice. Our results indicate that the effect of AZT on bone marrow BFUe is time dependent, with inhibition being observed only at early time points. These results further demonstrate the complex effects of AZT on erythropoiesis in vivo.

Effects of in vivo administration of stem cell factor on thrombopoiesis in normal and immunodeficient mice.

Thrombocytopenia is an important clinical problem for many acquired immunodeficiency syndrome (AIDS) patients. Recently, the utility of recombinant cytokines in alleviating the hematopoietic complications of AIDS and AIDS therapy has been evaluated. The newly cloned cytokine stem cell factor (SCF) has been demonstrated to be a potent regulator of hematopoietic progenitor cell proliferation. Therefore, we evaluated the ability of SCF to alleviate thrombocytopenia caused by infection with LP-BM5 murine leukemia virus (mLV) in a murine model of AIDS (MAIDS). In addition, we evaluated the effects of SCF on previously demonstrated azidothymidine (AZT)-induced elevations of platelet counts. SCF was administered to normal or LP-BMS-infected C57BL/6 mice in combination with oral AZT for up to 1 month and effects on platelet, megakaryocyte (MK), and megakaryocyte colony-forming cell (CFU-MK) numbers were evaluated. SCF alone significantly increased the number of circulating platelets in thrombocytopenic MAIDS mice by 53%. SCF also significantly elevated platelet levels by 29% in normal mice. AZT elevated platelet counts 100% in normal and 50% in MAIDS mice. AZT and SCF increased platelet counts in an additive manner. SCF alone was a potent inducer of splenic CFU-MK in both MAIDS and normal mice, increasing splenic CFU-MK 13- to 15-fold at day 15 as compared with untreated controls. By day 30, however, the numbers of splenic CFU-MK had returned to control levels. In infected mice, AZT alone increased the number of splenic CFU-MK. SCF administered to AZT-treated MAIDS mice did not further enhance these increases. In contrast, in normal mice, AZT decreased splenic CFU-MK numbers. In AZT-treated mice, SCF enhanced the numbers of splenic CFU-MK 90-fold at day 8. In MAIDS mice, the number of bone marrow CFU-MK was significantly increased by SCF treatment at all time points. SCF significantly affected the total number of femoral CFU-MK in AZT-treated mice only at day 15. In normal mice, SCF or SCF and AZT in combination increased the total number of bone marrow CFU-MK five-fold at day 8, but failed to induce changes in the total number of femoral CFU-MK after that. These results indicate that SCF elevates platelet levels in both thrombocytopenic MAIDS and normal mice and profoundly affects CFU-MK proliferation. Combinations of SCF and AZT may be further explored to enhance the therapeutic effectiveness of these two drugs in alleviating thrombocytopenia.

3'-Azido-3'-deoxythymidine ameliorates the thrombocytopenia observed in a murine model of AIDS.

3'-Azido-3'-deoxythymidine (AZT) is used in the management of acquired immunodeficiency syndrome (AIDS) and AIDS-related complex (ARC). The myelotoxic actions of AZT are well known but its effect on platelets is not clear. We studied the effect of AZT at 1 and 2.5 mg/ml in drinking water on platelets in a murine model of AIDS. Three stages of the disease were examined, as determined by the serum IgM levels and other physical features. As early as 15 days after the initiation of drug treatment, AZT was found to significantly increase platelet production. To ascertain that this activity was authentic, a further study was carried out using uninfected mice. Mice were given AZT at both doses for 15 and 30 days. All mice on AZT had significantly increased numbers of platelets. These increases were dose and time dependent. AZT is therefore a potent inducer of thrombocytosis and may be a potential candidate in the treatment of thrombocytopenia in AIDS.

Multiple-copy genes: production and modification of monomeric peptides from large multimeric fusion proteins.

A vector system has been designed for obtaining high yields of polypeptides synthesized in Escherichia coli. Multiple copies of a synthetic gene encoding the neuropeptide substance P (SP) (Arg-Pro-Lys-Pro-Gln-Gln-Phe-Phe-Gly-Leu-Met-NH2) have been linked and fused to the lacZ gene. Each copy of the SP gene was flanked by codons for methionine to create sites for cleavage by cyanogen bromide (CNBr). The isolated multimeric SP fusion protein was converted to monomers of SP analog, each containing a carboxyl-terminal homoserine lactone (Hse-lactone) residue (Arg-Pro-Lys-Pro-Gln-Gln-Phe-Phe-Gly-Leu-Hse-lactone), upon treatment with CNBr in formic acid. The Hse-lactone moiety was subjected to chemical modifications to produce an SP Hse amide. This method permits synthesis of peptide amide analogs and other peptide derivatives by combining recombinant DNA techniques and chemical methods.

Inhibitors of platelet aggregation in the fetoplacental unit and myometrium with particular reference to the ADP-degrading property of placenta.

Extracts of fresh tissue from the feto-placental unit and myometrium were tested for their ability to inhibit ADP-induced platelet aggregation and to degrade ADP. Placental extracts caused rapid reversal of aggregation and degraded ADP, both effects being mimicked by HPAP. However, whereas the latter was inhibited by L-phenylalanine but not by heating to 65 degrees C for 5 minutes, the reverse was true for crude placental extracts. Umbilical cord vessels and myometrium totally inhibited platelet aggregation in a similar way to pure PGI2. Both tissues also exhibited ADP-ase activity but were much less potent in this respect than placenta. In the system used, little or no anti-aggregatory activity was detected in extracts of non-vascular cord tissue, fetal membranes or amniotic fluid, although the two latter tissues had a weak ADP-degrading effect. Thus, it appears that in contrast to myometrium and umbilical cord vessels, the major inhibitor of platelet aggregation in placenta is an ADP-ase and not PGI2. While part of the inhibitory effect of placenta may be due to HPAP, other ADP-degrading enzymes also seem to contribute to the overall anti-aggregatory property of this organ.

Adolescent nicotine exposure alters cardiac autonomic responsiveness: beta-adrenergic and m2-muscarinic receptors and their linkage to adenylyl cyclase.

Recent work indicates that adolescent smokers have an abnormally high incidence of heart rate irregularities. In the current study, adolescent rats received nicotine by continuous infusion from postnatal days (PN) 30-47.5, using a regimen designed to produce plasma levels found in smokers. We then assessed the levels of cardiac beta-adrenergic and m2-muscarinic cholinergic receptor binding, and receptor linkages to adenylyl cyclase activity, during nicotine exposure and for 1 month afterwards. In the nicotine-exposed group, m2-receptors showed a significant reduction that persisted through PN75, 1 month after the termination of treatment. beta-Receptors showed a tendency toward initial suppression and subsequent elevation. The receptor changes were accompanied by corresponding alterations in the response of adenylyl cyclase to carbachol and isoproterenol: the inhibitory muscarinic response was reduced, so that the net response to combined treatment with carbachol and isoproterenol was enhanced. There were additional changes in basal and forskolin-Mn(2+)-stimulated adenylyl cyclase activity suggestive of shifts in enzymatic catalytic properties. The effects of adolescent nicotine exposure were distinct from those seen previously with fetal nicotine treatment. In light of the worldwide increase in tobacco use by teenagers, these studies raise concern that cardiovascular function may be especially vulnerable during this critical period.

Seizures associated with spontaneous subarachnoid hemorrhage.

We analysed the charts of 131 consecutive cases of spontaneous subarachnoid hemorrhage--without arteriovenous malformations--for seizures. Convulsions occurred in 31 patients (24%) and most often within 24 hours of bleeding. Motor manifestations of partial seizures were of no lateralizing value to aneurysm site. Early mortality, rebleeding and intracerebral hematoma were similar in both seizure and non-seizure groups. Late seizures were infrequent in survivors who had suffered seizures in the acute stage--thus questioning the necessity for routine, long term prophylactic anticonvulsants in these patients.

Comparative pharmacokinetics of vitamin A (retinol) in rats and hamsters.

The absorption and elimination of all-trans-retinol in the plasma of rats and hamsters were studied after an oral dose of 45 mg/kg body weight. The hamsters exhibited a higher pretreatment mean circulating retinol concentration than rats maintained on an identical diet. The increase in plasma retinol after a single oral dose was much greater in hamsters than rats. The area under the plasma concentration v. time curve was approximately 60% greater for rats than for hamsters. The elimination half-times for rats were much longer than for hamsters. Plasma retinol uptake and disappearance were consistent with a two-compartment open model with first-order absorption.