Letters to the Editor

Optimal management of desmoid fibromatosis

Hong Kong Med J 2018 Jun;24(3):316

DOI: 10.12809/hkmj187250

LETTER TO THE EDITOR

Optimal management of desmoid fibromatosis

Herbert HF Loong, FHKCP, FHKAM (Medicine)

Department of Clinical Oncology, Prince of Wales Hospital, Shatin, Hong Kong

Corresponding author: Dr Herbert HF Loong (h_loong@clo.cuhk.edu.hk)

Full paper in PDF

To the Editor—I read with great interest the recent report by Ng et al1 of mesenteric fibromatosis. I would like to take this opportunity to clarify the internationally accepted treatment approach for desmoid fibromatosis. In the concluding remarks, the authors have rightfully stated that “…surgical resection is usually indicated in large symptomatic cases of MF or in MF with complications” and “…decision for radiotherapy or systemic treatment…should be made after discussion with oncologists”. I cannot help but notice that they give the readers the impression that surgery remains the treatment modality of choice before the consideration of systemic or hormonal treatments. The authors have also referenced an outdated version of the European consensus that, incidentally, was further updated in 2017.2 Evidence suggests that surgery should only be considered as an option if the morbidity from the procedure is limited, and medical therapy, be it with hormonal agents, non-steroidal anti-inflammatory drugs, cytotoxics, or targeted therapies, should also be considered as first-line treatments. More importantly, I would like to emphasise that surgical margins have been shown to inconsistently correlate with recurrence.3 The common consensus is that an R0 resection is not necessary if it is at the expense of significant morbidities or risk of mortality. Ultimately, a multidisciplinary team approach is necessary to ensure the best possible outcome for patients with this rare disease.

Declaration

As an editor of this journal, the author was not involved in the peer review process of this article. The author had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

References

1. Ng EP, Kwok SY, Lok KF, Chow MP, Lau PY. Mesenteric fibromatosis: a rare cause of peritonitis. Hong Kong Med J 2018;24:84-6. Crossref

2. Kasper B, Baumgarten C, Garcia J, et al. An update on the management of sporadic desmoid-type fibromatosis: a European Consensus Initiative between Sarcoma PAtients EuroNet (SPAEN) and European Organization for Research and Treatment of Cancer (EORTC)/Soft Tissue and Bone Sarcoma Group (STBSG). Ann Oncol 2017;28:2399-408. Crossref

3. Salas S, Dufresne A, Bui B, et al. Prognostic factors influencing progression-free survival determined from a series of sporadic desmoid tumors: a wait-and-see policy according to tumor presentation. J Clin Oncol 2011;29:3553-8. Crossref

Early diagnosis of tuberculous pleural effusion: apart from pleural fluid adenosine deaminase, pleural biopsy still has a role

Hong Kong Med J 2018 Jun;24(3):316–7

DOI: 10.12809/hkmj187289

LETTER TO THE EDITOR

Early diagnosis of tuberculous pleural effusion: apart from pleural fluid adenosine deaminase, pleural biopsy still has a role

CF Wong, MB, BS, FHKCP

Tuberculosis & Chest Unit, Grantham Hospital, Wong Chuk Hang, Hong Kong

Corresponding author: Dr CF Wong (wongcf2001@yahoo.com.hk)

Full paper in PDF

To the Editor—I read with interest the paper by Chang et al1 on the utility of pleural fluid ADA (pADA) for diagnosis of tuberculous pleural effusion (TBPE) in Hong Kong. Their effort in establishing the best cut-off pADA level based on a large local cohort is to be commended.

In their paper, cases with pADA above 100 U/L were excluded in the analysis. Nonetheless, I am now treating a patient with confirmed TBPE in whom pleural fluid was straw-coloured and the pADA level was 127 U/L. Pleural biopsy (PLBx) showed classical granulomatous inflammation and both pleural fluid and sputum were positive on culture for tuberculosis. According to Chang et al’s paper,1 TBPE would have been excluded as a diagnosis based on his suggested pADA value.

This case illustrates well that pADA is just a biochemical marker with limited diagnostic accuracy and there are false-positive/-negative cases. The gold standards for TBPE diagnosis remain granulomatous inflammation on PLBx, and/or the presence of mycobacteria on culture of the pleural fluid and/or pleura. One should never diagnose TBPE based on pADA alone. Pleural biopsy, a simple and safe bedside procedure, has been well reported to be a useful means for early diagnosis of pleural diseases including TBPE.2 In Chang et al’s cohort,1 the diagnostic yield of PLBx was 76.7%. Nonetheless, this investigation was performed in only 53.6% (90/168) of TBPE cases. When PLBx was performed on all patients if feasible, an early definitive diagnosis would have been reached in many more patients with pleural effusion.

Declaration

The author has no conflicts of interest to disclose. The author had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

References

1. Chang KC, Chan MC, Leung WM, et al. Optimising the utility of pleural fluid adenosine deaminase for the diagnosis of adult tuberculous pleural effusion in Hong Kong. Hong Kong Med J 2018;24:38-47. Crossref

2. Rajawat GS, Batra S, Takhar RP, Rathi L, Bhandari C, Gupta ML. Diagnostic yield and safety of closed needle pleural biopsy in exudative pleural effusion. Avicenna J Med 2017;7:121-4. Crossref

Central aortic pressure monitoring using a brachial artery line: is it ready for use in cardiac surgery?

Hong Kong Med J 2018 Jun;24(3):321–2

DOI: 10.12809/hkmj187299

LETTER TO THE EDITOR

Central aortic pressure monitoring using a brachial artery line: is it ready for use in cardiac surgery?

Manijeh Yousefi Moghadam, MD

Department of Anesthesiology and Intensive Care, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran

Corresponding author: Dr Manijeh Yousefi Moghadam (yousefim@medsab.ac.ir)

Full paper in PDF

To the Editor—Accurate monitoring of intra-arterial pressure during low flow states is very important for patients undergoing cardiac surgery that involves cardiopulmonary bypass because inaccurate measurement of pressure can increase perioperative morbidity and mortality. Nonetheless selection of the best arterial site for pressure monitoring that is safe, uncomplicated, reliable, and accurate remains controversial.

In patients who undergo cardiac surgery, the radial, brachial, and femoral arteries are common sites for intra-arterial pressure monitoring. The radial artery is used most frequently because of its easy accessibility and the lower chance of ischaemic complications and arterial thrombosis.1 Nonetheless due to inherent problems in the measurement of central aortic pressure (eg, over- and under-estimation and radial-to-aortic pressure gradients), the use of this site in cardiac surgery that involves cardiopulmonary bypass has been criticised.2 3 Compared with that of the radial artery, femoral artery pressure more closely approximates central aortic pressure and is more reliable during cardiopulmonary bypass, but this site is associated with ischaemic and haemorrhagic complications as well as pseudoaneurysm formation.4

There is convincing evidence that measuring intra-arterial pressure using a brachial arterial site can better estimate the central aortic pressure and is more accurate and reliable than using a radial arterial site. Nonetheless until recently, concerns about the occurrence of ischaemic complications have restricted its use. The results of a new single-centre retrospective observational study of over 21 000 patients have shown that using a brachial arterial line for aortic pressure monitoring during cardiac surgery is associated with fewer complications such that the combined incidence of all complications related to a brachial arterial catheter was less than 0.2% (only 41 patients).5

Nonetheless due to the biases inherent in retrospective observational studies and secondary analyses, it has not been possible to establish definitive causal relationships. Findings may have been biased due to the lack of control of confounding variables. In addition, their study5 did not compare the incidence of complications of a brachial artery catheter with those of other arterial sites such as the radial or femoral arteries. Therefore, despite their valuable findings,5 the superiority of a brachial artery approach compared with other arteries in terms of complications is unclear. A decision to use the brachial artery for central aortic pressure monitoring in low flow states such as cardiopulmonary bypass may remain equivocal.

Considering the importance of accurately measuring the haemodynamic status of a patient undergoing cardiac surgery, and the high precision of a brachial arterial catheter for central aortic pressure monitoring, as well as the low incidence of brachial catheter–related complications, this method would appear to be a better alternative to other arterial pressure monitoring methods such as radial and femoral artery lines. To inform clinical practice, further well-designed prospective comparative observational studies and clinical trials (non-inferiority of superiority trial) are warranted to determine the advantages and disadvantages of brachial artery site over other sites of intra-atrial pressure monitoring in terms of non–catheter- and catheter-related complications (either minor or major) and technically related drawbacks (eg, the accuracy of measuring).

Declaration

References

1. Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg 2009;109:1763-81. Crossref

2. Fuda G, Denault A, Deschamps A, et al. Risk factors involved in central-to-radial arterial pressure gradient during cardiac surgery. Anesth Analg 2016;122:624-32. Crossref

3. Lakhal K, Robert-Edan V. Invasive monitoring of blood pressure: a radiant future for brachial artery as an alternative to radial artery catheterisation? J Thorac Dis 2017;9:4812-6. Crossref

4. Bouchard-Dechêne V, Couture P, Su A, et al. Risk factors for radial-to-femoral artery pressure gradient in patients undergoing cardiac surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2018;32:692-8. Crossref

5. Singh A, Bahadorani B, Wakefield BJ, et al. Brachial arterial pressure monitoring during cardiac surgery rarely causes complications. Anesthesiology 2017;126:1065-76. Crossref

Adenosine deaminase level in pleural fluid and the diagnosis of tuberculous pleural effusion

Hong Kong Med J 2018 Jun;24(3):317

DOI: 10.12809/hkmj187336

LETTER TO THE EDITOR

Adenosine deaminase level in pleural fluid and the diagnosis of tuberculous pleural effusion

John SM Leung, FCSHK, FHKAM (Surgery)

Cardiothoracic Surgery, St Paul’s Hospital, Causeway Bay, Hong Kong

Corresponding author: Dr John SM Leung (leungsiumanjohn@yahoo.com.hk)

Full paper in PDF

To the Editor—Tuberculous pleural effusion (TBPE) is often elusive to diagnostic investigations and clinicians often use adenosine deaminase level (ADA) as a surrogate marker to justify anti-tuberculosis (TB) treatment. In the February 2018 issue of the Hong Kong Medical Journal, Chang et al1 made an important contribution by defining a lower cut-off value to increase its sensitivity. The authors rightly pointed out the limitations of this marker and added an upper cut-off value of 100 U/L to enhance its efficacy. While appreciating the high value of this contribution, may I suggest the following caveats.

I have noticed that ADA was not tested in pleural fluid in some non-endemic areas where the prevalence of TB was low. The predictive value of this test is dependent on the prevalence of TB among the population. If TB prevalence is high, the positive predictive value will be higher but the negative predictive value will be lower. If TB prevalence is low, the effect will be reversed, the positive predictive value will be lower, and the negative predictive value will be higher.2 As the prevalence of TB varies from place to place and from time to time for the same place, the predictive values of the ADA test might need to be adjusted accordingly.

Secondly, among the most recent four cases of TBPE that I have encountered, one patient presented with an ADA of 102 U/L. His pleural biopsy was TB positive. If we had adopted the upper cut-off value of 100 U/L as advocated by Chang et al,1 we would have excluded this case.

Declaration

References

2. Pennsylvania State University. Eberly College of Science, STAT 507, Chapter 10.3. Sensitivity, specificity, positive predictive value and negative predictive value. Available from: https://webaccess.psu.edu/?cosign-onlinecourses.science.psu.edu&https://onlinecourses.science.psu.edu/stat507/node/71. Accessed 28 Feb 2018.

In search of the best organ donation legislative system for Hong Kong: further research is needed

Hong Kong Med J 2018 Jun;24(3):318–9

DOI: 10.12809/hkmj187371

LETTERS TO THE EDITOR

In search of the best organ donation legislative system for Hong Kong: further research is needed

Khaled Tafran, MEc (Health Policy)

Department of Administrative Studies and Politics, Faculty of Economics and Administration, University of Malaya, Kuala Lumpur 50603, Malaysia

Corresponding author: Mr Khaled Tafran (khaled@um.edu.my)

Full paper in PDF

To the Editor—Transplantation is advancing rapidly to such an extent that in the foreseeable future we may witness the first head transplantation.1 Low donation rates will be one of the main global barriers undermining transplantation.

I read with interest the article by Cheung et al2 and I would like to highlight a few issues concerning this research. Although the article analysed the willingness of potential donors under three systems (opt-out, opt-in, and opt-in with allocation priority), it did not consider an opt-out system with allocation priority. Previous research showed that an opt-out system with allocation priority may result in a higher willingness to donate than other systems.3 4 Cheung et al2 found that the difference in willingness between the opt-in and opt-out systems was not significant; therefore, it is highly possible that an opt-out system with allocation priority would result in a similar, or perhaps better, willingness to an opt-in system with allocation priority. Moreover, the opinion of health care professionals on donation legislative systems is critical in this context, as they play a vital role in facilitating the process of donation and transplantation.5

Although the findings of Cheung et al2 are imperative, more accurate policy recommendations in this context require further studies to investigate willingness to donate under an opt-out system with allocation priority as well as health care professionals’ opinion of donation legislative systems in Hong Kong.

Declaration

References

1. Tafran K. Religious barriers to head transplantation: an Islamic viewpoint. Int J Surg 2017;43:92-3. CrossRef

2. Cheung TK, Cheng TC, Wong LY. Willingness for deceased organ donation under different legislative systems in Hong Kong: population-based cross-sectional survey. Hong Kong Med J 2018;24:119-27. CrossRef

3. Tumin M, Tafran K, Mutalib MA, et al. Demographic and socioeconomic factors influencing public attitudes toward a presumed consent system for organ donation without and with a priority allocation scheme. Medicine (Baltimore) 2015;94:e1713. CrossRef

4. Li D, Hawley Z, Schnier K. Increasing organ donation via changes in the default choice or allocation rule. J Health Econ 2013;32:1117-29. CrossRef

5. Tumin M, Tafran K, Satar NM, et al. Factors associated with healthcare professionals’ attitude towards the presumed consent system. Exp Clin Transplant. In press.

Authors’ reply

TK Cheung, BSc; TC Cheng, BSc; LY Wong, MPH, PhD

The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong

Corresponding author: Prof LY Wong (lywong@cuhk.edu.hk)

To the Editor—We would like to thank Dr Tafran for his valuable comments on our article.1 First, in Spain, where the opt-out system is implemented, the deceased donor rate of 39.7 per million population (pmp) in 2015 (thanks for letting us know the typo of 34.0 reported in the Introduction)2 increased to 46.9 pmp in 2017. On the contrary, in Hong Kong, where an opt-in system is adopted, the deceased donor rate has remained at around 6 pmp over the same period of time. The gap between Hong Kong and Spain is large, and the gap is widening.

Second, as current participation in the opt-in system of deceased organ donation is low, our initial plan was to estimate the willingness rate under three proposed legislative options that have been adopted in other jurisdictions: “opt-out system”, “opt-out system with allocation priority”, and “opt-in system with allocation priority”. Nonetheless our pilot study revealed that the majority of participants experienced difficulty in distinguishing between “the opt-out system with allocation priority” and the other two options as they were confused about the concepts inherent in these legislative options with similar definitions. Considering the length of the questionnaire and the limited interview time and feasibility, we decided to only examine the “opt-out system” and the “opt-in system with allocation priority” in the final study design. The media has subsequently reported these two proposed options and have since generated public debate regarding this issue. We suggest that the next survey can include more legislative options using examples from other jurisdictions as well as suggestions from interviewed participants.

To summarise the key messages of our paper, it is crucial to understand and explore various stakeholders’ perspective with respect to different legislative options for deceased organ donation. These stakeholders shall include health policy-makers (eg, The Food and Health Bureau), and a variety of health care professionals and patient groups (eg, The Hong Kong Alliance of Patients’ Organizations).

Declaration

The authors have no conflicts of interest to disclose. The authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

References

1. Cheung TK, Cheng TC, Wong LY. Willingness for deceased organ donation under different legislative systems in Hong Kong: population-based cross-sectional survey. Hong Kong Med J 2018;24:119-27. Crossref

2. International Registry in Organ Donation and Transplantation. 2018. Available from: http://www.irodat.org/. Accessed 23 Dec 2018.

Pleural adenosine deaminase cut-off value for the diagnosis of tuberculous pleural effusion using the Diazyme assay

Hong Kong Med J 2018 Apr;24(2):207

DOI: 10.12809/hkmj187207

LETTER TO THE EDITOR

Pleural adenosine deaminase cut-off value for the diagnosis of tuberculous pleural effusion using the Diazyme assay

Aurélie Servonnet, PharmD¹; Christine Frederic¹; Francisca Fargeau¹; Hervé Delacour, PharmD^2,3

¹ French Armed Forces Biomedical Research Institute, B.P. 73 - 91223 Brétigny-sur-Orge Cedex, France

² Bégin Military Teaching Hospital, Fédération des Laboratoires, 69 Avenue de Paris - 94163 Saint-Mandé Cedex, France

³ Val-de-Grâce Military School, 1 Place Alphonse Laveran - 75230 Paris Cedex 05, France

Corresponding author: Prof Hervé Delacour (herve.delacour@intradef.gouv.fr)

Full paper in PDF

To the Editor—We read with interest the article by Chang et al.1 In the diagnosis of tuberculous pleural effusion (TBPE), they established that 26.5 U/L is the optimal cut-off value for pleural fluid adenosine deaminase activity when using the Diazyme assay (Diazyme Laboratories, San Diego [CA], United States) on the UniCel DxC 800 Synchron Clinical System (Beckman Coulter, Brea [CA], United States). The Diazyme assay can be used on various analytical systems. Therefore, one can ask the question: does the cut-off value differ according to the analytical system? The following two facts can provide an answer.

First, a cut-off value between 25 and 30 U/L has been previously recommended for TBPE diagnosis (ie, an interval including the cut-off value proposed by Chang et al1) if the Diazyme assay is used on the Cobas 6000 system (Roche Diagnostics, Meylan, France).2

Second, we have compared the results obtained from using the Diazyme assay on two analytical systems: Cobas 6000 (Roche Diagnostics) and Advia 1800 (Siemens Healthcare Diagnostics, Saint Denis, France) by parallel-testing 79 anonymous pleural fluid samples from different French hospitals. We observed a good correlation between the two analytical systems (r²=0.88; t test for correlation coefficient, P<0.001), even though bias was observed (~16 %). After using the cut-off value proposed by Chang et al,1 we observed only one misclassification between the two analytical systems (Fig).

Figure. Comparison of Diazyme assay performance between Advia 1800 and Cobas 6000 systems
(a) Correlation plot showing that values obtained on the Advia 1800 correlated well with those obtained on the Cobas 6000; however, after use of the cut-off value proposed by Chang et al (26.5 U/L),1 the interpretation of one sample was different (positive on the Cobas 6000 and negative on the Advia 1800). (b) Bland-Altman plot showing a negative bias (~ -16%), which increased with increasing pleural adenosine deaminase activity

In conclusion, we consider the cut-off value proposed by Chang et al1 for TBPE diagnosis to be appropriate on whichever analytical system the Diazyme assay is used.

Declaration

The authors have no conflicts of interest to disclose.

References

2. Delacour H, Sauvanet C, Ceppa F, Burnat P. Analytical performances of the Diazyme ADA assay on the Cobas^® 6000 system. Clin Biochem 2010;43:1468-71. Crossref

2-oxo-PCE: ketamine analogue on the streets

Hong Kong Med J 2017 Dec;23(6):665–6

DOI: 10.12809/hkmj177089

LETTER TO THE EDITOR

2-oxo-PCE: ketamine analogue on the streets

YK Chong, FHKCPath, FHKAM (Pathology)^1,2; Magdalene HY Tang, PhD¹; CL Chan, MSc²; YK Li, FHKCEM, FHKAM (Emergency Medicine)³; CK Ching, FRCPA, FHKAM (Pathology)^1,2; Tony WL Mak, FHKCPath, FHKAM (Pathology)^1,2

¹ Hospital Authority Toxicology Reference Laboratory, Princess Margaret Hospital, Laichikok, Hong Kong

² Chemical Pathology Laboratory, Department of Pathology, Princess Margaret Hospital, Laichikok, Hong Kong

³ Accident and Emergency Department, Princess Margaret Hospital, Laichikok, Hong Kong

Corresponding author: Dr Tong WL Mak (makwl@ha.org.hk)

Full paper in PDF

To the Editor—New psychoactive substances are recently emerged drugs that are chemically or pharmacologically similar to conventional drugs of abuse. Our laboratory has repeatedly identified new psychoactive substances in Hong Kong.1 2 3

We report the identification of 2-oxo-PCE [2-phenyl-2-(ethylamino)-cyclohexanone, also known as deschloro-N-ethyl-ketamine or deschloro-N-ethyl-norketamine] in urine samples of multiple unrelated patients in October 2017 with suspected ketamine abuse or related poisoning features. An unidentified substance was detected in these samples by general toxicology screening using high-performance liquid chromatography-diode array detection; further investigations at our laboratory confirmed the unidentified substance as 2-oxo-PCE by liquid chromatography-tandem mass spectrometry. This compound is not routinely covered by general toxicology screening and in our experience does not cross-react with at least one bedside ketamine immunoassay (ABON; Abon Biopharm [Hangzhou] Co Ltd, Hangzhou, PRC).

The drug, 2-oxo-PCE, is a new psychoactive substance in the arylcyclohexylamine class, with structural similarity to ketamine and methoxetamine. Historically, it was synthesised in 1962 in an attempt to develop a short-acting phencyclidine derivative, a project that culminated in the discovery of ketamine.4 Drugs of this class are known to possess N-methyl-D-aspartate receptor antagonist activity with variable effects towards other receptors,4 resulting in dissociative effects clinically. The use of this drug has been recently reported in Germany.5 To date, there have been no clinical poisoning reports of this drug in the scientific literature, but user reports on the internet show that 2-oxo-PCE causes a similar effect to ketamine, but is more potent.

Ketamine is one of the most prevalent drugs of abuse in Hong Kong. Our findings of 2-oxo-PCE in a cluster of unrelated patients with suspected ketamine abuse give rise to the suspicion of substitution of 2-oxo-PCE for ketamine in street supplies, possibly to evade detection. In patients presenting with ketamine-like toxidrome but with a negative urine toxicology result, the use of 2-oxo-PCE may need to be considered. Analysis of 2-oxo-PCE in urine specimens is provided in our laboratory and can be requested by clinicians in Hong Kong.

Declaration

All authors have disclosed no conflicts of interest.

References

1. Lau NK, Chong YK, Tang MH, Ching CK, Mak TW. Desoxy-D2PM: a novel psychoactive substance in convenience stores. Hong Kong Med J 2016;22:515. Crossref

2. Tang M, Ching CK, Tse ML, et al. Surveillance of emerging drugs of abuse in Hong Kong: validation of an analytical tool. Hong Kong Med J 2015;21:114-23. Crossref

3. Poon WT, Lai CF, Lui MC, Chan AY, Mak TW. Piperazines: a new class of drug of abuse has landed in Hong Kong. Hong Kong Med J 2010;16:76-7.

4. Morris H, Wallach J. From PCP to MXE: a comprehensive review of the non-medical use of dissociative drugs. Drug Test Anal 2014;6:614-32. Crossref

5. Piontek D, Hannemann TV. Medikamentenmissbrauch und der Konsum von neuen psychoaktiven Substanzen (NPS) in unterschiedlichen Risikopopulationen. Ergebnisse des Projekts Phar-Mon NPS aus den Jahren 2015 und 2016 [in German]. München: IFT Institut für Therapieforschung; 2017.

Missing key factors in nutritional assessment and bone density in children with eczema. Authors’ reply

Hong Kong Med J 2017 Dec;23(6):664–5

DOI: 10.12809/hkmj177056

LETTER TO THE EDITOR

Missing key factors in nutritional assessment and bone density in children with eczema

Martin Hofmeister, PhD

Consumer Centre of the German Federal State of Bavaria, Department Food and Nutrition, Mozartstraβe 9, D-80336 Munich, Germany

Corresponding author: Dr Martin Hofmeister (hofmeister@vzbayern.de)

Full paper in PDF

To the Editor—With clearly outlined prospects for research, I congratulate Dr Leung and his colleagues1 for the interesting study of “Assessment of dietary food and nutrient intake and bone density in children with eczema” in the October 2017 issue of the Hong Kong Medical Journal. There are two aspects worth mentioning.

As a nutrition scientist, I wonder why the authors have not integrated the consumption of beverages (water, tea, coffee, fruit juices, soft drinks, and others) and the intake of dietary magnesium into the nutritional assessment of children with eczema. One of the seven broad categories of the used food frequency questionnaire by Woo et al is ‘beverages’.2 In the local validation studies in children and adolescents cited by Leung et al, intake of beverages and magnesium was also analysed.3 It is well established that tea consumption and magnesium intake are significantly associated with bone mineral density in children and adults. It is possible that dietary intake of magnesium is also connected to protection against eczema.4

A recent analysis of the ‘Child and Adolescent Health Measurement Initiative’ with 91 642 study participants showed a positive association of severe eczema with bone problems in children. The adjusted odds ratio was 6.08 (95% confidence interval, 1.94-19.12; P=0.002).5 Therefore, I cannot agree with Leung et al1 about the implication for clinical practice that “Bone mineral density assessment is unnecessary for the majority of children with eczema”. Further research is required here. I think this good study by Leung et al1 can be strengthened by additional data analysis and discussion.

References

1. Leung TF, Wang SS, Kwok FY, Leung LW, Chow CM, Hon KL. Assessment of dietary food and nutrient intake and bone density in children with eczema. Hong Kong Med J 2017;23:470-9. CrossRef

2. Woo J, Leung SS, Ho SC, Lam TH, Janus ED. A food frequency questionnaire for use in the Chinese population in Hong Kong: description and examination of validity. Nutr Res 1997;17:1633-41. CrossRef

3. Chan RS, Woo J, Chan DC, Cheung CS, Lo DH. Estimated net endogenous acid production and intake of bone health-related nutrients in Hong Kong Chinese adolescents. Eur J Clin Nutr 2009;63:505-12. CrossRef

4. Nwaru BI, Erkkola M, Ahonen S, et al. Intake of antioxidants during pregnancy and the risk of allergies and asthma in the offspring. Eur J Clin Nutr 2011;65:937-43. CrossRef

5. Barrick BJ, Jalan S, Tollefson MM, et al. Associations of self-reported allergic diseases and musculoskeletal problems in children: A US population-based study. Ann Allergy Asthma Immunol 2017;119:170-6. CrossRef

Authors’ reply

TF Leung, MD, FRCPCH¹; SS Wang, PhD¹; FYY Kwok, MPhil¹; LWS Leung, BSc²; CM Chow, MB, ChB ¹; KL Hon, MD, FAAP¹

¹ Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong

² Faculty of Science, The University of Melbourne, Melbourne, Victoria, Australia

Corresponding author: Dr TF Leung (tfleung@cuhk.edu.hk)

To the Editor—Dr Hofmeister asked why we did not report the consumption of beverages and dietary magnesium intake. We recently reported a higher beverage intake in Chinese children with eczema, and a significant association between soft drink consumption and higher systolic blood pressure in these patients.1 This study collected data on these two items using a modified food frequency questionnaire for local Chinese population. Our analyses revealed similar intakes of magnesium, magnesium adjusted to total calories and beverage between patients with eczema and reference groups (respective P values of 0.980, 0.149, and 0.345 by Mann-Whitney U test). Thus, we did not include these items in our article.2

Dr Hofmeister cited a study3 about the possible protection afforded by dietary magnesium intake against eczema. Nonetheless, this article neither assessed personal intake of magnesium in eczematous children nor measured serum levels of magnesium and other antioxidants in mothers and their offspring to verify the consequences of respective dietary intake. Instead, the authors analysed possible associations between maternal antioxidant intake and the occurrence of eczema, asthma, and rhinitis in their offspring. We do not think that this is relevant to our study.

Dr Hofmeister cited another paper4 that described an association between self-reported eczema and bone problems in children. Table 1 revealed that only 1% of the subjects had “current bone problems”, the nature of which could not be verified by any objective outcome. It remained unknown if bone problems were related to diminished bone density. A more recent study of 3049 children and adolescents from the 2005-2006 National Health and Nutrition Examination Survey suggested that eczema was independently associated with low bone density at the femur and/or spine.5 Vitamin D deficiency, which was prevalent in local children,6 was a significant covariate for this finding.

In our study, eczema severity and bone density of the participants were assessed by objective SCORAD and non-invasive ultrasound methods.2 As most eczematous children in the community setting had mild-to-moderate disease, it was justifiable for us to propose that “bone mineral density assessment is unnecessary for the majority of children with eczema”. Of course, our message did not preclude the need for bone density measurement in patients with skeletal symptoms or those with extensive dietary restriction. We also fully agree with Dr Hofmeister that further research is needed to examine the relationship between eczema and bone density impairment.

References

1. Hon KL, Tsang YC, Poon TC, et al. Dairy and nondairy beverage consumption for childhood atopic eczema: what health advice to give? Clin Exp Dermatol 2016;41:129-37. Crossref

2. Leung TF, Wang SS, Kwok FY, Leung LW, Chow CM, Hon KL. Assessment of dietary food and nutrient intake and bone density in children with eczema. Hong Kong Med J 2017;23:470-9. Crossref

3. Nwaru BI, Erkkola M, Ahonen S, et al. Intake of antioxidants during pregnancy and the risk of allergies and asthma in the offspring. Eur J Clin Nutr 2011;65:937-43. Crossref

4. Barrick BJ, Jalan S, Tollefson MM, et al. Associations of self-reported allergic diseases and musculoskeletal problems in children: A US population-based study. Ann Allergy Asthma Immunol 2017;119:170-6. Crossref

5. Silverberg JI. Association between childhood atopic dermatitis, malnutrition, and low bone mineral density: a US population-based study. Pediatr Allergy Immunol 2015;26:54-61. Crossref

6. Wang SS, Hon KL, Kong AP, Pong HN, Wong GW, Leung TF. Vitamin D deficiency is associated with diagnosis and severity of childhood atopic dermatitis. Pediatr Allergy Immunol 2014;25:30-5. Crossref

Functional status and early surgery in elderly patients with hip fracture

Hong Kong Med J 2017 Oct;23(5):542

DOI: 10.12809/hkmj176916

LETTER TO THE EDITOR

Functional status and early surgery in elderly patients with hip fracture

Paolo Mazzola, MD

University of Milano-Bicocca, School of Medicine and Surgery, Monza (MB); NeuroMI – Milan Center for Neuroscience, Clinical Neuroscience Research Area, Milano (MI), Italy

Corresponding author: Paolo Mazzola (paolo.mazzola@unimib.it)

The author has disclosed no conflicts of interest. He would like to express his sincere appreciation to Justin S Brathwaite for proofreading this letter.

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To the Editor—I read with interest the paper by Liu et al1 that focused on elderly patients undergoing hip fracture surgery, showing that the longer the delay to surgery (>2 days), the higher the risk of death. Despite the potential limitations correctly identified by the authors, the introduction of the Key Performance Indicator in Hong Kong in 2008 undoubtedly led to an overall improved quality of life for these patients.

Liu et al1 acknowledge that data from health care utilisation databases lack important information about functional status or other geriatric indexes. I agree that the need to further stratify the population according to their clinical complexity or co-morbidity may prompt specific strategies for high-risk subjects. Nonetheless I suggest that the key role of functional status and its effect on risk of death be considered. It was previously shown that delaying hip surgery for more than 2 days in the subgroup of subjects with pre-existing disability carries the highest risk of 1-year mortality.2 In other words, in elderly patients, disability impacts mortality risk more than surgical delay, even after adjusting for age, gender, co-morbidity, drugs, and presence of delirium.3

Although Italy4 and Hong Kong have distinct populations, life expectancy and access to health care services are similar, at least when one considers the most densely inhabited areas. Consistent with the previous experience,5 stabilisation of medical conditions may sometimes be a necessity.1 It was also speculated that elderly patients with pre-existing disabilities, who are among the frailest individuals, Hong Kong Med J 2017;23:542 DOI: 10.12809/hkmj176916 are presumably those who will benefit most from early surgery.2

References

1. Liu SK, Ho AW, Wong SH. Early surgery for Hong Kong Chinese elderly patients with hip fracture reduces short-term and long-term mortality. Hong Kong Med J 2017;23:374-80. Crossref

2. Bellelli G, Mazzola P, Corsi M, et al. The combined effect of ADL impairment and delay in time from fracture to surgery on 12-month mortality: an observational study in orthogeriatric patients. J Am Med Dir Assoc 2012;13:664.e9-664.e14.

3. Mazzola P, Bellelli G, Broggini V, et al. Postoperative delirium and pre-fracture disability predict 6-month mortality among the oldest old hip fracture patients. Aging Clin Exp Res 2015;27:53-60. Crossref

4. Mazzola P, Rimoldi SM, Rossi P, et al. Aging in Italy: The Need for New Welfare Strategies in an Old Country. Gerontologist 2016;56:383-90. Crossref

5. Mazzola P, De Filippi F, Castoldi G, Galetti P, Zatti G, Annoni G. A comparison between two co-managed geriatric programmes for hip fractured elderly patients. Aging Clin Exp Res 2011;23:431-6. Crossref

A case for osteoporosis screening and treatment in older people to prevent hip fracture

Hong Kong Med J 2017 Aug;23(4):421

DOI: 10.12809/hkmj176857

LETTER TO THE EDITOR

A case for osteoporosis screening and treatment in older people to prevent hip fracture

Timothy Kwok, MD, FHKAM (Medicine); Dicky Choy, MB, ChB, DCH

Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Shatin, Hong Kong

Corresponding author: Dr Timothy Kwok (tkwok@cuhk.edu.hk)

Full paper in PDF

To the Editor—The hip fracture registry by Leung et al1 re-affirmed the serious consequences of hip fracture. There are drugs, including bisphosphonates, that can lower hip fracture risk by 40% in those with osteoporosis. Unfortunately, with concerns over rare side-effects, the use of bisphosphonates has been falling in recent years. Moreover, despite clinical guidelines that recommend dual-energy X-ray absorptiometry (DXA) scan in all men and women aged 70 years or more,2 few older people have followed this advice. In our osteoporosis clinic, only 29.2% are aged 70 years or older, of whom only 11.8% are men. Although men have a lower fracture risk than women, they are more likely to die following hip fracture.3 The Hospital Authority currently subsidises osteoporosis drugs in patients with fracture history in specialist out-patient clinics. According to Leung et al’s study,1 however, very few hip fracture patients received osteoporosis drugs before or after fracture. Now that DXA and osteoporosis drugs can be covered by elderly health care vouchers, doctors should encourage our older patients to have osteoporosis screening and treatment, both shown to be cost-effective.4 With a rising incidence of hip fractures, the Hong Kong SAR Government should consider funding screening and treatment for osteoporosis in older people as in Japan, South Korea, and many western countries. In the United Kingdom, a randomised trial of a screening questionnaire (The Fracture Risk Assessment Tool) mailed to older women lowered hip fracture incidence by 30% over 5 years.5 With the concerted efforts of the public and private medical sectors, the incidence of hip fracture can be controlled despite an ageing population.

References

1. Leung KS, Yuen WF, Ngai WK, et al. How well are we managing fragility hip fractures? A narrative report on the review with the attempt to set up a Fragility Fracture Registry in Hong Kong. Hong Kong Med J 2017;23:264-71. Crossref

2. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 2014;25:2359-81. Crossref

3. Man LP, Ho AW, Wong SH. Excess mortality for operated geriatric hip fracture in Hong Kong. Hong Kong Med J 2016;22:6-10. Crossref

4. Schott AM, Ganne C, Hans D, et al. Which screening strategy using BMD measurements would be most cost effective for hip fracture prevention in elderly women? A decision analysis based on a Markov model. Osteoporos Int 2007;18:143-51. Crossref

5. McCloskey EV, Lenaghan E, Clarke S, et al. Screening based on FRAX fracture risk assessment reduces the incidence of hip fractures in older community-dwelling women—results from the SCOOP study in the UK. Proceedings of the ASBMR 2016 Annual Meeting; 2016 Sep 16-19; Atlanta, Georgia, US; 2016.

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