Self-Administered Acupressure for Probable Knee Osteoarthritis in Middle-Aged and Older Adults: A Randomized Clinical Trial

Importance

The effects of self-administered acupressure (SAA) on knee osteoarthritis (OA) pain remain unclear.

Objective

To evaluate the effectiveness of SAA taught via a short training course on reducing knee OA pain in middle-aged and older adults.

Design, Setting, and Participants

This randomized clinical trial was conducted among community-dwelling individuals in Hong Kong who were aged 50 years or older with probable knee OA from September 2019 to May 2022.

Interventions

The intervention included 2 training sessions for SAA with a brief knee health education (KHE) session, in which participants practiced acupressure twice daily for 12 weeks. The control group (KHE only) received only education about maintaining knee health on the same schedule and duration.

Main Outcomes and Measures

The primary outcome was the numerical rating scale (NRS) pain score at 12 weeks. Other outcomes included Western Ontario and McMaster University Osteoarthritis Index, Short Form 6 Dimensions (SF-6D), Timed Up and Go, and Fast Gait Speed tests.

Results

A total of 314 participants (mean [SD] age, 62.7 [4.5] years; 246 [78.3%] female; mean [SD] knee pain duration, 7.3 [7.6] years) were randomized into intervention and KHE-only groups (each 157). At week 12, compared with the KHE-only group, the intervention group had a significantly greater reduction in NRS pain score (mean difference [MD], -0.54 points; 95% CI, -0.97 to -0.10 points; P = .02) and higher enhancement in SF-6D utility score (MD, 0.03 points; 95% CI, 0.003 to 0.01 points; P = .03) but did not have significant differences in other outcome measures. The cost-effectiveness acceptability curve demonstrated a greater than 90% probability that the intervention is cost-effective at a willingness to pay threshold of 1 GDP per capita.

Conclusions and Relevance

In this randomized clinical trial, SAA with a brief KHE program was efficacious and cost-effective in relieving knee pain and improving mobility in middle-aged and older adults with probable knee OA.

Trial Registration

ClinicalTrials.gov Identifier: NCT04191837.

A spectrum of viral diseases in Odisha state, eastern India: An evidence-based analysis from 2010-2017

Introduction

Emerging and re-emerging viral diseases are a major threat to public health. Proper laboratory surveillance plays an important role in estimating the disease burden that helps in taking preventive measures for controlling seasonal diseases. This study focuses on the prevalence of different viral diseases in the state of Odisha, India, from 2010-2017.

Material and Methods

A total of 43,397 patients with clinical suspicion of viral diseases were screened for different viral etiology during 2010-2017. The laboratory diagnosis was conducted by serology (ELISA) and RealTime RT-PCR for 24 different viruses, i.e., Dengue, Chikungunya, Japanese Encephalitis, Hepatitis A Virus, Hepatitis E Virus, Hepatitis B Virus, Hepatitis C Virus, Rotavirus, Herpes Simplex Virus-1 and Herpes Simplex Virus-2, Epstein -Barr Virus & Cytomegalo Virus, and respiratory viruses. Patients were enrolled from sporadic hospital admissions and outbreaks under different categories as per clinical diagnosis like fever with rash, diarrhoea, encephalitis, jaundice, respiratory illness, and fever of unknown etiology.

Results

The majority of patients belonged to exanthematous group, i.e., fever with rash (32.24%). The number of males were more in all categories except fever with rash, where females (53.34%) were more. Children <16 years of age were found to be the predominant age group for suspected viral diarrhoea (85.26%), encephalitis (76.96%), fever of unknown origin (40.16%), and respiratory infections (27.23%).

Conclusion

Odisha being one of the coastal states in the country, reports many viral illnesses due to its typical geographical location. Initially, it was thought to be the only vector-borne disease that posed a threat to the state, but subsequently, other viral illnesses were also diagnosed and reported. This is the first report of laboratory confirmation and distribution of different viral diseases in the state of Odisha and neighboring regions, which will support public health management.

346 Semi-Individualized Acupuncture for Insomnia Disorder: A Randomized Sham-Controlled Trial

Introduction

Acupuncture is an alternative treatment for improving sleep quality and the effectiveness is thought to be optimized with an individualized approach resembling real practice. However, existing evidence is limited by methodological shortcomings due to blinding issues, standardized measures, and diagnostic procedures. It was of the present study’s interest to examine the efficacy and safety of semi-individualized acupuncture treatment on insomnia.

Methods

Adults with DSM-5 insomnia disorder (n = 140) were randomized with 1:1 allocation to a 4-week intervention traditional acupuncture (TA) or validated non-invasive sham acupuncture (SA). The selection of acupoints was semi-individualized by the acupuncturist. As the primary outcome, the sleep efficiency (SE) by sleep diary was assessed at baseline, 1-week posttreatment, and 5-week posttreatment. Other sleep parameters derived from sleep diary, the wrist-actigraphy-derived sleep parameters, insomnia symptom severity, anxiety, and depressive symptoms, as well as the health-related quality of life, were also evaluated.

Results

Although linear mixed-effect model revealed both groups did not attain significant difference in sleep-diary-derived SE and other outcome measures (all P &gt; 0.05), TA promising effect on improving insomnia symptom (within-group effect size, d = 1.13 & 1.30 at 1-week & 5-week posttreatment respectively) and also a higher proportion of subjects achieved SE ≥ 85% compared with SA (55.6% versus 36.4% at week 9, P = 0.03). Besides, subjects in TA group reported significantly greater improvement in both the total sleep time (TST) derived from sleep diary and actigraph than those in the SA group at 1-week posttreatment (difference in mean changes from baseline: sleep diary = 22.0 min, p = 0.01; actigraphy =18.8 min, P = 0.02) but not 5-week posttreatment.

Conclusion

This study is the first to evaluate the effect of the TCM-theory-based individualized acupuncture on sleep using a sham-control design. A 4-week semi-individualized acupuncture is able to significantly increase total sleep time with few adverse events.

Support (if any)

Research Grants Council of Hong Kong, Early Career Scheme (Project no.: 25101017)

Electroacupuncture trigeminal nerve stimulation plus body acupuncture for chemotherapy-induced cognitive impairment in breast cancer patients: An assessor-participant blinded, randomized controlled trial

Chemotherapy causes various side effects, including cognitive impairment, known as 'chemobrain'. In this study, we determined whether a novel acupuncture mode called electroacupuncture trigeminal nerve stimulation plus body acupuncture (EA/TNS + BA) could produce better outcomes than minimum acupuncture stimulation (MAS) as controls in treating chemobrain and other symptoms in breast cancer patients. In this assessor- and participant-blinded, randomized controlled trial, 93 breast cancer patients under or post chemotherapy were randomly assigned to EA/TNS + BA (n = 46) and MAS (n = 47) for 2 sessions per week over 8 weeks. The Montreal Cognitive Assessment (MoCA) served as the primary outcome. Digit span test was the secondary outcomes for attentional function and working memory. The quality of life and multiple functional assessments were also evaluated. EA/TNS + BA treated group had much better performance than MAS-treated group on reverse digit span test at Week 2 and Week 8, with medium effect sizes of 0.53 and 0.48, respectively, although no significant differences were observed in MoCA score and prevalence of chemobrain between the two groups. EA/TNS + BA also markedly reduced incidences of diarrhoea, poor appetite, headache, anxiety, and irritation, and improved social/family and emotional wellbeing compared to MAS. These results suggest that EA/TNS + BA may have particular benefits in reducing chemotherapy-induced working memory impairment and the incidence of certain digestive, neurological, and distress-related symptoms. It could serve as an effective intervention for breast cancer patients under and post chemotherapy (trial registration: https://www.clinicaltrials.gov: NCT02457039).

Epidemiological and clinical profile of Influenza A(H1N1) pdm09 in Odisha, eastern India

Epidemic of flu is highly contagious and it spreads through air. In 2009 H1N1 influenza virus emerged after reassortment of North American TRIG and Eurasia Avian like virus of swine and started epidemic in Mexico. The first cases were reported from Hyderabad city on 16th May 2009 in India that spread rapidly within a short span of time. During this period large population of Odisha situated at the eastern side of India was also affected and incidences of H1N1 cases were recorded through state Government surveillance system. In this study real time RT-PCR based diagnosis was conducted for the throat swabs collected from suspected H1N1 cases in Odisha during 2009–2017. A total of 2872 throat swabs were received from 23 different Government and private hospitals and 21.1% positivity was confirmed. The disease affected mostly 46–60 years age group, males (50.6%) being more affected. The clinical features had shown that fever with cough (89.6%) was the most common symptom followed by shortness of breath (72.7%). Post monsoon was the peak season in which most of the cases were reported. Neurological signs, pregnancy, diabetes and hypertension were found to be risk factors for H1N1. The case fatality rate (CFR) was 15%.

3045Role of osteogenic circulating endothelial progenitor cells in dissemination of large arterial calcification in rheumatoid arthritis

Background

Rheumatoid arthritis is associated with both abnormal bone metabolism and atherogenesis but mechanistic links were missing.

Aim

This study aimed to investigate the role of osteocalcin (OCN)-expressing circulating endothelial progenitor cells (EPC)s in the severity and dissemination of systemic arterial calcifications in rheumatoid arthritis.

Methods

We performed flow cytometry studies in 145 consecutive patients with rheumatoid arthritis to determine osteogenic circulating levels of OCN-positive (OCN+) CD34+KDR+ and OCN+CD34+, versus conventional early EPC CD34+CD133+KDR+. Total calcium load of the thoracic aorta (ascending plus descending) and the carotid arteries were assessed by non-contrast computed tomography (CT) and contrast CT angiography.

Results

Osteogenic EPCs OCN+CD34+KDR+ (P=0.002) and OCN+CD34+ were strikingly associated with the clustered presence of aortic and carotid calcification (P=0.002 and 0.001 respectively, Figure). Multivariable analyses revealed that circulating OCN+CD34+KDR+ (B=14.4 [95% CI 4.0 to 24.8], P=0.007) and OCN+CD34+ (B=9.6 [95% CI 4.9 to 14.3], P<0.001) remained independently associated with increased aortic calcium load. OCN+CD34+ EPC (B=0.8 [95% CI 0.1 to 1.5], P=0.023), but not OCN+CD34+KDR+ EPC (B=1.2 [95% CI −0.2 to 2.6], P=0.09) was further independently associated with carotid calcium load. In comparison, conventional early EPC CD34+CD133+KDR+ had no significant association with aortic or carotid calcium load (P=0.46 and 0.88, respectively).

Conclusions

Circulating level of osteogenic EPC is associated with promulgated aortic and carotid calcification in patients with rheumatoid arthritis, suggesting a potential mechanistic role of the bone-vascular axis in pro-atherogenicity of rheumatic diseases.

Acknowledgement/Funding

General Research Fund, Hong Kong Research Grants Council

Molecular and phylogenetic analysis of the dengue strains circulating in Odisha, India

Dengue has emerged as a major public health challenge in terms of both changing clinical pattern and epidemiological features. The state of Odisha reported first dengue epidemic in the year 2010 and this continued each year in epidemic form during post monsoon period gradually becoming an endemic phenomenon. Present study depicts the changing epidemiological and clinical pattern of dengue with reference to its serotypes and genotypes. The study included 5320 suspected dengue cases from different health facilities of the state during 2010-2017. Dengue NS1 antigen and IgM antibody was done through ELISA. Serotyping was done through RTPCR by amplifying a part of core-pre-membrane gene (CprM) followed by sequencing and phylogenetic analysis. Dengue IgM antibody in 17.7% cases and NS1 antigen in 53.20% cases was detected. Dengue serotype 2 (DEN-2) was the only serotype detected in 2010 and 2011 where as all four serotypes 1, 2, 3, 4 were detected in 2012-2017, DEN-2 being dominant but in 2017 DEN-3 was found to be dominant. Phylogenetic analysis revealed genotype IV of DEN-2 and genotype III of DEN-1 and DEN-3 circulating in this region. In 6 cases involvement of DEN-2 in clinically evident encephalitis cases is an important observation in this region and needs public health attention. High prevalence of dengue was observed without any previous reported outbreaks in the state with increased number of cases from 2010 to 2012 affecting both urban and rural areas. High incidence in 2012 was due to co-circulation of more than one serotype which continued in the following years. Severity in some cases was associated with mixed infection but in most cases it was mild indicating the endemic nature of the virus in most parts of Odisha.

Changes in individual weight status based on body mass index and waist circumference in Hong Kong Chinese

Background

Weight change predicted diseases and mortality. We investigate 3-year changes in individual body mass index (BMI) and waist circumference in Hong Kong Chinese adults.

Methods

In the Population Health Survey, 7084 adults in 2003 (baseline) were followed up in 2006. Longitudinal anthropometric data were available in 2941 (41.5%) for BMI and 2956 for waist circumference. Weight status and central obesity were based on objectively measured BMI and waist circumference using Asian standards.

Results

Mean BMI (SD) increased from 22.8 (3.62) to 23.1 (3.95) (p<0.001) with 1.3 percentage point increase in prevalence of overweight and obesity (from 44.3% to 45.6%). One in 5 (22.0%) normal or underweight baseline respondents became overweight or obese and a similar proportion (24.8%) of overweight and obese respondents became normal or underweight. Prevalence of central obesity increased from 28.3% to 32.4% (p<0.001) with a non-significantly greater increase in women (30.0% to 38.1%) than men (23.0% to 26.1%) (p=0.63). A higher proportion of centrally obese respondents returned to normal (29.4%) than normal respondents developing central obesity (17.4%).

Conclusions

This is one of the few studies in Chinese, which found dynamic longitudinal changes (increase/stable/decrease) in individual weight status and waist circumference. Future studies with better follow-up and investigating the causes of such changes are warranted.

Are the 2006 World Health Organization standards for infant growth applicable to Hong Kong Chinese? Universalistic standards or epidemiological transition stage-specific norms

1. Parental socio-economic status was positively associated with length and body mass index of Hong Kong Chinese infants at 9 months. 2. Maternal smoking in pregnancy was negatively associated with infant length at 9 months. 3. Some of the World Health Organization (WHO) criteria for an optimal nurturing environment contributed positively to growth. At 36 months, Hong Kong Chinese infants were generally shorter and fatter than the WHO growth references.

Statistical algorithms for early detection of the annual influenza peak season in Hong Kong using sentinel surveillance data

In Hong Kong, influenza sentinel surveillance systems have been recently established. Methods that compare current data to data from recent weeks may be appropriate to indicate the start of peak influenza activity. These methods can produce reliable and timely alerts at the start of the annual influenza peak season.

Excess mortality associated with influenza A and B virus in Hong Kong, 1998-2009

BACKGROUND

Although deaths associated with laboratory-confirmed influenza virus infections are rare, the excess mortality burden of influenza estimated from statistical models may more reliably quantify the impact of influenza in a population.

METHODS

We applied age-specific multiple linear regression models to all-cause and cause-specific mortality rates in Hong Kong from 1998 through 2009. The differences between estimated mortality rates in the presence or absence of recorded influenza activity were used to estimate influenza-associated excess mortality.

RESULTS

The annual influenza-associated all-cause excess mortality rate was 11.1 (95% confidence interval [CI], 7.2-14.6) per 100,000 person-years. We estimated an average of 751 (95% CI, 488-990) excess deaths associated with influenza annually from 1998 through 2009, with 95% of the excess deaths occurring in persons aged ≥65 years. Most of the influenza-associated excess deaths were from respiratory (53%) and cardiovascular (18%) causes. Influenza A(H3N2) epidemics were associated with more excess deaths than influenza A(H1N1) or B during the study period.

CONCLUSIONS

Influenza was associated with a substantial number of excess deaths each year, mainly among the elderly, in Hong Kong in the past decade. The influenza-associated excess mortality rates were generally similar in Hong Kong and the United States.

Transmission of Japanese encephalitis virus in Hong Kong

1. Pigs are likely to be the main amplifying host for Japanese encephalitis virus. 2. The success of a swine vaccination programme depends on the timing of the loss of maternal antibody protection and seasonal dynamics of the vector population. 3. Vaccination may be ineffective in the face of strong natural infection because of the variability in timing of the loss of maternal antibody protection.4. Evidence in support of swine vaccination as a human health intervention was not found.

Digital dashboard design using multiple data streams for disease surveillance with influenza surveillance as an example

BACKGROUND

Great strides have been made exploring and exploiting new and different sources of disease surveillance data and developing robust statistical methods for analyzing the collected data. However, there has been less research in the area of dissemination. Proper dissemination of surveillance data can facilitate the end user's taking of appropriate actions, thus maximizing the utility of effort taken from upstream of the surveillance-to-action loop.

OBJECTIVE

The aims of the study were to develop a generic framework for a digital dashboard incorporating features of efficient dashboard design and to demonstrate this framework by specific application to influenza surveillance in Hong Kong.

METHODS

Based on the merits of the national websites and principles of efficient dashboard design, we designed an automated influenza surveillance digital dashboard as a demonstration of efficient dissemination of surveillance data. We developed the system to synthesize and display multiple sources of influenza surveillance data streams in the dashboard. Different algorithms can be implemented in the dashboard for incorporating all surveillance data streams to describe the overall influenza activity.

RESULTS

We designed and implemented an influenza surveillance dashboard that utilized self-explanatory figures to display multiple surveillance data streams in panels. Indicators for individual data streams as well as for overall influenza activity were summarized in the main page, which can be read at a glance. Data retrieval function was also incorporated to allow data sharing in standard format.

CONCLUSIONS

The influenza surveillance dashboard serves as a template to illustrate the efficient synthesization and dissemination of multiple-source surveillance data, which may also be applied to other diseases. Surveillance data from multiple sources can be disseminated efficiently using a dashboard design that facilitates the translation of surveillance information to public health actions.

The infection attack rate and severity of 2009 pandemic H1N1 influenza in Hong Kong

BACKGROUND

Serial cross-sectional data on antibody levels to the 2009 pandemic H1N1 influenza A virus from a population can be used to estimate the infection attack rates and immunity against future infection in the community.

METHODS

From April through December 2009, we obtained 12,217 serum specimens from blood donors (aged 16-59 years), 2520 specimens from hospital outpatients (aged 5-59 years), and 917 specimens from subjects involved in a community pediatric cohort study (aged 5-14 years). We estimated infection attack rates by comparing the proportions of specimens with antibody titers ≥ 1:40 by viral microneutralization before and after the first wave of the pandemic. Estimates were validated using paired serum samples from 324 individuals that spanned the first wave. Combining these estimates with epidemiologic surveillance data, we calculated the proportion of infections that led to hospitalization, admission to the intensive care unit (ICU), and death.

RESULTS

We found that 3.3% and 14% of persons aged 5-59 years had antibody titers ≥ 1:40 before and after the first wave, respectively. The overall attack rate was 10.7%, with age stratification as follows: 43.4% in persons aged 5-14 years, 15.8% in persons aged 15-19 years, 11.8% in persons aged 20-29 years, and 4%-4.6% in persons aged 30-59 years. Case-hospitalization rates were 0.47%-0.87% among persons aged 5-59 years. Case-ICU rates were 7.9 cases per 100,000 infections in persons aged 5-14 years and 75 cases per 100,000 infections in persons aged 50-59 years, respectively. Case-fatality rates were 0.4 cases per 100,000 infections in persons aged 5-14 years and 26.5 cases per 100,000 infections in persons aged 50-59 years, respectively.

CONCLUSIONS

Almost half of all school-aged children in Hong Kong were infected during the first wave. Compared with school children aged 5-14 years, older adults aged 50-59 years had 9.5 and 66 times higher risks of ICU admission and death if infected, respectively.

Epidemiology of SARS in the 2003 Hong Kong epidemic

1. The temporal and spatial evolution of the SARS epidemic in Hong Kong is described. 2. Estimates of key epidemiological distributions and their stability over the course of the epidemic are derived. 3. The characteristics of those who contracted the disease are determined including factors associated with the likelihood of mortality as a result of SARS coronavirus infection.

Prevalence of SARS-CoV antibody in all Hong Kong patient contacts

The near absence of transmission (seroprevalence=0.19%) resulting in asymptomatic infection in this representative high-risk group of close contacts indicates that the prevailing SARS-CoV strains in Hong Kong almost always led to clinically apparent disease.

Community psycho-behavioural surveillance and related impact on outbreak control in Hong Kong and Singapore during the SARS epidemic

1. The promotion of personal protective health practices must take into account background perceptions of risk and psychological responses in the community-at-large. 2. Population psycho-behavioural factors in Hong Kong and Singapore are shown to be an important potential vector for the transmission of an infectious agent. 3. Comparative psycho-behavioural surveillance and analysis can yield important insights into generic versus population-specific issues that could be used to inform, design and benchmark public health infection control measures.

A profile of the online dissemination of national influenza surveillance data

Background

Influenza surveillance systems provide important and timely information to health service providers on trends in the circulation of influenza virus and other upper respiratory tract infections. Online dissemination of surveillance data is useful for risk communication to health care professionals, the media and the general public. We reviewed national influenza surveillance websites from around the world to describe the main features of surveillance data dissemination.

Methods

We searched for national influenza surveillance websites for every country and reviewed the resulting sites where available during the period from November 2008 through February 2009. Literature about influenza surveillance was searched at MEDLINE for relevant hyperlinks to related websites. Non-English websites were translated into English using human translators or Google language tools.

Results

A total of 70 national influenza surveillance websites were identified. The percentage of developing countries with surveillance websites was lower than that of developed countries (22% versus 57% respectively). Most of the websites (74%) were in English or provided an English version. The most common surveillance methods included influenza-like illness consultation rates in primary care settings (89%) and laboratory surveillance (44%). Most websites (70%) provided data within a static report format and 66% of the websites provided data with at least weekly resolution.

Conclusion

Appropriate dissemination of surveillance data is important to maximize the utility of collected data. There may be room for improvement in the style and content of the dissemination of influenza data to health care professionals and the general public.

Short- and medium-term outcomes of accelerated infant growth in a Hong Kong Chinese birth cohort

1. In a large, population representative,Chinese birth cohort, higher birth weight and rapid growth, particularly at 0-3 months, were associated with higher body mass index (BMI) at 7 years. 2. Boys born heavy who had grown fast had the highest BMI, but rapid growth had the largest impact in lighter-born boys. 3. Rapid growth at 0-3 months or 3-12 months was not associated with a compensatory lower risk of serious infectious morbidity. 4. The ability to grow fast may be an embodiment of good health status, rather than fast growth being causally protective.

Birth weight, infant growth, and childhood body mass index: Hong Kong's children of 1997 birth cohort

OBJECTIVE

To investigate the association between birth weight, infant growth rate, and childhood adiposity as a proxy for adult metabolic or cardiovascular risk in a Chinese population with a history of recent and rapid economic development.

DESIGN

Prospective study in a population-representative birth cohort.

SETTING

Hong Kong Chinese population.

PARTICIPANTS

Six thousand seventy-five term births (77.5% successful follow-up). Main Exposures Birth weight and growth rate (change in the weight z score) at ages 0 to 3 and 3 to 12 months. Main Outcome Measure Body mass index (BMI) (calculated as the weight in kilograms divided by the height in meters squared) z score at about age 7 years.

RESULTS

Each unit increase in the weight z score at ages 0 to 3 and 3 to 12 months increased the BMI z score by 0.52 and 0.33, respectively. Children in the highest birth weight and growth rate tertiles had the highest BMI z scores. In the lowest birth weight tertile, increases in the weight z score at ages 0 to 3 months had a larger effect on the BMI z score in boys (mean difference, 0.88; 95% confidence interval 0.69-1.07) than in girls (mean difference, 0.52; 95% confidence interval, 0.33-0.71); these differences by birth weight, growth rate at ages 0 to 3 months, and sex were significant (P = .007).

CONCLUSIONS

Faster prenatal and postnatal growth were associated with higher childhood BMI in a population with a recent history of rapid economic growth and relatively low birth weight, suggesting that maximal growth may not be optimal for metabolic risk. However, there may be a developmental trade-off between metabolic risk and other outcomes.

Effectiveness of control measures during the SARS epidemic in Beijing: a comparison of the Rt curve and the epidemic curve

One of the areas most affected by SARS was Beijing with 2521 reported cases. We estimate the effective reproductive number Rt for the Beijing SARS epidemic, which represents the average number of secondary cases per primary case on each day of the epidemic and is therefore a measure of the underlying transmission dynamics. Our results provide a quantitative assessment of the effectiveness of public health control measures. More generally, our results illustrate how changes in Rt will reflect changes in the epidemic curve.

Cost of tobacco-related diseases, including passive smoking, in Hong Kong

BACKGROUND

Costs of tobacco-related disease can be useful evidence to support tobacco control. In Hong Kong we now have locally derived data on the risks of smoking, including passive smoking.

AIM

To estimate the health-related costs of tobacco from both active and passive smoking.

METHODS

Using local data, we estimated active and passive smoking-attributable mortality, hospital admissions, outpatient, emergency and general practitioner visits for adults and children, use of nursing homes and domestic help, time lost from work due to illness and premature mortality in the productive years. Morbidity risk data were used where possible but otherwise estimates based on mortality risks were used. Utilisation was valued at unit costs or from survey data. Work time lost was valued at the median wage and an additional costing included a value of USD 1.3 million for a life lost.

RESULTS

In the Hong Kong population of 6.5 million in 1998, the annual value of direct medical costs, long term care and productivity loss was USD 532 million for active smoking and USD 156 million for passive smoking; passive smoking accounted for 23% of the total costs. Adding the value of attributable lives lost brought the annual cost to USD 9.4 billion.

CONCLUSION

The health costs of tobacco use are high and represent a net loss to society. Passive smoking increases these costs by at least a quarter. This quantification of the costs of tobacco provides strong motivation for legislative action on smoke-free areas in the Asia Pacific Region and elsewhere.

Smoking and sexual dysfunction in Chinese males: findings from men's health survey

To describe the prevalence of erectile dysfunction (ED) and its association with smoking among the Chinese in Hong Kong, we conducted a cross-sectional study among 819 men (aged 31-60 years) who were randomly selected among the Hong Kong residents and interviewed by trained interviewers. A structured questionnaire was used for data collection. We found that current smokers who smoked 20 cigarettes or more daily had more dissatisfaction, erection difficulty and ED than never smokers. The prevalence of dissatisfaction, difficulty in erection and ED increased significantly (P<0.05) with increasing age. Compared with never-smokers, current smokers of more than 20 cigarettes daily had a greater risk of ED (age-adjusted odds ratio=1.47, 95% confidence interval: 1.00-2.16). Our results support that there are association between ED and smoking among the Chinese and suggest linking ED with smoking in the antismoking campaign and promoting smoking cessation to reduce ED among smokers.

SARS incubation and quarantine times: when is an exposed individual known to be disease free?

The setting of a quarantine time for an emerging infectious disease will depend on current knowledge concerning incubation times. Methods for the analysis of information on incubation times are investigated with a particular focus on inference regarding a possible maximum incubation time, after which an exposed individual would be known to be disease free. Data from the Hong Kong SARS epidemic are used for illustration. The incorporation of interval-censored data is considered and comparison is made with percentile estimation. Results suggest that a wide class of models for incubation times should be considered because the apparent informativeness of a likelihood depends on the choice and generalizability of a model. There will usually remain a probability of releasing from quarantine some infected individuals and the impact of early release will depend on the size of the epidemic.

Methods for estimating the case fatality ratio for a novel, emerging infectious disease

During the course of an epidemic of a potentially fatal disease, it is important that the case fatality ratio be well estimated. The authors propose a novel method for doing so based on the Kaplan-Meier survival procedure, jointly considering two outcomes (death and recovery), and evaluate its performance by using data from the 2003 epidemic of severe acute respiratory syndrome in Hong Kong, People's Republic of China. They compare this estimate obtained at various points in the epidemic with the case fatality ratio eventually observed; with two commonly quoted, naïve estimates derived from cumulative incidence and mortality statistics at single time points; and with estimates in which a parametric mixture model is used. They demonstrate the importance of patient characteristics regarding outcome by analyzing subgroups defined by age at admission to the hospital.

Pneumatosis intestinalis after lung transplant

Pneumatosis intestinalis may be idiopathic or associated with numerous conditions. Uncommonly, it has been associated with organ transplantation. We report one case of pneumatosis intestinalis after lung transplantation in an adult patient. To our knowledge, this finding has not been reported in the radiology literature.

Physicians' perceptions towards the impact of and willingness to pay for clinical computerization in Hong Kong

BACKGROUND AND OBJECTIVES

We evaluated factors associated with physicians' perceptions towards the effects of computers on health care and on current levels of computerization in their practice. We also performed a contingent valuation to quantify physicians' perceived benefits from computerization in a hypothetical ambulatory, solo clinic.

METHODS

We surveyed 949 representative physicians in Hong Kong by post. Factor analysis was performed to summarize similar items into categories. Multivariable log-linear regression models were employed to assess the relationships between different factor scores and the number of functions computerized. We elicited their willingness-to-pay (WTP) for three defined computer systems using contingent valuation techniques. WTP values were estimated using econometric modeling by both, parametric and geometric methods. Sociodemographic, attitudinal, and practice-related predictors of WTP were estimated through regression analyses.

RESULTS

Factor analysis revealed a three-factor solution which explained 53% of total variance. The overall mean score (mean = 3.51 +/- 0.45) showed a generally positive attitude towards the effects of computers on health care. Respondents with a higher level of computer knowledge had significantly higher mean overall (P = 0.002) and factor scores for all three factors (P < 0.01). Higher factor scores on the effects of computers on patient care and clinicians (P = 0.006) and on the health system (P = 0.032) were associated with a higher number of functions computerized. The parametric median WTP values for computerizing administrative, clinical, and both sets of functions were HK dollars 21205 (US dollars 2719), HK dollars 34231 (US dollars 4389), and HK dollars 45720 (US dollars 5862), respectively, which were lower than the estimates obtained from demand curves using the geometric method [HK dollars 43286 (US dollars 5549), HK dollars 59570 (US dollars 7637), and HK dollars 84623 (US dollars 10849), respectively]. Doctors with higher incomes were willing to pay more to computerize the clinic, with strong dose-response gradients demonstrated. Those who worked in corporate settings were also more likely to accept higher WTP values.

CONCLUSIONS

Our findings confirm that better knowledge about computers is contributory to a more positive attitude towards the effects of computers on health care, which is in turn significantly associated with higher levels of actual computerization in clinical practice. WTP values represent the likelihood, in monetary terms, of translating doctors' perceived benefits from computerization into investment action.

Depressive symptoms among Hong Kong adolescents: relation to atypical sexual feelings and behaviors, gender dissatisfaction, pubertal timing, and family and peer relationships

A representative community sample of Hong Kong boys (n = 1,024) and girls (n = 1,403), age 14-18 years, provided information regarding same-sex attraction, gender dissatisfaction, pubertal timing, early experience with sexual intercourse, and depressive symptoms. They also rated the quality of their family and peer relationships and self-perceived attractiveness. Depressive symptoms were higher in youths reporting same-sex attraction, gender dissatisfaction, early pubertal maturation, and early sexual intercourse. Family relationships were less satisfactory for those who reported same-sex attraction, gender dissatisfaction, and early sexual intercourse, and peer relationships were also worse for those who reported gender dissatisfaction. In multivariate analyses, same-sex attraction, early sexual intercourse, and early pubertal maturation were unique and direct contributors to depressive symptoms; however, gender dissatisfaction's association with depressive symptoms was largely accounted for by shared correlations with negative family and peer relationships. The multivariate model explained 11% of the variance of depressive symptoms. These findings offer a preliminary documentation of the prevalence and correlates of atypical sexual self-assessments and behavior among adolescents in Hong Kong. Such information is important if theories of sexual identity and risk factors for depressive symptoms are to have cross-cultural utility.

Percutaneous biopsy of periarterial soft tissue cuffs in the diagnosis of pancreatic carcinoma

Pancreatic cancer may present on computed tomography (CT) as an isolated cuff of tumor surrounding the superior mesenteric artery (SMA) or celiac trunk, without an identifiable pancreatic mass. We reviewed our experience with imaging-guided biopsy of the soft tissue cuff in this patient group. A retrospective review of our interventional database identified 163 patients referred for biopsy of suspected pancreatic carcinoma. Of these, eight patients underwent biopsy of an isolated cuff of soft tissue encasing the SMA (n = 6) or celiac trunk (n = 2). None of these eight patients had an identifiable pancreatic mass. The mean width of tissue cuff biopsied was 1.3 cm (range, 0.9-2.0 cm). Nine imaging-guided biopsies were performed in eight patients. Five biopsies were performed with color Doppler ultrasound and four with CT fluoroscopy. There was a median of two needle passes per procedure (range, 1-4). In six cases, a diagnosis of pancreatic adenocarcinoma was made at the first biopsy session. In one patient, ultrasound-guided biopsy was negative, but subsequent CT-guided biopsy was positive. In one additional patient with chronic pancreatitis, biopsy revealed benign fibrous tissue. There were no procedure-related complications. In patients with suspected pancreatic cancer (but without a focal parenchymal mass), imaging-guided biopsy of isolated periarterial tissue cuffs of tumor is accurate and safe.

Suicidality and cultural values among Hong Kong adolescents

Scholars have proposed that individualistic values resulting from globalization are associated with increasing behavioral and emotional problems among youth in modernizing cultures. This study examined specific individualistic and traditional values in the context of suicidal ideation and behaviors in Hong Kong among community adolescent youths (N=2427) ages 14-18 years. Participants indicated the extent to which self-direction/independence and obedience/respect for elders were important to them. They also reported on four progressive levels of suicidality: whether in the last year they had experienced suicidal ideation, made plans for a suicide attempt, attempted suicide, and (for attemptors) made a serious attempt requiring medical attention. After controlling for quality of family relationships and depressive symptoms, at least one of the values predicted suicidality at all but the highest level. There were sex-specific associations between values and suicidality. In general, endorsement of self-direction was correlated with reduced risk of suicidality for boys and was irrelevant to girls. In contrast, traditional emphases on obedience and respect for elders were more frequently protective against suicidality for girls and were inconsistent predictors for boys. The relationship between values and suicidality was generally independent of the effect of family relationships and depressive symptoms. Thus, values were associated with adolescent suicidality, but not consistently in the direction predicted by some theorists, and the association depended upon the adolescent's sex.

Passive smoking and its impact on employers and employees in Hong Kong

AIMS

To estimate the prevalence of passive smoking at work in the whole workforce in Hong Kong (population 6.8 million), the characteristics of the passive smokers, any extra use of health care among passive smokers, and who pays for that health care.

METHODS

A random sample of 14,325 households was contacted by telephone; 6,186 responding adults who worked full time were asked about their employment, their most recent use of health care and the cost of that care, their medical benefits, and their exposure to secondhand smoke in the workplace. After weighting the sample for sex, age, household size, and income, 4,739 subjects were included in the analysis.

RESULTS

Of 1,961 full time workers who did not smoke, 47.5% were exposed to secondhand smoke in the workplace compared with only 26% exposed at home. Exposure at work was associated with being younger, male, married, less educated, and having a lower income. Those exposed at work were 37% more likely to report having visited a doctor for a respiratory illness in the previous 14 days. Employers were paying 28% of the cost of these visits, the government paid 8%, and the individuals paid 63%. If extrapolated to the 3 million workers in the Hong Kong population, employers would pay just over US$9 million per year, while the affected workers would pay around US$20 million.

CONCLUSION

As well as the costs of active smoking, the cost of extra health care utilisation associated with passive smoking is an additional cost being paid by those employers who have not established smoke free workplaces and by their employees.

The effects of cash and lottery incentives on mailed surveys to physicians: a randomized trial

Low response rates, especially among physicians, are a common problem in mailed survey research. We conducted a randomized trial to examine the effects of cash and lottery incentives on response rates. A total of 4,850 subjects were randomized to one of three interventions accompanying a mailed survey-no incentive (n = 1,700), cash payment [three levels of Hong Kong dollars (HKD) $10, $20, and $40; N = 50 in each subgroup], or entry into a lottery (three levels of HKD$1,000, $2,000, and $4,000; N = 1,000 in each subgroup) on receipt of the completed questionnaire. The response rates were higher among those offered incentives than those without (19.8% vs. 16.8%, P =.012). Cash was the more effective incentive compared to lottery (27.3% vs. 19.4%, P =.017). Response also increased substantially between the first and second mailings (14.2% vs. 18.8%, P >.001). In addition, those with specialist qualifications were more willing to participate in mailed surveys. We found no significant differences in response outcomes among the various incentive arms. Cash reward at the $20 level was the most cost-effective intervention, in terms of cost per responder. Further systematic examination of the effects of different incentive strategies in epidemiologic studies should be encouraged.

Timing of pubertal maturation and heterosexual behavior among Hong Kong Chinese adolescents

This study presents a cross-sectional examination of the independent contribution of pubertal maturation timing to heterosexual activity among Chinese adolescents. A standardized self-administered questionnaire was designed to obtain information on a spectrum of physical heterosexual behaviors from dating to sexual intercourse, age at first nocturnal ejaculation in boys, age at menarche in girls, and several psychosocial variables that might be associated with sexual behavior in adolescents. A total of 4,116 students aged from 14 to 18 years (2,175 boys and 1,941 girls) were recruited in the Youth Sexuality Survey of the Hong Kong Family Planning Association in 1996-97. When groups were defined as "early," "average," and "late maturers," among boys, early maturers were youngest to report dating and to have sexual intercourse, followed by average and late maturers. Among girls, late maturers were slower to date and have sexual intercourse, but early maturers showed no difference from average maturers. Age of maturation was significantly lower for those reporting all heterosexual behaviors for both sexes. Our findings illustrate culture's moderation of the expression of biological differences.

Breast-feeding and its relation to smoking and mode of delivery

OBJECTIVE

To examine the effects of cesarean and forceps or vacuum delivery and parental smoking habits on the initiation and duration of breast-feeding.

METHODS

We conducted a prospective, population-based birth cohort study in 1997. Data were collected on breast-feeding history, household smoking habits, method of delivery, and other demographic, obstetric, behavioral, and potential confounding variables via a standardized self-administered questionnaire. Multivariable logistic regression was used to examine the association between method of birth (cesarean versus forceps or vacuum delivery versus normal vaginal birth) and either not initiating breast-feeding or doing so for less than 1 month. Among women who breast-fed for 1 month or more, multivariable survival analysis was employed to study the relationship between method of delivery and breast-feeding duration. We repeated these analyses to examine the link between parental smoking habits and breast-feeding initiation and duration.

RESULTS

A total of 7825 mother-infant pairs were followed up for 9 months. Cesarean delivery was a risk factor for not initiating breast-feeding, for breast-feeding less than 1 month, and remained a significant hazard against breast-feeding duration. Assisted delivery with forceps or vacuum, although not associated with breast-feeding initiation, was a significant risk against breast-feeding duration. Conversely, current parental smoking habits only affected breast-feeding initiation but were unrelated to breast-feeding duration.

CONCLUSION

This study indicates a possible effect of forceps or vacuum delivery on breast-feeding and of cesarean on long-term breast-feeding duration. The findings provide additional evidence in support of the avoidance of unnecessary obstetric interventions.

Physicians' attitudes towards the computerization of clinical practice in Hong Kong: a population study

OBJECTIVE

To identify the prevailing attitudes among physicians to use of computers in the clinical setting and specifically those attitudes that may be associated with the adoption of computers in practice.

DESIGN

A self-completed, 20-question postal questionnaire sent to 4850 randomly selected physicians. The questionnaire focused on details of the physicians' practice; actual computerization of or intention to computerize clinical and administrative functions; attitudes towards computerization; self-perceived computer ability and knowledge; and demographic information. The attitude statements were grouped under four themes according to a factor analysis.

RESULTS

The survey was completed by 897 physicians. Only physicians in 'individual' practices were included in the analysis. This group was further dichotomized into clinical users (those with one or more clinical functions computerized) and non-clinical users. Non-clinical users were older and had fewer specialist qualifications. Although there was strong support for the attitude statements among both groups with regard to the benefit of computerization to patient care, there was much less support for electronic medical records. Non-clinical users were concerned about the potentially negative impact of computerization on the clinical encounter and the perceived high cost of computerization.

DISCUSSION

The attitudes among current clinical users and non-users were substantially different. The most important disincentives to computerization were the potential for interference with the patient-physician encounter and the cost of computerizing multiple practice locations. Turning these disincentives into opportunities for change remains the challenge.

Prevalence and correlates of smoking and sexual activity among Hong Kong adolescents

PURPOSE

To report on the prevalence and correlates of smoking and sexual activity in a community sample of Hong Kong Chinese adolescents.

METHODS

Participants (N = 4116) aged 13 to 18 years were surveyed regarding smoking and physical heterosexual activity, relationships with family members, family involvement, social support, school performance and emotional adjustment. Data were analyzed using logistic regression analyses.

RESULTS

About 30% of participants reported ever smoking and 3.5% reported sexual intercourse. Current smoking was correlated with age, school performance and quality of relationship with mother. Sexual intercourse was correlated with age, gender, family involvement and social support. Smoking and sexual activity were significantly correlated with each other. Smoking and increasing levels of heterosexual physical contact were negatively correlated with emotional adjustment, even after controlling for common predictors to health-endangering behaviors and emotional adjustment.

CONCLUSIONS

Smoking and sexual activity among adolescents are far less common in Hong Kong than in the West and their presence in a Hong Kong adolescent should alert the health practitioner to the possibility of significant psychosocial stress and maladjustment.

Smoking and high-risk sexual behavior among young adults in Hong Kong

Young adults (n = 964; never married; age, 18-27 years) in Hong Kong were surveyed to obtain information about their smoking habits and sexual behaviors. Current smokers (15% of the entire sample) and those who had ever had sexual intercourse (28%) were more likely to be male, to have ended their education at secondary school, and to report less life satisfaction. After controlling for demographic and psychosocial correlates, sexual intercourse was associated with smoking status for both males and females. Among those who were sexually active, those who had multiple sexual partners, had their first sexual experience prior to age 18 years, and (for males) reported visiting massage parlors were more likely to have a history of smoking. Our findings extend those of our previous study with community adolescents in Hong Kong and suggest that smoking may be a marker for other high-risk behaviors among young Chinese adults.

Rates of cesarean births in Hong Kong: 1987-1999

BACKGROUND

High cesarean birth rates are an issue of international public health concern. The purpose of this paper was to examine the annual incidence and secular trend of cesarean births in Hong Kong and to correlate these rates with socioeconomic, demographic, and health indicators for the population since 1987.

METHODS

This was a descriptive and ecologic study. Annual population rates of cesarean sections were estimated for 1987 from a population-based survey, and for 1993 through 1999 from government data sources. The number of excess cesarean sections was calculated for each year using the 15 percent upper limit as proposed by the World Health Organization.

RESULTS

From 1987 to 1999 the overall annual cesarean section rate rose steadily from 16.6 to 27.4 per 100 hospital deliveries, resulting in a 65 percent increase over 12 years. The mean difference in rates of surgical delivery between public (mean(public) = 16.0%) and private (mean(private) = 43.4%) institutions was 27.4 percent (95% confidence interval (CI) = 24.1, 30.7; p < 0.001).

CONCLUSIONS

This is the first systematic report of secular variations of cesarean delivery rates in Asia. The high rates and increasing trend represent an unnecessary excess risk for mothers and their infants. Various strategies combating high cesarean rates have been proposed and have succeeded elsewhere. Concerted action from health care professionals, public health authorities, the general population, and the media is urgently required to implement solutions to reduce the rate of cesarean delivery.

Asymmetric epoxidation of olefins catalyzed by chiral iminium salts generated in situ from amines and aldehydes

[reaction: see text] A new approach for catalytic asymmetric epoxidation of olefins was developed that utilized chiral iminium salts, generated in situ from chiral amines and aldehydes, as catalysts. Epoxidation reactions can be conducted with 20 mol % of amines and aldehydes. The enantioselectivity of epoxides can be up to 65%. This modular approach obviates the difficulties inherent in the preparation and isolation of unstable exocyclic iminium salts.

An evaluation of the use of hand-held computers for bedside nursing care

Both keyboard-based and pen-based devices for data input have advantages and disadvantages. The suitability of the two input devices for entering different types of clinical data into computers remains unclear. This study aimed to determine the usefulness of different types of technology for nurses' data entry by comparing the utility and efficiency of keyboard and pen-based data input for clinical tasks. The study was conducted in the six largest specialties of an acute care hospital. In each specialty, several wards were randomly selected, and all nurses working in these wards were invited to participate. The input prototype was designed according to the type of text that was to be entered into the system. Task 1 mainly consisted of structured data, Task 2 contained equal amount of structured and textual data, and Task 3 was mainly in textual form. Each nurse was asked to complete the three simulations of nursing records (Tasks 1, 2 and 3). Preliminary findings showed that nurses found the pen-based interface easier to use than the keyboard for completing Tasks 1 and 2, but not Task 3. In terms of accuracy, the nurses preferred the keyboard to the pen when the data were more structured. The pen-based device is not a panacea for all kinds of user interface, and more importantly, the choice of input device should depend on the amount of structured and textual data.

Computerization of clinical practice in Hong Kong

The objective of this study was to assess the current level of computerization in clinical practice in Hong Kong through a population-based, physician survey conducted in 2000.A self-completed, 20-question, postal questionnaire was sent to 4850 randomly selected doctors in Hong Kong. We received 897 completed responses. Over one-third of doctors in the overall sample were already recording patient summaries, processing laboratory results and specialist reports, and preparing referral notes electronically. Patient registration (52.2%), billing systems (40.2%), appointment scheduling (39.9%), and payroll (36.9%), were the commonest administrative functions to have been computerized. Seventy per cent of doctors in solo or small-group ('individual') practices did not yet have any clinical function computerized compared with only 30.7% for those working in large, corporate organizations. Similarly, approximately two-thirds of administrative tasks in 'individual' clinics were not computerized, while corporate physicians reported a corresponding percentage of 39.3%. Younger age, male gender, specialist qualifications, more computers in the practice, higher numbers of administrative tasks already computerized, higher levels of knowledge about and positive attitudes towards computer applications in clinical practice were all positively associated with more clinical tasks already computerized in the practice. The present study has systematically documented the extent of clinical computer use in Hong Kong and identified areas for improvement as well as specific groups of physicians who might benefit from targeted efforts promoting computerization in practice.

The effects of environmental tobacco smoke on health services utilization in the first eighteen months of life

OBJECTIVE

To examine the effects of environmental tobacco smoke (ETS) on health services use in Chinese infants with nonsmoking mothers.

DESIGN

Prospective, population-based birth cohort.

SETTING

General population of Hong Kong in 1997-1998.

PARTICIPANTS

A total of 8327 parent-infant pairs who were followed up for 18 months.

MAIN OUTCOME MEASURES

Doctor consultations and hospitalizations. Results. After adjusting for the age, education level, and employment status of mothers-as well as infants' birth weight, method of delivery, breastfeeding status, and birth order-ETS exposure through the mother in utero was positively associated with higher consultation (adjusted odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.14, 1.39) and hospitalization (OR: 1.18; 95% CI: 1.05, 1.31) use in infants with nonsmoking mothers attributable to any illness. In addition, postnatal exposure to ETS at home was linked to higher rates of hospitalizations for any illness compared with nonexposed infants (OR: 1.12; 95% CI: 1.00, 1.25), although the relationship did not hold for outpatient consultation visits. The OR for higher hospital use in infants exposed to 2 or more smokers at home was 1.30 (95% CI: 1.08, 1.58).

CONCLUSIONS

The use of tobacco products by household members, even among nonsmoking mothers, has an enormous adverse impact on the health of children, as well as increases health services use and cost. The present data support the revision of public policy to reflect an evidence-based approach to the promotion of smoking cessation in all household members during and after pregnancy. environmental tobacco smoke, health services, infants.