Targeted Next-Generation Sequencing-Based Multiple Gene Mutation Profiling of Patients with Rectal Adenocarcinoma Receiving or Not Receiving Neoadjuvant Chemoradiotherapy

This study investigated whether oncogenic and tumor-suppressive gene mutations are involved in the differential outcomes of patients with rectal carcinoma receiving neoadjuvant chemoradiotherapy (nCRT). Genomic DNA was obtained from formalin-fixed paraffin-embedded (FFPE) specimens of patients with rectal carcinoma who received a complete nCRT course. Gene mutation status was examined in specimens from patients before and after nCRT by using the AmpliSeq platform. Our data revealed that the nonsynonymous p53, APC, KRAS, CDKN2A, and EGFR mutations were observed in 93.1%, 65.5%, 48.6%, and 31% of the patients with rectal adenocarcinoma, respectively. BRAF, FBXW7, PTEN, and SMAD4 mutations were observed in 20.7% of patients with rectal carcinoma. The following 12 gene mutations were observed more frequently in the patients exhibiting a complete response than in those demonstrating a poor response before nCRT: ATM, BRAF, CDKN2A, EGFR, FLT3, GNA11, KDR, KIT, PIK3CA, PTEN, PTPN11, SMAD4, and TP53. In addition, APC, BRAF, FBXW7, KRAS, SMAD4, and TP53 mutations were retained after nCRT. Our results indicate a complex mutational profile in rectal carcinoma, suggesting the involvement of BRAF, SMAD4, and TP53 genetic variants in the outcomes of patients with nCRT.

Incidence of gastrointestinal bleeding after transoesophageal echocardiography in patients with gastro-oesophageal varices: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transoesophageal echocardiography (TEE) is useful for cardiac assessment and intraoperative monitoring. However, the safety of TEE in cirrhotic patients with gastro-oesophageal varices has remained uncertain.

Purpose

This meta-analysis aims to determine the incidence of gastrointestinal bleeding after TEE in patients with varices. The secondary objectives are to compare the bleeding risks between patients with and without varices; and to determine the incidences of TEE-related oesophageal perforation and mortality.

Methods

Systematic literature search was conducted on MEDLINE, EMBASE and Cochrane Database using the terms "Transoesophageal echocardiography", "Varices", "Bleeding", and related terms. Articles describing the incidence of post-TEE bleeding in patients with varices were included. Non-English articles were excluded. Risk of bias was assessed through a validated scale for bias assessment in prevalence studies. The level of evidence was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation approach. Pooled weighted incidence of gastrointestinal bleeding and risk difference in bleeding were calculated with a random effects model.

Results

569 articles were identified initially, and 10 articles (comprising of 908 patients) were included. The incidence of post-TEE bleeding in patients with varices was 0.84% (95% CI 0.34%-1.56%). When stratified by TEE indication, the pooled incidence of bleeding was 0.68% (95% CI 0.11%-1.63%) in intraoperative TEE; and 1.03% (95% CI 0.23%-2.29%) in diagnostic TEE.  No cases of oesophageal perforation or mortality were reported. 6 studies included a comparator group of patients without varices, and the bleeding risk was comparable between patients with and without varices (risk difference 0.26%; 95% CI -0.80%-1.32%; I2 = 0%, p = 0.88). Eight studies had moderate or high risk of bias, and overall level of evidence was low.

Conclusion

TEE appears to be associated with low gastrointestinal bleeding incidence in patients with gastro-oesophageal varices. Nonetheless, results should be treated with caution due to bias and low level of evidence. Large-scale high-quality studies will be required to confirm the safety of TEE in patients with gastro-oesophageal varices. Abstract Figure. Study selection process  Abstract Figure. Forest plot of pooled bleeding incidence

'Organic Anxiety' in a Middle-aged Man Presenting with Dyspnoea: a Case Report

We report a case of pulmonary embolism in a patient who presented with repeated anxiety attacks and psychotic symptoms and was misdiagnosed as having withdrawal seizure or anxiety disorder not otherwise specified. This case highlighted the nonspecific clinical features of pulmonary embolism and the principles in making psychiatric diagnosis. Careful history taking, thorough physical examination, appropriate investigation, and a high index of suspicion led to the correct diagnosis. The principle of hierarchy of psychiatric diagnosis (ie, organic over non-organic) and the possibility of comorbidities should always apply.

Direct health-care cost utilization in Hong Kong inflammatory bowel disease patients in the initial 2 years following diagnosis

BACKGROUND AND AIM

There are scanty data on the health-care utilization from Asia where the incidence of inflammatory bowel disease (IBD) is rising rapidly. We aim to determine the direct health-care costs in the first 2 years of diagnosis in an IBD cohort from Hong Kong and the factors associated with high cost outliers.

METHODS

This is a retrospective cohort study that included patients newly diagnosed with IBD in a territory-wide IBD registry. Patients' clinical information, hospitalization records, investigations, and IBD treatments were retrieved for up to 2 years following diagnosis of IBD.

RESULTS

Four hundred and thirty-five newly diagnosed IBD patients were included: 198 with Crohn's disease and 237 with ulcerative colitis. Total direct medical expenditure for this cohort 2 years after the IBD diagnosis was $7 072 710: hospitalizations (33%), 5-aminosalicylic acid (23%), imaging and endoscopy (17%), outpatient visits (10%), surgery (8%), and biologics (6%). Mean direct medical costs per patient-year were significantly higher for Crohn's disease ($9918) than ulcerative colitis ($6634; P, 0.001). The total direct health-care cost decreased significantly after transition to the second year (P < 0.01). High cost (> 90th percentile) outliers were associated with surgery (OR 7.1, 95% CI 2.9-17.2) and low hemoglobin on presentation (OR 0.83, 95% CI 0.70-0.96).

CONCLUSIONS

Hospitalization and 5-aminosalicylic acid usage accounted for 56% of total direct medical costs in the first 2 years of our newly diagnosed IBD patients. Direct health-care costs were higher in the first year compared with the second year of diagnosis. Surgery and low hemoglobin on presentation were associated with high cost outliers.

Effects of di(2-ethylhexyl)phthalate exposure on 1,2-dimethyhydrazine-induced colon tumor promotion in rats

Di(2-ethylhexyl)phthalate (DEHP) may cause carcinogenicity in the liver; however, few have detailed on the potential effects of DEHP exposure on colorectal cancer. Male Sprague-Dawley rats received i.p. injections of 1,2-dimethylhydrazine (DMH) once-a-week for the first 4 weeks, and rats in each group were treated with DEHP through oral gavage daily for either 7, 10 or 15 weeks; after which, all rats were euthanized and their colons were assessed (a) morphologically for aberrant crypt foci (ACF) or tumors, (b) cytologically for mitotic index (MI), and (c) immunohistochemically for the expression of β-catenin, cyclooygenase (COX)-2, vascular endothelial growth factor (VEGF), proliferating cell nuclear antigen (PCNA), cyclin D1, and c-myc. Our results indicated that the mean total ACF, tumor incidence, and MI were significantly higher in the DEHP-treated DMH compared to control and the DEHP-alone groups. The level of β-catenin and cyclin D1 was increased in DEHP-exposed rats. Expression of β-catenin, COX-2, VEGF, and cyclin D1 was significantly higher in the combined DMH and DEHP-treated rats by comparison to that of the DMH group. In conclusion, this study indicates that exposure to DEHP may exacerbate DMH-induced colon tumorigenesis and provides impetus to evaluate the effect of DEHP in conjunction with other carcinogens.

Arm Selection Preference of MicroRNA-193a Varies in Breast Cancer

MicroRNAs (miRNAs) are short noncoding RNAs derived from the 3′ and 5′ ends of the same precursor. However, the biological function and mechanism of miRNA arm expression preference remain unclear in breast cancer. We found significant decreases in the expression levels of miR-193a-5p but no significant differences in those of miR-193a-3p in breast cancer. MiR-193a-3p suppressed breast cancer cell growth and migration and invasion abilities, whereas miR-193a-5p suppressed cell growth but did not influence cell motility. Furthermore, NLN and CCND1, PLAU, and SEPN1 were directly targeted by miR-193a-5p and miR-193a-3p, respectively, in breast cancer cells. The endogenous levels of miR-193a-5p and miR-193a-3p were significantly increased by transfecting breast cancer cells with the 3′UTR of their direct targets. Comprehensive analysis of The Cancer Genome Atlas database revealed significant differences in the arm expression preferences of several miRNAs between breast cancer and adjacent normal tissues. Our results collectively indicate that the arm expression preference phenomenon may be attributable to the target gene amount during breast cancer progression. The miRNA arm expression preference may be a means of modulating miRNA function, further complicating the mRNA regulatory network. Our findings provide a new insight into miRNA regulation and an application for breast cancer therapy.

Jaw osteoradionecrosis and dental extraction after head and neck radiotherapy: A nationwide population-based retrospective study in Taiwan

OBJECTIVES

Osteoradionecrosis of the jaws (ORNJ) is painful for patients and relatively difficult to treat clinically. The high risk of ORNJ for post radiotherapy R/T dental extraction is known; however, many patients still have to have teeth extracted after head and neck R/T. The objective of the present study is to review post R/T dental extraction and determine the ORNJ risk.

MATERIALS AND METHODS

We preformed a retrospective cohort study of 1759 patients with head and neck cancer s/p R/T from a random sample of 1,000,000 insurants in the National Health Insurance Research Database during 2000-2013 in Taiwan. Statistical methods included two-proportion Z-test.

RESULTS

We evaluated two cohorts: 522 patients with post R/T dental extraction and 1237 patients without post R/T extraction. Overall moderate-to-severe ORNJ after R/T was 2.22% (39/1759), and a total of 39 ORNJ cases were noted during an average of 3.02years (range: 0.62-8.89years, ±2.07). ORNJ prevalence in the overall post R/T extraction-exposed cohort (5.17%, 27/522) was significantly greater than that in the unexposed cohort (0.97%, 12/1237). In a group of patients with ⩽5 post R/T dental extractions (n=373), the ORNJ risk was 2.4% (ORNJ case n=9); in a group of patients with >5 dental extractions (n=149), the ORNJ risk was 12.1% (ORNJ case n=18) (Z-score=4.5062; p-value<0.0001). In the extraction-exposed cohort, the ORNJ risk is higher if the index day to first extraction day was ⩽0.5year (n=103) compared with the group with the index day to first extraction day >0.5year (n=419) (Z-score=-2.1506; p-value=0.0315).

CONCLUSION

A tooth extraction time less than half a year after R/T or during the head and neck R/T period, and extraction tooth number ⩽5 would significant lower the ORNJ prevalence.

Indium acetate toxicity in male reproductive system in rats

Indium, a rare earth metal characterized by high plasticity, corrosion resistance, and a low melting point, is widely used in the electronics industry, but has been reported to be an environmental pollutant and a health hazard. We designed a study to investigate the effects of subacute exposure of indium compounds on male reproductive function. Twelve-week old male Sprague-Dawley rats were randomly divided into test and control groups, and received weekly intraperitoneal injections of indium acetate (1.5 mg/kg body weight) and normal saline, respectively, for 8 weeks. Serum indium levels, cauda epididymal sperm count, motility, morphology, chromatin DNA structure, mitochondrial membrane potential, oxidative stress, and testis DNA content were investigated. The indium acetate-treated group showed significant reproductive toxicity, as well as an increased percentage of sperm morphology abnormality, chromatin integrity damage, and superoxide anion generation. Furthermore, positive correlations among sperm morphology abnormalities, chromatin DNA damage, and superoxide anion generation were also noted. The results of this study demonstrated the toxic effect of subacute low-dose indium exposure during the period of sexual maturation on male reproductive function in adulthood, through an increase in oxidative stress and sperm chromatin DNA damage during spermiogenesis, in a rodent model.

Efficacy and toxicity of intensity-modulated radiation therapy for prostate cancer in Chinese patients

OBJECTIVE

To report the treatment efficacy and toxicity profile of intensitymodulated radiation therapy in Chinese patients with clinically localised prostate cancer.

DESIGN

Historical cohort study.

SETTING

Oncology unit in a university teaching hospital in Hong Kong.

PATIENTS

Patients with clinically localised prostate cancer undergoing intensity-modulated radiation therapy in our institution between May 2001 and November 2009 were reviewed.

MAIN OUTCOME MEASURES

The 5-year biochemical failure–free survival, 5-year overall survival, as well as acute/late gastro-intestinal toxicities and genito-urinary toxicities.

RESULTS

A total of 182 patients were treated with prostate intensitymodulated radiation therapy with or without whole-pelvic radiotherapy. The median follow-up was 44 months. The median patient age was 72 years. Overall survival of the cohort was 92% after 5 years. The favourable, intermediate, and unfavourable risk category distributions of the National Comprehensive Cancer Network were 21 (12%), 42 (23%), and 119 (65%), respectively. The 5-year actuarial biochemical failure–free survival rates for patients in these categories were 95%, 82%, and 80%, respectively. Multivariate analysis identified early tumour stage, low pre-treatment prostate-specific antigen levels, and the use of adjuvant androgen deprivation as independent prognostic factors for better biochemical failure–free survival. Grade 2 and 3 late gastro-intestinal/genito-urinary toxicities occurred in 8%/3% and 4%/3% of the patients, respectively.

CONCLUSION

Intensity-modulated radiation therapy for prostate cancer is feasible and safe in the Chinese population. These data are consistent with the results of other series in Caucasian populations.

ATG4B promotes colorectal cancer growth independent of autophagic flux

Autophagy is reported to suppress tumor proliferation, whereas deficiency of autophagy is associated with tumorigenesis. ATG4B is a deubiquitin-like protease that plays dual roles in the core machinery of autophagy; however, little is known about the role of ATG4B on autophagy and proliferation in tumor cells. In this study, we found that ATG4B knockdown induced autophagic flux and reduced CCND1 expression to inhibit G 1/S phase transition of cell cycle in colorectal cancer cell lines, indicating functional dominance of ATG4B on autophagy inhibition and tumor proliferation in cancer cells. Interestingly, based on the genetic and pharmacological ablation of autophagy, the growth arrest induced by silencing ATG4B was independent of autophagic flux. Moreover, dephosphorylation of MTOR was involved in reduced CCND1 expression and G 1/S phase transition in both cells and xenograft tumors with depletion of ATG4B. Furthermore, ATG4B expression was significantly increased in tumor cells of colorectal cancer patients compared with adjacent normal cells. The elevated expression of ATG4B was highly correlated with CCND1 expression, consistently supporting the notion that ATG4B might contribute to MTOR-CCND1 signaling for G 1/S phase transition in colorectal cancer cells. Thus, we report that ATG4B independently plays a role as a positive regulator on tumor proliferation and a negative regulator on autophagy in colorectal cancer cells. These results suggest that ATG4B is a potential biomarker and drug target for cancer therapy.

MicroRNA expression profiles in human breast cancer cells after multifraction and single-dose radiation treatment

MicroRNAs (miRNAs) are small non-coding RNAs that contribute to modulating signaling pathways after radiation exposure and have emerged as a potential therapeutic target or biomarker in the radiation response of cancer. Exposing breast cancer cells to single-dose (SD) or multifractionated (MF) radiation may affect the cells differently. However, the roles of miRNAs in breast cancer cells after the response to SD or MF is not thoroughly understood. Therefore, the purpose of the present study was to comprehensively investigate the response of miRNAs in MDA-MB-361 by using various radiation exposing protocols. Our results revealed that only a small fraction of miRNAs exhibiting differential expressions (>1.5‑fold) was identified after MDA-MB-361 cells were exposed to SD (10 Gy) or MF radiation (2 Gy x 5 MF). In addition, we observed that several miRNAs in the MDA-MB-361 cells frequently exhibited differential responses to various types of radiation treatment. Among these miRNAs, the expression levels of an oncogenic miR-17-92 cluster increased following SD radiation treatment. Conversely, miR-19a-3p, miR-20a-5p, and miR-19b-3p expressions were inhibited by >1.5-fold in the following MF treatment. Further analysis of the miR-17-92 cluster expression levels revealed that miR-17, miR-18a, miR-19a/b and miR-20a were significantly overexpressed and miR-92a was downregulated in breast cancer. Functional annotation demonstrated that target genes of the miR-17-92 cluster were predominantly involved in the regulation of radiation-associated signal pathways such as mitogen-activated protein kinase (MAPK), ErbB, p53, Wnt, transforming growth factor-β (TGF-β), mTOR signaling pathways and cell cycles with an FDR <0.05. Overall, the results of the present study revealed distinct differences in the response of miRNAs to SD and MF radiation exposure, and these radiation-associated miRNAs may contribute to radiosensitivity and can be used as biomarkers for radiotherapy.

Comprehensive microRNA profiling of prostate cancer cells after ionizing radiation treatment

MicroRNAs (miRNAs) are small, non-coding RNAs that negatively regulate gene expression and have emerged as potential biomarkers in radiation response to human cancer. Only a few miRNAs have been identified in radiation response to prostate cancer and the involvement of the radiation-associated miRNA machinery in the response of prostate cancer cells to radiation is not thoroughly understood. Therefore, the purpose of the present study was to comprehensively investigate the expression levels, arm selection preference and isomiRs of radiation-response miRNAs in radiation-treated PC3 cells using a next-generation sequencing (NGS) approach. Our data revealed that the arm selection preference and 3′ modification of miRNAs may be altered in prostate cancer after radiation exposure. In addition, the proportion of AA dinucleotide modifications at the end of the read gradually increased in a time-dependent manner after PC3 radiation treatment. We also identified 6 miRNAs whose expression increased and 16 miRNAs whose expression decreased after exposure to 10 Gy of radiation. A pathway enrichment analysis revealed that the target genes of these radiation-induced miRNAs significantly co-modulated the radiation response pathway, including the mitogen-activated protein kinase (MAPK), Wnt, transforming growth factor-β (TGF-β) and ErbB signaling pathways. Furthermore, analysis of The Cancer Genome Atlas (TCGA) database revealed that the expression of these radiation-induced miRNAs was frequently dysregulated in prostate cancer. Our study identified radiation-induced miRNA candidates which may contribute to radiosensitivity and can be used as biomarkers for radiotherapy.

Mummification in a Chinese patient with grief: a morbid symptom or a cultural practice?

Mummification was first described by Gorer in 1965 as a feature of grief in which the deceased individual's belongings and, in extreme cases, his or her corpse are preserved as if he or she was still alive and, often, the grieving person acts as if the deceased will return at a later date. Little research has been done on the cultural differences of patients demonstrating mummification. In the Asian community, a common belief is that there is life after death. The spirits of the dead are believed to exist in the human world, and ancestral worship is a common practice among Chinese people. Gorer believed that mummification was a maladaptation of unresolved grief in a ritual-less society. While this may possibly be true in western societies, this theory does not necessarily comply with Chinese practices. This case study discusses the psychopathology of mummification in a grieving Chinese patient and explores the importance of considering cultural influences in assessing the morbidity of this symptom.

Co-modulated behavior and effects of differentially expressed miRNA in colorectal cancer

Background

MicroRNAs (miRNAs) are short noncoding RNAs (approximately 22 nucleotides in length) that play important roles in colorectal cancer (CRC) progression through silencing gene expression. Numerous dysregulated miRNAs simultaneously participate in the process of colon cancer development. However, the detailed mechanisms and biological functions of co-expressed miRNA in colorectal carcinogenesis have yet to be fully elucidated.

Results

The objective of this study was to identify the dysfunctional miRNAs and their target mRNAs using a wet-lab experimental and dry-lab bioinformatics approach. The differentially expressed miRNA candidates were identified from 2 miRNA profiles, and were confirmed in CRC clinical samples using reported target genes of dysfunctional miRNAs to perform functional pathway enrichment analysis. Potential target gene candidates were predicted by an in silico search, and their expression levels between normal and colorectal tumor tissues were further analyzed using real-time polymerase chain reaction (RT-PCR).

We identified 5 miRNAs (miR-18a, miR-31, miR-96, miR-182, and miR-224) and 10 miRNAs (miR-1, miR-9, miR-10b, miR-133a, miR-143, miR-137, miR-147b, miR-196a/b, and miR-342) that were significantly upregulated and downregulated in colon tumors, respectively. Bioinformatics analysis showed that the known targets of these dysregulated miRNAs simultaneously participated in epithelial-to-mesenchymal transition (EMT), cell growth, cell adhesion, and cell cycles. In addition, we identified that several pivotal target gene candidates may be comodulated by dysfunctional miRNAs during colon cancer progression. Finally, 7 candidates were proven to be differentially expressed, and had an anti-correlationship with dysregulated miRNA in 48 CRC samples.

Conclusion

Fifteen dysfunctional miRNAs were engaged in metastasis-associated pathways through comodulating 7 target genes, which were identified by using a multi-step approach. The roles of these candidate genes are worth further exploration in the progression of colon cancer, and could potentially be targets in future therapy.

Dosimetric advantages and superior treatment delivery efficiency of RapidArc over conventional intensity-modulated radiotherapy in high-risk prostate cancer involving seminal vesicles and pelvic nodes

AIMS

To compare the dosimetry and treatment delivery efficiency of RapidArc with conventional intensity-modulated radiotherapy (IMRT) in the treatment of high-risk prostate cancer.

MATERIALS AND METHODS

Fifteen patients with high-risk localised prostate cancer were studied. Sequential treatment was used. The initial planning target volume (PTV-L) included the prostate, seminal vesicles and pelvic lymphatics, whereas the prostate boost PTV (PTV-P) included the prostate and seminal vesicles only. The total prescription dose was 76 Gy (44 Gy to PTV-L, 32 Gy to PTV-P; 2 Gy/fraction). Two separate planning techniques were generated for each patient: seven static-field IMRT versus two-arc RapidArc. Dose-volume parameters for the organs at risk, conformity index and homogeneity index for the PTVs, the calculated monitor units and treatment delivery time for both techniques were compared.

RESULTS

RapidArc gave more conformal plans than IMRT for both PTVs. RapidArc gave a higher homogeneity index to the PTV-P and a similar homogeneity index to the PTV-L. The two techniques gave similar dosimetric results for the rectum, bladder and femoral heads. The mean dose (Dmean) and the maximum dose (Dmax) of the bowel space were reduced by 3.06 and 2.83%, respectively, with RapidArc. The V20 Gy, V30 Gy and V40 Gy for healthy tissues were reduced by 7.77, 14.25 and 17.55%, respectively, with RapidArc. The calculated treatment delivery time and monitor units were reduced by 74.09%/60.93% and 68.32%/48.06% for the PTV-L/PTV-P, respectively, with RapidArc.

CONCLUSION

RapidArc is better than conventional IMRT in terms of dosimetry and delivery efficiency for high-risk prostate cancer.

Silencing of miR-1-1 and miR-133a-2 cluster expression by DNA hypermethylation in colorectal cancer

MicroRNAs are small non-coding RNA molecules that play important roles in the multistep process of colorectal carcinoma (CRC) development. The present study evaluated the relationship between miR-1-1 and miR-133a-2 expression and DNA methylation, and its putative biological role in CRC. The results indicated that DNA methylation regulated the expression of the miR-1-1 and miR-133a-2 cluster in CRC cell lines. Expression of miR-1 and miR-133a was further evaluated in 64 paired tissue samples (CRC tumor and adjacent normal mucosa) using the stem-loop real-time polymerase chain reaction. The miR-1-133a cluster displayed significantly lower expression in CRC tissue compared to adjacent normal mucosa (P<0.001). The results also indicated frequent hypermethylation of the CpG islands upstream of miR-1-133a (54.6%). Liver metastatic tissues exhibited significantly lower miR-1 (P<0.001) and miR-133a (P<0.001) expression compared to adjacent normal mucosa. Expression of the miR-1-133a cluster inversely correlated with TAGLN2 in the tumor specimens. In conclusion, epigenetic repression of the miR-1-133a cluster may play a critical role in colorectal cancer metastasis by silencing TAGLN2.

The impact of image-guided radiotherapy (IGRT) for prostate cancer (PC) on radiotherapy (RT)-related acute toxicities and prostate-specific antigen (PSA) kinetics

e15110

Background: IGRT for PC could potentially improve the therapeutic ratio by enhancing accuracy of delivery of radiation to the prostate gland. Our aim is to compare the treatment outcomes in terms of RT-related acute toxicities and PSA kinetics of PC patients (pts) undergoing radical intensity-modulated radiotherapy (IMRT) with or without image-guidance. Methods: A cohort of 21 consecutive pts treated by IGRT (I) from January 2010, when the IGRT system was introduced in our institution, was compared with an immediately precedent cohort of 21 pts receiving IMRT without image-guidance (Non-I). The prescription dose (76Gy in 38 fractions) and the treatment margins were the same between the 2 groups (gps). In the I gp, daily online verification and correction of treatment position was performed with reference to image registration of the daily pre-treatment on-board imaging with the corresponding digitally reconstructed radiographs, based on three-dimensional matching of three intra-prostatic fiducial markers. Androgen deprivation therapy was not used in both gps. Acute toxicities were scored weekly during the course of RT according to the Common Terminology Criteria for Adverse Events Version 4.02. The pre- and the post-RT PSA within 6 months after completion of RT were obtained. The PSA halving time (PSAHT) was calculated by first order kinetics. Results: There was no statistically significant difference regarding the baseline clinical characteristics (age, PSA at diagnosis, Gleason score, T staging) between the gps. No grade 3 or 4 acute genitourinary (GU) or gastrointestinal (GI) toxicities was encountered in either gps. Acute grade 1 or 2 GI toxicities were significantly less frequent in the I gp (23.8% vs 81.0%, p=0.001), and their median duration of such toxicity were also significantly shorter (0.33 week vs 1.38 week, p=0.004).The frequencies of acute grade 1 or 2 GU toxicities were comparable between both gps (66.6% vs 81.0%, p=0.45).The I gp had a shorter median PSAHT than the non-I gp (3.36 week vs 5.49 week, p=0.09). Conclusions: IGRT is effective in reducing acute GI toxicities in treatment of PC, and may have more favorable PSA kinetics.

Immunoglobulin G4-related sclerosing disease: experience with this novel entity in a local hospital

OBJECTIVE

To review the site of involvement, clinical presentation, and treatment outcome of patients having immunoglobulin G4-related sclerosing disease in a local regional hospital.

DESIGN

Retrospective case series.

SETTING

Pamela Youde Nethersole Eastern Hospital, Hong Kong.

PATIENTS

All patients with a diagnosis of immunoglobulin G4-related sclerosing disease in the hospital diagnosed in the period from April 2008 to March 2010.

RESULTS

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.

CONCLUSION

Immunoglobulin G4-related sclerosing disease is a systemic disease and can involve various systems.

Public awareness of hepatitis B infection: a population-based telephone survey in Hong Kong

OBJECTIVE

To test our hypothesis that there is inadequate knowledge and awareness of hepatitis B infection among the general population in Hong Kong.

DESIGN

A random telephone survey using a structured multiple-choice questionnaire.

SETTING

Hong Kong community.

PARTICIPANTS

Hong Kong residents aged 18 years or above.

RESULTS

A total of 506 respondents were successfully interviewed in February 2010. Approximately half of respondents (55%) were aware that hepatitis B virus is the most common cause of chronic viral hepatitis in Hong Kong. Regarding knowledge about the mode of transmission, mother-to-infant transmission and blood contact were recognised as risk factors by 67% and 65% of respondents, respectively. Transmission by sexual contact, sharing a razor or toothbrush, and tattooing or body piercing were appreciated by 44%, 41%, and 37% of respondents, respectively. A majority (73%) had the mistaken belief that the virus is transmitted by eating contaminated seafood. Over half of respondents (53%) knew nothing about the clinical presentation of acute hepatitis B. Only 35% of respondents realised that periodic abdominal ultrasonographic examinations are indicated for asymptomatic hepatitis B carriers. While 51% of respondents reported being tested for hepatitis B virus infection, only 36% acknowledged being vaccinated against the infection. Education level, occupation, and marital status were factors associated with both hepatitis B virus screening and vaccination.

CONCLUSION

These findings support our hypothesis that there is inadequate knowledge and awareness about hepatitis B infection in the general population in Hong Kong.

Impact of intracranial extension on survival in stage IV nasopharyngeal carcinoma: identification of a subset of patients with better prognosis

OBJECTIVE

T-stage is an imperfect prognostic indicator for patients with nasopharyngeal carcinoma. We evaluated the effect of extent of intracranial involvement on survival after conventional radiotherapy in patients with Stage T4 nasopharyngeal carcinoma.

METHODS

We conducted a retrospective analysis of the results of computed tomography, magnetic resonance imaging and treatment outcomes in 84 consecutive patients with Stage T4 nasopharyngeal carcinoma during the period September 1993 to December 2002 in Taiwan. The patients were subcategorized into those who had limited intracranial involvement (primary nasopharyngeal tumors with involvement of the unilateral cavernous sinus or the parasellar region only) or extensive involvement (extension of the tumors to the bilateral cavernous sinus or the parasellar region, into the orbit and the ethmoid sinus anteriorly, or to the prepontine region and the posterior cranial fossa).

RESULTS

Extensive intracranial involvement was found in 51.2% of the patients. Among these patients, the 5-year rate of overall survival after conventional radiotherapy was only 3.4%. In contrast, the 5-year survival among patients with limited intracranial involvement was 42.9%. This difference was significant (P < 0.001). In the multivariate analysis, extensive intracranial involvement, advanced age and a nodal status of N3 correlated with poor overall survival (all P < 0.05).

CONCLUSIONS

Among patients with T4 nasopharyngeal carcinoma, better treatment outcomes were associated with limited intracranial involvement. We conclude that a subdivision of Stage T4 nasopharyngeal carcinoma disease based on the extent of intracranial involvement would provide better prognostic information.

Acute psychiatric disorders in foreign domestic workers in Hong Kong: a pilot study

AIM

To explore the psychopathology of foreign domestic workers (FDWs) who had an acute psychiatric disorder in Hong Kong.

METHOD

This was a retrospective chart review. Demographic and clinical data were extracted from case records of FDWs who were admitted for the first time as inpatients for psychiatric treatment to three regional hospitals of the same catchment area in Hong Kong between 2000 and 2004. Relevant socio-demographic data on local FDWs and the general population of Hong Kong were obtained from local government departments.

RESULTS

Twenty-seven Filipino and 14 Indonesian FDWs presenting with their first and so far only psychiatric admission were identified. There were significantly more FDWs who were single or never married in the sample. Filipino FDWs tended to fall ill after 4 years of service in Hong Kong while the corresponding figure for Indonesian FDWs was 2 years. Indonesian FDWs were older and had less access to social and medical services than their Filipino counterparts. Home sickness and marital problems were more commonly identified as stressors rather than work-related difficulties. Acute and Transient Psychotic Disorder (ICD-10) was diagnosed in over 60% of the subjects, making FDWs two times more vulnerable than local women of similar age for this illness.

CONCLUSIONS

FDWs constitute a vulnerable group in terms of psychiatric morbidity. Concerted political, social and psychological efforts would be require to alleviate the distress faced by this particularly disadvantaged subset of female expatriates.

Significance of genomic DNA group delineation in comparative studies of antimicrobial susceptibility of Acinetobacter spp

There were significant differences in antimicrobial susceptibilities in isolates of genomic DNA groups 2 (Acinetobacter baumannii), 3, and 13TU collected from the same sources, e.g., patients in intensive care units and general wards, and in isolates of the same group collected from different sources. The delineation of genomic groups is important in comparative surveillance studies of antimicrobial susceptibilities.

Carbon monoxide poisoning as a new method of suicide in Hong Kong

The incidence in Hong Kong of intentional carbon monoxide poisonings by burning charcoal in a confined space was investigated. In the two-year study period, 22 (39 percent) of the 56 reported cases occurred in the three months following a highly publicized case in which this method was used to commit suicide; no cases were reported before the publicized incident. Individuals who used this method were younger on average (mean, 39 years) than those who used the more common methods of jumping (mean, 47 years) and hanging (mean, 55 years). The authors speculate that this form of suicide is becoming more prevalent because it has been highly publicized, it is easily carried out, and it is culturally acceptable.

Epidemiology and infection control implications of Acinetobacter spp. in Hong Kong

In a previous study, we showed that Acinetobacter genomic DNA group 3 was the most common species among blood culture isolates and was commonly found on superficial carriage sites of the healthy and the sick, which are different findings from those reported in Europe and North America. We used amplified ribosomal DNA restriction analysis and pulsed-field gel electrophoresis to study further the molecular epidemiology of acinetobacters in our region. Over a study period of 6 weeks with 136 consecutive routine clinical isolates (1.33% of all specimens), genomic DNA groups 2 (Acinetobacter baumannii), 3, and 13TU were obtained from 59 of 69 positive patients. There is a significant difference in the specimen sources of the three genomic DNA groups, with group 13TU being significantly associated with the respiratory tract (chi-square exact test, P = 0.0064). Settle plates showed a significantly heavier environmental load from the intensive care unit (ICU) than from the four surgical wards examined (22 of 70 versus 76 of 120 plates with <5 colonies; chi-square test, P < 0. 0001). Genomic group 3 accounted for 6 of 12 clusters of possibly related strains among patients, between patients and the ICU environment, and in the ICU environment. Genomic groups 2 and 3 accounted for 21% of the 132 genomically identified isolates recovered from 21 of 41 local vegetables, 53 of 74 fish and meat samples, and 22 of 60 soil samples. Group 13TU was present only in patients' immediate surroundings. The role played by the environment and by human carriage should be evaluated in order to devise a cost-effective infection control program pertinent to our situation of acinetobacter endemicity.

Validation of the Chinese-Cantonese version of the hospital anxiety and depression scale and comparison with the Hamilton Rating Scale of Depression

OBJECTIVE

The aim of this study was to validate the Chinese-Cantonese version of the Hospital Anxiety and Depression Scale (HADS) and to compare it with the Hamilton Rating Scale of Depression (HRSD) as a screening tool for depressive disorders in general hospital in-patients.

METHOD

The Chinese-Cantonese version of the HADS was administered to general hospital in-patients seen on a consultation basis, and psychiatric diagnoses were made according to DSM-III-R. The subjects were further rated independently with the HRSD.

RESULTS

The Chinese-Cantonese version of the HADS was found to have good internal consistency and external validity, with favourable sensitivity and specificity for screening for psychiatric disorders. However, its performance was marginally inferior to that of the HRSD. The scale also performed poorly in identifying major depression.

CONCLUSION

The HADS has limitations with regard to identification of depressive disorders. However, despite its shortcomings, it remains one of the best paper-and-pencil tests for screening psychiatric disorders in the medically ill.

Skin carriage of acinetobacters in Hong Kong

We studied the carriage of Acinetobacter spp. at five superficial sites in 79 patients from two hospitals, in 133 healthy controls from the community (medical students and new nurses), and in 198 student nurses in different classes. A total of 431 isolates from 364 positive sites of 201 subjects and 124 blood culture isolates (1997 to 1998) were genospeciated by amplified ribosomal DNA restriction analysis. Genospecies 3 was the most common species. The carriage rate of student nurses (42 of 131) was significantly lower than that of new nurses from the community (25 of 38) (chi-square test, P = 0.0004; odds ratio [OR], 4.08; 95% confidence limits, 1.78 to 9.41) but not significantly different (P = 0.1) from that of patients in the same hospital (20 of 42). Genospecies from blood cultures and subjects (acute patients and student nurses) from Prince of Wales Hospital were similar to one another but different from subjects from the community or from another hospital (chi-square test, P < 0.0001). Half of the subjects who were positive at at least two sites had different genospecies. Of the 28 sites examined, 68% showed strain variation among isolates of the same genospecies by random amplified polymorphic DNA analysis. Half of the 106 subjects who had samples taken again within 6 weeks or 6 months later were positive only once. In the 17 subjects who were positive on at least two occasions, each occasion yielded different genospecies in 13 subjects. Our results indicate that skin carriage in the majority of healthy subjects is characterized by low density, variation in genospecies and strains, short-term duration, and the typicality of a given locality.

Karaoke therapy in the rehabilitation of mental patients

OBJECTIVES

To study the efficacy of karaoke singing and its implications in the rehabilitation of mental patients in Hong Kong Chinese.

METHODS

A double blind controlled trial was conducted over six weeks in a small sample of chronic schizophrenic patients matched in age, sex and duration of illness. The index group practised karaoke and the controlled group practised simple singing. Subjects were assessed in changes in mood and social interaction.

RESULTS

No significant difference was detectable within the 2 groups. However, significant differences of anxiety and social interaction at the end of the third and sixth weeks respectively, were detectable between the 2 groups.

CONCLUSION

Karaoke therapy may be more effective than simple singing in improving social interaction. There is preliminary evidence that it may be anxiety-provoking for unstable schizophrenic patients. More research is required for further elucidation of the characteristics of favourable candidates, optimal schedule and active components of the therapy.

A study of the use of radiological pelvimetry in a Chinese population

BACKGROUND

To audit the use of radiological pelvimetry in a teaching obstetric unit in a Chinese population.

METHODS

A prospective observational study included all radiological pelvimetries performed in one obstetric unit over 8 months. All pelvimetries were assessed by one of the authors, and the outcome of pregnancy was reviewed.

RESULTS

Among 5576 women delivered in that period, 298 (5.3%) had a pelvimetry. The anteroposterior diameter of the outlet (APO) was on average 9.3 mm smaller than the obstetric conjugate (OC), and was below the definition of pelvic contraction in more than 70% of cases. Previous Cesarean sections accounted for 90.9% of the antenatal radiological pelvimetries. The result of this investigation affected the clinical management in more than 80% of these patients. The chance of successful vaginal delivery was directly related to the pelvic dimensions.

CONCLUSIONS

Radiological pelvimetry may provide additional information which could facilitate the counseling of patients with a history of previous Cesarean section.

Clozapine: a mimicry of phaeochromocytoma

OBJECTIVE

To report a case of clozapine-induced hypertension with raised urinary catecholamines.

CLINICAL PICTURE

A 27-year-old man fulfilling DSM-III-R criteria for catatonic schizophrenia was treated with clozapine. He later developed both hypertension and raised urinary catecholamines which mimicked phaeochromocytoma.

TREATMENT

Clozapine was withdrawn.

OUTCOME

Both blood pressure and urinary catecholamines normalised.

CONCLUSIONS

Clozapine may induce sympathetic hyperactivity.

Suicide attempt due to metoclopramide-induced akathisia

Akathisia as a side-effect of metoclopramide has received increasing attention in consultation-liaison psychiatry in recent years. A case of metoclopramide-induced akathisia resulting in a suicide attempt is reported in order to highlight the suffering of such patients and the factors that lead to misdiagnosis.

Attempted suicide by Chinese elderly in Hong Kong

There is little information on attempted suicide in the elderly, especially among Chinese populations. Fifty-five elderly with suicidal attempts seen in a psychiatric unit in Hong Kong over a 2 1/2 year period were studied. The risk of suicidal attempt remained high after age 75 and only declined after 85. In contrast to western societies, self-injury was more common than self-poisoning. About half of the patients suffered from a mood disorder but very few had dementia. At follow-up 1 1/2-4 years after the suicidal attempt, the rate of repetition was 3.6% and the rate of completed suicide was 5.5%.

Querulous paranoia in Chinese patients: a cultural paradox

OBJECTIVE

There has been no reported case of querulous paranoia from the Asian population. A prospective study was undertaken to identify patients with querulous paranoia in an outpatient clinic.

METHOD

One thousand, five hundred and fifty-one new referrals to a university-affiliated psychiatric outpatient clinic in Hong Kong were screened for querulous paranoia during routine clinical work.

RESULTS

Three patients with querulous paranoia (0.19%) were identified during 1 year. The case histories of these three patients are reported.

CONCLUSION

Possible reasons for the low reporting rate are discussed and the importance of sociocultural traditions in the development and recognition of querulous paranoia is emphasised.

Body dissatisfaction among Chinese undergraduates and its implications for eating disorders in Hong Kong

OBJECTIVES

To study the body dissatisfaction of Chinese undergraduates and its implications for eating disorders in Hong Kong.

METHOD

A large sample of 1,581 subjects completed a "Body Dissatisfaction Questionnaire" (BDQ) which included 25 items about various body parts and questions on body indices, body shape dissatisfaction, and dieting.

RESULTS

Whereas male subjects wanted to be taller and stronger in their upper body, the majority of female subjects felt fat in their lower body and were cognitively inclined to weigh less even though they were not obese. They desired a slimming of the stomach, thighs, waist and hip, but not the breasts. Body dissatisfaction was substantially intensified in females who reported a history of dieting in the previous year. Factor analysis of the BDQ affirmed the gender specificity and multidimensionality of body dissatisfaction.

DISCUSSION

The typically "Western" pattern of body dissatisfaction has overshadowed the traditional Chinese notions of female beauty based on the face and other nontruncal features. In the context of a rapidly urbanizing Chinese society, this will predispose more females to weight control behavior and eating disorders.

A case of unrelenting pursuit of castration

OBJECTIVE

Explore the limitations of the classification of body dysmorphic disorder.

CLINICAL PICTURE

A chinese male relentlessly pursued castration to relieve painful erections which were never substantiated. The testes and corporaspongiosum had been removed. No psychotic symptom was prominent.

TREATMENT

Cognitive therapy and psychotropics were tried.

OUTCOME

The remaining corpora cavernosa was removed subsequently.

CONCLUSION

The distorted somatic perception and secondary cognitive amplification (painful erections) could represent a variant of body dysmorphic disorder involving internal body image; diagnostic classifications should accommodate such a category.

Study of endoscopic staple formation by specimen radiography on pulmonary wedges

The advent in video-assisted thoracic surgery has rendered us to rely more and more on mechanical devices. We prospectively studied staple formation on resected lung specimen by radiography and attempted to correlate this with the clinical outcome. From February 1994 to January 1995, 36 consecutive pulmonary wedges (23 apical bullae, 12 pulmonary metastases, 1 tuberculoma) from 31 patients who had undergone resection by endoscopic staple-cutter (Endo GIA30, USSC) were examined by two-plane radiography for staple alignment and closure. Imperfect staple formation was found in 21 (58%) of resected specimens. The median size of the resected bullae is 4.2 mL (range, 2.0 to 58.8 mL) compared with 36 mL (range, 1.2 to 222.8 mL) in the resected metastases and tuberculoma specimen. Despite detecting more imperfect staples in the metastases group (77% vs 57%), there was little difference in the two groups with respect to postoperative chest drainage duration (median, 3 vs 2 days) or hospital stay (median, 2 vs 2 days). We conclude that the currently available endoscopic staplers are by no means perfect, especially for resection of larger specimens, even though this may not be apparent clinically. A continuous search for improvement in endoscopic staplers designed specifically for lung resection is needed.

The syndrome of lethal catatonia

Lethal catatonia (LC) is a life-threatening neuropsychiatric syndrome associated with a host of psychiatric, neurologic and medical conditions. The clinical picture is characterised by fragmented psychotic symptoms, catatonic phenomena particularly alternating stupor and agitation, altered consciousness, hyperthermia and other autonomic disturbances. A case of LC in a 19-year-old Chinese woman showing a dramatic response to lorazepam and bromocriptine is described and a brief overview of the contemporary literature is provided.

Pseudologia fantastica and gender identity disturbance in a Chinese male

A Chinese patient with pathological lying (pseudologia fantastica) and gender identity disturbance is described. The stories "save face" and lack a truly self-aggrandising quality. The importance of keeping "face" and maintaining modest behaviour in the Chinese culture is central to the psychopathology.

Chopsticks and suicide

A case of serious suicidal attempt in a stroke patient by piercing a chopstick through the nostril, resulting in cerebral injury, is reported. The choice of the chopstick as a suicide tool is discussed in a clinical and cultural perspective. The potential of using chopsticks as an offensive weapon in suicidal patients is emphasised.

The Zung Self-rating Depression Scale: screening for depression among the Hong Kong Chinese elderly

Two studies were conducted respectively to examine the reliability and validity of the standard Zung Self-rating Depression Scale (SDS), and a 10-item shorter version of the same test. In particular, the scale's usefulness as a screening instrument for depression among the Hong Kong Chinese elderly was investigated. In addition to the SDS, the Geriatric Depression Scale and the Chinese Hamilton Depression Scale were used to assess the convergent validity of the SDS. Data were collected from 113 nondepressed community-dwelling and 80 depressed elderly subjects. The findings showed that both the original and the shorter version of the SDS were highly reliable and valid. Both versions were appropriate for use as screening instruments for geriatric depression in Hong Kong. When compared with the original scale, the shorter version appeared to be slightly superior in its sensitivity and specificity in discriminating between the depressed and nondepressed subjects.

Reliability, validity and structure of the Chinese Geriatric Depression Scale in a Hong Kong context: a preliminary report

Depression is one of the commonest psychiatric illness in the elderly. Screening instruments of depression can greatly facilitate its identification in the community, leading to early recognition and diagnosis. The Geriatric Depression Scale was translated into Chinese and its reliability, validity and factor structure examined in a population of Chinese elderly in Hong Kong. One hundred and thirteen normal and 80 depressed elderly subjects were studied and a cut-off score of 15 on the scale was found to be optimal. The scale's reliability and validity was satisfactory and thus it is a promising instrument for screening geriatric depression in Hong Kong.

Lorazepam in stupor

The use of lorazepam in relieving catatonic symptoms is illustrated by the dramatic response in a stuporous patient. The treatment allows further investigations and management. It is recommended that clinicians familiarise themselves with this simple pharmacological intervention.

Benzodiazepines in the treatment of catatonic syndrome

During a 5-month period, 18 (8%) of 212 patients admitted to a psychiatric unit affiliated to a teaching hospital were found to have a catatonic syndrome associated with various nonorganic mental disorders. Signs and symptoms of motor retardation predominated the clinical presentations. In the course of a prospective, open study, all 18 patients were challenged by a small dose of oral lorazepam or intramuscular diazepam. Catatonic signs and symptoms in 2 patients showed an immediate, complete, and sustained response to the medication. The remaining 16 patients were maintained on 1 of the 2 benzodiazepines for the next 48 h when their motor status was re-evaluated. Significant clinical improvement was detected in all but 2 patients. However, 9 patients needed electroconvulsive treatment to achieve further improvement. Short-term benzodiazepine administration proved to be a safe and effective treatment of the catatonic syndrome.