A middle-aged lady with a pyogenic liver abscess caused by Clostridium perfringens

The pyogenic liver abscess caused by Clostridium perfringens (C. perfringens ) is a rare, but rapidly fatal infection. It is usually associated with malignancy and immunosuppression. We report the case of 50-year-old lady with the secondary liver metastases from rectal cancer presented with fever and epigastric pain. The identification of Grampositive bacilli septicaemia, the presence of gas-forming liver abscess and massive intravascular hemolysis should lead to the suspicion of C. perfringens infection. Here we review twenty cases published since 1990 and their clinical features are discussed. The importance of "an aggressive treatment policy" with multidisciplinary team approach is emphasized.

Concurrent stenoses: A common etiology of stroke in Asians

Atherosclerosis of cerebral vessels is a common cause of stroke. Racial differences in the distribution of cerebrovascular occlusive disease are well documented.Extracranial stenosis is more common in Caucasians,while intracranial stenosis is more common in Asians,Hispanics and African-Americans. Concurrent atherosclerosis of extracranial and intracranial vessels is common in Asians. The incidence of concurrent stenoses ranges from 10% to 48% in patients with symptomatic cerebrovascular disease. The long-term prognosis of these patients is poor and they are at high risk of further vascular events or death. The purpose of this review is to examine the epidemiology, risk factors,stroke mechanism and genetics of concurrent stenoses and to discuss strategies for treatment.

Metabolic syndrome and benign prostatic hyperplasia:An update

Metabolic syndrome(MetS)is a cluster of metabolic abnormalities related to central adiposity and insulin resistance.Its importance is increasingly recognized as it associates with increased risks of metabolic and cardiovascular diseases.These metabolic aberrations of MetS may lead to development of benign prostatic hyperplasia(BPH)and lower urinary tract symptoms(LUTS)in men.A 26.5%-55.6% prevalence of MetS in men with LUTS was reported in worldwide studies.Although the exact biological pathway is not clear yet,insulin resistance,increased visceral adiposity,sex hormone alterations and cellular inflammatory reactions played significant roles in the related pathophysiological processes.Clinician should recognize the cardiovascular and metabolic impacts of MetS in men with LUTS,early risk factors optimization and use of appropriate medical therapy may possibly alter or slower the progression of LUTS/BPH,and potentially avoid unnecessary morbidities and mortalities from cardiovascular and metabolic diseases for those men.

Is hepatic neoplasm-related pyogenic liver abscess a distinct clinical entity?

AIM: To compare the clinical characteristics of pyogenic liver abscess (PLA) in patients with and without hepatic neoplasm (HN). METHODS: We performed a retrospective analysis involving patients with PLA. The demographic, clinical features, laboratory and imaging findings, management and outcome of patients with and without HN were studied. RESULTS: From January 2000 to December 2009 inclusive, 318 patients (35 with HN) had PLA, and mean age and comorbidity were comparable between the two groups. More patients with HN experienced right upper quadrant pain (68.6% vs 52.7%, P < 0.04), developed jaundice (14.3% vs 5.7%, P < 0.03) and hepatomegaly (17.1% vs 3.9%, P < 0.01), and had higher serum total bilirubin level (43.3 μmol/L vs 30.0 μmol/L, P = 0.05). Most patients in both groups had PLAs in the right hepatic lobe, and biliary tract disorder was the most common underlying cause (71.4% and 61.8%). However, more PLAs in the HN group were associated with thicker abscess wall (37.1% vs 19.4%, P < 0.01), septal lobulation (77.1% vs 58%, P < 0.02), gaseous cavitation (17% vs 7.8%, P = 0.03), portal thrombophlebitis (11.4% vs 1.8%, P < 0.01) and aerobilia (25.9% vs 5.5%, P < 0.01). Mixed bacterial growth (40% vs 15.2%, P < 0.01) and Gram-negative bacilli (22.8% vs 60.4%, P < 0.01) were dominant isolates in PLAs with and without HN, respectively. Although incidence of the complications was comparable between the two groups, patients with HN had a higher mortality rate than those without (71.4% vs 8.8%, P < 0.01). Multivariate logistic regression analysis revealed underlying active malignancy [odds ratio (OR): 40.45, 95% CI: 14.76-111.65], hypoalbuminemia (OR: 1.22, 95% CI: 1.14-1.38), disseminated intravascular coagulation (OR: 3.32, 95% CI: 1.19-9.69) and acute coronary syndrome (OR: 4.48, 95% CI: 1.08-17.8) were independent risk factors associated with mortality. However, several HN cases, presented concurrently with PLAs, were found to have curative resectable tumors and had good prognosis after surgery. CONCLUSION: PLA associated with HN tends to form a distinct clinical syndrome with a different extent of clinical manifestations, radiological and microbiological features and complications.

Chronic ulcerative gastroduodenitis as a first gastrointestinal manifestation of Hermansky-Pudlak syndrome in a 10-year-old child

A 10-year-old Chinese boy who had a history of congenital thrombocytopathy presented with severe iron deficiency anemia secondary to chronic gastric inflammation and duodenal ulcerations. Subtle oculocutaneous albinism led to the finding of diminished dense bodies in the platelets under electron microscopy, hence the diagnosis of Hermansky-Pudlak syndrome (HPS). Biopsies from the stomach and duodenum revealed a lymphocytic infiltration in the submucosa, but H pylori infection was absent. The gastroduodenitis responded to the treatment with omeprazole while iron deficiency anemia was corrected by oral iron therapy. HPS is a rare cause of congenital bleeding disorder with multisystemic manifestations. Upper gastrointestinal involvement is rare and should be distinguished from a mere manifestation of the bleeding diathesis.

Intravenous fluid selection rationales in acute clinical management

BACKGROUND: Intravenous fluid(IVF) is commonly used in acute clinical management. This study aimed to review the choice and primary considerations in IVF prescriptions and to evaluate the adequacy of guidelines and trainings on it in the New Territories West Cluster(NTWC) of Hong Kong.METHODS: This is a descriptive study based on data collected from an online survey. Data were processed by SPSS for statistical analysis. This study focused on a general description and doctor-nurse between group comparison. Participants were asked the choice of IVF for nine acute clinical scenarios and provide reason. A 1–10 scale was used to assess the sufficiency of guideline, training and information, and time for revision on IVF prescription.RESULTS: 0.9% sodium chloride was the most familiar IVF(36%), followed by 5% Dextrose solution(26%). In the nine scenarios, the most chosen IVF was 0.9% sodium chloride(37%–61%). There was significant difference in the choice of IVF between doctors and nurses in 7 cases. The second most chosen IVF for doctors was Plasma-Lyte A while that for nurses was Gelofusine. Departmental practice was the most chosen reason to account for the prescription. The adequacy of guideline, information and training, and time for revision was rated 5. Doctors had significantly more time at work than nurses to update knowledge in IVF prescription(5.41 versus 4.57).CONCLUSION: 0.9% sodium chloride was mostly chosen. The choice of IVF was mainly based on departmental practice. Adequacy of guideline, information and training, and time for revision on IVF prescription were average, indicating significant training deficit.

Prescription practice of antihistamines for acute upper respiratory tract infections in pediatric patients in a local emergency department in Hong Kong

BACKGROUND: Currently there is very limited data in the literature assessing the prevalence of antihistamine prescription, and there is no local prevalence data about the prescription of antihistamine agents among primary practitioner and emergency physicians. The objectives are 1) to report the prevalence of antihistamine prescription for children less than 6 years old with acute upper respiratory infection and 2) to explore the associated factors for the prescription practice.METHODS: This is a cross-sectional study. All consecutive cases of paediatric patients aged 6 or below who presented to the emergency department during a study period of one week from April 1 to July 4, 2009 with diagnosis of acute upper respiratory infection were included. Totally 162 patients were included.RESULTS: Among the 162 cases, 141(87%) patients were prescribed one antihistamine of any group. Sixty(37%) patients were prescribed two or more antihistamines. In multivariate logistic regression model, age was found to be signi? cantly(P<0.001) associated with multiple antihistamine prescription(OR=1.042, 95%CI=1.02 to 1.06). Years of graduation of attending physician for more than 5 years was also a strong predictor of multiple antihistamine prescription(OR=4.654, 95%CI=2.20 to 9.84, P<0.001).CONCLUSION: In the local emergency department, patients' age and the years of graduation from medical school of the attending physician were predictors of multiple antihistamine prescription for acute upper respiratory infections for children aged less than 6.

Initial validation of the Yin-Yang Assessment Questionnaire for persons with diabetes mellitus

AIM:To initially test for the content validity,comprehensibility,test-retest reliability and internal consistency reliability of the Yin-Yang Assessment Questionnaire(YYAQ).METHODS:The process of initial validity and reliability test covered:(1)content validation from the findings of 18 multiple-case studies,validated Yin-and Yangdeficiency assessment questionnaires,relevant literatures and registered Chinese medicine practitioners;(2)comprehension with the levels of comprehensibility for each item categorized on a 3-point scale(not comprehensible;moderately comprehensible;highly comprehensible).A minimum of three respondents selecting for each item of moderately or highly comprehensible were regarded as comprehensive;(3)test-retest reliability conducted with a 2-wk interval.The intraclass correlation coefficients(ICCs)and their 95%CIs were calculated using a two-way random effects model.Wilcoxon Signed Rank test for related samples was adopted to compare the medians of test-retest scores.An ICC value of 0.85 or higher together with P>0.05,was considered acceptable;and(4)internal consistency of the total items was measured and evaluated by Cronbach’s coefficient alpha(α).A Cronbach’sαof 0.7or higher was considered to represent good internal consistency.RESULTS:Eighteen Yin-deficiency and 14 Yang-deficiency presentation items were finalized from content validation.Five participants with type 2 diabetes mellitus(T2DM)performed the comprehensibility and testretest reliability tests.Comprehensibility score level of each presentation item was found to be moderate or high in three out of the five participants.Test-retest reliability showed that the single measure ICC of the total Yin-deficiency presentation items was 0.99(95%CI:0.89-0.99)and the median scores on the first and 14thdays were 17(IQR 6.5-27)and 21(IQR 6-29)(P=0.144)respectively.The single measure ICC of the total Yang-deficiency presentation items was 0.88(95%CI:0.79-0.99)and the median scores on the first and 14th days were 10(IQR 6-18)and 14(IQR 7-23)(P=0.144)respectively.The results of a descriptive correlation study on 140 survey participants with T2DM using the YY-AQ showed that internal consistency of the total Yin-deficiency and Yang-deficiency presentation items was satisfactory,with Cronbach’sαof 0.79 and 0.78respectively.CONCLUSION:The YY-AQ will be tested further for comprehensibility,test-retest and internal consistency reliabilities,scoring system validity,construct validity,convergent and discriminant validities,responsiveness and predictive validity.

Fulminant ulcerative colitis associated with steroid-resistant minimal change disease and psoriasis: A case report

A 43-year-old Chinese patient with a history of psoriasis developed fulminant ulcerative colitis after immunosuppressive therapy for steroid-resistant minimal change disease was stopped. Minimal change disease in association with inflammatory bowel disease is a rare condition. We here report a case showing an association between ulcerative colitis, minimal change disease, and psoriasis. The possible pathological link between 3 diseases is discussed.

Rare case of intussusception in an adult with acute myeloid leukemia

Intussusception is rarely reported in adult patients with acute leukemia. We report a case of intussusception in a 29-year-old woman with acute myeloid leukemia(AML). She developed right lower quadrant pain, fever, and vomiting on day 16 of induction chemotherapy.Physical examination showed tenderness and guarding at the right lower quadrant of the abdomen. Abdominal computed tomography(CT) showed distension of the cecum and ascending colon, which were filled with loops of small bowel, and herniation of the ileocecal valve into the cecum. We proceeded to laparotomy and revealed ileocecal intussusception with the ileocecal valve as the leading point. The terminal ileum was thickened and invaginated into the cecum, which showed gangrenous changes. Right hemicolectomy was performed and microscopic examination of the colonic tissue showed infiltration of leukemic cells. The patient recovered after the operation and was subsequently able to continue treatment for AML. This case demonstrates that the diagnosis of intussusception is difficult because the presenting symptoms can be non-specific, but abdominal CT can be informative for preoperative diagnosis. Resection of the involved bowel is recommended when malignancy is suspected or confirmed. Intussusception should be considered in any leukemia patients presenting with acute abdomen. A high index of clinical suspicion is important for early diagnosis.

Impact of IPMOE on nursing tasks in the medical ward: A time-motion study

Introduction:The In-patient Medication Order Entry System (IPMOE) was first implemented in the medical ward of Princess Margaret Hospital,Hong Kong.It was a local developed close-loop system including prescription,dispensing and administration modules.Evaluation on its impact on nursing tasks would be important for practice improvement and subsequent system enhancement.Objective:The study was conducted to quantify the nursing times across medication-associated tasks for paper-based MAR and computer-based IPMOE,including change in the tasks and time patterns before and after IPMOE implementation.Methods:This was a prospective observation study in medical wards before (Jan 2014-Jun 2014) and after (Mar 2015-Jun 2015) the implementation of IPMOE.We conducted 8-hr observation studies of individual nurses with a customized application to time various pre-categorized nursing tasks.Statistical inferences and interrupted time series analysis was performed to identify the change in the intercept and trends over time after implementation.Result:The average number of medication-related tasks was significantly reduced from 61.07 to 29.81,a reduction of 31.26 episodes per duty (P < 0.001,95% CI 22.9-39.63).The time for the medication-related tasks was reduced from 32 min (SD =21.57) to 26.57 min (SD =11.35) and the medication administration time increased from 37.93 min (SD-14.78) to 44.37 min (SD 19.45),but there was no overall significant difference in the time spent on each duty (P =0.315) between the two groups.An improving trend in the delayed effect was observed (P =0.03),which indicated a run-in period for new application was needed in clinical setting.Conclusion:Our study had shown the time motion observation could be applied to measure the impact of the IPMOE in a busy clinical setting.Through classification of activities,validation,objective measurement and longitudinal evaluation,the method could be applied in various systems as well as different clinical settings in measure efficiency.

Utilization of the Accident & Emergency Departments by Chinese elderly in Hong Kong

BACKGROUND: The epidemiological data on elderly patients attending Accident and Emergency Departments(AEDs) in Hong Kong is lacking. The study aimed to examine the epidemiology of geriatric patient visits to AEDs in Hong Kong, including demographic data and predictors of life-saving interventions(LSI) and admission.METHODS: A retrospective cross-sectional study of geriatric patients older than 64 years old attending three AEDs during the year 2012, with a sample of 1 200 patient visits recruited. The data were retrieved from the medical records of the respective hospitals. Descriptive characteristics of the visits were provided. Multivariate logistic regression was performed to evaluate the predictors of LSI and hospital admission.RESULTS: The mean age of the patients was 79.1 years. Totally 49.7% of the patients were male. "Diseases of the respiratory system" was the commonest diagnosis in AEDs as well as that required admission. The admission rate was 56.8%. Logistic regression demonstrated that dependent activity of daily living(ADL), arrival by ambulance, and the higher number of co-morbidities were predictors of LSI, while advanced age, dependent ADL, institutionalized patients, arrival by ambulance, and higher number of co-morbidities were predictors of hospital admission.CONCLUSIONS: Ageing population is creating an imminent burden on the emergency service in Hong Kong. Previously unavailable epidemiological information about geriatric attendance to AEDs was described. This forms the basis for development of future studies concerning the medical services on this specific group of patients.

Risk factors and natural history of breast cancer in younger Chinese women

AIM: To investigate the age differences in the risk factors, clinicopathological characteristics and patterns of treatment of female breast cancer patients. METHODS: Seven thousand one hundred and fiftytwo women with primary breast cancer from the Hong Kong Breast Cancer Registry were recruited after receiving patients' consent, they were asked to complete standardized questionnaires which captured their sociodemographic characteristics and risk factors associated with breast cancer development. Among them, clinicopathological data and patterns of treatment were further collected from medical records of 5523 patients with invasive breast cancers. Patients were divided into two groups according to the age at diagnosis: younger(< 40 years old) vs older patients(≥ 40 years old) for subsequent analyses.RESULTS: Analysis on the sociodemographic characteristics and exposure to risk factors were performed on 7152 women with primary breast cancer and the results revealed that younger patients were more likely to have unhealthy lifestyles; these include a lack of exercise(85.4% vs 73.2%, P < 0.001), having high stress in life(46.1% vs 35.5%, P < 0.001), having dairy/meat-rich diets(20.2% vs 12.9%, P < 0.001),having alcohol drinking habit(7.7% vs 5.2%, P = 0.002). Younger patients were also more likely to have hormone-related risk factors including nulliparity(43.3% vs 17.8%, P < 0.001) and an early age at menarche(20.7% vs 13.2%, P < 0.001). Analyses on clinicopathological characteristics and patterns of treatment were performed on 5523 women diagnosed with invasive breast cancer. The invasive tumours in younger patients showed more aggressive pathological features such as having a higher percentage of grade 3 histology(45.7% vs 36.5%, P < 0.001), having a higher proportion of tumours with lymphovascular invasion(39.6% vs 33.2%, P = 0.003), and having multifocal disease(15.7% vs 10.3%, P < 0.001); they received different patterns of treatment than their older counterparts.CONCLUSION: Younger patients in Hong Kong are more likely to encounter risk factors associated with breast cancer development and have more aggressive tumours than their older counterparts.

Granular Cell Tumor of the Esophagus: A Patient Treated by Endoscopic Mucosal Resection with Long Term Follow-Up

Granular cell tumors (GCTs) of the esophagus are uncommon. We report a case of granular cell tumor of esophagus treated by endoscopic mucosal resection (EMR) with long term follow-up.

Falling sperm counts and global oestrogenic pollution：postscript

This Special Issue provides reflections after 20 years, summarized in 12 papers, on the controversial issue of alleged decline in human sperm output due to global oestrogen pollution by industrial chemicals.

Choledochal varices bleeding:A case report

Choledochal varices are a rare cause of hemobilia associated with chronic portal vein thrombosis.We present a case of chronic portal vein thrombosis comp licated with bleeding from choledochal varices.The presentation,clinical manifestations and management are described.

The Asian Journal of Andrology： view of an outsider coming in

My interest in science in China, .stimulated in 1980 by reading theabridged version of Joseph Needham＇s ＂Science and Civilization in China＂, continued when I was a Consultant to the National Family Planning Research Institute in Beijing in 1983, and to the Shandong Stem Cell Engineering Research Center, Yantai in 2009-2012. During that time, I have acted as reviewer of the Asian Journal of Andrology （AJA）, and I continue to be one of its editorial board members. What I can contribute as the second Deputy Editor-in-Chief for the journal will depend on the challenges faced by the journal in the coming years.

A Technical Note: Inter-Observer and Inter-Modality Variability of Cone-Beam Computed Tomography (CBCT) and Ultrasound (US) in Stereotactic Body Radiotherapy for Kidney Cancer

Introduction: To investigate the inter-observer and inter-modality variabilities of two imaging guided equipments—cone-beam computed tomography (CBCT) and ultrasound (US) in kidney stereotactic body radiotherapy. Methods: A renal metastasis case implanted with three gold anchor fiducial markers was firstly scanned by US to acquire a 3-dimension US image and followed by 4-dimension CBCT in every fraction. Seven observers retrospectively registered the pre-treatment images with the corresponding reference images based on the gold markers. Registration uncertainty of the observers between two imaging modalities was evaluated. Results: The uncertainties over whole treatment course in CBCT were 0.88 mm, 1.94 mm and 0.86 mm in lateral, longitudinal and vertical directions respectively;while 0.8 mm, 0.97 mm and 1.36 mm were found in US. Conclusion: The greatest uncertainty was found in longitudinal direction in CBCT due to the fact that the respiration motion is the most rigorous in cranial-caudal direction. In US, since the probe was hold almost in upright position, the strong echo in vertical direction was attributed to the greatest uncertainty for such direction.

Effectiveness of a Patient-Specific Immobilization and Positioning System to Limit Interfractional Translation and Rotation Setup Errors in Radiotherapy of Prostate Cancers

Objective: To evaluate the effectiveness of a patient-specific immobilization and positioning device in prostate radiotherapy. Methods: Eighty patients were immobilized and positioned by a patient-specific device. Prostate translations and rotations were estimated from daily cone beam computed tomography scans using a contour-based approach assisted by auto-registration and quantified by the group mean GM, systematic Σ and random σ' errors. Dosimetric impacts of residual prostate rotations where the translation errors were corrected were evaluated by robustness plan analysis. Results: Using the patient-specific immobilization alone without online image-guidance, the GM, Σ and σ' of the prostate translations were 0.8, 1.7, and 1.5 mm (left-right;LR), 0.8, 2.1, and 1.9 mm (superior-inferior;SI), and 0.5, 1.7 and 1.5 mm (anterior-posterior;AP), while for the prostate rotations they were 0.0&deg;, 0.6&deg;, and 0.7&deg;(pitch), 0.2&deg;, 0.5&deg;, and 0.6&deg;(roll), and 0.2&deg;, 0.5&deg;, and 0.6&deg;(yaw). The resulting van Herk’s margin was 5.8 (LR), 7.3 (SI) and 5.8 (AP) mm. With adaptive online image-guidance based on estimates from the first 5 fractions, Σ were reduced by 0.7 - 1.2 mm for the prostate translations, resulting in a margin reduction by 2 - 3.5 mm. Changes of Σ and σ' in the prostate rotations were insignificant regardless of translation corrections. Dosimetric impacts of residual rotation errors were negligible if a 2 mm margin was applied. Conclusions: Our patient-specific immobilization system can effectively limit the prostate translations and rotations, which is important without 6D treatment couches or using ultrasound image-guidance without rotational corrections.