Background/Aims
Endoscopic screening for high‐risk gastro‐oesophageal varices (GOV) is recommended for compensated cirrhotic patients with transient elastography identifying increasing numbers of ...patients with cirrhosis without portal hypertension. Using liver stiffness measurement (LSM) ± platelet count, the aim was to develop a simple clinical rule to exclude the presence of high‐risk GOV in patients with Child–Pugh A cirrhosis.
Methods
A retrospective analysis of 71 patients with Child–Pugh A cirrhosis diagnosed by transient elastography (LSM >13.6 kPa) who underwent screening gastroscopy was conducted. A predictive model using LSM ± platelet count was assessed to exclude the presence of high‐risk GOV (diameter >5 mm and/or the presence of high‐risk stigmata) and validated using a second cohort of 200 patients from two independent centres.
Results
High‐risk GOV were present in 10 (15%) and 16 (8%) of the training and validation cohorts, respectively, which was associated with LSM and Pl count (P < 0.05). A combined model based on LSM and Pl count was more accurate for excluding the presence of high‐risk GOV than either alone (training cohort AUROC: 0.87 0.77–0.96 vs. 0.78 0.65–0.92 for LSM and 0.71 0.52–0.90 for platelets) with the combination of LSM ≤25 kPa and Pl ≥100 having a NPV of 100% in both the training and validation cohorts. A total of 107 (39%) patients meet this criterion.
Conclusion
The combination of LSM ≤25 kPa and Pl ≥100 can be used in clinical practice to exclude the presence of high‐risk GOV in patients with Child–Pugh A cirrhosis.
Few studies have described how an expanding elderly population influences the burden of antimicrobial resistance in micro-organisms. This study aimed to investigate trends in age-stratified ...extended-spectrum β-lactamase (ESBL)-positive Escherichia coli metrics in relation to an ageing population. The antimicrobial resistance database of E. coli from a healthcare region in Hong Kong from 2003 to 2012 was retrospectively reviewed. Future trends in age-stratified ESBL metrics were predicted up to 2022. Susceptibility results of clinical E. coli isolates from patients aged 0-74 years (n = 17 853) and aged ≥75 years (n = 17 047) were analysed. For the period 2003-2012, 23.7 % of the hospital admissions were of patients aged ≥75 years. However, approximately half of the annual ESBL-positive E. coli isolates were recovered from patients aged ≥75 years, being 55.0 % (233/424) in 2003 and 56.0 % (639/1142) in 2012. During this period of time, the annual prevalence and cumulative incidence of ESBL-positive E. coli in patients aged ≥75 years were significantly higher than in patients aged 0-74 years. From 2012-2022, it is predicted that ESBL-positive E. coli prevalence among patients aged 0-74 years and ≥75 years would increase from 25.4 % to 50.2 % and from 30.8 % to 70.0 %, respectively. In 2022, the predicted ESBL-positive E. coli cumulative incidence would be 63.7 per 10 000 admissions and 178.7 per 10 000 admissions among patients aged 0-74 years and ≥75 years, respectively. In conclusion, a rapidly expanding elderly population would substantially add to the burden of ESBL.
OBJECTIVE To assess the effectiveness of infection control preparedness for human infection with influenza A H7N9 in Hong Kong. DESIGN A descriptive study of responses to the emergence of influenza A ...H7N9. SETTING A university-affiliated teaching hospital. PARTICIPANTS Healthcare workers (HCWs) with unprotected exposure (not wearing N95 respirator during aerosol-generating procedure) to a patient with influenza A H7N9. METHODS A bundle approach including active and enhanced surveillance, early airborne infection isolation, rapid molecular diagnostic testing, and extensive contact tracing for HCWs with unprotected exposure was implemented. Seventy HCWs with unprotected exposure to an index case were interviewed especially regarding their patient care activities. RESULTS From April 1, 2013, through May 31, 2014, a total of 126 (0.08%) of 163,456 admitted patients were tested for the H7 gene by reverse transcription-polymerase chain reaction per protocol. Two confirmed cases were identified. Seventy (53.8%) of 130 HCWs had unprotected exposure to an index case, whereas 41 (58.6%) and 58 (82.9%) of 70 HCWs wore surgical masks and practiced hand hygiene after patient care, respectively. Sixteen (22.9%) of 70 HCWs were involved in high-risk patient contacts. More HCWs with high-risk patient contacts received oseltamivir prophylaxis (P=0.088) and significantly more had paired sera collected for H7 antibody testing (P<0.001). Ten (14.3%) of 70 HCWs developed influenza-like illness during medical surveillance, but none had positive results by reverse transcription-polymerase chain reaction. Paired sera was available from 33 of 70 HCWs with unprotected exposure, and none showed seroconversion against H7N9. CONCLUSIONS Despite the delay in airborne precautions implementation, no patient-to-HCW transmission of influenza A H7N9 was demonstrated.
A major complication of peritoneal dialysis is the development of peritonitis, which is associated with reduced technique and patient survival. The inflammatory response elicited by infection results ...in a fibrin and debris-rich environment within the peritoneal cavity, which may reduce the effectiveness of antimicrobial agents and predispose to recurrence or relapse of infection. Strategies to enhance responses to antimicrobial agents therefore have the potential to improve patient outcomes. This study presents pre-clinical data describing the compatibility of tPA and DNase in combination with antimicrobial agents used for the treatment of PD peritonitis. tPA and DNase were stable in standard dialysate solution and in the presence of antimicrobial agents, and were safe when given intraperitoneally in a mouse model with no evidence of local or systemic toxicity. Adjunctive tPA and DNase may have a role in the management of patients presenting with PD peritonitis.
Post-transplant cyclophosphamide (PTCy) platform has shown low rates of graft-versus-host disease (GvHD) and non-relapse mortality (NRM) after haploidentical hematopoietic cell transplantation ...(HaploHCT). However, due to the limited disease control, relapse rate remains a major cause of treatment failure in high-risk patients. Total marrow and lymphoid irradiation (TMLI) allow for delivery of high radiation to bone marrow and other targeted structures, without increasing off-target radiation exposure and toxicity to end-organs. In this phase I trial (NCT02446964), 31 patients with high-risk and/or active primary refractory leukemias or MDS underwent peripheral blood stem cells (PBSC)-HaploHCT with TMLI, fludarabine and cyclophosphamide as conditioning regimen. Primary objectives were to evaluate safety and determine TMLI’s recommended phase 2 dose (RP2D). Radiation dose was escalated in increments of 200cGy (1200-2000cGy). GvHD prophylaxis was PTCy with tacrolimus/mycophenolate mofetil. Grade-2 toxicities by Bearman-scale were mucositis (n=1), hepatic (n=3), gastrointestinal (n=5), and cardiac (n=2). One patient (1800cGy) experienced grade 3 pulmonary toxicity (dose limiting toxicity). The RP2D was determined at 2000 cGy. At follow-up duration of 23.9 months for the whole cohort; 2-year NRM was 13%. Cumulative incidence of day-100 grade 2-4 and 3-4 acute GvHD were 52%, 6%, respectively. Chronic GvHD at 2 years was 35%. For patients treated at the RP2D (n=12); median follow-up duration of 12.3 months; 1-year relapse/progression, progression-free survival and overall survival rates were 17%, 74% and 83%; respectively. In conclusion, HaploHCT-TMLI with PTCy was safe and feasible in our high-risk patient population. Promising low relapse/progression rate was achieved without increasing GvHD or transplant-related mortality.
Background: Recent studies have suggested the eradication rate for Helicobacter pylori infection with standard amoxycillin–clarithromycin‐containing triple therapy as first‐line treatment have ...fallen below 80%. Levofloxacin‐containing triple therapy was proposed as an alternative. The aim of this study is to compare the efficacy and tolerability of the standard 7‐day clarithromycin‐containing triple therapy against the 7‐day levofloxacin‐containing triple therapy, and to assess whether the classical triple therapy is still valid as empirical first‐line treatment for H. pylori infection in Hong Kong.
Methods: Three hundred consecutive H. pylori‐positive patients were randomized to receive either 1 week of EAL (esomeprazole 20 mg b.d., amoxycillin 1 g b.d., and levofloxacin 500 mg daily) or EAC (esomeprazole 20 mg b.d., amoxycillin 1 g b.d., and clarithromycin 500 mg b.d.). H. pylori status was rechecked by 13C‐urea breath test 6 weeks after treatment. Patients who failed either of the first‐line eradication therapy were invited to undergo H. pylori susceptibility testing.
Results: H. pylori eradication was achieved in 128 of 150 (85.3%) patients in EAL and 139 of 150 (92.7%) patients in EAC groups, respectively (p = .043), for both intention‐to‐treat and per‐protocol analysis. More patients in the clarithromycin‐ than the levofloxacin‐containing therapy group developed side effects from the medication (21.3% vs 13.3%, p = .060). Nine patients (six from the EAL group and three from the EAC group) who failed their corresponding eradication therapy returned for susceptibility testing. All nine isolates were highly resistant to levofloxacin (minimum inhibitory concentration or MIC > 32 μg/mL), whereas only two of the six isolates from the EAL group were resistant to clarithromycin (MIC > 0.5 μg/mL).
Conclusions: The standard 7‐day clarithromycin‐containing triple therapy is still valid as the most effective empirical first‐line eradication therapy for H. pylori infection in Hong Kong, as prevalence of primary resistance of H. pylori to amoxycillin and clarithromycin remains low. Patients who failed their empirical first‐line eradication therapy should undergo H. pylori susceptibility testing to guide further treatment.
Chlamydophila psittaci is found worldwide, but is particularly common among psittacine birds in tropical and subtropical regions. While investigating a human psittacosis outbreak that was associated ...with avian chlamydiosis in Hong Kong, we identified a novel adenovirus in epidemiologically linked Mealy Parrots, which was not present in healthy birds unrelated to the outbreak or in other animals. The novel adenovirus (tentatively named Psittacine adenovirus HKU1) was most closely related to Duck adenovirus A in the Atadenovirus genus. Sequencing showed that the Psittacine adenovirus HKU1 genome consists of 31,735 nucleotides. Comparative genome analysis showed that the Psittacine adenovirus HKU1 genome contains 23 open reading frames (ORFs) with sequence similarity to known adenoviral genes, and six additional ORFs at the 3' end of the genome. Similar to Duck adenovirus A, the novel adenovirus lacks LH1, LH2 and LH3, which distinguishes it from other viruses in the Atadenovirus genus. Notably, fiber-2 protein, which is present in Aviadenovirus but not Atadenovirus, is also present in Psittacine adenovirus HKU1. Psittacine adenovirus HKU1 had pairwise amino acid sequence identities of 50.3-54.0% for the DNA polymerase, 64.6-70.7% for the penton protein, and 66.1-74.0% for the hexon protein with other Atadenovirus. The C. psittaci bacterial load was positively correlated with adenovirus viral load in the lung. Immunostaining for fiber protein expression was positive in lung and liver tissue cells of affected parrots, confirming active viral replication. No other viruses were found. This is the first documentation of an adenovirus-C. psittaci co-infection in an avian species that was associated with a human outbreak of psittacosis. Viral-bacterial co-infection often increases disease severity in both humans and animals. The role of viral-bacterial co-infection in animal-to-human transmission of infectious agents has not received sufficient attention and should be emphasized in the investigation of disease outbreaks in human and animals.
It is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic consultation. The role of endoscopy performed within time frames ...shorter than 24 hours has not been adequately defined.
To evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy group) or between 6 and 24 hours (early-endoscopy group) after gastroenterologic consultation. The primary end point was death from any cause within 30 days after randomization.
A total of 516 patients were enrolled. The 30-day mortality was 8.9% (23 of 258 patients) in the urgent-endoscopy group and 6.6% (17 of 258) in the early-endoscopy group (difference, 2.3 percentage points; 95% confidence interval CI, -2.3 to 6.9). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and in 20 (7.8%) in the early-endoscopy group (difference, 3.1 percentage points; 95% CI, -1.9 to 8.1). Ulcers with active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent-endoscopy group and in 76 of 159 (47.8%) in the early-endoscopy group. Endoscopic hemostatic treatment was administered at initial endoscopy for 155 patients (60.1%) in the urgent-endoscopy group and for 125 (48.4%) in the early-endoscopy group.
In patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation. (Funded by the Health and Medical Fund of the Food and Health Bureau, Government of Hong Kong Special Administrative Region; ClinicalTrials.gov number, NCT01675856.).
PDF
