Forced Straightening of the Back Does Not Improve Body Shape

BACKGROUND

Sitting for a long time causes various postural problems, such as slump sitting. It has been reported that employing a corrected sitting position while lifting the sternum is effective in improving this form of posture. We investigated how a corrected sitting posture with the lifting of the sternum is different from a forced position that is applied through the command and passive positions.

MATERIALS AND METHODS

The postural angle of 270 subjects aged 19-23 years was measured in the passive, forced, and corrected positions using a Saunders inclinometer and a Formetric 4D system.

RESULTS

As a result, the corrected position had a small range (min-max) at all angles, but the forced position and passive position had a large range (min-max). The lumbar lordosis angle in the corrected position showed positive values throughout its range (min-max), while the other groups showed negative values, which indicates the kyphotic position of the lumbar section. In addition, the percentage error in the corrected position was small, but it presented high values in the other groups. When comparing the average angles between the groups, there were substantial changes observed between the corrected position and the other groups. It was found that the corrected position with the sternum lifted, which is applied to improve slump sitting in the clinical environment, exhibited an angle that differed from that of the forced position and the passive position.

CONCLUSIONS

Our results suggest that a forced position on the command "scapular retraction" does not meet the clinical assumptions of posture correction, in contrast to the corrected position with the lifting of the sternum for the improvement of slump sitting. The accurate correction of the position of the sternum and sacrum improves the position of the spine in the sagittal plane, enabling physiological values for the kyphosis and lordosis angle parameters to be obtained. This approach combines the ease of execution and precision of the effect. The fact that this method does not require complex tools to accurately correct the body encourages the implementation of this solution in clinical practice.

Developmentally delayed children with different muscle tone have different muscle activity and acceleration during sit-to-stand

Developmental delays cover a wide range, with different movement characteristics occurring depending on differences in muscle tone. We aimed to investigate muscle activity and acceleration during sit-to-stand in developmentally delayed (DD) children with different muscle tones. Forty participants were divided into three groups: typically developing (TD) children (n=18), DD children with hypertonia (n=12), and DD children with hypotonia (n=10). Electromyography was used to measure muscle activity and BTS G-Walk was used to measure acceleration. As a result, the activities of the rectus abdominal muscle and quadriceps muscle were lower in DD children with hypertonia than in TD children (P<0.05). The activity of the tibialis anterior muscle was higher in DD children with hypotonia than in TD children (P<0.05). The trunk angle was greater in DD children with hypotonia than in TD children (P<0.05), and vertical acceleration was lower in DD children with hypertonia than in TD children (P<0.05). Based on these differences, we will be able to provide intervention programs appropriate for the characteristics of DD children with different muscle tone.

Abdominal and lower extremity muscles activity and thickness in typically developing children and children with developmental delay

We investigated abdominal and lower extremity muscle activity and thickness in typically developing children and children with developmental delays. A total of 35 children participated: typically developing peers (n=13), children with hypotonia (n=10), and children with spasticity (n=12). Muscle activity and thickness were measured at rest and during activity. Electromyography was used to measure abdominal and lower extremity muscle activities, and abdominal muscle thickness was measured using ultrasonography. There was a significant difference between the groups in the activity of the rectus abdominis and quadriceps muscles at rest and during activity (P<0.05). There was a significant difference between the groups in the thickness of the external oblique and transversus abdominis muscles during activity (P<0.05). There was a significant difference between the groups in the thickness of the external oblique and internal oblique muscles in the sitting position (P<0.05). Therefore, the characteristics of muscle tone should be considered when applying interventions to children with developmental delay.

Vojta Therapy Affects Trunk Control and Postural Sway in Children with Central Hypotonia: A Randomized Controlled Trial

(1) Background: Decreased trunk stability is accompanied by delay in motor development in children with central hypotonia. We investigated the effect of Vojta therapy on trunk control in the sitting position in children with central hypotonia. (2) Methods: In 20 children with central hypotonia, Vojta therapy was applied to the experimental group (n = 10) and general physical therapy to the control group (n = 10). The intervention was applied for 30 min per session, three times a week, for a total of six weeks. We assessed abdominal muscle thickness, trunk control (segmental assessment of trunk control), trunk angle and trunk sway in a sitting position, and gross motor function measure-88. (3) Results: In the experimental group, the thicknesses of internal oblique and transversus abdominis were significantly increased (p < 0.05). The segmental assessment of trunk control score was significantly increased (p < 0.05), and the trunk sway significantly decreased (p < 0.05). Gross motor function measure-88 was significantly increased (p < 0.05). (4) Conclusions: Vojta therapy can be suggested as an effective intervention method for improving trunk control and gross motor function in children with central hypotonia.

Successful haploidentical hematopoietic stem cell transplantation (HSCT) and durable engraftment by repeated donor lymphocyte infusions for a Chinese patient with transfusion-dependent hemoglobin (Hb) Hammersmith and massive splenomegaly

BACKGROUND

Hemoglobin (Hb) Hammersmith is a rare form of unstable β-chain hemoglobinopathy causing hemolytic anemia. This rare event led to a more serious transfusion-dependent phenotype in a patient. It was successfully cured by haploidentical hematopoietic stem cell transplantation (HSCT).

METHODS AND RESULTS

A 9-year-old mainland Chinese male with a history of neonatal unconjugated hyperbilirubinemia was diagnosed to have hemoglobin (Hb) Hammersmith. He required regular blood transfusion but was unable to be transfused to desired parameters for 8 years prior to transplant due to social and geographical reasons. He subsequently developed marrow hyperplasia and progressive splenomegaly (down to umbilicus level), suggestive of extramedullary hematopoiesis. Eventually, the family came to Hong Kong and complied to a more intensive transfusion regimen and preconditioning chemotherapy 3 months prior to transplant. He underwent haploidentical HSCT using paternal TCRαβ/CD45RA-depleted graft but suffered from graft rejection, despite splenic irradiation for massive splenomegaly. It was successfully salvaged with second HSCT with unmanipulated graft from the same donor with additional serotherapy and donor lymphocyte infusions.

CONCLUSION

Allogenic haploidentical HSCT for hemoglobin Hammersmith is feasible but adequate immunosuppression during conditioning is crucial. Precise adoptive cell therapy can promote durable engraftment.

Outcomes of adolescents with acute lymphoblastic leukaemia

INTRODUCTION

Compared with young children who have acute lymphoblastic leukaemia (ALL), adolescents with ALL have unfavourable disease profiles and worse survival. However, limited data are available regarding the characteristics and outcomes of adolescents with ALL who underwent treatment in clinical trials. The aim of this study was to investigate the causes of treatment failure in adolescents with ALL.

METHODS

We retrospectively analysed the outcomes of 711 children with ALL, aged 1-18 years, who were enrolled in five clinical trials of paediatric ALL treatment between 1993 and 2015.

RESULTS

Among the 711 children with ALL, 530 were young children (1-9 years at diagnosis) and 181 were adolescents (including 136 younger adolescents [10-14 years] and 45 older adolescents [15-18 years]). Compared with young children who had ALL, adolescents with ALL were less likely to have favourable genetic features and more likely to demonstrate poor early response to treatment. The 10-year overall survival and event-free survival rates were significantly lower among adolescents than among young children (77.9% vs 87.6%, P=0.0003; 69.7% vs 76.5%, P=0.0117). There were no significant differences in the 10-year cumulative incidence of relapse, but the 10-year cumulative incidence of treatment-related death (TRD) was significantly greater among adolescents (7.2%) than among young children (2.3%; P=0.002). Multivariable analysis showed that both younger and older adolescents (vs young children) had worse survival and greater incidence of TRD.

CONCLUSION

Adolescents with ALL had worse survival because they experienced a greater incidence of TRD. There is a need to investigate optimal treatment adjustments and novel targeted agents to achieve better survival rates (without excessive toxicity) among adolescents with ALL.

Optimization of a solid culture medium based on Monochamus alternatus for Cordyceps militaris fruiting body formation

Monochamus alternatus (Coleoptera: Cerambycidae; M. alternatus), popularly known as the Japanese pine sawyer, is a vector of pinewood nematode (Bursaphelenchus xylophilus) that causes pine wilt disease. A solid medium culture with M. alternatus produced Cordyceps militaris fruiting bodies with the longest strips and the highest biological efficiency. Supplementing the original form of M. alternatus with oats resulted in slightly enhanced fruiting body production. The original form of M. alternatus showed higher production than its powder form. The solid culture medium was optimized using a response surface methodology, and the optimal medium contained the following: 8·5 g per bottle of M. alternatus and 11·5 g per bottle of oats mixed with 22·4 ml of water in a 300-ml cylindrical plastic bottle. The optimal culturing period for the fruiting body formation was 37·1 days. Under these conditions, a fruiting body dry weight of 38·0 g per bottle (actual value) was attained. The fruiting body produced using a solid culture medium based on M. alternatus had a cordycepin content of about 25 µg g^-1 . The solid culture medium containing M. alternatus is highly efficient and eco-friendly, and its effectiveness in large-scale fruiting body production from C. militaris has been demonstrated.

Changes of Neural Pathways after Vojta Approach in a Child with Developmental Delay

The development of motor function is related to the development of neural pathways in the white matter. Children with developmental delay (DD) and hypotonia have reduced motor function, and their neural pathways are observed differently from those of typically developed children. We investigated changes in neural pathways through diffusion tensor imaging (DTI) after utilizing the Vojta approach. The participant was a child with DD and hypotonia, and had delayed motor function. Although he had no brain damage on magnetic resonance imaging findings, damage to the neural pathway was confirmed through DTI due to cytomegalovirus infection in the mother's womb. From 11 months of age, the Vojta approach was performed for a total of 8 months. In this study, we found that in CST, the left FA and right TV increased in follow-up DTI more than in the initial DTI. In CRP, Wallerian degeneration was observed in the left FA, MD, and TV in follow-up DTI. GMFM-88 improved after intervention. The structural change of neural pathways through the Vojta approach influenced the improvement of gross motor function. Therefore, it is thought that the Vojta approach can be suggested as a meaningful intervention for children with DD and hypotonia.

Outcomes of allogeneic transplantation for hemoglobin Bart's hydrops fetalis syndrome in Hong Kong

BACKGROUND

Hemoglobin Bart's hydrops fetalis syndrome (BHFS) was once considered a fatal condition universally. Medical advances over the past three decades have resulted in increasing numbers of BHFS survivors. This retrospective review summarized local territory-wide experience and outcomes of BHFS patients who received allogeneic hematopoietic stem cell transplantation (HSCT) in Hong Kong.

METHODS

All BHFS patients who underwent allogeneic HSCT in Hong Kong, either in one of the two former pediatric transplant centers (Queen Mary Hospital and Prince of Wales Hospital) on or before 2019 or in the single territory-wide pediatric transplant center (Hong Kong Children's Hospital) since 2019, from January 1, 1996, till December 31, 2020, were included. Basic demographic data, perinatal history, transplant details, long-term outcomes, and morbidities were reviewed.

RESULTS

Total five allogeneic HSCT were performed in two males and three females at a median age of 22 months, which include one 8/8 matched-sibling bone marrow transplant, one 5/6 matched-sibling cord blood transplant with HLA-DR antigenic mismatch, two 12/12 matched-unrelated peripheral blood stem cell transplant (PBSCT), and one haploidentical PBSCT with TCRαβ/CD45RA depletion from maternal donor. Neutrophil and platelet engrafted (>20 × 10⁹ /L) at a median of 15 and 22 days, respectively. All achieved near full donor chimerism at 1 month. All patients survived and remained transfusion-independent without significant morbidities with median follow-up duration of 10 years.

CONCLUSION

To conclude, local data demonstrated favorable outcome of allogeneic HSCT for BHFS patients, but sample number is small. Non-directive approach in counseling and international collaboration is recommended.

The effect of scapular strengthening exercise using elastic band on balance and quality of life in the old people

The old people are weakened and misaligned due to aging, and their balance and quality of life are reduced. We investigated that the effect of scapular strengthening exercise on balance and quality of life in the old people. A scapular strengthening exercise was applied to the experimental group, and the general conditioning exercise was applied to the control group for 40 min per session, 5 times a week, for a total of 4 weeks. As a result, the static balance and Y-balance test performance improved in the experimental group (P<0.05). The physical function and mental health, and general health of 36-item Short Form health survey improved in the experimental group (P<0.05). Therefore, the scapular strengthening exercise could be suggested as an intervention method that could improve the balance and quality of life of the old people.

The effects of curl-up exercise in terms of posture and muscle contraction direction on muscle activity and thickness of trunk muscles

BACKGROUND

The curl-up exercise is widely used in clinical practice for strengthening abdominal muscles, but has been applied without a systematic method.

OBJECTIVE

The purpose of this study was to determine the most effective method considering the angle and muscle contraction direction during the curl-up exercise.

METHODS

Fourteen healthy males performed the curl-up exercise according to contraction direction (concentric and eccentric) and angle (30∘, 60∘, and 90∘). The muscle activity of the rectus abdominis (RA), external oblique (EO), internal oblique (IO), and iliopsoas (IP) was measured using electromyography (EMG), and the muscle thickness of transversus abdominis (TrA) was measured using ultrasonography.

RESULTS

The activities of the abdominal muscles (RA, EO, and IO) decreased with increasing angles (30∘, 60∘, and 90∘) (p< 0.05). There was no significant difference between eccentric and concentric contractions. The thickness ratio of TrA was the largest at an eccentric curl-up at 30∘, and the smallest at a concentric curl-up at 30∘ (p< 0.05).

CONCLUSIONS

The most effective angle for curl-up was 30∘. Although there is no difference in the direction of muscle contraction, eccentric curl-up at 30∘ could be considered the most effective posture for abdominal strengthening considering the importance of TrA.

Ankle exercise with functional electrical stimulation affects spasticity and balance in stroke patients

Stroke patients have limited motor function due to ankle spasticity, and various interventions are applied to solve this problem. The purpose of this study was to investigate the effects of functional electrical stimulation (FES) with ankle exercise on spinal cord motor neuron excitability and balance in stroke patients. Twenty-five stroke patients were divided into the three groups. For the intervention, the control group applied general physiotherapy, the experimental group I applied a sham FES with ankle exercise, and the experimental group II applied a FES with ankle exercise. All groups applied the intervention for 30 min per session, 5 times a week, for a total of 8 weeks. The functional reaching test (FRT), Timed Up and Go test was used to measure balance ability, and H-reflex was used to measure spinal motor neuron excitability. All tests were measured before and after the intervention. In the ankle exercise with FES group, spinal motor neuron excitability significantly decreased (P<0.05), and FRT was significantly increased (P<0.05). Therefore, FES with ankle exercise for stroke patients could be suggested as an effective intervention for improving motor function.

Attentional concentration during physiotherapeutic intervention improves gait and trunk control in patients with stroke

The restoration of motor function is important in daily life in patients with brain damage. Although attentional concentration can affect motor function, most physical therapists focus only on therapeutic exercise. Therefore, we investigated changes in motor function in patients with high attentional concentration during our intervention. A total of 21 subjects diagnosed with stroke participated in the study. They were divided into the high attentional concentration group and low attentional concentration group based on the self-programmed attention index. The subjects underwent trunk strengthening and gait training for 30 min per session, twice a day, 5 days a week, for a total of 4 weeks. All patients wore electroencephalogram (EEG) devices during the treatment to enable EEG examinations. Diagnostic ultrasound was used to measure muscles of the abdomen: external oblique abdominal, internal oblique abdominal, transversus abdominis, and rectus abdominal muscles. A trunk impairment scale was used to evaluate trunk control. We used Gaitrite to measure the spatial and temporal components during gait. The group with high attentional concentration showed significant differences in abdominal muscle strength and trunk control. In gait, there was a significant difference in swing cycle, stance cycle, single cycle, double support cycle, stance time, and double support time. Therefore, attentional concentration should be considered to improve motor function as a part of therapeutic exercises for stroke patients.

Severe cytomegalovirus gastritis after pembrolizumab in a patient with melanoma

Immunotherapy has emerged as a standard of cancer treatment, with an increasing number of indications. Recently, opportunistic infections have been reported in several cases in which immunotherapy has led to an increased susceptibility to infection. The present case is the first report of cytomegalovirus (cmv) gastritis occurring in a patient with melanoma during immunotherapy without immune-related adverse events (iraes) and without the use of immunosuppressant agents. A 43-year-old woman presented with stage iii malignant melanoma. She underwent wide excision of skin, with lymph node dissection, and she started immunotherapy with a 3-week cycle of pembrolizumab. The patient demonstrated stable disease response, and no iraes were observed during her initial treatment courses. However, after the 9th treatment cycle, she began to experience epigastric pain that worsened significantly, requiring a visit to the emergency centre. Imaging by computed tomography (ct) and integrated positron-emission tomography/ct revealed severe diffuse gastroduodenitis with acute pancreatitis. Esophagogastroduodenoscopy showed diffuse oozing, hemorrhagic, edematous, and exfoliative mucosa involving the entire gastric wall, defined as acute hemorrhagic gastritis. Biopsies of the gastric wall revealed cmv infection. Those findings were consistent with a diagnosis of cmv gastritis, and the patient received antiviral therapy with ganciclovir. After treatment, she recovered enough to resume immunotherapy. This case report presents a rare occurrence of cmv gastritis related to immunotherapy. As more patients are treated with immunotherapy, incidences of cmv infections are expected to increase; a high index of clinical suspicion is therefore needed in symptomatic patients.

A temporary forward head posture decreases function of cervical proprioception

Increased use of smartphones can cause abnormal alignment of head and neck, resulting in forward head posture (FHP). This can lead to change in the structures and function of the cervical vertebrae. The purpose of this study was to determine the impact on deep neck flexor muscles, proprioception, vestibular function, and balance of subjects with induced FHP by using smartphone. Twenty-two healthy persons were randomly divided into two groups. The FHP group maintained a craniovertebral angle (CVA) of <49° and a normal head posture group maintained a CVA of >50° watching the smartphone for 40 min. We measured the area of the longus colli and longus capitis muscles, cervical joint position sense, Romberg test, subjective visual vertical test, and subjective visual horizontal test. There was no significant difference in the deep neck flexor muscles, vestibular function, and static balance between the groups. However, there was a significant difference in the cervical proprioception (P<0.05). Proprioception may be considered to be the most influential factor in induced FHP by smartphone viewing.

The effect of smartphone uses on gait and obstacle collision during walking

OBJECTIVE

This study aims to investigate the impact of obstacle collision according to the presence or absence of light and the change of gait when using smartphones while walking.

STUDY DESIGN/SETTING

A cross-sectional study.

SUBJECTS

24 healthy young people.

METHODS

Obstacle collision was measured in participants as they passed through four obstacles at different heights (eyes, waist, knees, ankle level), with the lights turned on. The same was measured with the lights turned off. To measure spatiotemporal variables, GAITRite was used. Obstacle collision was used in the frequency analysis, and the spatiotemporal variables were assessed using one-way ANOVA test. The post-hoc Tukey's test was used to detect spatiotemporal variables differences (p < 0.05).

RESULTS

Obstacle collision was the highest at eye level when playing games and messaging while walking. It was also higher when lights were turned off rather than when lights were on. Gait function decreased while walking when messaging or playing games on a smartphone as compared to when walking without a smartphone.

CONCLUSION

Understanding the collision rate of various obstacles encountered when using smartphones while walking could contribute to the prevention of accidents.

Effects of Fresnel prism glasses on balance and gait in stroke patients with hemiplegia: A randomized controlled trial pilot study

BACKGROUND

Fresnel prism shifts the field of view and converts object position in space, but its effect on stroke patients without unilateral neglect has not been examined.

OBJECTIVE

We aimed to investigate the effect of Fresnel prism glasses on balance and gait in stroke patients with hemiplegia.

METHODS

This study included 17 stroke patients with hemiplegia without unilateral neglect. Balance and gait training were applied in the control group (n= 9), and Fresnel prism glasses were applied with balance and gait training in the experimental group (n= 8). In all groups, interventions were done for 30 min/day for 5 times/week for 4 weeks. Motor-free visual perception test for visual perception (MVPT), Berg Balance Scale (BBS), and functional reach test (FRT) for dynamic balance ability, and gait were performed. Measurements were done before and after interventions.

RESULTS

MVPT showed no significant difference between the groups (p> 0.05). A significant increase in BBS and FRT results was found before and after interventions in the experimental group (p< 0.05). Gait variables showed significant difference in the experimental group (p< 0.05).

CONCLUSION

Fresnel prism glasses may effectively improve dynamic balance and gait functions by shifting body weight to the affected side of stroke patients with hemiplegia without vision loss.

Effects of visual feedback training using transient Fresnel prism glasses on balance ability in stroke patients without hemispatial neglect

The center of mass of the body in patients with stroke was oriented toward the nonparetic side. Abnormal weight shift increases the risk of falls. Therefore, many therapists make an effort to help their functional recovery through balance training. Our aim was to investigate the effect of visual feedback intervention using a Fresnel prism on static and dynamic balance in stroke patients without hemispatial neglect. Participants were assigned to control group (n=10) and experimental group (n=9). In the control group, neurodevelopmental therapy was performance for 30 min. In the experimental group, Fresnel prism glasses were applied with neurodevelopmental therapy for 30 min. We executed motor-free visual perception test for visual perception, balancia for static balance ability, and functional reach test and Berg balance test for dynamic balance ability, respectively. All tests were measured immediately after intervention. The visual perception function showed significant difference between unaffected side performance behaviors and visual perceptual processing time (P<0.05). In the static balance, there was a significant difference in sway velocity and sway distances (P<0.05). Dynamic balance was also significant different between groups (P<0.05). Visual feedback using Fresnel prism helps to control the static and dynamic balance ability by inducing weight shift toward the affected side in stroke patients. Therefore, a Fresnel prism may be suggested as an intervention tool to assist weight training for patients with stroke.

The Vojta approach changes thicknesses of abdominal muscles and gait in children with spastic cerebral palsy: A randomized controlled trial, pilot study

BACKGROUND

Children with cerebral palsy (CP) have abnormal postures and gait patterns. Many physiotherapists use the Vojta approach as intervention for children with CP. However, its effects remain unclear.

OBJECTIVE

This study aimed to investigate the effect of the Vojta approach on abdominal muscles and gait in children with spastic CP.

METHODS

Thirteen children with spastic CP were randomly assigned to a general exercise and a Vojta approach group. The interventions were administered in 30 min sessions, 3 times a week for a total of 6 weeks. We used ultrasonography to measure the thicknesses of the abdominal muscles. The gait and foot pressure were measured by GAITRite.

RESULTS

The Vojta approach group showed significant difference in the thicknesses of the rectus abdominis, and external oblique abdominal muscles, which are involved in trunk stability (p< 0.05). There were significant differences in the step width, functional ambulation profile, swing time, stance time, and single support % of cycle as well as foot pressure distribution (p< 0.05).

CONCLUSION

The Vojta approach may be considered as an effective treatment method for improving trunk stability and gait functions of children with spastic CP.

Comparison of the paediatric blade of the Pentax-AWS and Ovassapian airway in fibreoptic tracheal intubation in patients with limited mouth opening and cervical spine immobilization by a semi-rigid neck collar: a randomized controlled trial

Background

We compared the performances of the paediatric blade of a Pentax Airway Scope and an Ovassapian airway in fibreoptic tracheal intubation in patients whose necks were stabilized by semi-rigid neck collars.

Methods

Ninety patients were enrolled in this prospective, open-label, randomized controlled trial. Patients were randomly allocated to one of two groups (Group OVA-FOB and Group AWS-FOB). The time to tracheal intubation, success rate of tracheal intubation, number of optimization manoeuvres (jaw thrust), and difficulty of manipulation of the fibreoptic bronchoscope were compared between the groups.

Results

The time to tracheal intubation was significantly shorter (32 vs 50 s; median difference 19 s; 95% confidence interval 14-25 s; P<0.001) and manipulation of the fibreoptic bronchoscope was significantly easier for Group AWS-FOB. Optimization manoeuvres were rarely required to facilitate fibreoptic tracheal intubation in Group AWS-FOB [jaw thrust, 0 (0%); jaw thrust with anterior neck collar removal, 1 (2%)] compared with that required in Group OVA-FOB [jaw thrust, 39 (87%); jaw thrust with anterior neck collar removal, 2 (4%)]. There was no significant difference in the success rate of tracheal intubation on the first attempt between groups [Group AWS-FOB, 45 (100%); Group OVA-FOB, 44 (98%)].

Conclusions

Combined use of the paediatric blade of a Pentax Airway Scope and a fibreoptic bronchoscope enabled rapid tracheal intubation, minimizing the use of external manoeuvres of the airway, in patients with limited mouth opening and cervical spine immobilization by semi-rigid neck collars, compared with use of the Ovassapian airway and the fibreoptic bronchoscope.

Clinical trial registration

NCT02827110.

Effects of Vojta approach on diaphragm movement in children with spastic cerebral palsy

The purpose of this study was to examine the effects of Vojta approach on the gross motor function and diaphragm movement in children with spastic cerebral palsy (CP). Ten children with spastic CP were randomly assigned to a general physiotherapy group (trunk strengthening exercise and gait training) (n=5) and a Vojta approach group (n=5). Interventions were implemented for 30 min per time, 3 times a week for a total of 6 weeks. Ultrasonography was used to measure the areas of the diaphragm (during inspiration, expiration) before and after the interventions, the gross motor function measure (GMFM)-88 was used for evaluation of the gross motor function. In the results of this study, there was a significant difference between before and after GMFM-sitting in the experimental group (P<0.05), a significant difference in changes of inspiration between the two groups (P<0.05). Given these results, Vojta approach may be presented as an effective treatment method for improving sitting position and diaphragm movement during inspiration in children with spastic CP.

Effects of ankle strengthening exercise program on an unstable supporting surface on proprioception and balance in adults with functional ankle instability

The present study was conducted to investigate the effect of ankle strengthening exercise applied on unstable supporting surfaces on the proprioceptive sense and balance in adults with functional ankle instability. As for the study method, 30 adults with functional ankle instability were randomly assigned to an ankle strengthening exercise group and a stretching group on unstable supporting surfaces, and the interventions were implemented for 40 min. Before and after the interventions, a digital dual inclinometer was used to measure the proprioceptive sense of the ankle, the Balancia program was used to measure static balance ability, and the functional reach test was used to measure dynamic balance ability. In the results, both proprioceptive sense and static dynamic balance ability were significantly different between before and after the intervention in the experimental group (P<0.05). When such results are put together, it can be seen that ankle strengthening exercise applied on unstable supporting surfaces may be presented as an effective treatment method for enhancing the proprioceptive sense and balance ability in adults with functional ankle instability.

Outcomes and morbidities of patients who survive haemoglobin Bart's hydrops fetalis syndrome: 20-year retrospective review

INTRODUCTION

Haemoglobin Bart's hydrops fetalis syndrome was once considered a fatal condition. However, advances over the past two decades have enabled survival of affected patients. Data relating to their morbidities and outcomes will help medical specialists formulate a management plan and parental counselling.

METHODS

All babies with the syndrome who survived beyond the neonatal period and were subsequently managed long-term in eight public hospitals in Hong Kong from 1 January 1996 to 31 December 2015 were included. Patient and parent characteristics, antenatal care, reasons for continuation of pregnancy, intrauterine interventions, perinatal course, presence of congenital malformations, stem-cell transplantation details, and long-term neurodevelopmental outcomes were reviewed.

RESULTS

A total of nine patients were identified, of whom five were female and four male. The median follow-up duration was 7 years. All were Chinese and were homozygous for the Southeast Asian α-thalassaemia deletion. Five of the nine mothers received antenatal care at a public hospital and opted to continue the pregnancy after antenatal diagnosis and counselling. Despite intrauterine transfusions, all babies were born with respiratory depression and required intubation and mechanical ventilation during the neonatal period. Hypospadias was identified in all four male infants. Growth retardation, global developmental delay, and residual neurological deficits were noted in two-thirds of the patients. Haematopoietic stem-cell transplantation was performed in two patients, who became transfusion-independent.

CONCLUSIONS

Survival of patients with Bart's hydrops fetalis syndrome is possible but not without short- and long-term complications; local epidemiology is comparable to that documented for an international registry. Detailed antenatal counselling of parents with a non-judgemental attitude and cautious optimism are imperative.

Effects of Vojta method on trunk stability in healthy individuals

Vojta reflex locomotion is important to main upright posture through stimulation of breast zone to patient with cerebral palsy. However, application in other diseases is no investigated. So, we determined the effects of stimulation of the breast zone on trunk stability in healthy individuals. Fourteen young healthy adults (7 males and 7 females) voluntarily participated in this study. The subjects were randomly divided into an experimental group (breast zone) and control group (arbitrary point). All groups were stimulated for 5 min on the left and right sides, respectively, for a total 10 times. We used the thickness of the external oblique abdominal muscle (EO), the internal oblique abdominal muscle, the transversus abdominis muscle (TrA), and the rectus abdominis muscles, as well as the area of the diaphragm by using ultrasonography. In the experimental group, the thickness of the TrA significantly increased during stimulation (P<0.05) while the thickness of the EO significantly decreased (P<0.05). Also, the area of diaphragm in inspiration was significantly different (P<0.05). Therefore, stimulation of the breast zone may be effective to improve trunk stability through activation of the TrA muscle and the diaphragm.

Cyclosporin A for persistent or chronic immune thrombocytopenia in children

Twenty percent of children with immune thrombocytopenia (ITP) develop a chronic course where treatment strategy is less established. Cyclosporin A (CSA) has been shown to be effective in small series of children with chronic ITP and might reduce the need for chronic steroid therapy and/or splenectomy. We reviewed consecutive patients below 18 years old with persistent or chronic ITP treated with CSA in our unit between January 1998 and June 2015. Thirty patients (14 boys and 16 girls) were included. The median age at initial diagnosis of ITP was 5 years (range 0.5-16.2 years). CSA was started at a median of 13.9 months (range 3.4-124 months) after initial diagnosis and given for a median duration of 9.3 months (range 0.2-63.9 months). The median platelet count before commencement was 12 × 10(9)/L (range 4-199 × 10(9)/L). The median dose of CSA was 6 mg/kg/day (range 2.4-7.5 mg/kg/day). Complete response (CR) or response (R) was achieved in 17 patients (57 %), and 7 (23 %) had sustained response. Side effects (most commonly hirsutism) were tolerable and reversible. CSA appeared effective in about half of persistent or chronic ITP patients and safe as a second-line agent in managing these children.

Remission With Donor Lymphocyte Infusion in a Child With Marrow Relapse After Haploidentical Stem Cell Transplantation for Relapsed Stage 4 Neuroblastoma

A 7-year-old male with Stage 4 neuroblastoma was treated with chemotherapy and autologous hematopoietic stem cell transplantation (HSCT), resulting in partial response with residual bone and marrow disease. He proceeded to haploidentical-HSCT with his mother as donor and achieved remission. The patient developed marrow relapse 2 years after haploidentical-HSCT with cytopenia and dropping donor chimerism. Donor lymphocyte infusion (DLI) using mother's whole blood was given resulting in clearance of marrow disease, resolution of cytopenia, and full donor chimerism. This is the first report of successful treatment for neuroblastoma relapse after haploidentical-HSCT using DLI alone, supporting the role of adoptive cell therapy post-HSCT in neuroblastoma.

Refractory acute lymphoblastic leukemia in Chinese children: bridging to stem cell transplantation with clofarabine, cyclophosphamide and etoposide

Refractory or relapsed acute lymphoblastic leukemia (r/r ALL) represents the leading cause of cancer mortality in children. Clofarabine is effective in inducing remission thus enabling bridging to hematopoietic stem cell transplantation (HSCT). We report the results in treating Hong Kong Chinese pediatric patients with r/rALL by clofarabine/cyclophosphamide/etoposide (CLO-218) combination therapy. A retrospective review of patients treated between January 2009 and December 2014 in the two tertiary referral pediatric oncology units in Hong Kong. Thirteen patients were identified. All were Chinese and seven were male. Median age at clofarabine treatment was 8 years and the median duration of follow-up was 10 months. Nine patients had B-ALL and four had T-ALL. All were refractory to the preceding regimen(s). The median number of prior treatment regimens was 2; two patients had previous HSCT. Complete remission (CR) was achieved in five patients, Complete remission with incomplete counts (CRi) in two, PR in two, and non-remission (NR) in two. All four patients with T-ALL responded with three patients achieving CR. Eight out of nine patients who responded could be bridged to HSCT. Among those who were transplanted, four remained alive and in remission, three relapsed post-HSCT, and one died from transplant-related mortality. Treatment toxicities were common including febrile neutropenia in all subjects and culture-proven bacteremia in five patients. Hepatotoxicity was mild and reversible with no case of veno-occlusive disease. The clofarabine-based regimen is a promising strategy to induce disease remission in r/rALL and bridge to HSCT. Septic complications are, however, frequent necessitating prompt management with adequate supportive care in specialized centers.

Malignancies in Chinese patients with neurofibromatosis type 1

OBJECTIVE

To investigate the pattern of malignancies in Chinese patients with neurofibromatosis type 1.

DESIGN

Historical cohort study.

SETTING

Queen Mary Hospital and Duchess of Kent Children's Hospital in Hong Kong.

PATIENTS

Patients with neurofibromatosis type 1 seen between January 1995 and August 2011.

RESULTS

We identified 123 Chinese patients with neurofibromatosis type 1, diagnosed at a median age of 4.9 years (range, 0.1-16.1 years); 75 (61%) were males. They were followed up for a median of 9.7 years (range, 0.2-27.6 years). Most (80%) of the patients participated in our surveillance programme. Twelve patients developed malignancies at the ages of 0.8 to 41.6 years. These malignancies included: peripheral nerve sheath tumours (n=3), juvenile myelomonocytic leukaemia (n=2), optic nerve glioma (n=1), thalamic pilocytic astrocytoma (n=1), rhabdomyosarcoma (n=1), osteosarcoma (n=1), neuroblastoma (n=1), anaplastic large cell lymphoma (n=1), and breast carcinoma and subsequently carcinoma of the ampulla of Vater (n=1). Among them, three had their tumours (optic glioma, thalamic astrocytoma, sacral malignant peripheral nerve sheath tumour) initially detected by surveillance imaging. Four patients survived without disease progression, three are alive with active disease, the remaining five died (when aged 3 to 56 years) with progressive or relapsed malignancies. The latter patients died from a neuroblastoma, a juvenile myelomonocytic leukaemia, a malignant peripheral nerve sheath tumour, a lymphoma, and a second primary tumour (carcinoma of ampulla of Vater, at the age of 56 years). In neurofibromatosis type 1 patients with malignancy, overall 30-year survival was significantly shorter than in those without malignancy (35% vs 93%, P<0.001).

CONCLUSION

Chinese patients with neurofibromatosis type 1 are susceptible to different malignancies which contribute to mortality. These findings are similar to reports from overseas. Outcomes were unfavourable, except in patients having low-grade gliomas. Surveillance imaging may help early detection of deep-seated malignancies but the benefits accruing from such monitoring warrants prospective evaluation.

Clinical and angiographic characteristics of multiple dural arteriovenous shunts

BACKGROUND AND PURPOSE

The pathogenesis and characteristics of multiple DAVSs are not well-known. The purpose of this study was to evaluate the angiographic and clinical characteristics of patients with multiple DAVSs with an emphasis on the pathomechanism.

MATERIALS AND METHODS

One hundred seventy-nine patients with DAVS were reviewed. Patients with ≥ 2 fistulas at anatomically separate sites were included. Multiple DAVSs were categorized into synchronous (simultaneous multiplicity) or metachronous (temporal sequential development of multiplicity) types. The angiographic and clinical characteristics of these lesions were analyzed.

RESULTS

Fourteen patients were diagnosed with multiple DAVSs (7.8%; synchronous, n = 7; metachronous, n = 7). Thirteen of the 14 patients showed CVR (93%, Borden type II/III). Multiple DAVSs were frequently associated with dural sinus thrombosis (71.4%, n = 10). Synchronous DAVSs developed in association with an occluded sinus (n = 5). De novo metachronous lesions developed in association with thrombosis of a previously patent dural sinus (n = 3) or reopening of an occluded sinus (n = 2). Multiplicity was associated with aggressive initial symptoms in 64.3% (n = 9). The newly developed lesions in the metachronous types were accompanied by hemorrhage (n = 1), neurologic deficit (n = 1), worsening of the initial benign symptoms (n = 2), and incidental detection (n = 3). The mean time interval between the initial diagnosis and de novo lesion detection was 31.3 ± 29.8 months (range, 12-92 months).

CONCLUSIONS

Multiplicity of DAVSs is associated with poor angiographic and clinical prognosis, requiring an aggressive treatment and management strategy. Sinus thrombosis has a prominent role in the pathomechanism of DAVSs.

Dural sinus thrombosis owing to polycythaemia vera in a 12-year-old girl

Because of the rarity of dural sinus thrombosis in children with polycythaemia vera (PV), the options for diagnosis and treatment remain elusive. A 12-year-old girl was admitted with dural sinus thrombosis associated with PV, diagnosed by magnetic resonance venography. She was managed with interventional endovascular thrombolectomy and venoplasty, phlebotomy, hydroxyurea, low molecular weight heparin, and aspirin followed by warfarin. She made a good recovery without residual neurological deficit. This case highlights the importance of diagnosis and appropriate intervention with multi-modality treatments in patients with PV and thrombosis.

A synopsis of current care of thalassaemia major patients in Hong Kong

OBJECTIVE

To provide a synopsis of current thalassaemia major patient care in Hong Kong.

DESIGN

Retrospective study.

SETTING

All haematology units of the Hospital Authority in Hong Kong.

PATIENTS

All patients with thalassaemia major with regular transfusion.

RESULTS

To date, there were 363 thalassaemia major patients under the care of the Hospital Authority. Prenatal diagnosis has helped to reduce the number of indigenous new cases, but in recent years immigrant cases are appearing. The patients have a mean age of 23 (range, 1-52) years, and 78% of them are adults. In 2009, they received 18 782 units of blood. This accounted for 9.5% of all blood consumption from the Hong Kong Red Cross. In the past, cardiac iron overload was the major cause of death (65%) and few patients survived beyond the age of 45 years. The availability of cardiac iron assessment by magnetic resonance imaging (T2 MRI) to direct the use of oral deferiprone chelation has reduced the prevalence of heart failure and cardiac haemosiderosis, which should reduce mortality and improve life expectancy.

CONCLUSION

The future for thalassaemia care in Hong Kong is bright. With better transfusion and chelation, it should be possible to avoid growth and endocrine deficiencies in younger patients.

Congenital Rosai-Dorfman disease presenting with anemia, thrombocytopenia, and hepatomegaly

Rosai-Dorfman disease (RDD) is a rare entity of non-Langerhans cell histiocytoses (non-LCH) which usually presents with bilateral painless cervical lymphadenopathy. We describe a neonate with RDD who presented with anemia, thrombocytopenia and hepatomegaly. He recovered spontaneously with conservative management. This represents an atypical presentation of RDD. Conservative management with close monitoring can be adopted for some with systemic involvement.

One-stop measurement of iron deposition in the anterior pituitary, liver, and heart in thalassemia patients

PURPOSE

To assess the feasibility of one-stop evaluation of iron load of myocardium, liver, and anterior pituitary gland in thalassemia patients.

MATERIALS AND METHODS

Fifty thalassemia major patients underwent a breath-hold magnetic resonance imaging (MRI) sequence for assessment of T2* for liver and myocardium, a short axis cine trueFISP sequence covering base to apex to assess the ejection fraction of left ventricle, and a turbo spin echo T2-weighted sequence for the anterior pituitary gland. The MRI parameters were correlated with serum growth hormone, insulin growth factor-1 (IGF-1), insulin growth factor binding protein-3 (IGFBP-3), and endocrine failure.

RESULTS

Ferritin was found to be associated with T2* liver (P < 0.005), T2SI (signal intensity) pituitary (P = 0.001), and T2 pituitary/fat (P = 0.001), but not with T2* heart. There was significant correlation of T2SI pituitary with IGF-1 and IGFBP-3. T2* liver (P < 0.001), T2* heart (P < 0.001), pituitary SI (P < 0.001) and pituitary/fat SI (P = 0.002) were also found to be significantly correlated with a history of hypogonadism. T2* heart was also found to be significantly correlated with IGF-1.

CONCLUSION

A quick MRI protocol for assessment of T2* liver, T2* heart, and T2SI pituitary is technically feasible. This might form an objective basis to monitor the response to different organs to chelation therapy.

Quality of life in patients with transfusion-dependent thalassemia after hematopoietic SCT

In this cross-sectional study, we compared the quality of life (QOL) in transfusion-dependent thalassemic patients who survived matched sibling hematopoietic SCT (HSCT, n=24) with patients treated conventionally with transfusion and iron chelation (n=74). WHOQOL-BREF(HK) and PedsQL questionnaires were administered to patients aged >18 years and 5-12 years, respectively. Patients aged 12-18 years received both questionnaires. WHOQOL-BREF(HK) revealed post transplant patients rated overall health better than those treated conventionally (score 3.67 vs 3.06, P=0.01). They are less dependent on medical aids (3.87 vs 2.96, P=0.006), having higher activity level (4.00 vs 3.36, P=0.026) and better personal relationships (4.13 vs 3.69, P=0.014). Physical health domain score was better (75.20 vs 63.94, P=0.007). These differences remained significant after adjustment for comorbidities. PedsQL revealed post transplant patients rated better for running (3.53 vs 2.72, P=0.001) and sports (3.20 vs 2.64, P=0.038), even after adjustment for comorbidities, but were less satisfied for school absence to attend hospital (2.53 vs 3.29, P=0.03). Post transplant patients were significantly more likely to consider marriage (100 vs 75.7%, P=0.033), but not childbearing (66.7 vs 51.4%, P=0.28). In conclusion, transplanted thalassemic patients enjoy better QOL, mainly in physical health, compared with conventionally treated patients. This information is important to patients considering HSCT.

Treatment outcome of rhabdomyosarcoma in Hong Kong Chinese children

OBJECTIVES

To review the treatment outcome of rhabdomyosarcoma in Hong Kong Chinese children.

DESIGN

Retrospective review.

SETTING

University teaching hospital, Hong Kong.

PATIENTS

Consecutive cases of rhabdomyosarcoma diagnosed and treated by the Department of Paediatrics and Adolescent Medicine of Queen Mary Hospital between 1989 and 2005. Each patient was staged and treated according to the Intergroup Rhabdomyosarcoma Study guidelines.

MAIN OUTCOME MEASURES

Overall and event-free survival rates, and toxicity data.

RESULTS

Of 19 patients (8 males and 11 females), 14 (74%) were younger than 10 years old. The median age at diagnosis was 6 (range, 0.5-17) years. Primary sites of rhabdomyosarcoma included: the head and neck (n=8; 6 classified as cranial parameningeal), genitourinary (3), extremity (3), pelvis (3), and trunk (2). Thirteen (68%) had embryonal and six (32%) had alveolar histology. Two, 2, 9, and 6 were classified as belonging to Intergroup Rhabdomyosarcoma Study groups 1, 2, 3, and 4, respectively. Respective 5-year overall and event-free survival rates of the entire cohort were 49% (95% confidence interval, 26-73%) and 32% (10-55%), with a median follow-up of 3.4 (range, 0.2-16.7) years. In non-metastatic cases (Intergroup Rhabdomyosarcoma Study groups 1-3), the 5-year overall survival rate was 66% (95% confidence interval, 39-93%) and in metastatic cases (group 4) it was 17% (0-46%). The 5-year overall survival rate for patients aged less than 10 years was 60% (95% confidence interval, 33-87%) compared to 20% (0-55%) in those aged 10 years and over. Significant treatment-related toxicities including myelosuppression, infections, peripheral neuropathy, and second cancers were encountered.

CONCLUSIONS

Treatment outcome of rhabdomyosarcoma in this cohort of Chinese children was less favourable than that reported in international studies. Whilst the main reason could have been related to the high proportion of metastatic cases, also non-metastatic cases faired worse. Improved outcomes may be achieved by advances in multidisciplinary (paediatric oncology, pathology, radiotherapy, and surgery) management and supportive care.

Risk factors and mortality predictors of hepatic veno-occlusive disease after pediatric hematopoietic stem cell transplantation

A cohort of 138 children with 144 hematopoietic stem cell transplantation (HSCT) performed in 1997-2006 were analyzed to evaluate risk factors and mortality predictors of hepatic veno-occlusive disease (VOD). Nineteen patients (13.2%) developed VOD (nine boys, median age 3.5 years) at 1-21 days after HSCT (median 13 days). Age < or =2 years at transplant (odds ratio (OR)=5.25, P=0.011), BU-CY conditioning (OR=5.16, P=0.001), thalassemia major (OR=3.97, P=0.015), platelet engraftment beyond day +21 (OR=8.67, P=0.025) were univariate risk factors for VOD. The first two remained significant in multivariate regression. Seven patients (36.8%) with VOD died, at a median of 44 days post transplant (range, 30-421 days). The 5-year survival was 62%. All surviving patients had normal liver function on follow-up at 0.5-9 years. Patients with VOD had higher 100-day mortality (16.3 vs 9.6%, P=0.024). Mortality predictors included donors other than autologous or matched sibling (hazard ratio (HR)=23.6, P=0.006), hepatic and cutaneous GVHD (HR=8.15, P=0.038), maximal weight gain >9% (HR=6.81, P=0.023), pleural effusion, intensive care unit admission, peak bilirubin >300 micromol l(-1) (HR=13.6, P=0.016), day +21 bilirubin >200 micromol l(-1) (HR=33.9, P=0.001), and rise of bilirubin >15 micromol l(-1) per day within the first week (HR=19.8, P=0.006). Mortality was substantially higher if >3 predictors were present (HR=33.9, P=0.001). Meticulous monitoring in high-risk patients and early treatment should be considered before VOD progresses beyond salvage.

Carotid intima-media thickness is increased and related to arterial stiffening in patients with beta-thalassaemia major

An increased iron store has been linked to the risk of atherosclerosis. The carotid intima-media thickness (IMT), stiffness index, Young's elastic modulus (YEM), and augmentation index were determined in 20 patients with beta-thalassaemia major. Compared with controls, patients had greater IMT (P < 0.001), YEM (P = 0.005), and stiffness (P = 0.009) and augmentation (P = 0.03) indices. The odds ratio for increased IMT in patients was 39. Carotid IMT correlated with YEM (P = 0.036), stiffness index (P = 0.036) and augmentation index (P = 0.006). Multivariate analysis identified patient status (P < 0.001) as the only significant determinant of IMT. These findings suggest the possibility of premature atherosclerosis in beta-thalassaemia major patients.

The shape control of ZnO based nanostructures

Tetrapod-shape ZnO nanostructures are formed on Si substrates by vapor phase transportation method. The effects of two important growth parameters, growth temperature and VI/II ratio, are investigated. The growth temperature is varied in the range from 600 degrees C to 900 degrees C to control the vapor pressure of group II-element and the formation process of nanostructures. VI/II ratio was changed by adjusting the flux of carrier gas which affects indirectly the supplying rate of group VI-element. From the scanning electron microscopy (SEM), systematic variation of shape including cluster, rod, wire and tetrapod was observed. ZnO tetrapods, formed at 800 degrees C under the carrier gas flux of 0.5 cc/mm2 min, show considerably uniform shape with 100 nm thick and 1-1.5 microm long legs. Also stoichiometric composition (O/Zn - 1) was observed without any second phase structures. While, the decrease of growth temperature and the increase of carrier gas flux, results in the irregular shaped nanostructures with non-stoichiometric composition. The excellent luminescence properties, strong excitonic UV emission at 3.25 eV without deep level emission, indicate that the high crystalline quality tetrapod structures can be formed at the optimized growth conditions.

Growth of well-aligned ZnO nanorods using auge catalyst by vapor phase transportation

Well-aligned ZnO nanorods have been achieved using new alloy (AuGe) catalyst. Zn powder was used as a source material and it was transported in a horizontal tube furnace onto an AuGe deposited Si substrates. The structural and optical properties of ZnO nanorods were characterized by scanning electron microscopy, high resolution X-ray diffraction, and photoluminescence. ZnO nanorods grown at 650 degrees C on 53 nm thick AuGe layer show uniform shape with the length of 8 +/- 0.5 microm and the diameter of 150 +/- 5 nm. Also, the tilting angle of ZnO nanorods (+/- 5.5 degrees) is confirmed by HRXRD. High structural quality of the nanorods is conformed by the photoluminescence measurement. All samples show strong UV emission without considerable deep level emission. However, weak deep level emission appears at high (700 degrees C) temperature due to the increase of oxygen desertion.

What is the difference between squamous cell carcinoma and adenocarcinoma of the cervix? A matched case–control study

The objective of this study was to investigate the efficacy of treatment strategies in patients with adenocarcinoma (AC) of the cervix and compare it with those with squamous cell carcinoma (SCC) of the cervix. Women with FIGO (1994) stage IB1 AC, especially pathologic tumor size of 2-4 cm, treated with class III hysterectomy, were compared with those with SCC treated with comparable strategy in a case-controlled study. Eighty patients (20 cases, 60 controls) were analyzed. Lymphvascular space invasion (P = 0.01) and lymph node metastasis (P = 0.07) were more frequent in patients with SCC than in those with AC. However, there was no significant difference in depth of stromal invasion (P = 0.51) and invasion of the parametrium (P = 0.44) between two groups. And there was also no statistically significant difference in disease-free survival (P = 0.86) and overall survival (P = 0.89) between two groups. Primary radical surgery followed by adjuvant therapy, same as for SCC, would be acceptable for AC with pathologic tumor size of 2-4 cm. Although it was difficult to determine whether AC recurred more systemically, more effective treatment strategies than those currently available for AC should be considered to reduce the systemic recurrence.

Successful treatment of spinal cord compression secondary to extramedullary hematopoietic mass by hypertransfusion in a patient with thalassemia major

A 15-year-old girl with thalassemia major who suffered from paraparesis with a history of progressive lower limb weakness for 2 years immigrated from mainland China to Hong Kong. She had not received regular blood transfusion since the age of 6 years after splenectomy. MRI of the spine showed thoracic spinal cord compression secondary to extramedullary hematopoietic mass. She made significant recovery with hypertransfusion therapy alone. MRI of the spine repeated 3 months later showed nearly complete resolution of the extramedullary hematopoietic mass.

Lymph node metastasis and lymph vascular space invasion in microinvasive squamous cell carcinoma of the uterine cervix

The objective of this study was to determine whether the depth of invasion was related to lymph vascular space invasion (LVSI) and lymph node metastasis and whether there was a correlation between LVSI and lymph node metastasis in stage IA cervical cancer. The medical records, including surgical notes and pathologic reports, of 202 patients with microinvasive squamous cell carcinoma of the uterine cervix were reviewed retrospectively. There was a positive correlation between the depth of invasion and the LVSI, and the incidence of lymph node metastasis was slightly higher than those reported hitherto for stage IA1 cervical cancer, especially in the depth of invasion of 1-3 mm group. However, among four patients with lymph node metastasis, only two patients had positive LVSI. There was no definite correlation between LVSI and lymph node metastasis. LVSI could not identify the patients with high risk for lymph node metastasis.

Improved outcome of acute lymphoblastic leukaemia treated by delayed intensification in Hong Kong children: HKALL97 study

OBJECTIVE

To study the outcome of children with acute lymphoblastic leukaemia who were treated using a protocol including one or two delayed intensifications.

DESIGN

Prospective single-arm multicentre study.

SETTING

Five designated children cancer units of the Hospital Authority of Hong Kong.

PATIENTS

Children aged between 1 and 17.9 years with newly diagnosed acute lymphoblastic leukaemia seen from November 1997 to December 2002.

INTERVENTION

Chemotherapy was modified from a German Berlin-Frankfurt-Muenster 95 (BFM95) protocol that included a delayed intensification similar to the induction phase repeated 5 months after diagnosis. High-risk patients were given double delayed intensification.

MAIN OUTCOME MEASURES

Overall survival and event-free survival of the whole group and the three risk groups (standard-, intermediate-, and high-risk groups), and comparison with historical controls.

RESULTS

A total of 171 patients were recruited with a median age at diagnosis of 5.57 years (range, 1.15-17.85 years). The induction remission rate was 95.3% and non-leukaemia mortality during remission was 2.3%. At 4 years, the relapse rate of this (HKALL97) study was significantly lower than that of the HKALL93 study (15.7 vs 37.3%; P<0.001). The 4-year overall survival of HKALL97 and HKALL93 studies were 86.5% and 81.8%, respectively (P=0.51). The 4-year event-free survival for HKALL97 and HKALL93 studies were 79% and 65%, respectively (P=0.007). Nonetheless the difference of event-free survival was most remarkable in the intermediate-risk group: 75.6% and 53.1% for HKALL97 and HKALL93 studies, respectively (P=0.06).

CONCLUSION

A more intensive delayed consolidation phase improved the outcome for children with acute lymphoblastic leukaemia by reducing relapses at 4 years. The early treatment complications were manageable and non-leukaemia mortality during remission remained low.

Hyperbilirubinemia and cholelithiasis in Chinese patients with hemoglobin H disease

Hemoglobin H disease (HbH) is a hemoglobinopathy peculiar to parts of the world with high incidence alpha-thalassemia mutations. Among 90 HbH cases, 50 cases suffered from clinically significant jaundice (bilirubin >30 mmol/l), including 14 with severe jaundice (bilirubin >60 mmol/l). Cholelithiasis was found in 38 cases. The incidence is roughly eight times higher than that in background control population but 50% lower than that in beta-thalassemia. The risk of gallstones was related to higher bilirubin levels but not alpha-globin genotype, sex, ferritin, and hemoglobin levels. Homozygotes or double heterozygotes for Gilbert alleles (17.2%), but not heterozgyotes (42.2%), were found to have a significantly increased risk of gallstones and jaundice. However, common Chinese Gilbert syndrome alleles do not completely explain the variable risks.

Ventriculo-vascular interactions in patients with beta thalassaemia major

OBJECTIVES

To determine potential interactions between the heart and arterial system in patients with beta thalassaemia major.

DESIGN AND PATIENTS

Vascular compliance, systemic vascular resistance, and left ventricular (LV) contractility was determined in 34 asymptomatic thalassaemia patients at 2-4 hours after blood transfusion and also in 34 age and sex matched controls using a non-invasive device. The results were compared between groups and inter-relationships between LV contractility and indices of vascular load were explored.

SETTING

Tertiary paediatric cardiac centre.

RESULTS

When compared with controls, patients had greater systemic vascular resistance (1633 (259) v 1377 (276) dynes/s/cm5, p < 0.001) and effective arterial elastance (E(a)) (1.86 (0.25) v 1.65 (0.29) mm Hg/ml, p = 0.001), an index of combined pulsatile and static vascular load. On the other hand, their systolic blood pressure (104 (9) v 112 (13) mm Hg, p = 0.006), pulse pressure (45 (9) v 57 (10) mm Hg, p < 0.001), adjusted systemic vascular compliance (1.21 (0.09) v 1.37 (0.14), p < 0.001), adjusted brachial artery distensibility (21 (0.29) v 7.95 (0.29)%/mm Hg, p < 0.001) and LV+dP/dt (1059 (183) v 1239 (237) mm Hg/s, p = 0.001) were significantly lower. Significant determinants of LV contractility, as reflected by LV+dP/dt, were age (standardised beta = -0.24, p = 0.003), body mass index (standardised beta = -0.34, p = 0.004), systolic blood pressure (standardised beta = 0.90, p < 0.001), and effective E(a) (standardised beta = -0.50, p < 0.001) (model R2 = 0.69). No significant correlation existed between serum ferritin concentration and any of the cardiac or vascular indices.

CONCLUSION

An unfavourable ventriculo-vascular interaction, as characterised by impaired cardiac contractility and increased static and pulsatile vascular load, occurs in patients with beta thalassaemia major.