To the Editor—Chan et al1 drew our attention to the fact that tuberculosis can be a great mimicker of other conditions when it affects the knee. Conversely the knee may be a site where problems may mimic other disorders. Knee injuries are among the most common disabling conditions that arise from sporting and other accidents or falls. The presence of septic arthritis may overlap or complicate a traumatic knee condition. Septic arthritis by itself may affect the knee, as well as autoimmune-related arthritis. Yet uncommonly, gout and other crystal arthritis may have a similar clinical and radiological presentation.2 Only when urate or calcium pyrophosphate are identified can the diagnosis be confirmed. The title ‘great mimicker’ was originally applied to syphilis, a disease that declined considerably in the last century but that is recently exhibiting a resurgence due to uncontrolled sexually transmitted diseases.3 Syphilis targets virtually every organ and the knee is no exception. In North America, another spirochete infection, Lyme disease, is known to infect people bitten by ticks or in contact with wild animals, and prominent among its symptoms is arthritis, including that of the knee.4 In Hong Kong, we do not have Lyme disease but we should maintain a high index of suspicion in individuals who have visited North America and who present with fever, fatigue and joint pain. The risk is not confined to recent exposures since the disease may be quiescent for months or even years before a flare-up.

The author solely contributed to the concept or design, acquisition of data, analysis or interpretation of data, drafting of the letter, and critical revision of the letter for important intellectual content. The author had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

The author has disclosed no conflict of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for profit sectors.

1. Chan HM, Fu H, Chiu KY. Tuberculosis of the knee as a great mimicker of inflammatory arthritis: a case report. Hong Kong Med J 2023;29:548-50. Crossref

2. Yun SY, Choo HJ, Jeong HW, Lee SJ. Comparison of MR findings between patients with septic arthritis and acute gouty arthritis of the knee. J Korean Soc Radiol 2022;83:1071-80. Crossref

3. Peeling RW, Hook EW 3rd. The pathogenesis of syphilis: the great mimicker, revisited. J Pathol 2006;208:224-32. Crossref

4. Arvikar SL, Steere AC. Diagnosis and treatment of Lyme arthritis. Infect Dis Clin North Am 2015;29:269-80. Crossref

To the Editor—We write in response to an article published in November 2023 on digital media that discussed the difficulties faced by local young cancer patients who are receiving oncology treatment.1 We would like to highlight the importance of addressing these challenges and propose solutions to help overcome them.

In 2021, young oncology patients comprised up to 4.1% of all cancer cases in Hong Kong.2 They experience a range of emotional, social, and financial challenges that greatly impact their overall well-being. Neglecting their needs not only strains their relationship with family, but also hampers their ability to effectively cope with the disease. The financial toxicity of cancer treatment, which includes the expenses, indirect costs and lost income associated with cancer treatment, further exacerbates these challenges.3 4

To address these issues effectively it is essential to provide services specifically designed for young cancer patients according to their stage of development. They are at high risk of psychosocial problems and should be prioritised for early integration into palliative care services to improve their quality of life and that of their family.5 Mental health professionals and support groups should be widely available for psychological support. Some medical allowances and social services are provided only for the older adults. Medical-social collaboration and educational resources could improve access by young adults to community support. Additionally, implementing targeted financial assistance programmes and providing employment support will help alleviate the financial burden. It is crucial to recognise and address the obstacles faced by young cancer patients.

All authors contributed to the concept or design, acquisition of data, or interpretation of data, drafting of the letter, and critical revision of the letter for important intellectual content. All 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.

All authors have disclosed no conflicts of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. HK01. Hong Kong young cancer patients established a mutual aid platform to help themselves as existing cancer support is mostly targeted at the middle-aged and older adults. [in Chinese]. 2023 November 22. Available from: https://www.hk01.com/article/957641?utm_source=01appshare&utm_medium=referral. Accessed 26 Nov 2023.

2. Hong Kong Cancer Registry, Hospital Authority, Hong Kong SAR Government. Overview of Hong Kong Cancer Statistics of 2021. Available from: https://www3.ha.org.hk/cancereg/default.asp. Accessed 28 Nov 2023.

3. Evan EE, Zeltzer LK. Psychosocial dimensions of cancer in adolescents and young adults. Cancer 2006;107(7 Suppl):1663-71. Crossref

4. Geue K, Götze H, Friedrich M, et al. Perceived social support and associations with health-related quality of life in young versus older adult patients with haematological malignancies. Health Qual Life Outcomes 2019;17:145. Crossref

5. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014;383:1721-30. Crossref

To the Editor—There was a local blog report in Hong Kong of a 5-year-old girl who experienced out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) after 31 minutes and was discharged with an implantable cardioverter defibrillator.1 However, ROSC within 30 minutes is usually required for a favourable outcome.2 3

We performed a literature search to determine the longest time to ROSC and survival rates of OHCA in children (Table). Out-of-hospital cardiac arrest in children has a poor prognosis and prolonged in-hospital resuscitation beyond 30 minutes does not improve survival.3 Predictors of survival to discharge include witnessed arrest (P=0.012), delivery of bystander cardiopulmonary resuscitation (P=0.003), and duration of resuscitation (P=0.028). However, none who received more than 30 minutes of in-hospital resuscitation survived.4 A prospective study found that no patients who required >2 doses of adrenaline or in-hospital resuscitation for longer than 20 minutes survived to discharge.5 However, it is possible that ROSC beyond 30 minutes has not been reported, or that this case is an exception.

Evidence suggests that either death or a poor outcome is inevitable if OHCA occurs more than 30 minutes from the nearest healthcare facility or the resuscitation exceeds 30 minutes.6 7 A 2017 study reported that the survival rate to discharge in Hong Kong was only 2.3%, which was considerably lower than the global survival rate in adults (8.8%).8 9 As OHCA in children has not been evaluated in Hong Kong until 2018,3 and prospective evaluation of OHCA in children has not yet been conducted, we concur with Wu10 who suggested the establishment of an OHCA registry.

Many parents and family members who are present during a resuscitation attempt would want to be in attendance if their child were likely to die, and this experience can help with later grieving without impacting on the resuscitation process. If appropriate, family-centred care should be practised and parents should be involved in the decision-making process.6 As paediatricians, although our patient is the child, his/her family members are also important—after all, if the child passes away, it is the family who must shoulder the lifelong emotional burden.

In summary, OHCA in children has a poor prognosis and prolonged resuscitation does not improve survival or outcome.

All authors contributed to the drafting of the letter and critical revision for important intellectual content. All authors approved the final version for publication and take responsibility for its accuracy and integrity.

As an editor of the journal, KL Hon was not involved in the peer review process. Other authors have disclosed no conflicts of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Philip. 死去31分鐘的女兒 [in Chinese]. Available from: https://todecidenow.wordpress.com/2021/01/31/死去31分鐘的女兒！/. Accessed 24 Jul 2023.

2. Hon KL, Tse TT, Au CC, et al. Brain death in children: a retrospective review of patients at a paediatric intensive care unit. Hong Kong Med J 2020;26:120-6. Crossref

3. Law AK, Ng MH, Hon KL, Graham CA. Out-of-hospital cardiac arrest in the pediatric population in Hong Kong: a 10-year review at a university hospital. Pediatr Emerg Care 2018;34:179-84. Crossref

4. Tham LP, Chan I. Paediatric out-of-hospital cardiac arrests: epidemiology and outcome. Singapore Med J 2005;46:289-96.

5. Schindler MB, Bohn D, Cox PN, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:1473-9. Crossref

6. American College of Surgeons Committee on Trauma; American College of Emergency Physicians Pediatric Emergency Medicine Committee; National Association of EMS Physicians; American Academy of Pediatrics Committee on Pediatric Emergency Medicine; Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics 2014;133:e1104-16. Crossref

7. American Heart Association. Highlights of the 2020 American Heart Association Guidelines for CPR and ECC. 2020. Available from: https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/highlights/hghlghts_2020_ecc_guidelines_english.pdf. Accessed 3 Apr 2021.

8. Fan KL, Leung LP, Siu YC. Out-of-hospital cardiac arrest in Hong Kong: a territory-wide study. Hong Kong Med J 2017;23:48-53. Crossref

9. Yan S, Gan Y, Jiang N, et al. The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis. Crit Care 2020;24:61. Crossref

10. Wu WY. Out-of-hospital cardiac arrest: the importance of a registry. Hong Kong Med J 2019;25:176-7. Crossref

To the Editor—From July 2022 to April 2023, the Hong Kong Poison Information Centre has recorded six cases of severe rhabdomyolysis associated with prescription of high-dose rosuvastatin (≥40 mg daily). All patients were Chinese and presented with a mean creatine kinase concentration of approximately 15 000 IU/L. All except one patient developed acute kidney injury and three required temporary renal replacement therapy. Concomitant liver injury was also evident in three patients. Although statin treatment is associated with development of rhabdomyolysis, the reported incidence is rare at 0.44 per 10 000 person-years.1 Nonetheless Asian patients possess pharmacogenetic factors placing them at high risk. It has been reported that Chinese subjects had a plasma rosuvastatin level 2.3 times that of white subjects, despite being prescribed the same dose.2 Other risk factors include advanced age, hypothyroidism, alcohol abuse, poor renal function, vitamin D deficiency, diabetes mellitus, and drug-drug interactions. The recent clustering of six cases raised concerns about the safety of high-dose rosuvastatin in the Hong Kong population.

In mainland China, the recommended maximum daily dose of rosuvastatin is only 20 mg. It should also be noted that when product inserts of Crestor (rosuvastatin calcium) were revised in 2022 in the United Kingdom,3 Australia4 and Canada,5 Asian ethnicity was a contraindication for prescription of Crestor 40 mg per day. Both prescribers and pharmacists should be aware of this change and doctors should be warned of the increased vulnerability of Chinese and other Asian patients. The licenced dose of rosuvastatin in Hong Kong may need to be revised urgently.

The author had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

The author has disclosed no conflicts of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Graham DJ, Staffa JA, Shatin D, et al. Incidence of hospitalized rhabdomyolysis in patients treated with lipid-lowering drugs. JAMA 2004;292:2585-90. Crossref

2. Lee E, Ryan S, Birmingham B, et al. Rosuvastatin pharmacokinetics and pharmacogenetics in white and Asian subjects residing in the same environment. Clin Pharmacol Ther 2005;78:330-41. Crossref

3. Crestor film-coated tablets (package insert). London: AstraZeneca UK Ltd; 2022.

4. Crestor (rosuvastatin calcium) film-coated tablets (package insert). Chatswood: Menarini Australia Pty Ltd; 2022.

5. Crestor (rosuvastatin calcium tablets) [package insert]. Mississauga: AstraZeneca Canada Inc; 2022.

To the Editor—Dr Ellen Tam and her Tuen Mun Hospital colleagues contributed an important study of coronavirus disease 2019 (COVID-19) infection among the older adults1 who are an increasingly large population in Hong Kong. Of particular interest is the higher mortality associated with increasing frailty but not necessarily increasing age. The latter seems to level off after age 90. May I substantiate this observation with the case of a centenarian who was fully vaccinated with two doses of Comirnaty and survived a breakthrough COVID-19 infection before proceeding to receive a third booster vaccination.

A female patient born in December 1920 had vascular dementia that had progressed over 15 years to a level at which she was completely dependent on a carer. She also had recurrent urinary and respiratory tract infections, osteoporosis and persistent bed sores. Echocardiogram revealed concentric left ventricular hypertrophy and diastolic dysfunction. Her clinical frailty score had been >7 for the last 10 years.

Two doses of Comirnaty were administered on the patient on 19 July and 22 August 2021, respectively. On 8 March 2022, while waiting for her third dose (booster), her whole family became infected with COVID-19 (tested positive by rapid antigen test) and developed cough and fever. The patient remained asymptomatic with no fever, cough, shortness of breath or loss of appetite. Family members recovered spontaneously and the patient remained negative on rapid antigen test from 12 March 2022 onwards. The third dose of Comirnaty was given to the patient after a delay of 4 months on 1 July 2022 and was well tolerated. Her severe acute respiratory syndrome coronavirus 2 nucleocapsid and envelope protein antibody titre was >2500 units/μL, well above the measuring capacity of our laboratory equipment.

This case shows how a centenarian with poor clinical frailty score was well protected against symptomatic COVID-19 infection during the height of the most severe wave of infection. Her antibody response after the third dose of Comirnaty was proven to be very high. We do not regularly test antibody level at a population level following vaccination but the level of protection can be seen from data in the official records (Table 2). Although older adults aged over 80 accounted for the great majority of COVID-19 deaths, those who received three doses of vaccine remained well protected with a mortality rate of ≤1%.2 Had this age-group been fully vaccinated, their mortality would have been reduced from 6542 to around 65.

Kordowitzki3 produced a report of COVID-19 infection in centenarians across various countries. Mortality rate of COVID-19 appeared to peak among octogenarians, as in this Hong Kong study, and showed some decline among those in their 90s. Although there are scanty reports of centenarian survival from COVID-19 infection from China, Germany and France, there has been little mention of the protection afforded by vaccination in this age-group. Genetic and acquired immune factors that favour extreme longevity might also favour immunity against COVID-19 infection.3

I hope the experience of this patient might be of interest to health workers dealing with the oldest section of our population, particularly in overcoming their vaccine hesitancy.

The author contributed to the drafting of the letter and critical revision for important intellectual content. The author approved the final version for publication and takes responsibility for its accuracy and integrity.

The author declared no conflict of interest.

1. Tam EM, Kwan YK, Ng YY, Yam PW. Clinical course and mortality in older patients with COVID-19: a clusterbased study in Hong Kong. Hong Kong Med J 2022;28:215-22 Crossref

2. Hong Kong SAR Government. Archive of statistics on 5th wave of COVID-19. Available from: https://www.coronavirus.gov.hk/eng/5th-wave-statistics.html#. Accessed 20 Jul 2022.

3. Kordowitzki P. Centenarians and COVID-19: is there a link between longevity and better immune defense? Gerontology 2022;68:556-7. Crossref