Childhood Adversity, Resilience, and Mental Health: A Sequential Mixed-Methods Study of Chinese Young Adults.

Resilience is a key health protective factor for those with adverse childhood experiences (ACEs), but little research has explored how it manifests in early adulthood or across cultures. The purpose of this study was to generate a fuller understanding of resilience and its contribution to the relationships between mental health problems and ACEs among Chinese young adults in Hong Kong. Using a sequential explanatory mixed-methods design, 433 Chinese young adults aged 18 to 24 years were surveyed online to examine the relationships between ACEs, resilience, and mental health problems (depression, anxiety, maladjustment, and posttraumatic stress symptoms). Among them, 34 participants with ACEs were purposively selected and interviewed to explore cultural factors that influenced their resilience. Quantitative data were analyzed using multiple hierarchical regression analyses; qualitative data were analyzed using a qualitative descriptive approach. Higher cumulative ACE exposure was associated with higher severity of adjustment disorder and odds for screening positive for posttraumatic stress disorders, but not for symptoms of depression or anxiety. Resilience significantly contributed to explaining variances across all mental health outcomes over and beyond ACEs and in a protective fashion. Four themes emerged from qualitative interviews: (a) Privacy, emotional restraint, and "saving face"; (b) Conforming to preserve harmony; (c) A will to excel; and (d) Viewing adversity as a matter of luck. These findings suggest Chinese young adults' resilience was influenced by cultural norms of restraint, conformity, competition, and superstition. The present study provides a model for future studies using a mixed-methods design to deeply examine resilience among younger people exposed to early adversities within sociocultural, historical, or geographical contexts.

Knowledge and Perceptions of Child Protection and Mandatory Reporting: A Survey of Nurses in Hong Kong.

In the absence of a mandatory reporting (MR) structure, it is unclear how nurses perceive or exercise their role in child protection. This study examined knowledge and perceptions of child protection and MR among nurses working in Hong Kong. This cross-sectional web-based survey used the Child Abuse Report Intention Scale to measure nurses' child protection knowledge and attitudes, and their perceived norms, control, and intention to report suspected maltreatment. Nurses also indicated if they support MR and to provide an explanation for their preference. Quantitative data were described and analyzed using bivariate and regression analyses. Open-ended responses were analyzed using directed content analysis. A convenient sample of 91 nurses working in Hong Kong completed the survey. The majority (86%) were female with a mean of 9.5 years of nursing experience; their mean knowledge score was 6.64 out of 13 (range 2-10). Compared with other maltreatment types, sexual abuse was perceived to be most severe and most likely to be reported. Perceived severity and attitudes toward child maltreatment was significantly associated with nurses' intention to report. Over half (58%) supported MR; those against MR expressed concerns about lack of support from management. Although nurses working in Hong Kong still hold polarized views about MR, findings point to the importance of creating a supportive reporting culture, and designing training programs that focus on changing perceptions about child protection in order to improve their tendency to report.

Patterns of exposure to adverse childhood experiences and their associations with mental health: a survey of 1346 university students in East Asia.

INTRODUCTION: Adverse childhood experiences (ACEs) constitute a significant global mental health burden. Prior studies typically investigated the impact of ACEs on mental health using a cumulative risk approach; most ACEs studies were also conducted in Western settings. PURPOSE: This study aimed to examine ACEs using a pattern-based approach and assess their associations with mental health outcomes by early adulthood in East Asia. METHODS: The present study included measures of exposure to 13 categories of ACEs, depression, anxiety, maladjustment, and posttraumatic stress in a sample of 1346 university students from Hong Kong, China, Taiwan, and Japan. RESULTS: Latent class analysis indicated three distinct patterns of ACE exposure: Class 1: Low ACEs (76.0%); Class 2: Household Violence (20.6%); and Class 3: Household Dysfunction (3.4%). Those representing Class 3 had significantly more ACEs compared with those in Classes 1 or 2. Controlling for age and sex, those in Class 2 reported significantly higher depression and maladjustment symptoms compared with those in Class 1; both Classes 2 and 3 had significantly higher anxiety symptoms and odds for meeting diagnostic criteria for posttraumatic stress disorders compared with those in Class 1. CONCLUSIONS: Study findings suggest that young adults' mental health, at least under certain contexts, is more closely linked with the nature and pattern of ACE co-occurrence, rather than the number of ACEs.

Hepatitis B Vaccination in Patients Receiving Oral Antiviral Therapy Without Hepatitis B Immunoglobulin After Liver Transplant.

Our study aimed to determine if a double-dose pre-S containing hepatitis B virus (HBV) vaccination (Sci-B-Vac) could elicit an adequate and sustainable immune response in HBV patients who developed spontaneous hepatitis B surface antibody (anti-HBs) response after liver transplant. PATIENTS AND METHODS: All patients who received transplants for HBV-related disease for >1 year with normal graft function and hepatitis B surface antigen seronegativity were evaluated. They received a 40-µg HBV vaccine if they were responders in our previous vaccine trial, if anti-HBs was positive for >1 year after liver transplant (LT), or if a peak anti-HBs at any time point after LT was >100 mIU/mL. Primary endpoint was the development of anti-HBs ≥ 10 mIU/mL from previous negative value or a 1-log increase from baseline. RESULTS: A total of 86 patients were recruited; 5 were responders from a previous trial; 45 patients had detectable anti-HBs >1 year after LT, and 36 patients had an anti-HBs >100 mIU/mL. All (5/5, 100%) previous responders responded to booster vaccination. For the remaining 81 patients, 10 of 81 (12.3%) responded. CONCLUSION: All previous responders responded to booster vaccination, implying durability and memory of HBV immune response, which is an important prerequisite for definitive host immunity for HBV. In patients who had spontaneous anti-HBs production after LT, a single vaccination can induce response in 12.3% of patients.

Changing Paradigm in the Surgical Management of Hepatocellular Carcinoma With Salvage Transplantation.

OBJECTIVE: The objective of this study was to compare the long-term outcomes of primary and salvage liver transplantation for patients with hepatocellular carcinoma (HCC). METHOD: This was a 10-year retrospective analysis in a tertiary referral center. RESULTS: There were 184 patients recruited (primary liver transplantation [pLT]:salvage liver transplantation [sLT], 143:41). The median follow-up time was 79 months. Operation time was shorter in the pLT group than the sLT group (661 ± 164 minutes vs 754 ± 206 minutes; P = .01) and the blood loss was 3749 mL and 3545 mL for pLT and sLT, respectively (P = .735). The reoperation rate was 5.6% and 4.9%, respectively (P = 1.0). The 5-year overall and disease-free survival rates from the time of transplantation for pLT and sLT were 84.1% versus 70.2% (P = .01) and 82.2% versus 65.8% (P = .01), respectively. The 5-year overall survival rate from the time of primary treatment for sLT was 80.3% (P = .1). Subgroup analysis of sLT showed that young age (50 vs 56 year old; P = .004) was the only factor associated with poor overall survival. Young age (P = .004) and microvascular permeation (P = .008) in the recurrent tumor were associated with HCC recurrence. Young age stands out to be the only independent factor associated with HCC recurrence. CONCLUSION: sLT is the treatment of choice for patients with recurrent HCC in regions of graft shortage.

Randomized clinical trial of hepatic resection versus radiofrequency ablation for early-stage hepatocellular carcinoma.

BACKGROUND: Hepatic resection and radiofrequency ablation (RFA) are treatment options for early-stage hepatocellular carcinoma (HCC). Whether tumour recurrence and long-term survival favour either treatment has not been established. This randomized trial aimed to test the hypothesis that RFA is superior to hepatic resection in terms of lower tumour recurrence rate and better long-term survival. METHODS: Patients with early-stage HCC (solitary tumour no larger than 5 cm; or no more than 3 tumours, each 3 cm or smaller) were randomized into hepatic resection and RFA groups. Demographic and clinical characteristics, and short- and long-term outcome measures were compared between groups. Primary and secondary outcome measures were overall tumour recurrence and survival respectively. RESULTS: Clinicopathological data were similar in the two groups, which each contained 109 patients. The RFA group had a shorter treatment duration, less blood loss and shorter hospital stay than the resection group. Mortality and morbidity rates were similar in the two groups. The overall tumour recurrence rate was similar in the resection and RFA groups (71·3 versus 81·7 per cent respectively). The 1-, 3-, 5- and 10-year overall survival rates were 94·5, 80·6, 66·5 and 47·6 per cent respectively in the resection group, compared with 95·4, 82·3, 66·4 and 41·8 per cent in the RFA group (P = 0·531). Corresponding disease-free survival rates were 74·1, 50·9, 41·5 and 31·9 per cent in the resection group, and 70·6, 46·6, 33·6 and 18·6 per cent in the RFA group (P = 0·072). CONCLUSION: RFA for early-stage HCC is not superior to hepatic resection, in terms of tumour recurrence, overall survival and disease-free survival. Registration number: HKUCTR-10 (http://www.hkuctr.com).

Should ALPPS be Used for Liver Resection in Intermediate-Stage HCC?

BACKGROUND: Extended liver resections in patients with hepatocellular carcinoma (HCC) are problematic due to hepatitis, fibrosis, and cirrhosis. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has been promoted as a novel method to induce hypertrophy for patients with extensive colorectal liver metastases, but outcomes in HCC have not been well investigated. METHODS: All patients registered in the international ALPPS Registry ( www.alpps.org ) from 2010 to 2015 were studied. Hypertrophy of the future liver remnant, perioperative morbidity and mortality, age, overall survival, and other parameters were compared between patients with HCC and patients with colorectal liver metastases (CRLM). RESULTS: The study compared 35 patients with HCC and 225 patients with CRLM. The majority of patients undergoing ALPPS for HCC fall into the intermediate-stage category of the Barcelona clinic algorithm. In this study, hypertrophy was rapid and extensive for the HCC patients, albeit lower than for the CRLM patients (47 vs. 76 %; p < 0.002). Hypertrophy showed a linear negative correlation with the degrees of fibrosis. The 90-day mortality for ALPPS used to treat HCC was almost fivefold higher than for CRLM (31 vs. 7 %; p < 0.001). Multivariate analysis showed that patients older than 61 years had a significantly reduced overall survival (p < 0.004). CONCLUSION: The ALPPS approach induces a considerable hypertrophic response in HCC patients and allows resection of intermediate-stage HCC, albeit at the cost of a 31 % perioperative mortality rate. The use of ALPPS for HCC remains prohibitive for most patients and should be performed only for a highly selected patient population younger than 60 years with low-grade fibrosis.

Emergency aortic stent grafting for traumatic rupture of the thoracic aorta.

OBJECTIVE: To investigate the role of aortic stent grafting in emergency treatment of traumatic rupture of the descending thoracic aorta in patients with multiple injuries. DESIGN: Retrospective study. SETTING: Cardiothoracic surgery facility of a tertiary referral hospital, Hong Kong. PATIENTS: Between September 2001 and September 2002, four patients who had sustained a blunt injury to the chest after high-speed deceleration injury were recruited. Three patients were treated with stent grafting because concomitant head injury and multiple other injuries precluded the use of open thoracic surgery. One patient had no head injury and was offered stent grafting as a less invasive treatment. INTERVENTION: The pseudoaneurysm was covered with an aortic stent graft under fluoroscopic and angiographic guidance. MAIN OUTCOME MEASURES: Technical success of treatment, complications, and treatment outcome. RESULTS: Three patients recovered and were discharged from hospital. The computed tomography scan at 3 months to 6 months after surgery showed resolution of the pseudoaneurysm. The final patient was still in the hospital. Follow-up computed tomography 2 weeks later showed exclusion of the pseudoaneurysm. There was one external iliac artery thrombosis on the side of femoral arteriotomy, which was recanalised with thrombectomy. There was another unintentional partial coverage of the left subclavian artery, which was asymptomatic. No other major complication was present and there was no paraplegia after the stent grafting. CONCLUSION: Aortic stent graft is useful for emergency treatment of descending thoracic aortic injury. In the short term, it causes less morbidity and mortality than does open surgery, and can be life-saving when there is no surgical alternative. The long-term effect is still unknown.