Metastatic testicular seminoma presenting as acute lower limb ischaemia.

We describe a unique presentation of acute lower limb ischaemia due to metastatic seminoma in a middle-aged man with a large retroperitoneal mass. The patient underwent vascular bypass surgery of the right lower limb, completed chemotherapy, and had a right scrotal orchiectomy. The patient had pre-existing vascular risk factors including peripheral vascular disease and smoking. To our knowledge this is the first published case in the literature that has described a large retroperitoneal seminoma compressing the abdominal aorta resulting in acute lower limb ischaemia.

The Utility of Intraluminal Therapies in Upper Tract Urothelial Carcinoma: A Narrative Review.

Nephron sparing surgery (NSS) is considered for selected cases of upper tract urothelial carcinoma (UTUC) as it maintains renal function and avoids morbidity associated with radical nephroureterectomy (RNU). The appropriate selection of patients suitable for NSS without compromising oncological outcomes can sometimes be difficult, given the limitations of diagnostic modalities. Recurrence rates for UTUC can be as high as 36 to 54% after NSS. Intraluminal adjuvant therapy can be attempted following NSS to reduce recurrence, but delivery to the upper tract is more challenging than into the bladder. Bacillus Calmette-Guerin (BCG) and chemotherapy such as Mitomycin (MMC) have been administered via nephrostomy or ureteric catheter, which requires invasive/repeated instrumentation of the upper urinary tract. Drug delivery by reflux from bladder instillation along indwelling stents has also been tried but can potentially be unreliable. Recently, a gel formulation of mitomycin has been developed for the controlled exposure of the upper urinary tract to treatment over a number of hours. Drug-eluting stents to deliver chemotherapy to the upper urinary tract have been developed but have not yet entered clinical practice. Endoluminal phototherapy utilising an intravenous photosensitising agent is another novel approach that has recently been described. Intraluminal therapies may be beneficial in decreasing recurrence rates in UTUC, but currently have some limitations in their usage.

Development and validation of risk prediction model for recurrent cardiovascular events among Chinese: the Personalized CARdiovascular DIsease risk Assessment for Chinese model.

Aims: Cardiovascular disease (CVD) is a leading cause of mortality, especially in developing countries. This study aimed to develop and validate a CVD risk prediction model, Personalized CARdiovascular DIsease risk Assessment for Chinese (P-CARDIAC), for recurrent cardiovascular events using machine learning technique. Methods and results: Three cohorts of Chinese patients with established CVD were included if they had used any of the public healthcare services provided by the Hong Kong Hospital Authority (HA) since 2004 and categorized by their geographical locations. The 10-year CVD outcome was a composite of diagnostic or procedure codes with specific International Classification of Diseases, Ninth Revision, Clinical Modification. Multivariate imputation with chained equations and XGBoost were applied for the model development. The comparison with Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS-2°P) and Secondary Manifestations of ARTerial disease (SMART2) used the validation cohorts with 1000 bootstrap replicates. A total of 48 799, 119 672 and 140 533 patients were included in the derivation and validation cohorts, respectively. A list of 125 risk variables were used to make predictions on CVD risk, of which 8 classes of CVD-related drugs were considered interactive covariates. Model performance in the derivation cohort showed satisfying discrimination and calibration with a C statistic of 0.69. Internal validation showed good discrimination and calibration performance with C statistic over 0.6. The P-CARDIAC also showed better performance than TRS-2°P and SMART2. Conclusion: Compared with other risk scores, the P-CARDIAC enables to identify unique patterns of Chinese patients with established CVD. We anticipate that the P-CARDIAC can be applied in various settings to prevent recurrent CVD events, thus reducing the related healthcare burden.

Salmonella Mississippi: An unusual cause of renal abscess in an immunocompetent patient.

Renal abscess is a rare manifestation of Salmonella infection. This usually occurs in the presence of risk factors that include immunosuppression, renal stones and urinary structural abnormality. We describe a 19-year-old male with no risk factors who developed a left renal abscess and gram-negative sepsis caused by Salmonella Mississippi. This was managed successfully with percutaneous drainage of the abscess and a prolonged course of antibiotics. To our knowledge, this is the first reported case of Salmonella Mississippi as a cause for renal abscess in an individual with no identifiable risk factors.

Effectiveness of BNT162b2 and CoronaVac vaccinations against mortality and severe complications after SARS-CoV-2 Omicron BA.2 infection: a case-control study.

Data regarding protection against mortality and severe complications after Omicron BA.2 infection with CoronaVac and BNT162b2 vaccines remains limited. We conducted a case-control study to evaluate the risk of severe complications and mortality following 1-3 doses of CoronaVac and BNT162b2 using electronic health records database. Cases were adults with their first COVID-19-related mortality or severe complications between 1 January and 31 March 2022, matched with up-to 10 controls by age, sex, index date, and Charlson Comorbidity Index. Vaccine effectiveness against COVID-19-related mortality and severe complications by type and number of doses was estimated using conditional logistic regression adjusted for comorbidities and medications. Vaccine effectiveness (95% CI) against COVID-19-related mortality after two doses of BNT162b2 and CoronaVac were 90.7% (88.6-92.3) and 74.8% (72.5-76.9) in those aged ≥65, 87.6% (81.4-91.8) and 80.7% (72.8-86.3) in those aged 50-64, 86.6% (71.0-93.8) and 82.7% (56.5-93.1) in those aged 18-50. Vaccine effectiveness against severe complications after two doses of BNT162b2 and CoronaVac were 82.1% (74.6-87.3) and 58.9% (50.3-66.1) in those aged ≥65, 83.0% (69.6-90.5) and 67.1% (47.1-79.6) in those aged 50-64, 78.3% (60.8-88.0) and 77.8% (49.6-90.2) in those aged 18-50. Further risk reduction with the third dose was observed especially in those aged ≥65 years, with vaccine effectiveness of 98.0% (96.5-98.9) for BNT162b2 and 95.5% (93.7-96.8) for CoronaVac against mortality, 90.8% (83.4-94.9) and 88.0% (80.8-92.5) against severe complications. Both CoronaVac and BNT162b2 vaccination were effective against COVID-19-related mortality and severe complications amidst the Omicron BA.2 pandemic, and risks decreased further with the third dose.

Left ectopic ureteral insertion into seminal vesicle detected after robotic assisted laparoscopic radical prostatectomy.

Ectopic ureters are rare congenital malformations of the urinary tract, more frequent in females and most commonly associated with single collecting system in males. We report a case of a prostate cancer patient undergoing robotically assisted laparoscopic radical prostatectomy. Duplication of vas deferens was thought to be found during surgery. Postoperatively, patient developed fevers. CT showed incidental finding of duplex collecting system on the left with dilatation of the upper moiety. Percutaneous nephrostomy was placed but an attempt at antegrade insertion of ureteric stent was unsuccessful. Robotic reimplantation of the ectopic ureter was successfully performed on day six post prostatectomy.

Prospective Memory Influences Social Functioning in People With First-Episode Schizophrenia: A Network Analysis and Longitudinal Study.

Background: Prospective memory (PM) impairment is associated with impaired social functioning, but evidence is limited to chronic schizophrenia samples and cross-sectional design. The aim of this study was to utilize network analysis to address the complex interplay between PM, psychopathology, and functional outcome.Methods: This longitudinal study recruited 119 people with first-episode DSM-IV schizophrenia and followed up with them for 2 to 6 years. PM and working memory were assessed at baseline (in 2010-2015) using valid computerized tasks and the Letter-Number Span Test, respectively. Psychopathology and social functioning were assessed at endpoint (in 2016-2017) using the Positive and Negative Syndrome Scale (PANSS) and the Social and Occupational Functioning Assessment Scale (SOFAS), respectively. Network analysis examined the effect of baseline PM on SOFAS while accounting for the effects of psychopathology.Results: The resultant network showed that social functioning, PANSS positive symptoms, and PANSS general symptoms clustered together, whereas time-based and event-based PM and working memory formed another cluster. Time-based PM linked event-based PM and working memory with social functioning. Time-based PM (expected influence [EI] = 0.69), event-based PM (EI = 0.65), and working memory (EI = 0.83) demonstrated high values of expected influence, but social functioning (variance explained = 0.685) and PANSS negative (variance explained = 0.657) and general (variance explained = 0.583) subscales demonstrated high values of predictability.Conclusions: Time-based PM is the central node linking neurocognitive functions with social functioning. PM and working memory are "target" nodes for interventions bringing changes to the network, whereas social functioning and psychopathology are "malleable" nodes. PM and working memory are promising intervention targets for functional recovery in schizophrenia.

Cognitive insight is correlated with cognitive impairments and contributes to medication adherence in schizophrenia patients.

OBJECTIVE: Cognitive insight refers to the ability to distance oneself from and evaluate one's own beliefs and interpretations. Little is known about whether cognitive insight could influence medication adherence in schizophrenia patients. This study examined the role of cognitive insight in medication adherence and how it would interact with neuropsychological functions. METHODS: Ninety clinically-stable schizophrenia patients completed the Beck's Cognitive Insight Scale (BCIS) and tasks measuring prospective (PM) and other neurocognitive functions. Medication adherence was estimated using a multi-axial method comprising interview, clinician-rating, pharmacy refill record and pill counting. Correlational and regression analyses were conducted to examine whether cognitive insight and PM would be associated with mediation adherence. Post-hoc mediational analysis was performed to examine the interplay between cognitive insight, PM and medication adherence. RESULTS: Clinical insight and cognitive insight together significantly influenced participants' medication adherence, after neurocognitive functions and psychopathology were accounted for. Time-based PM, compared with other neurocognitive functions, affected medication adherence more strongly. CONCLUSIONS: Cognitive insight complements clinical insight in affecting medication adherence in schizophrenia patients.

Actionable pharmacogenetic variants in Hong Kong Chinese exome sequencing data and projected prescription impact in the Hong Kong population.

Preemptive pharmacogenetic testing has the potential to improve drug dosing by providing point-of-care patient genotype information. Nonetheless, its implementation in the Chinese population is limited by the lack of population-wide data. In this study, secondary analysis of exome sequencing data was conducted to study pharmacogenomics in 1116 Hong Kong Chinese. We aimed to identify the spectrum of actionable pharmacogenetic variants and rare, predicted deleterious variants that are potentially actionable in Hong Kong Chinese, and to estimate the proportion of dispensed drugs that may potentially benefit from genotype-guided prescription. The projected preemptive pharmacogenetic testing prescription impact was evaluated based on the patient prescription data of the public healthcare system in 2019, serving 7.5 million people. Twenty-nine actionable pharmacogenetic variants/ alleles were identified in our cohort. Nearly all (99.6%) subjects carried at least one actionable pharmacogenetic variant, whereas 93.5% of subjects harbored at least one rare deleterious pharmacogenetic variant. Based on the prescription data in 2019, 13.4% of the Hong Kong population was prescribed with drugs with pharmacogenetic clinical practice guideline recommendations. The total expenditure on actionable drugs was 33,520,000 USD, and it was estimated that 8,219,000 USD (24.5%) worth of drugs were prescribed to patients with an implicated actionable phenotype. Secondary use of exome sequencing data for pharmacogenetic analysis is feasible, and preemptive pharmacogenetic testing has the potential to support prescription decisions in the Hong Kong Chinese population.

Validation of the traditional script Chinese version of the brief negative symptom scale.

Negative symptoms are a core feature of schizophrenia and account for much of the long-term morbidity and poor functional outcome of people with schizophrenia. The Brief Negative Symptom Scale (BNSS) was developed to address the main limitations of the existing scales for the assessment of negative symptoms. The BNSS has been translated into Italian, Spanish, German, Turkish and simplified Chinese versions with excellent psychometric properties. In this study, a Chinese (traditional script) version of the Brief Negative Symptom Scale (C-BNSS) was developed and validated to facilitate future research on the Chinese population in Hong Kong. Psychometric properties were examined in 149 individuals with schizophrenia. The C-BNSS showed excellent internal consistency (α = 0.96), high inter-rater reliability (intra-class correlation = 0.98), and high test-retest reliability (Spearman's r = 0.96). Convergent validity was supported by high correlations between C-BNSS total score and subscales with the Scale for Assessment of Negative Symptoms (SANS), Negative Symptom subscale of the Positive and Negative Syndrome Scale (PANSS), and Global Assessment of Functioning (GAF) score. Discriminant validity was supported by low correlations between the C-BNSS total score and the PANSS positive subscale, Calgary Depression Scale, and Simpson-Angus Scale for extrapyramidal symptoms. The C-BNSS showed a five- factor structure on Confirmatory Factor Analysis (CFA), confirming findings of previous studies. Findings indicate that the C-BNSS demonstrates excellent psychometric properties, which are comparable to the original English version. It is a promising instrument for use in clinical trials as well as in clinical practice.

Impaired olfactory identification and hedonic judgment in schizophrenia patients with prominent negative symptoms.

Introduction: Evidence suggests that schizophrenia patients have olfactory dysfunctions, but the relationship between olfactory identification, hedonic judgement, and negative symptomatology remains unclear. Few studies have investigated whether co-activation of pleasant and unpleasant emotions are more prevalent in schizophrenia patients.Methods: Thirty schizophrenia outpatients with prominent negative symptoms (PNS), 30 outpatients without PNS, and 30 controls completed the University of Pennsylvania Smell Identification Test, and were asked to identify the odourants and to rate their emotions. The effects of gender and medications on olfactory function were examined.Results: Schizophrenia patients exhibited olfactory identification impairments, even after accounting for gender and medication effects. Patients with PNS demonstrated larger magnitude of deficit than those without. Patients with PNS reported less pleasure to positive-valenced odourants, and less unpleasantness to negative-valenced odourants than controls. Olfactory anhedonia in patients with PNS disappeared after controlling for medication effect. Schizophrenia patients do not exhibit affective ambivalence in olfaction.Conclusions: Schizophrenia patients with PNS exhibit deficits in olfactory identification and hedonic judgement, even after controlling for gender and medication effects. Our findings support the close relationship between olfactory dysfunctions and negative symptoms. Further studies should investigate the effect of dopamine-blocking agents on the olfactory hedonic judgment in schizophrenia patients.

Tractography-based classification in distinguishing patients with first-episode schizophrenia from healthy individuals.

BACKGROUND: Schizophrenia has been characterized as a neurodevelopmental disorder of brain disconnectivity. However, whether disrupted integrity of white matter tracts in schizophrenia can potentially serve as individual discriminative biomarkers remains unclear. METHODS: A random forest algorithm was applied to tractography-based diffusion properties obtained from a cohort of 65 patients with first-episode schizophrenia (FES) and 60 healthy individuals to investigate the machine-learning discriminative power of white matter disconnectivity. Recursive feature elimination was used to select the ultimate white matter features in the classification. Relationships between algorithm-predicted probabilities and clinical characteristics were also examined in the FES group. RESULTS: The classifier was trained by 80% of the sample. Patients were distinguished from healthy individuals with an overall accuracy of 71.0% (95% confident interval: 61.1%, 79.6%), a sensitivity of 67.3%, a specificity of 75.0%, and the area under receiver operating characteristic curve (AUC) was 79.3% (χ2 p < 0.001). In validation using the held-up 20% of the sample, patients were distinguished from healthy individuals with an overall accuracy of 76.0% (95% confident interval: 54.9%, 90.6%), a sensitivity of 76.9%, a specificity of 75.0%, and an AUC of 73.1% (χ2 p = 0.012). Diffusion properties of inter-hemispheric fibres, the cerebello-thalamo-cortical circuits and the long association fibres were identified to be the most discriminative in the classification. Higher predicted probability scores were found in younger patients. CONCLUSIONS: Our findings suggest that the widespread connectivity disruption observed in FES patients, especially in younger patients, might be considered potential individual discriminating biomarkers.

Prospective memory in individuals with first-episode schizophrenia: A two-year longitudinal study.

AIM: The present study aimed to explore the two-year naturalistic trajectory of time- and event-based prospective memory (PM) in patients with first-episode schizophrenia. METHODS: We administered a computer-based dual-task PM paradigm to 57 individuals with first-episode schizophrenia at baseline and after 6 months, 12 months and 24 months. Forty-eight healthy controls were also recruited and completed all the measures at baseline. We compared the trajectories between time-based and event-based PM in first-episode schizophrenia patients using repeated measures ANOVAs, and examined the relationship between PM and clinical symptoms using Spearman's correlation. RESULTS: PM impairments improved significantly after 24 months of follow-up. However, time-based and event-based PM appeared to run different trajectories. After 24 months, first-episode schizophrenia patient performed poorer than healthy controls in time-based but not event-based PM. PM did not appear to be correlated with clinical symptoms, both cross-sectionally and longitudinally. CONCLUSIONS: This is one of the longest follow-up studies investigating PM in first-episode schizophrenia. Our results provide evidence to support that time-based PM is more temporally stable than event-based PM.

Problems in remembering to carry out future actions in first-episode schizophrenia: primary or secondary impairment?

Prospective memory (PM) is the ability to remember to carry out intended actions in the future. Empirical evidence suggests that PM deficits exist in individuals with chronic schizophrenia. However, it is unclear whether PM deficits in first-episode schizophrenia exist independently from other neuropsychological deficits. Moreover, prior research using patients with first-episode has been limited to small inpatient samples. We aimed to clarify the nature and extent of PM deficits in individuals with first-episode schizophrenia, using a large outpatient sample. Participants were 91 clinically stable outpatients with first-episode schizophrenia and 83 healthy controls. PM was assessed using both a subjective self-reported checklist and a laboratory-based task capturing time- and event-based PM. A battery assessing verbal and visuo-spatial working memory, as well as executive functions was also administered. ANOVA analyses showed that patients with first-episode schizophrenia performed significantly poorer than healthy controls in time- and event-based PM. Stepwise linear regression analyses suggested that cognitive flexibility predicted time- and event-based PM; and working memory predicted event-based PM. Subgroup analyses showed that "cognitive-preserved" patients with first-episode schizophrenia tended to perform poorer in time-based PM deficit than healthy controls who were matched in IQ and other neuropsychological functions. Overall, our results provide substantial evidence to support that time-based PM deficits in first-episode schizophrenia are apparent and not entirely attributable to other neuropsychological deficits. PM may constitute a neuropsychological marker for schizophrenia.

The effectiveness of a 'Do Not Use' list and perceptions of healthcare professionals on error-prone abbreviations.

BACKGROUND: The use of error-prone abbreviations has led to medication errors. Many safety organisations have introduced 'Do Not Use' lists (lists of error-prone abbreviations that should be avoided by prescribers), but the effectiveness of these lists have not been studied. OBJECTIVE: We assessed the effectiveness of the 'Do Not Use' list introduced to the study hospital, and sought the attitudes of healthcare professionals on other potentially dangerous abbreviations (not included in the 'Do Not Use' list) used in prescriptions. SETTING: The study was conducted in a university affiliated tertiary hospital in Hong Kong. METHODS: An uncontrolled observational study was conducted. In-patient prescriptions were reviewed to assess the use of error-prone abbreviations included in the 'Do Not Use' list before, after its introduction, and following the first reinforcement. An on-line survey was also conducted among prescribers, pharmacists and nurses. MAIN OUTCOME MEASURE: Rate of using error-prone abbreviations and other unapproved abbreviations among reviewed prescriptions. RESULTS: 3,238 prescriptions (23,398 drug items) were reviewed. The use of abbreviations in the 'Do Not Use' list decreased from 7.8 to 3.3 % after its introduction (P < 0.001) and to 1.3 % after the first reinforcement (P < 0.001). However, unapproved abbreviations were used to denote prescribing instructions in 19.2 % of the drugs prescribed. 49 different types of unapproved abbreviations were used for drug names. CONCLUSIONS: A 'Do Not Use' list is effective in reducing error-prone abbreviations. Reinforcements of the 'Do Not Use' list further improves prescriber adherence. However, many other unapproved abbreviations (not included in current 'Do Not Use' lists) are used when prescribing. Periodic reminders on error-prone abbreviations and education of prescribers on associated risks may help to reduce the use of error-prone abbreviations in hospitals.

Consensus statement: appropriate consumer education and communication programs for weight- loss agents in Asia.

BACKGROUND AND AIM: The increasing prevalence of overweight and obesity worldwide demands increased efforts in the prevention and management of obesity. This article aims to present consensus statements promoting appropriate consumer education and communication programs for weight-loss agents in Asia. METHODS: Panel members from various disciplines developed consensus statements based on an expert meeting on the benefits of consumer education and communication programs for over-the-counter weight-loss agents. Key opinion leaders discussed relevant data that served as the basis of the recommendations. RESULTS: Obesity is a growing epidemic in Asia, turning the region into a potential market for weight-loss products and services. Current trends in direct-to-consumer advertising demonstrate the pervasiveness of false representations lacking adequate substantiation. Relevant issues and recommendations were established. CONCLUSIONS: Public education on weight management is a shared responsibility; there is a need to raise public awareness of obesity and its health-related consequences. Advertising guidelines should ensure responsible direct-to-consumer advertising of weight-loss agents.

Job satisfaction and the association with involvement in clinical activities among hospital pharmacists in Hong Kong.

OBJECTIVES: To describe the relationship between job satisfaction of hospital pharmacists and the extent of their involvement in clinical pharmacy activities, and to examine if demographics and practice characteristics are associated with the extent of involvement in clinical pharmacy activities and job satisfaction. METHODS: A cross-sectional study was conducted by surveying with a self-administered questionnaire mailed to all full-time pharmacists employed by the Hospital Authority, Hong Kong. KEY FINDINGS: Respondents reporting job and career satisfaction averaged near the neutral point. The results indicated an unmet expectation of work balance between clinical activities and drug distribution, with the majority of responding pharmacists desiring a shift of work balance from more drug distributive roles towards more clinical activities. The results also suggested that an unmet expectation in work balance affects job and career satisfaction, particularly in younger, frontline pharmacists. CONCLUSIONS: Younger, frontline pharmacists reported lower job satisfaction and a greater gap of unmet expectations in their work balance. This study highlights the importance of pharmacists' involvement in clinical activities, as job enrichment would improve job satisfaction and maximise benefits towards patients and healthcare organisations.

Prospective memory in patients with first-onset schizophrenia and their non-psychotic siblings.

This behavioral study used a dual-task paradigm to compare PM performance in 35 patients with first-onset schizophrenia, 40 non-psychotic siblings and 35 healthy controls. It aimed specifically to examine the effect of schizophrenia group status on PM, the differential effect of group status on PM type, and correlations between PM and other neurocognitive functions and clinical data in first-onset schizophrenia. It also aimed to test the hypothesis that non-psychotic siblings had poorer PM performance than controls. The cohort of first-onset schizophrenia patients had relatively short illness durations (M=1.7 years). The three groups of participants were matched in terms of age, gender and years of education. Results of the study confirmed that first-onset schizophrenia status had a primary effect on PM after controlling for other neurocognitive functions. We also found that first-onset schizophrenia status did not differentially affect two different types of PM. In the first-onset schizophrenia cohort, PM was found to correlate significantly with IQ, executive functions and sustained attention. Finally, contrary to the findings of the previous study, this study did not find siblings of schizophrenia patients to have impaired PM. Taking into account the previous findings of PM in chronic schizophrenia, we concluded that schizophrenia has a primary effect on PM regardless of illness duration.

Neuropsychological profiles and short-term outcome in late-onset depression.

OBJECTIVE: Neuropsychological impairments are common in older persons with late-onset depression. This study examined the relationship between neuropsychological profiles and short-term outcome in late-onset depression. METHODS: A total of 54 non-demented Chinese elders presented with their first major depressive episode after 60 years of age participated in this study and were treated according to a standardised protocol. At entry, they were assessed on neurological signs (Parkinsonian features and neurological soft signs) and neuropsychological measures (executive function, psychomotor-speed, attention and working memory, episodic memory, conceptualisation, construction and global cognitive function). The Hamilton Depression Rating Scale (HAM-D) was administered at baseline, the sixth and 12th week of treatment. RESULTS: Abnormal fist-edge-palm (FEP) test, a sign reflecting impairment in motor sequencing, was more common in non-remitters (defined as HAM-D score above 7) at the 12th week of treatment. CONCLUSIONS: The FEP test may be included in the clinical assessment for patients with late-onset depression to identify a susceptible group who may require more intensive treatment. Further research is warranted to ascertain the link between late-onset depression, neuropsychological deficits and prognosis.