Diabetes in older people: position statement of The Hong Kong Geriatrics Society and the Hong Kong Society of Endocrinology, Metabolism and Reproduction.

Following a survey on the clinical practice of geriatricians in the management of older people with diabetes and a study of hypoglycaemia in diabetic patients, a round-table discussion with geriatricians and endocrinologists was held in January 2015. Consensus was reached for six domains specifically related to older diabetic people: (1) the considerations when setting an individualised diabetic management; (2) inclusion of geriatric syndrome screening in assessment; (3) glycaemic and blood pressure targets; (4) pharmacotherapy; (5) restrictive diabetic diet; and (6) management goals for nursing home residents.

Effect of daily short-duration weight-bearing on disuse-induced deterioration of musculoskeletal system.

OBJECTIVES: To investigate deterioration of musculoskeletal system due to prolonged disuse and the potential of daily short-duration weight-bearing as countermeasures. METHODS: Twenty-four adult male Sprague-Dawley rats were divided into Control Group (CG, no intervention), Tail-suspension Group (TG, tail-suspension without treatment), and Weight-Bearing Group (WBG, tail-suspension with 20 min/day, 5 days/week body weight loading). After four weeks of treatment, femur and tibia, soleus and extensor digitorum longus were evaluated for bone and muscle quality respectively. Tensile properties of bone-tendon insertion (BTI) were evaluated using patella-patellar tendon complex. RESULTS: Disuse induced deterioration on bone, muscle, and BTI after four weeks. Compared with CG, TG and WBG showed significant decrease in bone mineral density (BMD) of trabecular bone in distal femur (4.3-15.2%), muscle mass (31.3-52.3%), muscle cross-sectional area (29.1-35%), and failure strength of BTI (23.9-29.4%). Tensile test showed that the failure mode was avulsion of bone at the BTI. No significant difference was detected between TG and WBG for all assessments on bone, muscle, and BTI. CONCLUSIONS: Disuse caused deterioration of bone, muscle, and BTI while daily short-duration of weight-bearing did not prevent this deterioration. Mechanical stimulation with higher intensity and longer duration may be necessary to prevent musculoskeletal deterioration resulted from prolonged disuse.

Acute appendicitis complicating Amyand's hernia: imaging features and literature review.

Acute appendicitis complicating Amyand's hernia is an extremely rare condition, in which the appendix herniates into the inguinal sac and, subsequently, gets inflamed. The condition is difficult to diagnose clinically. Imaging is valuable for its diagnosis and detection of the associated complications. In this article, we will discuss the imaging features of acute appendicitis complicating Amyand's hernia and the results of a literature review on the condition.

Resistive vibration exercise retards bone loss in weight-bearing skeletons during 60 days bed rest.

UNLABELLED: Countermeasures are desirable to retard bone loss during long-term space flight. We evaluated the effect of an intervention protocol on bed rest-induced bone loss. INTRODUCTION: We developed a resistive vibration exercise (RVE) platform to test if an intervention RVE protocol would be effective to protect bed rest-induced bone loss. METHODS: Fourteen male subjects were assigned randomly to either the RVE group (n = 7) that performed daily supervised resistive vibration exercise or to the no any exercise control (CON) group (n = 7). Both dual-energy X-ray absorptiometry and peripheral quantitative computed tomography were used to monitor changes in bone mineral density. RESULTS: RVE significantly prevented bone loss at multiple skeletal sites, including calcaneus, distal tibia, hip, and lumbar spine (L2-L4). The ratio of urinary calcium and creatinine was found higher after starting bed rest in CON group while no significant changes were observed in RVE group. No significant temporal change was found for osteocalcin-N during and after bed rest in CON group. However, a significant increase was shown after bed rest in RVE group. In both groups, the urinary concentration of bone resorption markers, such as C-telopeptide of type I collagen (CTX-I) and deoxypyridinoline (DPD), were significantly elevated after bed rest. In the CON group, no significant temporal effect was found for hydroxyproline (HOP), CTX-I, and DPD during bed rest and the serum concentration of HOP and TGF-ß significantly increased about 52.04% and 24.03%, respectively only after bed rest. However, all these markers tended to decrease in the RVE group. CONCLUSIONS: Our results might imply that the intervention of RVE retarded bone loss induced by simulated microgravity in humans that was mainly attributed to its anabolic effects.

Atypical glandular cells diagnosed during pregnancy and the postpartum period: a retrospective analysis.

OBJECTIVES: The objective of the study was to determine the prevalence and clinical significance of atypical glandular cells (AGC) or atypical glandular cells of undetermined significance (AGUS) diagnosed in pregnant and postpartum women. STUDY DESIGN: Smears having a diagnosis of AGC or AGUS, taken from pregnant and postpartum (within six weeks after delivery) women between 1995 and 2008 were reviewed and subclassified according to the Bethesda 2001 classification. Case records were then reviewed and a second cytology review was performed after disclosure of the follow-up data. RESULTS: Among 91,133 smears taken from pregnant and postpartum women, 70 had AGC or AGUS (0.07%) diagnosed. Follow-up data were available in 40 cases, with mean duration of follow-up being 43 months. Among the 40 patients with follow-up data, nineteen had smears with coexisting squamous abnormalities. Thirty patients had positive pathology, including 18 (45%) cervical intraepithelial neoplasia III (CIN III), four (10%) cervical adenocarcinoma-in situ, three (7.5%) squamous cell carcinoma of cervix, four (10%) condylomas and one (2.5%) hydatidiform mole. On review, 24 out of 32 smears with AGC 'not otherwise specified' ('NOS') had significant pathology. CONCLUSIONS: AGC found on cervical smears during pregnancy and the postpartum period is uncommon. The chance of having significant cervical pathology, however, is high and colposcopy should be performed.

Human papillomavirus-16/18 AS04-adjuvanted cervical cancer vaccine: immunogenicity and safety in healthy Chinese women from Hong Kong.

OBJECTIVE: To assess the immunogenicity and safety of human papillomavirus-16/18 AS04-adjuvanted cervical cancer vaccine in Chinese women aged 18 to 35 years enrolled from Hong Kong. DESIGN: Double-blind, randomised controlled trial with vaccine and placebo groups. SETTING: Single-centre study in Hong Kong. PARTICIPANTS: Three hundred women enrolled (150 per group) between March 2006 and June 2007. INTERVENTIONS: Subjects received three doses of human papillomavirus-16/18 vaccine or placebo (aluminium hydroxide), administered intramuscularly at 0, 1, and 6 months. MAIN OUTCOME MEASURES: Human papillomavirus-16/18 seroconversion rates and geometric mean titres at month 7 (in human papillomavirus-16/18 recipients); reactogenicity and safety (in all subjects). RESULTS: A total of 294 women completed the study (148 in the vaccine group, 146 in placebo group). All initially seronegative subjects in the vaccine group had seroconverted for human papillomavirus-16/18 antibodies by month 7. Anti-human papillomavirus-16 and anti-human papillomavirus-18 antibody geometric mean titres were 10 422 (95% confidence interval, 8730-12 442) EL.U/mL and 4649 (3975-5437) EL.U/mL, respectively. High compliance (99% in both groups) was observed for the three-vaccination course. The frequencies of local injection site reactions were higher in the vaccine than placebo group; pain being the most common symptom in both groups. Regarding solicited symptoms, fatigue and myalgia were the most frequent in both groups. Five serious adverse events (four in vaccine group, one in placebo group) were reported, but all were considered unrelated to the vaccinations. CONCLUSION: The human papillomavirus-16/18 AS04-adjuvanted vaccine was highly immunogenic, safe, and generally well tolerated in Chinese women from Hong Kong.

Retroperitoneal schwannoma: a common tumour in an uncommon site.

We describe a female adult patient who presented with acute retention of urine and vague abdominal discomfort. A provisional diagnosis of ovarian tumour was made after cross-sectional imaging. At laparotomy a very large retroperitoneal mass was biopsied and found to be a schwannoma after pathological examination. The clinical, radiological, and pathological features of this disease are discussed in this report.

Acceptability of human papillomavirus vaccination among Chinese women: concerns and implications.

OBJECTIVE: To explore Chinese women's perceptions of human papillomavirus (HPV) vaccination and their intention to be vaccinated. DESIGN: A cross-sectional community-based survey study. SETTING: Thirteen community women's health centres of The Family Planning Association of Hong Kong. SAMPLE: A total of 1450 ethnic Chinese women aged 18 or above who attended the health centres. METHODS: Participants completed a written consent and an anonymous questionnaire onsite. MAIN OUTCOME MEASURES: Knowledge and beliefs about HPV and HPV vaccination against cervical cancer and participants' own intention to be vaccinated. RESULTS: About 38% of the participants (n = 527) had heard of HPV and 50% (n = 697) had heard of vaccination against cervical cancer. HPV infection was perceived to be stigmatising and detrimental to intimate, family and social relationships. Despite misconceptions and a grossly inadequate knowledge about HPV and HPV vaccination, 88% of the participants (n = 1219) indicated that they would likely be vaccinated. Majority of the participants believed that sexually experienced women should be vaccinated, while 27% opposed vaccinating sexually naive women. Younger age women who perceived a disruptive impact of HPV infection on intimate relationship and their partners' approval were significantly associated with a positive intention to be HPV vaccinated. CONCLUSIONS: The easy acceptability of HPV vaccination among the mostly sexually experienced Chinese participants and their knowledge deficit on the subject may implicate potential misuse of the vaccines and a false sense of security against cervical cancer. There is a dire need for culturally sensitive and tailored education for the public, women of different ages and their partners about HPV and HPV vaccination. Emphasis must be placed on the prophylactic nature of the current vaccines, the uncertain effects when given to sexually experienced women, the importance of adolescent vaccination and the need for continued cervical screening whether vaccinated or not.

Evaluation of prognostic factors and treatment outcomes in uterine carcinosarcoma.

OBJECTIVE: The aims of this study were to determine the prognostic factors, survival outcomes and response to adjuvant therapy in women with uterine carcinosarcoma treated in a single institution. STUDY DESIGN: This is a cohort study of women diagnosed with carcinosarcoma and treated at the Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, UK. The medical records of all patients diagnosed with carcinosarcoma between January 1960 and July 2002 were reviewed. RESULTS: A total of 93 women were identified during this period. The median age was 67 years. The most common presentation was abnormal vaginal bleeding, occurring in 85%, followed by pelvic mass in 45%, and abdominal pain in 38%. At surgery there was extra-uterine spread in 54% of women. The median follow-up was 33 months (range 4-146 months). Adjuvant therapy was not associated with survival advantage. Recurrence was diagnosed in 55 patients (59%) and the overall 5-year survival for all stages was 33%. On multivariate analysis depth of myometrial invasion, stage and pelvic nodes metastasis were associated with poor survival. CONCLUSION: The poor outcome for these patients may reflect the aggressive nature of carcinosarcoma and that at the time of presentation more than 50% have extra-uterine disease, which was associated with significant poorer survival. Systemic adjuvant therapy has not been associated with significant improvement in the outcome. More studies are needed to better define the appropriate treatment for this rare cancer.

The role of regular physical examination in the detection of ovarian cancer recurrence.

OBJECTIVE: To evaluate how ovarian recurrences were first detected and the relative role of Ca 125, symptom enquiry and physical examination in recurrence detection. METHODS: In this retrospective study, records from women with ovarian cancer recurrences diagnosed between 1999 and 2004 were reviewed to determine how the recurrences were first detected. Women were routinely followed up by a combination of symptom enquiry, physical examination and Ca 125. When recurrence was suspected, further investigations such as imaging and biopsy of the suspected recurrence would be arranged to confirm the diagnosis. The patients were followed up for a median of 53.5 months. RESULTS: Eighty patients were identified to have ovarian cancer recurrences, with median time to recurrence of 12 months. Although 41 (51%) had abnormal physical findings, only three (3.8%) first presented with physical findings and none had positive physical findings alone. Ca 125 taken at the clinic visits in these 3 patients when the signs were detected turned out to be raised. For the remaining 77 patients, 49 (61%) and 28 (35%) first presented with raised Ca 125 level and symptoms respectively. The median survival from the time of recurrence for those first presented with Ca 125, symptoms and physical findings were 25 months, 17 months and 11 months respectively. CONCLUSION: Routine physical examination had a very limited additional role and could be possibly omitted as part of the routine follow up strategy.

Natural history of pelvic lymphocysts as observed by ultrasonography after bilateral pelvic lymphadenectomy.

OBJECTIVES: To determine, in patients who have undergone bilateral pelvic lymphadenectomy for gynecological cancer, the incidence of lymphocyst formation, their change in size with time, risk factors and correlation with symptoms. METHODS: This was a prospective observational study of 108 patients undergoing bilateral pelvic lymphadenectomy for gynecological cancer in our unit. We performed serial three-dimensional (3D) ultrasound assessment at 2 and 6 weeks and 3, 6, 9 and 12 months after surgery. Before each ultrasound assessment, symptoms were recorded and a physical examination was performed. RESULTS: Forty-eight (44.4%) patients had unilateral or bilateral lymphocysts detected during the follow-up period; 26 were on the left side, 16 were on the right side and six were bilateral. In 39 (81.2%) of the patients, the lymphocysts were first noted 2 weeks after the operation. In nine (18.8%) the lymphocysts persisted until 12 months after surgery. There was no association between lymphocyst formation and diagnosis, type of operation performed, surgeon, operative blood loss, adjuvant radiotherapy and number of lymph nodes removed. Four lymphocysts were detected by physical examination before the ultrasound diagnosis. There was no association between lymphocyst and symptoms, including pain over the abdomen, pelvis, thigh, legs or back, lymphedema, fever or symptoms of cystitis. Only one patient developed an infection of the lymphocyst, which required surgical intervention. CONCLUSION: Lymphocyst formation is common following bilateral pelvic lymphadenectomy. Most patients with lymphocysts are asymptomatic and the development of major complications is rare.

Barriers and facilitators to human papillomavirus vaccination among Chinese adolescent girls in Hong Kong: a qualitative-quantitative study.

OBJECTIVES: To explore perceptions towards cervical cancer, human papillomavirus (HPV) infection and HPV vaccination and to identify factors affecting the acceptability of HPV vaccination among Chinese adolescent girls in Hong Kong. METHODS: Six focus groups were conducted with Chinese adolescent girls (median age 16 years, age range 13-20, n = 64) in Hong Kong in April 2007. Thematic analysis was employed to identify major themes related to cervical cancer and HPV vaccination. A supplementary questionnaire was administered to all participants before and after group discussion to assess their knowledge, attitudes and intention to be vaccinated and to collect demographic information. RESULTS: Participants' knowledge on cervical cancer was limited and HPV was largely unheard of. They had difficulty understanding the mechanism linking cervical cancer with HPV infection. Participants held a favourable attitude towards HPV vaccination but the perceived timing of vaccination varied. Barriers to vaccination include high monetary cost, uncertain length of vaccine effectiveness, low perceived risk of HPV infection, no immediate perceived need of vaccination, anticipated family disapproval and fear of the pain of injection. Factors conducive to vaccination include perceived family and peer support and medical reassurance on safety and efficacy of vaccine. The differences on knowledge, attitudes, intention to be vaccinated now and willingness to conform to significant others before and after the discussion were statistically significant, with an increased tendency towards favouring vaccination after the focus group. CONCLUSIONS: Participants favoured HPV vaccination despite not feeling an immediate need to be vaccinated. Interventions could focus on providing professional information on HPV vaccination and raising adolescents' perceived need to take preventive measures against HPV infection.

A combination of chemoirradiation and chemotherapy for treatment of advanced clear cell adenocarcinoma of the cervix.

Clear cell adenocarcinoma of the cervix (CCAC) is an uncommon tumor. No good treatment option has been reported for advanced disease, and the prognosis is generally poor. We report a case of a 14-year-old girl with stage III CCAC. She was given whole-pelvic external irradiation (40 Gy in 20 daily fractions) and high-dose rate brachytherapy with concurrent weekly cisplatin (40 mg/m(2)), followed by further external irradiation to the parametria with central shield (14 Gy in seven daily fractions). She then received one cycle of carboplatin (area under the curve [AUC] 6) with paclitaxel (175 mg/m(2)) and two cycles of carboplatin (AUC 4) with gemcitabine (1000 mg/m(2) on days 1 and 8) because she developed anaphylactic shock to paclitaxel. Chemotherapy was stopped after the third cycle due to initial poor general condition. However, she gradually improved while on palliative care. Reassessment 6 months later showed no evidence of residual disease, and she remained disease free during a follow-up of 1 year. The complete response in this case suggests that chemoirradiation followed by combination chemotherapy may be a treatment option for advanced CCAC.

The use of vaginal antimicrobial after large loop excision of transformation zone: a prospective randomised trial.

OBJECTIVE: To investigate whether the use of an antibacterial vaginal pessary containing tetracycline and amphotericin B would reduce complications from large loop excision of the transformation zone (LLETZ). DESIGN: Prospective randomised controlled trial. SETTING: Department of Obstetrics and Gynaecology, University of Hong Kong. POPULATION: A total of 321 women who underwent LLETZ. METHODS: Women were randomised to either receiving an antimicrobial vaginal pessary twice a day for 14 days after LLETZ or no medication. Before LLETZ, endocervical and high vaginal swabs were taken for the detection of Chlamydia and other pathogens. All women were given a diary to record the degree of symptoms, such as vaginal discharge, bleeding and pain for 3 weeks. These were then compared between the two groups. MAIN OUTCOME MEASURES: Bleeding, vaginal discharge and pain after LLETZ. RESULTS: There was no significant difference in the total bleeding, vaginal discharge and pain scores between the two groups. However, for women who had positive endocervical or high vaginal swabs, the treatment group had significantly less bleeding in the second week (Z=-2.083, P= 0.037) and less overall vaginal discharge (Z=-2.024, P= 0.043). CONCLUSIONS: An antimicrobial vaginal pessary containing tetracycline and amphotericin B did not provide any significant benefit after LLETZ, except for a subgroup of women with positive vaginal or endocervical swabs. Given that this group of women cannot be identified before the procedure since swabs are not routinely taken, the use of routine prophylactic topical antibiotics cannot be recommended for the general population.

Opportunistic breast cancer screening in Hong Kong; a revisit of the Kwong Wah Hospital experience.

OBJECTIVE: To analyse the performance of opportunistic breast screening in local Well Women Clinics during the 5-year period from 1998 to 2002, with reference to international as well as our own earlier experience (1991 to 1993 to 1995). DESIGN: Prospective study. SETTING: Well Women Clinics in regional Hong Kong hospitals. PARTICIPANTS: Women attending the Well Women Clinics of the Tung Wah Group of Hospitals for breast cancer screening. MAIN OUTCOME MEASURES: All screening-detected breast cancers. RESULTS: After 46 637 screening mammograms and excluding palpable masses detected by the patients themselves, 232 women were detected with cancers, yielding a crude detection rate of 5.0 per 1000. Age range for cancer detection was 35 to 72 (median, 49) years. Clinic staff detected palpable lumps in 83 patients, constituting 36% of the detected cancers, of which 15 (6.5% of all detected cancers) were not identified by mammography. The cancer detection rate was 5.9 per 1000 in the age-group 40-49 years and 3.7 per 1000 in those 50 years or older. The cancer detection rate was 58.5 per 1000 in the high-risk group (aged <40 years with positive family history). The minimal cancer detection rate was 2.2 per 1000, representing 45% of all cancers whose pathology was available to us. Ductal carcinoma in situ comprised 28% of all such cancers. Our recall rates were 4.6% for additional views only, 3.3% for ultrasound only, and 2.3% for both. Positive predictive values for abnormal mammograms and biopsies were 4.9% and 26.0%, respectively. CONCLUSION: Mammographic screening has been reported to reduce mortality up to 35% in western countries. However, data concerning Asian Chinese populations are meagre. Our Well Women Clinics pioneered large-scale self-referred breast screening in Hong Kong. Despite the lower incidence of breast cancers than in Occidental populations, our screening programme performed comparably to those in the West, and has improved over time. Our screening service for self-referred women detected breast cancers even at an early stage, which facilitated a better prognosis and more treatment options, whilst appearing to be highly acceptable to our community. Besides, it could provide training and expertise in breast radiology and mammography, which are essential prerequisites for establishing population screening.

Methylation profile in benign, borderline and malignant ovarian tumors.

PURPOSE: Promoter hypermethylation is a common phenomenon in neoplasm. The aims of this study were (a) to compare the methylation profiles in different types of ovarian tumors and (b) to determine the possible relationship between the methylation status and different clinicopathologic characteristics. METHODS: We examined the promoter methylation status of 9 tumor suppressor genes (RARbeta2, TMS1, RIZ1, P15, P16, PTEN, MINT31, APC and HIC1) in 89 ovarian cancers, 16 borderline ovarian tumors, 19 benign ovarian tumors, 16 normal ovarian tissue and 5 ovarian cancer cell lines. The methylation status was examined with respect to clinicopathologic characteristics of the ovarian cancer patients. RESULTS: Methylation indices for ovarian cancer, borderline ovarian tumor, benign ovarian tumor, normal ovarian tissue and ovarian cancer cell lines were 28.8, 20.1, 10.5, 11.8 and 42.2%, respectively. It was significantly higher in ovarian cancer, borderline ovarian tumor and ovarian cancer cell lines (X (2) test, P < 0.001, P = 0.01 and P < 0.001, respectively) than benign or normal ovarian tissues. In ovarian cancer, concurrent methylation of at least two genes (CM2) was associated with early stage disease (X (2) test, P = 0.035) and less recurrence (X (2) test, P = 0.020). When the methylation statuses of the nine genes as well as CM2 were included in multivariate Cox Regression analysis, CM2 was the only independent predictor for survival (P = 0.013). CONCLUSION: CM2 was an independent predictor for survival in ovarian cancer.

Ethnicity is a factor to be considered before dose planning in ovarian cancer patients to be treated with topotecan.

The objective of this study was to determine the efficacy and toxicity of topotecan in Chinese patients with ovarian cancer. A retrospective analysis on recurrent ovarian cancer patients receiving topotecan 1.25 mg/m(2) daily for 5 consecutive days on a 21-day cycle from 1997 to 2002 was conducted. The patients included were all treated with at least two cycles of topotecan. The patient characteristics were compared in relation to their toxicity profile and their response to treatment. Response was evaluated by physical findings, imaging techniques, and serum CA125 level. A total of 60 patients were included in the study. All patients were evaluable for response and toxicities. A total of 361 cycles were given (median, 5 per patient; range 2-15). The major toxicity was neutropenia, which was grade 4 in 45.0% of the patients and 10.2% of the cycles. Age was the only covariate predicting the occurrence of grade 4 neutropenia (logistic regression P= 0.046, CI 1.01-1.12). Neutropenic fever occurred in 8.3% of the patients. Eighteen (30%) patients were required to delay their chemotherapy and 11 (18.3%) required dose reduction. Nonhematologic toxicities were mild. The overall response rate was 21.6%, with eight (13.3%) complete responses and five (8.3%) partial responses. The median duration of response and median time to progression were 11 and 5 months, respectively. The median survival was 14 months. Topotecan 1.25 mg/m(2) in a five-times-daily schedule was well tolerated in a cohort of Chinese patients. Myelotoxicity was the most important side effect in our study, but the incidence is much lower than that reported in other studies. Age was an independent factor predicting the occurrence of grade 4 neutropenia.

The behaviors of seeking a second opinion from other health-care professionals and the utilization of complementary and alternative medicine in gynecologic cancer patients.

GOALS OF WORK: The aim of the study is to determine the predictors for seeking a second opinion and the utilization of complementary and alternative medicine (CAM) among gynecologic cancer patients. PATIENTS AND METHODS: Patients attending a gynecologic cancer clinic of a tertiary referral center were recruited over a period of 1 year. A survey was conducted for all the participants in a one-on-one basis. MAIN RESULTS: One hundred ninety-one patients were recruited. Eighty patients (41.9%) had consulted other health-care professionals (HCP) for a second opinion after they were diagnosed to have cancer and 89 (46.6%) had utilized CAM. In multivariate analysis, late-stage disease (OR=2.65, 95% CI 1.26-5.58), treatment with radiotherapy (OR=2.27, 95% CI 1.19-4.33) and tertiary education (OR=11.28, 95% CI 3.06-41.54) were independent predictors for seeking a second opinion from other HCP and utilization of CAM. Patients who sought a second opinion from other HCP were more likely to utilize CAM (OR=6.12, 95% CI 3.24-11.54). Eighty percent of the patients did not inform their usual caregiver their utilization of CAM. CONCLUSIONS: Seeking a second opinion from other HCP is common in gynecologic cancer patients. Patients who seek a second opinion are more likely to utilize CAM.