Park environment and moderate-to-vigorous physical activity in parks among adolescents in a high-density city: the moderating role of neighbourhood income.

BACKGROUND: Urban parks are critical environmental resources in which adolescents engage in physical activity (PA). Evidence on the associations between park environmental characteristics and park-based PA in adolescents is mixed, particularly for high-density cities. Evidence is also lacking concerning the moderating role of neighbourhood socioeconomic status on the park-PA relationships. The current study aimed to examine the associations between park environmental characteristics and moderate-to-vigorous physical activity (MVPA) in parks among adolescents in Hong Kong and the moderating effect of neighbourhood income on these associations. METHODS: A cross-sectional study involving direct observations of adolescents was conducted in 32 randomly selected urban parks in Hong Kong. Park environmental characteristics were measured using the Community Park Audit Tool. Park-based MVPA among adolescents was measured using the System for Observation Play and Recreation in Communities. Neighbourhood income was extracted from the 2011 Hong Kong Population Census data on median household income. RESULTS: There was a significant positive association between the quality of amenities and park-based MVPA (metabolic equivalents per observation) in adolescents. However, the associations between the diversity of active facilities, greenness and adolescents' park-based MVPA were not significant. Neighbourhood income moderated the association between adolescents' park-based MVPA and park safety, where the relationship between park safety and park-based MVPA was significantly positive in low-income neighbourhoods but not significant in high-income neighbourhoods. An income-by-environment interaction was also observed concerning park aesthetics, with a negative relationship between park aesthetics and park-based MVPA in high-income neighbourhoods but not in low-income neighbourhoods. CONCLUSION: Our findings provide evidence regarding how park environment and neighbourhood income impact adolescents' park-based MVPA in Hong Kong. These findings can inform urban planning and policymakers who seek to improve urban park development in high-density cities.

Urban environments and objectively-assessed physical activity and sedentary time in older Belgian and Chinese community dwellers: potential pathways of influence and the moderating role of physical function.

BACKGROUND: Many studies have examined neighbourhood environmental correlates of older adults' physical activity (PA) but only a few focused on sedentary time (ST). Only a small proportion of these studies used objective measures of PA/ST, such as accelerometer-assessed PA/ST, and only a couple employed accelerometer cut-points appropriate for older adults. Furthermore, although older adults experience declines in physical function as they age, there is a dearth of information on the impact of the neighbourhood environment on PA/ST in individuals with different levels of physical function. METHODS: We used data from two extant cross-sectional studies conducted in Hong Kong (China) and Ghent (Belgium) (N = 829). Participants were recruited from pre-selected administrative units stratified by socio-economic status and walkability. Moderate-to-vigorous PA (MVPA) and ST were assessed for 7 days using accelerometers and cut-points developed for older adults. Objective neighbourhood environmental attributes within 400 m and 1 km buffers surrounding participants' homes were quantified using Geographic Information Systems data. Lower extremity physical function was objectively assessed. Socio-demographic information was collected via interviews. Total, direct and indirect (mediated) effects of environmental attributes on MVPA and ST were estimated using generalised additive mixed models and the joint-significant test. RESULTS: Commercial/civic destination density and number of parks within 1 km from home showed positive total and direct effects on MVPA, and public transport density showed negative total and direct effects on ST, which were consistent across cities and physical function levels. The total and direct effects of residential density on MVPA depended on physical function, and those of residential density on ST differed by city. A complex network of potential inconsistent pathways linking all environmental attributes to MVPA and ST in the whole sample or in subgroups of participants was revealed. DISCUSSION: Access to parks and commercial/civic destinations appear to support older adults' MVPA in different geographical and cultural contexts and irrespective of their physical function level. By supporting MVPA, these characteristics also contribute to a reduction in ST. The potential effects of public transport, recreational facilities and residential density are less straightforward and point at inconsistent effects that may depend on the geographical context and level of physical function.

How urban densification shapes walking behaviours in older community dwellers: a cross-sectional analysis of potential pathways of influence.

BACKGROUND: Population growth, population ageing, and urbanisation are major global demographic trends that call for an examination of the impact of urban densification on older adults' health-enhancing behaviours, such as walking. No studies have examined the pathways through which urban densification may affect older adults' walking. This information is key to evidence-based, health-oriented urban and transport planning. This study aimed to identify neighbourhood environment characteristics potentially responsible for the effects of neighbourhood densification on older adults' frequency and amount of transportation and recreation walking within and outside the neighbourhood. METHODS: The Active Lifestyle and the Environment in Chinese Seniors (ALECS) project collected self-reported data from 909 older adults (≥ 65 years) living in 128 physically and socially diverse neighbourhoods in Hong Kong (71% response rate). Walking was measured using the Neighbourhood Walking Questionnaire for Chinese Seniors. Objective residential density and other neighbourhood environmental attributes were assessed using Geographic Information Systems. Generalised additive mixed models examined the total effects of neighbourhood residential density on walking and the mediating role of other environmental attributes and car ownership. RESULTS: A complex network of potential pathways of positive and negative influences of neighbourhood residential density on different aspects of walking was revealed. While residential density was positively related to within-neighbourhood transportation and outside-neighbourhood recreation walking only, it exhibited positive and/or negative nonlinear indirect effects on all examined aspects of walking via recreation, public transport, food/retail and street intersection densities, and/or car ownership. CONCLUSIONS: High-density environments appear to support within-neighbourhood walking by providing access to food and retail outlets via well-connected street networks and discouraging car ownership. However, extreme density may lead to reductions in walking. Public transport density accompanying high-density areas may facilitate outside-neighbourhood walking but deter within-neighbourhood walking. The development of activity-friendly communities for ageing populations need to consider these opposing influences.

Associations of built environment and proximity of food outlets with weight status: Analysis from 14 cities in 10 countries.

The study aimed to examine associations of neighborhood built environments and proximity of food outlets (BE measures) with body weight status using pooled data from an international study (IPEN Adult). Objective BE measures were calculated using geographic information systems for 10,008 participants (4463 male, 45%) aged 16-66 years in 14 cities. Participants self-reported proximity to three types of food outlets. Outcomes were body mass index (BMI) and overweight/obesity status. Male and female weight status associations with BE measures were estimated by generalized additive mixed models. Proportion (95% CI) of overweight (BMI 25 to <30) ranged from 16.6% (13.1, 19.8) to 41.1% (37.3, 44.7), and obesity (BMI ≥ 30) from 2.9% (1.3, 4.4) to 31.3% (27.7, 34.7), with Hong Kong being the lowest and Cuernavaca, Mexico highest for both proportions. Results differed by sex. Greater street intersection density, public transport density and perceived proximity to restaurants (males) were associated with lower odds of overweight/obesity (BMI ≥ 25). Proximity to public transport stops (females) was associated with higher odds of overweight/obesity. Composite BE measures were more strongly related to BMI and overweight/obesity status than single variables among men but not women. One standard deviation improvement in the composite measures of BE was associated with small reductions of 0.1-0.5% in BMI but meaningful reductions of 2.5-5.3% in the odds of overweight/obesity. Effects were linear and generalizable across cities. Neighborhoods designed to support public transport, with food outlets within walking distance, may contribute to global obesity control.

Physical activity in relation to urban environments in 14 cities worldwide: a cross-sectional study.

BACKGROUND: Physical inactivity is a global pandemic responsible for over 5 million deaths annually through its effects on multiple non-communicable diseases. We aimed to document how objectively measured attributes of the urban environment are related to objectively measured physical activity, in an international sample of adults. METHODS: We based our analyses on the International Physical activity and Environment Network (IPEN) adult study, which was a coordinated, international, cross-sectional study. Participants were sampled from neighbourhoods with varied levels of walkability and socioeconomic status. The present analyses of data from the IPEN adult study included 6822 adults aged 18-66 years from 14 cities in ten countries on five continents. Indicators of walkability, public transport access, and park access were assessed in 1·0 km and 0·5 km street network buffers around each participant's residential address with geographic information systems. Mean daily minutes of moderate-to-vigorous-intensity physical activity were measured with 4-7 days of accelerometer monitoring. Associations between environmental attributes and physical activity were estimated using generalised additive mixed models with gamma variance and logarithmic link functions. RESULTS: Four of six environmental attributes were significantly, positively, and linearly related to physical activity in the single variable models: net residential density (exp[b] 1·006 [95% CI 1·003-1·009]; p=0·001), intersection density (1·069 [1·011-1·130]; p=0·019), public transport density (1·037 [1·018-1·056]; p=0·0007), and number of parks (1·146 [1·033-1·272]; p=0·010). Mixed land use and distance to nearest public transport point were not related to physical activity. The difference in physical activity between participants living in the most and least activity-friendly neighbourhoods ranged from 68 min/week to 89 min/week, which represents 45-59% of the 150 min/week recommended by guidelines. INTERPRETATION: Design of urban environments has the potential to contribute substantially to physical activity. Similarity of findings across cities suggests the promise of engaging urban planning, transportation, and parks sectors in efforts to reduce the health burden of the global physical inactivity pandemic. FUNDING: Funding for coordination of the IPEN adult study, including the present analysis, was provided by the National Cancer Institute of National Institutes of Health (CA127296) with studies in each country funded by different sources.

The potential benefits of location-specific biometeorological indexes.

It is becoming popular to use biometeorological indexes to study the effects of weather on human health. Most of the biometeorological indexes were developed decades ago and only applicable to certain locations because of different climate types. Merely using standard biometeorological indexes to replace typical weather factors in biometeorological studies of different locations may not be an ideal research direction. This research is aimed at assessing the difference of statistical power between using standard biometeorological indexes and typical weather factors on describing the effects of extreme weather conditions on daily ambulance demands in Hong Kong. Results showed that net effective temperature and apparent temperature did not perform better than typical weather factors in describing daily ambulance demands in this study. The maximum adj-R 2 improvement was only 0.08, whereas the maximum adj-R 2 deterioration was 0.07. In this study, biometeorological indexes did not perform better than typical weather factors, possibly due to the differences of built environments and lifestyles in different locations and eras. Regarding built environments, the original parameters for calculating the index values may not be applicable to Hong Kong as buildings in Hong Kong are extremely dense and most are equipped with air conditioners. Regarding lifestyles, the parameters, which were set decades ago, may be outdated and not suitable to modern lifestyles as using hand-held electrical fans on the street to help reduce heat stress are popular. Hence, it is ideal to have tailor-made updated location-specific biometeorological indexes to study the effects of weather on human health.

International variation in neighborhood walkability, transit, and recreation environments using geographic information systems: the IPEN adult study.

BACKGROUND: The World Health Organization recommends strategies to improve urban design, public transportation, and recreation facilities to facilitate physical activity for non-communicable disease prevention for an increasingly urbanized global population. Most evidence supporting environmental associations with physical activity comes from single countries or regions with limited variation in urban form. This paper documents variation in comparable built environment features across countries from diverse regions. METHODS: The International Physical Activity and the Environment Network (IPEN) study of adults aimed to measure the full range of variation in the built environment using geographic information systems (GIS) across 12 countries on 5 continents. Investigators in Australia, Belgium, Brazil, Colombia, the Czech Republic, Denmark, China, Mexico, New Zealand, Spain, the United Kingdom, and the United States followed a common research protocol to develop internationally comparable measures. Using detailed instructions, GIS-based measures included features such as walkability (i.e., residential density, street connectivity, mix of land uses), and access to public transit, parks, and private recreation facilities around each participant's residential address using 1-km and 500-m street network buffers. RESULTS: Eleven of 12 countries and 15 cities had objective GIS data on built environment features. We observed a 38-fold difference in median residential densities, a 5-fold difference in median intersection densities and an 18-fold difference in median park densities. Hong Kong had the highest and North Shore, New Zealand had the lowest median walkability index values, representing a difference of 9 standard deviations in GIS-measured walkability. CONCLUSIONS: Results show that comparable measures can be created across a range of cultural settings revealing profound global differences in urban form relevant to physical activity. These measures allow cities to be ranked more precisely than previously possible. The highly variable measures of urban form will be used to explain individuals' physical activity, sedentary behaviors, body mass index, and other health outcomes on an international basis. Present measures provide the ability to estimate dose-response relationships from projected changes to the built environment that would otherwise be impossible.

Weather factors in the short-term forecasting of daily ambulance calls.

The daily ambulance demand for Hong Kong is rising, and it has been shown that weather factors (temperature and humidity) play a role in the demand for ambulance services. This study aimed at developing short-term forecasting models of daily ambulance calls using the 7-day weather forecast data as predictors. We employed the autoregressive integrated moving average (ARIMA) method to analyze over 1.3 million cases of emergency attendance in May 2006 through April 2009 and the 7-day weather forecast data for the same period. Our results showed that the ARIMA model could offer reasonably accurate forecasts of daily ambulance calls at 1-7 days ahead of time and with improved accuracy by including weather factors. Specifically, the inclusion of average temperature alone in our ARIMA model improved the predictability of the 1-day forecast when compared to that of a simple ARIMA model (8.8% decrease in the root mean square error, RMSE=53 vs 58). The improvement in the 7-day forecast with average temperature as a predictor was more pronounced, with a 10% drop in prediction error (RMSE=62 vs 69). These findings suggested that weather forecast data can improve the 1- to 7-day forecasts of daily ambulance demand. As weather forecast data are readily accessible from Hong Kong Observatory's official website, there is virtually no cost to including them in the ARIMA models, which yield better prediction for forward planning and deployment of ambulance manpower.

Quantifying the burden of disease due to premature mortality in Hong Kong using standard expected years of life lost.

BACKGROUND: To complement available information on mortality in a population Standard Expected Years of Life Lost (SEYLL), an indicator of premature mortality, is increasingly used to calculate the mortality-associated disease burden. SEYLL consider the age at death and therefore allow a more accurate view on mortality patterns as compared to routinely used measures (e.g. death counts). This study provides a comprehensive assessment of disease and injury SEYLL for Hong Kong in 2010. METHODS: To estimate the SEYLL, life-expectancy at birth was set according to the 2004 Global Burden of Disease study at 82.5 and 80 years for females and males, respectively. Cause of death data for 2010 were corrected for misclassification of cardiovascular and cancer causes. In addition to the baseline estimates, scenario analyses were performed using alternative assumptions on life-expectancy (Hong Kong standard life-expectancy), time-discounting and age-weighting. To estimate a trend of premature mortality a time-series analysis from 2001 to 2010 was conducted. RESULTS: In 2010 524,706.5 years were lost due to premature death in Hong Kong with 58.3% of the SEYLL attributable to male deaths. The three overall leading single causes of SEYLL were "trachea, bronchus and lung cancers", "ischaemic heart disease" and "lower respiratory infections" together accounting for about 29% of the overall SEYLL. Further, self-inflicted injuries (5.6%; ranked 5) and liver cancer (4.9%; ranked 7) were identified as important causes not adequately captured by classical mortality measures. Scenario analyses highlighted that by using a 3% time-discount rate and non-uniform age-weights the SEYLL dropped by 51.6%. Using Hong Kong's standard life-expectancy values resulted in an overall increase of SEYLL by 10.8% as compared to the baseline SEYLL. Time-series analysis indicates an overall increase of SEYLL by 6.4%. In particular, group I (communicable, maternal, perinatal and nutritional) conditions showed highest increases with SEYLL-rates per 100,000 in 2010 being 1.4 times higher than 2001. CONCLUSIONS: The study stresses the mortality impact of diseases and injuries that occur in earlier stages of life and thus presents the SEYLL measure as a more sensitive indicator compared to classical mortality indicators. SEYLL provide useful additional information and supplement available death statistics.

Surgical considerations for large asymptomatic cardiac fibromas in the context of fatal ventricular arrhythmias.

Cardiac fibromas are rare intracardiac neoplasms but represent the most common resectable tumours of childhood. They can remain asymptomatic for extended periods of time but a pertinent and unpredictable risk of sudden cardiac death and fatal ventricular arrhythmia always exists even in asymptomatic patients. We report a case of an asymptomatic two month-old with cardiac fibroma who presented with a ventricular tachycardia (VT) arrest. Here, we discuss management of cardiac fibroma in the context of occurrence of sudden VT.

The impact of geographic mobility on the spread of COVID-19 in Hong Kong.

The modern highly globalised economy is jeopardising human health as the increased mobility and interconnectedness has the potential to rapidly transmit pathogens across the globe. This was recently confirmed by the coronavirus disease 2019 outbreak, which quickly led to localised outbreaks in virtually every country. As the existing health systems were unprepared, the world has witnessed a critical shortage of life-supporting and health-sustaining resources. In the absence of effective non-pharmaceutical interventions to suppress the virus transmission, many governments imposed total or partial lockdowns, with devastating economic consequences. The case of Hong Kong in quickly suppressing the virus from spreading can thus be a lesson for all. In this study, open data sources of infected individuals are employed to compile maps of disease incidents at various geographic scales with the aim of better understanding the transmission dynamics and discern spatial variability. Our findings show that tracking human mobility patterns can improve awareness of spatiotemporal factors driving the risks of human exposure to viruses. Moreover, we have demonstrated that spatial tools can be successfully employed to explore connections between individuals and wider communities with the aim of informing adaptation of policies at different spatial scales and for different time periods. As was shown in the case of Hong Kong, disease control encompasses the interrelated tasks of reducing social interactions and encouraging adoption of protective behaviours.

A spatiotemporal data mining study to identify high-risk neighborhoods for out-of-hospital cardiac arrest (OHCA) incidents.

Out-of-hospital cardiac arrest (OHCA) is a worldwide health problem. The aim of the study is to utilize the territorial-wide OHCA data of Hong Kong in 2012-2015 to examine its spatiotemporal pattern and high-risk neighborhoods. Three techniques for spatiotemporal data mining (SaTScan's spatial scan statistic, Local Moran's I, and Getis Ord Gi*) were used to extract high-risk neighborhoods of OHCA occurrence and identify local clusters/hotspots. By capitalizing on the strengths of these methods, the results were then triangulated to reveal "truly" high-risk OHCA clusters. The final clusters for all ages and the elderly 65+ groups exhibited relatively similar patterns. All ages groups were mainly distributed in the urbanized neighborhoods throughout Kowloon. More diverse distribution primarily in less accessible areas was observed among the elderly group. All outcomes were further converted into an index for easy interpretation by the general public. Noticing the spatial mismatches between hospitals and ambulance depots (representing supplies) and high-risk neighborhoods (representing demands), this setback should be addressed along with public education and strategic ambulance deployment plan to shorten response time and improve OHCA survival rate. This study offers policymakers and EMS providers essential spatial evidence to assist with emergency healthcare planning and informed decision-making.

City planning policies to support health and sustainability: an international comparison of policy indicators for 25 cities.

City planning policies influence urban lifestyles, health, and sustainability. We assessed policy frameworks for city planning for 25 cities across 19 lower-middle-income countries, upper-middle-income countries, and high-income countries to identify whether these policies supported the creation of healthy and sustainable cities. We systematically collected policy data for evidence-informed indicators related to integrated city planning, air pollution, destination accessibility, distribution of employment, demand management, design, density, distance to public transport, and transport infrastructure investment. Content analysis identified strengths, limitations, and gaps in policies, allowing us to draw comparisons between cities. We found that despite common policy rhetoric endorsing healthy and sustainable cities, there was a paucity of measurable policy targets in place to achieve these aspirations. Some policies were inconsistent with public health evidence, which sets up barriers to achieving healthy and sustainable urban environments. There is an urgent need to build capacity for health-enhancing city planning policy and governance, particularly in low-income and middle-income countries.

Using open data and open-source software to develop spatial indicators of urban design and transport features for achieving healthy and sustainable cities.

Benchmarking and monitoring of urban design and transport features is crucial to achieving local and international health and sustainability goals. However, most urban indicator frameworks use coarse spatial scales that either only allow between-city comparisons, or require expensive, technical, local spatial analyses for within-city comparisons. This study developed a reusable, open-source urban indicator computational framework using open data to enable consistent local and global comparative analyses. We show this framework by calculating spatial indicators-for 25 diverse cities in 19 countries-of urban design and transport features that support health and sustainability. We link these indicators to cities' policy contexts, and identify populations living above and below critical thresholds for physical activity through walking. Efforts to broaden participation in crowdsourcing data and to calculate globally consistent indicators are essential for planning evidence-informed urban interventions, monitoring policy effects, and learning lessons from peer cities to achieve health, equity, and sustainability goals.

Does patient gender affect outcomes after concomitant coronary artery bypass graft and aortic valve replacement? An Australian Society of Cardiac and Thoracic Surgeons Database study.

OBJECTIVES: Women undergoing isolated coronary artery bypass graft (CABG) surgery have been previously shown to be at an independently increased risk for post-operative morbidity and mortality. However, there are considerably less data on whether this trend remains true in patients undergoing concomitant aortic valve replacement (AVR) and CABG surgery. The aim of our study was to investigate this pertinent issue. METHODS: Data obtained between June 2001 and December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program were retrospectively analysed. Demographic, operative data and post-operative complications were compared between male and female patients using χ(2) and t tests. Long-term survival analysis was performed using Kaplan-Meier survival curves and the log-rank test. Independent risk factors for short- and long-term mortality were identified using binary logistic and Cox regression, respectively. RESULTS: Concomitant AVR and CABG surgery was undertaken in 2,563 patients; 31.8% were female. Female patients were older (mean age 76 vs. 73 years; p < 0.001) and presented more often with hypertension (p < 0.001) but less often with severely impaired ejection fraction (p < 0.001), peripheral vascular disease (p < 0.001) and triple vessel disease (p < 0.001). Women did not demonstrate an increased risk of 30-day mortality (4.8 vs. 3.3%) on univariate (p = 0.069) or multivariate (p = 0.236) analysis. Female gender was independently associated with post-operative myocardial infarction (p = 0.022) and red blood cell transfusion (p < 0.001). There was no difference in long-term survival between men and women on multivariate analysis (p = 0.413). CONCLUSION: Female gender is not associated with poorer short- or long-term outcomes after concomitant CABG and AVR surgery.

Identification of superspreading environment under COVID-19 through human mobility data.

COVID-19 reaffirms the vital role of superspreaders in a pandemic. We propose to broaden the research on superspreaders through integrating human mobility data and geographical factors to identify superspreading environment. Six types of popular public facilities were selected: bars, shopping centres, karaoke/cinemas, mega shopping malls, public libraries, and sports centres. A historical dataset on mobility was used to calculate the generalized activity space and space-time prism of individuals during a pre-pandemic period. Analysis of geographic interconnections of public facilities yielded locations by different classes of potential spatial risk. These risk surfaces were weighed and integrated into a "risk map of superspreading environment" (SE-risk map) at the city level. Overall, the proposed method can estimate empirical hot spots of superspreading environment with statistical accuracy. The SE-risk map of Hong Kong can pre-identify areas that overlap with the actual disease clusters of bar-related transmission. Our study presents first-of-its-kind research that combines data on facility location and human mobility to identify superspreading environment. The resultant SE-risk map steers the investigation away from pure human focus to include geographic environment, thereby enabling more differentiated non-pharmaceutical interventions and exit strategies to target some places more than others when complete city lockdown is not practicable.

Pre- and Post-operative determinants of transplantation-free survival after Fontan. The Australia and New Zealand experience.

BACKGROUND: This review identifies the predictors of late mortality and heart transplantation that remain relevant in the contemporary population of patients with a Fontan circulation, focusing on the potential impact of post-Fontan morbidities on the late outlook of these patients. METHODS AND RESULTS: A total of 1561 patients who had survived the Fontan operation in Australia or New Zealand from 1975 to 2018 were included in this review. Over a median duration of 11.4 years, there was a total of 117 deaths (7%) and 32 heart transplantations (2%). Freedom from death and heart transplantation at 10, 20 and 35 years post Fontan surgery were 94% (95% CI 93-95%), 87% (95 %CI 85-90%) and 66% (95 %CI 57-78%) respectively. Being male, having an atriopulmonary Fontan, pre-Fontan atrioventricular valve intervention, or prolonged pleural effusions post Fontan were predictive of late death or heart transplantation. However, time-dependent variables such as the development of atrial arrhythmia, protein/losing enteropathy or late ventricular dysfunction were stronger predictors of the same outcome. Patients who developed a time-dependent risk factor had a freedom from death and heart transplantation rate of 54% (95 %CI 43-66) at 15 years and 44% (95 %CI 33-57) at 25 years post Fontan. However, 95% (95 %CI 91-99) of patients without any of the identified risk factors were free from death or heart transplantation rate at 25 years post Fontan. CONCLUSION: In conclusion, the occurrence of post-operative complications such as PLE, arrhythmia and ventricular dysfunction will likely precede the late demise of these patients.

Modes of late mortality in patients with a Fontan circulation.

OBJECTIVES: The mechanisms of attrition of the Fontan population have been poorly characterised and it is unclear whether some of the deaths are potentially preventable. We analysed the circumstances of late death in patients with a Fontan circulation, with a special focus on identifying lesions amenable to intervention that may have contributed to the decline of their circulation. METHODS: Between 1975 and 2018, a total of 105 patients from a Bi-National Registry died beyond 1 year after Fontan completion, at a median age of 18.6 (IQR 13.8-26.0) years old, 12.7 (IQR 6.0-19.3) years after Fontan completion. RESULTS: A total of 105 patients died-63 patients (60%) with an atriopulmonary (AP) Fontan, 21 patients (20%) with a lateral tunnel (LT) and 21 patients (20%) with an extracardiac conduit (ECC). 72 patients (69%) were reviewed within 2 years preceding death, with 32% (23/72) deemed to be clinically well. Fontan circulatory failure was the most common cause of death in 42 patients (45%). Other causes of death included sudden death/arrhythmia (19%), perioperative death (12%), neurological complication (7%) and thromboembolism (7%). All patients with an LT or ECC who died from Fontan failure had at least one surgical defect that was amenable to intervention at time of death. CONCLUSIONS: Conventional clinical surveillance has been insensitive in detecting a significant proportion of patients at risk of late death. Fontan circulatory failure contributes to half of the late deaths. Patients with an LT or ECC Fontan who died with a clinical picture of circulation failure may have potentially correctable lesions.

Provision of Convenient Play Space in a Densely Populated City.

The focus of this study is on examining sufficiency and quality of play space in a densely populated city from the spatial perspective. The study employed a three-stage multilevel mixed-method design using spatial analysis, user questionnaire, and site surveys. Provision of play space was assessed based on location, user perception, and proximity to residential areas and roads. The spatial distribution of play space was mapped and examined by applying GIS-based multicriteria analysis. Without considering play space provided by private housing estates, the study found a mismatch between children population and location of play space. The study also identified stair, slope, and sidewalk conditions as key issues of accessibility to selected playgrounds, even in districts with sufficient play space. Kowloon has limited play space of which a high percentage is inferior in terms of safety and pollution standards. Spatial analysis can help inform optimal locations for play space. Future studies should be based on more well-rounded and complete data to advise urban planning. Additionally, policy makers should focus more on quality standards of play space (i.e., openness, absence of pollution, attraction, safety, etc.) when planning as opposed to simply meeting the minimum area per person quota for open space.

The impact of morphological characteristics on late outcomes in patients born with hypoplastic left heart syndrome†.

OBJECTIVES: Patients with hypoplastic left heart syndrome are at high risk of late adverse events after Fontan completion, but it is unclear whether their morphological characteristics influence these outcomes. METHODS: Retrospective review of the data from the Australian and New Zealand Fontan Registry identified 185 patients with hypoplastic left heart syndrome who survived to hospital discharge after Fontan completion. Their outcomes were reviewed to identify predictors of adverse events with a particular focus on the impact of morphological characteristics. All available echocardiographic parameters were collected, and the hypoplasia of the left ventricle was subjectively considered to be mild, moderate or severe. RESULTS: The mean follow-up after the Fontan procedure was 6.4 ± 4.7 years. The median age at Fontan procedure was 4.41 years, 95% (176/185) of patients underwent an extracardiac conduit Fontan procedure and 71% (132/185) of those were fenestrated. At 15 years after Fontan, freedom from death and cardiac transplantation was 90% [95% confidence interval (CI) 85-97], freedom from Fontan failure was 78% (95% CI 70-87) and freedom from adverse events was 32% (95% CI 22-46). Morphological parameters did not influence transplant-free survival or Fontan failure. Independent risk factors predicting higher incidence of adverse events included aortic atresia (P = 0.003). CONCLUSIONS: The long-term survival of Fontan survivors with hypoplastic left heart syndrome is excellent and appears comparable to that of the general Fontan population. However, intrinsic morphological characteristics may continue to burden patients with late morbidity.