Study protocol of a sequential, multiple assignment, randomised trial using an adaptive intervention to reduce loneliness among Chinese older adults in Hong Kong.

BACKGROUND: Loneliness is a prevalent and alarming issue among older adults that requires effective interventions. While randomised controlled trials have been commonly undertaken to explore reduction in loneliness, there is a growing recognition that a comprehensive treatment strategy involving multiple interventions may yield better outcomes. Therefore, this study aims to develop and identify a two-stage adaptive intervention that combines telephone-delivered behavioural activation (Tele-BA) and mindfulness techniques (Tele-MF) to reduce loneliness in older adults in Hong Kong. METHODS: A Sequential, Multiple Assignment, Randomised Trial (SMART) design will be adopted. 244 lonely older adults will be recruited from the community and randomly assigned to either one of the 4-week two-stage, embedded adaptive interventions involving different sequences and dosages of Tele-BA and Tele-MF (eg, 4 weeks of Tele-BA followed by booster sessions for responders or 4 weeks of Tele-BA followed by 4 weeks of Tele-BA with motivational component or 4 weeks of Tele-MF for non-responders) based on a set of decision rules. The primary outcome will be loneliness measured by the Revised University of California Los Angeles (UCLA) Loneliness Scale. Secondary outcomes, such as De Jong Gierveld Loneliness Scale, perceived stress, sleep quality and depressive and anxiety symptoms, will be assessed. Adhering to the intention-to-treat principles, the data will be analysed using linear mixed models. The findings may have implications for the development of psychosocial adaptive interventions involving BA and MF to reduce loneliness and improve well-being among older adults in Hong Kong using the SMART design. ETHICS AND DISSEMINATION: Ethical approval was obtained by the Human Research Ethics Committee at The Education University of Hong Kong (reference: 2022-2023-0117). The findings from this study will be presented in academic conferences and submitted for publication. TRIAL REGISTRATION NUMBER: ChiCTR2300077472.

Effects of Wisdom-Enhancement Narrative-Therapy and Empathy-Focused interventions on loneliness over 4 weeks among older adults: A Randomized Controlled Trial.

OBJECTIVE: In this three-armed RCT, we tested the effects of a telephone-delivered wisdom enhancement narrative therapy-based intervention (Tele-NT) and a telephone-delivered empathy-focused intervention (Tele-EP) in reducing loneliness against an active control group that received regular call (ACG) at the 4-week follow-up assessment. DESIGN, SETTING, INTERVENTION, AND PARTICIPANTS: To evaluate the effects of the interventions on loneliness, we randomized 287 older adults based in Hong Kong, ages 65 to 90, into Tele-NT (N = 97), Tele-EP (N = 95), or ACG (N = 95). MEASUREMENT: The primary outcome was loneliness, calculated using the De Jong Gierveld Scale and the UCLA Loneliness Scale. Secondary outcomes were sleep quality, depressive symptoms, social network engagement, and perceived social support. Assessments were done before training and 4 weeks after the intervention period. RESULTS: Results from linear mixed models showed significant positive effects of Tele-NT on loneliness measured by the De Jong Gierveld Loneliness Scale compared to ACG. Compared to the ACG, the Tele-NT group significantly reduced loneliness at the 4-week follow-up (mean difference = -0.51, p = 0.019, Cohen's d = 0.60). However, the difference between Tele-EP and the ACG at the 4-week follow-up was not significant (MD = -0.34, p = 0.179, Cohen's d = 0.49). Tele-NT and Tele-EP did not show significant effects on the secondary outcomes, compared to the ACG. CONCLUSIONS: In this randomized clinical trial, we found that a 4-week wisdom enhancement narrative therapy program significantly reduced feelings of loneliness. This effective telephone-based, lay-therapist-delivered program is scalable for broader implementation.

Individualised Transcranial Magnetic Stimulation Targeting of the Left Dorsolateral Prefrontal Cortex for Enhancing Cognition: A Randomised Controlled Trial.

Repetitive transcranial magnetic stimulation (rTMS) has been demonstrated to produce cognitive enhancing effects across different neuropsychiatric disorders; however, so far, these effects have been limited. This trial investigated the efficacy of using a novel individualised approach to target the left dorsolateral prefrontal cortex (L-DLPFC) for enhancing cognitive flexibility based on performance on a cognitive task. First, forty healthy participants had their single target site at the L-DLPFC determined based on each individual's performance on a random letter generation task. Participants then received, in a cross-over single-blinded experimental design, a single session of intermittent theta burst stimulation (iTBS) to their individualised DLPFC target site, an active control site and sham iTBS. Following each treatment condition, participants completed the Task Switching task and Colour-Word Stroop test. There was no significant main effect of treatment condition on the primary outcome measure of switch reaction times from the Task Switching task [F = 1.16 (2, 21.6), p = 0.33] or for any of the secondary cognitive outcome measures. The current results do not support the use of our novel individualised targeting methodology for enhancing cognitive flexibility in healthy participants. Research into alternative methodological targeting approaches is required to further improve rTMS's cognitive enhancing effects.

Outcomes of Thumb Carpometacarpal Joint Osteoarthritis Treated with Arthroscopic Fusion.

Background The thumb carpometacarpal joint (CMCJ) osteoarthritis is one of the most common pathologies in the hand with controversial treatment options. Description of Technique Describe the use of arthroscopic technique for thumb CMCJ arthrodesis and the clinical outcome. Patients and Methods Cases with Eaton III thumb CMCJ osteoarthritis treated with arthroscopic arthrodesis were reviewed. Patient evaluations include: grip strength, pinch strength, range of motion, Kapandji score, Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and the visual analog scores for pain. All cases were assessed before the surgery and at 3, 6, 12, and 24 months after surgery. Radiographs were reviewed. Results There were total 16 patients with 18 arthrodesis performed. The average age was 62.2 years with M:F ratio of 2:7. The average follow-up time was 57.2 months. There was improvement of pain score as early as at postop 3 months ( p < 0.001) and continued to improve at 6, 12, and 24 months. There was improvement of grip strength and pinch strength at 12 and 24 months (p < 0.001). The DASH score showed improvement as early as at 3 months ( p = 0.012). There was a reduction of Kapandji score and interphalangeal joint motion at 3 months postop, but these returned to normal at 6 months. There was no major complication. There was one case of nonunion (5.6%). Conclusion Arthroscopic arthrodesis is a feasible treatment option and provides excellent pain relief, restore thumb strength and stability, retain functional thumb mobility, and hence improvement in hand function.

Cognitive Effects Following Offline High-Frequency Repetitive Transcranial Magnetic Stimulation (HF-rTMS) in Healthy Populations: A Systematic Review and Meta-Analysis.

High-frequency repetitive transcranial magnetic stimulation (HF-rTMS) is a commonly used form of rTMS to treat neuropsychiatric disorders. Emerging evidence suggests that 'offline' HF-rTMS may have cognitive enhancing effects, although the magnitude and moderators of these effects remain unclear. We conducted a systematic review and meta-analysis to clarify the cognitive effects of offline HF-rTMS in healthy individuals. A literature search for randomised controlled trials with cognitive outcomes for pre and post offline HF-rTMS was performed across five databases up until March 2022. This study was registered on the PROSPERO international prospective protocol for systematic reviews (PROSPERO 2020 CRD 42,020,191,269). The Risk of Bias 2 tool was used to assess the risk of bias in randomised trials. Separate analyses examined the cognitive effects of excitatory and inhibitory forms of offline HF-rTMS on accuracy and reaction times across six cognitive domains. Fifty-three studies (N = 1507) met inclusion criteria. Excitatory offline HF-rTMS showed significant small sized effects for improving accuracy (k = 46, g = 0.12) and reaction time (k = 44, g = -0.13) across all cognitive domains collapsed. Excitatory offline HF-rTMS demonstrated a relatively greater effect for executive functioning in accuracy (k = 24, g = 0.14). Reaction times were also improved for the executive function (k = 21, g = -0.11) and motor (k = 3, g = -0.22) domains following excitatory offline HF-rTMS. The current review was restricted to healthy individuals and future research is required to examine cognitive enhancement from offline HF-rTMS in clinical cohorts.

Actor-partner effects of wellbeing, hope and self-esteem on depression in stroke survivor-caregiver dyads: A randomized controlled trial.

BACKGROUND: Stroke is a disabling, long-term condition that challenges the mental and physical health of stroke-survivors concurrently with their primary family-caregivers (dyad). However, there has been a lack of emphasis on this dyadic need. Thus, this study aims to investigate the impacts of two interventions on hope, self-esteem and hedonic wellbeing on depression among the stroke-survivor-caregiver dyad. METHODS: This randomized-controlled-trial applied the actor-partner interdependence model to 100 randomly-selected dyads (N = 200) of stroke-survivors, mean (SD) age was 73.63(7.22) and family-caregivers, mean (SD) age was 62.49(14.44) years, recruited from Hong Kong hospitals and rehabilitation centres. The intervention was eight-weekly two-hour narrative therapy group sessions (n = 54 dyads), compared with the current model of psychoeducational group to each dyad as needed. Outcomes were collected via questionnaires and interviews, at four time-points: baseline (T1), during-intervention (T2) (1-month), immediately post-intervention (T3) (2-months) and follow-up (T4) (6-months). RESULTS: The results demonstrated that there are actor effects on stroke-survivors (ß = -0.353, p < 0.05) and caregivers (ß = -0.383, p < 0.05), where higher levels of hedonic wellbeing were associated with fewer depressive symptoms. Partner effects were observed as caregivers' depressive symptoms were possessing a significant negative relationship with stroke survivors' wellbeing (ß = -0.387, p < 0.05). Those stroke survivors in the intervention group had a significantly higher level of self-esteem associated with lower levels of depression (ß = -0.314, p < 0.05). CONCLUSIONS: Improving hope, self-esteem and wellbeing through narrative therapy significantly mediates depressive symptoms, strengthening the dyadic support of stroke survivors and family caregivers.

Fingertip Injuries in Mask Factory Workers during the COVID-19 Pandemic.

Background: The COVID-19 pandemic has caused a dramatic increase in the demand of face masks. The aim of this study is to look into the demographics, clinical details, clinical outcome and the risk factors for fingertip injuries in mask manufacturing factory workers. Methods: This is a retrospective review of all patients admitted to a regional hospital following a fingertip injury sustained at a mask making factory over a 6-month period from March 2020 to August 2020. Data with regard to gender, age, hand dominance, job position, injured finger, type of injury, mechanism of injury, treatment, clinical outcome (time to return to work), as well as risk factors for injuries (training before work, duration of work before injury, previous experience on working on similar machines, protective measures and working hours) were collected and analysed. Results: There were seven patients in total (M:F = 6:1) with a mean age of 38.4 years. Four patients had injuries on their dominant hands. The most commonly injured finger was the middle finger (n = 3). The most common injury pattern was fingertip amputation (n = 5). Five patients required operative management. Only four patients received training before work and six patients were injured within the first month of work. No patient had previous experience in operating similar machines. Long working hours is also a related risk factor. Conclusions: Better occupational safety and training should be employed to prevent these injuries. Level of Evidence: Level IV (Therapeutic).

Positive life stories of Stroke-Survivor's spousal caregiving in Hong Kong: Lessons for policy and practice.

BACKGROUND: Advances in medical-care for immediately post-stroke mean that many stroke-survivors now live a normal lifespan, although they may suffer residual disability. They are often cared for at home by their spouse, who may be ill-prepared for this task, and may also have health concerns. As demands on formal services increase with population aging in Hong Kong, equipping spousal-caregivers with positive effective caring strategies is increasingly important. OBJECTIVE: To understand what constitutes positive spousal-caregiving for stroke-survivors in Hong Kong within the cultural lens of 'Zhong (Loyalty)' METHOD: Naturalistic qualitative research was employed to hear stories about positive caregiving from Hong Kong couples living with stroke sequelae. Three in-depth face-to-face semi-structured interviews were undertaken with eleven dyads (stroke-survivor alone, spousal-caregiver alone, then the couple together). Data validation was by member-checking, further questions, and feedback at a second interview, and corroboration by field-notes. FINDINGS: A strength-based interactive model of positive spousal-caregiving was described, whose core tenet was Zhong (Loyalty). This fostered, and in turn was nurtured by, three paired key behaviours (1. Learning new skills linked with satisfaction when efforts paid off; 2. Utilizing formal and informal resources linked with supporting others; 3. Cherishing and bringing out the best linked with managing life- and self-care). Couples' capacity to develop these behaviours reflected their inner strengths. CONCLUSIONS: Couples who practiced positive caring and were resilient in the face of adversity were likely to optimise dyadic health and deal constructively with unexpected challenges. To address a looming shortfall between client need, and formal health and social services in Hong Kong, evidence-based policies are required to support effective, positive community-based spousal-caregiving.

Narrative Group Intervention to Rediscover Life Wisdom Among Hong Kong Chinese Older Adults: A Single-Blind Randomized Waitlist-Controlled Trial.

BACKGROUND AND OBJECTIVES: We developed a new group practice using strength- and meaning-based narrative therapy (NT) for older Chinese living in Hong Kong (HK), to enhance their life wisdom. This paper reports on the intervention and its short- and longer-term effectiveness. RESEARCH DESIGN AND METHODS: A randomized waitlist-controlled trial was conducted. A total of 157 older adults were randomly recruited, of whom 75 were randomly assigned to the intervention group which received four 2-hr biweekly NT sessions using the "Tree of Life" metaphor. The others were placed on a waitlist. Perceived wisdom was assessed using the Brief Self-Assessed Wisdom Scale. Assessment occurred at baseline (T0), end of treatment (T1), and 4 (T2) and 8 months later (T3). Overtime effects of NT on wisdom scores were assessed using latent growth curve models with time-invariant covariates for impact. RESULTS: The intervention (NT) group showed significant, sustainable overtime within-group improvement in perceived wisdom. Furthermore, when compared to the control group, the NT group showed significant immediate improvements in perceived wisdom [F(2.726, p = .041)], which were maintained at all follow-up points. This effect remained after controlling for age, gender, and educational level (T ML(11) = 17.306, p = .098, root mean square error of approximation = 0.079, comparative fit index = 0.960). No adverse reaction was recorded. DISCUSSION AND IMPLICATIONS: NT underpinned by a ToL methodology offers a new theory to understand, promote, and appreciate perceived wisdom in older Chinese living in HK. It contributes to psychotherapy and professional social work practice for older Chinese.

Treatment of Dangling-Type Thumb Polydactyly: Suture Ligation vs. Surgical Excision.

Background: To review the cases of dangling-type thumb polydactyly treated with suture ligation vs surgical excision. Methods: Cases of dangling-type thumb polydactyly treated in 2 different hospitals from 1994 to 2014 were recruited. Group 1 includes cases treated with suture ligation in hospital 1; Group 2 includes cases treated with surgical excision in hospital 2. The demographics data, early clinical outcomes and early complications were retrieved from clinical notes. All cases were contacted for a final assessment. Results: There were 23 cases recruited in group 1 and 26 cases recruited in group 2. The mean age at the time of procedure was 15.9 days (group 1) vs. 14 months (group 2). The infection rate was comparable in both groups (4.35% vs. 3.85%). 12 cases in group 1 and 14 cases in group 2 completed a final assessment. Residual tissue is common in group 1 (58.5%) and 4 cases (33.3%) required revision surgery. No case in group 2 had residual tissue and none require revision surgery. There was no painful neuroma in both groups and all patients achieved normal thumb and hand functions. The parental satisfaction score was 7.8 (group 1) and 8.8 (group 2) with no statistical difference (p = 0.061). Conclusions: Suture ligation and surgical excision are safe and effective treatment options for dangling-type thumb polydactyly. Both methods received comparable parental satisfaction. However, residual tissue is common after suture ligation while this problem is not observed after surgical excision.

Three Cases of Translunate Perilunate Injury Treated with Wrist Arthroscopy.

Background An acute fracture of the lunate is an uncommon injury with the reported incidence ranging from 0.5 to 1% of all carpal bone fractures. The combination of lunate fracture and perilunate injury is even rarer and Bain et al first introduced the "translunate arc concept" in 2008. We reported three cases of translunate perilunate injury treated with wrist arthroscopy. Materials and Methods All the three cases had been treated successfully with the use of wrist arthroscopy. A novel technique of arthroscopic reduction and fixation of a volar pole of lunate fracture was illustrated. The lunate fracture healed in all cases with normal carpal alignment. Results All patients achieved a painless and functional joint with good range of motion at an average follow-up of 15 months. There was no radiological evidence of avascular necrosis of the lunate in all three cases. Conclusion Translunate perilunate injury is rare and a high index of suspicion is necessary for diagnosis. There was no consensus on the surgical approach to this kind of injury. Wrist arthroscopy had proven to be successful in treating the greater and lesser arc perilunate injury. For translunate perilunate injury, wrist arthroscopy is also a feasible option with the advantages of lower risk of arthrofibrosis and avascular necrosis.

Neurovascular Island Flap for Pulp and Nail Augmentation in Thumb Duplication Reconstruction: A Surgical Method With Long-Term Follow-Up.

PURPOSE: Pulp and nail atrophy and asymmetry are commonly seen in thumb duplication. In hypoplasia of both digits, conventional reconstruction or Bilhaut-Cloquet procedure and its modifications may not be possible or may lead to a poor cosmetic outcome. The purpose of the study was to review a reconstruction technique with a neurovascular island flap developed to improve the aesthetic and functional results of treatment. METHODS: Fourteen patients with thumb duplication aged 8 to 18 months were operated between 2002 and 2013 in our center. All patients had significant hypoplasia and asymmetry of the pulp and nail of the digit planned to be retained. A neurovascular island flap including part of the pulp tissue, nail bed, with or without the associated phalangeal bone, was raised from the planned ablated digit base on its single neurovascular bundle. The nail bed, nail fold, and pulp tissue from the 2 digits were apposed with fine sutures under magnification. All patients were followed to monitor the aesthetic, functional, and radiological outcome. RESULTS: The mean follow-up period was 7 years, 11 months. Thirteen patients underwent the flap procedure and all flaps survived. In 1 patient, the flap procedure was aborted because the vascular pedicle was not well formed. The nail width and pulp circumference were restored to a similar size as the contralateral thumb. CONCLUSIONS: In selected cases of thumb duplication with significant pulp hypoplasia and nail asymmetry, the neurovascular island flap is a safe and effective means to restore size and symmetry. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Effects of strength-based intervention on health outcomes of family caregivers of persons with dementia: A study protocol.

AIMS: This study aims at identifying the health effects of a strength-based intervention on family caregivers of persons with dementia and to explore the underlying mechanism. The perception of family caregivers on the strength-based intervention will also be explored. DESIGN: This sequential mixed-method study comprises a double-blind randomized controlled trial and a descriptive qualitative study. METHODS: A group of 372 family caregivers of persons with dementia will be recruited from community settings. They will be randomized to receive the strength-based intervention or a dementia education program. Based on Antonovksy's theory of salutogenesis, the strength-based intervention integrates skills of narrative therapy and empowerment strategies. It comprises 14 weekly group-based sessions and two bi-weekly follow-up telephone calls. The education program serves as the control intervention. Validated instruments are used to measure sense of coherence, coping, caregiver burden, and health-related quality of life at baseline, 14 weeks, and 22 weeks. Mixed-effects models and path analysis will be used to identify the treatment effect and the mediating mechanism. A subsample of 30 caregivers who report differential changes in the health outcome will be engaged in qualitative interviews. The study was funded in 2017. DISCUSSION: This study marks the first attempt to adopt a theory-driven strength-based approach to improve the health outcomes of family caregivers of persons with dementia. The stringent and comprehensive evaluation will inform its effects and the underlying mechanism. IMPACT: This study will have important theoretical and public health implications. Theoretically, the study will enhance understanding of Antonovsky's theory of salutogenesis by examining the modifiability of sense of coherence and the way it enhances health-related outcomes. In terms of public health implications, the strength-based intervention focusing on optimizing the inner strength can provide a new paradigm to promote the adjustment of family caregivers of persons with dementia. TRIAL REGISTRATION: This project was registered in the Clinical Trials Registry of the Centre for Clinical Research and Biostatistics (registration number: CUHK_CCRB00551; date registered: 6 April 2017).

Type IIIB and IV hypoplastic thumb reconstruction with non-vascularized fourth metatarsal.

We treated 16 patients with 17 hypoplastic thumbs (eight Type IIIB and nine Type IV) using a non-vascularized fourth metatarsal transfer with a rotational flap and multi-staged reconstruction. The average age at the first operation was 24 months. The average follow-up time was 46 months. All patients achieved reasonable hand function and were able to use the reconstructed thumb to grip small and large objects. The operated thumb achieved an average Kapandji score of 6.7 and average pinch strength of 0.9 kg. There were two cases of graft nonunion. All parents are satisfied with the function and appearance of the reconstructed thumb and donor foot. We conclude that non-vascularized fourth metatarsal transfer is a feasible reconstruction method for patients with Types IIIB and IV hypoplastic thumbs. The reconstruction allows for the preservation of a 5-digit hand with reasonable function and appearance and minimal donor site morbidity, although long-term growth of the metatarsals still need to be monitored.Level of evidence: IV.

Functional Outcome for Arthroscopic Treatment of Septic Arthritis of the Wrist.

Background Septic arthritis is a potentially joint-destructing condition if not treated properly. Septic wrist accounts for ∼5% of all septic arthritis. Arthroscopic lavage is a well-documented treatment for septic arthritis of the knee, hip, or shoulder only. Previous studies on septic wrist were limited to case reports or retrospective studies focusing on open treatment, and functional outcome was seldom documented. Our study aims to evaluate the effectiveness of arthroscopic treatment and to investigate the functional outcome. Materials and Methods Patients were retrospectively reviewed over a period of 10 years. Parameters including age, gender, history of prior injury, duration of symptoms, joint aspirates and intraoperative tissue culture, radiological and arthroscopic findings, antibiotics used, number of operations, and hospital stay were reviewed. Functional outcomes were evaluated with QuickDASH (disabilities of the arm, shoulder, and hand) score. Results From 2007 to 2016, 14 patients (15 septic wrists) underwent arthroscopic surgery. One patient had bilateral involvement. The average age was 63.9 years and the average duration of symptoms was 6.08 days. Average follow-up time was 10 months. All except two patients (85.7%) responded to single arthroscopic treatment. Two required subsequent operations for concomitant tenosynovitis. There were no major complications. The most common isolated organism was Staphylococcus aureus . Only one case had severe joint erosion during follow-up. The average QuickDASH score was 19.7. Duration of symptoms 5 days or more before admission was associated with higher QuickDASH score ( p = 0.04). Conclusion Early arthroscopic treatment should be considered for all patients admitted for septic arthritis of the wrist if not contraindicated. Level of Evidence This is a Level III, retrospective review.

Development and Evaluation of the Psychometric Properties of a Brief Wisdom Development Scale.

This study was to develop an 18-item Brief Wisdom Development Scale, based on the original 66-item Wisdom Development Scale, and evaluate the psychometric properties of the proposed scale using a sample of older adults. This longitudinal study recruited 153 community-dwelling adults (mean = 72.55 years old; SD = 8.47) from older adult service centres. Using a repeated measures design, the study obtained four waves of data from the participants over 12 months. The Brief Wisdom Development Scale (BWDS) was developed based on the Stepwise Confirmatory Factor Analytical approach (SCOFA), with further verification of its factorial validity using confirmatory factor analysis (CFA). The results suggest that the BWDS comprising 18 items with a six-factor structure is comparable with its full version and possesses good psychometric properties in internal consistency, concurrent validity, and factorial validity. The BWDS provides an efficient, reliable, and valid construct to measure wisdom. The implications for research development are discussed here.

Development and validation of a brief self-assessed wisdom scale.

BACKGROUND: This longitudinal study aimed to develop a nine-item Brief Self-Assessed Wisdom Scale (BSAWS) derived from the original 40-item Self-Assessed Wisdom Scale (SAWS). METHODS: The psychometric properties of the shortened scale were evaluated based on a sample of 157 older adults. The factor structure and dimensionality of the original SAWS were examined using confirmatory factor analysis. Subsequent explorative factor analysis of the BSAWS supported the construct validity of the shortened scale. RESULTS: The internal consistency, convergent validity and construct validity of the shortened scale were also evaluated and the results indicated that the BSAWS possesses good psychometric properties and is comparable with the full version. CONCLUSIONS: This scale refinement may help researchers and practitioners conduct epistemological surveys or clinical research related to wisdom.

The role of meaning in life: mediating the effects of perceived knowledge of stroke on depression and life satisfaction among stroke survivors.

OBJECTIVE: Meaning-making is a way of coping when facing adverse events. A paucity of literature suggests other possible factors (e.g. delivery of knowledge) can influence how chronic illness survivors (i.e. stroke survivors in rehabilitation) cope with illness. This article explores the importance and significance of meaning in life as a mediator between perceived stroke knowledge and psychological wellbeing among stroke survivors and how such processes can be applied in practice to promote their psychological wellbeing. METHODS: A sample of N = 192 elderly aged 60 or above who experienced a recent stroke completed a survey to assess their levels of cognitive ability, physical function, perceived knowledge of stroke, meaning in life, life satisfaction, and depression. Correlation and mediation analyses using the Sobel test were conducted to clarify the role of meaning in life among stroke survivors. RESULTS: Both perceived knowledge of stroke ( r = 0.35, P < 0.001) and meaning in life had positive correlations with life satisfaction ( r = 0.37, P < 0.001) and a negative correlation with depression. Analyses revealed that meaning in life is a significant mediator between perceived knowledge of stroke and depression ( z = -3.71, P < 0.001) and between perceived knowledge of stroke and life satisfaction ( z = 3.97, P < 0.001) in two separate models. CONCLUSION: The role of meaning in life is clear and can affect the dynamics between knowledge of stroke and one's psychological wellbeing.

Narrative therapy an evaluated intervention to improve stroke survivors' social and emotional adaptation.

OBJECTIVE: To describe a theoretical and practical framework of using a train metaphor in narrative therapy for stroke rehabilitation in group practice. BACKGROUND: There is a paucity of literature on the application of narrative therapy in meeting the psycho-social-spiritual needs of stroke survivors in rehabilitation. In the current article, the use of narrative therapy being evaluated in a formal randomized study in stroke survivors is described in detail. The metaphor may be of practical interest to those working with populations confronted with unpredictable life challenges. METHOD: Narrative practice using the metaphor of 'Train of life' is an alternative practice to psychopathology, which provides a means for the participants to deconstruct from the illness experience, re-author their lives, and reconstruct their identity with hopes and dreams. This therapeutic conversations, primarily using questions, can be divided into six steps: (1) engaging participants to a Concord station; (2) unfolding the experience with Stroke: where each of the participants are coming from; (3) dialoging directly with Stroke; (4) co-constructing the train carriage; (5) planning for a future life journey with Stroke; and (6) celebrating the unlocking of a new journey. Along with the train of life metaphor, therapeutic documents and outsider witness conversations are used to strengthen the preferred identity, as opposed to the problem-saturated identity of the participants. DISCUSSION: This metaphor poses an alternative methodology in stroke rehabilitation by reconnecting the survivors' inner resources, skills, and competencies. Eventually, it could re-author the survivors' identity developed from previous life challenges and reconstruct their purpose in life.

Digital ischaemia: a rare but severe complication of jellyfish sting.

We report a case of digital ischaemia in a 31-year-old man who presented with sudden hand numbness, swelling, and cyanosis 4 days after a jellyfish sting. This is a rare complication of jellyfish sting, characterised by a delayed but rapid downhill course. Despite serial monitoring with prompt fasciotomy and repeated debridement, he developed progressive ischaemia in multiple digits with gangrenous change. He subsequently underwent major reconstructive surgery and aggressive rehabilitation. Although jellyfish stings are not uncommon, no severe jellyfish envenomation has been reported in the past in Hong Kong and there has not been any consensus on the management of such injuries. This is the first local case report of jellyfish sting leading to serious hand complications. This case revealed that patients who sustain a jellyfish sting deserve particular attention to facilitate early detection of complications and implementation of therapy.