Introducing external cephalic version in a Malaysian setting

ABSTRACT
Hong Kong Med J 2007;13:40-5 | Number 1, February 2007
ORIGINAL ARTICLE
Introducing external cephalic version in a Malaysian setting
SPY Yong
Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong
 
 
OBJECTIVE. To assess the outcome of external cephalic version for routine management of malpresenting foetuses at term.
 
DESIGN. Prospective observational study.
 
SETTING. Tertiary teaching hospital, Malaysia.
 
PATIENTS. From September 2003 to June 2004, a study involving 41 pregnant women with malpresentation at term was undertaken. An external cephalic version protocol was implemented. Data were collected for identifying characteristics associated with success or failure of external cephalic version.
 
MAIN OUTCOME MEASURES. Maternal and foetal outcome measures including success rate of external cephalic version, maternal and foetal complications, and characteristics associated with success or failure; engagement of presenting part, placental location, direction of version, attempts at version, use of intravenous tocolytic agent, eventual mode of delivery, Apgar scores, birth weights, and maternal satisfaction with the procedure.
 
RESULTS. Data were available for 38 women. External cephalic version was successful in 63% of patients; the majority (75%) of whom achieved a vaginal delivery. Multiparity (odds ratio=34.0; 95% confidence interval, 0.67-1730) and high amniotic fluid index (4.9; 1.3- 18.2) were associated with successful external cephalic version. Engagement of presenting part (odds ratio=0.0001; 95% confidence interval, 0.00001-0.001) and a need to resort to backward somersault (0.02; 0.00001-0.916) were associated with poor success rates. Emergency caesarean section rate for foetal distress directly resulting from external cephalic version was 8%, but there was no perinatal or maternal adverse outcome. The majority (74%) of women were satisfied with external cephalic version.
 
CONCLUSIONS. External cephalic version has acceptable success rates. Multiparity, liquor volume, engagement of presenting part, and the need for backward somersault were strong predictors of outcome. External cephalic version is relatively safe, simple to learn and perform, and associated with maternal satisfaction. Modern obstetric units should routinely offer the procedure.
 
Key words: Breech presentation; Obstetric surgical procedures; Patient satisfaction; Pregnancy outcome; Version, fetal
 
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Management and outcome of antenatally diagnosed congenital cystic adenomatoid malformation of the lung

ABSTRACT
Hong Kong Med J 2007;13:31-9 | Number 1, February 2007
ORIGINAL ARTICLE
Management and outcome of antenatally diagnosed congenital cystic adenomatoid malformation of the lung
PC Chow, SL Lee, MHY Tang, KL Chan, CP Lee, BCC Lam, NS Tsoi
Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, University of Hong Kong, Pokfulam Road, Hong Kong
 
 
OBJECTIVE. To review the management and outcome of babies with antenatally diagnosed congenital cystic adenomatoid malformation.
 
DESIGN. Retrospective cohort review.
 
SETTING. Tertiary neonatal care unit at Queen Mary Hospital and antenatal diagnostic centre at Tsan Yuk Hospital.
 
PATIENTS. Consecutive patients with antenatally suspected congenital cystic adenomatoid malformation in their concepti among antenatal patients attending Tsan Yuk Hospital from 1994 to 2002. Twentyfour of 33 cases were referred to Queen Mary Hospital for postnatal management and for whom comprehensive records were available for analysis in 23.
 
INTERVENTIONS. Postnatal interventions in their babies included investigational imaging for congenital cystic adenomatoid malformation and surgery.
 
MAIN OUTCOME MEASURES. Antenatal and postnatal outcome, as well as pathology of the excised lesions.
 
RESULTS. Antenatal outcome: termination of pregnancy in two cases and spontaneous abortion in one; in-utero regression was documented in nine cases and in one hydropic change was apparent. Postnatal outcome: only eight of 20 babies born alive had symptoms in neonatal period. Two developed serious infective complications in infancy, one with documented in-utero regression. Pulmonary parenchymal abnormalities were detected on computed tomography of the thorax in six of seven cases with normal or non-specific chest radiograph findings. Among nine cases with in-utero regression, congenital cystic adenomatoid malformation was confirmed by operative histology in five and abnormal computed tomography findings in three. Fifteen babies underwent surgical excision, one of whom died because of severe pre-existing pulmonary hypoplasia and nine endured minor postoperative complications. A favourable outcome was documented at a mean follow-up of 22 months (range, 2 months-7 years).
 
CONCLUSIONS. In-utero regression of congenital cystic adenomatoid malformation on antenatal ultrasound may not represent genuine resolution. Computed tomographic thorax should be considered in all newborns with antenatally diagnosed congenital cystic adenomatoid malformation, and if confirmed early operation before first hospital discharge is recommended.
 
Key words: Cystic adenomatoid malformation of lung, congenital; Prenatal diagnosis; Treatment outcome
 
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Vaginal hysterectomies in patients without uterine prolapse: a local perspective

ABSTRACT
Hong Kong Med J 2007;13:27-30 | Number 1, February 2007
ORIGINAL ARTICLE
Vaginal hysterectomies in patients without uterine prolapse: a local perspective
TC Pun
Department of Obstetrics and Gynaecology, Queen Mary Hospital, Pokfulam Road, Hong Kong
 
 
OBJECTIVE. To review the results of vaginal hysterectomies in patients without uterine prolapse.
 
DESIGN. Retrospective chart review.
 
SETTING. University affiliated hospital, Hong Kong.
 
PATIENTS. Patients who had vaginal hysterectomies in the absence of uterine prolapse, from 1999 to 2005 inclusive.
 
MAIN OUTCOME MEASURES. The number, indications, operative procedures, and complications of such hysterectomies.
 
RESULTS. A total of 94 patients who underwent vaginal hysterectomy fulfilled the inclusion criteria. They accounted for 4.3 to 8.2% of all hysterectomies performed annually for benign diseases in the department, over the inclusive period 2000 to 2004. The incidences of complications, except bladder injuries, were comparable to those reported in other studies. The incidence of vault haematoma decreased as each surgeon's experience increased and more attention was paid to 'bleeders' at the "four and eight o'clock areas" and more cephalic regions of the vaginal incision. Increased size of the uterus was an important determinant of the risk of complications.
 
CONCLUSIONS. Vaginal hysterectomy is an underutilised approach in Hong Kong. With more experience and better patient selection, complication rates can be further reduced. Further evaluation is suggested for the role of bleeders at "four and eight o'clock regions" as potential causes of vault haematoma.
 
Key words: Hematoma; Hysterectomy, vaginal; Organ size
 
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Incidence of neonatal chlamydial conjunctivitis and its association with nasopharyngeal colonisation in a Hong Kong hospital, assessed by polymerase chain reaction

ABSTRACT
Hong Kong Med J 2007;13:22-6 | Number 1, February 2007
ORIGINAL ARTICLE
Incidence of neonatal chlamydial conjunctivitis and its association with nasopharyngeal colonisation in a Hong Kong hospital, assessed by polymerase chain reaction
TPP Yip, WH Chan, KT Yip, TL Que, MM Lee, NS Kwong, CK Ho
Department of Ophthalmology, Tuen Mun Hospital, Tsing Chung Koon Road, Tuen Mun, Hong Kong
 
 
OBJECTIVES. Using polymerase chain reactions, this study aimed to evaluate the incidence of neonatal chlamydial conjunctivitis in our region of Hong Kong and explore any association between such conjunctivitis and nasopharyngeal colonisation with Chlamydia trachomatis.
 
DESIGN. Prospective epidemiological study.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. Consecutive patients with neonatal conjunctivitis presenting to our hospital were recruited from May 2004 to April 2005 inclusive. Both eyes were investigated separately for Chlamydia trachomatis by polymerase chain reaction, direct immunofluorescent assay, and cell culture by two assigned ophthalmologists. Neonates diagnosed to have ocular Chlamydia trachomatis infection were subjected to additional nasopharyngeal investigations. Complete sets of ocular and nasopharyngeal investigations were also undertaken 1 week after oral erythromycin treatment to confirm complete eradication of Chlamydia trachomatis.
 
RESULTS. Of 192 patients with neonatal conjunctivitis, 24 were diagnosed to have chlamydial conjunctivitis. Fifteen of them had nasopharyngeal colonisation with Chlamydia trachomatis. Among the 20 neonatal chlamydial conjunctivitis patients that completed the follow-up study, one suffered treatment failure. None had clinically diagnosed systemic Chlamydia trachomatis infection 3 months after oral erythromycin.
 
CONCLUSIONS. The incidence of neonatal chlamydial conjunctivitis in our region of Hong Kong was 4 in 1000 live births, of whom 63% had nasopharyngeal presence of Chlamydia trachomatis. Owing to the high rate of nasopharyngeal isolation and possibility of treatment failure, post-treatment ocular and nasopharyngeal polymerase chain reaction testing for Chlamydia trachomatis may be considered to confirm complete eradication.
 
Key words: Chlamydia infections; Chlamydia trachomatis; Conjunctivitis, bacterial; Nasopharyngeal diseases; Polymerase chain reaction
 
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A study on body weight perception and weight control behaviours among adolescents in Hong Kong

ABSTRACT
Hong Kong Med J 2007;13:16-21 | Number 1, February 2007
ORIGINAL ARTICLE
A study on body weight perception and weight control behaviours among adolescents in Hong Kong
PCH Cheung, PLS Ip, ST Lam, H Bibby
Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong
 
 
OBJECTIVE. To examine the relationships between body weight perceptions, estimated body mass index, gender, and weight control behaviours.
 
DESIGN. Cross-sectional survey.
 
SETTING. Three secondary schools in Hong Kong.
 
PARTICIPANTS. A total of 1132 secondary school forms 1 and 3 students.
 
MAIN OUTCOME MEASURES. The strength of agreement between perceived weight and estimated body mass index, and the association between perceived weight, estimated body mass index, and weight control behaviours.
 
RESULTS. A total of 14% of students were estimated to be overweight or obese. The agreement between actual (estimated) body mass index and perceived weight was poor in females and fair in males (Kappa 0.137 and 0.225, respectively). In females, there was no evidence of a relationship between body mass index and weight control behaviours. However, there was a relationship between perceived weight and weight control behaviours such that females who perceived themselves as overweight were more likely to exercise, restrict caloric intake, self medicate with diet pills, purge, or use laxatives. In males, there was evidence of a relationship between perceived weight, body mass index, and weight control behaviours. Males who perceived themselves as overweight or were overweight, were more likely to exercise or restrict caloric intake.
 
CONCLUSIONS. Body weight perceptions are not in agreement with actual weight in adolescents. This discrepancy is more marked in females who use a variety of weight control behaviours. These behaviours are motivated by perceived weight rather than actual (estimated) body mass index. Overweight adolescents should be encouraged to adopt appropriate weight control behaviours for their health needs.
 
Key words: Adolescent; Body image; Body Weight; Obesity; Weight loss
 
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Fine-needle aspiration cytology of thyroid nodules--how well are we doing?

ABSTRACT
Hong Kong Med J 2007;13:12-5 | Number 1, February 2007
ORIGINAL ARTICLE
Fine-needle aspiration cytology of thyroid nodules--how well are we doing?
YS Cheung, CM Poon, SM Mak, MWM Suen, HT Leong
Department of Surgery, North District Hospital, Po Kin Road, Sheung Shui, Hong Kong
 
 
OBJECTIVES. To review the accuracy of fine-needle aspiration cytology in diagnosing non-toxic thyroid nodules and determine what factors are predictive of malignancy in patients with indeterminate cytology results.
 
DESIGN. Retrospective study.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. Patients with non-toxic thyroid nodules undergoing thyroidectomy from December 1999 to December 2003.
 
MAIN OUTCOME MEASURES. Sensitivity, specificity, positive and negative predictive value of fine-needle aspiration cytology, predictive factors for malignancy in patients with indeterminate fine-needle aspiration cytology results.
 
RESULTS. The sensitivity, specificity, positive predictive value, and negative predictive value of fine-needle aspiration cytology were 54%, 100%, 100%, and 75% respectively. For the 92 patients with fine-needle aspiration cytology reported as 'indeterminate for malignancy' aspiration cytology subgroup (P=0.005) and age (P=0.001) were significant risk factors for diagnosing malignancy.
 
CONCLUSIONS. Fine-needle aspiration cytology has high positive predictive value for thyroid cancer, enabling us to 'rule-in' malignant lesions with confidence. Among those with indeterminate fine-needle aspiration cytology, atypical cell lesions and age greater than 40 years conferred increased risk of malignancy.
 
Key words: Biopsy, needle; Frozen sections; Predictive value of tests; Thyroid nodule
 
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Clinical relevance of intra-operative sentinel lymph node examination in breast cancer management

ABSTRACT
Hong Kong Med J 2007;13:8-11 | Number 1, February 2007
ORIGINAL ARTICLE
Clinical relevance of intra-operative sentinel lymph node examination in breast cancer management
KM Leung, KW Chan, GPS Yeoh, JKC Chan, PSY Cheung
Diagnostix Pathology Laboratories Ltd, Canossa Hospital, 1 Old Peak Road, Hong Kong
 
 
OBJECTIVES. To determine the sensitivity, accuracy, and clinical relevance of intra-operative examination of sentinel lymph nodes in breast cancer management.
 
DESIGN. Retrospective study.
 
SETTING. Private anatomical pathology practice.
 
PARTICIPANTS. Three hundred breast cancer patients who underwent axillary sentinel lymph node biopsies for intra-operative assessment between January 2004 and March 2006.
 
MAIN OUTCOME MEASURES. Correct identification of metastatic carcinoma in sentinel lymph nodes during intra-operative examination, sparing patient a second surgery.
 
RESULTS. The intra-operative diagnosis of sentinel lymph node biopsies from 300 consecutive patients were compared with the final pathological diagnoses. The final pathology results showed metastatic carcinoma in 74 patients, of whom 63 (85%) were correctly diagnosed during frozen section examination. There was no false-positive case (positive predictive value 100%). The sensitivity for detecting macro- and micro-metastases were 95% and 50%, respectively (P<0.01). The sensitivity for detecting metastases in T1 and T2/ above tumours were 72% and 90%, respectively (P<0.05).
 
CONCLUSIONS. Intra-operative examination is a reliable and sensitive method for the detection of sentinel lymph node metastasis. Eighty-five percent of the patients with metastatic disease were correctly diagnosed and spared a second operation for axillary dissection. The disadvantage of missing a positive lymph node is by far outweighed by the advantage of a single stage operation in case of a positive diagnosis. The benefit of intra-operative examination was slightly less in patients with smaller tumours.
 
Key words: Axilla; Breast neoplasms; Frozen sections; Lymph node excision
 
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Postoperative outcome in Chinese patients having primary total knee arthroplasty under general anaesthesia/intravenous patient-controlled analgesia compared to spinal-epidural anaesthesia/analgesia

ABSTRACT
Hong Kong Med J 2006;12:442-7 | Number 6, December 2006
ORIGINAL ARTICLE
Postoperative outcome in Chinese patients having primary total knee arthroplasty under general anaesthesia/intravenous patient-controlled analgesia compared to spinal-epidural anaesthesia/analgesia
CPW Chu, JCCM Yap, PP Chen, HH Hung
Department of Anaesthesia and Operating Services, Alice Ho Miu Ling Nethersole Hospital, 11 Chuen On Road, Tai Po, Hong Kong
 
 
OBJECTIVE. To compare postoperative outcomes in patients having primary total knee arthroplasty receiving general or regional anaesthesia.
 
DESIGN. Randomised prospective study.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. Patients having primary total knee replacement were randomised to either general anaesthesia followed by postoperative intravenous patient-controlled analgesia with morphine, or combined spinal-epidural anaesthesia followed by postoperative epidural infusion of bupivacaine 0.1% with fentanyl 2 micrograms/mL.
 
MAIN OUTCOME MEASURES. Visual analogue scale pain scores, perioperative blood loss, time to first meal and ambulation, and prevalence of postoperative complications.
 
RESULTS. Sixty consecutive patients were enrolled in this study. Postoperative median pain scores were consistently lower at 1 (P<0.0001), 6 (P=0.08), 12 (P=0.003), 24 (P=0.14), and 48 hours (P=0.007) in those given regional anaesthesia. Although there was a trend towards fewer complications in the latter group, there were no statistically significant differences between the two groups with respect to the incidence of postoperative blood loss, haemodynamic instability, pruritus, nausea, vomiting, urinary retention, or other surgical/medical complications. Postoperatively, patients given regional anaesthesia also resumed meals earlier (P<0.0001), and showed a trend towards earlier ambulation and hospital discharge.
 
CONCLUSION. Chinese patients undergoing total knee arthroplasty with regional anaesthesia/regionally delivered analgesia enjoyed better postoperative pain relief and resumed meals earlier than those receiving general anaesthesia/intravenous patient-controlled analgesia. The former also showed trends towards less adverse effects, postoperative complications, earlier ambulation, and earlier hospital discharge.
 
Key words: Analgesia, epidural; Analgesia, patient-controlled; Anesthesia, general; Anesthesia, local; Arthroplasty, replacement, knee
 
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Management of primary postpartum haemorrhage with arterial embolisation in Hong Kong public hospitals

ABSTRACT
Hong Kong Med J 2006;12:437-41 | Number 6, December 2006
ORIGINAL ARTICLE
Management of primary postpartum haemorrhage with arterial embolisation in Hong Kong public hospitals
SPY Yong, KB Cheung
Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong
 
 
OBJECTIVE. To assess the utilisation, effectiveness, and safety of arterial (angiographic) embolisation for management of severe primary postpartum haemorrhage in Hong Kong public hospitals.
 
DESIGN. Retrospective study.
 
SETTING. All eight obstetrics and gynaecology units of the Hospital Authority in Hong Kong.
 
PATIENTS. Women who underwent arterial embolisation for primary postpartum haemorrhage from July 1999 to June 2004 inclusive.
 
MAIN OUTCOME MEASURES. Cause of primary postpartum haemorrhage, estimated blood loss, patient condition before embolisation, and the intervals between the diagnosis of postpartum haemorrhage and the procedure.
 
RESULTS. Primary postpartum haemorrhage occurred in 7200 (3.9%) cases of 183 700 deliveries; 90 (0.05%) underwent total hysterectomy, whilst 29 (0.016%) received angiographic embolisation. Arterial embolisation was 90% effective in treating medically uncontrollable primary postpartum haemorrhage, except in three patients who failed to respond and underwent a hysterectomy. All 29 patients survived, although due to severe haemorrhage one had a cardiac arrest, whilst another had transient right-leg claudication. Six patients developed mild fever.
 
CONCLUSIONS. In Hong Kong, arterial embolisation for severe primary postpartum haemorrhage is a safe and effective treatment modality but is underutilised. If first-line medical treatment fails and patients are haemodynamically stable, the procedure should be considered an alternative management option. A prompt decision and early resort to arterial embolisation are advisable so as to reduce the morbidity and avoid resorting to open surgery.
 
Key words: Embolization, therapeutic; Hemostatic techniques; Obstetric labor complications; Postpartum hemorrhage; Treatment outcome
 
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Practice of breastfeeding and factors that affect breastfeeding in Hong Kong

ABSTRACT
Hong Kong Med J 2006;12:432-6 | Number 6, December 2006
ORIGINAL ARTICLE
Practice of breastfeeding and factors that affect breastfeeding in Hong Kong
EYL Leung, KYA Au, SSW Cheng, SY Kok, HK Lui, WCW Wong
Department of Community and Family Medicine, School of Public Health, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVES. To describe the patterns of and factors affecting breastfeeding and to find out any significant relationship between breastfeeding and health of the child.
 
DESIGN. Cohort study.
 
SETTING. Postnatal ward of the Prince of Wales Hospital.
 
PARTICIPANTS. A total of 243 infants born in 1998 to 2001 at the hospital. Each infant was followed up for 3 years. Home visits were carried out at 3, 15, 24, and 36 months of age by medical students from the Chinese University of Hong Kong. A questionnaire was completed at each visit. Independent sample t-tests and Pearson Chi squared tests were used.
 
RESULTS. Of the 243 subjects, 213 provided data on the method of infant feeding. There were 66.7% of mothers initiating breastfeeding, with a median duration of 1 month. Only 13.4% met the World Health Organization's recommendations on breastfeeding. Breastfeeding was found to have a statistically significant relationship with (i) the infant's birth order and (ii) the mother's and father's education level. During follow-up, 44.6% of the infants were hospitalised but there was no significant relationship between breastfeeding and number of hospitalisations.
 
CONCLUSIONS. The current breastfeeding rate in Hong Kong falls below expectations when compared with other developed nations. To raise this rate, more support is needed for families with parents having a lower education level or more than two children, as they are the least likely to breastfeed. This might be achieved by encouraging antenatal class attendance, counselling of husbands, and more support for breastfeeding from doctors.
 
Key words: Breast feeding; Infant, newborn; Infant nutrition
 
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