Update to the Hong Kong Epilepsy Guideline: evidence-based recommendations for clinical management of women with epilepsy throughout the reproductive cycle.

Since the publication of the Hong Kong Epilepsy Guideline in 2009, there has been significant progress in antiepileptic drug development. New AEDs have emerged, and data about their uses have been published. Women require special attention in epilepsy care. Drug teratogenicity, pregnancy, breastfeeding, contraception, reproduction technology, menopause, and catamenial epilepsy are major topics. Antiepileptic drugs should be chosen individually for patients who are pregnant or may become pregnant with consideration of their teratogenicity and seizure control properties. Folate is commonly prescribed for women of childbearing age who are taking antiepileptic drugs. Spontaneous vaginal delivery and breastfeeding are not contra-indicated in most cases but need to be considered individually based on the patient's medical condition and wishes. Serum drug level monitoring of certain antiepileptic drugs during pregnancy and puerperium can guide dosage adjustment. For catamenial epilepsy, intermittent benzodiazepines such as clobazam during the susceptible phase of the menstrual cycle could be a treatment option.

Effectiveness of Pelvic Floor Muscle Training Alone and in Combination With Biofeedback, Electrical Stimulation, or Both Compared to Control for Urinary Incontinence in Men Following Prostatectomy: Systematic Review and Meta-Analysis.

Background: The efficacy of pelvic floor muscle training (PFMT) alone and in combination with biofeedback (BFB), electrical stimulation (ES), or both for urinary incontinence in men following prostatectomy is inconclusive. Purpose: The purpose of this study was to determine whether PFMT works well alone or in combination with BFB, ES, or both in comparison with a control. Data Sources: The databases Ovid Medline, EMBASE, CENTRAL, Scopus, and Web of Science, and the specialized register of the Citroen Incontinence Review Group were searched from study inception to August 2017. Abstract proceedings from urological meetings, including the European Association of Urology and the American Urological Association, were also searched. Study Selection: Randomized controlled trials that compared PFMT alone and PFMT with ES, BFB, or both and no treatment, placebo, or sham were included in the review. Data Extraction, Synthesis, and Quality: Two independent reviewers completed data extraction and quality appraisal. The Grading of Recommendations, Assessment, Development, and Evaluation tool was used for quality appraisal. Meta-analysis was done with software used for preparing and maintaining Cochrane reviews. Limitations: Methodological flaws in the included studies limited internal validity. Conclusions: PFMT alone, PFMT plus BFB and ES, and PFMT plus ES were more effective than the control for urinary incontinence following prostatectomy. The effect of PFMT plus BFB on postprostatectomy incontinence remains uncertain.

Method for Electrochemical Detection of Brain Derived Neurotrophic Factor (BDNF) in Plasma.

Currently, a blood test for the diagnosis of endometriosis, a common estrogen-dependent gynecological disease, does not exist. Recent studies suggest that circulating concentrations of brain-derived neurotrophic factor (BDNF) have potential for the diagnosis of endometriosis. However, at present, BDNF can only be measured by ELISA, which requires a clinic visit, a routine blood sample, and laboratory testing. Therefore, we developed a point-of-care device (EndoChip) for use with small blood volumes that can be collected through a finger prick. Specifically, the presented device is a polymer-based chip with a nanoporous, wrinkled gold film acting as the electrode/sensing layer, allowing for the electrochemical detection of BDNF in plasma. Increasing concentrations of BDNF (0.1-2.0 ng/mL) induced significant differences in redox current. The biosensor produces a signal readout in a matter of seconds, and is ideal for realizing multiplexing. Blood samples were collected from women ( n = 20) with chronic pelvic pain undergoing a diagnostic laparoscopy. Plasma BDNF concentrations measured by commercial ELISA were positively correlated ( r2 = 0.8033; p < 0.001) with results from the EndoChip. Our results demonstrate a quick and reliable method for point-of-care quantification of circulating concentrations of BDNF and a promising diagnostic tool for endometriosis.

Online drug information platform for the public in Hong Kong-Review of local drug information use and needs.

INTRODUCTION: In view of the popularity of Internet usage in Hong Kong, an interactive web-based drug information platform entitled "Ask My Pharmacist - Online University Led drug Enquiry Platform" (AMPOULE) was launched in 2009 to better serve the needs of drug information in Hong Kong. This paper aimed to evaluate the utility of AMPOULE in improving drug-related knowledge among the public and to reassess the needs of the general public in Hong Kong. METHODS: All enquiries sent via AMPOULE were reviewed. Demographic data, nature of questions and types of drug class covered were analyzed. The workload of pharmacists was examined with respect to the preparation time needed for the enquiry, the lag days to reply and also the timing of enquiry recipient. RESULTS: 2122 enquiries were received from 2009 to 2017. Most enquirers were from Hong Kong (56.6%) and female gender (49.2%). 13% of the concerned subjects were aged over 61-year-old. The most frequent types of questions and medications covered were "Drug Ingredients and Indications" (28.0%) and Adverse Drug Reactions (26.8%) and "Cardiovascular Medication" (21.9%) respectively but these varied in different age groups or enquirer groups. The median time for preparation was 40.0 min (IQR: 25-65 min) while the median time lag was found to be 2.5 days (IQR: 1.0-5.0 days). The number of enquiries received was evenly distributed throughout the day except during 1:00 am to 9:00 am and 7:00 pm to 8:00 pm. CONCLUSION: AMPOULE has demonstrated that an online platform providing patient-oriented drug information service through the Internet is promising and further promotion is warranted. Current data suggested that the need of different age groups and enquirer groups are different and should therefore be individualized.

An update of the Hong Kong Epilepsy Guideline: consensus statement on the use of antiepileptic drugs in Hong Kong.

OBJECTIVE: New information about antiepileptic drugs has arisen since the publication of the Hong Kong Epilepsy Guideline in 2009. This article set out to fill the knowledge gap between 2007 and 2016 on the use of antiepileptic drugs in Hong Kong. PARTICIPANTS: Between May 2014 and April 2016, four consensus meetings were held in Hong Kong, where a group comprising 15 professionals (neurologists, paediatricians, neurosurgeons, radiologists, and clinical psychologists) from both public and private sectors aimed to review the best available evidence and update all practising physicians on a range of clinical issues including drug-related matters. All participants were council members of The Hong Kong Epilepsy Society. EVIDENCE: A literature review of the clinical use of antiepileptic drugs as monotherapy suggested Level A evidence for levetiracetam and Level B evidence for lacosamide. No change in the level of evidence was found for oxcarbazepine (Level A evidence) or pregabalin (undesignated), and no evidence was found for perampanel. A literature review on the clinical use of antiepileptic drugs as adjunctive therapy suggested Level A evidence for both lacosamide and perampanel. No change to the level of evidence was found for levetiracetam (Level A evidence), oxcarbazepine (Level A evidence), or pregabalin (Level A evidence). A literature search on the use of generic antiepileptic drugs suggested Level A evidence for the use of lamotrigine in generic substitution. CONSENSUS PROCESS: Three lead authors of the Subcommittee drafted the manuscript that consisted of two parts-part A: evidence on new antiepileptic drugs, and part B: generic drugs. The recommendations on monotherapy/adjunctive therapy were presented during the meetings. The pros and cons for our health care system of generic substitution were discussed. The recommendations represent the 'general consensus' of the participants in keeping with the evidence found in the literature. CONCLUSIONS: Recommendations for the use of levetiracetam, lacosamide, oxcarbazepine, pregabalin, and perampanel were made. The consensus statements may provide a reference to physicians in their daily practice. Controversy exists over the use of generic products among patients who are currently taking brand medications. In this regard, approvals from prescriber and patient are pivotal. Good communication between doctors and patients is essential, as well as enlisting the assistance of doctors, nurses, and pharmacists, therapeutic blood monitoring if available, and the option of brand antiepileptic drug as a self-financed item. The physical appearance of generic drugs should be considered as it may hamper drug compliance. Support from medical services is recommended. In the longer term, the benefit of flexibility and the options to have a balance between the generic and brand drug market may need to be addressed by institutions and regulatory bodies.

Review and update of the Hong Kong Epilepsy Guideline on status epilepticus.

Convulsive status epilepticus is the most extreme form of seizure. It is a medical and neurological emergency that requires prompt and appropriate treatment. Treatment of convulsive status epilepticus is usually divided into stages/steps. The International League Against Epilepsy has released a new definition of status epilepticus that may help to unify the definition in future studies. Over the last few years new information has become available regarding its management. The Rapid Anticonvulsant Medication Prior to Arrival Trial demonstrated non-inferiority of intramuscular midazolam in early status epilepticus compared with intravenous lorazepam. Valproate and levetiracetam have also emerged as possible alternatives to phenytoin in established status epilepticus. The potential role of lacosamide in this stage of status epilepticus remains to be defined. The ongoing Established Status Epilepticus Treatment Trial may help to determine the most effective treatment for benzodiazepine-resistant status epilepticus. Management of refractory status epilepticus and super-refractory status epilepticus remains mostly non-evidence-based. Increasing recognition of a possible autoimmune aetiology has led to the use of immune-modulation in super-refractory status epilepticus. Ketamine is also increasingly used in this challenging condition. There are also reports of potential use of a ketogenic diet and magnesium.

Efficacy of birth ball exercises on labour pain management.

OBJECTIVES: To evaluate the efficacy of a birth ball exercise programme conducted by physiotherapists on pain relief, psychological care, and facilitation of the labour process at a labour ward in a regional hospital. DESIGN: Case series with before-after comparisons. SETTING: Kwong Wah Hospital, Hong Kong. PARTICIPANTS: Chinese women admitted to the labour ward for spontaneous vaginal delivery between April and August 2012 were recruited. Physiotherapists taught birth ball exercises in groups or individually for 30 minutes. Labour pain intensity, back pain intensity, frequency of labour pain, stress and anxiety levels, and subjective pressure level over the lower abdomen were captured before and after birth ball exercises. Most of the parameters were measured using self-reported visual analogue scales. After the exercise session, physiotherapists measured the women's satisfaction level. Midwives recorded pethidine usage. RESULTS: A total of 203 pregnant women participated in this programme; 181 were in the latent phase group, whereas 22 were categorised into the no-labour-pain group. In both groups, there were statistically and clinically significant differences in back pain level, stress and anxiety levels, as well as pressure level over the lower abdomen before and after the exercise (P<0.05). In the latent phase group, significant decreases in labour pain and frequency of labour pain were demonstrated. Mean satisfaction scores were high, with visual analogue scale scores higher than 8.2 in both groups. Pethidine usage showed a further decreasing trend (6.4%) compared with the past 2 years. CONCLUSION: Birth ball exercise could be an alternative means of relieving back pain and labour pain in the labour ward, and could decrease pethidine consumption in labouring women.

Treatment of ganglion cysts.

Ganglion cysts are soft tissue swellings occurring most commonly in the hand or wrist. Apart from swelling, most cysts are asymptomatic. Other symptoms include pain, weakness, or paraesthesia. The two main concerns patients have are the cosmetic appearance of the cysts and the fear of future malignant growth. It has been shown that 58% of cysts will resolve spontaneously over time. Treatment can be either conservative or through surgical excision. This review concluded that nonsurgical treatment is largely ineffective in treating ganglion cysts. However, it advised to patients who do not surgical treatment but would like symptomatic relief. Compared to surgery, which has a lower recurrence rate but have a higher complication rate with longer recovery period. It has been shown that surgical interventions do not provide better symptomatic relief compared to conservative treatment. If symptomatic relief is the patient's primary concern, a conservative approach is preferred, whilst surgical intervention will decrease the likelihood of recurrence.

Another light in the dark: review of a new method for the arthroscopic repair of triangular fibrocartilage complex.

The triangular fibrocartilage complex (TFCC) is an anatomically and biomechanically important structure. Repair of radial-sided TFCC tear has previously been challenging. We designed a new method of radial-sided TFCC tear repair and found that it was also applicable for ulnar-sided TFCC tear repair. From October 2006 to December 2010, 10 patients underwent this operation and were reviewed: 9 men and 1 woman, with a mean age of 33.9 years. Average postoperative follow-up was 8 months. We graded results according to the Mayo modified wrist score. We rated 2 of the 10 patients (20%) as "excellent," 3 (30%) as "good," and 5 (50%) as "fair." The 5 patients who were rated as "fair" returned to regular jobs or had restricted employment. Based on this small sample, we recommend that this technique be considered an alternative method for TFCC repair.

The development of a strength-focused mutual support group for caretakers of children with cerebral palsy.

OBJECTIVE: To examine the efficacy of a strength-focused mutual support group for reducing stress and enhancing psychological well-being of the caretakers of children with cerebral palsy. METHODS: This pre- and post-intervention outcome study, conducted by Department of Orthopaedics and Traumatology, Duchess of Kent Children's Hospital, recruited 12 primary caretakers of children with cerebral palsy in Hong Kong. A strength-focused support group manual was developed to help such caretakers to identify and cultivate the character strengths of their children and enhance their own positive emotions. Participants were asked to complete a full set of questionnaires at 3 time-points: before and immediately after the intervention (consisting of 4 weekly sessions), and after the 1-month follow-up booster session. Two additional questionnaires were administered before each session to check mood. Parenting stress, anxiety, depression, social support, hope, and other psychological well-being measures were also assessed. RESULTS: Half of the caretakers (n = 6) who had attended the full intervention programme were included in the data analysis. Participants exhibited a significantly lower level of parental stress and higher hope level both after the 4 intervention sessions and at the booster session. Their perceived social support was significantly increased when the group was ongoing but not after it ended. CONCLUSION: This group intervention programme could effectively help caretakers reduce their parenting stress and enhance their hopefulness. Launching a similar programme with more sessions and regular follow-up sessions might help maintain positive effects and establish a social support network.

Dynamic treatment for proximal phalangeal fracture of the hand.

PURPOSE: To assess a protected mobilisation programme (dynamic treatment) for proximal phalangeal fracture of the hand, irrespective of the geometry. METHODS: Clinical and radiological results of 32 consecutive patients with proximal phalangeal fracture of the hand treated from January 2001 to February 2007 were evaluated. Our supervised rehabilitation programme was strictly followed to gain full range of movement of the proximal interphalangeal joint and to prevent the development of an extension lag contracture. Patients were followed up for a mean period of 15 (range, 13-16) months. Results were evaluated using the Belsky classification. RESULTS: The results were excellent in 72% of the patients, good in 22%, and poor in 6%. Some patients defaulted follow-up, which made long-term assessment difficult. The poor results may have been related to patient non-compliance or default from rehabilitation. Many good results upgraded to excellent following further rehabilitation. CONCLUSION: Skeletal stability, not rigidity, is necessary for functional movements of the hand. Proximal phalangeal fractures can be effectively treated by closed methods, using the stabilising effect of soft tissues (zancolli complex-metacarpophalangeal retention apparatus) and external devices (metacarpophalangeal block splint), thus enabling bone healing and movement recovery at the same time.

Study of wrist posture, loading and repetitive motion as risk factors for developing carpal tunnel syndrome.

Occupational risk factors of carpal tunnel syndrome (CTS) are popular current research targets, with main emphasis put on wrist posture and dynamics. In this study, we do not intend to pinpoint individual occupations, but aim to identify high risk wrist postures and actions which may occur across various occupations. It is hoped that prevention can thus be instituted in a general population by directing at the particular causative wrist actions rather than exclusively targeting isolated occupations. We performed a case-control study with 166 cases and 111 controls recruited from different hospitals in Hong Kong in 2004. All cases and controls completed the survey on their general health condition, smoking status, wrist posture and motion as well as psychosocial status at the time of diagnosis of CTS. Frequent flexion OR = 4.436 (95% CI: 1.833-10.734), frequent extension OR = 2.691 (95% CI: 1.106-6.547) of the wrist were found to be associated with CTS. Frequent sustained forceful motion of the wrist OR = 2.588 (95% CI: 1.144-5.851) was also found to be associated with CTS. Neutral wrist position and repetitive wrist motion were not associated with CTS. Adjustment was made for age, sex, BMI, smoking and psychosocial stress. Our study confirms that frequent flexion, extension and sustained force of the wrist increase the risk of developing CTS.

Efficacy of multidisciplinary approach in treatment of constipation: a pilot study.

OBJECTIVE: To evaluate a multidisciplinary Hong Kong treatment programme for patients with constipation. DESIGN: Pilot study. SETTING: A joint collaboration among the departments of surgery, physiotherapy, and dietetics in a regional hospital in Hong Kong. PATIENTS: Thirty-one constipated patients with normal colonic transit and pelvic floor dyssynergia. INTERVENTION: Multidisciplinary treatment including dietary modification, bowel habit adjustment, and physiotherapy. MAIN OUTCOME MEASURES: Anorectal manometry, fibre intake, subjective improvement, bowel frequency, Bristol score, and straining time and effort. RESULTS: Significant improvement was found in mean fibre intake, straining time and effort, but not in anal manometric results. A total of 78% of patients demonstrated more than 50% improvement in subjective symptoms, whereas 70% of the patients enjoyed objective improvement in pelvic floor dyssynergia documented by electromyography and anal pressure during a push effort. CONCLUSION: The multidisciplinary rehabilitative programme for constipated patients significantly improved symptoms. Electromyography and anal pressure during a push effort are useful tools for objective assessment of the treatment effect.

A simple method for the preparation of pseudopure states in nuclear magnetic resonance quantum information processing.

The use of nuclear magnetic resonance (NMR) to carry out quantum information processing (QIP) often requires the preparation, transformation, and detection of pseudopure states. In our previous work, it was shown that the use of pairs of pseudopure states (POPS) as a basis for QIP is very convenient because of the simplicity in experimental execution. It is now further demonstrated that the product of the NMR spectra corresponding to two sets of POPS that share a common pseudopure state has the same peak frequencies as those of the common (single) pseudopure state. Examples of applying two different quantum logic gates to a 5-qubit system are given.

Prediction of breast cancer size by ultrasound, mammography and core biopsy.

Neoadjuvant chemotherapy and non-surgical tumor ablation rely upon imaging studies to determine tumor size. In this study the accuracy of ultrasound (US) mammography and core biopsy in determining tumor size was examined in 202 patients with Stages I and II breast cancer. The most accurate single modality for determining tumor size was mammography with a correlation coefficient of 0.66, followed by US (r = 0.48) and core biopsy (r = 0.28). Size measurements were less accurate in lobular than ductal cancers. The combination of the three modalities understaged 25% of the tumors > 1cm in size, and overstaged 10% of those < 1cm. The inability to accurately determine tumor size has important implications for the use of non-surgical ablation.

Patterns of failure, prognostic factors and survival in locoregionally advanced head and neck cancer treated with concomitant chemoradiotherapy: a 9-year, 337-patient, multi-institutional experience.

BACKGROUND: Locoregionally advanced, stage IV head and neck cancer has traditionally carried a poor prognosis. We sought to assess changes in patterns of failure, prognostic factors for recurrence, and overall outcome, using two different strategies of chemoradiotherapy conducted in prospective, multi-institutional phase II trials. PATIENTS AND METHODS: Three hundred and thirty-seven stage IV patients were treated from 1989 to 1998. We compared locoregional and distant recurrence rates, overall survival and progression-free survival from two different treatment strategies: intensive induction chemotherapy followed by split-course chemoradiotherapy (type 1, n=127), or intensified, split-course, hyperfractionated multiagent chemoradiotherapy alone (type 2, n=210). Univariate and multivariate analyses of 12 chosen covariates were assessed separately for the two study types. RESULTS: The pattern of failure varied greatly between study types 1 and 2 (5-year locoregional failure of 31% and 17% for study types 1 and 2, respectively, P=0.01; 5-year distant failure rate of 13% and 22% for study types 1 and 2, P=0.03). Combined 5-year overall survival was 47% [95% confidence interval (CI) 41% to 53%) and progression-free survival was 60% (95% CI 55% to 66%). Both treatment strategies yielded similar survival rates. Poor overall survival and distant recurrence were best predicted by advanced nodal stage. Locoregional recurrence was extremely rare for patients with T0-T3 tumor stage, regardless of lymph-node stage. CONCLUSIONS: This analysis suggests that pattern of failure in primary head and neck cancer may be dependent upon treatment strategy. Randomized clinical trials of induction chemotherapy are warranted as a means to determine if a decrease in distant metastases can lead to an increase in survival rates in the setting of effective chemoradiotherapy for locoregional control. Additionally, this analysis provides impetus for randomized clinical trials of organ preservation chemoradiotherapy in sites outside the larynx and hypopharynx.