Ka-Tak Wong

Viral clearance and inflammatory response patterns in adults hospitalized for pandemic 2009 influenza A(H1N1) virus pneumonia.

BACKGROUND Little is known about the virological and inflammatory responses of severe pandemic 2009 influenza A(H1N1) virus pneumonia during antiviral treatment. METHODS In a prospective observational study, we recruited consecutive adults hospitalized with confirmed pandemic 2009 H1N1 infection during a 16-week period. Nasopharyngeal aspirate and non-respiratory samples (blood, stool and urine) were collected at presentation, and serial nasopharyngeal flocked swabs (NPFS) and tracheal aspirates (TA) were collected after initiating oseltamivir treatment for quantitative viral RNA assay, using real-time reverse transcriptase-PCR. Serial plasma samples were collected for cytokine/chemokine assay using cytometric bead array. Patients with severe pneumonia (lung infiltrates and hypoxaemia) were compared to those with milder illnesses. RESULTS A total of 66 patients were studied (mean age 43 ±20 years); 28 (42%) developed severe pneumonia, of whom 10 (15%) required intubation. Severe pneumonia was associated with older age, dyspnoea, delayed presentation >2 days from onset, extrapulmonary virus detection (13-28%) and higher viral concentration despite late-presentation (multiple linear regression, β=0.94, 95% confidence interval 0.15-1.74; P=0.02). Patients with severe pneumonia exhibited slow viral clearance with oseltamivir treatment, particularly in the lower respiratory tract (median [interquartile range] durations of RNA positivity after antiviral initiation were NPFS 6.0 days [3.0-8.0], TA 11.0 days [7.8-14.3] versus milder illness group NPFS of 2.0 days [1.0-3.0] days; P<0.01). High viral load in lower respiratory tract despite upper-tract RNA negativity and viral rebound after stopping treatment were noted in some patients. H275Y mutation was absent. High plasma levels of interleukin (IL)-6, CXCL-8 (IL-8), CCL2 (monocyte chemoattractant protein-1) and soluble tumour necrosis factor receptor-1 were observed, which correlated with the extent and progression of pneumonia in hospital. CONCLUSIONS In severe 2009 H1N1 pneumonia, viral clearance is slow with treatment, particularly in the lower respiratory tract. A more sustained antiviral regime appears warranted.

A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers

BACKGROUND In patients with bleeding peptic ulcers in whom endoscopic hemostasis fails, surgery usually follows. Transarterial embolization (TAE) has been proposed as an alternative. OBJECTIVE To compare the outcomes of TAE and salvage surgery for patients with peptic ulcers in whom endoscopic hemostasis failed. DESIGN Retrospective study. SETTING A university hospital. PATIENTS Patients with peptic ulcer bleeding in whom endoscopic hemostasis failed. INTERVENTIONS TAE and surgery as salvage of peptic ulcer bleeding. MAIN OUTCOMES MEASUREMENTS All-cause mortality, rebleeding, reintervention, and complication rate. RESULTS Thirty-two patients underwent TAE and 56 underwent surgery. In those who underwent TAE, the bleeding vessels were gastroduodenal artery (25 patients), left gastric artery (4 patients), right gastric artery (2 patients), and splenic artery (1 patient). Active extravasation was seen in 15 patients (46.9%). Embolization was attempted in 26 patients, and angiographic coiling was successful in 23 patients (88.5%). Bleeding recurred in 11 patients (34.4%) in the TAE group and in 7 patients (12.5%) in the surgery group (P=.01). More complications were observed in patients who underwent surgery (40.6% vs 67.9%, P=.01). There was no difference in 30-day mortality (25% vs 30.4%, P=.77), mean length of hospital stay (17.3 vs 21.6 days, P=.09), and need for transfusion (15.6 vs 14.2 units, P=.60) between the TAE and surgery groups. LIMITATIONS Retrospective study. CONCLUSIONS In patients with ulcer bleeding after failed endoscopic hemostasis, TAE reduces the need for surgery without increasing the overall mortality and is associated with fewer complications.

Evaluation of real-time qualitative sonoelastography of focal lesions in the parotid and submandibular glands: applications and limitations

ObjectiveTo evaluate qualitative ultrasound elastography for focal salivary gland masses identified during routine clinical practice.MethodsSixty-five parotid or submandibular masses in 61 patients underwent real-time qualitative ultrasound elastography and were scored on colour-scaled elastograms in terms of their stiffness relative to adjacent normal salivary parenchyma from ES 1 (soft) to ES 4 (stiff). This was correlated with diagnosis from aspiration cytology or histology.ResultsThere were 29 Warthin’s tumours (WTs), 23 pleomorphic adenomas (PAs), 2 adenoid cystic carcinomas, 1 adenosquamous carcinoma, 1 nodal metastasis from nasopharyngeal carcinoma, 1 lymphoma (2 deposits), 3 Kuttner tumours and 4 cases of Kimura’s disease. ES scores showed clustering according to pathological condition. In this respect, PAs were firmer than WTs (P < 0.004, Fisher’s exact test). Nine, 19, 14 and 17 of the benign masses and 0, 1, 2 and 3 of the malignant masses were ES 1, 2, 3 and 4 respectively. All three primary salivary malignancies were ES 4 compared with 1/29 WTs and 16/23 PAs.ConclusionThese preliminary findings suggest that qualitative real-time ultrasound elastography, although an ancillary technique to conventional ultrasound in the salivary glands, is likely to have a poor ability to discriminate benign lesions (particularly PAs) from malignant disease.

Development of a Scoring System From Noncontrast Computerized Tomography Measurements to Improve the Selection of Upper Ureteral Stone for Extracorporeal Shock Wave Lithotripsy

PURPOSE We investigated the role of noncontrast computerized tomography in predicting the treatment outcome of shock wave lithotripsy on upper ureteral stones to formulate a clinical algorithm to facilitate clinical management. MATERIALS AND METHODS Adult patients with upper ureteral stones confirmed by noncontrast computerized tomography and scheduled for primary in situ shock wave lithotripsy were prospectively recruited. Standardized treatment was performed on each patient. The primary end point was stone-free status at 3 months. Pretreatment noncontrast computerized tomography was assessed by a single radiologist blinded to the clinical parameters. Predictive values of computerized tomography measurements on the treatment outcome were then assessed. RESULTS Between October 2004 and July 2007 a total of 94 patients (60 male and 34 female) were recruited for the study. Logistic regression showed that stone volume, mean stone density and skin-to-stone distance were potential predictors of successful treatment. From ROC curves the optimum cutoff for predicting treatment outcomes for stone volume, mean stone density and skin-to-stone distance was 0.2 cc, 593 HU and 9.2 cm, respectively. A simple scoring system was constructed based on the 3 factors of stone volume less than 0.2 cc, mean stone density less than 593 HU or skin-to-stone distance less than 9.2 cm. The stone-free rate for patients having 0, 1, 2 and 3 factors was 17.9%, 48.4%, 73.3% and 100%, respectively (linear-by-linear association test 22.83, p <0.001). CONCLUSIONS Stone volume, mean stone density and skin-to-stone distance were potential predictors of the successful treatment of upper ureteral stones with shock wave lithotripsy. A scoring system based on these 3 factors helps separate patients into outcome groups and facilitates treatment planning.

Strong Immunohistochemical Expression of Vascular Endothelial Growth Factor Predicts Overall Survival in Head and Neck Squamous Cell Carcinoma

BackgroundHead and neck squamous cell carcinoma (HNSCC) has high morbidity and mortality, and its relationship with tumor angiogenesis as measured by mircovessel density (MVD) or vascular endothelial growth factor (VEGF) expression has shown mixed results, with some, but not others, reporting correlation with outcome.MethodsA retrospective study of 186 patients with HNSCC was performed. Patients were evaluated for MVD and VEGF and to correlate the levels with clinical parameters, including age at diagnosis, sex, site of tumor, stage, survival (disease free and overall), pathological tumor grade, and the presence of lymph node metastases.ResultsThe 186 cancers included the following sites: oral tongue (n = 69), palate (n = 9), maxillary sinus (n = 8), floor of mouth (n = 13), oropharynx (n = 27), hypopharynx (n = 26) and larynx (n = 34). Over three-quarters of patients had advanced tumor (stage III/IV) and 58.6% had lymph node metastases. MVD and VEGF were assessed in 166 and 164 cases, respectively, but these were not correlated with site and grade. The 3-year overall and disease-free survival rates were 55.4% and 53.2%, respectively. Both univariate and multivariate survival analysis showed that advanced T stage, nodal metastasis, and strong VEGF intensity were independent adverse predictors for overall and disease-free survival. In stage IV disease, strong VEGF immunoreactivity was found to be the single adverse factor affecting the overall survival and a contributory factor for disease-free survival.ConclusionsVEGF immunoreactivity is a strong predictor of adverse outcome, particularly in locoregionally advanced disease.

Real-Time Qualitative Ultrasound Elastography of Miscellaneous Non-Nodal Neck Masses: Applications and Limitations

To evaluate real-time qualitative ultrasound elastography as an adjunct to conventional sonography for evaluation of non-nodal neck masses identified in routine clinical practice, 52 consecutive masses in 49 patients underwent both techniques. Lesion stiffness was graded visually on chromatic-scale elastograms from ES0-3 (low to high). Diagnosis was based on (cyto)pathology (11), corroborative cross-sectional imaging (18) or characteristic conventional sonography (23). There were 16 lipomas, 15 lymphatic/venous vascular malformations (LVVMs), six neurogenic tumours/neuromas, five thyroglossal duct cysts (TGCs), five (epi)dermoids, three abscesses, one second-arch branchial cleft cyst (BCC), and one soft-tissue metastasis. In general terms, lesion stiffness was high (ES2-3) for neurogenic tumours/neuromas, (epi)dermoids and metastasis, and low (ES0-1) for lipomas, LVVM, TGCs and BCC. Abscesses displayed variable stiffness according to fluid content. Technical limitations and artefacts of elastograms were identified. Data from real-time qualitative ultrasound elastography may be a useful adjunct to sonography for diagnosis of non-nodal neck masses.

HER2 expression predicts improved survival in patients with cervical node–positive head and neck squamous cell carcinoma

OBJECTIVE: To investigate the prognostic value of HER2 and p63 expression in head and neck squamous cell carcinoma (HNSCC). STUDY DESIGN: A case review of 186 HNSCCs from the oral tongue, palate, maxillary sinus, floor of mouth, oropharynx, hypopharynx, and larynx. SUBJECTS AND METHODS: All primary tumor specimens were evaluated by immunohistochemistry for HER2 and p63 expressions, which were correlated with clinical parameters including age, sex, grade, lymph node metastases, stage, and survival. RESULTS: One hundred forty-one patients had stage III-IV disease and 109 had lymph node metastases. For all cases, T and N stages were significant prognostic predictors for both overall and disease-free survivals. In the node-positive subgroup, T stage and HER2 expression were significant prognostic predictors for both overall and disease-free survivals. CONCLUSION: HER2 may be associated with longer survival in node-positive patients with HNSCC.

Increased prevalence of coronary plaque in patients with psoriatic arthritis without prior diagnosis of coronary artery disease

Objectives To evaluate coronary atherosclerosis in patients with psoriatic arthritis (PsA) and control subjects using coronary CT angiography (CCTA). Methods Ninety consecutive patients with PsA (male: 56(62.2%); 50.3±11.1 years) were recruited. 240 controls (male: 137(57.1%); 49.6±10.7 years) without known cardiovascular (CV) diseases who underwent CCTA due to chest pain and/or multiple CV risk factors were recruited for comparison. Results Patients with PsA and controls were matched in age, gender and traditional CV risk factors (all p>0.2). The prevalence of overall plaque (54(60%)/84(35%), p<0.001), calcified plaque (CP) (29(32%)/40(17%), p=0.002), mixed plaque (MP) (20(22%)/18(8%), p<0.001), non-calcified plaque (NCP) (39(43%)/53(22%), p<0.001) and combined MP/NCP (46(51%)/62(26%), p<0.001) were all significantly higher in patients with PsA. Three-vessel disease was diagnosed in 12(13%) patients with PsA and 7(3%) controls (p<0.001), while obstructive plaques (>50% stenosis) were observed in 8(9%) patients with PsA and 7(3%) controls (p=0.033). After adjusting for traditional CV risk factors, PsA remained an independent explanatory variable for all types of coronary plaques (OR: 2.730 to 4.064, all p<0.001). PsA was also an independent explanatory variable for three-vessel disease (OR: 10.798, p<0.001) and obstructive plaque (3.939, p=0.024). In patients with PsA, disease duration was the only disease-specific characteristic associated with more vulnerable plaques (MP/NCP) in multivariate analysis (1.063, p=0.031). The other independent explanatory variables were age ≥55 years (5.636, p=0.005) and male gender (8.197, p=0.001). Conclusions Patients with PsA have increased prevalence, burden and severity of coronary atherosclerosis as documented by CCTA. Longer disease duration was independently associated with the presence of vulnerable MP/NCP plaques in patients with PsA. Trial registration number NCT02232321.

Intramural Left Atrial Hematoma Complicating Catheter Ablation for Atrial Fibrillation

![Figure][1] [![Graphic][3] ][3] A 52-year-old woman became hypotensive during radiofrequency ablation for paroxysmal atrial fibrillation. She received heparin 5,000 IU after transseptal puncture, and continued as an infusion to maintain an activated clotting time of 270 s during the

The effect of renal cortical thickness on the treatment outcomes of kidney stones treated with shockwave lithotripsy.

Purpose Because the shock wave passes through various body tissues before reaching the stone, stone composition may affect the treatment efficacy of shock wave lithotripsy (SWL). We investigated the effect of various tissue components along the shock wave path on the success of SWL. Materials and Methods From October 2008 to August 2010, a total of 206 patients with kidney stones sized 5 to 20 mm were prospectively recruited for a study of the factors that affect the outcome of treatment with a Sonolith Vision lithotripter. Successful SWL was defined as either stone-free status or residual fragments <4 mm at 12 weeks. Logistic regression analysis was performed to assess the factors that predicted treatment outcomes. Potential predictors included the patients age, shock wave delivery rate, stone volume (SV), mean stone density (MSD), skin-to-stone distance (SSD), and the mean thickness of the three main components along the shock wave path: renal cortical thickness (KT), muscle thickness (MT), and soft-tissue thickness (ST). Results The mean age of the patients was 53.8 years (range, 25-82 years). The overall treatment success rate after one session of SWL was 43.2%. The mean KT, MT, and ST were 26.9, 16.6, and 40.8 mm, respectively. The logistic regression results showed that a slower shock wave delivery rate, smaller SV, a lower MSD, and a thicker KT were found to be significant predictors for successful SWL. SSD, MT, and ST were not predictors of successful treatment. Conclusions Among the main tissue components along the shock wave path, a thicker KT was a favorable factor for successful SWL after adjustment for SV, MSD, and the shock wave delivery rate.