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Objective To compare predictive validity of the Wilson Sims Fall Risk Assessment Tool (WSFRAT) with that of the Morse Fall Scale (MFS) in psychogeriatric inpatients. Methods Psychogeriatric patients from Shatin Hospital, Tai Po Hospital, Castle Peak Hospital, and United Christian Hospital who had fall incident between April 2019 and April 2020 were identified. Their fall risks were assessed by the WSFRAT and the MFS, and their falls incidents during hospitalisation were recorded. Patients were classified as having high fall risk when their MFS score was ≥45 and when their WSFRAT score was ≥7. Sensitivity, specificity, and positive and negative predictive values of the two scales were calculated. Results We identified 183 (90 male and 93 female) psychogeriatric patients aged ≥65 years who had fall incident and were assessed by both the WSFRAT and the MFS during the study period. Among the 183 patients, four sustained a fall during hospital stay, giving a prevalence of 2.19%. All four patients were classified as having high risk of fall by WSFRAT, but only two of them were classified so by MFS. The sensitivity of WSFRAT was 100%, which was higher than the 50% by MFS, but specificity of MFS was higher than that of WSFRAT (45.81% vs 54.75%). Conclusion WSFRAT is a better fall risk assessment scale for psychiatric inpatients than MFS, because of higher sensitivity (100% vs 50%). It has items specific to psychiatric patients and should replace MFS in psychiatric settings.

Purpose The aim of this prospective, randomized study was to compare the performance of a rotator interval approach with the posterior glenohumeral approach for ultrasound-guided contrast injection prior to MR shoulder arthrography. Method This study was approved by the institutional review board. One hundred and twenty consecutive patients referred for MR shoulder arthrography were randomized into four groups: rotator interval approach in-plane (n = 30); rotator interval approach out-of-plane (n = 30); posterior approach in-plane (n = 30); and posterior approach out-of plane (n = 30). Outcome measures included procedure time, number of injection attempts, patient-reported pain score (0−10), and radiologist-reported technical difficulty (0–10). MR arthrograms were assessed for adequacy of joint distension, diagnostic utility, and extra-capsular contrast leakage. Results All 120 patients had a successful ultrasound-guided injection with adequate joint distension and diagnostic utility for MR arthrography. In-plane needle guidance was less technically demanding, quicker, required fewer injection attempts, and had a lower frequency of contrast leakage than out-of-plane needle guidance. The posterior glenohumeral approach was less technically demanding though had a higher frequency of contrast leakage and caused more patient discomfort than the rotator interval approach. Conclusion For ultrasound-guided shoulder joint injection, an in-plane approach is preferable. The posterior glenohumeral approach is less technically demanding though causes more patients discomfort than the rotator interval approach possibly due to the longer needle path.

To (i) devise a new semi-quantitative scoring system known as Early Rheumatoid Arthritis Magnetic Resonance Score (ERAMRS) to assess inflammation of the wrist on magnetic resonance imaging in early rheumatoid arthritis and to (ii) test ERAMRS and other MR scoring systems against everyday used clinical scorings. One hundred six treatment-naive patients (81 females, 25 males, mean age 53 ± 12 years) with early rheumatoid arthritis (ERA) underwent clinical/serological testing as well as 3-T MRI examination of the most symptomatic wrist. Clinical assessment included Disease Activity Score-28 and Health Assessment Questionnaire; erythrocyte sedimentation rate and C-reactive protein were measured. MR imaging data was scored in all patients using three devised MR semi-quantitative scoring systems, namely, the (a) ERAMRS system, (b) Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) system, and the (c) McQueen Score system. Synovitis was present in 106 (100%), tenosynovitis in 98 (92%), and bone marrow edema in 84 (79%) of 106 ERA wrists. ERAMRS had the highest correlation with clinical disease activity scores (r = 0.476, p

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.

To investigate the accuracy of ultrasound in characterising the type of mass and likelihood of malignancy in deep soft tissue masses.Five hundred seventy-nine deep soft tissue masses were prospectively studied by ultrasound. Masses (n = 137) with prior MRI or CT were not included. Following ultrasound examination, the likely nature of the mass as well as the confidence of the reporting radiologist ('fully confident' versus 'not fully confident') about the ultrasound diagnosis was recorded. Clinical and ultrasound diagnoses were compared with the histological diagnosis which was available in 134 (23%) of the 579 masses.Compared with histology, clinical and ultrasound accuracy for characterising the type of mass were 47% and 88% respectively when all differential diagnoses were considered. The radiologist was fully confident regarding the type of 436 (75%) of 579 masses and, in this setting, for those cases that could be compared with histology, diagnostic accuracy was 96%. For the remaining masses, where the radiologist was not fully confident, accuracy compared with histology was 58% for the first differential diagnosis and 80% for all differential diagnoses. For identifying malignancy, sensitivity, specificity, and positive and negative predictive value of ultrasound were 97%, 58%, 67%, and 99% respectively. Ultrasound alone was considered sufficient for diagnostic workup in over half of all deep soft tissue masses.Ultrasound is useful at characterising and recognising malignancy in deep soft tissue masses. Provided local practice patterns are favourable, ultrasound may be considered a first-line investigation in the diagnostic workup of deep soft tissue masses.• In three-quarters of cases, one can be fully confident about characterising the nature of deep soft tissue masses on ultrasound and, for those fully confident cases that could be compared with histology, the diagnostic accuracy of ultrasound was 96%. • Ultrasound can correctly recognise nearly all malignant deep soft tissue masses but some benign masses will also be considered possibly malignant. • Ultrasound alone was considered sufficient for imaging workup in over half of deep soft tissue masses.

BACKGROUND This study compares median nerve cross-sectional area (CSA) measurements at the wrist obtained with ultrasound (US) and magnetic resonance imaging (MRI) using cadaveric measurements as the gold standard. METHODS Median nerve CSA was measured using US and MRI in 9 cadaveric wrists obtained from 5 subjects at 5 locations: distal forearm, proximal to tunnel inlet, at tunnel inlet, at tunnel outlet, and distal to tunnel outlet and then on identical cadaveric transverse sections obtained with a bandsaw. All US, MRI, and cadaveric measurements were repeated to determine reliability. Median nerves of 10 patients with clinical carpal tunnel syndrome (CTS) were measured with US and MRI using an identical method US. RESULTS Median nerve CSA MRI measurements correlated better (Pearson correlation: 0.80-0.95, P

To investigate the diagnostic performance of ultrasound-guided synovial biopsy. Clinical notes, pathology and microbiology reports, ultrasound and other imaging studies of 100 patients who underwent 111 ultrasound-guided synovial biopsies were reviewed. Biopsies were compared with the final clinical diagnosis established after synovectomy (n = 43) or clinical/imaging follow-up (n = 57) (mean 30 months). Other than a single vasovagal episode, no complication of synovial biopsy was encountered. One hundred and seven (96 %) of the 111 biopsies yielded synovium histologically. Pathology ± microbiology findings for these 107 conclusive biopsies comprised synovial tumour (n = 30, 28 %), synovial infection (n = 18, 17 %), synovial inflammation (n = 45, 42 %), including gouty arthritis (n = 3), and no abnormality (n = 14, 13 %). The accuracy, sensitivity, and specificity of synovial biopsy was 99 %, 97 %, and 100 % for synovial tumour; 100 %, 100 %, and 100 % for native joint infection; and 78 %, 45 %, and 100 % for prosthetic joint infection. False-negative synovial biopsy did not seem to be related to antibiotic therapy. Ultrasound-guided Tru-cut synovial biopsy is a safe and reliable technique with a high diagnostic yield for diagnosing synovial tumour and also, most likely, for joint infection. Regarding joint infection, synovial biopsy of native joints seems to have a higher diagnostic yield than that for infected prosthetic joints. • Ultrasound-guided Tru-cut synovial biopsy has high accuracy (99 %) for diagnosing synovial tumour. • It has good accuracy, sensitivity, and high specificity for diagnosis of joint infection. • Synovial biopsy of native joints works better than biopsy of prosthetic joints. • A negative synovial biopsy culture from a native joint largely excludes septic arthritis. • Ultrasound-guided Tru-cut synovial biopsy is a safe and well-tolerated procedure.

BACKGROUND: The objective of this study is to evaluate the effects of the Multi-disciplinary Orthopaedics Rehabilitation Empowerment (MORE) Program on reducing chronic disability among injured workers and improving efficiency of work rehabilitation process. METHODS:A cohort of patientswithworkplace injuries inthelower back were recruitedfrom orthopaedics clinicsand assigned to either MORE group (n = 139) or control group (n = 106). Patients in MORE group received an early MRI screening and a coordinated multi-disciplinary management, while patients in the control group received conventional care. Outcome variables are time to return-to-work (RTW) from date of injury, waiting time for MRI screening and time to medical assessment board (MAB). RESULTS: Patients in the MORE Program had significantly shorter duration for RTW (MORE: 6.1 months, Control: 12.8 months, p< 0.01), and more RTW cases (n = 64, 46.0%) compared to Control group (n = 29, 27.4%). The MORE group also had much shorter waiting time for MRI scans (91.85 vs. 309.2 days, p< 0.001) and MAB referral after MRI scans (97.2 vs. 178.9 days, p = 0.001) compared to Control group. CONCLUSIONS: The MORE Program which emphasizes early intervention and early MRI screening, is shown to be effective in shortening sick leave and improving RTW outcomes of injured workers.

The aim of this study was to investigate the direct muscle cell-mediated actions of androgens by comparing two different mouse lines. The cre-loxP system was used to delete the DNA-binding activity of the androgen receptor (AR) in mature myofibers (MCK mARΔZF2) in one model and the DNA-binding activity of the AR in both proliferating myoblasts and myofibers (α-actin mARΔZF2) in another model. We found that hind-limb muscle mass was normal in MCK mARΔZF2mice and that relative mass of only some hind-limb muscles was reduced in α-actin mARΔZF2mice. This suggests that myoblasts and myofibers are not the major cellular targets mediating the anabolic actions of androgens on male muscle during growth and development. Levator ani muscle mass was decreased in both mouse lines, demonstrating that there is a myofiber-specific effect in this unique androgen-dependent muscle. We found that the pattern of expression of genes includingc-myc,Fzd4andIgf2is associated with androgen-dependent changes in muscle mass; therefore, these genes are likely to be mediators of anabolic actions of androgens. Further research is required to identify the major targets of androgen actions in muscle, which are likely to include indirect actions via other tissues.

To compare axial and oblique axial planes on MR arthrography (MRA) and multidetector CT arthrography (CTA) to evaluate dorsal and volar parts of scapholunate (SLIL) and lunotriquetral interosseous (LTIL) ligaments.Nine cadaveric wrists of five male subjects were studied. The visibility of dorsal and volar parts of the SLIL and LTIL was graded semi-quantitatively (good, intermediate, poor) on MRA and CTA. The presence of a ligament tear was determined on arthrosocopy and sensitivity, specificity and accuracy of tear detection were calculated.Oblique axial imaging was particularly useful for delineating dorsal and volar parts of the LTIL on MRA with overall 'good' visibility increased from 11 % to 78 %. The accuracy of MRA and CTA in revealing SLIL and LTIL tear was higher using the oblique axial plane. The overall accuracy for detecting SLIL tear on CTA improved from 94 % to 100 % and from 89 % to 94 % on MRA; the overall accuracy of detecting LTIL tear on CTA improved from 89 % to 100 % and from 72 % to 89 % on MRA CONCLUSION: Oblique axial imaging during CT and MR arthrography improves detection of tears in the dorsal and volar parts of both SLIL and LTIL.• Oblique axial imaging improves SLIL and LTIL visibility and tear detection. • This improvement is greater for the LTIL than for the SLIL ligament. • Overall, CT arthrography performed better than MR arthrography.

Lesion location is an important determinant for post-stroke cognitive impairment. Although several ‘strategic’ brain regions have previously been identified, a comprehensive map of strategic brain regions for post-stroke cognitive impairment is lacking due to limitations in sample size and methodology. We aimed to determine strategic brain regions for post-stroke cognitive impairment by applying multivariate lesion-symptom mapping in a large cohort of 410 acute ischemic stroke patients. Montreal Cognitive Assessment at three to six months after stroke was used to assess global cognitive functioning and cognitive domains (memory, language, attention, executive and visuospatial function). The relation between infarct location and cognition was assessed in multivariate analyses at the voxel-level and the level of regions of interest using support vector regression. These two assumption-free analyses consistently identified the left angular gyrus, left basal ganglia structures and the white matter around the left basal ganglia as strategic structures for global cognitive impairment after stroke. A strategic network involving several overlapping and domain-specific cortical and subcortical structures was identified for each of the cognitive domains. Future studies should aim to develop even more comprehensive infarct location-based models for post-stroke cognitive impairment through multicenter studies including thousands of patients.

The purpose of this study was to assess the effects of traction during MR arthrography of the wrist on joint space widening, cartilage visibility, and detection of tears of the triangular fibrocartilage complex (TFCC) and intrinsic ligaments.A prospective study included 40 wrists in 39 patients (25 men, 14 women; mean age, 35 years). MR arthrography was performed with a 3-T MRI system with and without axial traction. Two radiologists independently measured wrist and carpal joint space widths and semiquantitatively graded articular cartilage visibility. Using conventional arthrography as the reference standard and working in consensus, they assessed for the presence of tears of the TFCC, lunotriquetral ligament (LTL), and scapholunate ligament (SLL). Visibility of a tear before traction was compared with visibility after traction.With traction, all joint spaces in the wrist and carpus were significantly widened (change, 0.15-1.01 mm; all p0.006). Subjective cartilage visibility of all joint spaces improved after traction (all p ≤ 0.048) except for that of the radioscaphoid space, which was well visualized even before traction. Conventional arthrography depicted 24 TFCC tears, seven LTL tears, and three SLL tears. The accuracy of tear detection improved after traction for the TFCC (98% after traction vs 83% before traction), the LTL (100% vs 88%), and the SLL (100% vs 95%). Tear visibility improved after traction for 54% of TFCC tears, 71% of LTL tears, and 66% of SLL tears.Wrist MR arthrography with axial traction significantly improved the visibility of articular cartilage and the detection and visibility of tears of the TFCC and intrinsic ligaments. The results favor more widespread use of traction during MR arthrography of the wrist.

Mycoplasma pneumoniae infection usually presents with upper and lower respiratory tract infection. Extrapulmonary involvement is not uncommon, however. We report two cases of predominantly extrapulmonary manifestations of Mycoplasma pneumoniae infection without significant pulmonary involvement. Both cases were diagnosed by serology. These cases illustrate the diversity of clinical presentations of Mycoplasma pneumoniae infection. Clinicians should maintain a high index of suspicion.

The aim of this study was to investigate the effect of an upright position on cerebellar tonsillar level in patients with adolescent idiopathic scoliosis (AIS). Twenty-five patients with clinically diagnosed AIS and 18 normal controls were examined in both supine and upright positions using 0.25T MRI. The position of the inferior cerebellar tonsil tip relative to a reference line connecting the basion to the opisthion (BO line) was measured in millimetres. None of the 18 normal control subjects had cerebellar tonsillar descent below the BO line in either supine or the upright position. Forty-eight percent of AIS patients had tonsillar descent in the upright position, compared to 28 % in the supine position. In the upright position, cerebellar tonsillar position was lower in AIS patients than in normal subjects (mean −0.7 ± 1.5 vs. +2.1 ± 1.7, p

STUDY DESIGN Cohort study. OBJECTIVE To investigate the diagnostic capability of low-field magnetic resonance imaging (MRI) compared with high-field MRI for degenerative disease of the lumbar spine. SUMMARY OF BACKGROUND DATA Low-field MRI has several advantages over high-field magnetic resonance systems (easier installation, lower purchase, and maintenance cost). The diagnostic capability of low-field MRI for degenerative disease of the lumbar spine has not been compared with that of high-field MRI. METHODS Hundred patients (mean age: 56.3 yr, range: 32-80; F:M = 59:41) with neurogenic claudication or sciatica were studied. All patients underwent MRI of the lumbar spine on both low-field (0.25T) and high-field (1.5T or 3.0T) magnetic resonance systems. Intervertebral disc herniation, central canal, lateral recess, and exit foraminal stenosis as well as nerve root compression at L3-L4, L4-L5, and L5-S1 were evaluated by 2 radiologists for both low- and high-field systems using established reliable grading systems. RESULTS There was excellent agreement between low- and high- field MRI with regard to grading the presence and severity of disc herniation (r = 0.92-0.94; P < 0.05), central canal stenosis (r = 0.89-0.91; P < 0.05), lateral recess stenosis (r = 0.81-0.87; P < 0.05), and exit foramen stenosis (r = 0.81-0.89; P < 0.05). Descending or exiting nerve root compression occurred in 52% of patients at L3-L4, L4-L5, or L5-S1 levels, with good agreement between low-field and high-field MRI (r = 0.71-0.76; P < 0.05) for nerve root compression. CONCLUSION Excellent reliability between low- and high- field MRI was found for most features of lumbar disc degeneration, with good agreement for nerve root compression. 0.25T MRI was more susceptible to motion artifact, probably due to longer scanning time. LEVEL OF EVIDENCE 3.

Strongyloidiasis is a parasitic disease caused by Strongyloides stercoralis, a nematode predominately endemic to tropical and subtropical regions, such as Southeast Asia. Autoinfection enables the organism to infect the host for extended periods. Symptoms, when present, are non-specific and may initially lead to misdiagnosis, particularly if the patient has additional co-morbid conditions. Immunosuppressive states place patients at risk for the Strongyloides hyperinfection syndrome (SHS), whereby the organism rapidly proliferates and disseminates within the host. Left untreated, SHS is commonly fatal. Unfortunately, the non-specific presentation of strongyloidiasis and the hyperinfection syndrome may lead to delays in diagnosis and treatment. We describe an unusual case of SHS in a 30-year-old man with a long-standing history of systemic lupus erythematosus who underwent a partial colectomy. The diagnosis was rendered on identification of numerous organisms during histologic examination of the colectomy specimen.

An accurate in vivo method of measuring dimensions of the anteromedial (AM) and posterolateral (PL) anterior cruciate ligament (ACL) bundles has not been established. The purpose of this study was to measure each individual bundle using double oblique axial MR imaging of the ACL, to compare this with cadaveric measurements, and to investigate the range of measurements seen in normal subjects.In five cadaveric knees, measurements obtained of the proximal, middle, and distal segments of each ACL bundle from double oblique axial MR images were compared with direct measurements following anatomical dissection. Thereafter, the size of both bundles from 24 normal knees was measured using an identical MR technique. Inter-observer variation was calculated using intraclass correlation.ACL bundle measurement in the cadaveric knees had a strong correlation (r = 0.93) with measurements obtained following anatomical dissection. No significant difference existed between measurements obtained from cadaveric knees and living normal subjects (p 0.05). Interobserver correlation for MR measurements was excellent (R = 0.92-0.93). Overall, the long and short axis of the AM bundle were significantly larger than those of the PL bundle (p 0.05). Also, men showed significantly larger AM and PL bundles than women (p 0.05). Bundle size was not related to age or knee dominance.The individual ACL bundles can be accurately measured on double oblique axial MR imaging. The AM bundle is larger in caliber than the PL bundle. Both bundles are larger in men than in women and there is no significant side-to side difference.

This study compares the diagnostic performance of multidetector CT arthrography (CTA), conventional 3-T MR and MR arthrography (MRA) in detecting intrinsic ligament and triangular fibrocartilage complex (TFCC) tears of the wrist. Ten cadaveric wrists of five male subjects with an average age 49.6 years (range 26–59 years) were evaluated using CTA, conventional 3-T MR and MRA. We assessed the presence of scapholunate ligament (SLL), lunotriquetral ligament (LTL), and TFCC tears using a combination of conventional arthrography and arthroscopy as a gold standard. All images were evaluated in consensus by two musculoskeletal radiologists with sensitivity, specificity, and accuracy being calculated. Sensitivities/specificity/accuracy of CTA, conventional MRI, and MRA were 100 %/100 %/100 %, 66 %/86 %/80 %, 100 %/86 %/90 % for the detection of SLL tear, 100 %/80 %/90 %, 60 %/80 %/70 %, 100 %/80 %/90 % for the detection of LTL tear, and 100 %/100 %/100 %, 100 %/86 %/90 %, 100 %/100 %/100 % for the detection of TFCC tear. Overall CTA had the highest sensitivity, specificity, and accuracy among the three investigations while MRA performed better than conventional MR. CTA also had the highest sensitivity, specificity, and accuracy for identifying which component of the SLL and LTL was torn. Membranous tears of both SLL and LTL were better visualized than dorsal or volar tears on all three imaging modalities. Both CT and MR arthrography have a very high degree of accuracy for diagnosing tears of the SLL, LTL, and TFCC with both being more accurate than conventional MR imaging.

To investigate the agreement among magnetic resonance (MR) imaging, computed tomography (CT), and arthroscopy in the measurement of glenoid bone loss.This study was approved by the institutional ethics committee. One hundred seventy-six patients (158 male and 18 female patients; mean age, 26.8 years ± 12.3) with anterior shoulder dislocation underwent both shoulder MR imaging and CT examination. Anterior straight line length, glenoid width, and best-fit bone loss were measured with MR imaging and CT. Sixty-five patients also underwent arthroscopy, which was used as the standard of reference. Assessment of glenoid bone loss at MR imaging was compared with that at CT and arthroscopy. Inter- and intrareader reproducibility of MR imaging-derived measurements of glenoid bone loss was evaluated.There was excellent correlation between CT and MR imaging with regard to anterior straight line length (r = 0.97, P.0001), glenoid width (r = 0.95, P.0001), and severity of glenoid bone loss-particularly with use of best-fit circle width (r = 0.83, P.0001) rather than best-fit circle area (r = 0.82, P.0001). In the assessment of glenoid bone loss, the correlation between CT and arthroscopy (r = 0.91, P.0001) was marginally better than that between MR imaging and arthroscopy (r = 0.84, P.0001). The inter- and intrareader correlations of MR imaging-derived measurements of glenoid bone loss were excellent (R = 0.90-0.95).MR imaging assessment of glenoid bone loss, particularly with use of glenoid width, is almost as accurate as CT assessment.

This study examined the use of the Hong Kong version of the Rivermead Behavioral Memory Test-Third Edition (RBMT-3) for older adults, and by presenting the optimal cut-off scores for patients with cognitive impairments, and for a group of peers who have functional everyday cognition. Hundred older adults residing in community dwellings were recruited from three non-government organisations and completed the RBMT-3: 29 patients with mild to moderate dementia, 34 persons at risk for MCI, and 37 matched older adults with everyday functional cognition for a healthy control group (NC). The test has excellent inter-rater (ICC [2, 1] = 0.997), intra-rater (ICC [3, 1] = 0), and parallel version (ICC [3, 1] = 0.990) reliabilities, as well as satisfactory internal consistency (Cronbach's alpha: 0.643-0.832). The scores of the MCI group were significantly lower than those of NC group in four subtests. The optimal cut-off scaled scores of ≤ 41.5, ≤ 102.5, and ≤ 131.5 are suggested for the RBMT-3 to discriminate between patients with mild and moderate dementia, mild dementia and MCI, and MCI and NC, with sensitivities 73%, 100% and 94.1%, respectively. This version is useful to differentiate those with or without risk of cognitive impairments.

Background An occult pneumothorax (OP) is a pneumothorax not seen on a supine chest X-ray (CXR) but detected on abdominal or thoracic computed tomography (CT) scanning. With the increasing use of CT in the management of significantly injured trauma patients, more OPs are being detected. The aim of this study was to classify OPs diagnosed on thoracic CT (TCT) and correlate them with their clinical significance. Methods Retrospective analysis of prospectively collected trauma registry data. Total 36 ( N = 36) consecutive significantly injured trauma patients admitted through the emergency department (ED) who sustained blunt chest trauma and underwent TCT between 1 January 2007 and 31 December 2008 were included. OP was defined as the identification (by a consultant radiologist) of a pneumothorax on TCT that had not been detected on supine CXR. OPs were classified by laterality (unilateral/bilateral) and location (apical, basal, non apical/basal). The size of pneumothoraces, severity of injury [including number of associated thoracic injuries and injury severity score (ISS)], length of hospital stay and mortality were compared between groups. The need for tube thoracostomy and clinical outcome were also analysed. Results Patients with bilateral OPs ( N = 8) had significantly more associated thoracic injuries (median: 2 vs. 1, p = 0.01), higher ISS (median: 35 vs. 23, p = 0.02) and longer hospital stay (median: 20 days vs. 11 days, p = 0.01) than those with a unilateral OP ( N = 28). Basal OPs ( N = 7) were significantly larger than apical ( N = 10) and non-apical/basal Ops ( N = 11). Basal OPs were associated with significantly more associated thoracic injuries (median: 2 vs. 1, p = 0.01), higher ISS (median: 35 vs. 25, p = 0.04) and longer hospital stays (median: 23 days vs. 17 days, p = 0.02) than apical Ops, which had higher ISS (median: 35 vs. 25, p = 0.04) and longer hospital stays (median: 23 days vs. 15 days, p = 0.02) than non-apical/basal OPs. Non-apical/basal OPs were associated with more related injuries (median: 2 vs. 1, p = 0.02) than apical OPs. All apical and non-apical/basal OPs were successfully managed expectantly without associated mortality. Conclusion This TCT classification of OP is proposed to help clinicians to decide on subsequent management of the OP. Basal OPs are significantly larger in size, and both basal and bilateral OPs are associated with higher severity of injury and longer hospital stay. These groups of patient may benefit from prophylactic tube thoracostomy instead of conservative treatment. On the other hand, apical and non-apical/basal groups is smaller in size, less severely injured and thus can be successfully managed expectantly.

We describe the uncommon development of leptomeningeal lipomatosis in a girl with encephalocraniocutaneous lipomatosis (ECCL). Leptomeningeal involvement had not been present at 2 years of age, but was demonstrated on CT and MRI at 10 years of age. Our case demonstrates follow-up neuroimaging features of ECCL that may be helpful to radiologists in suggesting the correct diagnosis, as ocular and cutaneous lesions may be non-specific clinically. The developmental nature of leptomeningeal involvement in our case suggests that close clinical and radiological follow-up is important in children with suspected or established ECCL.

Acute appendicitis complicating Amyand's hernia is an extremely rare condition, in which the appendix herniates into the inguinal sac and, subsequently, gets inflamed. The condition is difficult to diagnose clinically. Imaging is valuable for its diagnosis and detection of the associated complications. In this article, we will discuss the imaging features of acute appendicitis complicating Amyand's hernia and the results of a literature review on the condition.

Phlegmonous gastritis is a rare acute bacterial infection of the gastric wall with an extremely high mortality rate. Early diagnosis is crucial for immediate treatment that could improve the outcomes. Here we report a case in which a patient with underlying chronic myelomonocytic leukemia was diagnosed with phlegmonous gastritis on biopsy. This 57-year-old man presented with shortness of breath and intermittent upper quadrant abdominal pain for 4 days. Laboratory tests showed markedly increased white blood cell. A diagnosis of chronic myelomonocytic leukemia was made based on a peripheral blood smear and flow cytometry. Gastric biopsy showed suppurative inflammation in the submucosal region, prompting the diagnosis of phlegmonous gastritis. The patient was given empirical antibiotic treatment, and the white blood cell decreased dramatically. Surgical intervention was discussed but deferred. Despite continued antibiotics treatment, the patient died. The limited autopsy confirmed the diagnosis of phlegmonous gastritis. Immunohistochemical studies further revealed the occurrence of myeloid sarcoma that involved the gastrointestinal tract.

Androgens have anabolic actions in skeletal muscle and could potentially act to: (a) increase proliferation of myoblasts; (b) delay differentiation to myotubes; and (c) induce protein accretion in post-proliferative myofibers. To identify the site of androgens action, we investigated the proliferative response of the C2C12 mouse myoblast cell line to testosterone and dihydrotestosterone (DHT) treatment. Neither androgens affected cell proliferation after up to 7 days treatment, nor was there a synergistic effect of androgens on the proliferative response of C2C12 cells to IGF-I treatment. However, proliferating C2C12 cells expressed 0.1% of the level of androgen receptor (AR) mRNA found in adult mouse gastrocnemius muscle (p

This paper presents a study to develop a heat index, for use in hot and humid sub-tropical climate in Hong Kong. The study made use of hospitalization data and heat stress measurement data in Hong Kong from 2007 to 2011. The heat index, which is called Hong Kong Heat Index (HKHI), is calculated from the natural wet bulb temperature, the globe temperature, and the dry bulb temperature together with a set of coefficients applicable to the high humidity condition in the summer of Hong Kong. Analysis of the response of hospitalization rate to variation in HKHI and two other heat indices, namely Wet Bulb Globe Temperature (WBGT) and Net Effective Temperature (NET), revealed that HKHI performed generally better than WBGT and NET in reflecting the heat stress impact on excess hospitalization ratio in Hong Kong. Based on the study results, two reference criteria of HKHI were identified to establish a two-tier approach for the enhancement of the heat stress information service in Hong Kong.

Background: Recently, the Chinese Verbal Learning Test (ChVLT) was developed to assess episodic memory in Chinese speakers. The goal of this analysis was to determine whether memory consolidation as measured by the ChVLT was specifically associated with hippocampal volume in patients with cognitive impairment. Methods: We administered the ChVLT to 22 Chinese-speaking patients with mild cognitive impairment and 9 patients with dementia and obtained hippocampal and cortical volumes from T1-weighted magnetic resonance imaging. Results: Linear regression revealed that hippocampal volume explained 9.9% of the variance in delayed memory ( P = .018) after controlling for the effects of age, education, immediate recall after the last learning trial, overall level of cognitive impairment, and volumes of other cortical regions. conclusion: These results indicate that the ChVLT is specifically correlated with hippocampal volume, supporting its utility for detecting hippocampal disease and monitoring hippocampal state over time.

We report a rare complication of factor V deficiency in a patient having Legionella pneumonia. This patient also had other complications like severe acute respiratory distress syndrome, acute kidney injury, and septic shock that required venous-venous extracorporeal membrane oxygenation support. This is the first reported case of acquired factor V deficiency in a patient receiving extracorporeal membrane oxygenation for Legionella pneumonia. With the combined use of intravenous immunoglobulin, rituximab and plasma exchange, we achieved rapid clearance of the factor V inhibitor within 1 week so as to allow safe decannulation of extracorporeal membrane oxygenation.

A high degree of gait symmetry is characteristic of healthy gait. The aim of this study is to examine the symmetry of various gait parameters in subjects with unilateral trans-tibial amputation over a range of acceptable anteroposterior translational and tilt alignments, and further to examine if a consistent alignment of highest symmetry can be found. Acceptable alignments were determined by bench, static and dynamic testing on level and non-level surfaces. A total of 15 kinetic and kinematic parameters were then measured in the seven subjects participating in this study. Results indicate that some parameters show consistently higher symmetries, particularly the vertical ground reaction force parameters and the stance duration, step length and time to full knee flexion during the swing phase. Symmetries in other parameters such as knee flexion at loading response, acceleration impulse, and peak anteroposterior propulsive force seem to have little relevance in determining whether the gait pattern for that prosthetic alignment is acceptable or not. While analysis of the symmetry of more relevant gait parameters may assist the prosthetist in consistently and objectively identifying a most symmetrical alignment within the acceptable range, further clinical study is required before any conclusions can be drawn regarding evaluation of symmetry as a tool in defining any optimum alignment.

Aims: To compare the anatomical and visual outcomes of macular hole repair surgery using indocyanine green (ICG) or trypan blue (TB) staining of the internal limiting membrane (ILM). Method: Retrospective analysis of 37 eyes from 37 consecutive patients with stage 2, 3, and 4 idiopathic macular holes who underwent macular hole repair by one surgeon using the same technique but utilising different dyes for ILM peeling. In 19 patients ICG was used while 18 patients had TB. The anatomical and visual results in these two groups were compared. Results: There were no significant differences in the demographic and macular hole characteristics of the ICG and TB groups. Macular hole closure was achieved in 91.9% of all patients of which the ICG group had an 89.5% hole closure rate and the TB group had a 94.4% hole closure rate. After excluding cases with failed hole closure and other vision affecting complications, there was no significant difference between the preoperative visual acuities in the TB and ICG groups but the postoperative visual acuities were better in the TB than the ICG group (p = 0.036). The TB group also had more Snellen lines of improvement than the ICG group (2.94 v 1.79 lines; p = 0.046). Conclusion: TB appears to be less toxic than ICG when used in dye assisted peeling of ILM during macular hole repair as reflected by the better visual results in the TB group of patients.

Studying ethnically diverse groups is important for furthering our understanding of biological mechanisms of disease that may vary across human populations. The ε4 allele of apolipoprotein E (APOE ε4) is a well-established risk factor for Alzheimer’s disease (AD), and may confer anatomic and functional effects years before clinical signs of cognitive decline are observed. The allele frequency of APOE ε4 varies both across and within populations, and the size of the effect it confers for dementia risk may be affected by other factors. Our objective was to investigate the role APOE ε4 plays in moderating brain volume in cognitively normal Chinese older adults, compared to older white Americans. We hypothesized that carrying APOE ε4 would be associated with reduced brain volume and that the magnitude of this effect would be different between ethnic groups. We performed whole brain analysis of structural MRIs from Chinese living in America (n = 41) and Shanghai (n = 30) and compared them to white Americans (n = 71). We found a significant interaction effect of carrying APOE ε4 and being Chinese. The APOE ε4xChinese interaction was associated with lower volume in bilateral cuneus and left middle frontal gyrus (Puncorrected

To compare the effect of traction during non-arthrographic and arthrographic MR examination of the wrist with regard to joint space width, joint fluid dispersion and cartilage surface visibility.Prospective 3-T MRI study of 100 wrists in 96 patients. The first 50 wrists underwent MR arthrography first without traction and then with traction. The following 50 wrists underwent standard MR first without traction and then with traction. On these examinations, two radiologists independently measured (i) joint space width, semi-quantitatively graded (ii) joint fluid dispersion between opposing cartilage surfaces and (iii) articular cartilage surface visibility. The three parameters were compared between the two groups.Traction led to an increase in joint space width at nearly all joints in all patients (p 0.05), although more so in the arthrography (∆ = 0.08-0.79 mm, all p 0.05) than in the non-arthrography (∆ = 0.001-0.61 mm, all p 0.05) group. Joint fluid dispersion and cartilage surface visibility improved after traction in nearly all joints (p 0.05) in all patients and more so in the arthographic than in the non-arthrography group.Traction did significantly improve cartilage surface visibility for standard MRI of the wrist although the effect was not as great as that seen with MR arthography or MR arthrography with traction. Advances in knowledge: This is the first study to show the beneficial effect of traction during standard non-arthrography MRI of the wrist and compare the effect of traction between non-arthrographic and arthrographic MRI of the wrist.

To compare the assessment of wrist synovitis severity, synovial volume and synovial perfusion parameters on a dedicated low-field (0.25-T) to that of a high-field (3-T) whole-body MR system in patients with rheumatoid arthritis (RA). Twenty-one patients (mean age 50.0 ± 9.8 years) with active RA were recruited prospectively. Dynamic contrast-enhanced MRI examination of the most severely affected wrist was performed at both 0.25 T and 3 T. Three MRI-derived parameters, synovitis severity (RAMRIS grade), synovial volume (ml3) and synovial perfusion indices (maximum enhancement and enhancement slope), were compared. Comparing 0.25- and 3-T MRI, there was excellent agreement for semiquantitative assessment (r: 0.80, p

A 61-year-old Caucasian woman presented with a 4-day history of an acute blistering rash over her arms and legs. She had also developed swelling and puffiness around her eyes with associated vomiting and fever. She had been completely well up to 4 days prior to presentation. Her only medication was bendrofluazide 2.5 mg daily for her long-standing hypertension. She had never smoked and reported no previous skin conditions, allergies or recent travel. On examination, she looked unwell and was pyrexial at 38.3°C. She had bilateral peri-orbital oedema and palpable supraclavicular lymph nodes. There were raised tender erythematous plaques, associated with tense blisters on some lesions, on her legs (figure 1), arms and face. Larger bullae were found on her forearms and upper back (figure2). There were no nail changes or oral lesions. She had a regular tachycardia of 100 beats/min and a blood pressure of 120/60 mmHg. The rest of …

Alpha-dystroglycanopathies are a group of diseases due to reduced glycosylation of alpha-dystroglycan, which commonly result from mutations in POMT1, POMT2, and POMGnT1. Patients with alpha-dystroglycanopathies present with muscular, cerebral, and ocular involvements with differing severities. We reported a boy who presented with muscular dystrophy, developmental delay, and non-specific white matter lesions. Mutation analysis of POMT1 was performed and revealed two novel mutations, a substitution mutation (c.176T>G) and a duplication mutation (c.2059dupC) which results in premature termination of translation. In-silico prediction in five different platforms concurred that the substitution is damaging, and functional studies by immunofluorescence revealed lack of staining in the carbohydrate moiety of alpha-dystroglycan, confirming the molecular findings in a functional manner. In conclusion, we reported the first case of genetically confirmed alpha-dystroglycanopathy due to mutations in POMT1 in Chinese.

Low back pain is one of commonest problems prompting a visit to the family physician. Up to 5% of patients with chronic low back pain in the primary care setting are diagnosed as having spondyloarthritis, which includes the prototype disease ankylosing spondylitis. Making a diagnosis of ankylosing spondylitis is often delayed for years, leading to significant pain, impairment of quality of life, disability and productivity loss. A recent breakthrough in the treatment of spondyloarthritis is the anti-tumor necrosis factor-alpha biologics, which lead to rapid relief of pain and inflammation, and improvement in all clinical parameters of the disease. Patients with early spondyloarthritis often respond better than those with late established disease. With proper recognition of inflammatory back pain, and the use of magnetic resonance imaging, spondyloarthritis can now be diagnosed much earlier before features are evident on plain radiographs. Referral to the rheumatologist based on onset of back pain (> 3 months) before the age of 45 years, and an inflammatory nature of the pain, or the presence of human leukocyte antigen-B27, or sacroiliitis by imaging, have been confirmed in multi-center international studies to be a pragmatic approach to enable early diagnosis of spondyloarthritis. This referral strategy has recently been adopted by the Hong Kong Society of Rheumatology for primary care physicians and non-rheumatology specialists.

OBJECTIVE. Standard percutaneous bone biopsy involves manual needle insertion. Recently, a battery-powered needle drilling biopsy system (OnControl) has been introduced. We report our experience using this drill biopsy system for CT-guided percutaneous bone biopsy in 25 patients. CONCLUSION. CT-guided percutaneous biopsy using the OnControl bone access system is a safe, quick, and effective method for sampling bone lesions visible on CT.

Objective To evaluate the morphologic changes of aldosterone-producing adenoma (APA) on computed tomography (CT) before and after radiofrequency ablation (RFA) and to assess the factors that are important in determining successful complete ablation of these tumours. Method Between August 2004 and August 2011, 24 consecutive patients with APA undergoing CT-guided percutaneous RFA were identified from our prospective database. The pre-RFA and post-RFA CT appearances of these APAs that showed positive biochemical response were reviewed retrospectively for their 3-dimensional size, tumour volume, and CT attenuation in terms of Hounsfield units (HU). A comparison of these parameters before and after RFA was performed. Results In this study, there were 23 APAs in these 24 patients that showed biochemical cure of primary aldosteronism after RFA. When comparing post-RFA to pre-RFA CTs, there was no significant change in tumour size (14.5 mm vs 14.6 mm: P = .83) and tumour volume (1.55 cm3 vs 1.59 cm3; P = .41) after RFA. In nonenhanced CT images, there was no significant reduction in HU from pre-RFA to post-RFA measurements (4.4 HU vs 7.9 HU; P = .52). In contrast-enhanced CTs, there was a significant drop in HU after RFA (from 48.3 HU to 14.7 HU; P = .03). None of the included cases showed a focal region of contrast enhancement to suggest residual tumour. Conclusion A change in tumour size, tumour volume, and HU in nonenhanced CT were unreliable in defining radiologic treatment success. Only changes in HU in contrast-enhanced CT was useful in confirming a positive treatment response after RFA for APA.

Pathological fracture is an uncommon presentation in patients with long bone osteosarcoma.We retrospectively reviewed the database of all patients with histologically proven osteosarcoma under the age of 18 years from 1991 to 2011 in a tertiary pediatric oncology referral center. Five patients with pathological fractures as the first presentation of osteosarcoma were identified. The treatment strategies and complications were evaluated. Ten sex-, age-, and site- matched osteosarcoma patients without pathological fracture were selected as controls. The incidence of distant metastases and outcome, including local recurrence and survival, were compared between the index (with pathological fracture) and the control (without pathological fracture) groups.In the index group, all five patients were boys and the mean age of onset was 13.1 years (range 9.2-14.9). Three patients (60%, 3/5) received amputation and two (40%) had wide local excision of the tumor. Pathological fracture group showed higher rate of lung (60% vs. 10%, P = 0.04) and bone (60% vs. 10%, P = 0.04) metastases at presentation, and shorter overall 5-year survival (P = 0.04) than the control group. There was no significant difference of local recurrence (20%, P = 1.00) between these two groups regardless of the type of operation.Osteosarcoma complicated by pathological fracture as first presentation had higher incidence of lung and bone metastases at presentation and worse survival rate when compared with patients without pathological fracture.

When taking molds for foot orthoses, it is accepted practice to position the subtalar joint in its neutral position. However, foot orthoses have no contact with the talus, and this leads to a hypothesis that as long as there is correction available to appropriately align the forefoot relative to the hindfoot when taking a mold, changes in subtalar joint angles do not lead to significant alterations in the plantar surface shapes of the molds taken. This study tested this presumption with 20 subjects between 22 and 46 years old. During non-weight-bearing casting, the subtalar joints were aligned at positions of 4° of eversion, 2° of eversion, 2° of inversion, and in neutral. At each orientation, forces were applied over the forefoot such that the metatarsal heads were aligned with the rearfoot. Digital scanning was used to analyze the shape of each negative mold. There were significant changes in projection volume in different subtalar joint orientations. However, the changes in arch heights, navicular height, and protrusion were insignificant and very small. It is therefore suggested that as long as the forefoot and hindfoot are appropriately aligned, variations in the orientation of the subtalar joint would be acceptable.

OBJECTIVES. To develop a questionnaire for measuring the perceived importance of the elements of mental health recovery in psychiatric inpatients in Hong Kong and to test the psychometric properties of the questionnaire. METHODS. Thematic content analysis of identified literature on mental health recovery was performed to identify the elements related to mental health recovery. A questionnaire was developed to assess the perceived importance of the identified elements. An expert panel was set up to evaluate the content validity and patient focus group's face validity of the questionnaire. Participants were recruited from medium-stay and rehabilitation wards of Castle Peak Hospital. RESULTS. A total of 101 psychiatric inpatients completed the questionnaire, the majority of whom suffered from schizophrenia (75%). Having meaning in life was rated by 91% of the participants as an important element of recovery, followed by hope (86%) and general health and wellness (85%). Cronbach's alpha for internal consistency was 0.91. Explorative factor analysis yielded 7 factors and intraclass correlation coefficients revealed a fair-to-good test-retest reliability. CONCLUSIONS. The results supported the psychometric properties of the questionnaire for measurement of mental health recovery and serve as a basis for the future development of recovery-oriented services in the psychiatric inpatient settings in this locality.

Background Radiological examinations are commonly requested for patients to aid clinical diagnosis. However, many doctors do not realise how much radiation dosage their patients are exposed to during radiological investigations. This study aims to assess and compare the knowledge of radiologists and non-radiologists about radiation doses of common radiological investigations. Methods A prospective questionnaire study of doctors about the dosage of commonly performed radiological investigations in a university teaching hospital in Hong Kong. Participants were asked to indicate the average dose of radiation (in mSv) for a standard chest x-ray exposure. Doctors were then asked to estimate the doses of radiation (measured in chest x-ray equivalents) for various radiological procedures. The results of radiologists and non-radiologists were compared. Results 158 doctors (25 radiologists and 133 non-radiologists) completed the questionnaire. The overall accuracy was 40% for radiologists and 16% for non-radiologists. One-third of non-radiologists could not distinguish radiological examinations with or without ionising radiation. No non-radiologists correctly stated the radiation dose (in mSv) of a conventional chest x-ray, and 77% underestimated the dose of radiological examinations. For radiologists, only 32% were correct for the radiation dose of a conventional chest x-ray while 7% underestimated the radiation doses. Conclusion Knowledge of radiation doses of investigation is generally inadequate among radiologists, and particularly poor in non-radiologists. Underestimation of radiation doses may expose patients to increasing radiological investigation and exposure to radiation hazards. Awareness of the radiation hazard of radiological examinations should be raised among medical professionals.

To review the site of involvement, clinical presentation, and treatment outcome of patients having immunoglobulin G4-related sclerosing disease in a local regional hospital.Retrospective case series.Pamela Youde Nethersole Eastern Hospital, Hong Kong.All patients with a diagnosis of immunoglobulin G4-related sclerosing disease in the hospital diagnosed in the period from April 2008 to March 2010.A total of 12 patients with involvement of various organs were identified. There was a male predominance (male-to-female ratio=5:1). The mean age at diagnosis was 65 years. The salivary glands, biliary tract, pancreas, and cervical lymph nodes were the commonest involved sites. The immunoglobulin G4 level was elevated in 83% of the patients. Patients usually appeared to respond well to steroid treatment.Immunoglobulin G4-related sclerosing disease is a systemic disease and can involve various systems.

The aim of this study is to determine if the Odc1 gene, which encodes ornithine decarboxylase (ODC), the rate-limiting enzyme in polyamine biosynthesis, is directly regulated by the androgen receptor (AR) in skeletal muscle myoblasts and if Odc1 regulates myoblast proliferation and differentiation. We previously showed that expression of Odc1 is decreased in muscle from AR knockout male mice. In this study, we show in vivo that Odc1 expression is also decreased >60% in muscle from male muscle-specific AR knockout mice. In normal muscle homeostasis, Odc1 expression is regulated by age and sex, reflecting testosterone levels, as muscle of adult male mice expresses high levels of Odc1 compared with age-matched females and younger males. In vitro, expression of Odc1 is 10- and 1.5-fold higher in proliferating mouse C2C12and human skeletal muscle myoblasts, respectively, than in differentiated myotubes. Dihydrotestosterone increases Odc1 levels 2.7- and 1.6-fold in skeletal muscle cell myoblasts after 12 and 24 h of treatment, respectively. Inhibition of ODC activity in C2C12myoblasts by α-difluoromethylornithine decreases myoblast number by 40% and 66% following 48 and 72 h of treatment, respectively. In contrast, overexpression of Odc1 in C2C12myoblasts results in a 27% increase in cell number vs. control when cells are grown under differentiation conditions for 96 h. This prolonged proliferation is associated with delayed differentiation, with reduced expression of the differentiation markers myogenin and Myf6 in Odc1-overexpressing cells. In conclusion, androgens act via the AR to upregulate Odc1 in skeletal muscle myoblasts, and Odc1 promotes myoblast proliferation and delays differentiation.

The naturally occurring polyamines, spermidine, spermine, and their precursor putrescine, play indispensible roles in both prokaryotic and eukaryotic cells, from basic DNA synthesis to regulation of cell proliferation and differentiation. The rate-limiting polyamine biosynthetic enzymes, ornithine decarboxylase (ODC) and S-adenosylmethionine decarboxylase, are essential for mammalian development, with knockout of the genes encoding these enzymes, Odc1 and Amd1, causing early embryonic lethality in mice. In muscle, the involvement of polyamines in muscle hypertrophy is suggested by the concomitant increase in cardiac and skeletal muscle mass and polyamine levels in response to anabolic agents including β-agonists. In addition to β-agonists, androgens, which increase skeletal mass and strength, have also been shown to stimulate polyamine accumulation in a number of tissues. In muscle, androgens act via the androgen receptor to regulate expression of polyamine biosynthetic enzyme genes, including Odc1 and Amd1, which may be one mechanism via which androgens promote muscle growth. This review outlines the role of polyamines in proliferation and hypertrophy, and explores their possible actions in mediating the anabolic actions of androgens in muscle.

This paper details the experience of establishing an integrated skills training centre for use in undergraduate nursing education in The Open University of Hong Kong.Skills training is an essential element in undergraduate nursing education. Owing to the increasing complexity of the health-care system and patient health needs, undergraduate nursing students should be well prepared for integrated skills competency, critical thinking and rapid decision-making. To achieve this goal, the use of simulation as a skills training tool is being recommended.The Clinical Nursing Education Centre is established. It adopts simulation as a teaching and learning tool. It has four specific education units, namely: (1) clinical simulation education unit, (2) virtual reality education unit, (3) nursing skills education unit, and (4) Chinese medicinal education unit. These units are specifically designed for the teaching and learning of nursing skills related to general, mental and Chinese medicinal nursing from elementary to advanced level. Experiences pertaining to the conceptualization, exploration and actualization phases of the establishment are presented. Details of the structure and specific functions of the centre are also illustrated. Finally, there is discussion on the challenges encountered during the establishment process and how they were overcome.

Hepatitis B virus (HBV) recurrence following orthotopic liver transplantation (OLT) is generally preventable by prophylaxis with hepatitis B immunoglobulin (HBIG) and lamivudine (LAM). However, HBV recurrence sometimes develops despite prophylaxis. This study assessed posttransplant outcomes and identified predictors of HBV recurrence. We analyzed the outcomes of 209 consecutive patients positive for hepatitis B surface antigen who underwent OLT, who received either combination prophylaxis with HBIG and LAM (89.0%) or HBIG monoprophylaxis (11.0%). The median follow-up was 36.8 months (range, 1.0-84.4). Posttransplant HBV recurrence occurred in 22 patients (10.5%), including 13 patients with drug-resistant mutations. HBV recurrence was observed in six patients after hepatocellular carcinoma (HCC) recurrence. Independent predictors of HBV recurrence were recurrent HCC (p0.001), LAM therapy1.5 years (p = 0.001) and high HBV DNA titers (or =10(5) copies/mL) at OLT (p = 0.036). In conclusion, high viremia at OLT and prolonged exposure to LAM should be further stressed as main predictors of HBV recurrence.

We report the first fatality caused by novel influenza A (H1N1) infection despite having the diagnosis confirmed and being given antiviral treatment after hospitalisation. This patient was also the first with influenza A (H1N1) to be supported with extracorporeal membrane oxygenation in Hong Kong. Although extracorporeal membrane oxygenation is an effective means of supporting patients with refractory hypoxaemia on high mechanical ventilatory support, it is labour-intensive and technically demanding. We also discuss the challenges faced when managing this case.

A 78-year-old woman was admitted to hospital with central chest pain and the electrocardiographic and cardiac marker changes typical of acute anterior myocardial infarction. Coronary angiography revealed normal epicardial coronary arteries, and left ventriculography showed apical akinesis as well as basal hyperkinesis. This is a case of transient left ventricular apical ballooning or takotsubo cardiomyopathy, possibly attributable to catecholamine-mediated myocardial stunning.