Sublingual misoprostol compared to artificial rupture of membrames plus oxytocin infusion for labour induction in nulliparous women with a favourable cervix at term

ABSTRACT
Hong Kong Med J 2006;12:345-50 | Number 5, October 2006
ORIGINAL ARTICLE
Sublingual misoprostol compared to artificial rupture of membrames plus oxytocin infusion for labour induction in nulliparous women with a favourable cervix at term
TK Lo, WL Lau, KS Wong, LCH Tang
Department of Obstetrics and Gynaecology, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong
 
 
OBJECTIVE. To compare the efficacy of labour induction using sublingual misoprostol versus combined artificial rupture of membranes and oxytocin infusion for nulliparous women with a favourable cervix at term.
 
DESIGN. Open randomised controlled trial.
 
SETTING. Regional hospital, Hong Kong. PATIENTS. Fifty nulliparous women with a favourable cervix (Bishop score 6 or more) at term and indications for labour induction.
 
INTERVENTIONS. With their informed consent, 100 eligible women were to be randomised to receive either sublingual misoprostol 50 micrograms every 4 hours for up to five doses or oxytocin infusion after artificial rupture of membranes. Interim analysis was planned at a sample size of 50.
 
MAIN OUTCOME MEASURES. Vaginal delivery within 24 hours of induction.
 
RESULTS. The study was terminated when interim analysis of the first 50 recruits showed that a significantly smaller proportion of misoprostol-treated women delivered vaginally within 24 hours of induction than in the conventional treatment group (68% vs 100%; relative risk, 0.68; 95% confidence interval, 0.51-0.91; P=0.009), although comparable numbers of women eventually delivered vaginally. The mean induction to vaginal delivery interval was 4.5 hours longer in the misoprostol group (P=0.027). After misoprostol treatment, all women went into labour. Forty percent of them delivered without oxytocin. There was no significant difference in uterine hyperstimulation rate, operative delivery rate, and neonatal outcomes. Maternal satisfaction was higher in the misoprostol group (92% vs 60%; relative risk, 1.53; 95% confidence interval, 1.09-2.16; P=0.008).
 
CONCLUSIONS. Despite being well accepted by women, labour induction using this regimen of sublingual misoprostol is less effective in achieving vaginal delivery within 24 hours.
 
Key words: Cervix uteri; Labor, induced; Misoprostol; Oxytocin
 
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Twelve years' local experience in ambulatory anaesthesia

ABSTRACT
Hong Kong Med J 2006;12:339-44 | Number 5, October 2006
ORIGINAL ARTICLE
Twelve years' local experience in ambulatory anaesthesia
AKW Lai, V Ho, YF Chow
Department of Anaesthetia, Queen Elizabeth Hospital, 30 Gascoigne Road, Hong Kong
 
 
OBJECTIVES. To determine the incidence of adverse events after ambulatory anaesthesia (postoperative nausea and vomiting, postoperative pain, difficulty in movement), and to evaluate the level of satisfaction of patients with our service.
 
DESIGN. Retrospective study with questionnaire survey.
 
SETTING. Tertiary referral centre, Hong Kong.
 
PARTICIPANTS. All patients whose duly completed questionnaires were available.
 
MAIN OUTCOME MEASURES. Incidence of adverse events and level of patient satisfaction.
 
RESULTS. A total of 9197 patients underwent surgery under general anaesthesia or neuraxial blockade by anaesthetists in ambulatory settings from October 1993 to December 2005: questionnaires filled out by 8231 of these patients were analysed, whereas 549 questionnaires were lost, and 417 patients could not be contacted. The response rate was 90%; 59% of the respondents were males, 50% were younger than 15 years and 5% older than 60 years. Fifty-one percent of surgery with anaesthetists' involvement was performed under general anaesthesia and 48.9% under general anaesthesia and regional blocks and 0.1% under neuraxial blockade. There were 3.3% of patients experienced postoperative nausea and vomiting, 60.2% experienced episodes of pain between the time of discharge and the time of interview, and 46% required analgesics. Nonetheless, 80% resumed normal activities within 5 hours after anaesthesia and 97.5% resumed normal diet the following morning. Over 99% rated our service as good or excellent.
 
CONCLUSION. Although ambulatory anaesthesia was associated with minor adverse events, patients could resume normal diet and daily activities quickly and were satisfied with the service.
 
Key words: Ambulatory care; Ambulatory surgical procedures; Anesthesia; Postoperative nausea and vomiting
 
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Drug-induced hypoglycaemia--new insight into an old problem

ABSTRACT
Hong Kong Med J 2006;12:334-8 | Number 5, October 2006
ORIGINAL ARTICLE
Drug-induced hypoglycaemia--new insight into an old problem
CK Ching, CK Lai, WT Poon, MC Lui, YH Lam, CC Shek, TWL Mak, AYW Chan
Hospital Authority Toxicology Reference Laboratory, Princess Margaret Hospital, Laichikok, Hong Kong
 
 
OBJECTIVE. To review the causes of drug-induced hypoglycaemia in patients not taking hypoglycaemic medications.
 
DESIGN. Retrospective study.
 
SETTING. Regional hospitals in Hong Kong.
 
PATIENTS. Patients with suspected drug-induced hypoglycaemia without a known history of exposure to hypoglycaemic agents, referred to the Hospital Authority Toxicology Reference Laboratory from June 2005 to March 2006 inclusive.
 
MAIN OUTCOME MEASURES. Rate of positive cases, laboratory findings, possible causes, age distribution, and final outcomes. RESULTS. A total of 51 such patients were referred, in whom the presence of oral hypoglycaemic agents was detected (or inferred) in 23 (45%). In 12 of the 23 patients, oral hypoglycaemic agents could only be detected by target analysis, not through broad-spectrum screening. Gliclazide and glibenclamide were detected in 14 and eight patients respectively, whereas glimepiride, nateglinide and rosiglitazone were detected in the remaining patient. Possible sources of oral hypoglycaemic agents included drug administration errors in residential care homes for the elderly (n=9), mistakenly taking medication of a family member or employer (n=6), taking stock medication by mistake (n=2), taking Chinese proprietary medicine adulterated with oral hypoglycaemic agents (n=1), taking unknown pills bought from a retail pharmacy (n=1), and unknown (n=4). Regarding these 23 patients, 17 (74%) were aged 70 years or above and 21 (91%) recovered uneventfully.
 
RESULTS. 
 
CONCLUSION. Hypoglycaemia due to inadvertent use of oral hypoglycaemic agents is a recognised problem, particularly in cases where family members living in the same household are taking similar medications. Possible drug administration errors in residential care homes for the elderly should be investigated, and procedures rectified if confirmed. Health care providers should be vigilant to such potential errors, especially in cases of unexplained hypoglycaemia.
 
Key words: Hypoglycemia; Poisoning; Sulphonylurea compounds
 
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Risk factors for injury to married women from domestic violence in Hong Kong

ABSTRACT
Hong Kong Med J 2006;12:289-93 | Number 4, August 2006
ORIGINAL ARTICLE
Risk factors for injury to married women from domestic violence in Hong Kong
KL Tsui, AY Chan, FL So, CW Kam
Department of Accident and Emergency Medicine, Tuen Mun Hospital, Tsing Chung Koon Road, Tuen Mun, Hong Kong
 
 
OBJECTIVE. To examine risk factors for injury to married women from domestic violence in Hong Kong.
 
DESIGN. Case control study.
 
SETTING. Regional public hospital, Hong Kong.
 
PATIENTS. All married women aged 18 to 60 years who attended an accident and emergency department for treatment of a domestic violence injury from January 2004 to June 2005.
 
MAIN OUTCOME MEASURES. Social and health characteristics of abused women and their husbands.
 
RESULTS. A total of 293 cases were compared to 313 controls. Eight predictive variables were found to be significant by univariate analysis: woman who is a new immigrant (P=0.003), woman with no job (P=0.019), husband with low educational level (P<0.001), presence of extramarital affairs (P<0.001), husband's unemployment (P<0.001), husband's alcohol abuse (P<0.001), husband's illicit drug abuse (P=0.032), husband's mental illness (P<0.001). Five factors were found to be significant in a logistic regression analysis: husband with a low educational level (nil to primary) [adjusted odds ratio=2.78; 95% confidence interval, 1.149-6.727], husband unemployed (adjusted odds ratio=9.031; 95% confidence interval, 5.163-15.796), presence of extramarital affairs (adjusted odds ratio=5.218; 95% confidence interval, 2.899-9.395), husband's alcohol abuse (adjusted odds ratio=6.089; 95% confidence interval, 3.460-10.716), husband's mental illness (adjusted odds ratio=9.443; 95% confidence interval, 2.351-37.926).
 
CONCLUSIONS. Several significant risk factors have been identified for injury incurred during domestic violence to married women in Hong Kong. It provides information useful for developing local preventive strategies.
 
Key words: Battered women; Domestic violence; Risk factors
 
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Nissen fundoplication and gastrostomy in severely neurologically impaired children with gastroesophageal reflux

ABSTRACT
Hong Kong Med J 2006;12:282-8 | Number 4, August 2006
ORIGINAL ARTICLE
Nissen fundoplication and gastrostomy in severely neurologically impaired children with gastroesophageal reflux
KM Cheung, HW Tse, PWT Tse, KH Chan
Department of Paediatrics, Caritas Medical Centre, 111 Wing Hong Street, Shamshuipo, Hong Kong
 
 
OBJECTIVES. To study the effect of Nissen fundoplication and gastrostomy in severely neurologically impaired children.
 
DESIGN. Prospective observational study.
 
SETTING. Developmental Disabilities Unit of a regional medical centre in Hong Kong.
 
PATIENTS. Children with severe neurological impairment and gastroesophageal reflux who were institutionalised between 1999 and 2004 inclusive.
 
MAIN OUTCOME MEASURES. Incidence of vomiting, gastro-intestinal bleeding, and pneumonia in the baseline year and consecutive years following surgery; 24-hour oesophageal pH monitoring; recurrence rate (determined by 24-hour oesophageal monitoring); body weight; complications of surgery; and mortality.
 
RESULTS. Twenty children, with a mean age at surgery of 8.5 (standard deviation, 3.5) years, were recruited. Nissen fundoplication was performed in nine children and 11 children underwent laparoscopic fundoplication. Children were monitored for 1.3 to 5.7 years (median, 3.5 years) after surgery. The incidence of vomiting and gastro-intestinal bleeding was significantly decreased following surgery (P<0.001 and P=0.001, respectively; Friedman's test). There was no difference between the preoperative and postoperative incidence of pneumonia (P=0.973, Friedman's test). The median reflux index was reduced from 5.7% to 0.15% after surgery but six (30%) patients had recurrent gastroesophageal reflux. The mean body weight was 17.4 kg (standard deviation, 4.7 kg) at baseline and 22.8 kg (standard deviation, 4.4 kg) at the end of follow-up (P<0.05, Student's t test). One patient had mild dumping syndrome soon after fundoplication. One patient had one episode of intestinal obstruction. Four patients died 1.9 to 5.0 years following surgery due to respiratory disease.
 
CONCLUSION. Our results indicate that in severely neurologically impaired children with gastroesophageal reflux, vomiting, gastro-intestinal bleeding, and reflux indices based on 24-hour oesophageal pH monitoring were significantly reduced following fundoplication and gastrostomy. The incidence of pneumonia was unchanged. The recurrence rate of reflux was 30% and mortality rate was 20%.
 
Key words: Child; Fundoplication; Gastroesophageal reflux; Mental retardation; Recurrence
 
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Subcutaneous extralesional triamcinolone acetonide injection versus conservative management in the treatment of chalazion

ABSTRACT
Hong Kong Med J 2006;12:278-81 | Number 4, August 2006
ORIGINAL ARTICLE
Subcutaneous extralesional triamcinolone acetonide injection versus conservative management in the treatment of chalazion
CF Chung, JSM Lai, PSH Li
Department of Ophthalmology, United Christian Hospital, Kwun Tong, Hong Kong
 
 
OBJECTIVE. To compare the efficacy of subcutaneous extralesional triamcinolone acetonide injection versus conservative treatment for chalazion.
 
DESIGN. Randomised controlled trial.
 
SETTING. Eye clinics of two regional hospitals in Hong Kong.
 
PATIENTS. Patients over 18 years old presenting with primary chalazion were randomised into two groups. In group 1, 12 patients were treated with lid hygiene, warm compresses, and chloramphenicol 1% ointment 4 times a day. In group 2, 16 patients were treated with 0.3 mL triamcinolone acetonide (10 mg/mL) injection to the subcutaneous tissue extralesionally via the percutaneous route. Exclusion criteria were: acutely infected chalazion with preseptal cellulitis, recurrent chalazion, small chalazion (<=2 mm), and prior treatment to chalazion.
 
MAIN OUTCOME MEASURES. Size of chalazion, recurrence of chalazion, intraocular pressure, and complications from treatment, including skin pigmentary change or atrophy and pyogenic granuloma.
 
RESULTS. There was a clinically and statistically significant difference between the success rates in group 1 (58.3%) and group 2 (93.8%). In group 1, the mean prior duration of chalazion before treatment was significantly shorter in success cases than in failed cases. One patient with multiple chalazia in group 2 developed hypopigmentary skin changes at one treatment site.
 
CONCLUSION. Lupus vulgaris and tuberculosis verrucosa cutis remain the commonest forms of true cutaneous tuberculosis, and erythema induratum is the most common tuberculid. Culture and polymerase chain reaction are positive in a small proportion of patients.
 
Key words: Chalazion; Injections, subcutaneous; Triamcinolone acetonide
 
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Cutaneous tuberculosis in Hong Kong: an update

ABSTRACT
Hong Kong Med J 2006;12:272-7 | Number 4, August 2006
ORIGINAL ARTICLE
Cutaneous tuberculosis in Hong Kong: an update
CK Ho, MH Ho, LY Chong
Social Hygiene Service (Dermatology Division), Department of Health, Yaumatei Dermatology Clinic, 12/F, Yaumatei Specialist Clinic, 143 Battery Street, Hong Kong
 
 
OBJECTIVE. To provide an update on cutaneous tuberculosis in Hong Kong.
 
DESIGN. Retrospective study.
 
SETTING. Social Hygiene Service (Dermatology Division), the largest dermatological referral centre in Hong Kong.
 
PATIENTS. Patients presented with cutaneous tuberculosis between 1993 and 2002 inclusive. Case notes, histology reports, and microbiological reports were reviewed with particular reference to the epidemiology, duration of illness, history of contact with tuberculosis, culture results, and response to treatment.
 
RESULTS. There were 147 patients with cutaneous tuberculosis; among these a few had true cutaneous tuberculosis (n=16) and the remainder were tuberculids (n=131). In all they accounted for 0.04% of new dermatology cases diagnosed. Cases of cutaneous tuberculosis were distributed as follows: lupus vulgaris (n=6, 4%), tuberculosis verrucosa cutis (n=6, 4%), tuberculosis of the skin unclassified (n=2, 1%), and orificial tuberculosis (n=2, 1%). Culture and polymerase chain reaction was positive in less than half of the latter cases. All responded well to anti-tuberculosis therapy. Erythema induratum was the most common form (n=127, 86%), but papulonecrotic tuberculids (n=4, 3%) were uncommon. Erythema induratum affected the lower limb in all patients, with a female predominance, and responded to isoniazid monotherapy, multidrug anti-tuberculosis therapy, or doxycycline.
 
CONCLUSION. Lupus vulgaris and tuberculosis verrucosa cutis remain the commonest forms of true cutaneous tuberculosis, and erythema induratum is the most common tuberculid. Culture and polymerase chain reaction are positive in a small proportion of patients.
 
Key words: Erythema induratum; Isoniazid; Lupus; Tetracycline; Tuberculosis, cutaneous
 
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Intestinal tuberculosis in a regional hospital in Hong Kong: a 10-year experience

ABSTRACT
Hong Kong Med J 2006;12:264-71 | Number 4, August 2006
ORIGINAL ARTICLE
Intestinal tuberculosis in a regional hospital in Hong Kong: a 10-year experience
VKS Leung, ST Law, CW Lam, ISC Luk, TN Chau, TKL Loke, WH Chan, SH Lam
Department of Medicine and Geriatrics, United Christian Hospital, Kwun Tong, Hong Kong
 
 
OBJECTIVE. To study the clinical and pathological characteristics of patients with intestinal tuberculosis.
 
DESIGN. Retrospective study.
 
SETTING. United Christian Hospital, Hong Kong.
 
PATIENTS. Patients with intestinal tuberculosis diagnosed between January 1995 and December 2004 inclusive.
 
RESULTS. The median age of the 13 male and 9 female patients was 53 years (range, 12-81 years). Nineteen (86%) had a definitive diagnosis of intestinal tuberculosis confirmed by the presence of caseating granulomas and/or acid-fast bacilli in histological specimens. In three (14%) the diagnosis was based on histology revealing non-caseating granulomas and a positive response to anti-tuberculous treatment. Common symptoms included abdominal pain (82%), diarrhoea (55%), weight loss (55%), and fever (45%). Three (14%) of the patients were complicated by intestinal obstruction, and another two (9%) had intestinal perforation. Four (18%) had concomitant active pulmonary tuberculosis. The most frequently involved site was the ileocaecal region, which was affected in 19 (86%) patients. Other sites included the jejunum, ascending and sigmoid colon. The diagnosis of intestinal tuberculosis was facilitated by examination of colonoscopic biopsy specimens (11 patients), and by examination of resected surgical specimens in the remainder. Two patients died from terminal malignancy. The remainder completed anti-tuberculous therapy and responded satisfactorily.
 
CONCLUSIONS. The diagnosis of intestinal tuberculosis is difficult due to the lack of specific signs or symptoms. Colonoscopy with ileoscopy are useful tools in the search for colonic and terminal ileal tuberculosis. Surgical exploration is reserved for equivocal cases and for those who present as emergencies.
 
Key words: Cecum; Colonoscopy; Granuloma; Ileum; Tuberculosis, gastrointestinal
 
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Seizure-related injury in an adult tertiary epilepsy clinic

ABSTRACT
Hong Kong Med J 2006;12:260-3 | Number 4, August 2006
ORIGINAL ARTICLE
Seizure-related injury in an adult tertiary epilepsy clinic
S Tiamkao, SD Shorvon
Division of Neurology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
 
 
OBJECTIVE. To assess the frequency, characteristics, and risk of injury during seizure attacks.
 
DESIGN. Questionnaire survey.
 
SETTING. Epilepsy out-patient clinic of the National Hospital for Neurology and Neurosurgery, Institute of Neurology, London.
 
PATIENTS. One hundred consecutive epileptic patients and their caretakers or relatives, who attended the hospital between 1 May and 30 June 2000.
 
MAIN OUTCOME MEASURES. Details of epilepsy including the age of onset, causes, types, and number of seizures during the previous 12 months; injuries incurred as a result of seizures; and treatment required.
 
RESULTS. The mean age of the 100 patients (38 male, 62 female) was 39 years (range, 16-78 years). Generalised tonic-clonic seizures occurred in 51% of patients and complex partial seizures in 40%. Hippocampal sclerosis was found in 12% of patients. Twenty-seven patients reported 222 seizure-related injuries. The total number of seizures per year was 4459 (mean, 45), of which 1094 (mean, 11) were with a fall (24.5%). Soft-tissue injury was the most common (61%), followed by burns (17%), head injury (14%), orthopaedic injury (5%), and injuries in water (3%). The most common site of soft-tissue injury and burns were to the face: 49% and 38% respectively. Burns occurred during cooking in 78% of cases. Two patients had skull fractures. Orthopaedic injuries usually occurred at home (73%). In cases of seizures in water, five of six occurred while swimming. Injury occurred once in every 20 seizures, every 11 generalised tonic-clonic seizures, and every five seizures with a fall. The significant risk factors for injury were generalised tonic-clonic seizures, high frequency of seizures, and seizures with a fall.
 
CONCLUSION. Soft-tissue injury was the most common seizure-related injury. Injury occurred once in every 20 seizures. The risk factors were generalised tonic-clonic seizures, high frequency of seizures, and seizures with a fall.
 
Key words: Risk factors; Seizures; Soft tissue injuries
 
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Use of lithium in the treatment of thyrotoxicosis

ABSTRACT
Hong Kong Med J 2006;12:254-9 | Number 4, August 2006
ORIGINAL ARTICLE
Use of lithium in the treatment of thyrotoxicosis
YW Ng, SC Tiu, KL Choi, FKW Chan, CH Choi, PS Kong, CM Ng, CC Shek
Department of Medicine, Queen Elizabeth Hospital, 30 Gascoigne Road, Hong Kong
 
 
OBJECTIVES. To evaluate the efficacy and safety of lithium in the treatment of thyrotoxicosis, and to study the dose and serum levels at which therapeutic response occurs.
 
DESIGN. Retrospective study.
 
SETTING. Thyroid clinic of a regional hospital in Hong Kong.
 
PATIENTS. Thirteen patients with thyrotoxicosis pending therapy with radioiodine or surgery, in whom thionamides were contra-indicated due to adverse reactions or failure of treatment.
 
MAIN OUTCOME MEASURES. Free thyroxine levels, time to euthyroidism, and side-effects of lithium.
 
RESULTS. A satisfactory response, defined as a fall by 40% or more in free thyroxine levels and clinical improvement, was achieved in eight patients within 1 to 2 weeks of lithium therapy. In four others, response occurred in 3 to 5 weeks. Response was slow and inadequate in one patient due to 'escape'. The median dosage of lithium was 750 mg daily, with a range of 500 to 1500 mg daily. The median serum lithium level was 0.63 mmol/L. Lithium toxicity was observed in one patient.
 
CONCLUSIONS. A relatively low dose of lithium offers a safe and effective alternative means of controlling thyrotoxicosis in patients who cannot tolerate or do not respond to thionamides.
 
Key words: Graves' disease; Lithium; Thyrotoxicosis; Thyroxine
 
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