Epidemiology of Legionnaires' Disease, Hong Kong, China, 2005-2015.

We reviewed findings of clinical, epidemiologic, and environmental investigations for 288 confirmed case-patients with Legionnaires' disease reported in Hong Kong, China, during January 2005-December 2015. We found that chronic renal failure/impairment (adjusted odds ratio [aOR] 4.09), chronic pulmonary diseases (aOR 3.22), malignancy (aOR 3.04), and heart diseases (aOR 2.15) were independently associated with a higher risk for severe Legionnaires' disease. However, patients with hyperlipidemia had a lower risk for severe outcome (aOR 0.17). Legionella positivity rate was 22% for 1,904 water samples collected. We found a higher positivity rate in summer months (28%-30%), which corroborated with months of highest rainfalls. Our novel finding that Legionnaires' disease patients with hyperlipidemia had a lower risk for severe outcome deserves further study to confirm the observation and ascertain the underlying reason.

Enhancing emotion recognition in young autistic children with or without attention-deficit/hyperactivity disorder in Hong Kong using a Chinese App version of The Transporters.

TRIAL REGISTRATION: This study was registered with the German Clinical Trials Register - Deutschen Register Klinischer Studien (DRKS) on 23 December 2018. The Trial Registration Number (TRN) is DRKS00016506. LAY ABSTRACT: The Transporters App is an intervention programme with 15 animated episodes that teach emotion recognition skills to autistic children between 4 and 6 years of age. Each episode contains a story depicting social interactions between characters in the form of a vehicle, with human faces grafted on to each of them. Each episode teaches a specific emotion in a story context. Autistic children watched at least three episodes at home for about 15 min daily for a month, with parental guidance. Its automated, home-based format is cost-saving and readily accessible. This study translated The Transporters to a Cantonese-Chinese version. Results showed a significant improvement in emotion recognition following viewing The Transporters in a group of Hong Kong Chinese autistic children, between 4 and 6 years of age, with and without attention-deficit/hyperactivity disorder (n = 48) relative to a control group (n = 24). A non-autistic group (n = 23) showed that the autistic children scored lower in emotion recognition pre-intervention. Post-intervention, the autistic children had improved in emotion recognition to the level of the non-autistic children. The autistic children in the intervention groups also generalized their learning to novel situations/characters not taught within The Transporters. There was no dosage effect, with the standard recommended number of episodes viewed being sufficient to achieve significant improvement. This study confirms the effectiveness of The Transporters for Chinese autistic children and contributes to the literature/practice by expanding the range of applicability of The Transporters to autistic children with attention-deficit/hyperactivity disorder, which is important given the high rate of co-occurrence between autism and attention-deficit/hyperactivity disorder.

Comparative epidemiology of pandemic and seasonal influenza A in households.

BACKGROUND: There are few data on the comparative epidemiology and virology of the pandemic 2009 influenza A (H1N1) virus and cocirculating seasonal influenza A viruses in community settings. METHODS: We recruited 348 index patients with acute respiratory illness from 14 outpatient clinics in Hong Kong in July and August 2009. We then prospectively followed household members of 99 patients who tested positive for influenza A virus on rapid diagnostic testing. We collected nasal and throat swabs from all household members at three home visits within 7 days for testing by means of quantitative reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay and viral culture. Using hemagglutination-inhibition and viral-neutralization assays, we tested baseline and convalescent serum samples from a subgroup of patients for antibody responses to the pandemic and seasonal influenza A viruses. RESULTS: Secondary attack rates (as confirmed on RT-PCR assay) among household contacts of index patients were similar for the pandemic influenza virus (8%; 95% confidence interval [CI], 3 to 14) and seasonal influenza viruses (9%; 95% CI, 5 to 15). The patterns of viral shedding and the course of illness among index patients were also similar for the pandemic and seasonal influenza viruses. In a subgroup of patients for whom baseline and convalescent serum samples were available, 36% of household contacts who had serologic evidence of pandemic influenza virus infection did not shed detectable virus or report illness. CONCLUSIONS: Pandemic 2009 H1N1 virus has characteristics that are broadly similar to those of seasonal influenza A viruses in terms of rates of viral shedding, clinical illness, and transmissibility in the household setting.

Accumulated Hard Tissue Debris and Root Canal Shaping Profiles Following Instrumentation with Gentlefile, One Curve, and Reciproc Blue.

INTRODUCTION: This laboratory study aimed to evaluate the accumulated hard tissue debris (AHTD) and shaping performance following root canal instrumentation with a novel stainless steel rotary system (Gentlefile; MedicNRG, Kibbutz Afikim, Israel) compared with two single-file nickel-titanium instruments of different kinematics through micro-computed tomography (micro-CT) analysis. METHODS: Thirty isthmus-containing mesial roots of human mandibular molars with a curvature of 15°-35° were scanned with micro-CT at an isotropic resolution of 12 µm and randomly assigned to three groups (n = 10) according to the instruments used for canal preparation: Gentlefile (GF; #23/.04), One Curve (OC; #25/.06; Micro-Mega, Besancon, France), and Reciproc Blue R25 (RB; #25/.08; VDW, Munich, Germany). The AHTD, unprepared canal surface area, volume changes, surface area changes, and transportation were evaluated by comparing preoperative and postoperative micro-CT images. In addition, the time required for canal preparation was recorded. Data were statistically analyzed using the one-way analysis of variance (ANOVA) test or the Kruskal-Wallis test at a significance level of 5%. RESULTS: No significant differences were observed in the percentage of AHTD or in the unprepared canal surface area between the three groups (P > .05). The RB group demonstrated a significantly greater percentage increase in volume and surface area than the GF group (P < .05). The GF and OC groups showed significantly less transportation at 3 mm from the apex than the RB group (P < .001). The OC group required significantly less time for instrumentation than the RB and GF groups (P < .05). CONCLUSIONS: Instrumentation with GF (#23/.04), OC, and RB yielded similar levels of AHTD and unprepared surface area in isthmus-containing curved canals. GF achieved this with less dentin removal and apical transportation, at the expense of a longer preparation time.

Elastic-plastic properties of titanium and its alloys modified by fibre laser surface nitriding for orthopaedic implant applications.

Laser nitriding is one of the most promising approaches to improve wear resistance of Ti alloy surfaces and may extend the use in orthopaedic implants. In this study, three types of Ti alloys, namely alpha commercially pure Ti ("TiG2"), alpha-beta Ti-6Al-4V ("TiG5"), and beta Ti-35.5Nb-7.3Zr-5.7Ta ("ßTi"), were subjected to an open-air laser nitriding treatment. Essential elastic-plastic mechanical properties including elastic modulus, hardness, elastic energy, plasticity index, and hardness-to-elasticity ratio of the laser-treated Ti alloys were characterized using nanoindentation experiment. The results showed that the elastic modulus, hardness and elastic energy values of all Ti samples significantly increased in the nitrided layer compared to respective bare substrates for all three Ti materials. Across different Ti samples, ßTi sustained its relatively lower elastic modulus, but presented comparable hardness, elastic energy, plasticity index, as well as hardness-to-elasticity ratio in the nitrided layer compared to the other two Ti alloys. Overall, amongst three medical grade Ti alloys in this study, ßTi appeared as the most appealing candidate for joint replacement applications even solely in view of mechanical compatibility when combined with surface laser nitriding. Nevertheless, laser nitriding treatment in this study tended to cause a residual compressive stress on all Ti alloys as displayed by cracks developed in the nitrided layer and analyzed on ßTi by X-ray diffraction (XRD) and further nanoindentation tests.

Titanium for Orthopedic Applications: An Overview of Surface Modification to Improve Biocompatibility and Prevent Bacterial Biofilm Formation.

Titanium and its alloys have emerged as excellent candidates for use as orthopedic biomaterials. Nevertheless, there are often complications arising after implantation of orthopedic devices, most notably prosthetic joint infection and aseptic loosening. To ensure that implanted devices remain functional in situ, innovation in surface modification has attracted much attention in the effort to develop orthopedic materials with optimal characteristics at the biomaterial-tissue interface. This review will draw together metallurgy, surface engineering, biofilm microbiology, and biomaterial science. It will serve to appreciate why titanium and its alloys are frequently used orthopedic biomaterials and address some of the challenges facing these biomaterials currently, including the significant problem of device-associated infection. Finally, the authors shall consolidate and evaluate surface modification techniques employed to overcome some of these issues by offering a unique perspective as to the direction in which research is headed from a broad, interdisciplinary point of view.

Optimization of anti-wear and anti-bacterial properties of beta TiNb alloy via controlling duty cycle in open-air laser nitriding.

A multifunctional beta TiNb surface, featuring wear-resistant and antibacterial properties, was successfully created by means of open-air fibre laser nitriding. Beta TiNb alloy was selected in this study as it has low Young's modulus, is highly biocompatible, and thus can be a promising prosthetic joint material. It is, however, necessary to overcome intrinsically weak mechanical properties and poor wear resistance of beta TiNb in order to cover the range of applications to load-bearing and/or shearing parts. To this end, open-air laser nitriding technique was employed. A control of single processing parameter, namely duty cycle (between 5% and 100%), led to substantially different structural and functional properties of the processed beta TiNb surfaces as analyzed by an array of analytical tools. The TiNb samples nitrided at the DC condition of 60% showed a most enhanced performance in terms of improving surface hardness, anti-friction, anti-wear and anti-bacterial properties in comparison with other conditions. These findings are expected to be highly important and useful when TiNb alloys are considered as materials for hip/knee articular joint implants.

Translating evidence-based protocol of wound drain management for total joint arthroplasty into practice: A quasi-experimental study.

BACKGROUND: Although various drains have long been used in total joint replacement, evidence suggests inconsistent practice exists in the use of drainage systems including intermittently applying suction or free of drainage suction, and variations in the optimal timing for wound drain removal. A comprehensive systematic review of available evidence up to 2013 was conducted in a previous study and a protocol was adapted for clinical application according to the summary of the retrieved information (Tsang, 2015). AIMS: To determine if the protocol could reduce blood loss and blood transfusion after operation and to develop a record form so as to enhance communication of drainage record amongst surgeons and nurses. METHODS: A quasi-experimental time-series design was undertaken. In the conventional group, surgeons ordered free drainage if the drain output was more than 300 ml. The time of removal of the drain was based on their professional judgement. In the protocol group the method of drainage was dependant of the drainage output as was the timing of the removal of the drain. A standardized record form was developed to guide operating room and orthopaedic ward nurses to manage the drainage system. RESULTS: The drain was removed significantly earlier in the protocol group. Blood loss rate at the first hour of post-operation was extremely low in the protocol group due to clamping effect. Blood loss in volume during the first three hours in the protocol group was significantly lower than that in the conventional group. Only in 11.1% and 4% of cases was it necessary to clamp at the three and four hour post-operative hours. No clamping was required at the two and eight hour postoperative period. There was no significant difference in blood loss during the removal of the drain and during blood transfusion, which was required for patients upon removal of the drain in the two groups. CONCLUSION: This is the first clinical study to develop an evidence-based protocol to manage wound drain effectively in Hong Kong. Total blood loss and blood transfusions were not significantly different between the conventional and protocol groups. A standard documentation document is beneficial to enhance communication between doctors and nurses as well as to monitor and observe drainage effectively.

Highly active antiretroviral therapy per se decreased mortality and morbidity of advanced human immunodeficiency virus disease in Hong Kong.

BACKGROUND: Morbidity and mortality of advanced human immunodeficiency virus infection (HIV) have declined in Western industrialized countries since the availability of highly active antiretroviral therapy (HAART). It is unclear if this has also happened in Hong Kong. METHODS: We studied a retrospective cohort of patients with advanced HIV disease in Hong Kong, China. First, the mortality of advanced HIV disease per year was calculated for the decade 1993 to 2002, both annually and according to patient observation before and after 1997. Second, the event rates were estimated for the clinical end points of acquired immune deficiency syndrome (AIDS) and death. Univariate and multivariate analyses were then performed to identify associated factors. RESULTS: The crude mortality of advanced HIV disease declined from 10.8-30.4 per 100 patients during 1993-1996, to 0.8-6.9 per 100 patients during 1997-2002. A rate ratio of 4.04 (95% CI, 2.52-6.47) was evident for those observed in 1993-1996, compared to those in 1997-2002. In a multivariate analysis where calendar period was adjusted, use of highly active antiretroviral therapy was associated with rate ratios of 0.13 (95% CI, 0.05-0.33) for death after AIDS, 0.08 (95% CI, 0.04-0.19) for AIDS after a CD4 cell count < 200/microl, and 0.21 (95% CI, 0.07-0.67) for death after CD4 cell count < 200/microl. In the same analysis, calendar period ceased to be a significant factor after adjustment for use of HAART. CONCLUSIONS: The mortality and morbidity of advanced human immunodeficiency virus disease have declined in Hong Kong. This improved prognosis was attributable to the use of highly active antiretroviral therapy.

Human epidermal growth factor enhances healing of diabetic foot ulcers.

OBJECTIVE: To study the healing effect of recombinant human epidermal growth factor (hEGF) on diabetic foot ulcers. RESEARCH DESIGN AND METHODS: A total of 127 consecutive patients were screened and 61 diabetic subjects were recruited into this double-blind randomized controlled study. Predetermined criteria were used for diagnosis and classification of the diabetic wound. The patients were randomized into three groups. All patients attended our Diabetes Ambulatory Care Center every other week for joint consultation with the diabetologist and the podiatrist. Group 1 (control) was treated with Actovegin 5% cream (Actovegin), group 2 with Actovegin plus 0.02% (wt/wt) hEGF, and group 3 with Actovegin plus 0.04% (wt/wt) hEGF. The study end point was the complete closure of the wound. Failure to heal was arbitrarily defined as incomplete healing after 12 weeks. RESULTS: Final data were obtained from 61 patients randomly assigned into three groups. The mean ages of the patients, wound sizes, wound duration, metabolic measurements, and comorbidities were comparable within groups, except that group 3 had more female patients. Mean follow-up for the patients was 24 weeks. Data were cutoff at 12 weeks, and results were analyzed by intention to treat. After 12 weeks, in group 1 (control) eight patients had complete healing, two patients underwent toe amputation, and nine had nonhealing ulcers. In group 2 (0.02% [wt/wt] hEGF) 12 patients experienced wound healing, 2 had toe amputations, and 7 had nonhealing ulcers. Some 20 of 21 patients in group 3 (0.04% [wt/wt] hEGF) showed complete wound healing. Healing rates were 42.10, 57.14, and 95% for the control, 0.02% (wt/wt) hEGF, and 0.04% (wt/wt) hEGF groups, respectively. Kaplan-Meier survival analysis suggested that application of cream with 0.04% (wt/wt) hEGF caused more ulcers to heal by 12 weeks and increased the rate of healing compared with the other treatments (log-rank test, P = 0.0003). CONCLUSIONS: Our data support the contention that application of hEGF-containing cream, in addition to good foot care from a multidisciplinary team, significantly enhances diabetic foot ulcer wound healing and reduces the healing time.

A study of the efficacy of cervical ripening with nitric oxide donor versus placebo for cervical priming before second-trimester termination of pregnancy.

This was a double-blind randomized control study to evaluate the efficacy of cervical priming by nitric oxide donor before second-trimester induced abortion. One-hundred healthy women with a singleton pregnancy between 14 and 20 weeks of gestation were randomized into either 40 mg isosorbide mononitrate or placebo, given intravaginally 12 h before induction. This was followed by intravaginal misoprostol induction. The induction-abortion interval, abortion rate, side effects and the woman's acceptability of the priming agent were recorded. All women completed the study and there was no severe complication recorded. There was no significant difference in the induction-abortion interval and abortion rate between the two groups. Isosorbide mononitrate group reported significantly more side effects of headache. More than 90% of the women in both groups found the priming agent acceptable. The application of intravaginal nitric oxide donors prior to the prostaglandins induction did not significantly improve the second-trimester induced-abortion process.

Oral health of foreign domestic workers: exploring the social determinants.

Foreign domestic helpers constitute a significant proportion of migrant workers worldwide. This population subgroup provides an opportunity for understanding social determinants of oral health in immigrant community. A random sample of 122 Indonesian domestic helpers in Hong Kong completed a questionnaire on their demographic background, social characteristics (competency in local languages, immigration history, living condition, social connections, and leisure activities) and oral health behaviours (knowledge, attitudes, practice and self-efficacy). Their tooth status and periodontal health were assessed. Participants tended to start flossing after settling in Hong Kong. Favourable oral health knowledge was found in more acculturated participants, as indicated by proficiency in local languages and immigration history. Engagement in social and/or religious activities and decent living condition provided by employers were associated with favourable oral health behaviours and/or better oral health. Social determinants explained 13.2 % of variance in caries severity. Our findings support the significant impact of social circumstances on oral health of domestic workers.

A pharmacist care program: positive impact on cardiac risk in patients with type 2 diabetes.

OBJECTIVE: To investigate the effect of a pharmacist care program on cardiovascular risks in type 2 diabetic patients. METHODS: A 9-month, prospective, randomized, controlled study was conducted in a public hospital in Hong Kong. Patients in the intervention group had regular drug-counseling sessions with pharmacists in addition to routine medical care, whereas patients in the control group received only routine medical care. The primary outcome was the change in coronary heart disease (CHD) risk. RESULTS: A total of 105 patients completed the study. Patients in the intervention group had a statistically significant reduction in CHD risk compared to those in the control group (-1.64% ± 3.56%; n = 51 vs -0.01% ± 3.08%; n = 54, P = .013). For stroke, a reduction in risk was noted in the intervention group, while an increased risk was noted in the control group (-1.06% ± 1.82% vs 0.31% ± 2.51%, P = .002). In addition, hemoglobin A1c levels were significantly reduced in the intervention group compared with the control group (-1.57% ± 1.50% vs -0.40% ± 1.19%, P < .001); a similar profile was seen with low-density lipoprotein cholesterol (-0.36 ± 0.76 vs -0.03 ± 0.74, P = .026). Furthermore, there were nonsignificant improvements in high-density lipoprotein cholesterol, triglyceride, and blood pressure in the intervention group. The increased level of understanding regarding medications in the intervention group was statistically significant (P < .001), yielding a better enhancement in compliance compared with patients in the control group (22.5% ± 13.4% vs 2.0% ± 5.0%, P < .001). CONCLUSION: The pharmacist care program implemented in this study demonstrated a significant cardiovascular risk reduction in type 2 diabetic patients; therefore such a program would be a valuable addition to a multidisciplinary care of diabetic patients.