Polymyxin-induced neuromuscular weakness: a case report

Polymyxin-induced neuromuscular blockade is a rare but potentially fatal condition, with majority of cases that were reported between 1962 and 1973. We describe a patient who developed hypercapnic respiratory failure after initiation of polymyxin for multi-drug resistant Escherichia Coli bacteremia, due to polymyxin-induced neuromuscular dysfunction. After cessation of polymyxin, he regained full strength, had complete resolution of ptosis, and was successfully extubated. In light of the renewed use of polymyxin in this era of antimicrobial-resistance, this case aims to raise awareness about this rare but life-threatening condition, which is easily reversible with early recognition and prompt discontinuation of the drug.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Approach to headache disorders and the management of migraine: consensus guidelines from the Headache Society of Singapore, first edition (2023)

Headache disorders, particularly migraine, are one of the most common and disabling neurological disorders. There is a need for high-quality, accessible care for patients with headache disorders across all levels of the healthcare system in Singapore. The role of the Headache Society of Singapore is to increase awareness and advance the understanding of these disorders and to advocate for the needs of affected patients. In this first edition of local consensus guidelines, we focus on treatment approaches for headaches and provide consensus recommendations for the management of migraine in adults. The recommendations in these guidelines can be used as a practical tool in routine clinical practice by primary care physicians, neurologists and other healthcare professionals who have a common interest in headache disorders.

Cerebellar Transcranial Magnetic Stimulation (TMS) Impairs Visual Working Memory

An increasing body of evidence points to the involvement of the cerebellum in cognition. Specifically, previous studies have shown that the superior and inferior portions of the cerebellum are involved in different verbal working memory (WM) mechanisms as part of two separate cerebro-cerebellar loops for articulatory rehearsal and phonological storage mechanisms. In comparison, our understanding of the involvement of the cerebellum in visual WM remains limited. We have previously shown that performance in verbal WM is disrupted by single-pulse transcranial magnetic stimulation (TMS) of the right superior cerebellum. The present study aimed to expand on this notion by exploring whether the inferior cerebellum is similarly involved in visual WM. Here, we used fMRI-guided, double-pulse TMS to probe the necessity of left superior and left inferior cerebellum in visual WM. We first conducted an fMRI localizer using the Sternberg visual WM task, which yielded targets in left superior and inferior cerebellum. Subsequently, TMS stimulation of these regions at the end of the encoding phase resulted in decreased accuracy in the visual WM task. Differences in the visual WM deficits caused by stimulation of superior and inferior left cerebellum raise the possibility that these regions are involved in different stages of visual WM.

Novel Autoantibodies in Idiopathic Small Fiber Neuropathy

Objective

Small fiber neuropathy (SFN) is clinically and etiologically heterogeneous. Although autoimmunity has been postulated to be pathophysiologically important in SFN, few autoantibodies have been described. We aimed to identify autoantibodies associated with idiopathic SFN (iSFN) by a novel high‐throughput protein microarray platform that captures autoantibodies expressed in the native conformational state.

Methods

Sera from 58 SFN patients and 20 age‐ and gender‐matched healthy controls (HCs) were screened against >1,600 immune‐related antigens. Fluorescent unit readout and postassay imaging were performed, followed by composite data normalization and protein fold change (pFC) analysis. Analysis of an independent validation cohort of 33 SFN patients against the same 20 HCs was conducted to identify reproducible proteins in both cohorts.

Results

Nine autoantibodies were screened with statistical significance and pFC criteria in both cohorts, with at least 50% change in serum levels. Three proteins showed consistently high fold changes in main and validation cohorts: MX1 (FC = 2.99 and 3.07, respectively, p = 0.003, q = 0.076), DBNL (FC = 2.11 and 2.16, respectively, p = 0.009, q < 0.003), and KRT8 (FC = 1.65 and 1.70, respectively, p = 0.043, q < 0.003). Further subgroup analysis into iSFN and SFN by secondary causes (secondary SFN) in the main cohort showed that MX1 is higher in iSFN compared to secondary SFN (FC = 1.61 vs 0.106, p = 0.009).

Interpretation

Novel autoantibodies MX1, DBNL, and KRT8 are found in iSFN. MX1 may allow diagnostic subtyping of iSFN patients. ANN NEUROL 2022;91:66–77

Headache Related to PPE Use during the COVID-19 Pandemic

PURPOSE OF REVIEW

Personal protection equipment (PPE)-associated headache is an unusual secondary headache disorder that predominantly occurs in healthcare workers as a consequence of the donning of protective respirators, face masks and/or eyewear. The appreciation of this entity is important given the significant ramifications upon the occupational health of healthcare workers and could additionally have an impact on persons living with pre-existing headache disorder(s).

RECENT FINDINGS

There has been a renewed interest and recognition of PPE-associated headaches amongst healthcare professionals, largely brought about by the ongoing COVID-19 pandemic which has besieged healthcare systems worldwide. De novo PPE-associated headaches may present with migrainous or tension-type features and can be viewed as a subtype of external compression headache. The prognosis of the disorder is generally favourable, given that most headaches are short-lived without long-term sequalae. Several aetiologies have been postulated to account for the development of these headaches. Notably, these headaches can affect the occupational health and work performance of healthcare workers. In this review, we discuss the epidemiology, clinical characteristics, probable etiopathogenesis, management and prognosis of PPE-associated headaches in the context of the COVID-19 pandemic. Future directions for research and PPE development are proposed.

Neutrophil-to-Lymphocyte Ratio Predicts Development of Immune-Related Adverse Events and Outcomes from Immune Checkpoint Blockade: A Case-Control Study

The utility of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) utility in predicting immune-related adverse events (irAEs) and survival have not been well studied in the context of treatment with immune checkpoint inhibitors (ICIs). We performed a case-control study of cancer patients who received at least one dose of ICI in a tertiary hospital. We examined NLR and PLR in irAE cases and controls. Logistic and Cox regression models were used to identify independent risk factors for irAEs, progression-free survival (PFS), and overall survival (OS). The study included 91 patients with irAEs and 56 controls. Multiple logistic regression showed that NLR < 3 at baseline was associated with higher occurrence of irAEs. Multivariate Cox regression showed that development of irAEs and reduction in NLR from baseline to week 6 were associated with longer PFS. Higher NLR values at baseline and/or week 6 were independently associated with shorter OS. A reduction in NLR from baseline to week 6 was associated with longer OS. In this study of cancer patients treated with ICIs, NLR has a bidirectional relationship with adverse outcomes. Lower NLR was associated with increased occurrence of irAEs while higher NLR values were associated with worse clinical outcomes.

Lo, the ever confounding nipple shadow!

The discovery of a solitary pulmonary nodule (SPN) on chest imaging can be alarming for both the clinician and the patient. In the absence of a uniform guideline, managing SPN is nothing short of challenging for primary care physicians (PCPs). We present a case here of a patient presenting with prolonged cough who also displayed unilateral SPN on her chest radiograph. Through further examination, this presence was later shown to be a nipple shadow simulating SPN, and the patient was spared unnecessary testing and psychological distress.

Economic burden of migraine in Singapore

Objective:

Despite the high prevalence and disabling nature of migraine, studies evaluating its economic burden in Singapore remain scant. This study aims to quantify the per capita and aggregate economic cost of episodic migraine (EM; ≤14 monthly headache days) without aura among full-time employees in Singapore.

Methods:

We administered a cross-sectional online survey to full-time employees in Singapore who met the International Classification of Headache Disorders (third edition, 2018) criteria for EM without aura. Eligible participants were classified by the frequency of monthly migraine days (MMDs): lower end episodic migraine (LEM; ≤3 MMDs) and upper end episodic migraine (UEM; 4–14 MMDs). The survey captured per capita healthcare resource utilization and lost work productivity (absenteeism and presenteeism) for each subgroup. Healthcare costs were obtained by multiplying unit costs by healthcare utilization. Finally, per capita (patient) costs of each subgroup were then imputed and multiplied by prevalence data to quantify the aggregate burden of migraine in Singapore.

Results:

Of the 606 participants who completed the survey, 81% experienced ≤3 MMDs. Total annual per capita costs were SGD4925 (USD 3620; 95% confidence interval (CI): SGD 4438–5411) and SGD14,476 (USD 10,639; 95% CI: SGD 11,908–17,045) for the LEM and UEM subgroup, respectively. Healthcare costs on average accounted for 17.6% of per capita costs, of which was driven primarily by diagnostic tests (33.6%), followed by consultations (17.1%), medications (16.7%), alternative medications (16.6%) and hospitalizations (14.8%). Lost productivity accounted for 82.4% of costs, chiefly attributable to absenteeism in the LEM group (38.2%), followed by presenteeism in the UEM group (26.0%), absenteeism in the UEM group (18.8%) and presenteeism in the LEM group (17.1%). The total cost to Singapore for EM in 2018 was approximately SGD 1 billion (USD 0.75 billion; SGD 1.00 = USD 0.74).

Conclusion:

Overall, EM imposes a substantial economic burden on society in Singapore. Total migraine cost per capita is greater in the UEM (4–14 MMDs) as compared to the LEM subgroup. Majority of the overall costs result from missed workdays and lost work productivity. Future research should determine the extent to which optimized migraine treatments could improve productivity, and by extension, mitigate the staggering costs of this disorder.

Methods and clinical outcomes of in situ fenestration for aortic arch revascularization during thoracic endovascular aortic repair

OBJECTIVE

Despite endovascular advances in fenestrated and branched devices, thoracic endovascular aortic repair (TEVAR) for arch pathologies remains challenging. The aim of this study was to provide a contemporary review on the current evidence for in situ fenestration during TEVAR and to evaluate its short- and mid-term clinical outcome in the management of arch pathology.

METHODS

A systematic literature review on in situ fenestration of thoracic aortic stent-graft from January 2003 to September 2018 was performed under the instruction of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement.

RESULTS

Our initial search yielded 169 studies, of which 21 articles were relevant to the topic and were finally included. One hundred and forty-five in situ fenestration procedures in 99 patients were reviewed, involving 25 innominate arteries (17%), 33 left common carotid arteries (23%) and 87 left subclavian arteries (60%). Twelve patients (12/99, 12%) had two-vessel fenestration and three-vessel fenestration was performed in 17 patients (17/99, 17%). Technical success was achieved in 136 arteries (136/145, 93%). Talent/Valiant with monofilament twill woven polyester fabric was the most common (50/99, 51%) stent-graft used for fenestration. Three methods reported for in situ fenestration were needle, laser and radiofrequency. Needle was the most frequently used device for fenestration, which was performed in 60 patients (60/99, 61%). Three patients (3/99, 3%) died with 30 days, none were in situ fenestration TEVAR procedure-related. Perioperative complications including one (1%) retrograde type A aortic dissection, two (2%) type II endoleaks, and three (3%) strokes were reported. The pooled estimate for overall technical success, perioperative mortality and stroke was 88.3% (95% CI, 78.6%-93.9%), 5.9% (95% CI, 2.5%-13.4%) and 9.5% (95% CI, 4.1%-20.6%), respectively. Four patients (4/96, 4%) died during follow-up, none were aortic-related. All the fenestration bridging stents were reportedly patent, with only 1 (1/96, 1%) asymptomatic left subclavian stent stenosis. Two patients (2/96, 2%) with type II endoleak from left subclavian artery required secondary intervention.

CONCLUSION

In situ fenestration appeared to be a feasible and effective method to extend proximal landing zone during TEVAR. It had an acceptable short-term result with high technical success and low fenestration related morbidity. Long-term durability data were lacking, and there was no high level evidence to recommend the routine use of in situ fenestration TEVAR for the management of arch pathology.

Clinical Toxicology and Overdose of Psychiatric Medications

This article reviews the poisoning epidemiology in Hong Kong, assessment and treatment of acute poisoning, and management of acute psychiatric medication overdose. In 2016, nearly 4000 poisoning cases involving approximately 6000 poisons were reported to Hong Kong Poison Information Centre. About 25% of the poisons involved were psychiatric-related medications. The initial medical assessment on poisoning includes history taking, vital signs monitoring, and focused physical examination. Approaches in managing acute poisoning include supportive measures, decontamination, antidote use, and enhanced elimination. Management on overdose of psychiatric medications (zopiclone, tricyclic antidepressants, selective serotonin reuptake inhibitor, antipsychotics, valproic acid, lithium, and methylphenidate) are discussed with practical tips highlighted.

Delayed open conversion after endovascular aortic repair

AIM

We present the clinical outcomes of patients who underwent delayed (>30 days) open surgical repair after endovascular aortic aneurysm repair.

METHODS

All patients receiving delayed open repair of infrarenal and juxtarenal aortic aneurysms after endovascular repair from July 2001 to December 2017 were retrospectively reviewed. Patients' baseline characteristics, indications for delayed open conversion, and time between endovascular repair and open conversion are described. Early outcomes included operative approach, morbidity, and mortality. Midterm outcomes included survival.

RESULTS

Twenty-two (3.3%) of 667 patients with prior infrarenal endovascular aortic aneurysm repair had delayed open conversion (20 elective and 2 emergency). The time from endovascular repair to open conversion was 60 ± 36 months. The indications were 6 (27%) type Ia endoleaks, 6 (27%) type II endoleaks with enlarging sac size, 2 (9%) endotensions, 7 (32%) unknown types of endoleak, and 1 (5%) graft infection. The 7 minutes unknown endoleaks were confirmed as lumbar leaks in 4 cases and fabric leaks in 3. Operative time was 222 ± 48 min with blood loss of 2211 ± 2057 mL. Hospital stay after conversion was 12 ± 8 days. There was no 30-day mortality. Estimated survival rates were 96%, 91%, 86%, 79% and 57% at 1, 2, 3, 4, and 5 years postoperatively.

CONCLUSION

Delayed conversion to open surgery after endovascular aortic aneurysm repair by endograft explantation appears to be safe with good short- and mid-term outcomes. With careful preoperative assessment, open conversion remained a realistic and viable option in patients with failed endovascular treatment.

Arch branch endografts for arch aneurysms associated with bovine anomaly

Bovine aortic arch is known to be associated with an increased rate of aortic arch expansion. The most frequently observed human variant of bovine aortic arch is a common origin of the innominate trunk and left common carotid artery. This is a report of two patients who had successful custom-made arch branch endograft treatment for an arch aneurysm associated with bovine arch anomaly. Modular endovascular repair of aortic arch aneurysms using an inner-branched device adds to the armamentarium of treatment options, and is a minimally invasive management modality without the need for sternotomy or intraoperative extracorporeal bypass.

Accidental Ecstasy Poisoning in a Five-Year-Old Boy

We report a 5-year-old child with fever and confusion after ingestion of a tablet of methylenedioxymethamphetamine (MDMA). He was treated successfully with supportive measures and titrated doses of benzodiazepine. In children with unexplained fever, sympathetic hyperactivity, confusion or convulsion, MDMA poisoning should be considered.

Hong Kong Poison Information Centre: Annual Report 2015

Objective

To report and analyse the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2015.

Methods

In 2015, all poisoning cases received by HKPIC were retrieved from its database [Poison Information and Clinical Management System (PICMS)] for analysis.

Results

A total of 3,960 poisoned cases were analysed. There were 1,770 male patients (44.7%), 2,176 female patients (55.0%) and 14 sex unspecified patients (0.4%). The majority of the cases (63.5%) were between 20 and 59 years old. Common causes for poisoning were suspected self-harm/suicidal attempt (38.4%), unintentional exposure (17.4%) and abusive substances use (11.6%). Excluding the common co-ingestant ethanol, the five commonest types of poison were paracetamol, benzodiazepine, household products, zopiclone and Chinese herbal medicine. Most patients were managed with supportive measures, while 16.4% and 16.2% of them were treated by decontamination and antidotes respectively. Majority of the cases had uneventful recovery; 1% resulted in death and 4.3% had major outcomes. Seven interesting cases and one outbreak were discussed.

Conclusions

This 10th annual report provided updated epidemiological information on poisoning pattern in Hong Kong and highlighted important changes in comparing with our previous reports.

Hong Kong Poison Information Centre: Annual Report 2008

Objective

To report the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2008.

Methods

From 1st January 2008 to 31st December 2008, all poisoning cases received by HKPIC were retrieved from its database (DATOX & PIC-MS) for analysis.

Results

4,029 poisoned cases were analyzed. There were 1,755 male patients (43.6%) and 2,262 female patients (56.1%). Nearly two-thirds of them were between 20 and 59 years old. Common causes of exposure were suspected self harm/suicidal attempt, unintentional exposure and abusive use. Sedatives, household products, paracetamol, and ketamine were common poisons exposed and non-benzodiazepine sedative-hypnotics were involved in about one-seventh of the poisoning cases. The majority of the patients were managed conservatively, with 6.0% and 5.9% treated by decontamination and antidotes respectively. Most cases had uneventful recovery; about 1% of the poison exposure resulted in death and about 5% of the exposure had major outcomes.

Conclusions

This annual report provides updated epidemiological information on poisoning in Hong Kong in 2008 and highlights some changes in comparison with our previous reports. The increase in abusive substance poisoning, in particular ketamine, requires further attention.

Venomous Fish Sting Cases Reported to Hong Kong Poison Information Centre: A Three-Year Retrospective Study on Epidemiology and Management

Objective

To study the epidemiology of venomous fish sting injuries, management and clinical outcomes of injured patients reported to the Hong Kong Poison Information Centre (HKPIC).

Methods

All venomous fish sting cases reported to HKPIC from July 2005 to June 2008 were retrieved from its database (DATOX) and the Hong Kong Hospital Authority (HA) Electronic Patient Record (ePR) computer system for analysis.

Results

There were a total of 33 fish sting cases in this study. The average age of the patients was 43 years (range 20 to 84) and 24 patients were males. Most cases were injured by catfish (n=12), followed by stonefish (n=7) and lionfish (n=4). Ten cases sustained fish sting injury whilst at work. Five patients developed fish sting complications including cellulitis, subacute tenosynovitis, abscess formation and foreign body retention. No mortality was recorded. Within 7 cases of stonefish injury, 3 cases were classified as moderate effect outcome. Two patients received stonefish antivenom and none developed anaphylaxis.

Conclusion

The majority of marine envenomations did not result in significant morbidity and required only supportive management. However, stonefish injuries might be associated with an increased risk of severe local symptoms which therefore required aggressive treatment including antivenom.

Hong Kong Poison Information Centre: Annual Report 2007

Objective

To report the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2007.

Methods

From 1st January 2007 to 31st December 2007, all poisoning cases received by HKPIC were retrieved from its database (DATOX) for analysis.

Results

2842 poisoned cases were analyzed. There were 1199 male and 1610 female patients and more than two-thirds of the cases were between 20 and 59 years old. Common causes of exposure were suicidal attempt, accident and abusive use. Non-benzodiazepine sedative-hypnotic, household products and paracetamol were common poisons exposed. The majority of the patients were managed conservatively, with 8.4% and 6.4% treated by decontamination and antidotes respectively. Most cases had uneventful recovery; less than 1% of the poison exposure resulted in death and about 5% of the exposure had major outcomes.

Conclusions

This 2007 annual report provided updated epidemiological information on the poisoning pattern in Hong Kong and highlighted some changes in comparison to the situation in 2006.

Extensive Bowel Ischaemia after Nifedipine Overdose

A 57-year-old woman presented with abdominal distension and vomiting two days after overdosing an unknown amount of sustained-release nifedipine tablets. She had refractory shock requiring calcium chloride, glucagon, insulin-glucose and multiple high-dose inotropic agent infusions in the intensive care unit. Her abdominal computed tomography showed features of bowel ischaemia and exploratory laporotomy reviewed non-salvageable massive bowel ischaemia. She finally succumbed after 22 days of hospital treatment. This case illustrates the importance of awareness of this potentially fatal complication of calcium channel blocker overdose, requiring early recognition and intervention.

Reliability and Validity of the “Extended - Hurt, Insult, Threaten, Scream” (E-Hits) Screening Tool in Detecting Intimate Partner Violence in Hospital Emergency Departments in Hong Kong

Objectives

To assess the reliability and validity of a brief screening instrument, “E-HITS” (Extended - Hurt, Insult, Threaten, Scream), for detecting female intimate partner violence (IPV) in Hong Kong emergency departments (EDs).

Method

Quantitative data were collected from a victim group (n=110) and a control group (n=116). Statistical properties of the instruments were analysed to ascertain its internal consistency, test/re-test reliability, concurrent validity and discriminant validity.

Results

Cronbach's alpha was 0.90 for the E-HITS. Two-week test/re-test reliability was 0.71 (p<0.001). Respondents' scores on the E-HITS positively correlated with those on psychological aggression, physical assault, sexual coercion and injury scales, and negatively correlated with the negotiation scale of the revised Conflict Tactics Scale at a statistically significant level. Subsequent Receiver Operating Characteristic (ROC) curve analysis revealed that E-HITS reached a sensitivity of 98.2% and a specificity of 94.8% at a cut-off of 8.5. The overall accuracy of the E-HITS indicated by the area under curve (AUC) in the ROC is 0.991.

Conclusion

These results show that the E-HITS has good internal consistency, test/re-test reliability, as well as concurrent and discriminant validity. The E-HITS is a valid and reliable tool for screening intimate partner violence in Hong Kong EDs.

Hong Kong Poison Information Centre: Annual Report 2009

Objective

To report and analyse the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2009.

Methods

In 2009, all poisoning cases received by HKPIC were retrieved from its database (PICMS) for analysis.

Results

Totally 4338 poisoned cases were analysed. There were 1955 male patients (45.1%), 2,367 female patients (54.6%) and 16 patients with no gender specified. More than two-third of cases (68.6%) were between 20 and 59 years old. Common causes of exposure were suspected self harm/suicidal attempt, abusive use and unintentional exposure. Paracetamol, ketamine, zopiclone, benzodiazepine and household products were the common poisons exposed. Majority of the patients were managed supportively, with 13.6% and 13.1% treated by decontamination and antidotes respectively. Most cases had uneventful recovery; about 1% of the poison exposure resulted in death and about 5% of the exposure had major outcomes.

Conclusions

The 2009 annual report provides updated epidemiological information on poisoning pattern in Hong Kong and emphasized some changes in comparing with our previous reports.

Hong Kong Poison Information Centre: Annual Report 2010

Objective

To report and analyse the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2010.

Methods

In 2010, all poisoning cases received by HKPIC were retrieved from its database (PICMS) for analysis.

Results

A total of 4,418 poisoned cases were analysed. There were 1,863 male patients (42.2%) and 2,540 female patients (57.5%). More than two-third of cases (68.3%) were between 20 and 59 years old. Common causes of exposure were suspected self harm/suicidal attempt, unintentional exposure and abusive use. Benzodiazepine, paracetamol, ketamine, zopiclone, and Chinese herbal medicine were the common agents involved. Majority of the patients were managed supportively, with 10.2% and 9.7% treated by decontamination and antidotes respectively. Most cases had uneventful recovery; 1.0% of the poison exposure resulted in death and 5.3% of the exposure had major outcomes.

Conclusions

This fifth annual report provides updated epidemiological information on poisoning pattern in Hong Kong and emphasized some changes in comparing with our previous reports.

A Case of Methanol Poisoning

A 29-year-old male took about 300 ml industrial alcohol in a suicidal attempt. The industrial alcohol was later confirmed to be methanol. He presented to the emergency department 10 hours post-ingestion with an anion gap metabolic acidosis and an osmol gap of 76.7 mOsm/kg. Ethanol infusion was started in the emergency department at 11 hours post-ingestion before the availability of serum methanol level. The clinical diagnosis of toxic alcohol ingestion was based on the history, arterial blood gases results and the presence of a significant osmol gap. The patient was then admitted to the intensive care unit for ethanol therapy and haemodialysis. Prompt initiation of ethanol therapy and the subsequent intensive care prevented the development of life-threatening complications of methanol poisoning in this case.

A Prospective Epidemiological Study of Acute Poisoning in Hong Kong

Objective

To update our epidemiological knowledge of acute poisoning in Hong Kong.

Methods

A multi-centred prospective study was conducted for six months in six major accident and emergency departments in Hong Kong. A specially designed form was used to collect demographic data, type of poison involved, cause of poisoning, management, disposal as well as final outcome of the poisoned patients.

Results

A total of 1,467 patients (male: 588, female: 879) were included in the study. Most of them were young adults (32% were between 20 and 40 years old). Suicidal attempt (64%) was the most common cause of poisoning. Notably, 379 (26%) patients took more than one poison. Among the 2,007 counts of poison taken, sleeping pills (24%) and analgesics (18%) were the most commonly used drugs and paracetamol was the commonest single ingredient involved in poisoning. Most patients were treated with supportive measures, and about 40% and 15% of the patients were given gastrointestinal decontamination and specific antidotes respectively in their management, in which activated charcoal and N-acetylcysteine were the most common. Concerning disposal from the emergency department, 91% of the poisoned cases required in-patient management. Most patients had an uneventful recovery but 5 (0.3%) had significant disability and 21 (1.4%) died. Suicidal carbon monoxide poisoning was the leading cause of mortality in our study.

Conclusions

Most acute poisonings in Hong Kong were suicidal in nature and paracetamol was the commonest agent. Activated charcoal was the most commonly used decontamination method and most patients had an uneventful recovery.

Hong Kong Poison Information Centre: Annual Report 2013

Objective

To report and analyse the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2013.

Methods

In 2013, all poisoning cases received by HKPIC were retrieved from its database [Poison Information and Clinical Management System (PICMS)] for analysis.

Results

A total of 3,783 poisoned cases were analysed. There were 1,595 male patients (42.2%), 2,185 female patients (57.8%) and 3 sex unspecified patients (0.1%). Middle aged group (30-39 years) composed about one-fifth (20.8%) of the poisoning cases while about two-third (66.8%) of them were between 20 and 59 years old. Common causes for poisoning were suspected self-harm/suicidal attempt (43%), unintentional exposure (15.3%) and abusive substances use (14.5%). Five commonest types of poison exposed were paracetamol, benzodiazepine, zopiclone, household products and Chinese herbal medicine. Majority of the patients were managed with supportive measures, and 13.2% and 10.8% of them were treated by decontamination and antidotes respectively. Most cases had uneventful recovery; 0.9% of the poisoning resulted in death and 4.3% had major outcomes.

Conclusions

This 8th annual report provided updated epidemiological information on poisoning pattern in Hong Kong and highlighted important changes in comparing with our previous reports. (Hong Kong j. emerg.med. 2014;21:249-259)

Clinical Experience in the Use of Intravenous Lipid Emulsion in Hydroychloroquine and Chloroquine Overdose with Refractory Shock

Hydroxychloroquine overdose is a rare condition and often results in severe cardiovascular toxicities. We report 2 cases of fatal hydroxychloroquine overdose (1 patient had co-ingestion of chloroquine). Both patients developed refractory cardiovascular collapse and cardiac arrest soon after the drug overdose. Both of them were treated with high dose adrenaline and diazepam. However, they deteriorated rapidly despite the treatments. In view of similar toxicological profile of hydroxychloroquine to other lipophilic cardiotoxic medications, intravenous lipid emulsion was given as the last resort but both of them died eventually. Based on the clinical experience from these 2 cases, Intravenous lipid emulsion is not effective in reversing the cardiotoxic effects of hydroxychloroquine and chloroquine overdose.

Case Report: Paracetamol Poisoning in a 2-Year-Old Child – from International Overview to the Role of the Hong Kong Poison Information Centre

We report a 2-year-old girl suffering from acute liver failure as a result of paracetamol poisoning. The child successfully recovered after intensive care. We performed literature search for the past decade and found that the pathophysiological response in the child was different from that of the adult. Despite paracetamol poisoning being one of the most common poisonings in the world, there is still no consensus in the treatment protocol. Hence the role of the Hong Kong Poison Information Centre is briefly discussed.

Hong Kong Poison Information Centre: Annual Report 2011

Objective

To report and analyse the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2011.

Methods

In 2011, all poisoning cases received by HKPIC were retrieved from its database: Poison Information and Clinical Management System (PICMS) for analysis.

Results

A total of 4,331 poisoned cases were analysed. There were 1,915 male patients (44.2%), 2,411 female patients (55.7%) and 5 patients with sex unknown. More than two-third (68%) of them were between 20 and 59 years old. Common causes of exposure were suspected self-harm/suicidal attempt, unintentional exposure and abusive use. Paracetamol, benzodiazepine, household product, zopiclone, and Chinese herbal medicine were the top five commonest poisons encountered. Majority of the patients were managed supportively, with 12.1% and 8.5% treated by decontamination and antidotes respectively. Most cases had uneventful recovery; 1.0% of the poison exposure resulted in death and 4.8% of the exposure had major outcomes.

Conclusions

This 6th annual report provided updated epidemiological information on poisoning pattern in Hong Kong and emphasized some changes in comparing with our previous reports.

Two Cases of Anticholinergic Poisoning from Transdermal Scopolamine Patch

Scopolamine transdermal patch is a form of anticholinergic drug used to prevent motion sickness. We reported two cases of anticholinergic poisoning resulting from scopolamine transdermal patch. The first case experienced local toxicity and presented with right eye mydriasis for five days. The second case developed systemic anticholinergic toxidrome contributed by the scopolamine patch and presented with acute confusion. She was treated successfully by physostigmine, an anticholinergic antidote. The recommendation on physostigmine use was also discussed. We hope that these two case reports will raise the clinician awareness of the potential side effect of this kind of product.

Hong Kong Poison Information Centre: Annual Report 2006

Objective

To report the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2006.

Methods

From 1st January 2006 to 31st December 2006, all poisoning cases received by HKPIC were retrieved from its database (DATOX) for analysis.

Results

A total of 2555 poisoned cases were analysed. There were 1051 male and 1466 female patients and nearly 60% of the cases were between 20 and 49 years old. Common causes of exposure were suicidal attempts and accidents. Paracetamol, sedative-hypnotic and household products were common sources of poison exposure. The majority of the patients were managed conservatively, with 18.8% and 10.5% treated by decontamination and antidotes respectively. Most cases had uneventful recovery; less than 1% of the poison exposure resulted in death and about 5% of the exposure had major outcomes. Nearly half of the cases were managed in the accident & emergency department without hospitalisation.

Conclusions

This annual report provides updated epidemiological information on poisoning in Hong Kong. Subsequent annual reports would provide important information on the trend of poisoning pattern and may guide further strategies in poison control and prevention in Hong Kong.

A Study of Drug Radiopacity by Plain Radiography

Plain abdominal X-ray (AXR) may be helpful in the management of acute poisoning in the emergency department if the drugs involved are radiopaque. There are varying radiopacity among different medications and even for the same medication from different manufacturers. Therefore, we performed this study to detect local drug radiopacity in Hong Kong. A total of 430 drugs under the formulary of the United Christian Hospital were tested by standard AXR (75 kV, 23 mA) in a specially designed box which corresponded to the soft tissue density of the abdomen. Two different radiologists classified the drug radiopacity into three grades. Eight drugs (1.9%) were graded as definitely radiopaque (ranitidine bismuth citrate, tripotassium dicitratobismuthate, Drixoral SR, amiodarone, ferrous sulphate, sodium chloride, calcium carbonate, and Cafertamin). Another 129 drugs (30.0%) were slightly radiopaque, including slow release drugs, neuroleptics, antacids, ionic salts, beta-blockers, tricyclic antidepressants, antibiotics and others. The remaining 293 drugs were undetectable. As a significant number of drugs (31.9%) were detectable by plain AXR in vitro and some of them were potentially lethal, we should consider AXR as an adjunct in managing a suspected poisoned patient. Further study may be needed to evaluate these drugs' radiopacity in vivo with respect to the dosage and time of ingestion to assess its clinical application.

Hong Kong Poison Information Centre: Annual Report 2012

Objective

To report and analyze the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2012.

Methods

In 2012, all poisoning cases received by HKPIC were retrieved from its database: Poison Information and Clinical Management System (PICMS) for analysis.

Results

A total of 4,814 poisoned cases were analyzed. There were 1,771 male patients (42.3%), 2,399 female patients (57.3%) and 14 sex unspecified patients (0.3%). Middle aged group (30-39 years) contributed about one-fifth (20.1%) of the poisoning cases while more than two-third (67.7%) of them were between 20 and 59 years old. Common causes for poisoning were suspected self-harm/suicidal attempt (45%), abusive substances use (13.9%) and unintentional exposure (13.0%). Five commonest types of poison exposed were paracetamol, benzodiazepine, zopiclone, bites and envenomation and household products. Majority of the patients were managed with supportive measures, and 15.7% and 11.9% of them were treated by decontamination and antidotes respectively. Most cases had uneventful recovery; 0.6% of the poison exposure resulted in death and 4.7% of the exposure had major outcomes.

Conclusions

This seventh annual report provides updated epidemiological information on poisoning pattern in Hong Kong and highlights important changes in comparing with our previous reports. (Hong Kong j.emerg.med. 2013;20:371-381)

Maximizing T c by tuning nematicity and magnetism in FeSe1-x S x superconductors

A fundamental issue concerning iron-based superconductivity is the roles of electronic nematicity and magnetism in realising high transition temperature (T c). To address this issue, FeSe is a key material, as it exhibits a unique pressure phase diagram involving non-magnetic nematic and pressure-induced antiferromagnetic ordered phases. However, as these two phases in FeSe have considerable overlap, how each order affects superconductivity remains perplexing. Here we construct the three-dimensional electronic phase diagram, temperature (T) against pressure (P) and isovalent S-substitution (x), for FeSe1-x S x . By simultaneously tuning chemical and physical pressures, against which the chalcogen height shows a contrasting variation, we achieve a complete separation of nematic and antiferromagnetic phases. In between, an extended non-magnetic tetragonal phase emerges, where T c shows a striking enhancement. The completed phase diagram uncovers that high-T c superconductivity lies near both ends of the dome-shaped antiferromagnetic phase, whereas T c remains low near the nematic critical point.

Immunotherapy for diabetic amyotrophy

BACKGROUND

People with diabetes mellitus (DM) sometimes present with acute or subacute, progressive, asymmetrical pain and weakness of the proximal lower limb muscles. The various names for the condition include diabetic amyotrophy, diabetic lumbosacral radiculoplexus neuropathies, diabetic femoral neuropathy or Bruns-Garland syndrome. Some studies suggest that diabetic amyotrophy may be an immune-mediated inflammatory microvasculitis causing ischaemic damage of the nerves. Immunotherapies would therefore be expected to be beneficial. This is the second update of a review first published in 2009.

OBJECTIVES

To review the evidence from randomised trials for the efficacy of any form of immunotherapy in the treatment of diabetic amyotrophy.

SEARCH METHODS

On 5 September 2016 we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE and Embase. We also contacted authors of relevant publications and other experts to obtain additional references, unpublished trials, and ongoing trials.

SELECTION CRITERIA

We intended to include all randomised and quasi-randomised trials of any immunotherapy in participants with the condition fulfilling all the following: diabetes mellitus as defined by internationally recognised criteria; acute or subacute onset of pain and lower motor neuron weakness involving predominantly the proximal muscles of the lower limbs; weakness that is not confined to one nerve or nerve root distribution; and exclusion of other causes of lumbosacral radiculopathies and plexopathy.

DATA COLLECTION AND ANALYSIS

Two authors independently examined all references retrieved by the search to select those meeting the inclusion criteria.

MAIN RESULTS

We found only one completed placebo-controlled trial (N = 75) using intravenous methylprednisolone in diabetic amyotrophy (Dyck 2006). The results have not been fully published and were not available for analysis. The risk of bias was unclear because there was too little information to make a judgement, but we considered the trial at high risk of selective reporting. The published abstract did not report adverse events. We found no additional trials when the searches were updated in September 2016.

AUTHORS' CONCLUSIONS

There is presently no evidence from randomised trials to support a positive or negative effect of any immunotherapy in the treatment in diabetic amyotrophy.

Spontaneous Retroperitoneal Hematoma Simulating Ruptured Infrarenal Aortic Aneurysm in a Patient with End-Stage Renal Disease

We reported a case of spontaneous retroperitoneal hematoma (SRH) simulating a ruptured infrarenal aortic aneurysm. A 72-year-old man with a history of infrarenal aortic aneurysm and end-stage renal disease on hemodialysis presented with malaise and nonspecific central abdominal pain and left loin discomfort. An emergency computed tomography scan showed a large retroperitoneal hematoma and clinical suspicion of ruptured infrarenal aortic aneurysm. However, the hematoma was discontinuous with the aneurysm sac and raised the clinical suspicion on dual pathology. The SRH was treated conservatively with transfusion of blood products, and the aneurysm was treated with nonemergency endovascular repair electively. This case demonstrates the importance of recognizing different clinical and radiological characteristics and be aware of dual pathology.

Surgical management of carotid body tumor – Is Shamblin classification sufficient to predict surgical outcome?

Background

The study aims to conduct a review of the surgical management of carotid body tumor.

Methods

Consecutive patients with CBT who received surgical interventions from January 1994 to January 2014 at our institution were reviewed. Clinical, operative, pathological and follow up information were reported.

Results

Twenty patients (four males; median age was 36) with 21 CBT operations were recorded during the period. One patient undertook sequential operations for bilateral CBTs. Patients had 19 neck mass, 1 incidental finding and 1 facial nerve palsy. Six CBTs (28.6%) were Shamblin class I, ten (47.6%) were class II and five (23.8%) were class III. Nine CBTs had preoperative conjunctive embolization. Two operations required internal carotid artery resection and reconstruction. Four patients received subtotal resections, while 17 achieved complete resection. Complications included two major strokes, three hoarse voice and two Horner’s syndrome. Shamblin class was significant predictor of operative time, blood loss, and whether complete resection accomplished, but could not predict postoperative complication. With median follow up period of 94 months, there was no tumor recurrence found in those had complete resection.

Conclusions

This small cohort showed that Shamblin class was significant in predicting technical difficulties but could not predict occurrence of complications.

Two cases of valproic acid poisoning treated with l-carnitine

Two cases of acute valproic acid poisoning with central nervous system depression and raised ammonia level without hepatotoxicity were reported. They were treated successfully with the use of the antidotes: l-carnitine and other supportive measures. Clinical manifestation and progress was described, and discussion is focused on the use of l-carnitine in valproic acid–induced hyperammonemia, from its mechanism to the clinical experiences in the literature. Based on the favorable response of our two cases and the literature review, we recommend the administration of intravenous l-carnitine in patients of valproic acid overdose with hyperammonemia or valproic acid–induced hyperammonemic encephalopathy and hepatotoxicity at a dose of 50 mg/kg every 8 h for the first initial 24 h with further individual assessment.

Modality specificity in the cerebro-cerebellar neurocircuitry during working memory

Previous studies have suggested cerebro-cerebellar circuitry in working memory. The present fMRI study aims to distinguish differential cerebro-cerebellar activation patterns in verbal and visual working memory, and employs a quantitative analysis to deterimine lateralization of the activation patterns observed. Consistent with Chen and Desmond (2005a,b) predictions, verbal working memory activated a cerebro-cerebellar circuitry that comprised left-lateralized language-related brain regions including the inferior frontal and posterior parietal areas, and subcortically, right-lateralized superior (lobule VI) and inferior cerebellar (lobule VIIIA/VIIB) areas. In contrast, a distributed network of bilateral inferior frontal and inferior temporal areas, and bilateral superior (lobule VI) and inferior (lobule VIIB) cerebellar areas, was recruited during visual working memory. Results of the study verified that a distinct cross cerebro-cerebellar circuitry underlies verbal working memory. However, a neural circuitry involving specialized brain areas in bilateral neocortical and bilateral cerebellar hemispheres subserving visual working memory is observed. Findings are discussed in the light of current models of working memory and data from related neuroimaging studies.

Nerve ultrasound in electrophysiologically verified tarsal tunnel syndrome

INTRODUCTION

Tarsal tunnel syndrome (TTS) arises from tibial nerve damage under the flexor retinaculum of the fibro-osseus tunnel at the medial malleolus. It is notoriously difficult to diagnose, as many other foot pathologies result in a similar clinical picture. We examined the additional value of nerve ultrasound in patients with tarsal tunnel syndrome confirmed by nerve conduction.

METHODS

We performed a retrospective analysis of nerve ultrasound changes in electrophysiologically confirmed TTS spanning our records from 2007 to 2015.

RESULTS

Nine feet with TTS were identified, all of which showed abnormal nerve ultrasound findings, which in 6 feet, led to identification of the underlying cause.

CONCLUSIONS

This study shows that nerve ultrasound is abnormal in all cases of electrophysiologically verified TTS. The pattern of nerve abnormality is varied. This, and the fact that in the majority of patients causation was identified, suggests nerve ultrasound should form part of standard work-up for TTS. Muscle Nerve 53: 906-912, 2016.

Influence of meteorological factors on acute aortic events in a subtropical territory

BACKGROUND/OBJECTIVE

This study aims to examine the relationship between weather changes and acute aortic events in a subtropical territory.

METHODS

A linear regression analysis was performed in a pan-territory epidemiological survey for a period of 10 years on the impacts of meteorological factors (ambient temperature, atmospheric pressure, relative humidity, amount of cloud, rainfall, number of lightning strikes, presence of typhoon, and thunderstorm warning) on the daily incidences of acute aortic dissections and ruptured aortic aneurysms. Meteorological variables were retrieved on a daily basis from a well-established observatory, and the daily incidences of aortic dissections and rupture of aortic aneurysms were retrieved from the Clinical Data Analysis and Reporting System.

RESULTS

During the study period (January 2005 to December 2014), 3878 patients were identified as having acute aortic dissections, and 1174 patients had ruptured aortic aneurysms. Corresponding averaged daily incidences were 1.06 and 0.32, respectively. The incidences of aortic dissection and ruptured aortic aneurysm in a day could be predicted by ambient temperature in degrees Celsius using the following linear regression models: (1) incidence of aortic dissection = 1.548 - 0.021 × temperature; (2) incidence of ruptured aortic aneurysm = 0.564 - 0.010 × temperature. In addition, both high atmospheric pressure and absence of thunderstorm warning are positively associated with more aortic dissections. For rupture of aortic aneurysms, high atmospheric pressure and low relative humidity were positive predictors. In multiple regression analysis, however, ambient temperature was the only significant predictor for both acute aortic dissections and ruptured aortic aneurysms.

CONCLUSION

This is the first pan-territory study to show an attributable effect of ambient temperature on acute aortic events. This paper confirms that even in a subtropical country, meteorological variables were important factors influencing acute aortic events.