Tuen Mun Hospital Research Articles

Intracranial vasculopathy with MR vessel wall imaging: a case series.

Conventional luminal imaging, often the first line investigation, has helped physicians in diagnosing countless patients with cerebrovascular disease but regrettably, it offers little diagnostic clues in patients with challenging vasculopathy, which the latter often requires invasive histopathological diagnosis. In past decade, MR vessel wall imaging has quickly emerged as a non-invasive modality that greatly enhances radiologists' capability of differentiating underlying aetiology. Not only it minimizes surgical trauma to patients, but also provide timely and accurate diagnosis for physicians to offer prompt appropriate treatment and avoid devastating outcomes. Tuen Mun Hospital, the neuroscience centre serving more than 1.3 million population in New Territories, Hong Kong, has been the pioneer in optimizing this novel modality within the district. In this article, we hope to share few interesting cases in our centre on how we utilize its advantage in solving some challenging cases. We would also discuss some common imaging pitfalls and tips on interpretation.

The Omicron variant of COVID-19 and its association with croup in children: a single-centre study in Hong Kong.

The fifth wave of the coronavirus disease 2019 (COVID-19) pandemic in Hong Kong was dominated by the Omicron variant, which may cause more upper airway involvement in children. This study was performed to identify any associations between the Omicron variant of COVID-19 and croup in children. This retrospective study reviewed the electronic medical records of patients admitted to Tuen Mun Hospital in Hong Kong from 1 January 2018 to 31 March 2022 under the diagnostic code for croup (J05.0 in the International Classification of Diseases 10th Edition). Patients were categorised into three groups according to their admission periods, namely, non-COVID-19, COVID-19-pre-Omicron, and COVID-19-Omicron groups. Disease associations and severity were compared according to incidence, Westley Croup Score, length of hospital stay, medication use, respiratory support, and intensive care unit admissions. The COVID-19 incidence among patients with croup was significantly higher in the COVID-19-Omicron group than in the COVID-19-pre-Omicron group (90.0% vs 2.0%; P<0.001). Compared with patients in the COVID-19-pre-Omicron and non-COVID-19 groups, patients in the COVID-19-Omicron group also had a higher Westley score (moderate and severe disease in the COVID-19-Omicron group: 56.7%; COVID-19-pre-Omicron group: 22.0%, P=0.004; non-COVID-19 group: 24.8%, P<0.001), longer median hospital stay (COVID-19-Omicron group: 3.00 days; COVID-19-pre-Omicron group: 2.00 days, P<0.001; non-COVID-19 group: 2.00 days, P=0.034), and higher mean dexamethasone requirement (COVID-19-Omicron group: 0.78 mg/kg; COVID-19-pre-Omicron group: 0.49 mg/kg, P<0.001; non-COVID-19 group: 0.58 mg/kg, P=0.001). The Omicron variant of COVID-19 is associated with croup and can cause more severe disease in Hong Kong children.

Clinical course and mortality in older patients with COVID-19: a cluster-based study in Hong Kong.

Compared with previous waves of the coronavirus disease 2019 (COVID-19) pandemic in Hong Kong, the third wave involved a greater number of frail older patients. Because local healthcare policy required hospitalisation for all older adults with COVID-19, we aimed to investigate the clinical course and outcomes in such patients. This retrospective observational study included all patients aged ≥65 years who were admitted to Tuen Mun Hospital for management of COVID-19 between 1 July 2020 and 31 August 2020. We reviewed baseline characteristics, clinical presentation, laboratory results, complications, and outcomes. We also investigated the associations of age and Clinical Frailty Scale (CFS) score with in-patient mortality. In total, 101 patients were included (median age, 73 years); 52.5% were men and 85% had at least co-morbid chronic disease. The most common symptoms were fever (80.2%) and cough (63.4%). Fifty-two patients (51.5%) developed hypoxia, generally on day 8 (interquartile range, 5-11) after symptom onset. Of the 16 patients who required intensive care unit support, 13 required mechanical ventilation. The overall mortality rate was 16.8%. Patients aged 65-69, 70-79, 80-89, and ≥90 years had mortality rates of 9.1%, 10%, 30%, and 25%, respectively. Patients with CFS scores of 1-2, 3-4, 5-6, and ≥7 had mortality rates of 5.7%, 14.7%, 23.5%, and 40%, respectively. A linear relationship was confirmed between the two mortality trends. Clinical deterioration was common in older patients with COVID-19; their overall mortality rate was 16.8%. Mortality increased linearly with both age and CFS score.

Spontaneous pneumo‐mediastinum ‐ A benign rarity?

AbstractBackgroundSpontaneous pneumo‐mediastinum (SPM) is defined as the spontaneous occurrence of free gas in the mediastinum. Although SPM is rare, this is a unique differential cause for pneumo‐mediastinum. It bears a benign clinical course with good clinical outcome, unlike others potentially life threatening causes of pneumo‐mediastinum, such as oesophageal perforation and necrotizing mediastinitis.Methods and ResultsA retrospective study about SPM was conducted in the Department of Surgery, Tuen Mun Hospital, HKSAR. SPM cases were retrieved through hospital's electronic records from 7/2000 to 6/2020. Patients' demographic data, clinical presentation, management and outcomes were reviewed. One hundred five SPM patients were retrieved with mean age 21.3 (0–68). More than 85% (91 cases) of them were younger age group (younger than the age of 30). Eighty‐seven cases (82.9%) were male while 18 cases (17.1%) were female. The top 3 presentation symptoms were: chest pain (69 cases, 65.7%), neck pain (43 cases, 41%) and sore throat (42 cases, 40%). Physical examination revealed surgical emphysema in 63 patients (60%). 61 (58.1%) patients enjoyed good past health and without any potential predisposing factors. Common precipitating factors included: vigorous cough (28 cases, 26.7%), vigorous exercise (16 cases, 15.2%), sneezing (15 cases, 14.3%) and vomiting/retching (14 cases, 13.3%).CXR showed pneumo‐mediastinum in 98 cases (93.3%). Additional investigations, such as CT neck/thorax/abdomen with contrast (63 cases, 60%) and oesophago‐gastro‐duodenoscopy (OGD) (29 cases, 27.6%), were performed to rule out other differential diagnosis in suspicious cases.All the SPM patients were treated conservatively (e.g. bed rest, analgesics, antibiotics, oxygen supplement). None of them required operative treatment with recurrence rate 0%. Average length of hospital stay was 4.1 days (1–35 days). Two out of 105 cases (1.9%) resulted in hospital mortality due to other underlying medical illnesses.ConclusionSPM is an uncommon disease, mainly affecting the younger age group. Although SPM carries a benign and good clinical outcome, it is essential to exclude other potential life threatening conditions with similar presentations.

A Descriptive Pilot Study on Stereotactic Radiosurgery of Brain Arteriovenous Malformation in Tuen Mun Hospital, a Regional Hospital in Hong Kong

A Descriptive Pilot Study on Stereotactic Radiosurgery of Brain Arteriovenous Malformation in Tuen Mun Hospital, a Regional Hospital in Hong Kong

Comparison of atrio-femoral and femoro-atrial venovenous extracorporeal membrane oxygenation in adult.

Different cannulation approaches existed for veno-venous extracorporeal membrane oxygenation (VV ECMO). We aimed to compare the atrio-femoral (AF) and femoro-atrial (FA) configuration in terms of their flow efficiency and influence on patient outcome. This was a single-centre, retrospective case control study. Adult patients admitted to the Intensive Care Unit and required VV ECMO service at Tuen Mun Hospital, Hong Kong, from June 2015 to January 2020 were included. Data were collected from our ECMO database for comparison. Between June 2015 and January 2020, eight patients received AF configuration and 19 patients received FA configuration. The maximum achieved flow in the AF group was significantly higher than that in the FA group (4.08 ± 0.57 L/min vs. 3.52 ± 0.58 L/min, p = 0.03). The fluid balance in first 3 days of ECMO was significantly lower in the AF group compared to that in the FA group (1.16 ± 2.71 L vs. 3.46 ± 1.97 L, p = 0.02). As well, the chance for successful awake ECMO was statistically higher in the AF group (p = 0.048). Atrio-femoral configuration in VV ECMO was associated with a higher maximum achieved ECMO flow, less fluid gain in first 3 days of ECMO and more successful awake ECMO.

Rheumatology Drugs and COVID-19

Journal of Clinical Rheumatology and ImmunologyVol. 20, No. 01, pp. 1-3 (2020) EDITORIALOpen AccessRheumatology Drugs and COVID-19Chi Chiu MokChi Chiu MokDepartment of Medicine, Tuen Mun Hospital, Tsing Chung Koon Rd, Tuen Mun, Hong Kong SAR, ChinaE-mail Address: [email protected] Search for more papers by this author https://doi.org/10.1142/S2661341720010014Cited by:0 Next AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsRecommend to Library ShareShare onFacebookTwitterLinked InRedditEmail

Pre-operative CT localization for patients with subsolid opacities expecting video-assisted thoracoscopic surgery—single center experience of fluorescent iodized emulsion and hook-wire localization technique

To describe our clinical experience of using combination of fluorescent iodized emulsion, indocyanine green & lipiodol, and hook-wire in pre-operative CT localization of patients with subsolid lung lesions prior to video-assisted thoracoscopic surgery (VATS). A retrospective review between June 2018 and July 2019 of consecutive Chinese patients whom underwent VATS for subsolid lung lesions with pre-operative CT localization done with combination of fluorescent iodized emulsion and hook-wire technique in a tertiary hospital (Tuen Mun Hospital, Hong Kong SAR). The duration and complications related to the localization procedure were recorded The clinical records, operative findings and pathology reports were retrieved from the hospital electronic clinical management system. Combination fluorescent iodized emulsion with hook-wire enabled accurate localization and resection of all subsolid lung lesions in VATS. No major complications were reported. Combination of fluorescent iodized emulsion and hook-wire placement under CT guidance is a simple, safe and cost- effective procedure that enabled accurate localization and resection of subsolid nodule in VATS. VATS has been the mainstay for indeterminate pulmonary nodules for diagnostic and/or curative purpose. The main problem that surgeons may encounter during operation is the difficulty in locating the target lesion particularly for subsolid lesions. Many pre-operative localization methods have been developed in this regard. With the novel technique that we described, we were able to overcome disadvantages of most described methods.

A survey of patient satisfaction of obstetric anaesthesia service in Tuen Mun Hospital, Hong Kong

Patient satisfaction is an important healthcare performance indicator that has come to the forefront in recent years. Although patient satisfaction surveys have been performed assessing various medical services, there is a lack of survey evaluating patient satisfaction towards the anaesthesia services in Hong Kong. In this study, we looked into the perioperative concerns and patient satisfaction in a group of obstetric patients undergoing anaesthesia for caesarean section (CS) in Tuen Mun Hospital (TMH), which is a large regional hospital in Hong Kong with more than 5500 deliveries per year. Between June 2017 and May 2018, 263 Chinese obstetric patients undergoing elective or emergency CS were recruited into the survey. The median of the satisfaction mark obtained was 139 out of 190. Patients were less satisfied in the aspect of “fear” and “discomfort”, which were correlated with severe postoperative pain, general anaesthesia and emergent CS. Improvement in pain management program and alleviating fear and discomfort were recommended. Follow-up survey is recommended to assess the effectiveness of improvement measures. Further patient satisfaction survey can be considered in other patient groups.

Natural clinical course of progressive supranuclear palsy in Chinese patients in Hong Kong.

Progressive supranuclear palsy (PSP) is a common type of atypical parkinsonism. To the best of our knowledge, there has been no study of its natural clinical course among Chinese patients. This retrospective study included 21 patients with PSP who had radiological evidence of midbrain atrophy (confirmed by magnetic resonance imaging) from the geriatrics clinics of Queen Mary Hospital and Tuen Mun Hospital. Clinical information was retrieved from clinical records, including age at onset, age at presentation, age at death, duration of symptoms, level of education, sex, presenting scores on Cantonese version of Mini-Mental State Examination, clinical symptoms, and history of levodopa or dopamine agonist intake and response. Clinical symptoms were clustered into the following categories and the dates of development of these symptoms were determined: motor symptoms, bulbar symptoms, cognitive symptoms, and others. Motor symptoms developed early in the clinical course of disease. Cox proportional hazards modelling showed that the number of episodes of pneumonia, time to vertical gaze palsy, and presence of pneumonia were predictive of mortality. Apathy, dysphagia, pneumonia, caregiver stress, and pressure injuries were predictive of mortality when analysed as time-dependent covariates. There was a significant negative correlation between the age at presentation and time to mortality from presentation (Pearson correlation=-0.54, P=0.04). Approximately 40% of caregivers complained of stress during the clinical course of disease. Important clinical milestones, including the development of dysphagia, vertical gaze palsy, significant caregiver stress, pressure injuries, and pneumonia, may guide advanced care planning for patients with PSP.

1602P - 30-day mortality in palliative radiotherapy

BackgroundIn terminal cancer patients with a limited prognosis, excessive radiotherapy (RT) fractionation can be considered an avoidable harm and poor use of healthcare resource. 30-day mortality (30DM) as a clinical indicator for the avoidance of harm, through appropriate patient selection, in palliative RT has not previously been demonstrated in Hong Kong. We aimed to assess 30DM following palliative RT at our centre. MethodsA retrospective analysis of 30DM for all palliative RT delivered in Tuen Mun Hospital in 2017. Episodes were identified using the in-house radiotherapy electronic record with linkage to electronic patient records. 30DM was assessed across all patient groups and by sites and fractionation pattern. Results1,065 palliative RT episodes were identified. Overall, 199 (18.7%) treatment were delivered to the spine, 151 (14.2%) to the chest, 97 (9.1%) to the brain, and 77 (7.2%) to the bones. Median treatment duration was 5 days (range 1–12). 84.3% received 5 fractions or less. Overall 30DM was 17.7% (188 patients), among which 61 (32.4%) treatment episodes were delivered to female. The most commonly treated diagnosis was lung cancer (39.4%). Factors having a significant impact upon 30DM were sex (male vs female odds ratio [OR] 1.56, 95% confidence interval [CI] 1.12, 2.18) and primary cancer diagnosis (Lip, oral cavity, and pharynx OR 0.31 [0.11, 0.87], genitourinary organs OR 0.57 [0.33, 0.98], and respiratory and intrathoracic organs 1.60 [1.17, 2.20]).Table1602P odd ratios for different factors relating to the 30DM of palliative RTTableYes (mortality within 30 days)NoTotal n=1065No. of Cases (%)No. of Cases (%)Odd ratios (95% CI)Radiotherapy SitesLip, oral cavity, and pharynx4 (7)57 (93)0.31 (0.11, 0.87)Genitourinary organs16 (11)124 (89)0.57 (0.33, 0.98)Bone, connective tissue, skin and breast23 (14)144 (86)0.71 (0.44, 1.14)Other and unspecified sites8 (17)40 (83)0.93 (0.43, 2.02)Digestive organs and peritoneum35 (18)159 (82)1.03 (0.69, 1.55)Respiratory and intrathoracic organs92 (22)328 (78)1.60 (1.17, 2.20)Lymphatic and hematopoietic Tissue10 (29)25 (71)1.92 (0.90, 4.06)SexMale127 (20)501 (80)1.56 (1.12, 2.18)Female61 (14)376 (86)Abbreviation: CI: confidence interval ConclusionsThis is the first large-scale study of 30-day mortality for unselected adult palliative RT in Hong Kong. A balance needs to be achieved between duration of RT course and potential benefits through appropriate patient selection. The observed differences in early mortality by fractionation support the use of this measure in assessing clinical decision making in palliative RT, and further studies in other centres and health care systems are required. Legal entity responsible for the studyShing Fung Lee. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

PB1672 REVIEW OF BLOODSTREAM INFECTION IN ADULT PATIENTS OF ACUTE LYMPHOBLASTIC LEUKEMIA TREATED WITH HYPERCVAD – A TERTIARY CENTRE EXPERIENCE

Background:Aside from high relapse rate, the toxicity of HyperCVAD also renders the management of adult patients with acute lymphoblastic leukemia (ALL) challenging. Cycle A of HyperCVAD includes cyclophosphamide, vincristine and doxorubicin while cytarabine and methotrexate are the key components in cycle B.Aims:This study aims to evaluate the bloodstream infection (BSI) of HyperCVAD in ALL patients at Tuen Mun Hospital (TMH).Methods:In this retrospective single centre study from January 2013 to June 2017, 18 de novo ALL patients (7 Philadelphia‐positive, 7 Philadelphia‐negative and 4 T‐lineage) were treated with HyperCVAD +/‐ tyrosine kinase inhibitor (TKI). Anti‐bacterial prophylaxis was not routinely prescribed in our centre. Complete blood count was checked once every two days during chemotherapy and patients would receive granulocyte colony‐stimulating factor (G‐CSF) if there was grade 3 or above neutropenia. Septic workup would be performed when body temperature was ≥ 38 oC. Intravenous piperacillin‐tazobactam or levofloxacin in case of penicillin allergy would be started and intravenous vancomycin would be added in patients with history of methicillin‐resistant Staphylococcus aureus (MRSA) infection. Antibiotics would be adjusted in accordance with culture results and sensitivity profiles. BSI was defined as positive blood culture of a recognized pathogen from a single blood culture or of a common commensal from multiple blood cultures. The primary outcome is the measure of BSIs in incidence density, defined as the number of BSIs per patient‐day. Secondary outcomes include periods of neutropenia in each cycle, organism types and sensitivity profilesResults:The median age of this cohort was 50 years old (21‐67 years old) and 13 (72%) patients were of good past health. Among 88 admissions for HyperCVAD, 31 episodes of BSIs were documented in 16 patients. Three (16.7%) patients had more than one BSI in a single admission. The overall incidence density was 17.9 BSIs per 1,000 patient‐days. The incidence density of BSIs was significantly higher in induction phase (23.8 BSIs per 1,000 patient‐days) and cycle B (Median: 20.6 BSIs per 1,000 patient‐days) when compared with that of cycle A (Median: 5.9 BSIs per 1,000 patient‐days) (p = 0.008). Patients with BSIs were associated with significantly longer duration of neutropenia than those without BSIs (9 days vs. 5 days, p &lt; 0.001). The addition of TKI in Philadelphia‐positive patients did not result in more BSI compared with Philadelphia‐negative or T‐lineage ALL patients (p = 0.294). Gram‐negative bacilli (GNB) accounted for 71% of BSIs and half of the GNB were Escherichia coli. 45.5% of E. coli were extended spectrum beta‐lactamase (ESBL) producing. The remaining 29% of BSIs were caused by gram‐positive cocci (GPC) with Streptococcus mitis as the most common GPC. Majority of cases (61%) did not have an identifiable source of infection. There were three deaths directly related to BSIs.Summary/Conclusion:Bloodstream infection is more common in induction phase and cycle B of HyperCVAD and gram negative bacilli are the main causative agents. Antibacterial prophylaxis can be considered but the emerging drug resistance imposes great challenges. More studies on the effectiveness of antibacterial prophylaxis in the era of multidrug resistant organisms are necessary.

Postoesophagectomy chylothorax: A single‐centre, 14‐year review

AimThe reported incidence of postoesophagectomy chylothorax is 1.2–4 per cent. The diagnosis is based on clinical suspicion: milky chest drain fluid and/or high volume chest drain output. Confirmatory tests involve sending fluid for laboratory investigations. Chylothorax is a potentially lethal condition and carries a high morbidity rate. An early diagnosis can potentially help to identify those who might require operation, dietary restrictions or other treatments. The aim of the present study was to evaluate chylothorax in postoesophagectomy patients.Patients and MethodsWe extracted data from patients who underwent oesophagectomy at Tuen Mun Hospital from 2004 to 2018 for the present retrospective study. Chest drain fluid from every patient was sent every postoperative day for testing for chyle, regardless of quantity and whether or not it was milky. The characteristics of the patients, disease, operations, perioperative conditions, postoperative complications, hospital stay, interventions, morbidity and mortality and chest drain outputs were compared.ResultsThe incidence of chylothorax in our cohort was 9 per cent (14/155). There were nine biochemical chyle leaks (64.3 per cent) and five clinical leaks (35.7 per cent). The biochemical leakage group had a significantly higher 1‐month morbidity rate compared to the nonchylothorax patients (89.9 vs 50 per cent, P = 0.03). All biochemical leaks were resolved with conservative management.The entire chylothorax group also had a longer hospital stay (25.5 vs 17 days, P = 0.04) compared to the nonchylothorax group. Thoracotomy was done in two patients with clinical leaks, and the remaining leaks were resolved with conservative management. In subgroup analysis, the biochemical leak subgroup was found to have a higher 1‐month morbidity rate (88.9 versus 50 per cent, P = 0.03) compared to the nonchylothorax group.ConclusionBy routinely screening for chylothorax, the incidence was found to be 9 per cent, higher than that reported in the literature. The biochemical leak subgroup was found to have a higher 1‐month morbidity rate. This could suggest that biochemical leakage of chyle might have a clinical impact on the recovery of postoesophagectomy patients.

The Value of Prognostic Nutritional Index in Follicular Lymphoma.

Previous studies reported that prognostic nutritional index (PNI), a marker of host inflammatory and nutritional status, is associated with prognoses in a number of cancer types. Thus, we investigated PNI at diagnosis as a prognostic factor in FL. We reviewed FL patients in Tuen Mun Hospital, Hong Kong from 2000 to 2014 (n=88). PNI was calculated by serum albumin (g/L)+5×absolute lymphocyte count (10/L). We determined the best PNI cut-off value using receiver-operating characteristic curves. The extent to which progression-free survival (PFS) and overall survival differed by PNI cut-off was assessed using Kaplan-Meier and log-rank tests. Cox proportional hazards model was utilized to adjust for covariates. The best cut-off value for PNI was determined to be 45. Patients with high PNI (>45) had a higher complete response (CR) rate after primary treatment, 46 of 61 (75.4%) patients with high PNI had CR, compared with 10 of 23 (43.5%) for low PNI (2-sample test of proportions P-value=0.006). Further, higher PNI at relapse as a continuous variable was associated with superior postprogression survival with a hazard ratio (HR) 0.88 (95% confidence interval [CI], 0.81-0.96). In multivariate analysis, high PNI at diagnosis had superior PFS (adjusted HR of 0.37; 95% CI, 0.15-0.93). PNI was shown to be independent prognostic factor of PFS in FL. It is a cheap and widely available biomarker. Future study is needed to validate its prognostic value and clinical utility in a prospective cohort.

Effects of non-invasive brain stimulation for upper limb rehabilitation in acute stroke patients - A controlled clinical trial

This study was conducted in Tuen Mun Hospital (TMH) to evaluate the effects of rTMS and tDCS on upper limb functional recovery in acute stroke patients. Patients with acute stroke were randomly assigned to rTMS, tDCS or control group. For rTMS group, patient received 1 Hz rTMS at 90% of resting motor threshold to M1 of the unaffected hemisphere for 1200 pulses. For tDCS group, patient received 1 mA anodal stimulation to hand area of the affected hemisphere for 20 minutes. Five consecutive sessions of rTMS or tDCS together with intensive physiotherapy upper limb training were given. For control group, only intensive physiotherapy upper limb training were given. The upper extremity section of Fugl–Meyer Scale (UE-FM) was used as outcome measure. Twenty-nine patients (17 female and 12 male) were assigned to the rTMS ( n = 9), tDCS ( n = 11) and control ( n = 9) group. The mean age was 62.7 ± 12.0 years old and the mean time between stroke onset and the first UE-FM assessment was 9.14 ± 3.30 days. There was no statistically significant difference in mean age, baseline UE-FM mean score, mean time between stroke onset and the first UE-FM assessment among three groups [X 2 (2) = 4.81, P = 0.09] [X 2 (2) = 1.56, P = 0.457] [X 2 (2) = 0.04, P = 0.98]. No adverse effects of rTMS or tDCS were reported. For between-group comparison, the changes in mean score of UE-FM in rTMS (20.8 ± 6.59) and tDCS group (16.1 ± 4.97) were statistically significantly larger than that in control group (10.6 ± 4.13) (U = −2.97, P = 0.002) (U = −2.29, P = 0.02). However, there was no significant difference between rTMS and tDCS group (U = −1.49, P = 0.152). Findings of the present study showed that both rTMS and tDCS could augment physiotherapy treatment in enhancing upper limb motor functional recovery in acute stroke patients. These positive findings warrant further investigation of the application of non-invasive brain stimulation techniques to neurorehabilitation.

Clinical and biochemical characteristics of infants with prolonged neonatal jaundice.

Protocols for investigating neonatal prolonged jaundice vary and the yield from screening has not been assessed. International guidelines recommend establishing cholestasis before proceeding to investigate the underlying pathology. However, in most hospitals administered by the Hospital Authority, full liver function is checked at the first neonatal jaundice clinic visit. To study the diagnostic yield of this approach, we carried out a retrospective study of all infants referred for prolonged jaundice. Attendance records from the neonatal jaundice clinic at the Tuen Mun Hospital, Hong Kong, the clinical management system, and electronic patient records were used to retrieve epidemiological, clinical, and laboratory data, and patients' clinical progress. During the 8-month study period from 8 July 2015 to 8 March 2016, 1164 infants were referred to the neonatal jaundice clinic for prolonged jaundice. Among them, 16 (1.4%) infants had conjugated hyperbilirubinaemia. Diagnoses included biliary atresia (n=1), cytomegalovirus (CMV) infection (n=3), neonatal hepatitis syndrome (n=2), and transient cholestasis (n=10). In total, 98 (8.42%) infants had elevated alanine transaminase levels. Diagnoses included biliary atresia (n=1), hepatic congestion related to congestive heart failure (n=1), CMV infection (n=5), neonatal hepatitis syndrome (n=16), and non-specific elevated alanine transaminase (n=75). In total, 59 infants had elevated alkaline phosphatase levels. A stepwise approach is recommended, in which full liver function is checked and the underlying cause of jaundice is investigated only after confirming cholestasis.

Outcomes of salvage radiotherapy for recurrent prostate cancer after radical prostatectomy.

Salvage radiotherapy (SRT) provides effective biochemical control for patients with prostate cancer who have prostate specific antigen (PSA) failure after radical prostatectomy. However, the effect of SRT on long-term clinical outcomes remains unknown. Therefore, we report the natural history of patients treated with SRT. We identified 84 Chinese patients with prostate cancer treated with SRT to the prostatic fossa alone during 2006-2017 at Tuen Mun Hospital, Hong Kong. Survival was calculated using Kaplan-Meier method. Log-rank test and Cox regression were used to determine significance of clinical parameters with outcomes. Median SRT dose given was 70 Gy (range, 64-76 Gy). Median pre-SRT PSA level was 0.4 ng/mL (0.2-7.4 ng/mL). After SRT, 47 (56%) patients had undetectable (<0.1 ng/mL) PSA levels. After median follow-up of 48 months (2 months to 10 years), 25 (30%) patients had further biochemical progression. Subsequently, 12 patients received androgen deprivation therapy and nine (11%) developed distant metastasis. The 5-year biochemical progression-free survival, androgen deprivation therapy-free survival and metastasis-free survival were 62.7%, 83.5% and 86.7%, respectively. Early PSA failure after radical prostatectomy (hazard ratio 7.4), negative surgical margin (hazard ratio 2.7), positive extracapsular extension (hazard ratio 4.6), and detectable PSA levels after SRT (hazard ratio 17.3) were associated with lower biochemical progression-free survival after SRT. High-dose SRT with intensity-modulated radiotherapy/volumetric modulated arc radiotherapy is an effective local treatment that can prevent distant metastasis and avoid the need for androgen deprivation therapy in Chinese patients who have PSA failure after radical prostatectomy.

Outcome following the introduction of a procedure specific pain management program for caesarean section

Based on the results of a prospective audit conducted in 2014 among 310 post caesarean section patients (Group A) at Tuen Mun Hospital, Hong Kong, a procedure specific postoperative pain management programme was implemented. To complete the audit cycle, a second prospective audit was conducted in 2015 among 332 patients (Group B). The proportion of patients with severe pain (VAS>=7/10) reduced significantly from 55.5% (Group A) to 23.0% (Group B) (p

Thrombolytic Therapy in Acute Ischemic Stroke in Patients Not Fulfilling Conventional Criteria.

There are many exclusion criteria in early randomized control trials for intravenous recombinant tissue plasminogen activator use in acute ischemic stroke, thus, many patients were not eligible for the treatment. This study aimed to compare the safety and short-term treatment outcome between those who fulfilled the criteria and those who did not. All acute ischemic stroke patients treated with intravenous thrombolysis from 2004 to 2015 in Tuen Mun hospital were recruited. They were divided into an on-label group if they did not have any of the contraindications and an off-label group if contraindication existed. Primary outcome of symptomatic hemorrhage, and secondary outcome of early neurological change, 3-month mortality and functional outcome were measured. Multivariate analysis with logistic regression with adjustment of baseline characteristics was done. Totally, 323 patients received intravenous thrombolysis and 162 (50.2%) had at least one contraindication. None of the contraindications were associated with symptomatic intracranial hemorrhage. Patients with previous stroke and diabetes mellitus performed similarly in all outcome measures. Patients with minor stroke had less early neurological deterioration and better functional outcome. Old age and high blood pressure were shown to have less early neurological improvement and less good functional outcome. Severe stroke was related to increased mortality and none had a good functional outcome. This study demonstrated that the off-label group had comparable symptomatic intracranial hemorrhagic risk which gave ground for further study into its safety. However, some subgroups had less favorable outcome, including high blood pressure, severe stroke, and old age. This may be due to underlying comorbidities and limited rehabilitation potential rather than thrombolysis per se.

Effects of non-invasive brain stimulation for upper limb rehabilitation in acute stroke patients – A controlled clinical trial

Introduction/Background This study was conducted in Tuen Mun Hospital (TMH) to evaluate the effects of rTMS and tDCS on upper limb functional recovery in acute stroke patients. Material and method Patients with acute stroke were randomly assigned to rTMS, tDCS or control group. For rTMS group, patient received 1 Hz rTMS at 90% of resting motor threshold to M1 of the unaffected hemisphere for 1200 pulses. For tDCS group, patient received 1 mA anodal stimulation to hand area of the affected hemisphere for 20 minutes. Five consecutive sessions of rTMS or tDCS together with intensive physiotherapy upper limb training were given. For control group, only intensive physiotherapy upper limb training were given. The upper extremity section of Fugl–Meyer Scale (UE-FM) was used as outcome measure. Results Twenty-nine patients (17 female and 12 male) were assigned to the rTMS ( n = 9), tDCS ( n = 11) and control ( n = 9) group. The mean age was 62.7 ± 12.0 years old and the mean time between stroke onset and the first UE-FM assessment was 9.14 ± 3.30 days. There was no statistically significant difference in mean age, baseline UE-FM mean score, mean time between stroke onset and the first UE-FM assessment among three groups [X 2 (2) = 4.81, P = 0.09] [X 2 (2) = 1.56, P = 0.457] [X 2 (2) = 0.04, P = 0.98]. No adverse effects of rTMS or tDCS were reported. For between-group comparison, the changes in mean score of UE-FM in rTMS (20.8 ± 6.59) and tDCS group (16.1 ± 4.97) were statistically significantly larger than that in control group (10.6 ± 4.13) (U = −2.97, P = 0.002) (U = −2.29, P = 0.02). However, there was no significant difference between rTMS and tDCS group (U = −1.49, P = 0.152). Conclusion Findings of the present study showed that both rTMS and tDCS could augment physiotherapy treatment in enhancing upper limb motor functional recovery in acute stroke patients. These positive findings warrant further investigation of the application of non-invasive brain stimulation techniques to neurorehabilitation.