North District Hospital

RATIONALE: Some patients with severe asthma are immunologically sensitized to one or more fungi, a clinical entity categorized as severe asthma with fungal sensitization (SAFS). It is not known whether SAFS responds to antifungal therapy. OBJECTIVES: To evaluate the response of SAFS to oral itraconazole. METHODS: Patients with severe asthma sensitized to at least one of seven fungi by skin prick or specific IgE testing were recruited. All had total IgE less than 1,000 IU/ml and negative Aspergillus precipitins. They were treated with oral itraconazole (200 mg twice daily) or placebo for 32 weeks, with follow-up for 16 weeks. MEASUREMENTS AND MAIN RESULTS: The primary end point was change in the Asthma Quality of Life Questionnaire (AQLQ) score, with rhinitis score, total IgE, and respiratory function as secondary end points. Fifty-eight patients were enrolled, of whom 41% had been hospitalized in the previous year. Baseline mean AQLQ score was 4.13 (range, 1-7). At 32 weeks, the improvement (95% confidence interval) in AQLQ score was +0.85 (0.28, 1.41) in the antifungal group, compared with a -0.01 (-0.43, 0.42) change in the placebo group (P = 0.014). Rhinitis score improved (-0.43) in the antifungal, and deteriorated (+0.17) in the placebo group (P = 0.013). Morning peak flow improved (20.8 L/minute, P = 0.028) in the antifungal group. Total serum IgE decreased in the antifungal group (-51 IU/ml) but increased in placebo group (+30 IU/ml) (P = 0.001). No severe adverse events were observed, but seven patients developed adverse events requiring discontinuation, five in the antifungal group. CONCLUSIONS: SAFS responds to oral antifungal therapy as judged by large improvements in quality of life in about 60% of patients.

Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory disease of the breast that mimics carcinoma of the breast. Its etiology and treatment remain unclear. A retrospective review of nine women with histopathologic diagnosis of IGM was performed. The women had a mean follow-up of 18.7 months and a mean age of 45.7 years (range 32-83 years). The main presentation was breast mass (100%). Clinically and radiologically, 55.6% of the women were suspected to have malignancy. One patient was treated with lumpectomy without recurrence. Eight patients were treated with expectant management with close regular surveillance. No surgery was performed and no medications were given. Fifty percent of the patients had spontaneous complete resolution of disease after a mean interval of 14.5 months. These four patients had no recurrence. Fifty percent of patients had static disease. In conclusion, it is important to differentiate IGM from carcinoma of the breast. Tissue biopsy remains the gold standard to confirm the diagnosis. Expectant management with close regular surveillance is the treatment of choice.

The scope of arthroscopy and endoscopy of the foot and ankle is expanding. New techniques are emerging to deal with diverse ankle pathology. Some of the conditions that can be dealt with arthroscopically are as follows: hallux valgus deformity, lesser toe deformity, first metatarsophalangeal instability, cock-up deformity of the big toe, peroneal tendon instability, lateral ankle and subtalar instability, hindfoot deformity or arthrosis, first metatarsocuneiform hypermobility, Lisfranc joint arthrosis, various stages of posterior tibial tendon insufficiency, foot and ankle arthrofibrosis, late complications after calcaneal fracture, acute and chronic Achilles tendon rupture, insertional Achilles tendinopathy, entrapment of the first branch of the lateral plantar nerve, Freiberg's infarction, flexor digitorum longus tenosynovitis, flexor hallucis longus pathology, calcaneonavicular coalition or "too-long" anterior process of the calcaneus, and ganglions. With sound knowledge regarding the indications, merits, and potential risks of new techniques, they will be powerful tools in foot and ankle surgery.

PURPOSE: The purpose of this study was to compare intraoperative stress radiography and ankle arthroscopy in the evaluation of distal tibiofibular syndesmosis disruption in acute ankle fracture. TYPE OF STUDY: Prospective study. METHODS: We treated 53 Weber type B or C ankle fractures without radiographic evidence of frank syndesmosis diastasis. Intraoperative stress radiography and ankle arthroscopy were performed. Syndesmotic screws were inserted in those patients with syndesmosis diastasis. Screws were removed 12 weeks later and second-look ankle arthroscopy was performed at the same time. RESULTS: Sixteen cases (30.2%) had positive intraoperative stress radiographs; 35 cases (66.0%) had positive arthroscopic findings of syndesmosis diastasis, including various combinations of coronal, sagittal, and rotational planes of instability. During second-look arthroscopy, 31 of 34 patients with syndesmotic screws showed healing of the syndesmotic ligaments and the syndesmosis became stable. CONCLUSIONS: Ankle arthroscopy excels intraoperative stress radiography in detecting syndesmosis disruption. It also provides assessment of different planes of instability and assists anatomic reduction of the syndesmosis. Intraoperative radiography still does play an important role in assessing fracture reduction and proper restoration of fibular length and longitudinal orientation of the syndesmosis. LEVEL OF EVIDENCE: Level 2.

INTRODUCTION: Diagnosis of severe influenza pneumonia remains challenging because of a lack of correlation between the presence of influenza virus and clinical status. We conducted gene-expression profiling in the whole blood of critically ill patients to identify a gene signature that would allow clinicians to distinguish influenza infection from other causes of severe respiratory failure, such as bacterial pneumonia, and noninfective systemic inflammatory response syndrome. METHODS: Whole-blood samples were collected from critically ill individuals and assayed on Illumina HT-12 gene-expression beadarrays. Differentially expressed genes were determined by linear mixed-model analysis and overrepresented biological pathways determined by using GeneGo MetaCore. RESULTS: The gene-expression profile of H1N1 influenza A pneumonia was distinctly different from those of bacterial pneumonia and systemic inflammatory response syndrome. The influenza gene-expression profile is characterized by upregulation of genes from cell-cycle regulation, apoptosis, and DNA-damage-response pathways. In contrast, no distinctive gene-expression signature was found in patients with bacterial pneumonia or systemic inflammatory response syndrome. The gene-expression profile of influenza infection persisted through 5 days of follow-up. Furthermore, in patients with primary H1N1 influenza A infection in whom bacterial co-infection subsequently developed, the influenza gene-expression signature remained unaltered, despite the presence of a superimposed bacterial infection. CONCLUSIONS: The whole-blood expression-profiling data indicate that the host response to influenza pneumonia is distinctly different from that caused by bacterial pathogens. This information may speed the identification of the cause of infection in patients presenting with severe respiratory failure, allowing appropriate patient care to be undertaken more rapidly.

Objective To estimate the accuracy of transvaginal ultrasound ( TVS ) measurement of endometrial thickness ( ET ) in diagnosing endometrial cancer in postmenopausal women with vaginal bleeding ( PMB ). Design Retrospective cohort study. Setting One‐stop PMB clinic in a Hong Kong teaching hospital. Population A cohort of 4383 women with PMB . Methods Transvaginal ultrasonic measurement of ET and endometrial biopsies were obtained in women presenting with PMB between 2002 and 2013. Endometrial histology was used as the reference standard to calculate accuracy estimates. Main outcome measures Accuracy data for TVS ET presented as sensitivity, specificity, and area under the receiver operator characteristic ( ROC ) curve. Results Endometrial cancer was diagnosed in 3.8% of women. The median ET in those with endometrial cancer was significantly higher than those with benign conditions (15.7 versus 3.2 mm, P < 0.001). The area under the ROC curve was 0.92 (95% CI 0.89–0.94). The sensitivity for the detection of endometrial cancer at 3‐, 4‐, and 5‐mm cut‐offs were 97.0% (95% CI 94.5–99.6%), 94.1% (95% CI 90.5–97.6%), and 93.5% (95% CI 89.7–97.2%), respectively. The corresponding estimates of specificity at these thresholds were 45.3% (95% CI 43.8–46.8%), 66.8% (65.4–68.2%), and 74.0% (72.7–75.4%). Conclusions Transvaginal ultrasound using a 3‐mm cut‐off has high sensitivity for detecting endometrial cancer and can identify women with PMB who are highly unlikely to have endometrial cancer, thereby avoiding more invasive endometrial biopsy.

OBJECTIVE: This article describes rice bodies found in patients with atypical mycobacterial tenosynovitis and bursitis, emphasizing the sonographic and MR imaging appearances of these small bodies. CONCLUSION: Rice bodies occur in patients with atypical mycobacterial tenosynovitis and bursitis. When small, rice bodies are better visualized on MR imaging than on sonography, allowing the radiologist to consider appropriate diagnoses.

OBJECTIVE: To review the clinical features and response to treatment of hyperthyroidism in elderly hospitalised patients. PARTICIPANTS AND SETTING: Sixty patients over the age of 70: 41 admitted to a geriatric hospital and 19 to an acute-care hospital, 1990-1993. METHODS: Thyroid function tests were performed routinely in the geriatric hospital but only on demand at the acute-care hospital. Hyperthyroidism was defined as elevation of plasma free thyroxine (FT4) or total tri-iodothyronine (T3) level and suppression of thyroid-stimulating hormone (TSH) level. Seventy-seven per cent of patients were seen personally; in the remainder details were obtained from their hospital records. Outcome was assessed by clinical and biochemical improvement. RESULTS: Clinical features - Fifty-two women and eight men with hyperthyroidism were identified. Their average age was 80.2 years (range, 70-101; median, 80.0). The most common clinical features were weight loss (83%) and atrial fibrillation (60%); 58% were agitated and 15% apathetic. Fifty-two per cent had cognitive impairment with either dementia or confusion. The diagnosis was not initially suspected in 62%. Thyroid antibodies were absent in 35/40 and an isotope scan showed a nodular thyroid in 27/29. Contrast radiography with iodine-containing media had been performed within the preceding six months in 23% of patients. Treatment and outcome - Forty-seven patients were treated with antithyroid drugs in standard doses and 21 received radioactive iodine. In 35 adequately assessed patients, including 21 with dementia, clinical improvement and normal results of thyroid function tests were achieved, but five patients died with uncontrolled hyperthyroidism. CONCLUSIONS: Hyperthyroidism in the elderly is usually due to autonomous thyroid nodules, and in about 20% of hospitalised patients may follow a contrast radiography procedure. The more common clinical features of hyperthyroidism occur frequently as unrelated symptoms in the elderly so that the diagnosis is often not apparent, particularly in the presence of cognitive impairment. As the response to standard biochemical treatment is rewarding, screening of the elderly with thyroid function tests should be done routinely.

We describe an arthroscopic technique by which to reconstruct both the calcaneofibular ligament and anterior talofibular ligament anatomically. The ankle joint is examined through the anteromedial portal and a lateral portal close to the talar insertion of the anterior talofibular ligament. The subtalar joint is examined through the anterolateral portal and the middle portal. Associated intra-articular pathology (e.g., osteochondral defect) is evaluated and addressed. The calcaneofibular ligament is an extracapsular structure that can be examined arthroscopically through the anterolateral portal in the extra-articular plane. The peroneal tendon sheath is stripped with a small periosteal elevator through the middle subtalar portal, and the calcaneal insertion of the calcaneofibular ligament is identified. The plantaris tendon is identified and freed through multiple small wounds at the medial calf, and the tendon is cut proximally and retrieved to its calcaneal insertion. A calcaneal bone tunnel (tunnel 1) is created between the plantaris tendon and the calcaneofibular ligament insertions by use of a 3.5-mm drill bit. The tendon graft is then looped onto a suture, and the suture is passed through the tunnel to the calcaneofibular ligament insertion and retrieved to the middle subtalar portal. Through the anterolateral subtalar portal, the fibular insertion of the calcaneofibular ligament is identified. Another bone tunnel is created from this point to the posterior edge of the fibula (tunnel 2) with a 3.5-mm drill through the middle subtalar portal. The fibular insertion of the anterior talofibular ligament is identified on ankle arthroscopy. Tunnel 3 is created from this point to the exit point of tunnel 2 through the lateral ankle portal. The tendon graft is retrieved to the lateral ankle joints through the second and third tunnels and is pierced through the lateral ankle capsule and course from intracapsular to extracapsular. The tendon graft loop is anchored to the insertion point of the anterior talofibular ligament by a 4.0-mm cancellous screw with a spiked washer. The tendon graft is tensioned by pulling the free end of the tendon graft while tightening the screw. The free end of the tendon graft and the stay stitch are sutured to surrounding soft tissue or anchored with another 4.0-mm cancellous screw and spiked washer. The procedure is then completed, and a short leg cast is applied. The patient is advised to perform non-weight-bearing walking for 6 weeks.

The course of the flexor hallucis tendon (FHL) is divided into three zones. Zone 1 is located behind the ankle joint, from the musculotendinous junction to the orifice of the tunnel underneath the sustentaculum tali. Zone 2 is located from the tunnel underneath the sustentaculum tali to the knot of Henry. Zone 3 is located from the knot of Henry to the tendon insertion to the base of the distal phalanx of the big toe. The zone 1 FHL tendon is examined with posterior ankle endoscopy with the posterolateral and posteromedial portals. The zone 2 FHL tendon can be examined through the posteromedial and the plantar portals. The zone 3 FHL tendon is examined with the toe flexor tendoscopy. By means of different endoscopic approach to the each zone of the FHL tendon, the complete course of the tendon can be examined from the musclotendinous junction to its insertion.

Our objective is to assess whether the tendoscopic synovectomy is effective to control the stage I posterior tibial tendon dysfunction. Our study is a retrospective one. The participants, six patients with stage I posterior tibial tendon dysfunction, were treated with tendoscopy with synovectomy for the past 3 years. The results show that this is a safe procedure and we could achieve similar effectiveness as the traditional open procedure. There was no complication found. None of our patients have progressed to stage II or above posterior tibial tendon dysfunction. In conclusion, tendoscopic debridement is a minimal invasive surgery. It is effective to control the stage I posterior tibial tendon dysfunction. In addition, it had the advantages of smaller scars, less wound pain and a short hospital stay.

This is a technical note on endoscopic peroneal retinaculum reconstruction in the management of peroneal tendons instability. The surgical trauma of open peroneal retinaculum reconstruction can be minimized with endoscopic approach. The author describes the surgical principle and technique of this endoscopic approach.

Triple arthrodesis is a common procedure in foot and ankle surgery. It has a significant role in treating hind foot osteoarthrosis and deformity. We describe a new arthroscopic approach of triple arthrodesis. Through carefully planned portal placement of midtarsal joint arthroscopy, together with subtalar arthroscopy, we can denude articular cartilage of the 3 joints with minimal resection of subchondral bone. The 3 joints are put into the desired position and fixed with cannulated screws. This has the potential advantage of minimal bone removal and better fusion surface preparation, especially of the talonavicular joint.

PURPOSE: Our purpose was to evaluate the clinical and radiologic results of arthroscopy-assisted hallux valgus deformity correction with percutaneous screw fixation. METHODS: Ninety-four feet underwent arthroscopy-assisted hallux valgus deformity correction. Patients in whom the 1,2-intermetatarsal angle could be reduced manually and who had no significant abnormality of the distal metatarsal articular angle were included, and an endoscopic distal soft tissue procedure was performed. Those patients with first tarsometatarsal hypermobility, in whom the 1,2-intermetatarsal angle cannot be reduced manually, or those who had a significantly abnormal distal metatarsal articular angle were excluded. Patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale. The pre- and postoperative hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, and sesamoid position were measured. RESULTS: The mean score on the AOFAS scale was 93 +/- 8 out of 100 points. The hallux valgus angle improved from 33 degrees +/- 7 degrees (range, 20 degrees to 58 degrees ) to 14 degrees +/- 5 degrees (range, 4 degrees to 30 degrees ). The intermetatarsal angle improved from 14 degrees +/- 3 degrees (range, 10 degrees to 26 degrees ) to 9 degrees +/- 2 degrees (range, 5 degrees to 18 degrees ). Complications of hallux varus, skin impingement, screw breakage, and first metatarsophalangeal stiffness were experienced. Two patients with symptomatic recurrence had revision operation performed. CONCLUSIONS: Our study shows that arthroscopic correction of the hallux valgus deformity can achieve good clinical and radiologic results, provided that careful preoperative clinico-radiologic assessment is made to exclude patients contraindicated for the procedure. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Fashion production has been split between a globalized clothing industry, which tends towards extreme centralization, and localized designer fashion sectors, acting as intermediaries between international suppliers and national events, media, and public. Under these conditions, designer fashion takes on national significance, in terms of staging events and displays, and engaging with cultural references outside the field of fashion. This article explores how such place-making abilities structure the polycentric world of fashion, taking the United Nations Security Council as a model for the interaction between first- and second-tier fashion cities. The article analyzes the rhetoric of new fashion centers as a traveling discourse that detaches fashion design from the concerns of textile and clothing industries and links it with those of cultural institutions and governments. It also examines how notions of cultural superiority have held European designers back from giving local flavor to their designs, but how there has recently been an approximation between fashion and folk culture.

INTRODUCTION: We report the first case of laparoscopic sleeve gastrectomy with loop bipartition (a modified form of Santoro's operation) in the treatment of type II diabetes mellitus associated with obesity. PRESENTATION OF CASE: A 46-year-old gentleman (baseline BMI 32.9; BW 98.5kg) with 7-year history of type II diabetes mellitus (DM) underwent the procedure in Hong Kong. The control of DM was poor even with intensive medical therapy before the operation. Standard laparoscopic sleeve gastrectomy (SG) was performed and a loop gastroileostomy was fashioned at the antrum 250cm from the ilececal valve without division of the 1st part of duodenum after SG. The resultant gastric tube has two outlets, one to the first part of duodenum and the other to the ileum with preferential passage of food through the gastroileostomy as shown on subsequent contrast study. The patient's recovery was uneventful. The excess BMI loss was 97% with complete normalization of all metabolic parameters at 1-year follow-up. DISCUSSION: This new surgical procedure (sleeve gastrectomy with loop bipartition: SG+LB) was evolved and derived from the combined concepts of sleeve gastrectomy with transit bipartition (SG+TB), single anastomosis duodenal-ileostomy (SADI), mini-gastric bypass (MGB) and duodenal-jejunal bypass (DJB) with less nutritional and surgical complications. CONCLUSION: Sleeve gastrectomy with loop bipartition may be a very effective and simple operation to treat uncontrolled DM associated with obesity with a lot of apparent advantages over most current metabolic procedures available at the moment.

PURPOSE: To report the operative findings of ankle arthroscopy during open reduction and internal fixation of acute ankle fractures. METHODS: This was a retrospective review of 254 consecutive patients with acute ankle fractures who were treated with open reduction and internal fixation of the fractures, and ankle arthroscopy was performed at the same time. The accuracy of fracture reduction, the presence of syndesmosis disruption and its reduction, and the presence of ligamentous injuries and osteochondral lesions were documented. Second-look ankle arthroscopy was performed during syndesmosis screw removal 6 weeks after the key operation. RESULTS: There were 6 patients with Weber A, 177 patients with Weber B, 51 patients with Weber C, and 20 patients with isolated medial malleolar fractures. Syndesmosis disruption was present in 0% of patients with Weber A fracture, 52% of patients with Weber B fracture, 92% of patients with Weber C fracture, and 20% of the patients with isolated medial malleolar fracture. Three patients with Weber B and one patient with Weber C fracture have occult syndesmosis instability after screw removal. Osteochondral lesion was present in no patient with Weber A fracture, 26% of the Weber B cases, 24% of the Weber C cases, and 20% of isolated medial malleolar fracture cases. The association between the presence of deep deltoid ligament tear and syndesmosis disruption (warranting syndesmosis screw fixation) in Weber B cases was statistically significant but not in Weber C cases. There was no statistically significant association between the presence of posterior malleolar fracture and syndesmosis instability that warrant screw fixation. CONCLUSIONS: Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture. Direct arthroscopic visualization ensures detection and evaluation of intra-articular fractures, syndesmosis disruption, and associated osteochondral lesions and ligamentous injuries. LEVEL OF EVIDENCE: Level IV, case series.

OBJECTIVES: To compare the contributions of patients, emergency physicians, and surgeons in the delay of diagnosis and treatment of appendicitis, and the effects of delay on disease stage and complication rate. DESIGN: Retrospective study. SETTING: Accident and emergency department of a district public hospital, Hong Kong. PATIENTS: All patients undergoing emergency appendectomy between August 1998 to September 1999. MAIN OUTCOME MEASURES: Patient delay in presentation, emergency physician delay in hospital admission, and surgeon delay in performing the operation; operative findings; and postoperative complications. RESULTS: Of 158 patients undergoing emergency operation, 14 had no pathological diagnosis and four had a diagnosis other than that of acute appendicitis. Of the 140 pathologically confirmed cases of appendicitis, the mean emergency patient delay was greater in advanced appendicitis than it was in simple appendicitis (42.0 hours versus 24.9 hours; P<0.005). The mean emergency physician delay in advanced appendicitis was also greater than it was in simple appendicitis (17.9 hours versus 5.8 hours; P<0.05). The difference in the mean surgeon delay in simple (10.9 hours) and advanced (16.3 hours) appendicitis, however, was not significant. The mean emergency physician delay showed a significant association with the postoperative complication rate (P=0.05). The delay was mainly because of a failure to diagnose the condition and admit the patient at the first visit to the accident and emergency department (22.1%). The diagnostic accuracy showed a significant association with the level of experience of the emergency physician involved (P<0.05). CONCLUSION: There should be a higher index of suspicion, better surgical training, and better senior supervision at accident and emergency departments, to avoid preventable morbidity and mortality in acute appendicitis.

Calcaneonavicular coalition and the "too long" anterior process (TLAP) of the calcaneus can manifest as lateral foot pain, peroneal spastic flatfoot, and repeated ankle sprain. Surgical resection of the bone bar is frequently required. We present here an arthroscopic approach that can be used to accurately assess pathoanatomy and resect the bone bar. A portal is established slightly dorsal to the angle of Gissane. This is the primary visualization portal. The working portal, which is identified under an image intensifier, is located at the space between the talonavicular and calcaneocuboid joints, directly over the TLAP or the calcaneonavicular coalition. With the 2.7-mm 30 degrees arthroscope placed at the primary visualization portal, soft tissue around the TLAP or the calcaneonavicular coalition is cleared up with the use of an arthroscopic shaver at the working portal. After the TLAP or the calcaneonavicular coalition is clearly visualized, it can be resected with an arthroscopic burr through the working portal. The bone bar is resected proximally until the medial side of the calcaneocuboid joint, the lateral side of the taloavicular joint, and the plantar-lateral aspect of the talar head are clearly seen. Inversion stress should then be applied to the foot to prevent further impingement of the anteromedial process of the calcaneus to the plantar-lateral part of the talar head.

The distal soft tissue procedure is the basis of surgical hallux valgus correction. It involves release of the transverse metatarsal ligament, adductor hallucis, and lateral joint capsule, which permits the proximal phalanx to be realigned on the metatarsal head. The attenuated medial capsule is plicated after the medial bony prominence has been excised. We describe a new endoscopic approach for the distal soft tissue procedure with better cosmetic results.