OBJECTIVE. To evaluate the efficacy and safety of a new generation of 2.45-GHz microwave to ablate hepatocellular carcinoma by surgical approach.

DESIGN. Case series with prospective follow-up.

SETTING. A university teaching hospital in Hong Kong.

PATIENTS. From March 2009 to January 2011, 26 consecutive patients (19 men and 7 women) with a median age of 63 (range, 49-79) years with hepatocellular carcinoma were recruited. Five (19%) of the patients had recurrent hepatocellular carcinoma after previous treatment.

INTERVENTION. Microwave ablation for hepatocellular carcinomas (one tumour, n=24; two tumours, n=2) using a laparoscopic (n=16) or open approach (n=10).

MAIN OUTCOME MEASURES. Operative mortality and morbidity, rate of incomplete ablation, recurrence rate, and survival rate.

RESULTS. The median tumour diameter was 3.8 cm (range, 2.0-6.0 cm). Complications occurred in five (19%) of the patients; only one was ablation-related, and there was no operative mortality. One (4%) of the patients experienced incomplete ablation. Recurrent tumours were noted in 11 (42%) of the patients (5 were local, 2 were remote, and 4 were multifocal) after a median follow-up of 14 (range, 4-26) months. The failure rate for local disease control was 23%, and was 14% if patients with recurrent hepatocellular carcinoma were excluded. All but one patient survived until the time of censorship. The mean survival was 25 (standard deviation, 1) months.

CONCLUSION. This new-generation microwave technique is safe and effective for local ablation of hepatocellular carcinoma. It is a valuable treatment option for patients who are not candidates for hepatectomy.

Key words: Ablation techniques; Carcinoma, hepatocellular; Liver neoplasms; Microwaves

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OBJECTIVE. To report our experience with the first series of serial transverse enteroplasty operations (a novel bowel-lengthening procedure for patients with short bowel syndrome).

DESIGN. Case series.

SETTING. A tertiary paediatric surgery referral centre in Hong Kong.

PATIENTS. Four patients with short bowel syndrome aged 11 months to 14 years underwent serial transverse enteroplasty between November 2007 and June 2010.

RESULTS. A total of six such serial procedures were performed; two patients had repeated operations. Median pre-serial transverse enteroplasty small bowel length was 17.5 cm. The median increase in small bowel length was 90%. One patient experienced transient postoperative intestinal obstruction that resolved after conservative management. The median postoperative follow-up period was 31 months. The median enteral nutrition tolerance increased from 24% to 47%. The median weight-for-age z score increased by 0.55, and the median weight-for-height z score increased by 0.98. One patient had successfully weaned off parenteral nutrition.

CONCLUSION. Serial transverse enteroplasty is a feasible and safe treatment for short bowel syndrome patients, which helps to improve enteral nutrition and promote growth. Repeated serial transverse enteroplasty can be performed in patients with ultra-short bowel lengths. Follow-up is necessary to assess the long-term outcomes.

Key words: Intestinal obstruction; Intestine, small; Reconstructive surgical procedures; Short bowel syndrome

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OBJECTIVE. To investigate whether requests for standard paediatric electroencephalograms accord with guideline recommendations, subsequent changes in clinical management according to reported results, and extent to which the service meets waiting time targets.

DESIGN. Case series.

SETTING. Regional hospital, Hong Kong.

PATIENTS. All patients aged less than 18 years who underwent electroencephalography between December 2009 and February 2010.

MAIN OUTCOME MEASURES. Appropriateness of the electroencephalogram request and the impact of its findings on clinical management.

RESULTS. A total of 109 patients were recruited, but requests for standard electroencephalograms were considered 'inappropriate' with respect to guidelines in 44% of the patients, of which 50% were made to diagnose 'funny turns'. The standard electroencephalogram contributed to the diagnosis or management in only 28% of patients. In all of the latter, the request for an electroencephalogram had been appropriate. Non-specialists made referrals for 86% of the patients. Inadequate information was provided in 66% of the requests. Standard electroencephalograms were performed within guideline targets, the wait being less than 4 weeks in 95% of requests.

CONCLUSION. An effective electroencephalogram service was being provided, though abuses were common. These were mainly because of misconceptions regarding the role and limitations of standard electroencephalograms. Through an educative, non-confrontational approach, and with time to explain guideline recommendations to clinicians, sustainable change in practice could be achieved so as to benefit patients, clinicians, and service provision.

Key words: Child; Electroencephalography; Hospitals, district; Practice guidelines as topic; Utilization review

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OBJECTIVE. To study the success rate, predictors for success, and pregnancy outcomes after external cephalic version.

DESIGN. Historical cohort study.

SETTING. Regional hospital, Hong Kong.

PATIENTS. All women who had singleton term breech pregnancies at term and opted for external cephalic version during 2001 and 2009. Their demographic data, clinical and ultrasound findings, procedure details, complications, and delivery outcomes were analysed.

MAIN OUTCOME MEASURES. Predictive factors for successful external cephalic version.

RESULTS. A total of 209 external cephalic versions were performed during the 9-year period. The success rate was 63% (75% for multiparous and 53% for nulliparous women). There was no significant complication. On univariate analysis, predictors of successful external cephalic version were: multiparity, unengaged presenting part, higher amniotic fluid index (≥10 cm), thin abdominal wall, low uterine tone, and easily palpable fetal head (subjective assessment by practitioners before external cephalic version). On multivariate analysis, only multiparity, non-engagement of the fetal buttock and thin maternal abdomen were associated with successful external cephalic version. In all, 69% of those who had successful external cephalic version succeeded in the first roll (P<0.001), and 82% of the women with successful external cephalic versions had vaginal deliveries (93% in multiparous and 69% in nulliparous women). Uptake rate of external cephalic version was studied in the latter part of the study period (2006-2009). Whilst 735 women were eligible for external cephalic version, 131 women chose to have the procedure resulting in an uptake rate of 18%.

CONCLUSION. External cephalic version was effective in reducing breech presentations at term and corresponding caesarean section rates, but the uptake rate was low. Further work should address the barriers to the low acceptance of external cephalic version. The results of this study could encourage women to opt for external cephalic version.

Key words: Breech presentation; Cesarean section; Version, fetal

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OBJECTIVE. To audit secondary preventive care in non-acute stroke patients in a local General Outpatient Clinic of the Hospital Authority.

DESIGN. Comparison of two samples from a case series at different time-points.

SETTING. General Outpatient Clinic, Hong Kong.

PATIENTS. Non-acute stroke patients fulfilling the inclusion criteria and regularly followed up in a local General Outpatient Clinic during the audit cycle were recruited. Evidence-based audit criteria and performance standards were established after thorough literature review. A sample from this case series was compared retrospectively at two time-points. First-phase evaluation was performed in October 2009 and deficiencies were identified. After 9 months of active intervention, second-phase evaluation was performed in July 2010. Chi squared test and student's t test were used to compare the significance of relevant changes noted.

RESULTS. First-phase data showed marked deficiencies in proper assessment of cardiovascular risk factors. Satisfactory blood pressure, glucose and lipid control was evident only in 47% of the hypertensive, 45% of the diabetic, and 37% of the dyslipidaemic stroke patients, respectively. After 9 months of implementing changes, significant improvements were noted with respect to standard targets being achieved. In the second phase, more comprehensive tackling of cardiovascular risk factors was noted, with satisfactory blood pressure control in 73% of hypertensive patients, and adequate metabolic control in 62% diabetic patients (P<0.01 for both). Only 59% of the dyslipidaemic stroke patients had optimal lipid control, though their mean low-density lipoprotein concentration was significantly reduced (P<0.05).

CONCLUSION. This study provided a valuable lesson in identifying deficiencies in secondary prevention for stroke patients managed in a local primary care facility. Using a team approach intervention, quality assurance was promoted and a definite impact on patient care was demonstrated.

Key words: Cardiovascular diseases; Guideline adherence; Hypertension; Secondary prevention; Stroke

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