Recommendations for eligibility criteria concerning bariatric and metabolic surgical and endoscopic procedures for obese Hong Kong adults 2024: Hong Kong Society for Metabolic and Bariatric Surgery Position Statement.

The surgical management of obesity in Hong Kong has rapidly evolved over the past 20 years. Despite increasing public awareness and demand concerning bariatric and metabolic surgery, service models generally are not standardised across bariatric practitioners. Therefore, a working group was commissioned by the Hong Kong Society for Metabolic and Bariatric Surgery to review relevant literature and provide recommendations concerning eligibility criteria for bariatric and metabolic interventions within the local population in Hong Kong. The current position statement aims to provide updated guidance regarding the indications and contraindications for bariatric surgery, metabolic surgery, and bariatric endoscopic procedures.

Pattern of biopsy-proven renal disease in Sabah: A retrospective cross-sectional study over 3.5 years.

OBJECTIVES: To explore the epidemiological and histopathological patterns of glomerular diseases in Sabah. METHODS: A state-wide cross-sectional study was conducted. There were 336 native renal biopsies in 296 eligible patients from 1st January 2013 to 30th June 2016. All patients aged ≥12 years with sufficient sampling (≥8 glomeruli) for histopathological assessment were included. Graft kidney biopsies, protocol-based biopsies and patients with uncertain demographics were excluded. Demographics of patients, clinical data, laboratory parameters prior to biopsy, and histology findings of renal biopsies were collected from local unit database and recorded into a standardised data collection form. Descriptive statistical analyses were employed and factors associated with Lupus nephritis (LN) were explored using logistic regression. RESULTS: The mean age during biopsy was 34.53 years (Standard Deviation 0.759). Primary glomerulonephritis (PGN) accounted for 42.6% (126) of all native renal biopsies. The commonest cause of PGN was minimal change disease (38.9%, 49) followed by focal segmental glomerulosclerosis (33.3%, 42) and IgA nephropathy (14.3%, 18). LN is the leading cause for secondary glomerulonephritis (SGN) (87.2%, 136). Younger age (Odds Ratio, OR 0.978; 95% Confidence Interval, 95%CI 0.960, 0.996); female gender (OR 17.53; p<0.001); significant proteinuria (OR 132.0; p<0.001); creatinine level at biopsy (OR 11.26; p=0.004); positive antinuclear antibody (ANA) (OR 46.7; p<0.001); and ANA patterns (OR 8.038; p=0.018) were significant in predicting the odds of having LN. CONCLUSION: This is the first epidemiology study of glomerular diseases in Sabah. The predominance of LN suggests lower threshold for renal biopsy in patients with suspected glomerular disorders. We have identified significant predictors for early detection and treatment of LN.

Does the use of monopolar energy as the preferred mode of dissection effectively reduce seroma formation in laparoscopic total extra peritoneal hernioplasty? A prospective double-blinded randomized control trial.

INTRODUCTION: Seroma is a commonly encountered sequela after hernia repair. Tremendous effort has been spent to investigate the effective way to prevent this "complication" including the modification of surgical technique, use of per-peritoneal drainage, etc. There were debates about the use of monopolar diathermy versus blunt dissection in laparoscopic TEP in the prevention of seroma formation. This randomized study aims to compare the effects of using 2 techniques in laparoscopic TEP on pre-peritoneal drain output and seroma formation. METHOD: From 1.9.2018 to 30.9.2019, all male and female patients presented with the first occurrence, unilateral inguinal hernia anticipated for laparoscopic TEP were enrolled into the study after informed consent. Patients were randomized into "monopolar dissection preferred" (MDP) group and "blunt dissection-preferred" (BDP) group just before commencing of operation after general anesthesia. Surgeons were instructed to use monopolar energy as main dissection method for the whole operation if possible (MDP), whereas blunt dissection is the preferred choice in BDP group, but the use of monopolar energy was allowed if needed. Total energy time was measured by a specially designed homemade device attaching to the monopolar pedals as accurate as to millisecond (ms). Pre-peritoneal drains were inserted for drainage and removed 23 h after operation. Drainage output, total operating time, energy time, clinical and ultrasonic seroma sizes at day 1, day 6, 1-month post operations, recurrence are compared between 2 groups. RESULTS: A total of 103 patients where included. There was no significant difference in age, gender, co-morbidities, side of hernia, mean defect size, operating time, fixation adjuncts, or postoperative stay. The drain volume in BDP group is 71.13 ± 31.42 mL while it in MDP group is 56.36 ± 21.46 mL. The MDP group had significantly fewer drain output at 23 h post operation (p = 0.007) and lower seroma incidence on days 6 (p = 0.036). Overall incidence of seroma formation was 12% on postoperative day 1, 11% on postoperative day 7. No statistically differences in postoperative pain score or complications were observed at the first week, 1- and 3-months' post operation. There was no correlation with energy time to the drain output. No recurrence was found in subsequent follow-up. CONCLUSION: Pre-peritoneal drainage is clinically safe in laparoscopic totally extra-peritoneal hernioplasty and can effectively reduce the size and incidence of seroma. The seroma formation can be further reduced by appropriate use of monopolar energy as preferred dissection approach in lap TEP. Due to limitation in measuring the actual energy time, the result should be further validated by randomized multi-centers trial on its potential benefit in hernia repair by a more accurate measuring device on energy used.

Long-term pharyngeal dysphagia after esophagectomy for esophageal cancer-an investigation using videofluoroscopic swallow studies.

Dysphagia is a common symptom of esophageal cancer (EC). Esophagectomy should relieve the presenting dysphagia as the mechanical obstruction caused by the tumor is removed. However, the new onset oropharyngeal dysphagia develops after esophagectomy and the deficit may persist increasing the risk of aspiration pneumonia and mortality as well as adversely affecting quality of life (QOL). This study investigates the persistent swallowing deficits in long-term postesophagectomy patients and explores the factors associated with dysphagia severity, penetration, and aspiration. A better understanding of the swallowing function can aid future management of the condition. A total of 29 patients who were more than six months postesophagectomy for EC, had no history of disease that would likely affect swallowing function or vocal cord palsy underwent detailed videofluoroscopic swallow studies and completed the European Organisation for Research and Treatment of Cancer QLQ-C30 and OES18 QOL questionnaires. Swallowing deficits were analyzed and rated using the videofluoroscopic dysphagia scale (VDS) and the penetration-aspiration scale (PAS). These variables were correlated with the clinical and QOL parameters to determine which factors would affect swallowing function. Our cohort consisted of 27 males and 2 females. The mean duration after esophagectomy when the swallowing study was performed was 3.2 years (range: 0.5-18.4 years). Swallowing deficits were mainly found in the pharyngeal phase of swallowing. The mean total VDS score was 36.1 (SD = 15.2, range: 11.0-69.5) out of a possible 100. The mean PAS score was 4.1 (SD = 2.5, range: 1-8) and 1.5 (SD = 0.9, range: 1-4) for thin and semisolids, respectively. Dysphagia was significantly more severe in males, those of more advanced age at esophagectomy and at swallowing assessment. Increasing pathological N stage significantly correlated with worse PAS score for thin fluid. Self-reports of more pain and less troubles with coughing were also associated with less penetration and aspiration. This study demonstrated that a mild to moderate pharyngeal dysphagia is present late after esophagectomy even in patients without VC palsy or anastomotic stricture. The long-term aspiration rate is comparable to the figures in the literature for those early after esophagectomy. It is suggested that damage to the intercostal nerves and the pulmonary vagus may affect oropharyngeal swallowing function in this population.

Preperitoneal closed-system suction drainage after totally extraperitoneal hernioplasty in the prevention of early seroma formation: a prospective double-blind randomised controlled trial.

OBJECTIVES: Seroma is a virtually unavoidable early sequela after TEP hernioplasty. This randomised controlled trial evaluated the outcomes of preperitoneal closed-system suction drainage in laparoscopic totally extraperitoneal (TEP) hernioplasty for inguinal hernia. METHODS: Ninety patients aged 18-80 years who presented to our hospital between May 2016 and February 2017 with primary unilateral inguinal hernia were randomised into the preperitoneal drain and no-drain groups. The primary outcome was seroma size on postoperative day 6. Secondary outcomes included clinical seroma formation and seroma size on day 1, day 6, 1 and 7 months postoperatively, length of postoperative stay, pain score, and recurrence. RESULTS: There was no significant difference in age, sex, co-morbidities, hernia side, mean hernia size, operating time, fixation adjuncts, or postoperative stay. The overall incidence of clinical seroma formation was 25.6% on postoperative day 1, 60.3% on postoperative day 6, 13.2% 1 month and 0% 7 months postoperatively. The mean drain output was 57.9 ml. The drain group had significantly fewer patients with seroma on day 1 (6 vs 14, p = 0.022) and day 6 (17 vs 30, p = 0.000), and a smaller mean seroma size on days 1 and 6 (p = 0.000). Subgroup analysis showed that sac ligation versus reduction, peritoneal perforation, and fixation adjuncts had no significant effects on seroma formation or size. There is a trend of lower early post-operation VAS score and more urinary retention in drain group was observed but not reaching statistical significance. No differences in postoperative pain score or complications were observed at 1 and 7 months' post operation. CONCLUSIONS: Preperitoneal drainage for 23 h after laparoscopic TEP hernioplasty for inguinal hernia can effectively decrease seroma formation in the early postoperative period, and potentially improving postoperative pain. The benefit is short-term and no significant difference was demonstrated after 1-month post operations. This tradition technique applied to novel operative repair of inguinal hernia is safe and feasible with no significant morbidity demonstrated. Preperitoneal drainage after TEP can be considered as an option to improve patient satisfactions and recovery in selected patient group for maximal benefit, especially for those with prolonged operation which may associate with higher chance of seroma formation.

Appropriate timing for surgery after neoadjuvant chemoradiation for esophageal cancer.

Optimal interval between neoadjuvant chemoradiotherapy (CRT) and surgery is not elucidated for esophageal squamous carcinoma. The aim of this study is to evaluate the impact of this time interval on patient outcome. Patients treated with neoadjuvant CRT followed by surgery between 2002 and 2009 were analyzed. Patients were divided into two groups based on the median interval to surgery (64 days): A  64 days (n = 53). A second analysis was performed by re-classifying patients into three interval groups: A* ≤ 40 days (n = 16); B* 41-80 days (n = 60); C* > 80 days (n = 31). Operative outcome, pathological data, and long-term survival were analyzed. One hundred and seven (n = 107) patients were analyzed. Five patients (9.4%) in group B had an anastomotic leak compared with no leakage from group A (P < 0.021). The complete pathological response was comparable in groups A and B (35% vs. 24.5%, p = 0.23). R0 was significantly lower in group A* (A*: 56.3%, B*: 90%, C*: 74.2%, P = 0.006). In patients with R0 resection, 5-year survival was significantly better in group A than B (71.7% vs. 51%, P = 0.032) and in group A* (A* 100% vs. B* 60.2% & C* 48.3%; A* vs. B*, P = 0.036; A* vs. C*, P = 0.019). Complete pathological response was an independent predictor of survival. Early surgery with R0 resection following neoadjuvant CRT may lead to a better outcome. Further prospective studies are still necessary to provide better insight into the issue. At present, timing of surgery should be individualized and performed at the earliest opportunity.

Newly diagnosed end stage kidney disease in a single centre in Sabah.

AIM: To study the epidemiology, clinical characteristics, vascular access, and the short term survival of ESRD patients initiated on dialysis from Hospital Queen Elizabeth (HQE). BACKGROUND: The number of patients with ESRD is increasing in Sabah, Malaysia. Most patients present late and some live in remote areas with difficult access to healthcare services. Many therefore present with potentially fatal complications. METHODS: All the newly confirmed ESRD patients who were initiated on renal replacement therapy (RRT) from 1 January to 31 December 2014 were included. The basic epidemiological and clinical data were collected. They were divided into three groups: Group 1 - those known to the medical service and had been prepared properly for the initiation of RRT; Group 2 - those known to the medical service, but were not prepared for the RRT; Group 3 - those with undiagnosed CKD. Outcome is mainly survival at 3rd, 6th, 9th and 12th month. RESULTS: There were 249 ESRD patients. 153 (61.4%) were male. The average age was 53.3 (range 12 - 83). The main cause of ESRD was diabetic nephropathy (128 patients, 51.4%). Most patients were started on RRT with a catheter (74.3%), 47 patients (18.9%) with a fistula, and 17 patients (6.8%) with a Tenckhoff catheter. 185 (74.3%) patients were not prepared properly (Group 2 - 66.3%, and Group 3 - 8.0%). The survival for 249 patients were 86.3% at 6 months, 77.9% at 12 months. Group 2 has the worst survival (81.9% at 6 months, 71.1% at 12 months). CONCLUSIONS: Our data showed that most patients (74.3%) were started on dialysis in an unplanned manner with poor survival. A comprehensive and well-supported predialysis programme is needed.

Translation and validation of the Chinese version of the short Warwick-Edinburgh Mental Well-being Scale for patients with mental illness in Hong Kong.

OBJECTIVE: Quality of life outcomes are useful in the assessment of mental and social wellbeing and for informed health care decision-making, especially in the choice of interventions in psychiatric rehabilitation. In its original form, the Warwick-Edinburgh Mental Well-being Scale (WEMWBS) is a proven reliable and valid tool for assessing quality of life in normal adults, but not in adults from Asian countries. A shortened 7-item version of WEMWBS (SWEMWBS) with good internal construct validity was used for this study. The present study describes the translation of WEMWBS from English to Chinese and its validation in a sample of Chinese-speaking patient population. METHODS: Participants included patients admitted to the inpatient units, and those attending the day hospital and outpatient units of the Kowloon Hospital (n = 126). Translation was performed using the multiple forward and backward translation protocol. Patients also completed the 5-item World Health Organization Well-being Index (WHO5) questionnaire. A case therapist completed the Brief Psychiatric Rating Scale within 2 days. A total of 20 patients were selected for test-retest measurements performed after 2 weeks. RESULTS: The sample displayed a normal distribution of the Chinese version of SWEMWBS (C-SWEMWBS) scores (mean ± standard deviation, 23.16 ± 5.39; skewness, -0.068; kurtosis, -0.355). Internal reliability coefficient (Cronbach's alpha) for C-SWEMWBS was 0.89 which was consistent with that of English version. The corrected item-total correlation was high with Spearman's rank correlation coefficients ranging from 0.57 (item 6) to 0.75 (item 5). Good test-retest reliability was observed (r = 0.677; p = 0.001). Principal components factor analysis identified a single component (eigenvalues, 4.28; 61.1% variance), similar to the English version. Scores of C-SWEMWBS were positively correlated with the scores of WHO5 (r = 0.49; p < 0.001), suggesting good concurrent validity. Few item scores including 'feeling useful', 'dealing with problems well', 'able to make decisions', and the total score were significantly correlated with diagnostic groups (p < 0.05). Education and diagnosis of mental illness were valid predictors for C-SWEMWBS (F = 5.41; p = 0.01). There were no effects due to age and gender. CONCLUSION: The C-SWEMWBS showed high levels of internal consistency and reliability against accepted criteria. It is short, acceptable, and culturally meaningful to clients with mental illness. Further large-scale studies in normal subjects and varied patient groups are recommended to generalise the findings.

Achieving 'excellent' indoor air quality in commercial offices equipped with air-handling unit--respirable suspended particulate.

UNLABELLED: A study was carried out to investigate the feasibility of achieving ultra low respirable suspended particulates (RSP) in commercial offices without major modification of existing ventilation systems by enhancing the particulates removal efficiency of existing central ventilation systems. Four types of filters which include pre-filters, cartridge filters, bag filters and high efficiency particulates air (HEPA) filters were tested in a commercial building in Causeway Bay. The results show that an RSP objective of <20 microg/m3 could be met by removing RSP from both the return air and outdoor air supply simultaneously. This level of performance is classed as 'excellent' by the Hong Kong Government, Environmental Protection Department. Filters with efficiency that exceed 80% placed both in the return air and outdoor air were sufficient to meet the objective. It is not necessary to install HEPA filters to achieve the 'excellent' class. The outdoor air filter has great influence on the steady state indoor RSP concentration while the effective cleaning rate is governed by the return air filter. Higher efficiency filters increased the static drop but the volume flow of the air fan was not affected significantly. The additional cost incurred was <5% of the existing operation cost. PRACTICAL IMPLICATIONS: This paper reports a field study of RSP control for an indoor office environment. The results are directly applicable to building service engineering in the design of ventilation systems using air-handling units. Field observations indicated that indoor RSP in an office environment could be suppressed below 20 microg/m3 within 1 h by the simultaneous filtration of outdoor air and return air. Outdoor air filtration has a great influence on the steady state indoor concentration and return air filtration governs the cleaning rate. It is believed that the results of this study could be extended to the cleaning of other indoor pollutants such as volatile organic compounds.

Nerve growth factor potentiated the sodium butyrate- and PMA-induced megakaryocytic differentiation of K562 leukemia cells.

We have recently reported that retinoic acid (RA) induced the expression of trkA, the high affinity receptor for nerve growth factor (NGF), in human chronic myelogenous leukemia K562 cells. In this paper, we examined the ability of several other differentiation inducers to regulate the expression of trkA and NGF in K562 cells. We found that the expression of trkA was dramatically induced by the two megakaryocyte lineage inducers sodium butyrate (NaBut) and phorbol 12-myristate 13-acetate (PMA), but not by the two erythrocyte lineage inducers hemin or 1-beta-D-arabinofuranosyl cytosine (Ara-C). Furthermore, activation of the up-regulated trkA receptor by exogenous NGF potentiated the megakaryocytic differentiation of K562 cells induced by NaBut and PMA. Our results demonstrated that trkA is one of the essential genes that are up-regulated and involved in the megakaryocytic differentiation of K562 leukemia cells triggered by these differentiation inducers. Our findings suggest that NGF, in addition to its pivotal roles in the nervous system, may also play important roles in hematopoietic differentiation.

Induction of TrkA expression by differentiation inducers in human myeloid leukemia KG-1 cells.

We have recently reported that retinoic acid (RA) induced the expression of trkA, the high affinity receptor for nerve growth factor (NGF), in human myeloid leukemia KG-1 cells. In the present study, we report that the expression of trkA was also induced by several other differentiation inducers, including 1alpha, 25-dihydroxyvitamin D3 (Vit D3), 1-beta-D-arabinofuranosyl cytosine (Ara-C), sodium butyrate (NaBut), and phorbol 12-myristate 13-acetate (PMA). Interestingly, RA in combination with NaBut or PMA synergistically induced cellular differentiation as well as the expression of trkA in KG-1 cells. Furthermore, activation of the induced trkA receptor by exogenous NGF potentiated the differentiating effects of RA and NaBut. Our results demonstrated that the induction of trkA is an event associated with the differentiation of KG-1 cells. Our findings suggest that NGF, in addition to its pivotal roles in the nervous system, may also play important roles in hematopoietic differentiation.

IL-6 enhanced the retinoic acid-induced differentiation of human acute promyelocytic leukemia cells.

It has been shown that retinoic acid (RA) induced the expression of interleukin-6 (IL-6) in human acute promyelocytic leukemia HL-60 cells. In the present study, we examined the ability of RA to induce the expression of gp130, the signal-transducing receptor component for IL-6, in HL-60 and a RA-supersensitive cell line HL-60/S4. We found that RA induced the expression of gp130, at both the mRNA and protein levels, in HL-60 and HL-60/S4 cells. Interestingly, the induction of gp 130 expression observed in the RA-supersensitive HL-60/S4 cells was much more pronounced than that observed in HL-60 cells. Furthermore, activation of the RA-induced gp130 by exogenous IL-6 potentiated the differentiating effects of RA. The synergistic effects observed for IL-6 and RA was also much stronger in HL-60/S4 cells than in HL-60 cells. Our findings suggest that the differentiating effects of RA may partially be mediated by the up-regulation of IL-6/gp130 signaling in HL-60 and HL-60/S4 cells.

Induction of gp130 and LIF by differentiation inducers in human myeloid leukemia K562 cells.

It has been previously shown that phorbol 12-myristate 13-acetate (PMA), a potent differentiation inducer, induced the expression of both interleukin-6 (IL-6) and IL-6 receptor alpha component (IL-6Ralpha) in K562 leukemia cells. In the present study, we examined the ability of several differentiation inducers to regulate the expression of the signal-transducing receptor component for IL-6, gp130, and cytokine leukemia inhibitory factor (LIF) in K562 cells. We found that the expression of gp130 was dramatically induced at both the mRNA and protein levels by the two megakaryocytic inducers sodium butyrate (NaBut) and PMA. In contrast, the mRNA expression of LIF was induced by the two erythroid inducers 1-beta-D-arabinofuranosyl cytosine (Ara-C) and hemin. Furthermore, activation of the PMA-induced gp130 receptor by exogenous IL-6 potentiated the differentiating effects of PMA. Our findings suggest that IL-6/gp130 signaling may be involved in the regulation of the megakaryocytic differentiation of K562 cells.

RB regulates the stability and the apoptotic function of p53 via MDM2.

The binding of RB to MDM2 is shown to be essential for RB to overcome both the antiapoptotic function of MDM2 and the MDM2-dependent degradation of p53. The RB-MDM2 interaction does not prevent MDM2 from inhibiting p53-dependent transcription, but the RB-MDM2 complex still binds to p53. Since RB specifically rescues the apoptotic function but not the transcriptional activity of p53 from negative regulation by MDM2, transactivation by wild-type p53 is not required for the apoptotic function of p53. However, an RB-MDM2-p53 trimeric complex is active in p53-mediated transrepression. These data link directly the function of two tumor suppressor proteins and demonstrate a novel role of RB in regulating the apoptotic function of p53.

mdm2: a bridge over the two tumour suppressors, p53 and Rb.

The inactivation of the p53 and Rb pathways would account for the majority of human tumours. There are many levels of cross talk between p53 and Rb that have been identified. However, the identification of the mdm2-Rb interaction established a closer link between the two most well studied tumour suppressors, p53 and Rb. Recent studies of the novel trimeric complex Rb-mdm2-p53 provided us with a functional insight of how the two tumour suppressors can act together in regulating p53 induced apoptosis. Beginning with the properties of the Rb-mdm2-p53 trimeric complex, we shall review the propounding evidence suggesting that the apoptotic function of p53 is linked to its transrepression function. The uncoupling of the apoptotic function and transactivation function of p53 will also be discussed.

An evaluation of the role of the night nurse practitioner.

A study was carried out at a London teaching hospital to ascertain the perceived need for night nurse practitioners. The majority of nurses questioned acknowledged the benefit of night nurse practitioners' experience and believed them to be key to maintaining the optimum level of care during the night. Junior doctors also found they provided valuable clinical support and greatly reduced their workload after midnight.