Localisation of occult breast lesion: a comparative analysis of hookwire and radioguided procedures

ABSTRACT
Hong Kong Med J 2010;16:367–72 | Number 5, October 2010
ORIGINAL ARTICLE
Localisation of occult breast lesion: a comparative analysis of hookwire and radioguided procedures
Tiffany YC Chu, CY Lui, WK Hung, SK Kei, Catherine LY Choi, HS Lam
Department of Radiology, Kwong Wah Hospital, Kowloon, Hong Kong
 
 
OBJECTIVES. For occult breast lesions, to retrospectively compare the performance of radioguided and hookwire methods in terms of ease of localisation and surgical procedures, and the ability to obtain a specimen with a clear margin.
 
DESIGN. Retrospective study.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. All patients who underwent occult breast lesion localisation by either ultrasonography- or stereotactic-guided radioguided occult lesion localisation or hookwire localisation from August 2003 to December 2007 were included.
 
MAIN OUTCOME MEASURES. Demographic data, localisation and operation procedure time, size of specimens and margin clearance.
 
RESULTS. In all, 165 patients (mean age, 52 years) having these procedures were assessed. In 98 instances, the procedure (hookwire=53, radioguided=45) was for diagnostic purposes and in 67 (hookwire=23, radioguided=44) for therapy. Both techniques attained a very high success rate (>95%). For radioguided occult lesion localisation, there was a significantly shorter mean localisation time than for hookwire localisation (18 min versus 31 min; P<0.001), while the mean operating time was similar. Radioguided occult lesion localisation entailed larger specimens and fewer cases with close or involved margins, or recourse to intra-operative re-excision or a second operation, but these differences were not statistically significant. Within the radioguided occult lesion localisation group, there were 42 patients who had a simultaneous sentinel lymph node biopsy (sentinel node and occult lesion localisation), with a 98% success rate although no lymph node metastasis was revealed.
 
CONCLUSION. Radioguided occult lesion localisation excels in yielding a much shorter localisation time and is as good as hookwire localisation in terms of specimen margin clearance and need for re-excision. It also offers the advantage of enabling simultaneous sentinel lymph node biopsy for invasive cancers. Therefore it is a recommended procedure that should be used more widely.
 
Key words: Breast neoplasms/radionuclide imaging; Breast neoplasms/surgery; Breast neoplasms/ultrasonography; Mastectomy
 
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Ten-year review of epidemiology, clinical features, and treatment outcome of achalasia in a regional hospital in Hong Kong

ABSTRACT
Hong Kong Med J 2010;16:362–6 | Number 5, October 2010
ORIGINAL ARTICLE
Ten-year review of epidemiology, clinical features, and treatment outcome of achalasia in a regional hospital in Hong Kong
KY Ng, KF Li, KH Lok, Lawrence Lai, CH Ng, KK Li, ML Szeto
Division of Gastroenterology and Hepatology, Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong
 
 
OBJECTIVE. To describe the epidemiology, clinical features, and treatment outcome of achalasia in Chinese patients.
 
DESIGN. Retrospective study.
 
SETTING. Major regional hospital, Hong Kong.
 
PATIENTS. Clinical records of patients with the diagnosis of achalasia from July 1997 to June 2007 were reviewed.
 
RESULTS. Thirty-two patients were diagnosed with achalasia during the study period. The mean age at diagnosis was 50 years (standard deviation, 20 years). The female-to-male ratio was 1.3:1. The main presenting symptoms were dysphagia (78%) and vomiting (50%). Nine laparoscopic and two open Heller's operations had been performed and 16 patients had undergone endoscopic dilatations. Four patients had botulinum toxin injection and four were taking calcium channel blocker (nifedipine) medications. Botulinum toxin injection and medical therapy had poor shortand long-term responses. Laparoscopic myotomy and pneumatic dilatation had comparable good short- and long-term responses.
 
CONCLUSION. Achalasia affected all age-groups but there was a peak at middle age. Pneumatic dilatation and Heller's myotomy (open or laparoscopic approach) appeared able to maintain longer symptom responses than medical therapy and botulinum toxin injection.
 
Key words: Cardia; Esophageal achalasia; Esophageal sphincter, lower; Laparoscopy; Treatment outcome
 
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Prevalence of allergic rhinitis and its associated morbidity in adults with asthma: a multicentre study

ABSTRACT
Hong Kong Med J 2010;16:354–61 | Number 5, October 2010
ORIGINAL ARTICLE
Prevalence of allergic rhinitis and its associated morbidity in adults with asthma: a multicentre study
Fanny WS Ko, Mary SM Ip, CM Chu, Loletta KY So, David CL Lam, David SC Hui
Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
 
 
OBJECTIVES. To assess the prevalence of allergic rhinitis in adult patients with asthma in Hong Kong, and to compare the morbidity endured by asthma patients with and without allergic rhinitis.
 
DESIGN. Cross-sectional study.
 
SETTING. Respiratory clinics of four major public hospitals in Hong Kong.
 
PATIENTS. A total of 600 adults with asthma were recruited from March to May 2007.
 
MAIN OUTCOME MEASURES. Doctors and patients completed separate questionnaires evaluating symptoms, treatment, and health care utilisation. Spirometry data were obtained for a subgroup of patients at the time of survey completion.
 
RESULTS. The patients consisted of 267 males and 333 females, with 251 having spirometry data. The mean pre-bronchodilator 1-second forced expiratory volume predicted among those who had spirometry performed was 88% (standard deviation, 28%). In all, 50% of the patients had intermittent and 50% had persistent asthma. Over three quarters (463/600; 77%) of patients had experienced allergic rhinitis symptoms in the past 12 months, of whom 96% had a previous diagnosis of allergic rhinitis. Asthmatics without allergic rhinitis symptoms had higher rates of visits to doctors, pharmacy visits, emergency department attendances, and hospitalisations for asthma than those with both conditions. Among subjects with asthma and allergic rhinitis, those taking nasal steroid (226/463; 49%) had lower rates of emergency department visits (13 vs 25%, P=0.002) and hospitalisations (7 vs 13%, P=0.045) for asthma than those who were not.
 
CONCLUSION. Allergic rhinitis is a common co-morbid condition of asthma in this hospital clinic cohort. Treatment of allergic rhinitis with intra-nasal steroid was associated with less health care utilisation for asthma.
 
Key words: Asthma; Comorbidity; Rhinitis
 
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Primary percutaneous coronary intervention for ST elevation myocardial infarction: performance with focus on timeliness of treatment

ABSTRACT
Hong Kong Med J 2010;16:347–53 | Number 5, October 2010
ORIGINAL ARTICLE
Primary percutaneous coronary intervention for ST elevation myocardial infarction: performance with focus on timeliness of treatment
Gary SH Cheung, KL Tsui, CC Lau, HL Chan, CH Chau, KL Wu, CY Cheung, MC Choi, TS Tse, KK Chan, SK Li
Department of Medicine, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong
 
 
OBJECTIVE. To review primary percutaneous coronary interventions performed for patients with ST elevation myocardial infarction with a focus on door-to-treatment time, especially after introduction of a new management programme in November 2003.
 
DESIGN. Retrospective study.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. All patients with ST elevation myocardial infarction who underwent primary percutaneous coronary intervention in our hospital from January 2002 to December 2007.
 
RESULTS. In all, 209 patients with ST elevation myocardial infarction had primary percutaneous coronary interventions between January 2002 and December 2007; 140 of them were admitted within office hours, 125 of whom came directly from Accident and Emergency Department. The mean door-to-balloon time of these patients was 115 minutes, and in 41% the time was less than 90 minutes (as recommended by the American College of Cardiology/American Heart Association guidelines). Since introduction of the new programme, the mean door-to-balloon time has diminished significantly, from 146 to 116 minutes (P=0.047). Delay in diagnosis (28%) and Cardiac Catheterization Laboratory being occupied (20%) were the two most common reasons for prolonged door-to-balloon times.
 
CONCLUSION. We achieved satisfactory performance in our primary percutaneous coronary intervention programme, providing timely reperfusion therapy for patients with ST elevation myocardial infarction. A well-organised and systematic clinical pathway is a prerequisite for a centre that provides a timely and effective primary percutaneous coronary intervention service for patients with ST elevation myocardial infarction. Better public education and greater awareness on the part of medical service providers are needed, so as to facilitate urgent revascularisation and improve outcomes in patients with ST elevation myocardial infarction.
 
Key words: Angioplasty, transluminal, percutaneous coronary; Myocardial infarction; Myocardial reperfusion; Thrombolytic therapy; Time factors
 
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Use of propranolol in infantile haemangioma among Chinese children

ABSTRACT
Hong Kong Med J 2010;16:341–6 | Number 5, October 2010
ORIGINAL ARTICLE
Use of propranolol in infantile haemangioma among Chinese children
KK Chik, CK Luk, HB Chan, HY Tan
Department of Paediatrics, United Christian Hospital, Kwun Tong, Hong Kong
 
 
OBJECTIVE. To describe the use of propranolol as first-line treatment or as single therapy to control the proliferating phase of infantile haemangioma in Chinese children.
 
DESIGN. Retrospective study.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. Children 3 years old or younger with facial haemangioma who took oral propranolol between 1 December 2008 and 1 December 2009.
 
RESULTS. There were 12 such patients, all of whom underwent prior clinical evaluation before starting the treatment. Ten patients had a solitary facial haemangioma and two had multiple haemangiomas. The mean age of symptom onset was 12 days. The mean age for starting propranolol treatment was 7 months, and in all cases a clinical response was observed within 7 days. Five (41%) of the patients had complete resolution 2 to 6 months after starting medication, at which time they were 5 to 12 months old. Two of them had a recurrence of the haemangioma within 8 weeks of stopping the drug, but responded to a second treatment course. In these two patients, the propranolol dosage had been tailed down rapidly and the therapy was of a shorter duration than in those without recurrence. The remaining seven patients are still taking propranolol and responding satisfactorily. Hypotension was observed in two patients, one of whom tolerated a lower dose and in the other, therapy was reinitiated at her older age. No serious side-effect was encountered in the remaining patients.
 
CONCLUSION. Propranolol was useful as first-line or single-agent treatment of facial infantile haemangioma in Chinese children, and gave rise to minimal side-effects. Although recurrence of infantile haemangioma occurred after propranolol was tailed off rapidly after a relatively short duration, an optimal treatment duration and tapering schedule has not yet been defined. Nevertheless, patients responded well to second courses of propranolol therapy.
 
Key words: Adrenergic beta-antagonists; Facial neoplasms; Hemangioma; Infant; Propranolol
 
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An institutional review of paediatric haemangiomas: prevalence, imaging features, and outcomes

ABSTRACT
Hong Kong Med J 2010;16:334–40 | Number 5, October 2010
ORIGINAL ARTICLE
An institutional review of paediatric haemangiomas: prevalence, imaging features, and outcomes
Darshana D Rasalkar, Winnie CW Chu, Frankie WT Cheng, Vincent Lee, KH Lee, CK Li
Department of Diagnostic Radiology and Organ Imaging, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVE. To review the demographic data, imaging features, and outcomes of paediatric haemangiomas.
 
DESIGN. Retrospective study.
 
SETTING. University teaching hospital, Hong Kong.
 
PATIENTS. A total of 58 children diagnosed with haemangioma between 1998 and 2007.
 
MAIN OUTCOME MEASURES. Demographic data, imaging features, type of treatment received, and outcomes.
 
RESULTS. In all, 19 (33%) of these patients were males and 39 (67%) were females. Most of the lesions (64%) were in the head and neck region. Three (5%) of the patients were complicated by the Kasabach-Merritt syndrome; 21 underwent no imaging, and 37 had ultrasound and/or magnetic resonance imaging. In the majority (85%), ultrasound of the lesions revealed mixed echogenicity and/or phleboliths with variable colour Doppler patterns. On magnetic resonance imaging, most (87%) of the lesions were T1 iso- to hypo-intense and T2 hyperintense with slight heterogeneous signalling and revealed presence of central flow voids (vascular channels) or low-signal areas (fibrous tissue or calcification). In all, 85% appeared homogeneous while 15% showed heterogeneous enhancement. Of 58 patients, 39 (67%) patients received conservative treatment; the lesions resolved spontaneously in 34 (87%) patients, enlarged in 2 (5%), and remained static in 3 (8%). Interventions were directed at the lesions in 19 patients. These entailed surgical excision (n=7), argon laser therapy (n=3), and medical treatment (n=9). Of the latter patients, treatment included: systemic steroids (n=5), interferon (n=1), steroids and interferon (n=1), vincristine (n=1), and sclerotherapy (n=1). Partial or complete resolution of the lesions ensued in 15 (79%) of the patients, while their size remained static in four (21%).
 
CONCLUSION. Though ultrasound and magnetic resonance imaging features varied, the diagnosis of most haemangiomas could be confidently made by imaging. About 33% of haemangiomas underwent surgical/medical interventions, for which imaging was useful to monitor post-treatment progress.
 
Key words: Child; Hemangioma; Magnetic resonance Imaging; Soft tissue neoplasms; Ultrasonography, Doppler, color
 
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Surgical excision for challenging upper limb nerve sheath tumours: a single centre retrospective review of treatment results

ABSTRACT
Hong Kong Med J 2010;16:287–91 | Number 4, August 2010
ORIGINAL ARTICLE
Surgical excision for challenging upper limb nerve sheath tumours: a single centre retrospective review of treatment results
YW Hung, WL Tse, HS Cheng, PC Ho
Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVE. To review the accuracy of different investigation modalities for upper limb nerve sheath tumours and the resulting surgical outcomes, and propose a standard algorithm to deal with such tumours to minimise complications.
 
DESIGN. Retrospective review.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. All patients with upper limb nerve sheath tumours being excised in our hospital from 1999 to 2008.
 
MAIN OUTCOME MEASURES. The accuracy rate of different investigations, as well as corresponding neurological deficits after excision and recurrence rates.
 
RESULTS. A total of 23 (10 male and 13 female) patients, aged between 28 and 72 (mean, 46) years, underwent excision of 25 lesions during the study period. The mean duration of symptom was 2.5 years and tumour size ranged from 1 to 10.5 cm (mean, 2.6 cm). A majority (80%) presented with a typical triad; only one had a true neurological deficit. Twenty-two ultrasonography and 20 magnetic resonance images were obtained, with a diagnostic accuracy of 77% and 100%, respectively. Eight fine-needle aspiration cytology examinations and two core biopsies were performed, which had respective accuracy rates of 13% and 100%. Fifteen patients experienced neurological deficits after the operation; three showed spontaneous recovery. Among 12 patients with long-term residual neurological sequelae, five had both motor and sensory deficits and four had moderate-to-severe disability. No recurrence was reported.
 
CONCLUSION. Nerve sheath tumours in the hand need to be managed with care. Among the different investigation modalities, magnetic resonance imaging was considered to be the gold standard. Yet ultrasonography is still the most easily accessible and least invasive investigation in public hospital setting. Complications are liable to ensue even if patients are managed by hand specialists. Thus, well-planned operations and detailed discussions with the patient are important prerequisites before operation.
 
Key words: Nerve sheath neoplasms; Neurilemmoma; Treatment outcome; Upper extremity
 
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Should lidocaine spray be used to ease nasogastric tube insertion? A double-blind, randomised controlled trial

ABSTRACT
Hong Kong Med J 2010;16:282–6 | Number 4, August 2010
ORIGINAL ARTICLE
Should lidocaine spray be used to ease nasogastric tube insertion? A double-blind, randomised controlled trial
CP Chan, FL Lau
St Teresa's Hospital, Prince Edward Road, Hong Kong
 
 
OBJECTIVE. To investigate the efficacy and safety of lidocaine nasal spray before nasogastric tube insertion in an emergency department.
 
DESIGN. Double-blind, randomised controlled study.
 
SETTING. Emergency department of a major regional hospital in Hong Kong.
 
PATIENTS. A total of 206 adult patients, for whom nasogastric tube insertion was indicated.
 
MAIN OUTCOME MEASURES. Primary outcome was discomfort gauged on a visual analogue scale, and Likert scale addressing difficulty of nasogastric tube insertion.
 
RESULTS. Compared with placebo spray use, lidocaine spray use was associated with less patient discomfort, and less difficulty in nasogastric tube insertion, both difference being statistically significant.
 
CONCLUSION. Intranasal lidocaine spray before nasogastric tube insertion was safe and effective in reducing patient discomfort related to the procedure.
 
Key words: Anesthetics, local; Intubation, gastrointestinal; Lidocaine; Lubrication; Pain measurement
 
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Fetoscopic laser photocoagulation in the management of twin-twin transfusion syndrome: local experience from Hong Kong

ABSTRACT
Hong Kong Med J 2010;16:275–81 | Number 4, August 2010
ORIGINAL ARTICLE
Fetoscopic laser photocoagulation in the management of twin-twin transfusion syndrome: local experience from Hong Kong
X Yang, TY Leung, Warwick D Ngan Kee, M Chen, LW Chan, TK Lau
Prenatal Diagnostic Centre, Guangzhou Obstetrics and Neonatal Hospital, Guangzhou, Guangdong, PR China
 
 
OBJECTIVE. To review the perinatal outcome of monochorionic twin pregnancies treated by fetoscopic laser coagulation for twin-twin transfusion syndrome.
 
DESIGN. Retrospective study.
 
SETTING. A university teaching hospital in Hong Kong.
 
PATIENTS. Thirty consecutive cases of fetoscopic laser coagulation of placental anastomoses for twin-twin transfusion syndrome performed in a single centre.
 
MAIN OUTCOME MEASURES. Operative complications and perinatal survival rates.
 
RESULTS. The median gestational age at initial presentation, laser photocoagulation, and delivery were 22 (range, 16-27) weeks, 23 (18-28) weeks, and 32 (21-37) weeks, respectively. To improve the visualisation, in three cases amnio-exchange was undertaken; the procedure was abandoned in two due to poor visualisation. The overall fetal survival rate, the double infant survival rate, and survival rate for at least one twin were 72% (43/60), 60% (18/30), and 83% (25/30), respectively. The most common peri-operative complication was bleeding from the uterine wall into the amniotic cavity, which affected three (10%) patients.
 
CONCLUSIONS. Our results of fetoscopic laser surgery for twin-twin transfusion syndrome were similar to those in specialised centres in other countries.
 
Key words: Fetofetal transfusion; Fetoscopy; Laser coagulation; Pregnancy outcome; Twins, monozygotic
 
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Antibiotic lock solutions for the prevention of catheter-related bacteraemia in haemodialysis patients

ABSTRACT
Hong Kong Med J 2010;16:269–74 | Number 4, August 2010
ORIGINAL ARTICLE
Antibiotic lock solutions for the prevention of catheter-related bacteraemia in haemodialysis patients
KM Chow, YL Poon, MP Lam, KL Poon, CC Szeto, Philip KT Li
Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
 
 
OBJECTIVE. To investigate the effect of antibiotic lock solutions for preventing catheter-related bacteraemia in patients receiving haemodialysis.
 
DESIGN. Retrospective study.
 
SETTING. University teaching hospital, Hong Kong.
 
PATIENTS. Consecutive patients from March 2006 to April 2007 who had central venous catheter insertion for haemodialysis in our centre were included in this historically controlled study. In all, 75 patients had catheters with heparin solution alone and 74 had catheters with a gentamicin antibiotic lock. The majority of catheters were non-tunnelled (95%). Cumulative catheter survival free of catheter-related bacteraemia in the two groups was compared.
 
RESULTS. Baseline characteristics in the two groups were similar apart from a slightly lower serum albumin level in those with gentamicin locks. There were 18 and five catheter-related bacteraemia episodes before and after recourse to gentamicin antibiotic locks, respectively. Staphylococcus aureus contributed to over half (65%) of the total bacteraemia episodes. Use of gentamicin antibiotic locks significantly reduced catheter-related bacteraemia episodes per 1000 catheter days from 4.6 to 1.5 (P=0.002). Kaplan-Meier survival analysis using the log rank test showed significantly better bloodstream infection-free survival associated with using gentamicin antibiotic locks (P=0.032). A similar survival advantage was associated with gentamicin antibiotic locks when the analysis was restricted to non-tunnelled catheters. There was no significant association of catheter-related bacteraemia with patient age, obesity, gender, baseline serum albumin level, or diabetes mellitus. No serious adverse events were attributable to the use of gentamicin antibiotic locks.
 
CONCLUSION. Use of gentamicin lock solutions effectively reduced catheter-related bacteraemia in haemodialysis patients, including those with non-tunnelled catheters.
 
Key words: Anti-infective agents; Bacteremia; Catheters, indwelling; Infection control; Renal dialysis
 
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