Drug-induced hypoglycaemia--new insight into an old problem

ABSTRACT
Hong Kong Med J 2006;12:334-8 | Number 5, October 2006
ORIGINAL ARTICLE
Drug-induced hypoglycaemia--new insight into an old problem
CK Ching, CK Lai, WT Poon, MC Lui, YH Lam, CC Shek, TWL Mak, AYW Chan
Hospital Authority Toxicology Reference Laboratory, Princess Margaret Hospital, Laichikok, Hong Kong
 
 
OBJECTIVE. To review the causes of drug-induced hypoglycaemia in patients not taking hypoglycaemic medications.
 
DESIGN. Retrospective study.
 
SETTING. Regional hospitals in Hong Kong.
 
PATIENTS. Patients with suspected drug-induced hypoglycaemia without a known history of exposure to hypoglycaemic agents, referred to the Hospital Authority Toxicology Reference Laboratory from June 2005 to March 2006 inclusive.
 
MAIN OUTCOME MEASURES. Rate of positive cases, laboratory findings, possible causes, age distribution, and final outcomes. RESULTS. A total of 51 such patients were referred, in whom the presence of oral hypoglycaemic agents was detected (or inferred) in 23 (45%). In 12 of the 23 patients, oral hypoglycaemic agents could only be detected by target analysis, not through broad-spectrum screening. Gliclazide and glibenclamide were detected in 14 and eight patients respectively, whereas glimepiride, nateglinide and rosiglitazone were detected in the remaining patient. Possible sources of oral hypoglycaemic agents included drug administration errors in residential care homes for the elderly (n=9), mistakenly taking medication of a family member or employer (n=6), taking stock medication by mistake (n=2), taking Chinese proprietary medicine adulterated with oral hypoglycaemic agents (n=1), taking unknown pills bought from a retail pharmacy (n=1), and unknown (n=4). Regarding these 23 patients, 17 (74%) were aged 70 years or above and 21 (91%) recovered uneventfully.
 
RESULTS. 
 
CONCLUSION. Hypoglycaemia due to inadvertent use of oral hypoglycaemic agents is a recognised problem, particularly in cases where family members living in the same household are taking similar medications. Possible drug administration errors in residential care homes for the elderly should be investigated, and procedures rectified if confirmed. Health care providers should be vigilant to such potential errors, especially in cases of unexplained hypoglycaemia.
 
Key words: Hypoglycemia; Poisoning; Sulphonylurea compounds
 
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Risk factors for injury to married women from domestic violence in Hong Kong

ABSTRACT
Hong Kong Med J 2006;12:289-93 | Number 4, August 2006
ORIGINAL ARTICLE
Risk factors for injury to married women from domestic violence in Hong Kong
KL Tsui, AY Chan, FL So, CW Kam
Department of Accident and Emergency Medicine, Tuen Mun Hospital, Tsing Chung Koon Road, Tuen Mun, Hong Kong
 
 
OBJECTIVE. To examine risk factors for injury to married women from domestic violence in Hong Kong.
 
DESIGN. Case control study.
 
SETTING. Regional public hospital, Hong Kong.
 
PATIENTS. All married women aged 18 to 60 years who attended an accident and emergency department for treatment of a domestic violence injury from January 2004 to June 2005.
 
MAIN OUTCOME MEASURES. Social and health characteristics of abused women and their husbands.
 
RESULTS. A total of 293 cases were compared to 313 controls. Eight predictive variables were found to be significant by univariate analysis: woman who is a new immigrant (P=0.003), woman with no job (P=0.019), husband with low educational level (P<0.001), presence of extramarital affairs (P<0.001), husband's unemployment (P<0.001), husband's alcohol abuse (P<0.001), husband's illicit drug abuse (P=0.032), husband's mental illness (P<0.001). Five factors were found to be significant in a logistic regression analysis: husband with a low educational level (nil to primary) [adjusted odds ratio=2.78; 95% confidence interval, 1.149-6.727], husband unemployed (adjusted odds ratio=9.031; 95% confidence interval, 5.163-15.796), presence of extramarital affairs (adjusted odds ratio=5.218; 95% confidence interval, 2.899-9.395), husband's alcohol abuse (adjusted odds ratio=6.089; 95% confidence interval, 3.460-10.716), husband's mental illness (adjusted odds ratio=9.443; 95% confidence interval, 2.351-37.926).
 
CONCLUSIONS. Several significant risk factors have been identified for injury incurred during domestic violence to married women in Hong Kong. It provides information useful for developing local preventive strategies.
 
Key words: Battered women; Domestic violence; Risk factors
 
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Nissen fundoplication and gastrostomy in severely neurologically impaired children with gastroesophageal reflux

ABSTRACT
Hong Kong Med J 2006;12:282-8 | Number 4, August 2006
ORIGINAL ARTICLE
Nissen fundoplication and gastrostomy in severely neurologically impaired children with gastroesophageal reflux
KM Cheung, HW Tse, PWT Tse, KH Chan
Department of Paediatrics, Caritas Medical Centre, 111 Wing Hong Street, Shamshuipo, Hong Kong
 
 
OBJECTIVES. To study the effect of Nissen fundoplication and gastrostomy in severely neurologically impaired children.
 
DESIGN. Prospective observational study.
 
SETTING. Developmental Disabilities Unit of a regional medical centre in Hong Kong.
 
PATIENTS. Children with severe neurological impairment and gastroesophageal reflux who were institutionalised between 1999 and 2004 inclusive.
 
MAIN OUTCOME MEASURES. Incidence of vomiting, gastro-intestinal bleeding, and pneumonia in the baseline year and consecutive years following surgery; 24-hour oesophageal pH monitoring; recurrence rate (determined by 24-hour oesophageal monitoring); body weight; complications of surgery; and mortality.
 
RESULTS. Twenty children, with a mean age at surgery of 8.5 (standard deviation, 3.5) years, were recruited. Nissen fundoplication was performed in nine children and 11 children underwent laparoscopic fundoplication. Children were monitored for 1.3 to 5.7 years (median, 3.5 years) after surgery. The incidence of vomiting and gastro-intestinal bleeding was significantly decreased following surgery (P<0.001 and P=0.001, respectively; Friedman's test). There was no difference between the preoperative and postoperative incidence of pneumonia (P=0.973, Friedman's test). The median reflux index was reduced from 5.7% to 0.15% after surgery but six (30%) patients had recurrent gastroesophageal reflux. The mean body weight was 17.4 kg (standard deviation, 4.7 kg) at baseline and 22.8 kg (standard deviation, 4.4 kg) at the end of follow-up (P<0.05, Student's t test). One patient had mild dumping syndrome soon after fundoplication. One patient had one episode of intestinal obstruction. Four patients died 1.9 to 5.0 years following surgery due to respiratory disease.
 
CONCLUSION. Our results indicate that in severely neurologically impaired children with gastroesophageal reflux, vomiting, gastro-intestinal bleeding, and reflux indices based on 24-hour oesophageal pH monitoring were significantly reduced following fundoplication and gastrostomy. The incidence of pneumonia was unchanged. The recurrence rate of reflux was 30% and mortality rate was 20%.
 
Key words: Child; Fundoplication; Gastroesophageal reflux; Mental retardation; Recurrence
 
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Subcutaneous extralesional triamcinolone acetonide injection versus conservative management in the treatment of chalazion

ABSTRACT
Hong Kong Med J 2006;12:278-81 | Number 4, August 2006
ORIGINAL ARTICLE
Subcutaneous extralesional triamcinolone acetonide injection versus conservative management in the treatment of chalazion
CF Chung, JSM Lai, PSH Li
Department of Ophthalmology, United Christian Hospital, Kwun Tong, Hong Kong
 
 
OBJECTIVE. To compare the efficacy of subcutaneous extralesional triamcinolone acetonide injection versus conservative treatment for chalazion.
 
DESIGN. Randomised controlled trial.
 
SETTING. Eye clinics of two regional hospitals in Hong Kong.
 
PATIENTS. Patients over 18 years old presenting with primary chalazion were randomised into two groups. In group 1, 12 patients were treated with lid hygiene, warm compresses, and chloramphenicol 1% ointment 4 times a day. In group 2, 16 patients were treated with 0.3 mL triamcinolone acetonide (10 mg/mL) injection to the subcutaneous tissue extralesionally via the percutaneous route. Exclusion criteria were: acutely infected chalazion with preseptal cellulitis, recurrent chalazion, small chalazion (<=2 mm), and prior treatment to chalazion.
 
MAIN OUTCOME MEASURES. Size of chalazion, recurrence of chalazion, intraocular pressure, and complications from treatment, including skin pigmentary change or atrophy and pyogenic granuloma.
 
RESULTS. There was a clinically and statistically significant difference between the success rates in group 1 (58.3%) and group 2 (93.8%). In group 1, the mean prior duration of chalazion before treatment was significantly shorter in success cases than in failed cases. One patient with multiple chalazia in group 2 developed hypopigmentary skin changes at one treatment site.
 
CONCLUSION. Lupus vulgaris and tuberculosis verrucosa cutis remain the commonest forms of true cutaneous tuberculosis, and erythema induratum is the most common tuberculid. Culture and polymerase chain reaction are positive in a small proportion of patients.
 
Key words: Chalazion; Injections, subcutaneous; Triamcinolone acetonide
 
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Cutaneous tuberculosis in Hong Kong: an update

ABSTRACT
Hong Kong Med J 2006;12:272-7 | Number 4, August 2006
ORIGINAL ARTICLE
Cutaneous tuberculosis in Hong Kong: an update
CK Ho, MH Ho, LY Chong
Social Hygiene Service (Dermatology Division), Department of Health, Yaumatei Dermatology Clinic, 12/F, Yaumatei Specialist Clinic, 143 Battery Street, Hong Kong
 
 
OBJECTIVE. To provide an update on cutaneous tuberculosis in Hong Kong.
 
DESIGN. Retrospective study.
 
SETTING. Social Hygiene Service (Dermatology Division), the largest dermatological referral centre in Hong Kong.
 
PATIENTS. Patients presented with cutaneous tuberculosis between 1993 and 2002 inclusive. Case notes, histology reports, and microbiological reports were reviewed with particular reference to the epidemiology, duration of illness, history of contact with tuberculosis, culture results, and response to treatment.
 
RESULTS. There were 147 patients with cutaneous tuberculosis; among these a few had true cutaneous tuberculosis (n=16) and the remainder were tuberculids (n=131). In all they accounted for 0.04% of new dermatology cases diagnosed. Cases of cutaneous tuberculosis were distributed as follows: lupus vulgaris (n=6, 4%), tuberculosis verrucosa cutis (n=6, 4%), tuberculosis of the skin unclassified (n=2, 1%), and orificial tuberculosis (n=2, 1%). Culture and polymerase chain reaction was positive in less than half of the latter cases. All responded well to anti-tuberculosis therapy. Erythema induratum was the most common form (n=127, 86%), but papulonecrotic tuberculids (n=4, 3%) were uncommon. Erythema induratum affected the lower limb in all patients, with a female predominance, and responded to isoniazid monotherapy, multidrug anti-tuberculosis therapy, or doxycycline.
 
CONCLUSION. Lupus vulgaris and tuberculosis verrucosa cutis remain the commonest forms of true cutaneous tuberculosis, and erythema induratum is the most common tuberculid. Culture and polymerase chain reaction are positive in a small proportion of patients.
 
Key words: Erythema induratum; Isoniazid; Lupus; Tetracycline; Tuberculosis, cutaneous
 
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Intestinal tuberculosis in a regional hospital in Hong Kong: a 10-year experience

ABSTRACT
Hong Kong Med J 2006;12:264-71 | Number 4, August 2006
ORIGINAL ARTICLE
Intestinal tuberculosis in a regional hospital in Hong Kong: a 10-year experience
VKS Leung, ST Law, CW Lam, ISC Luk, TN Chau, TKL Loke, WH Chan, SH Lam
Department of Medicine and Geriatrics, United Christian Hospital, Kwun Tong, Hong Kong
 
 
OBJECTIVE. To study the clinical and pathological characteristics of patients with intestinal tuberculosis.
 
DESIGN. Retrospective study.
 
SETTING. United Christian Hospital, Hong Kong.
 
PATIENTS. Patients with intestinal tuberculosis diagnosed between January 1995 and December 2004 inclusive.
 
RESULTS. The median age of the 13 male and 9 female patients was 53 years (range, 12-81 years). Nineteen (86%) had a definitive diagnosis of intestinal tuberculosis confirmed by the presence of caseating granulomas and/or acid-fast bacilli in histological specimens. In three (14%) the diagnosis was based on histology revealing non-caseating granulomas and a positive response to anti-tuberculous treatment. Common symptoms included abdominal pain (82%), diarrhoea (55%), weight loss (55%), and fever (45%). Three (14%) of the patients were complicated by intestinal obstruction, and another two (9%) had intestinal perforation. Four (18%) had concomitant active pulmonary tuberculosis. The most frequently involved site was the ileocaecal region, which was affected in 19 (86%) patients. Other sites included the jejunum, ascending and sigmoid colon. The diagnosis of intestinal tuberculosis was facilitated by examination of colonoscopic biopsy specimens (11 patients), and by examination of resected surgical specimens in the remainder. Two patients died from terminal malignancy. The remainder completed anti-tuberculous therapy and responded satisfactorily.
 
CONCLUSIONS. The diagnosis of intestinal tuberculosis is difficult due to the lack of specific signs or symptoms. Colonoscopy with ileoscopy are useful tools in the search for colonic and terminal ileal tuberculosis. Surgical exploration is reserved for equivocal cases and for those who present as emergencies.
 
Key words: Cecum; Colonoscopy; Granuloma; Ileum; Tuberculosis, gastrointestinal
 
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Seizure-related injury in an adult tertiary epilepsy clinic

ABSTRACT
Hong Kong Med J 2006;12:260-3 | Number 4, August 2006
ORIGINAL ARTICLE
Seizure-related injury in an adult tertiary epilepsy clinic
S Tiamkao, SD Shorvon
Division of Neurology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
 
 
OBJECTIVE. To assess the frequency, characteristics, and risk of injury during seizure attacks.
 
DESIGN. Questionnaire survey.
 
SETTING. Epilepsy out-patient clinic of the National Hospital for Neurology and Neurosurgery, Institute of Neurology, London.
 
PATIENTS. One hundred consecutive epileptic patients and their caretakers or relatives, who attended the hospital between 1 May and 30 June 2000.
 
MAIN OUTCOME MEASURES. Details of epilepsy including the age of onset, causes, types, and number of seizures during the previous 12 months; injuries incurred as a result of seizures; and treatment required.
 
RESULTS. The mean age of the 100 patients (38 male, 62 female) was 39 years (range, 16-78 years). Generalised tonic-clonic seizures occurred in 51% of patients and complex partial seizures in 40%. Hippocampal sclerosis was found in 12% of patients. Twenty-seven patients reported 222 seizure-related injuries. The total number of seizures per year was 4459 (mean, 45), of which 1094 (mean, 11) were with a fall (24.5%). Soft-tissue injury was the most common (61%), followed by burns (17%), head injury (14%), orthopaedic injury (5%), and injuries in water (3%). The most common site of soft-tissue injury and burns were to the face: 49% and 38% respectively. Burns occurred during cooking in 78% of cases. Two patients had skull fractures. Orthopaedic injuries usually occurred at home (73%). In cases of seizures in water, five of six occurred while swimming. Injury occurred once in every 20 seizures, every 11 generalised tonic-clonic seizures, and every five seizures with a fall. The significant risk factors for injury were generalised tonic-clonic seizures, high frequency of seizures, and seizures with a fall.
 
CONCLUSION. Soft-tissue injury was the most common seizure-related injury. Injury occurred once in every 20 seizures. The risk factors were generalised tonic-clonic seizures, high frequency of seizures, and seizures with a fall.
 
Key words: Risk factors; Seizures; Soft tissue injuries
 
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Use of lithium in the treatment of thyrotoxicosis

ABSTRACT
Hong Kong Med J 2006;12:254-9 | Number 4, August 2006
ORIGINAL ARTICLE
Use of lithium in the treatment of thyrotoxicosis
YW Ng, SC Tiu, KL Choi, FKW Chan, CH Choi, PS Kong, CM Ng, CC Shek
Department of Medicine, Queen Elizabeth Hospital, 30 Gascoigne Road, Hong Kong
 
 
OBJECTIVES. To evaluate the efficacy and safety of lithium in the treatment of thyrotoxicosis, and to study the dose and serum levels at which therapeutic response occurs.
 
DESIGN. Retrospective study.
 
SETTING. Thyroid clinic of a regional hospital in Hong Kong.
 
PATIENTS. Thirteen patients with thyrotoxicosis pending therapy with radioiodine or surgery, in whom thionamides were contra-indicated due to adverse reactions or failure of treatment.
 
MAIN OUTCOME MEASURES. Free thyroxine levels, time to euthyroidism, and side-effects of lithium.
 
RESULTS. A satisfactory response, defined as a fall by 40% or more in free thyroxine levels and clinical improvement, was achieved in eight patients within 1 to 2 weeks of lithium therapy. In four others, response occurred in 3 to 5 weeks. Response was slow and inadequate in one patient due to 'escape'. The median dosage of lithium was 750 mg daily, with a range of 500 to 1500 mg daily. The median serum lithium level was 0.63 mmol/L. Lithium toxicity was observed in one patient.
 
CONCLUSIONS. A relatively low dose of lithium offers a safe and effective alternative means of controlling thyrotoxicosis in patients who cannot tolerate or do not respond to thionamides.
 
Key words: Graves' disease; Lithium; Thyrotoxicosis; Thyroxine
 
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A prospective case-control study of ankle fracture in postmenopausal women

ABSTRACT
Hong Kong Med J 2006;12:208-11 | Number 3, June 2006
ORIGINAL ARTICLE
A prospective case-control study of ankle fracture in postmenopausal women
PY Ho, N Tang, SW Law, HF Tsui, TP Lam, KS Leung
Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVES. To compare bone mineral density of women with postmenopausal ankle fractures with controls and review patient characteristics, injury mechanisms, and outcomes.
 
DESIGN. Prospective case-control study.
 
SETTING. University teaching hospital, Hong Kong.
 
PARTICIPANTS. Women older than 60 years, admitted with ankle fractures between 2002 and 2003 and controls (age-matched women with femoral neck fractures).
 
MAIN OUTCOME MEASURES. Demographic data, bone mineral density, mechanism of injury, fracture pattern, treatment, and the functional outcome.
 
RESULTS. The mean age of the study group (18 ankle fracture patients) was 74 years. The fractures usually resulted from a low-energy trauma; isolated lateral malleolar fracture was the most common (8/18), whilst six had bimalleolar fractures. Their mean T-score bone mineral density values at the spine and hip were -1.67 and -1.70, respectively; corresponding Z-scores were +0.73 and +0.99. The bone mineral density of the study group was significantly higher than in patients with fractured neck of femur (controls) and the general population (P<0.05). Nine of the study group had diabetes and one had impaired glucose tolerance. Treatment comprised casting in 10 patients and operative fixation in seven. Good functional recovery was achieved; most patients were able to resume their premorbid level of independent daily activities with a good motor functional independence score (85.18/91) 1 year post-injury.
 
CONCLUSION. In this case-control study, postmenopausal ankle fractures were not associated with osteoporosis. Diabetic neuropathy may have been a risk factor for such injury. The functional outcome of such patients was generally satisfactory, provided appropriate treatment was given.
 
Key words: Ankle injuries; Bone density; Fractures, bone; Osteoporosis, postmenopausal
 
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Prevalence of subclinical infection and transmission of severe acute respiratory syndrome (SARS) in a residential care home for the elderly

ABSTRACT
Hong Kong Med J 2006;12:201-7 | Number 3, June 2006
ORIGINAL ARTICLE
Prevalence of subclinical infection and transmission of severe acute respiratory syndrome (SARS) in a residential care home for the elderly
LCL Heung, T Li, SK Mak, WM Chan
Elderly Health Services, Department of Health, 35/F Hopewell Centre, 183 Queen's Road East, Wanchai, Hong Kong
 
 
OBJECTIVE. To ascertain the prevalence of subclinical severe acute respiratory syndrome–coronavirus (SARS-CoV) infection and study the transmission of SARS-CoV in a local outbreak at a residential care home for the elderly.
 
DESIGN. Cross-sectional study.
 
SETTING. A residential care home for the elderly in Hong Kong with a local outbreak of SARS.
 
PARTICIPANTS. Residents and staff in the residential care home who had contact with three patients with SARS (residents A and B, and staff C).
 
MAIN OUTCOME MEASURES. Blood samples were tested for total antibodies to SARS-CoV by immunofluorescence antibody test. The transmission of SARS was elucidated based on information from standardised questionnaires, and records of investigation and surveillance by the Department of Health.
 
RESULTS. Among the 90 eligible residents, three died, one moved out, and 19 refused to participate. Of the 32 eligible staff, six refused to participate. None of the remaining 93 participants tested positive for antibody to SARS-CoV. Based on the chronological order, resident A might have transmitted infection to resident B and staff C. Sitting close to the bathroom doorway while resident A took a shower was the only contact of resident B with resident A. The only opportunity for staff C to have contact with body fluids/excreta of resident A was in the handling of rubbish from the resident’s room.
 
CONCLUSION. Subclinical SARS-CoV infection was rare in a residential care home for the elderly with an outbreak of SARS. Nonetheless the close working and living conditions for staff and residents in such a home may facilitate transmission of SARS despite vigilant precautionary measures.
 
Key words: Aged; Disease transmission; Homes for the aged; Seroepidemiologic studies; Severe acute respiratory syndrome
 
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