Prevention-Focused Care: The Potential Role of Chiropractors in Hong Kong's Primary Healthcare Transformation.

Hong Kong's healthcare system is moving toward preventive and primary care to address the complicated demands of the aging population. Chiropractic professionals are in an advantageous position to support a prevention-focused strategy by identifying musculoskeletal problems early, reducing risks, and promoting healthy lifestyles. This article examines how the involvement of chiropractors in public health programs could improve population health in Hong Kong and boost primary care. The inclusion of chiropractors in district health centers and other initiatives would offer safer and more cost-effective choices for treating functional problems and chronic pain. Chiropractors should be involved in policymakers' attempts to create a sustainable healthcare system that meets Hong Kong's long-term healthcare requirements.

Recognizing Hong Kong Chiropractors' Sick Leave Authority: Valuing a Conservative Approach to Workers' Compensation.

Although registered under Hong Kong's legislative framework, chiropractors are not able to certify sick leave, restricting the effectiveness of their services for patients with musculoskeletal issues requiring time away from work. This paper explores the evolution of chiropractic regulation in Hong Kong, the growth of the profession, and the tardy recognition of chiropractors' power to issue sick leave certificates. The chiropractic profession and its patients have long lobbied for this authority, but the government has been slow to respond. This document presents a comprehensive analysis of the benefits and restrictions of allowing chiropractors prescriptive authority for sick leave and requests that this change in policy be considered. Developing responsible criteria for chiropractors to prescribe sick leave within their scope of practice could legitimize chiropractic's position in the population's health and interdisciplinary pain care while lowering the burden on injured workers.

Meeting Future Demand for Chiropractic Services in Hong Kong: A Strategic Manpower Planning Approach.

Chiropractic treatment in Hong Kong has demonstrated high effectiveness in cases where traditional therapies have failed, with minimal associated adverse events. The growing aging population, prevalence of disabilities, and musculoskeletal conditions have increased the demand for rehabilitation services. Over the past few years, the chiropractic profession has raised awareness of treatment benefits. Providing high-quality training and education, licensing/regulation, interprofessional collaboration, increased accessibility, and research are factors influencing the chiropractic workforce and meeting the population's health needs. To achieve the number of chiropractors required by Hong Kong for adequate service according to international standards, future efforts could include increased licensing/registration efficiency, expanded coverage of public/private insurance, system integration/interprofessional collaboration, public education, and local research to build evidence and to support workforce growth and acceptance.

Effectiveness of qigong and tai chi in the quality of life of patients with cancer: protocol for an umbrella review.

INTRODUCTION: Qigong and tai chi (QTC) have been adopted by many patients with cancer as a complementary treatment with their conventional mainstream cancer management. Findings from current systematic reviews are inconsistent. Some research indicated that either qigong or tai chi interventions could enhance quality of life (QoL), and improve cancer-related symptoms such as fatigue, sleep disturbance and anxiety; while others argued that there was a lack of efficacy of QTC on QoL improvement. This umbrella review will analyse and synthesise the findings from published systematic reviews and meta-analyses regarding the effectiveness of QTC in the QoL of patients with cancer. Twenty-five databases will be searched from their respective inception to December 2021. METHODS AND ANALYSIS: We will conduct a search in 21 English and 4 Chinese databases to identify qualified systematic reviews and meta-analyses. Two reviewers will independently screen all the titles and abstracts, and determine whether the article meets the inclusion criteria. After the identified systematic reviews and/or meta-analyses are confirmed, important information from each article will be extracted to the characteristics table by two reviewers independently. Two reviewers will independently analyse the quality of the selected reviews based on the Assessment of Multiple Systematic Reviews guideline. Findings from the systematic reviews and/or meta-analyses will be summarised and reported. ETHICS AND DISSEMINATION: This review does not require ethics approval as the study is based on the published articles. The results drawn from the present review will be submitted to peer-reviewed journals for publication or presented at conferences. PROSPERO REGISTRATION NUMBER: CRD42021253216.

Effect of Steroid in Local Infiltration Analgesia in One-Stage Bilateral Total Knee Arthroplasty: A Paired-Randomized Controlled Study.

Although local infiltration analgesia (LIA) is effective in relieving pain after total knee arthroplasty (TKA), its effect is short lasting and the optimal combination of drugs is unknown. Steroids being a potent and long-acting anti-inflammatory drug might extend LIA's effect. This study aims to evaluate the role of steroids in LIA. This is a paired-randomized controlled study involving one-stage bilateral TKA patients. LIA containing ropivacaine, ketorolac, and adrenaline with or without triamcinolone was given. One knee was randomized to receive LIA with steroids, while the other received LIA without steroids. The primary outcome was knee pain in terms of the visual analog scale (VAS). Secondary outcomes were rehabilitation progress, functional scores, and complications. Outcomes were compared between the knees of the same patient and documented up to 1 year. A total of 45 patients (90 TKAs) were included. LIA with steroid knees showed lower VAS score at rest and during activity from postoperation day 1 to 5 and at 6 weeks (p < 0.05). Passive and active range of movement was also greater in LIA with steroid group from day 1 to 7 and day 2 to 5, respectively (p < 0.05). Steroid-treated knees also achieved active straight leg raise earlier (1.2 vs. 2.0 days, p < 0.05). No differences in Knee Society Score and complication rates between both groups. Steroids in LIA offer additional and extended benefit in pain control and rehabilitation after TKA, while no adverse effects were found up to 1-year follow-up.

Adjuncts to local anesthetic wound infiltration for postoperative analgesia: a systematic review.

Local anesthetics (LAs) are commonly infiltrated into surgical wounds for postsurgical analgesia. While many adjuncts to LA agents have been studied, it is unclear which adjuncts are most effective for co-infiltration to improve and prolong analgesia. We performed a systematic review on adjuncts (excluding epinephrine) to local infiltrative anesthesia to determine their analgesic efficacy and opioid-sparing properties. Multiple databases were searched up to December 2019 for randomized controlled trials (RCTs) and two reviewers independently performed title/abstract screening and full-text review. Inclusion criteria were (1) adult surgical patients and (2) adjunct and LA agents infiltration into the surgical wound or subcutaneous tissue for postoperative analgesia. To focus on wound infiltration, studies on intra-articular, peri-tonsillar, or fascial plane infiltration were excluded. The primary outcome was reduction in postoperative opioid requirement. Secondary outcomes were time-to-first analgesic use, postoperative pain score, and any reported adverse effects. We screened 6670 citations, reviewed 126 full-text articles, and included 89 RCTs. Adjuncts included opioids, non-steroidal anti-inflammatory drugs, steroids, alpha-2 agonists, ketamine, magnesium, neosaxitoxin, and methylene blue. Alpha-2 agonists have the most evidence to support their use as adjuncts to LA infiltration. Fentanyl, ketorolac, dexamethasone, magnesium and several other agents show potential as adjuncts but require more evidence. Most studies support the safety of these agents. Our findings suggest benefits of several adjuncts to local infiltrative anesthesia for postoperative analgesia. Further well-powered RCTs are needed to compare various infiltration regimens and agents. PROTOCOL REGISTRATION: PROSPERO (CRD42018103851) (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=103851).

Ondine's curse: anesthesia for laparoscopic implantation of a diaphragm pacing stimulation system.

PURPOSE: Central alveolar hypoventilation syndrome (CAHS) is a rare disease characterized by the loss of autonomic control of breathing. This condition causes hypoventilation and obstruction during sleep. Throughout their lives, these patients require ventilatory assistance by means of positive pressure ventilation to their lungs via mask, tracheotomy, or other means, such as phrenic nerve pacers. The diaphragm pacing stimulation system (DPSS) is a new treatment where electrodes are implanted into the diaphragm and cause contraction on stimulation. The DPSS has been used successfully in tetraplegic patients and patients suffering from amyotrophic lateral sclerosis (ALS). It has been shown to improve quality of life and to extend survival in patients with advanced respiratory muscle weakness. In our case, we describe the perioperative management of an adult patient with acquired CAHS who presented for laparoscopic DPSS insertion. CLINICAL FEATURES: Our patient was a 50-yr-old female who developed CAHS at age thirteen after contracting encephalitis. Since the onset of her disease, she had been managed with positive pressure ventilation to her lungs via mask. Due to her longstanding disease, she presented with pulmonary hypertension and cor pulmonale and was scheduled for laparoscopic DPSS implantation. Our anesthetic technique included a total intravenous technique with remifentanil and propofol, and her trachea was intubated without the use of muscle relaxants. The pacemakers were switched on when the patient emerged from anesthesia, which provided her with ventilatory support and allowed us to extubate her trachea. CONCLUSION: We present the successful anesthetic management of an adult patient with CAHS undergoing laparoscopic DPSS insertion.

Epigallocatechin-3-gallate induced modulation of cell deadhesion and migration on thermosensitive poly(N-isopropylacrylamide).

Epigallocatechin-3-gallate (EGCG), which is the main polyphenolic constituent of green tea, has emerged as a promising candidate for potential applications in selected anticancer therapeutics. Generally, tumor metastasis is known to be correlated with the alterations in cell adhesion and migration of normal cells. Nevertheless, the effect of EGCG on the biophysical responses of tumor cell adhering on extracellular matrix remains obscure. In this study, a thermosenstive poly(N-isopropylacrylamide) (PIPAAm) system was developed to elucidate the potential anti-tumor effect of EGCG on the deadhesion and migration of HepG2 cells. First, both XPS and ELISA validated the coating of laminin (LA) on PIPAAm. Second, a change of nanotopology of LA layer on PIPAAm across the lower solution critical temperature (LCST) was detected with AFM. HepG2 cells seeded on LA-coated PIPAAm surface was shown to go through deadhesion by lowering the temperature below the LCST. Interestingly, EGCG was shown to decelerate the thermally triggered deadhesion of HepG2 cell on LA coated PIPAAm. Moreover, the inhibition of cell deadhesion in EGCG treated cells was shown to be driven by actin remodeling. Interestingly, the modulation of cell deadhesion on LA coated PIPAAm by EGCG leads to the reduction of cell motility as shown by real-time cell migration assay. Overall, the use of PIPAAm system demonstrated the promise of EGCG as anticancer therapy through the suppression of cell deadhesion and migration.

Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study.

OBJECTIVE: The minimally invasive coronary artery bypass grafting (MICS CABG) operation performed via a small thoracotomy has not previously been examined in a direct comparison to sternotomy off-pump coronary artery bypass grafting (OPCAB). METHODS: We matched, according to age, gender, left ventricular function, and median number of distal anastomoses, 150 patients who underwent MICS CABG via small left thoracotomy, and 150 patients who received sternotomy OPCAB. All operations were performed by the same surgeon. RESULTS: There was no perioperative mortality (0/300). In the MICS CABG group, pump assistance was used in 28/150 (19%) patients, and conversion to sternotomy occurred in 10/150 (6.7%) patients. In the OPCAB group, conversion to on-pump occurred in 3/150 (2.0%) patients. There were four (2.7%) reoperations for bleeding and one (0.7%) for anastomotic revision in each group. The median hospital length of stay was 5 days for MICS CABG (average 5.4), and 6 days for OPCAB (average 7.2) (P=0.02). New-onset atrial fibrillation occurred in 35 (23%) MICS CABG patients and in 42 (28%) OPCAB patients (P=0.3). No wound infection occurred with MICS CABG versus six (4.0%) with OPCAB (P=0.03). A self-limiting left pleural effusion developed in 22 (15%) MICS CABG patients and in six (4.0%) OPCAB patients (P=0.002). The median time to return to full physical activity was 12 days in MICS CABG patients versus >5 weeks in OPCAB patients (P<0.001). CONCLUSIONS: MICS CABG is a valuable alternative for patients in need of multivessel CABG. The operation appears at least as safe as OPCAB, and associated with shorter hospital length of stay, less wound infections, and faster postoperative recovery than OPCAB.

Green tea attenuates cardiovascular remodelling and metabolic symptoms in high carbohydrate-fed rats.

Excess carbohydrate in the diet may initiate a chronic state of oxidative stress exacerbating the clinical and biochemical symptoms of diet-induced type 2 diabetes, especially glucose intolerance, lipid abnormalities and cardiovascular complications. This study has tested whether green tea, rich in antioxidants, improves both cardiovascular symptoms and glucose intolerance and also reduces oxidative stress in rats fed a high carbohydrate diet. Male 8 week old Wistar rats were fed a diet including fructose and condensed milk (each 40%) for 16 weeks (112 days); control rats were fed corn starch. Green tea-containing food was started from day 1 for the prevention protocol and from day 56 for the reversal protocol. High carbohydrate diet-fed rats showed glucose intolerance, hypertension, mild left ventricular hypertrophy, approximate doubling of cardiac interstitial and perivascular collagen deposition, increased passive diastolic stiffness and increased plasma malondialdehyde concentrations. Administration of green tea to high carbohydrate diet-fed rats prevented and reversed glucose intolerance and the increased systolic blood pressure, left ventricular wet weight, interstitial collagen and passive diastolic stiffness. Plasma malondialdehyde concentrations were also normalized. In summary, treatment with green tea both prevented and reversed the cardiovascular remodelling and metabolic changes seen in high carbohydrate-fed rats suggesting a chronic state of oxidative stress plays a key role in the symptom initiation and progression. Further, green tea may be a useful complementary therapy in diet-induced type 2 diabetes.

Impairment of human cell-based vasculogenesis in rats by hypercholesterolemia-induced endothelial dysfunction and rescue with L-arginine supplementation.

OBJECTIVE: Clinical efficacy of cardiac cell therapy may be compromised by its target population, patients with endothelial dysfunction. In vivo inhibition by endothelial dysfunction has been demonstrated for protein angiogenesis but remains unclear for cell therapy. We examined whether hypercholesterolemia inhibits vasculogenic effects of transplanted human circulating progenitor cells in ischemic tissue and whether L-arginine, a nitric oxide donor, might prevent impairment. METHODS: Athymic rats were fed either normal (group A) or high-cholesterol diets, the latter without (group B) or with (group C) oral L-arginine supplementation. Two weeks later, these rats underwent left femoral artery ligation followed by injection of 2 x 10(6) human circulating progenitor cells into left hind-limb muscle. A fourth group (group D) received supplemented high-cholesterol diets but no cells. RESULTS: Group B had biochemical evidence of endothelial dysfunction and reduced tissue endothelial nitric oxide synthase expression, whereas group A levels were the same as in group C. By 21 postoperative days, left hind-limb perfusion had recovered fully in groups A and C, partially in D, and not at all in B (38% lower than group A, P < or = .004). Lower arteriolar densities were found in groups and B and D than in groups A and C (P < or = .02). Engrafted human cell numbers were equivalent in all cell-transplanted groups after 3 weeks. CONCLUSIONS: Endothelial dysfunction inhibited effects of cell therapy, specifically vasculogenesis, suggesting a role for substrate modification to overcome this inhibition. Involved mechanisms appear related to use of cells but not engraftment and require further investigation.

Intraspinal techniques for pain management in cancer patients: a systematic review.

PURPOSE: This systematic review outlines current evidence regarding the effectiveness of intraspinal techniques for cancer pain and addresses practical implementation issues. METHODS: A search of electronic databases identified systematic reviews and randomized controlled trials (RCTs) evaluating the effectiveness of intraspinal techniques in the setting of cancer pain. An environmental scan was completed via the internet to identify practice guidelines and resource documents addressing organizational and implementation issues in the delivery of intraspinal analgesia. Elements reviewed included patient selection, contraindications, monitoring, aftercare, follow-up, hospital discharge equipment, health personnel, patient education, and safety. MAIN RESULTS: Three systematic reviews, three consensus conferences, and 12 RCTs met the inclusion criteria for evidence of effectiveness. No single systematic review or consensus conference included all relevant RCTs or specifically addressed the use of intraspinal techniques for cancer pain. Six RCTs compared intraspinal techniques alone or combined with other interventions alone or in combination, four compared different intraspinal medications, and two compared different intraspinal techniques. In general, the evidence supported the use of intraspinal techniques for cancer pain management. The two main indications consistently identified were intractable pain not controlled by other conventional medical routes and/or side effects from conventional pain management strategies preventing dose escalation. Reports indicate intraspinal analgesia is equally or more effective than conventional medical management and often associated with fewer side effects. Thirteen resource documents addressed issues surrounding the delivery of intraspinal analgesia and program implementation. CONCLUSIONS: Intraspinal techniques monitored by an interprofessional health care team should be included as part of a comprehensive cancer pain management program.

Concomitant treatment with oral L-arginine improves the efficacy of surgical angiogenesis in patients with severe diffuse coronary artery disease: the Endothelial Modulation in Angiogenic Therapy randomized controlled trial.

OBJECTIVE: Endothelial dysfunction and decreased nitric oxide bioavailability may explain why therapeutic angiogenesis and cell therapy have mostly failed in humans. Building from previous large animal work, the Phase I Endothelial Modulation in Angiogenic Therapy trial tested the hypothesis that L-arginine, a nitric oxide donor, may be safe and effective in potentiating surgical angiogenesis in humans. METHODS: Patients with surgical triple-vessel coronary disease and a severely diffusely diseased left anterior descending artery were randomized in 2 x 2 factorial fashion to receive ten 200-microg injections of vascular endothelial growth factor-165 plasmid DNA or placebo in the anterior myocardium along the proximal and mid-left anterior descending arteries, plus oral L-arginine supplementation at a dose of 6 g per day or placebo for 3 months. The distal left anterior descending artery and other coronary arteries were grafted. End points included 3-month changes in myocardial perfusion and contractility of the anterior myocardium, using (13)N-ammonia positron emission tomography and echocardiography. Baseline scans were obtained 3 to 7 days postoperatively to delineate treatment effects from the effects of coronary artery bypass grafting. RESULTS: Patient (N = 19) characteristics were equivalent between groups. There was no perioperative or late mortality. Patients who received the combination of vascular endothelial growth factor and L-arginine had improved anterior wall perfusion on positron emission tomography (P = .02), a trend toward smaller perfusion defects (P = .10), and better anterior wall contractility (P = .02, Kruskal-Wallis) at 3 months versus baseline. This was corroborated by a trend toward better disease perception at 3 months versus baseline on the Seattle Angina Questionnaire (score improvement of 47 +/- 35, combination treatment group; P = .1, Kruskal-Wallis). CONCLUSION: To our knowledge, this is the first study to examine concomitant substrate modification in patients undergoing new biosurgical therapies by using vascular endothelial growth factor angiogenesis. The results suggest safety and efficacy. Concomitant endothelial modulation with L-arginine not only has the potential to make angiogenesis effective but also may have implications for cell therapy trials.

The rationale for a multimodal approach in the management of breakthrough cancer pain: a review.

Breakthrough pain has been described differently in various countries, and not surprisingly, recommendations for its management vary according to the institution. Usually when breakthrough pain occurs, the patient's pain has already been managed according to the World Health Organization 3-step ladder for cancer pain. After this point, the treatment choice is usually based on clinical judgment, the physician's personal experience with interventional procedures, and local resources available. Opioids remain the mainstay of the management of breakthrough cancer pain. However, the combination of radio-oncology, adjuvant drugs, and interventional pain procedures can improve pain relief. This review addresses those questions and proposes a multimodal approach to manage breakthrough cancer pain.

Lactoferrin is a potent regulator of bone cell activity and increases bone formation in vivo.

Lactoferrin is an iron-binding glycoprotein present in epithelial secretions, such as milk, and in the secondary granules of neutrophils. We found it to be present in fractions of milk protein that stimulated osteoblast growth, so we assessed its effects on bone cell function. Lactoferrin produced large, dose-related increases in thymidine incorporation in primary or cell line cultures of human or rat osteoblast-like cells, at physiological concentrations (1-100 microg/ml). Maximal stimulation was 5-fold above control. Lactoferrin also increased osteoblast differentiation and reduced osteoblast apoptosis by up to 50-70%. Similarly, lactoferrin stimulated proliferation of primary chondrocytes. Purified, recombinant, human, or bovine lactoferrins had similar potencies. In mouse bone marrow cultures, osteoclastogenesis was dose-dependently decreased and was completely arrested by lactoferrin, 100 microg/ml, associated with decreased expression of receptor activator of nuclear factor-kappaB ligand. In contrast, lactoferrin had no effect on bone resorption by isolated mature osteoclasts. Lactoferrin was administered over calvariae of adult mice for 5 d. New bone formation, assessed using fluorochrome labels, was increased 4-fold by a 4-mg dose of lactoferrin. Thus, lactoferrin has powerful anabolic, differentiating, and antiapoptotic effects on osteoblasts and inhibits osteoclastogenesis. Lactoferrin is a potential therapeutic target in bone disorders such as osteoporosis and is possibly an important physiological regulator of bone growth.

Bioadhesive characterization of poly(methylidene malonate 2.12) microparticle on model extracellular matrix.

The efficacy of a drug delivery system is predicated on its retention in the target tissue. Microparticle is one of the most popular and effective drug delivery configurations. Recently, it has been shown that the interaction between drug-loaded microparticles and tissues is related to the effectiveness of paclitaxel delivery to the bladder wall of mice for treating superficial bladder cancer. In this study, the adhesive interaction between poly(methylidene malonate 2.12) or PMM 2.1.2 microparticles and collagen, which serves as the model extracellular matrix for bladder wall, was probed with confocal reflectance interference contrast microscopy (C-RICM), single-particle compressive force measurement and contact mechanics theory. Young's modulus of single PMM 2.1.2 microparticle was determined as 1.56 +/- 0.25 x 10(4)N/m(2). For plain PMM 2.1.2 microparticle in water (pH 5.5), the degree of deformation (a/R) on collagen coated substrate decreased from 0.77 to 0.26 against the increase of mid-plane diameter from 2 to 18 microm. The adhesion energy of PMM 2.1.2 microparticle was determined from Maguis-JKR theory and remained at around 1.5 mJ/m(2) against the increase of particle diameter. At pH 4, the average degree of particle deformation and adhesion energy was increased by 11% and 32%, respectively, in comparison with that at pH 5.5. The loading of paclitaxel in PMM 2.1.2 microspheres enhanced the deformation and adhesion of microspheres at pH 5.5. It is hypothesized that the electrostatic repulsion between paclitaxel and collagen at pH 4 reduces the adhesion energy of PMM 2.1.2-paclitaxel microsphere. This study may offer insight for design of future microparticulate delivery systems by providing the experimental and theoretical tools to study the bioadhesive interaction between drug-loaded microparticles and model extracellular matrices.