Predictors of high-dose antipsychotic prescription in psychiatric patients in Hong Kong

ABSTRACT
Hong Kong Med J 2008;14:35-9 | Number 1, February 2008
ORIGINAL ARTICLE
Predictors of high-dose antipsychotic prescription in psychiatric patients in Hong Kong
Gabriel BK Hung, HK Cheung
Castle Peak Hospital, Tuen Mun, Hong Kong
 
 
OBJECTIVE. To determine the factors associated with high-dose antipsychotic prescribing for psychiatric patients in Hong Kong.
 
DESIGN. Retrospective cross-sectional study.
 
SETTING. Psychiatric in-patients and out-patients in the New Territories West Cluster, Hong Kong.
 
PATIENTS. A total of 1129 in-patients and 7520 out-patients who received antipsychotic medications on the study date.
 
MAIN OUTCOME MEASURES. Demographic and clinical data were compared for patients receiving ?normal??and high dosages of antipsychotic medications.
 
RESULTS. High dosages were prescribed for 104 (9.2%) of the in-patients and 137 (1.8%) of out-patients. Antipsychotic polypharmacy was the most powerful predictor of high-dose prescribing, with an odds ratio of 8.88 for in-patients and 10.82 for out-patients.
 
CONCLUSION. Antipsychotic polypharmacy was the main determinant of high-dose antipsychotic prescribing in this study. Further studies should be conducted to look for other variables contributing to such prescribing in Hong Kong.
 
Key words: Antipsychotic agents; Risk factors
 
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Limb salvage in extensive diabetic foot ulceration: an extended study using a herbal supplement

ABSTRACT
Hong Kong Med J 2008;14:29-33 | Number 1, February 2008
ORIGINAL ARTICLE
Limb salvage in extensive diabetic foot ulceration: an extended study using a herbal supplement
PC Leung, Margaret WN Wong, WC Wong
Institute of Chinese Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
 
 
OBJECTIVE. To further study the clinical value of a herbal supplement in the treatment of chronic foot ulcers in diabetic patients.
 
DESIGN. Double-blind randomised, placebo-control trial.
 
SETTING. Two general hospitals in Hong Kong.
 
PATIENTS. Eighty patients were recruited according to strict selection criteria.
 
INTERVENTIONS. Clinical measures included standard antidiabetic treatment, daily wound care including antiseptic bath, debridement, toe removal for gangrene when necessary, and the daily consumption of a herbal drink or placebo.
 
MAIN OUTCOME MEASURES. The primary outcome was limb salvage. Secondary outcomes included: granulation maturation, local temperature and circulatory changes, tumour necrosis factor–alpha levels, and adverse events.
 
RESULTS. Limb salvage was achieved in 85% of the patients. Among the early failures, three each came from the treatment and placebo groups. After shifting to herbal treatment (without unblinding of the original treatment), all were rescued in those initially assigned to herbal concoction (6 out of 6) while only 50% (6 out of 12) were rescued from among those initially assigned to placebo. The speed of granulation maturation, and decline in tumour necrosis factor–alpha levels indicating control of inflammation, were also more favourable with the herbal group. No serious adverse events were observed.
 
CONCLUSION. The herbal adjuvant therapy was effective in helping the healing of chronic diabetic ulcers.
 
Key words: Diabetes mellitus; Drugs, Chinese herbal; Wound healing
 
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Neurodevelopmental outcomes of extreme-low-birth-weight infants born between 2001 and 2002

ABSTRACT
Hong Kong Med J 2008;14:21-8 | Number 1, February 2008
ORIGINAL ARTICLE
Neurodevelopmental outcomes of extreme-low-birth-weight infants born between 2001 and 2002
High Risk Follow-up Working Group (Kowloon Region)
 
 
OBJECTIVE. To report the neurodevelopmental outcomes of extreme-low-birth-weight survivors.
 
DESIGN. Multicentre cohort study.
 
SETTING. Three regional hospitals in Hong Kong.
 
PATIENTS. Surviving extreme-low-birth-weight infants born in 2001 and 2002 underwent neurodevelopmental, neurosensory, and functional assessment under the High Risk Follow-up Program in three Child Assessment Centres.
 
MAIN OUTCOME MEASURES. Demographic characteristics, neonatal diagnoses and treatment given, as well as neurodevelopmental outcomes were prospectively collected, and possible maternal and neonatal risk factors for major disability evaluated.
 
RESULTS. Of 81 extreme-low-birth-weight infants, 49 had undergone evaluation under the High Risk Follow-up Program. Their mean gestational age was 26.2 (standard deviation, 1.8) weeks and mean birth weight was 789 g (standard deviation, 125 g). Seventeen infants were less than 750 g and 32 were between 751 and 999 g. The rates of cerebral palsy, intellectual impairment, hearing deficit, and visual impairment were 12%, 16%, 4%, and 6%, respectively. Fifteen (31%) infants had at least one major disability. There was no association between neurodevelopmental disability and low birth weight. For neurodevelopmental disabilities, postnatal use of steroids conferred a significant risk (relative risk=7.4; 95% confidence interval, 1.9-29.2). Corresponding figures for other significant risk factors were as follows: severe grades of intraventricular haemorrhage (2.7; 1.2-5.9), presence of periventricular leukomalacia (4.5; 2.1-9.3), patent ductus arteriosus requiring ligation (2.8; 1.3-6.1), severe grades of retinopathy of prematurity (2.4; 1.0-5.6), and severe grades of necrotising enterocolitis (3.2; 1.6-6.3).
 
CONCLUSION. Extreme-low-birth-weight infants are at risk of major neurodevelopmental disability. Our rates of cerebral palsy, intellectual disability, and significant visual and hearing impairment were comparable to those reported in many western studies. Further longitudinal study to assess long-term neurodevelopmental outcomes in this group of children is needed.
 
Key words: Developmental disabilities; Infant, premature; Infant, very low birth weight; Neurologic examination
 
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Bronchial artery embolisation can be equally safe and effective in the management of chronic recurrent haemoptysis

ABSTRACT
Hong Kong Med J 2008;14:14-20 | Number 1, February 2008
ORIGINAL ARTICLE
Bronchial artery embolisation can be equally safe and effective in the management of chronic recurrent haemoptysis
Samuel Lee, Johnny WM Chan, Susan CH Chan, YH Chan, TL Kwan, MK Chan, CK Ng, MP Lee, WL Law, Thomas YW Mok
Department of Medicine, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong
 
 
OBJECTIVE. To examine the efficacy and safety of bronchial artery embolisation in patients with acute major haemoptysis and those with chronic recurrent haemoptysis.
 
DESIGN. Retrospective review of clinical records.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. Clinical records of 70 consecutive patients who had undergone bronchial artery embolisation in Queen Elizabeth Hospital from 1998 to 2003 were reviewed. Altogether 74 bronchial artery embolisation procedures were attempted, 46 (62%) for acute major haemoptysis, and 28 (38%) for chronic recurrent bleeding. Follow-up data were available for 32 patients.
 
MAIN OUTCOME MEASURES. After bronchial artery embolisation, the Kaplan-Meier method and log-rank tests were used to compare the probability of recurrence in the two patient categories.
 
RESULTS. Overall immediate control was attained following 99% of the procedures, with a complication rate of 13%; all complications were mild and self-limiting. For the 32 patients (19 having acute major haemoptysis and 13 having chronic recurrent bleeding) with follow-up data available, the overall recurrence rate was 36% (26% in the acute and 47% in chronic group). No statistically significant difference in recurrence probability between the two groups was observed (P=0.24). Presence of active pulmonary tuberculosis was associated with increased risk of recurrence (P=0.005).
 
CONCLUSION. Bronchial artery embolisation was noted to be effective and safe in both acute major and chronic recurrent haemoptysis.
 
Key words: Bronchial arteries; Bronchiectasis; Embolization, therapeutic; Hemoptysis; Recurrence
 
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Rapid aneuploidy testing (knowing less) versus traditional karyotyping (knowing more) for advanced maternal age: what would be missed, who should decide?

ABSTRACT
Hong Kong Med J 2008;14:6-13 | Number 1, February 2008
ORIGINAL ARTICLE
Rapid aneuploidy testing (knowing less) versus traditional karyotyping (knowing more) for advanced maternal age: what would be missed, who should decide?
WC Leung, WL Lau, Rebecca Tang, Shell Fean Wong, TK Lau, KT Tse, SF Wong, WK To, Lucy KL Ng, TT Lao, Mary HY Tang, ET Lau
Kwong Wah Hospital, Hong Kong
 
 
OBJECTIVES. The application of rapid aneuploidy testing as a stand-alone approach in prenatal diagnosis is much debated. The major criticism of this targeted approach is that it will not detect other chromosomal abnormalities that will be picked up by traditional karyotyping. This study aimed to study the nature of such chromosomal abnormalities and whether parents would choose to terminate affected pregnancies.
 
DESIGN. Retrospective study on a cytogenetic database.
 
SETTING. Eight public hospitals in Hong Kong.
 
PARTICIPANTS. The karyotype results of 19 517 amniotic fluid cultures performed for advanced maternal age (??5 years) from 1997 to 2002 were classified according to whether they were detectable by rapid aneuploidy testing. The outcomes of pregnancies with abnormal karyotypes were reviewed from patient records.
 
RESULTS. In all, 333 (1.7%) amniotic fluid cultures yielded abnormal karyotypes; 175 (52.6%) of these were detected by rapid aneuploidy testing, and included trisomy 21 (n=94, 28.2%), trisomy 18 or 13 (n=21, 6.3%), and sex chromosome abnormalities (n=60, 18.0%). The other 158 (47.4%) chromosomal abnormalities were not detectable by rapid aneuploidy testing, of which 63 (18.9%) were regarded to be of potential clinical significance and 95 (28.5%) of no clinical significance. Pregnancy outcomes in 327/333 (98.2%) of these patients were retrieved. In total, 143 (42.9%) of these pregnancies were terminated: 93/94 (98.9%) for trisomy 21, 20/21 (95.2%) for trisomy 18 or 13, 19/60 (31.7%) for sex chromosome abnormalities, and 11/63 (17.5%) for other chromosomal abnormalities with potential clinical significance. There were no terminations in the 95 pregnancies in which karyotyping results were regarded to be of no clinical significance.
 
CONCLUSIONS. 'Knowing less' by the rapid aneuploidy stand-alone testing could miss about half of all chromosomal abnormalities detectable by amniocentesis performed for advanced maternal age. Findings from two fifths of the latter were of potential clinical significance, and the parents chose to terminate one out of six of the corresponding pregnancies. If both techniques are available, parents could have enhanced autonomy to choose.
 
Key words: Abortion, induced; Amniocentesis; Aneuploidy; Karyotyping; Prenatal diagnosis
 
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Identifying prognostic factors for survival in advanced cancer patients: a prospective study

ABSTRACT
Hong Kong Med J 2007;13:453-9 | Number 6, December 2007
ORIGINAL ARTICLE
Identifying prognostic factors for survival in advanced cancer patients: a prospective study
PT Lam, MW Leung, CY Tse
Department of Medicine and Geriatrics, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong
 
 
OBJECTIVE. To identify potential prognostic factors affecting the survival in patients with advanced cancer in a local palliative care unit.
 
DESIGN. Prospective cohort study.
 
SETTING. Palliative Care Unit of a regional hospital in Hong Kong.
 
PATIENTS. All advanced cancer in-patients and out-patients who were enrolled into the palliative care service of the United Christian Hospital between January and December 2002 were recruited.
 
MAIN OUTCOME MEASURES. Potential prognostic factors including demographic data, tumour characteristics, blood parameters, functional status, co-morbidities, total symptom score, and psychosocial parameters were recorded upon enrolment.
 
RESULTS. A total of 170 patients were eligible for analysis; their mean age was 69 (standard deviation, 12) years, of which 106 (62%) were male. Overall median survival was 77 (interquartile range, 31-160) days. The most frequent primary malignancy was lung (n=58, 34%), followed by liver (n= 24, 14%) and lower gastro-intestinal tract (n=24, 14%). By univariate analysis, 11 factors affected survival, including: age (P=0.040), number of metastatic sites involved (P=0.001), peritoneal metastases (P=0.009), skin metastases (P=0.011), tachycardia (P=0.009), serum albumin concentration (P<0.001), white cell count (P=0.002), Karnofsky Performance Status score (P<0.001), Hamilton Depression Scale score (P=0.004), Edmonton Symptom Assessment System score (P=0.003), and McGill Quality of Life (Hong Kong)-single item score (P=0.002). Multivariable Cox regression analysis revealed that only age (hazard ratio=0.84; 95% confidence interval, 0.73-0.96), number of metastatic sites involved (1.33; 1.13-1.56), serum albumin concentration (0.95; 0.92-0.98), Karnofsky Performance Status score (0.86; 0.78-0.96), and Edmonton Symptom Assessment System score (1.22; 1.05-1.41) were independent prognosticators.
 
CONCLUSION. Age, number of involved metastatic sites, serum albumin, Karnofsky Performance Scale score, and Edmonton Symptom Assessment System score were independent prognosticators. Further studies are needed to provide a prognostic instrument applicable in local clinical settings.
 
Key words: Life expectancy; Prognosis; Neoplasms; Survival analysis
 
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Bleeding pseudoaneurysms complicating upper abdominal surgery

ABSTRACT
Hong Kong Med J 2007;13:449-52 | Number 6, December 2007
ORIGINAL ARTICLE
Bleeding pseudoaneurysms complicating upper abdominal surgery
Hester YS Cheung, CN Tang, KH Fung, Michael KW Li
Department of Surgery, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong
 
 
OBJECTIVE. To review the management of ruptured pseudoaneurysms following upper abdominal surgery.
 
DESIGN. Retrospective study.
 
SETTING. Minimal access surgery centre, Hong Kong.
 
PATIENTS. Patients who were diagnosed to have a pseudoaneurysm after undergoing major upper abdominal surgery were recruited during the period of 1998 to 2006.
 
MAIN OUTCOME MEASURES. Success rate of haemostasis, re-bleeding rate, re-intervention rate, and mortality.
 
RESULTS. During the study period, a total of eight patients (median age, 61 years) were managed in our department for bleeding pseudoaneurysms following cholecystectomy, gastrectomy, or Whipple's operation. Five patients underwent upper endoscopy as the initial investigation. In four of these five patients, visceral artery pseudoaneurysms were identified by angiography and haemostasis was achieved without re-bleeding. The one for whom angiographic identification of the bleeding source failed, was successfully treated subsequently by open plication. In three other patients, open surgical haemostasis was resorted to and achieved in two of them. However, one of the latter had re-bleeding, which was successfully treated by embolisation. The one who failed open identification of the bleeding source, was eventually also treated successfully by embolisation. The overall success rates of embolisation and open surgery were 80% and 67%, respectively, and the re-bleeding rates were 0% and 33%, respectively. The corresponding mortality rates were 20% and 33%; both deaths were associated with multi-organ failure. There were no procedure-related complications following embolisation.
 
CONCLUSIONS. Based on our experience, visceral angiography can enable the diagnosis and treatment of ruptured pseudoaneurysm in a single session. The procedure is safe, the re-bleeding rate is low, and it is as effective as alternative treatments, and should be considered a first-line intervention in patients with bleeding pseudoaneurysms complicating upper abdominal surgery.
 
Key words: Angiography; Cholecystectomy; Embolization, therapeutic; Gastrointestinal hemorrhage
 
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Laparoscopic versus open hepatectomy for liver tumours: a case control study

ABSTRACT
Hong Kong Med J 2007;13:442-8 | Number 6, December 2007
ORIGINAL ARTICLE
Laparoscopic versus open hepatectomy for liver tumours: a case control study
KF Lee, YS Cheung, CN Chong, Yvonne YY Tsang, Wilson WC Ng, Eva Ling, John Wong, Paul BS Lai
Division of Hepato-biliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
 
 
OBJECTIVE. To evaluate the benefits of laparoscopic versus open resection of liver tumours.
 
DESIGN. Case control study.
 
SETTING. Tertiary teaching hospital, Hong Kong.
 
PATIENTS. Data from 25 patients who underwent laparoscopic resections for liver tumours from 2003 to 2006 were compared to a retrospective series of 25 patients who underwent open hepatectomy in a pair-matched design.
 
MAIN OUTCOME MEASURES. Duration of operation, operative morbidity and mortality, blood loss, tumour resection margin, analgesics usage, days to return to an oral diet, duration of postoperative hospital stay, and survival of patients with malignancy.
 
RESULTS. The demographic data and the tumour characteristics were comparable in the two patient groups, as were mortality (0% in both groups) and morbidity rates (4% in both groups). Two (8%) of the patients having laparoscopic resections were converted to open surgery. There was no statistically significant difference between the two groups in terms of operating time or resection margins. However, the laparoscopically treated patients experienced significantly less blood loss (median, 100 vs 250 mL), had shorter hospital stays (median, 4 vs 7 days), were prescribed less analgesia (median morphine dosage, 0.16 vs 0.83 mg per kg body weight), and resumed oral diet earlier (median, 1 vs 2 days). For patients with malignant tumours, there was no significant difference between the two groups in terms of actuarial and disease-free survival.
 
CONCLUSION. Compared to open hepatectomy, in selected patients laparoscopic liver resection delivers the benefits of decreased blood loss, shorter hospital stay, lesser requirement for analgesics, and an earlier return to an oral diet, without evidence of compromised oncological clearance.
 
Key words: Hepatectomy; Laparoscopy; Liver diseases; Liver neoplasms; Treatment outcome
 
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The epidemiology and clinical characteristics of Crohn's disease in the Hong Kong Chinese population: experiences from a regional hospital

ABSTRACT
Hong Kong Med J 2007;13:436-41 | Number 6, December 2007
ORIGINAL ARTICLE
The epidemiology and clinical characteristics of Crohn's disease in the Hong Kong Chinese population: experiences from a regional hospital
KH Lok, HG Hung, CH Ng, KK Li, KF Li, ML Szeto
Department of Medicine and Geriatrics, Tuen Mun Hospital, Tuen Mun, Hong Kong
 
 
OBJECTIVE. To study the descriptive epidemiology and clinical profile of patients with Crohn's disease.
 
DESIGN. Retrospective study.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. Patients with Crohn's disease diagnosed between January 1991 and December 2006 inclusive.
 
RESULTS. Over the period studied, 27 Chinese patients were diagnosed with Crohn's disease in our hospital. Our hospital-based incidence and prevalence rate had increased more than 2- and 5-fold, respectively over that period. The mean age at diagnosis was 26 years and median duration of disease was 81 months. Most patients had ileocolonic disease (67%) followed by Crohn's colitis (22%) and ileal disease (11%); more patients had non-stricturing and non-penetrating disease (63%) than stricturing (15%) or penetrating disease (22%). Peri-anal disease occurred in 37% of our patients. At diagnosis, many of the patients (41%) had mild-moderate disease, but 30% each had moderate-severe and severe-fulminant disease. At the time of this study, 85% of the patients were in disease remission with medical treatment. However, 48% had undergone surgery for diagnosis or complications. No patient had developed colorectal cancer or died.
 
CONCLUSIONS. The incidence and prevalence of Crohn's disease are increasing in the Chinese population. It usually affects young persons with a substantial proportion of patients presented with severe-fulminant disease. More epidemiological and clinical studies are needed for this emerging disease in Asian regions.
 
Key words: Crohn disease; Epidemiologic studies; Incidence; Prevalence
 
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Dosing of proton pump inhibitors in a private hospital in Hong Kong

ABSTRACT
Hong Kong Med J 2007;13:430-5 | Number 6, December 2007
ORIGINAL ARTICLE
Dosing of proton pump inhibitors in a private hospital in Hong Kong
Alan CW Mui, Titus CY Fan
Baptist Hospital, Waterloo Road, Hong Kong
 
 
OBJECTIVE. To study the prescribing pattern of proton pump inhibitors with regard to the time of dosing.
 
DESIGN. Retrospective study.
 
SETTING. Private hospital, Hong Kong.
 
PATIENTS. All patients prescribed three specific proton pump inhibitors from 1 January to 31 July 2006 were included.
 
MAIN OUTCOME MEASURES. For all three proton pump inhibitors, the prescribed dosing instructions were recorded as well as the specialties of the corresponding prescribers.
 
RESULTS. The ratio of doctors prescribing proton pump inhibitors before meals versus at other times was 1:105. The ratio of patients receiving proton pump inhibitors before meals versus at other times was 1:341. The number of tablets of proton pump inhibitors prescribed before meals versus at other times was 1:409.
 
CONCLUSIONS. The overwhelming majority of doctors in this study did not prescribe proton pump inhibitors before meals.
 
Key words: Anti-ulcer agents; Omeprazole; Prescriptions, drug; Proton pumps
 
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