As-Required Filgrastim for Late-Onset Neutropenia Complicating Long-Term Clozapine Treatment: a Case Report.

Clozapine is considered the most effective antipsychotic for schizophrenia, but it can cause neutropenia and even agranulocytosis. We describe the first case in Hong Kong involving the use of filgrastim, a recombinant form of human granulocyte colony-stimulating factor, to enable clozapine continuation therapy for a severely ill patient with treatment-resistant schizoaffective disorder who developed recurrent neutropenia after almost 20 years of continuous clozapine therapy. Therefore, clinical vigilance is important, regardless of clozapine treatment duration. Filgrastim can facilitate long-term clozapine therapy in patients with clozapine-induced neutropenia.

Posttraumatic Stress, Anxiety, and Depression in COVID-19 Survivors.

OBJECTIVES: This study aims to examine the rates of anxiety, depression, and posttraumatic stress disorder (PTSD) after hospital discharge among COVID-19 survivors and to determine the associated risk factors. METHODS: Adult COVID-19 survivors discharged from hospitals between March 2020 and March 2021 were asked to complete a questionnaire at 4 weeks after discharge. The Chinese version of the 22-item Impact of Event Scale - Revised (IES-R) was used to measure symptoms of PTSD. The 9-item Patient Health Questionnaire (PHQ-9) was used to assess symptoms of major depressive disorder. The 7-item Generalised Anxiety Disorder Scale (GAD-7) was used to measure symptoms of generalised anxiety disorder. The rates of anxiety, depression, and PTSD among discharged patients were determined, as were associations between psychosocial factors and outcome measures and predictors for moderate-tosevere symptoms of anxiety, depression, and PTSD. RESULTS: 96 men and 103 women aged 18 to 81 years returned the completed questionnaire. 12.1% to 20.1% of them reported symptoms of PTSD, anxiety, or depression. Higher symptom severity was associated with higher perceived life threat, lower emotional support, lower disease severity upon admission, and longer hospital stay. Women had more PTSD symptoms than men, particularly when knowing someone under quarantine. CONCLUSION: COVID-19 survivors with higher perceived life threat, lower emotional support, lower disease severity upon admission, and longer hospital stay were associated with higher severity of symptoms of PTSD, anxiety, and depression. Timely intervention should provide to at-risk survivors.

Miconazole and terbinafine induced reactive oxygen species accumulation and topical toxicity in human keratinocytes.

There are an estimated 1 billion cases of superficial fungal infection globally. Fungal pathogens form biofilms within wounds and delay the wound healing process. Miconazole and terbinafine are commonly used to treat fungal infections. They induce the accumulation of reactive oxygen species (ROS) in fungi, resulting in the death of fungal cells. ROS are highly reactive molecules, such as oxygen (O2), superoxide anion (O2•-), hydrogen peroxide (H2O2) and hydroxyl radicals (•OH). Although ROS generation is useful for killing pathogenic fungi, it is cytotoxic to human keratinocytes. To the best of our knowledge, the effect of miconazole and terbinafine on HaCaT cells has not been studied with respect to intracellular ROS stimulation. We hypothesized that miconazole and terbinafine have anti-wound healing effects on skin cells when used in antifungal treatment because they generate ROS in fungal cells. We used sulforhodamine B protein staining to investigate cytotoxicity and 2',7'-dichlorofluorescein diacetate to determine ROS accumulation at the 50% inhibitory concentrations of miconazole and terbinafine in HaCaT cells. Our preliminary results showed that topical treatment with miconazole and terbinafine induced cytotoxic responses, with miconazole showing higher cytotoxicity than terbinafine. Both the treatments stimulated ROS in keratinocytes, which may induce oxidative stress and cell death. This suggests a negative correlation between intracellular ROS accumulation in keratinocytes treated with miconazole or terbinafine and the healing of fungi-infected skin wounds.

Wilson Sims Fall Risk Assessment Tool Versus Morse Fall Scale in Psychogeriatric Inpatients: a Multicentre Study.

OBJECTIVE: To compare predictive validity of the Wilson Sims Fall Risk Assessment Tool (WSFRAT) with that of the Morse Fall Scale (MFS) in psychogeriatric inpatients. METHODS: Psychogeriatric patients from Shatin Hospital, Tai Po Hospital, Castle Peak Hospital, and United Christian Hospital who had fall incident between April 2019 and April 2020 were identified. Their fall risks were assessed by the WSFRAT and the MFS, and their falls incidents during hospitalisation were recorded. Patients were classified as having high fall risk when their MFS score was ≥45 and when their WSFRAT score was ≥7. Sensitivity, specificity, and positive and negative predictive values of the two scales were calculated. RESULTS: We identified 183 (90 male and 93 female) psychogeriatric patients aged ≥65 years who had fall incident and were assessed by both the WSFRAT and the MFS during the study period. Among the 183 patients, four sustained a fall during hospital stay, giving a prevalence of 2.19%. All four patients were classified as having high risk of fall by WSFRAT, but only two of them were classified so by MFS. The sensitivity of WSFRAT was 100%, which was higher than the 50% by MFS, but specificity of MFS was higher than that of WSFRAT (45.81% vs 54.75%). CONCLUSION: WSFRAT is a better fall risk assessment scale for psychiatric inpatients than MFS, because of higher sensitivity (100% vs 50%). It has items specific to psychiatric patients and should replace MFS in psychiatric settings.

The role of reactive oxygen species in the biological activity of antimicrobial agents: An updated mini review.

Antimicrobial resistance remains a serious problem that results in high mortality and increased healthcare costs globally. One of the major issues is that resistant pathogens decrease the efficacy of conventional antimicrobials. Accordingly, development of novel antimicrobial agents and therapeutic strategies is urgently needed to overcome the challenge of antimicrobial resistance. A potential strategy is to kill pathogenic microorganisms via the formation of reactive oxygen species (ROS). ROS are defined as a number of highly reactive molecules that comprise molecular oxygen (O2), superoxide anion (O2•-), hydrogen peroxide (H2O2) and hydroxyl radicals (•OH). ROS exhibit antimicrobial actions against a broad range of pathogens through the induction of oxidative stress, which is an imbalance between ROS and the ability of the antioxidant defence system to detoxify ROS. ROS-dependent oxidative stress can damage cellular macromolecules, including DNA, lipids and proteins. This article reviews the antimicrobial action of ROS, challenges to ROS hypothesis, work to solidify ROS-mediated antimicrobial lethality hypothesis, recent developments in antimicrobial agents using ROS as an antimicrobial strategy, safety concerns related to ROS, and future directions in ROS research.

Combining hippocampal volume metrics to better understand Alzheimer's disease progression in at-risk individuals.

To date nearly all clinical trials of Alzheimer's disease (AD) therapies have failed. These failures are, at least in part, attributable to poor endpoint choice and to inadequate recruitment criteria. Recently, focus has shifted to targeting at-risk populations in the preclinical stages of AD thus improved predictive markers for identifying individuals likely to progress to AD are crucial to help inform the sample of individuals to be recruited into clinical trials. We focus on hippocampal volume (HV) and assess the added benefit of combining HV and rate of hippocampal atrophy over time in relation to disease progression. Following the cross-validation of previously published estimates of the predictive value of HV, we consider a series of combinations of HV metrics and show that a combination of HV and rate of hippocampal atrophy characterises disease progression better than either measure individually. Furthermore, we demonstrate that the risk of disease progression associated with HV metrics does not differ significantly between clinical states. HV and rate of hippocampal atrophy should therefore be used in tandem when describing AD progression in at-risk individuals. Analyses also suggest that the effects of HV metrics are constant across the continuum of the early stages of the disease.

DNA barcoding implicates 23 species and four orders as potential pollinators of Chinese knotweed (Persicaria chinensis) in Peninsular Malaysia.

Chinese knotweed (Persicaria chinensis) is of ecological and economic importance as a high-risk invasive species and a traditional medicinal herb. However, the insects associated with P. chinensis pollination have received scant attention. As a widespread invasive plant we would expect P. chinensis to be associated with a diverse group of insect pollinators, but lack of taxonomic identification capacity is an impediment to confirm this expectation. In the present study we aimed to elucidate the insect pollinators of P. chinensis in peninsular Malaysia using DNA barcoding. Forty flower visitors, representing the range of morphological diversity observed, were captured at flowers at Ulu Kali, Pahang, Malaysia. Using Automated Barcode Gap Discovery, 17 morphospecies were assigned to 23 species representing at least ten families and four orders. Using the DNA barcode library (BOLD) 30% of the species could be assigned a species name, and 70% could be assigned a genus name. The insects visiting P. chinensis were broadly similar to those previously reported as visiting Persicaria japonica, including honey bees (Apis), droneflies (Eristalis), blowflies (Lucilia) and potter wasps (Eumedes), but also included thrips and ants.

Six-month Follow-up of Cognitive Impairment and Depressive Symptoms in Late-onset Depression.

OBJECTIVE: To assess cognitive performance in elderly depressed patients following treatment for 6 months. Remission rate of depression after 6 months of treatment was calculated. METHODS: The study was performed in a consecutive group of patients aged ≥ 65 years with late-onset depression. Severity of depression was assessed by the Hamilton Depression Scale, cognitive performance by the Hong Kong Montreal Cognitive Assessment, and functional level by the Instrumental Activities of Daily Living Scale. RESULTS: A total of 52 patients were recruited. In all, 28 (53.8%) were found to have cognitive impairment at baseline and 8 (28.6%) of them had improvement after 6 months. This cognitively impaired group was older and had a lower Instrumental Activities of Daily Living Scale score. The remission rate of depression was 61.5%. CONCLUSIONS: Cognitive impairment constituted a stable feature in a considerable number of elderly patients with depression. About two-thirds of patients achieved remission of depression after 6 months of treatment.

Consultation-liaison service in a regional hospital in Hong Kong.

OBJECTIVE: To examine consultation-liaison psychiatric services in a general hospital in Hong Kong. METHODS: All records of Tseung Kwan O Hospital psychiatric consultations from 1 July 2012 to 30 June 2013 were extracted from the database. Patients' demographic data, sources and reasons of referral, psychiatric and suicidal histories, current suicidal attempt, psychiatric diagnoses, psychiatric outcomes, as well as waiting times were analysed accordingly. RESULTS: A total of 1392 psychiatric consultations were received, of which 82% were attended to within the same working day when the referral was received, and 99% were attended to by the end of the next working day. The commonest reasons of consultation were unstable emotion followed by suicidal / deliberate self-harm and aggression. There were 246 consultations with actual suicidal attempt. Overall, 270 (19%) patients who received consultation-liaison psychiatric services were admitted to the psychiatric wards. Follow-up in the psychiatric outpatient department was arranged for 691 (50%) patients while 57 (4%) required referral to the community psychiatric nursing service in addition to outpatient department arrangement. CONCLUSIONS: Management of suicidal attempters and provision of risk assessment continue to be the major tasks of consultation-liaison psychiatrists and nurses. A readily available on-site consultation-liaison psychiatric service is an essential component of services provided in acute general hospitals.

Promotion of a healthy public living environment: participatory design of public toilets with visually impaired persons.

OBJECTIVES: The principal objective of a healthy living environment is to improve the quality of everyday life. Visually impaired persons (VIPs) encounter many difficulties in everyday life through a series of barriers, particularly in relation to public toilets. This study aimed to explore the concerns of VIPs in accessing public toilets, and identify methods for improvement. Considerations about user participation are also discussed. STUDY DESIGN: Adopting a case study approach, VIPs were invited to participate in the research process. METHODS: In addition to in-depth interviews and field visits, models and a simulated full-scale environment were produced to facilitate the VIPs to voice their opinions. RESULTS: The key findings indicate that the design of public toilets for promoting public health should be considered and tackled from a three-level framework: plain, line and point. Governments, professionals and the public need to consider the quality of public toilets in terms of policy, implementation and management. CONCLUSIONS: VIPs have the right to access public toilets. Governments and professionals should respect the particular needs and concerns of VIPs. A three-level framework (plain, line and point) is required to consider the needs of VIPs in accessing public toilets, and user participation is a good way to reveal the actual needs of VIPs.

Patients committing suicide whilst under the care of the elderly suicide prevention programme of a regional hospital in Hong Kong.

OBJECTIVE: To examine the risk factors for suicide in elderly Hong Kong Chinese. METHODS: Case notes, mortality reports and hospital records of all the patients, who committed suicide from 1 July 2002 to 31 March 2010 whilst under the active care of the Elderly Suicide Prevention Programme of the Castle Peak Hospital in Hong Kong, were reviewed. RESULTS: A total of 1230 elderly with high risk of suicide were assessed and treated from 1 July 2002 to March 2010. A total of 8 patients in this programme who committed suicide during this period were identified, of whom 63% were male and the most frequent method employed was jumping from a height. All the suicides ensued within the first 6 weeks of treatment under the programme. All these patients were diagnosed to have a depressive illness, and all but 1 had an associated physical illness that possibly precipitated the suicide. They had all been admitted to either a mental or general hospital, about 1 month before committing suicide. CONCLUSIONS: The first 2 months of treatment is associated with the highest risk of suicide. Intensive care and support with proper education about effects of antidepressants, and the building-up of a trusted therapeutic alliance with close relatives are particularly important in this vulnerable period.

Management and prevention of spontaneous pneumothorax using pleurodesis in Hong Kong.

BACKGROUND: The practice of pleurodesis for the management and prevention of spontaneous pneumothorax (SP) is uncertain. DESIGN: A retrospective multicentre analysis of patients admitted to 12 hospitals in Hong Kong with SP in 2004 and who subsequently underwent pleurodesis for the same episode. RESULTS: Pleurodesis was performed in 394 episodes. Initial medical chemical pleurodesis was performed for 258 (65.5%) patients ('initial medical group'), while 136 (34.5%) underwent initial surgical pleurodesis ('initial surgical group'). Secondary spontaneous pneumothorax (SSP; 237 episodes, 60.2%) was the most common indication for pleurodesis; it was also performed after a first episode of primary spontaneous pneumothorax (PSP) in 22 episodes (5.6%). Tetracycline derivatives (172 episodes, 66.7%) were the most popular sclerosing agents in the initial medical group. Those in the initial medical group were older and were more likely to be males, have SSP, chronic obstructive pulmonary disease and a history of past pleurodesis (P < 0.05) compared to the initial surgical group. Compared to the tetracycline group, more patients who initially received talc slurry had the procedure performed by surgeons, had larger (≥2 cm) pneumothorax or required suction during initial drainage (P < 0.05). CONCLUSIONS: Despite the availability of international guidelines, there is considerable variation in pleurodesis for SP.

A rare combination of recurrent pneumonia, diarrhoea, and visual loss in a patient after thymectomy: good syndrome.

This report describes a 68-year-old Chinese man who was diagnosed with Good syndrome 6 years after initial presentation when he underwent thymectomy. He presented with recurrent pneumonia, diarrhoea, weight loss, and visual symptoms. Extensive examination for anaemia and neutropenia was done, yet no conclusive diagnosis could be derived. During his last admission for pneumonia, his history of AB thymoma suggested the possibility of Good syndrome. Immunological testing revealed low T cells, absent B cells, and low immunoglobulin M and immunoglobulin G levels. Moreover, he had histologically identified cytomegalovirus pneumonia, cytomegalovirus colitis, and fundoscopic features of cytomegalovirus retinitis. He was treated with a 2-week course of intravenous ganciclovir, lifelong oral valganciclovir, and monthly immunoglobulin infusion. It took 6 years for the diagnosis to be established, therefore, early attention and vigorous search for such potentially treatable conditions in post-thymectomy patients presenting with recurrent infections is recommended.

Minocycline and talc slurry pleurodesis for patients with secondary spontaneous pneumothorax.

SETTING: Few studies have evaluated the sclerosing efficacy of minocycline, and none have specifically compared its sclerosing efficacy and safety profiles with talc slurry in secondary spontaneous pneumothorax (SSP). DESIGN: A retrospective analysis was conducted in patients with SSP who underwent chemical pleurodesis from January to December 2004 with minocycline or talc slurry in 12 public hospitals of Hong Kong. RESULT: There were 121 episodes of minocycline pleurodesis and 64 episodes of talc slurry pleurodesis. Immediate procedural failure were similar in the minocycline and talc slurry groups (21.5% vs. 28.1%, P = 0.31). Presence of interstitial lung disease, ≥ 2 previous episodes of pneumothorax, requiring mechanical ventilation during pleurodesis and persistent air leak before pleurodesis were independently associated with procedural failure. Pain was experienced in respectively 44.6% and 37.5% of the minocycline and the talc slurry groups. Pain was more common in patients receiving high doses of talc (≥ 5 g; P = 0.03). Respiratory distress was found in respectively 1.7% and 1.6% of the minocycline and talc slurry groups. CONCLUSION: Minocycline and talc slurry had comparable sclerosing efficacy in SSP, with immediate success rates of >70%. Pain was the most common adverse effect and respiratory distress was uncommon. Both appeared to be effective and safe for chemical pleurodesis in SSP.

Body weight perception and methods of weight reduction used by patients with first-episode psychotic disorders in Hong Kong.

OBJECTIVES: To examine subjective weight perception of patients with first-episode psychotic disorders, perceived reasons for believing they were overweight, and methods employed for weight reduction (about 1 year) whilst in receipt of antipsychotics. METHODS: A total of 160 consecutive participants with a 1-year history of first-episode psychotic disorders were recruited and their body mass index, subjective weight perception, and the wish to do something about their weight were assessed. RESULTS: For patients of both genders with first-episode psychotic disorders, weight control behaviours were more associated with the perceived weight status than their actual weight. Most participants who perceived themselves as overweight believed that their weight problem was caused by the antipsychotics they had been taking. Self-reduction of antipsychotics was the commonest method they resorted to in the belief it would result in weight reduction. CONCLUSIONS: There is a need to implement more structured weight loss and physical exercise programmes for patients with first-episode psychotic disorder in order to maintain their physical and mental health.

Extent of weight gain in patients with first-episode psychotic disorders after one year of antipsychotic treatment in Hong Kong.

OBJECTIVES: This study aimed to examine the extent of weight gain in a group of patients with first-episode psychotic disorders after receiving antipsychotic treatment for 1 year, and to examine any relationship with the type of antipsychotics prescribed. PARTICIPANTS AND METHODS: A total of 160 consecutive participants with 1-year history of first-episode psychotic disorders were recruited, and their body mass index values before and 1 year after antipsychotic treatment were calculated. RESULTS: About half of the participants gained more than 7% of their baseline body weight. In general, the participants gained a median weight of 4.8 kg (interquartile range, 0.7-9.0 kg) after 1 year of treatment. Forty percent of the female and 47% of the male participants were overweight after treatment. Patients taking second-generation antipsychotics had more severe weight gain than those taking first-generation agents. Olanzapine treatment was associated with the greatest weight gain. CONCLUSIONS: Weight gain is a significant problem even in the early stages of psychotic disorders. Health care professionals need to be aware of this issue and address it early in the course of management, so as to prevent harmful consequences of weight gain in the future.

Contactless recording of photoplethysmogram on a sleeping bed.

This paper reports a novel contactless monitoring method to record reflective mode photoplethysmogram (PPG) on a sleeping bed for heart rate (HR) estimation. The electrocardiogram (ECG) and pulse transit time (PTT) were also measured in this study. ECG was measured from subjects' limbs whilst PPG was obtained from their right index fingers and their backs with and without direct contact between the PPG sensor and the subjects' skin respectively. Clear PPG waveforms were obtained from the subjects' backs even though the sensor was not directly attached to their skin. Beat-to-beat HRs derived from the back PPGs were closely correlated with those measured from the finger PPGs and ECGs. Thus we found that contactless PPG could be captured from the subjects' backs to determine HR accurately.

Impedance cardiography for cuffless and non-invasive measurement of systolic blood pressure.

In this study, we have used impedance cardiography to determine blood pressure (BP) cufflessly and non-invasively. We have devised a new parameter, QdZ [the duration measured from the foot of electrocardiogram (ECG) Q wave to the peak of impedance cardiogram (ICG)], for this purpose. Twenty-two subjects performed four minutes of treadmill exercise such that systolic BP (SBP) was increased significantly. We found that SBP was closely correlated with QdZ (R(2)=0.65) demonstrating the potential application of ICG to cuffless and non-invasive BP measurement.

Autoimmunity in bullous pemphigoid.

Bullous pemphigoid (BP) is an autoimmune blistering disease primarily of the elderly, characterized by the development of urticarial plaques surmounted by subepidermal blisters and the deposition of immunoglobulins and complement at the basement membrane zone (BMZ). Immunologically, it is characterized by the development of autoantibodies targeting two structural proteins of the hemidesmosomes, BP180 (collagen XVII) and BP230. BP230 is intracellular protein of the hemidesmosomal plaque, while BP180 is a transmembrane protein with a collagenous extracellular domain. The weight of experimental evidence indicates that BP180 is the primary target of the pathogenic autoantibodies. Autoantibodies are of both the IgG or IgE class, and their binding in the skin triggers complement activation, mast cell degranulation and the accumulation of inflammatory cells, including eosinophils, mast cells, and neutrophils. Release of proteases from these inflammatory cells results in cleavage of the BMZ and blister formation. While the initial triggers of autoantibody production remain obscure, a better understanding of the pathomechanisms of blister formation will lead to the development of new therapeutic strategies.