Update on the Hong Kong Reference Framework for Hypertension Care for Adults in Primary Care Settings-review of evidence on the definition of high blood pressure and goal of therapy.

The Hong Kong Reference Framework for Hypertension Care for Adults in Primary Care Settings is updated regularly to ensure it reflects the latest medical development and best practice. In 2017, guidelines from the United States included a major change, adopting the lower blood pressure values of 130/80 mm Hg in defining hypertension, in contrast to the prevailing international consensus of 140/90 mm Hg. After thorough review of the literature and international guidelines, the Advisory Group on Hong Kong Reference Framework for Care of Diabetes and Hypertension in Primary Care Settings (Advisory Group) recommends that the definition of hypertension adopted in the Reference Framework should remain unchanged as a blood pressure of ≥140/90 mm Hg, as there is currently inadequate evidence and lack of general consensus to support such change in Hong Kong. The Advisory Group agrees on individualised treatment goals, and recommends that the initial blood pressure goal for individuals with uncomplicated hypertension should be <140/90 mm Hg; for those who can tolerate it, the goal should be ≤130/80 mm Hg. A lower blood pressure is advisable for young or overweight/obese patients, smokers, and patients with other cardiovascular risk factors.

Prevalence and associated comorbidities of moderate to severe chronic renal impairment in Chinese nursing home older adults.

OBJECTIVE: To investigate the prevalence and associated comorbidities of Stage 3 (GFR 30-59 mL/min/1.73m(2)) and Stages 4 and 5 (GFR <30 mL/min/1.73m(2)) chronic kidney disease (CKD) among Chinese nursing home older adults. DESIGN: Retrospective cross-sectional study. Glomerular filtration rate (GFR) was estimated by Modification of Diet in Renal Disease Study (Chinese-adjusted) equation and The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. SETTING: Nine nursing homes in Hong Kong PARTICIPANTS: Participants included 812 nursing home older adults (271 men and 571 women), mean age 86.0 ± 7.6. MEASUREMENTS: Prevalence of Stage 3 (GFR 30-59 mL/min/1.73m(2)) and Stages 4 and 5 (GFR <30 mL/min/1.73m(2)) CKD. The comorbidities associated with renal impairment were also assessed. RESULTS: There were 18.4% of nursing home older adults who had elevated serum creatinine levels above the normal limits. Using Modification of Diet in Renal Disease Study and CKD-EPI equations, 26.4% and 21.2% of them had Stage 3 CKD, whereas 6.8% and 4.4% had Stage 4-5 CKD, respectively. Diabetes mellitus, hypertension, congestive heart failure, and ischemic heart disease correlated significantly with moderate to severe renal impairment in Chinese nursing home older adults. CONCLUSION: Stages 3 to 5 CKD are prevalent in Chinese nursing home older adults. Early identification of these patients facilitates drug prescription, renal management, and advance care planning.

Interleukin-6 promotes anti-OspA borreliacidal antibody production in vitro.

Determination of the immunological mediators responsible for promoting the production of borreliacidal antibody may facilitate the development of an improved borreliosis vaccine for human and veterinary use. Previously, we developed an in vitro assay to determine if borreliacidal antibody production could be augmented by treatment with different cytokines. In this study, in vitro treatment of lymph node cells producing borreliacidal antibody with recombinant interleukin-6 (rIL-6) resulted in a fourfold enhancement of anti-OspA borreliacidal antibody. Moreover, rIL-6 enhanced Western immunoblot titers and increased the number of B lymphocytes. In contrast, treatment of anti-OspA borreliacidal antibody-producing cells with anti-IL-6 resulted in a fourfold reduction in borreliacidal activity. Treatment with anti-IL-6 also inhibited enhanced borreliacidal antibody production induced by anti-gamma interferon. These data suggest that IL-6 plays a significant role in the production of anti-OspA borreliacidal antibodies.

CD4(+) CD25(+) T cells prevent arthritis associated with Borrelia vaccination and infection.

CD4(+) CD25(+) T cells are a population of regulatory T cells associated with control of arthritis in anti-interleukin-17 antibody-treated Borrelia-vaccinated and challenged gamma interferon-deficient mice. Here, we present direct evidence that adoptive transfer of enriched CD4(+) CD25(+) T cells from these mice can prevent the development of arthritis in Borrelia-vaccinated and challenged mice. These findings establish a major role for CD4(+) CD25(+) T cells in the prevention of arthritis in Borrelia-vaccinated and challenged animals.

Suprasellar ectopic pituitary adenoma presenting as cranial diabetes insipidus.

We describe the occurrence of a supracellar ectopic pituitary adenoma in a 34 year old woman who presented with cranial diabetes insipidus and subsequently developed galactorrhoea-amenorrhoea. The tumour was demonstrated by both contrast computed tomography scan and magnetic resonance imaging with gadolinium enhancement and was confirmed at operation. Histological examination showed that the suprasellar lesion consisted of a pituitary adenoma while the pituitary biopsy revealed an unrelated pituitary microadenoma embedded in normal pituitary tissues. A review is made of the reported cases of ectopic pituitary adenomas.

Wound-healing complications following biopsy of the irradiated breast.

A retrospective review evaluated results of 38 posttreatment biopsies (with resulting benign pathologic findings) that were performed on 32 irradiated breasts or axillae in 31 of 232 patients who underwent conservation treatment of early-stage breast cancer. Postbiopsy wound-healing complications developed in eight (30%) of 27 patients who were undergoing open biopsies but in none of 11 who underwent only needle biopsies. Wound-healing complications occurred in two of five patients who underwent incisional skin biopsy, three of five who underwent mammographic needle-localized excisional biopsy, and three of 17 who underwent other types of open biopsies. Frequency of wound-healing complications following open biopsy was not related to patient age, diabetes mellitus, cigarette smoking, or use of chemotherapy. Wound-healing complications were related to breast size, developing in four (67%) of six patients with large breasts (brassiere cup size D or DD) as compared with that in only four (19%) of 21 patients with smaller breasts. Significant worsening of cosmetic breast retraction was frequently associated with wound-healing complications, especially wounds that took more than 1 month to heal.

Factors affecting cosmetic outcome in breast-conserving cancer treatment--objective quantitative assessment.

A battery of objective measurements of cosmetic outcome was performed on 114 patients who had been treated by breast-preservation techniques for breast cancer. Cosmetic breast retraction, as determined by Breast Retraction Assessment (BRA) measurements, was significantly greater in patients who underwent extensive primary tumor resection, were more than 60 years old, weighed more than 150 lbs, or had a primary tumor in an upper breast quadrant. While use of a local RT boost, per se, was not a significant factor, those patients with high dose and/or large volume local boosts more frequently had marked retraction. Breast telangiectasia and depigmentation (T/D) was related to use of a local RT boost, patient age greater than 60 years, and use of separate nodal RT fields. Breast T/D was significantly more frequent with use of electron beam local RT boost which delivered a boost skin dose exceeding 1600 cGy. Objective quantitative assessments, such as BRA and T/D area measurements, provide data to determine factors related to each type of cosmetic change and thus provide guidelines for optimizing cosmetic outcome. Limiting the extent of primary tumor resection may minimize the amount of breast retraction. Omitting the local RT boost, particularly large volume, high dose boosts, may reduce the frequency of marked cosmetic retraction and skin T/D.

Heating patterns of microwave applicators in inhomogeneous arm and thigh phantoms.

Heating rate (HR) patterns in cylindrical structures were studied with inhomogeneous limb phantoms. These phantoms, arm and thigh models consisting of fat, bone, and muscle material, were heated with Clini-Therm L, M, and MS applicators at 915 MHz. The thigh model is 18 cm in diameter with 2.65-cm-thick fat on the outside and a 4-cm-diam bone in the center. The arm model is 9 cm in diameter with 1.35-cm-thick fat and 2-cm-diam bone. All models are 29 cm long with phantom muscle in the space between fat and bone and were heated with their long axes parallel or perpendicular to the E field. HR patterns in the transverse and longitudinal planes were obtained thermographically. A large water bolus, with the water channels parallel to the E field, was used in every case. In the thigh model, maximum heating was in the muscle for both L and M applicators when the E field was parallel to the long axis. When it was perpendicular, the maximum heating occurred in the fat layer. However, the peak HR in the fat remained about the same for both E field orientations. For the small applicator, heating was mostly in the fat, and the two field orientations did not cause much difference in the heating pattern. In the arm model, the maximum heating of all three applicators occurred mostly in the muscle for both E-field orientations. However, the maximum HR was reduced by a factor of 2 to 3 when the E field was perpendicular rather than parallel to the long axis.(ABSTRACT TRUNCATED AT 250 WORDS)

Design of intracavitary microwave applicators for the treatment of uterine cervix carcinoma.

A 915 MHz intracavitary applicator was designed to heat tumours in the cervical and upper vaginal regions. The applicator has a 3.5-turn helical coil wound around the distal 19 mm of a dielectric rod 43 mm long and 30 mm in diameter. For treating uterine cancer, a 2450 MHz, 4 mm diameter helical applicator was made by replacing 6 cm of the outer conductor of a coaxial cable with six turns of copper wire soldered to the outer conductor. The heating patterns were determined thermographically in a muscle phantom. The maximum heating rates were 0.42 and 0.83 degrees C/W-min, respectively, for the 915 and 2450 MHz applicators. Intracavitary temperature distributions in the upper vagina, cervix and uterus were measured at the surface of the applicators with thermocouples. The average temperature was 46.0 +/- 2.1 degrees C (S.D.) at mid-tumour and 44.5 +/- 0.8 degrees C at the tumour periphery. The maximum temperature, up to 51.5 degrees C, was measured at the surface of the cervical applicator. The majority of the patients (28/30) tolerated the investigational treatment without burns or pain. Rectal temperatures were also monitored. The location of the hot-spot (40.7 degrees C) in the rectum, 5-7 cm above the anus, corresponded to the tip of the cervical applicator (47.1 degrees C).

Intracavitary hyperthermia applicators for treating nasopharyngeal and cervical cancers.

Many intracavitary microwave applicators have been designed to heat tissues along the side of an antenna. For tumours in nearly closed-end cavities such as the nasopharynx and cervix, heating near the tip of the applicators is necessary for effective treatment. A nasopharyngeal applicator made of Micro Coax UT-250A and a cervical applicator made of RG-9/U cables were designed to provide heating at the tip. Return losses of 8-12 dB were obtained at 915 MHz by varying the size of two metal sleeves and adjusting the distance between these sleeves and the reflectors at the applicator tips. Heating patterns were evaluated on a muscle phantom with a thermograph. At 915 MHz, maximum heating rates of 1.3 and 0.85 degrees C/W-min, respectively, were observed near the tip of the nasopharyngeal applicator and at its first sleeve opening. When operated at 915 MHz the cervical applicator has a maximum heating rate of 0.25 degrees C/W-min at the tip. Clinically, both applicators require a maximum power of 30 W to provide effective heating. This makes it possible to provide intracavitary hyperthermia at rural hospitals and small clinics with a small portable system.

Effects of fat thickness on heating patterns of the microwave applicator MA-151 at 631 and 915 MHz.

Previous studies showed that the surface heating patterns of the MA-151 applicator on a 2 cm fat and 10 cm thick muscle phantom had center heating at 581 and 930 MHz and two hot spots near the edges of the applicator at 657 and 779 MHz. The hot spots at 657 MHz were consistent with two blisters on a patient's thigh. Since the heating patterns on muscle only showed good center elliptical heating at all frequencies, in this study we have investigated the effects of fat thickness on the heating patterns. Thermograms of fat and muscle surfaces were taken on phantoms with 0, 0.25, 0.5, 1, and 2 cm thick fat exposed to 631 or 915 MHz energy. The 631 MHz was selected to provide reasonable energy coupling for all phantoms. At 631 MHz, two hot spots were evident on all fat surfaces. The pattern on the muscle surface under the 0.25 cm fat did not show two hot spots, but the heating was elongated in the E-field direction. At 915 MHz, the heating was elongated on the surface of the 0.25 and 2 cm fat, and two hot spots were observed on the 0.5 and 1 cm fat surfaces. However, the muscle heating was elliptical in all cases. The ratio of muscle to fat heating decreased as the fat thickness increased. At 0.5 cm fat the ratio was about 1. These results indicate that fat thickness influences heating in muscle. During treatment with this applicator, surface temperature probes should be placed over potential hot spots. Surface cooling is desirable for heating tumors beneath the fat.

Evaluation of captive bolus applicators.

Three square (L, M, MS) and one rectangular (HN) applicators with captive boluses were provided by the Clini-Therm Corporation for evaluation. Surface cooling is achieved by attaching a mineral oil captive bolus to the built in water-circulating tubes at the aperture of the applicators. These applicators were tested on a phantom with a 2-cm fat slab over 10-cm-thick muscle. Surface and sagittal heating patterns were obtained using a thermograph. All captive-bolus applicators have heating patterns similar to that of the regular Clini-Therm applicators. Due to hot spots at the edges of the applicators where the E fields terminate, these modified applicators should not be placed in direct contact with patients when boluses are not used. Tests with Clini-Therm regular water bolus instead of the captive oil bolus indicated that the orientation of water flow should be parallel to the E field to minimize perturbation of the heating patterns. Thermal conduction studies showed that the captive bolus reacts too slowly for skin temperature control. The modified captive bolus applicators did not improve the performance of the system.

The reverse hockey stick technique: postmastectomy radiation therapy for breast cancer patients with locally advanced tumor presentation or extensive loco-regional recurrence.

A combination of photon and electron radiation therapy (RT) fields was devised to treat patients with initial or recurrent breast cancer presentations which extensively involved the chest wall (CW) and/or the axilla. The ipsilateral supraclavicular, infraclavicular, axillary, and lateral CW regions are treated in continuity by anterior and posterior opposed photon beam "reverse hockey stick" fields. The internal mammary and medial chest wall regions are treated by an anterior electron beam field which is tightly junctioned to the photon beam fields. Electron beam energy and thickness of applied bolus are selected so that the electron beam 80% depth isodose curve matches the anterior pleural surface and/or deepest extent of tumor. The goal of treatment is to deliver 4400-5000 cGy to regions at risk of microscopic tumor with local boosts to 6000-7500 cGy to sites of gross disease. Between January 1977, and June 1985, this technique was selectively used in 46 patients, 31 patients with loco-regional tumor recurrence and 15 post-mastectomy patients who initially presented with locally advanced disease. A minimum tumor dose of 4400 cGy was delivered in all except five patients. A diffuse moist skin reaction developed in 31 of the 44 (70%) patients who received at least 3800 cGy. This healed in less than 1 month in all except seven. Frequency of CW diffuse moist skin reaction within the electron beam field was related to the daily applied RT dose. Diffuse moist skin reactions were also noted to be more frequent among patients who had received prior or concurrent Adriamycin. Significant complications included symptomatic arm lymphedema in seven; CW ulcer in two; and acute radiation pneumonitis; steroid-withdrawal radiation pneumonitis, pleuritis, and marked thrombocytopenia in one patient each. With a follow-up of 36-100 months, there was no evidence of loco-regional tumor relapse in 55% of patients treated for recurrent disease and in 73% treated following mastectomy for locally advanced presentations. In summary, we find the reverse hockey stick technique to be a simple, highly reproducible and effective RT approach for postmastectomy breast cancer patients with extensive initial presentation or recurrent disease.

Changes in heating patterns of interstitial microwave antenna arrays at different insertion depths.

The changes in heating patterns of interstitial microwave antennas at different insertion depths were investigated in a static phantom at 915 MHz. Antennas for the Clini-Therm Mark VI system were inserted 5-15 cm into muscle-equivalent material, through nylon catheters. The phantom was heated with arrays of antennas at 2 cm spacings for 60 s at 15 W per antenna. Midplane and transverse heating patterns were determined thermographically with the antennas inserted parallel or perpendicular to the split of the phantom. Hot spots, independent of heating near the junction plane, were observed in the midplane of the 2 x 2 and 2 x 4 arrays at 2.8 cm from the insertion end. The magnitudes of these hot spots were reduced by 40-45 per cent as insertion depth was increased from 7 to 10.5 cm. With insertion depths of more than 11.5 cm the hot spots gradually diminished and heating occurred mostly near the junction plane. The observed heating patterns were caused by changes in impedance of the antenna arrays at different insertion depths. The impedance mismatch had resulted in different wave propagation within the tissue material which produced different radiation patterns. During treatments, because heating varies with insertion depth, great care must be exercised in monitoring temperatures.

Perturbations due to the use of catheters with non-perturbing thermometry probes.

Perturbations due to the use of catheters with non-perturbing thermometry probes were investigated in static phantom at 915 MHz. Fibre optic probes for the Luxtron and Clini-Therm thermometry systems, and Vitek probes for the BSD hyperthermia systems, were inserted in closed-end catheters at depths up to 2 cm in the phantom and exposed parallel to the E-field. The probes alone produced 0-12 per cent changes in heating and catheters alone were 0-20 per cent. When the probes were inserted in catheters, perturbations were 0-12 per cent at the surface and 1 cm depth, and 5-15 per cent at 2 cm depth. Even with non-perturbing probes it is important to place catheters perpendicular to the E-field during microwave hyperthermia.

Total skin electron irradiation for mycosis fungoides: relationship between acute toxicities and measured dose at different anatomic sites.

From June 1978 to June 1986, 50 patients with primary and recurrent mycosis fungoides were treated with total skin electron irradiation (TSEI), using the Stanford technique, to a total dose of 3600 cGy. TSEI was used alone, or in combination with low dose total body photon irradiation, or MOPP. Thermoluminescent dosimeter (TLD) measurements of the prescribed skin dose were obtained on twenty patients. The dorsum of the foot was 24% higher. The axillae, the bottom, and the arch of the foot were significantly underdosed. Frequencies of acute toxicities noted at 2000 cGy were: Skin, Grade I-II (RTOG) 80%. Partial epilation: scalp, 100%; eyebrows and at eyelashes, 20%. Nail dystrophy, 48%. Edema: hands and feet, 44%. Bullae: dorsum of feet, 8%; hands, 4%; and 3600 cGy: Skin, grade III 22%. Total epilation: scalp, 66%; eyebrows and eyelashes, 56%. Nail loss, 38%. Edema: hands and feet, 76%. Bullae: dorsum of feet, 34%; hands, 12%. Conjunctivitis, 4%. Large bullae, were more significant on the dorsum of the feet. Severe moist desquamation occurred in eight patients who had ulcerated lesions on initial presentation. Three patients were hospitalized due to ulceration and skin infection. All patients completed treatment after a short to moderate break. No patient developed skin necrosis, or corneal ulceration. No correlation exists between dose level, degree and onset of toxicity with previous chemotherapy or TBI. We conclude that the overall toxicity of TSEI is well tolerated.

Changes in heating patterns due to perturbations by thermometer probes at 915 and 434 MHz.

The changes in heating patterns due to perturbations by thermometer probes in microwave fields were investigated in static phantoms at 915 and 434 MHz. Thermograms taken parallel to the plane of E and H fields, at depths of up to 2 cm, indicated heating changes of +25 to -45 per cent at 915 MHz and +/- 15 per cent at 434 MHz. The amount of perturbation is dependent on the length, size and location of the probes in the RF fields and their orientations to the electric field. If proper probe placement techniques are not observed when metallic probes are involved, hot and cool spots can be generated and shifted to sites that are not measured. Therefore misleading temperatures can result when changes in heating patterns are not detected. Perturbation also varies with applicator designs and phantom geometry. If thermistors and thermocouples are used, the effects of perturbation should be investigated with individual applicators under applicable clinical conditions.

To boost or not to boost: decreasing radiation therapy in conservative breast cancer treatment when "inked" tumor resection margins are pathologically free of cancer.

A retrospective study was performed to compare local treatment approaches for 108 treated breasts in 105 patients with Stage I or II breast cancer. Six cases with intraductal carcinoma have shown no evidence of recurrence. The other 102 cases had invasive cancer. In 54 treated breasts in 53 patients, the treatment approach involved surgical resection of the primary tumor, pathological determination of tumor-free "inked" specimen margins and 5000 cGy to the whole breast. Local radiation therapy (RT) boosts to the primary site were not given. This approach produced a 100% local control rate (mean follow-up of 38 months). In 28 treated breasts in 27 patients, the treatment approach involved tumor excision without evaluation of specimen margins followed by RT which included a local boost by either interstitial Iridium-192 implant or electron beam. This approach yielded an actuarial local control rate of 87% at 48 months (mean follow-up of 47 months). The difference in local control rate between the two groups was statistically significant (p less than 0.03). Among patients with clear surgical margins who received a local RT boost, 1 of 9 developed a local recurrence. Among those with tumor involving specimen margins who received a local boost, 1 of 8 developed local recurrence. Local recurrence developed more frequently among patients with poorly differentiated cancers (2 of 11 cases) than among those with other invasive cancers (3 of 91 cases). Comparison of treatment approaches was limited since poorly differentiated cancer was present in 25% of cases with unknown specimen margins, as compared with only 2% of those with clear surgical margins who did not receive a local RT boost. Our preliminary findings suggest that when "inked" primary tumor resection margins are pathologically free of cancer, 5000 cGy whole breast RT appears to be highly effective for local tumor control in patients with Stage I or II disease. Our results are inconclusive as to whether patients with poorly differentiated cancers should receive a local RT boost even when surgical margins are clear.