User perceptions of COVID-19 telemedicine testing services, disease risk, and pandemic preparedness: findings from a private clinic in Hong Kong.

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, telemedicine has been regarded as a method for providing safe access to healthcare. Here, we explored the experiences of individuals using telemedicine in Hong Kong during the COVID-19 pandemic to understand their risk perceptions and preparedness measures. METHODS: We conducted a cross-sectional online survey of telemedicine users of private clinic-based COVID-19 testing services from 6 April to 11 May 2020. All users were invited to complete an anonymous online survey regarding COVID-19 risk perception and preparedness measures. The results of the survey were compared with the findings of a previous territory-wide survey. RESULTS: In total, 141 of 187 telemedicine users agreed to participate; the response rate was 75.4%. Of the participants, 95.1% (116/122) believed that telemedicine consultations were useful. Nearly half of the participants (49.0%) agreed or strongly agreed that telemedicine consultations were appropriate during the COVID-19 pandemic. Most participants believed that telemedicine consultations could perform the functions of 'health protection, promotion and disease prevention' (73.6%) and 'diagnosis' (64.0%). Concerning the choice of telemedicine provider, almost all participants (99.2%) were willing to consult medical doctors; more than half of the participants (54.1%) were willing to consult registered nurses, but only 13.1% were willing to consult non-clinical staff who had been trained to provide telemedicine services. CONCLUSION: The use of telemedicine for screening and patient education can be encouraged during the COVID-19 pandemic in Hong Kong.

Scientific evidence on natural disasters and health emergency and disaster risk management in Asian rural-based area.

INTRODUCTION: Disaster epidemiological studies indicate that Asia has the highest frequency of natural disasters. Rural communities are heavily impacted by natural disasters and have different healthcare needs to urban ones. Referencing Asian countries, this paper's objective is to provide an overview of health impacts and the current evidence for designing programmes and policies related to rural health emergency and disaster risk management (health-EDRM). SOURCES OF DATA: This paper uses published English-only reports and papers retrieved from PubMed, Google Scholar, Embase, Medline and PsycINFO on rural disaster and emergency responses and relief, health impact and disease patterns in Asia (January 2000-January 2018). AREAS OF AGREEMENT: Earthquakes are the most studied natural disasters in rural communities. The medical burden and health needs of rural communities were most commonly reported among populations of extreme age. Most of the existing research evidence for rural interventions was reported in China. There lacks published peer-reviewed reports of programme impacts on personal and community preparedness. AREAS OF CONTROVERSY: There is a lack of evidence-based health-EDRM interventions to evaluate implementation effectiveness in rural areas despite vast volumes of health-related disaster literature. GROWING POINTS: Climate change-related disasters are increasing in frequency and severity. Evidence is needed for disaster risk reduction interventions to address the health risks specific to rural populations. AREAS TIMELY FOR DEVELOPING RESEARCH: To support global policy development, urgent evidence is needed on the intervention effectiveness, long-term health outcomes, local and cultural relevance as well as sustainability of health relief produced by Health-EDRM programmes in rural areas.

A meta-analysis on dose-response relationship between night shift work and the risk of breast cancer.

This study aimed to conduct a systematic review to sum up evidence of the associations between different aspects of night shift work and female breast cancer using a dose-response meta-analysis approach. We systematicly searched all cohort and case-control studies published in English on MEDLINE, Embase, PSYCInfo, APC Journal Club and Global Health, from January 1971 to May 2013. We extracted effect measures (relative risk, RR; odd ratio, OR; or hazard ratio, HR) from individual studies to generate pooled results using meta-analysis approaches. A log-linear dose-response regression model was used to evaluate the relationship between various indicators of exposure to night shift work and breast cancer risk. Downs and Black scale was applied to assess the methodological quality of included studies. Ten studies were included in the meta-analysis. A pooled adjusted relative risk for the association between 'ever exposed to night shift work' and breast cancer was 1.19 [95% confidence interval (CI) 1.05-1.35]. Further meta-analyses on dose-response relationship showed that every 5-year increase of exposure to night shift work would correspondingly enhance the risk of breast cancer of the female by 3% (pooled RR = 1.03, 95% CI 1.01-1.05; Pheterogeneity < 0.001). Our meta-analysis also suggested that an increase in 500-night shifts would result in a 13% (RR = 1.13, 95% CI 1.07-1.21; Pheterogeneity = 0.06) increase in breast cancer risk. This systematic review updated the evidence that a positive dose-response relationship is likely to present for breast cancer with increasing years of employment and cumulative shifts involved in the work.

Acute postoperative pain following hospital discharge after total knee arthroplasty.

OBJECTIVE: The increasingly shorter hospitalization following total knee arthroplasty (TKA) requires patients to assume earlier responsibility to self-manage their pain. Poorly managed acute pain increases the risk of persistent pain, reduces quality of life and increases unnecessary healthcare utilization. This study aims to examine post-discharge pain intensity, pain management behaviors and potential barriers to optimal self-management of pain. DESIGN: We administered a questionnaire at 2 weeks after discharge to 174 patients undergoing TKA in 10 Australian hospitals. Participants rated pain expectation and severity, use of analgesics and non-pharmacological methods, side-effects, walking and exercise times, perceptions of analgesics, adequacy of pain management information provided and satisfaction with pain relief. RESULTS: Of 171 (98%) participants who completed the questionnaire, 88 (52%) reported that the worst pain period occurred during the first 2 weeks at home. During the first 2 weeks at home, the average pain was 'severe/extreme' for 40 (23%) participants and 92 (54%) experienced severe pain at least some of the time. Many participants sought further medical help for their pain. Adequate information on analgesics and non-pharmacological methods for pain relief were reported by only 73% and 47%, respectively. Approximately 20% had negative perceptions about analgesic use. Higher pain severity was associated with lower satisfaction and less time spent walking daily. CONCLUSIONS: Effective pain relief after hospital discharge following TKA is a challenge. Many participants reported significant pain, sought further medical help for pain relief and had inadequate information at discharge to effectively self-manage their postoperative knee pain.

Evaluation of performance of measurement of faecal α(1)-antitrypsin clearance and technetium-99m human serum albumin scintigraphy in protein-losing enteropathy.

BACKGROUND AND AIM: Our study aimed to compare the performance of faecal α(1)-antitrypsin clearance (AATC) and radiolabelled human serum albumin (HSA) scintigraphy in protein-losing enteropathy (PLE). METHODS: Patients studied by both AATC and technetium-99m ((99m)Tc)-labelled HSA scintigraphy were recruited and categorized into PLE and non-PLE groups based on clinical and laboratory findings. The performance of AATC and (99m)Tc-labelled HSA scintigraphy was evaluated using clinical diagnosis of PLE as a gold standard. RESULTS: 29 patients were recruited and 13 patients were considered to have definite PLE (PLE group). In the PLE group, all patients had a positive HSA scinigraphy and 10 (77%) had demonstrable positive tracing in the early phase. Conversely, only 6 of them (46%) had elevated AATC level (>13 m/day). Results of (99m)Tc-labelled HSA scan (but not AATC) showed significant agreement with the clinical diagnosis (κ 0.35, p = 0.013). (99m)Tc-labelled HSA scintigraphy carried higher sensitivity (100 vs. 46%) and negative predictive value (100 vs. 63%) compared to AATC in diagnosing PLE. The correlation between the results of these two investigations was only modest (κ 0.27, p = 0.04). The area under the receiver operating characteristic curve of AATC level showed no optimal diagnostic cut-off for PLE. CONCLUSION: (99m)Tc-labelled HSA scintigraphy was superior to AATC in diagnosing PLE.

A synopsis of current care of thalassaemia major patients in Hong Kong.

OBJECTIVE: To provide a synopsis of current thalassaemia major patient care in Hong Kong. DESIGN: Retrospective study. SETTING: All haematology units of the Hospital Authority in Hong Kong. PATIENTS: All patients with thalassaemia major with regular transfusion. RESULTS: To date, there were 363 thalassaemia major patients under the care of the Hospital Authority. Prenatal diagnosis has helped to reduce the number of indigenous new cases, but in recent years immigrant cases are appearing. The patients have a mean age of 23 (range, 1-52) years, and 78% of them are adults. In 2009, they received 18 782 units of blood. This accounted for 9.5% of all blood consumption from the Hong Kong Red Cross. In the past, cardiac iron overload was the major cause of death (65%) and few patients survived beyond the age of 45 years. The availability of cardiac iron assessment by magnetic resonance imaging (T2 MRI) to direct the use of oral deferiprone chelation has reduced the prevalence of heart failure and cardiac haemosiderosis, which should reduce mortality and improve life expectancy. CONCLUSION: The future for thalassaemia care in Hong Kong is bright. With better transfusion and chelation, it should be possible to avoid growth and endocrine deficiencies in younger patients.

"Optimization of Surgical Resident Safety and Education During the COVID-19 Pandemic - Lessons Learned".

The COVID-19 pandemic has engendered rapid and significant changes in patient care. Within the realm of surgical training, the resultant reduction in clinical exposure and case volume jeopardizes the quality of surgical training. Thus, our general surgery residency program proceeded to develop a tailored approach to training that mitigates impact on resident surgical education and optimizes clinical exposure without compromising safety. Residents were engaged directly in planning efforts to craft a response to the pandemic. Following the elimination of elective cases, the in-house resident complement was effectively decreased to reduce unnecessary exposure, with a back-up pool to address unanticipated absences and needs. Personal protective equipment availability and supply, the greatest concern to residents, has remained adequate, while being utilized according to current guidelines. Interested residents were given the opportunity to work in designated COVID ICUs on a volunteer basis. With the decrease in operative volume and clinical duties, we shifted our educational focus to an intensive didactic schedule using a teleconferencing platform and targeted areas of weakness on prior in-service exams. We also highlighted critical COVID-19 literature in a weekly journal club to better understand this novel disease and its effect on surgical practice. The long-term impact of the COVID-19 pandemic on resident education remains to be seen. Success may be achieved with commitment to constant needs assessment in the changing landscape of healthcare with the goal of producing a skilled surgical workforce for public service.

A staged approach with vincristine, adriamycin, and dexamethasone followed by bortezomib, thalidomide, and dexamethasone before autologous hematopoietic stem cell transplantation in the treatment of newly diagnosed multiple myeloma.

Bortezomib-based regimens have significant activities in multiple myeloma (MM). In this study, we tested the efficacy of a total therapy with a staged approach where newly diagnosed MM patients received vincristine/adriamycin/dexamethsone (VAD). VAD-sensitive patients (> or =75% paraprotein reduction) received autologous hematopoietic stem cell transplantation (auto-HSCT), whereas less VAD-sensitive patients (<75% paraprotein reduction) received bortezomib/thalidomide/dexamethasone (VTD) for further cytoreduction prior to auto-HSCT. On an intention-to-treat analysis, a progressive increase of complete remission (CR) rates was observed, with cumulative CR rates of 48% after HSCT. Seven patients progressed leading to three fatalities, of which two had central nervous system disease. The 3-year overall survival and event-free survival were 75.1% and 48.3%, respectively. Six patients developed oligoclonal reconstitution with new paraproteins. In the absence of anticoagulant prophylaxis, no patients developed deep vein thrombosis. The staged application of VAD+/-VTD/auto-HSCT resulted in an appreciable response rate and promising survivals. Our approach reduced the use of bortezomib without compromising the ultimate CR rate and is of financial significance for less affluent communities.

Literature review of health impact post-earthquakes in China 1906-2007.

BACKGROUND: Over the last 100 years, China has experienced the world's three most fatal earthquakes. The Sichuan Earthquake in May 2008 once again reminded us of the huge human toll geological disaster can lead to. METHODS: In order to learn lessons about the impact of earthquakes on health in China during the past century, we conducted a bilingual literature search of the publicly available health-related disaster databases published between 1906 and 2007. RESULTS: Our search found that research was limited and there were major gaps in the published literature about the impact on health in the post-earthquake period. However, the experiences recorded were similar to those of other parts of the world. The available studies provide useful information about preparedness and rapid early response. Gaps identified included care of chronic disease. CONCLUSION: Our literature review highlights the paucity of literature on the impact on health post-earthquake in China between 1906 and 2007. Disaster mitigation policies need to reflect the needs not only of the disaster-related impacts on health but also of the ongoing health needs of the chronically ill and to establish safeguards for the well-being of the vulnerable populations.

RasGRP, a Ras guanyl nucleotide- releasing protein with calcium- and diacylglycerol-binding motifs.

RasGRP, a guanyl nucleotide-releasing protein for the small guanosine triphosphatase Ras, was characterized. Besides the catalytic domain, RasGRP has an atypical pair of "EF hands" that bind calcium and a diacylglycerol (DAG)-binding domain. RasGRP activated Ras and caused transformation in fibroblasts. A DAG analog caused sustained activation of Ras-Erk signaling and changes in cell morphology. Signaling was associated with partitioning of RasGRP protein into the membrane fraction. Sustained ligand-induced signaling and membrane partitioning were absent when the DAG-binding domain was deleted. RasGRP is expressed in the nervous system, where it may couple changes in DAG and possibly calcium concentrations to Ras activation.

Development of a Brief Caregiver-centric Screening Tool to Identify Risk of Depression among Caregivers of Hospitalized Older Adults.

OBJECTIVES: Caregivers of hospitalized older adults experience elevated levels of stress and are at risk of poor health outcomes. There is a lack of screening tools based on self-reported caregiver variables incorporating both protective and risk factors, for early identification of at-risk caregivers. This study reports the development of a caregiver-centric screening tool to identify risk of depression at admission and predicts 3-month risk of depression and quality of life amongst caregivers of older adults with an unplanned admission. DESIGN, SETTING AND PARTICIPANTS: This prospective cohort study was conducted in the medical wards of a tertiary-care hospital from July 2015 to May 2017. We recruited family caregivers of patients aged 65 years and above who fulfilled the following criteria: a) unplanned admission, b) not residing in nursing homes; and c) requiring assistance in activities of daily living. MEASUREMENTS: We examined 11 candidate caregiver variables (mastery, burden and nine demographic variables). Risk of depression (score ≥8 on Hospital Anxiety and Depression Scale (HADS-D) depression subscale) was the primary outcome, and was assessed during the index admission. Logistic regression models were used to identify risk factors and risk scores (weights). The total risk scores were then stratified into three risk levels. Predictive validity of the screening tool was assessed using 3-months post-discharge risk of depression and health-related quality of life (HRQoL). RESULTS: The study included 274 caregiver-patient dyads. The mean (SD) age of the caregivers was 59 (10) years with 33.6% caregivers screening positive for risk of depression. The final model comprised three caregiver variables: mastery, burden and education. The total risk scores ranged from 0 to 6 and showed good discrimination (AUC:0.82, 95% CI: 0.77 to 0.87). Caregivers were classified into low-risk (0-1 points), intermediate-risk (2-4 points), and high-risk (5-6 points) groups, with corresponding rates of risk of depression (HADS-D≥8) of 10.7%, 44.6% and 73.3%, during admission. Relative risk rates of the intermediate- and high- risk group using the low-risk group as reference were 4.16 and 6.84 respectively. At 3-months post-discharge, the rates of caregivers at risk of depression or having poor HRQoL also increased corresponding to the three risk levels as per baseline, supporting the predictive validity of the tool. CONCLUSIONS/IMPLICATIONS: The caregiver-centric tool is a novel, practical, self-administered, relatively brief caregiver-centric instrument that can be used for rapid screening and stratification of caregivers at risk of depression. Uniquely, the tool comprised of assessment of protective factor (mastery) in addition to risk factors to provide a holistic assessment of the caregiver. It can be incorporated as part of older adults' admission evaluation so that prompt intervention can be rendered to their at-risk caregivers.

Relationship between Mastery and Caregiving Competence in Protecting against Burden, Anxiety and Depression among Caregivers of Frail Older Adults.

OBJECTIVE: Studies suggest the protective effect of mastery and caregiving competence against psychological stressors of caregiving in the context of dementia, although the interplay between the two with caregiver outcomes is not well understood. This study examines the independent and moderating impact of mastery and caregiving competence on burden, anxiety and depression among caregivers of older adults with frailty-related care needs. DESIGN, SETTING AND PARTICIPANTS: This is a cross-sectional study of 274 older adults-family caregiver dyads from a hospital in Singapore. Mean ages of the older adults and their caregivers were 85 and 59 years respectively. MEASUREMENTS: We performed hierarchical linear regression models to examine the independent influence of mastery and caregiving competence on caregiver burden, anxiety and depression. We also examined the interaction effect between mastery and caregiving competence for each outcome. RESULTS: Mastery and caregiving competence were independently negatively associated with caregiver burden, anxiety and depression. Mastery explained more variance than caregiving competence and had a stronger correlation with all outcomes. There was a statistically significant interaction between mastery and caregiving competence for depression (interaction term beta=.14, p<0.01), but not burden and anxiety. High levels of mastery are associated with less depression. particularly among caregivers with below-average levels of caregiving competence. Likewise, high levels of caregiving competence are associated with less depression. particularly among caregivers with below-average levels of mastery. CONCLUSION: Our findings suggest potential benefits adressing targeted interventions for mastery and caregiving competence of caregivers to older adults as they independently influence caregiver outcomes and moderate each other's effect on depression. Mastery-based interventions should be incorporated into current caregiver training which traditionally has focused on caregiver competence alone.

Hypothermic stress leads to activation of Ras-Erk signaling.

The small GTPase Ras is converted to the active, GTP-bound state during exposure of vertebrate cells to hypothermic stress. This activation occurs more rapidly than can be accounted for by spontaneous nucleotide exchange. Ras-guanyl nucleotide exchange factors and Ras GTPase-activating proteins have significant activity at 0 degrees C in vitro, leading to the hypothesis that normal Ras regulators influence the relative amounts of Ras-GTP and Ras-GDP at low temperatures in vivo. When hypothermic cells are warmed to 37 degrees C, the Raf-Mek-Erk protein kinase cascade is activated. After prolonged hypothermic stress, followed by warming to physiologic temperature, cultured fibroblasts assume a rounded morphology, detach from the substratum, and die. All of these biologic responses are attenuated by pharmacologic inhibition of Mek. Previously, it had been found that low temperature blocks acute growth factor signaling to Erk. In the present study, we found that this block occurs at the level of Raf activation. Temperature regulation of Ras signaling could help animal cells respond appropriately to hypothermic stress, and Ras-Erk signaling can be manipulated to improve the survival of cells in cold storage.