Immediate postpartum cessation of tenofovir did not increase risk of virological or clinical relapse in highly viremic pregnant mothers with chronic hepatitis B infection.

Background & Aims: Peripartum prophylaxis (PP) with tenofovir disoproxil fumarate (TDF) is the standard of care to prevent mother-to-child transmission of chronic hepatitis B (CHB) infection in mothers who are highly viremic. We investigated the maternal and infant outcomes in a large Chinese cohort of TDF-treated CHB pregnant participants. Methods: In this prospective study, treatment-naive mothers with CHB and highly viremic (HBV DNA ≥200,000 IU/ml) but without cirrhosis were treated with TDF at 24-28 weeks of pregnancy. In accordance with Chinese CHB guidelines, TDF was stopped at delivery or ≥4 weeks postpartum. Serum HBV DNA and alanine aminotransferase were monitored every 6-8 weeks to determine virological relapse (VR). Infants received standard neonatal immunization, and HBV serology was checked at 7-12 months of age. Results: Among 330 participants recruited (median age 30, 82.7% HBeAg+, median HBV DNA 7.82 log IU/ml), TDF was stopped at delivery in 66.4% and at ≥4 weeks in 33.6%. VR was observed in 98.3%, among which 11.6% were retreated with TDF. Timing of TDF cessation did not alter the risk of VR (99.0 vs. 96.9%), clinical relapse (19.5 vs. 14.3%), or retreatment (12.6 vs. 10.1%) (all p > 0.05). A similar proportion of patients developed alanine aminotransferase flare five times (1.1 vs. 2.1%; p = 0.464) and 10 times (0.5 vs. 0%; p = 0.669) above the upper limit of normal (ULN) in the early withdrawal and late withdrawal groups, respectively. No infants developed HBsAg-positivity. Conclusions: PP-TDF and neonatal immunization were highly effective in preventing mother-to-child transmission of HBV in mothers who are highly viremic. Timing of cessation of PP-TDF did not affect the risk of VR or retreatment. Impact and Implications: In pregnant mothers with chronic hepatitis B infection who are started on peripartum tenofovir to prevent mother-to-child-transmission (MTCT), the optimal timing for antiviral withdrawal during the postpartum period remains unknown. This prospective study demonstrates that stopping tenofovir immediately at delivery, compared with longer treatment duration of tenofovir, did not lead to an increased risk of virological relapse, retreatment, or transmission of the virus to the baby. Shortening the duration of peripartum antiviral prophylaxis from 12 weeks to immediately after delivery can be considered. The immediate withdrawal of peripartum tenofovir, combined with standard neonatal immunization schemes, is 100% effective in preventing MTCT among pregnant mothers with CHB who are highly viremic, with a high rate of vaccine response in infants.

Effect of a Mobile Game-Based Intervention to Enhance Child Safety: Randomized Controlled Trial.

BACKGROUND: Evidence supports the effectiveness of serious games in health education, but little is known about their effects on the psychosocial well-being of children in the general population. OBJECTIVE: This study aimed to investigate the potential of a mobile game-based safety education program in improving children's safety and psychosocial outcomes. METHODS: Safe City is a mobile roleplaying game specifically designed to educate children in Hong Kong about safety. This randomized controlled trial included 340 children in grades 4 through 6. Intervention arm participants (n=170) were instructed to play the Safe City mobile game for 4 weeks, whereas control arm participants (n=170) received a safety booklet. All participants completed a survey on safety knowledge and behaviors and psychosocial problems at baseline (T1), 1 month postintervention (T2), and 3 months postintervention (T3). Cumulative game scores and mini-game performance were analyzed as a proxy for the extent of exposure to the game. Outcome data were analyzed using 2-sample 2-tailed t tests to compare mean change from T1 to T2 and to T3 for intervention versus control arm participants. The association of game use with outcome changes postintervention was analyzed using generalized additive models. RESULTS: No significant differences were found in mean changes between the intervention and control arms. However, use analyses showed that higher game scores were associated with improvements in safe behavior (P=.03) and internalizing problems (P=.01) at T3. Matching and Spot the Danger mini-game performance significantly predicted improvements in safety knowledge at T2 and T3. CONCLUSIONS: Analysis of use has shown that playing the Safe City mobile game can result in significant improvements in safety knowledge and reductions in unsafe behavior and internalizing problems. These findings provide evidence for the positive impact of serious games on psychological and social well-being, highlighting the potential of technology-driven interventions to assist children in learning about safety and preventing injuries. TRIAL REGISTRATION: ClinicalTrials.org NCT04096196; https://clinicaltrials.gov/show/NCT04096196. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/17756.

Association between birth weight and insulin resistance in US adolescents: A retrospective cohort study exploring the role of concurrent body mass index.

BACKGROUND AND AIMS: This study aimed to investigate the association between birth weight (BW) and abnormal HOMA-IR in US adolescents aged 12-15 years. The role of concurrent body mass index (BMI) in adolescence was also examined. METHODS AND RESULTS: This retrospective cohort study included 3429 participants from NHANES with data in 1999-2020. HOMA-IR ≥2.3 was considered abnormal. Participants were classified as low (LBW; <2.5 kg), normal (NBW; 2.5-4.0 kg), or high (HBW; >4.0 kg) BW. Logistic regression was used to explore the association between BW and HOMA-IR. Mediation analysis was used to examine whether BMI z-score in adolescence mediated the association between BW and HOMA-IR. Compared with those in NBW, the odds ratios (95 % CI) of abnormal HOMA-IR in LBW and HBW groups were 1.26 (0.99-1.60), and 0.62 (0.47-0.83) respectively. The association between BW and abnormal HOMA-IR was consistent in all subgroups with no significant interactions. Mediation analysis showed that BW is associated with lower risk of HOMA-IR directly, but with higher risk indirectly via BMI in adolescence. CONCLUSION: There was a negative linear relationship between BW and the prevalence of abnormal HOMA-IR in adolescents aged 12-15 independent of concurrent BMI. Children who were born with LBW but had high BMI in adolescence were of particularly higher risk of insulin resistance.

Improved neonatal outcomes by multidisciplinary simulation-a contemporary practice in the demonstration area of China.

Background: Simulation-based training improves neonatal resuscitation and decreases perinatal mortality in low- and middle-income countries. Interdisciplinary in-situ simulation may promote quality care in neonatal resuscitation. However, there is limited information regarding the effect of multidisciplinary in-situ simulation training (MIST) on neonatal outcomes. We aimed to investigate the impact of MIST on neonatal resuscitation in reducing the incidence of neonatal asphyxia and related morbidities. Methods: Weekly MIST on neonatal resuscitation has been conducted through neonatal and obstetrical collaboration at the University of Hong Kong-Shenzhen Hospital, China, since 2019. Each simulation was facilitated by two instructors and performed by three health care providers from obstetric and neonatal intensive care units, followed by a debriefing of the participants and several designated observers. The incidence of neonatal asphyxia, severe asphyxia, hypoxic-ischemic encephalopathy (HIE), and meconium aspiration syndrome (MAS) before (2017-2018) and after (2019-2020) the commencement of weekly MIST were analyzed. Results: There were 81 simulation cases including the resuscitation of preterm neonates of different gestational ages, perinatal distress, meconium-stained amniotic fluid, and congenital heart disease with 1,503 participant counts (225 active participants). The respective incidence of neonatal asphyxia, severe asphyxia, HIE, and MAS decreased significantly after MIST (0.64%, 0.06%, 0.01%, and 0.09% vs. 0.84%, 0.14%, 0.10%, and 0.19%, respectively, all P < 0.05). Conclusions: Weekly MIST on neonatal resuscitation decreased the incidence of neonatal asphyxia, severe asphyxia, HIE, and MAS. Implementation of regular resuscitation simulation training is feasible and may improve the quality of neonatal resuscitation with better neonatal outcomes in low- and middle-income countries.

Development and Validation of Indicators for Population Injury Surveillance in Hong Kong: Development and Usability Study.

BACKGROUND: Injury is an increasingly pressing global health issue. An effective surveillance system is required to monitor the trends and burden of injuries. OBJECTIVE: This study aimed to identify a set of valid and context-specific injury indicators to facilitate the establishment of an injury surveillance program in Hong Kong. METHODS: This development of indicators adopted a multiphased modified Delphi research design. A literature search was conducted on academic databases using injury-related search terms in various combinations. A list of potential indicators was sent to a panel of experts from various backgrounds to rate the validity and context-specificity of these indicators. Local hospital data on the selected core indicators were used to examine their applicability in the context of Hong Kong. RESULTS: We reviewed 142 articles and identified 55 indicators, which were classified into 4 domains. On the basis of the ratings by the expert panel, 13 indicators were selected as core indicators because of their good validity and high relevance to the local context. Among these indicators, 10 were from the construct of health care service use, and 3 were from the construct of postdischarge outcomes. Regression analyses of local hospitalization data showed that the Hong Kong Safe Community certification status had no association with 5 core indicators (admission to intensive care unit, mortality rate, length of intensive care unit stay, need for a rehabilitation facility, and long-term behavioral and emotional outcomes), negative associations with 4 core indicators (operative intervention, infection rate, length of hospitalization, and disability-adjusted life years), and positive associations with the remaining 4 core indicators (attendance to accident and emergency department, discharge rate, suicide rate, and hospitalization rate after attending the accident and emergency department). These results confirmed the validity of the selected core indicators for the quantification of injury burden and evaluation of injury-related services, although some indicators may better measure the consequences of severe injuries. CONCLUSIONS: This study developed a set of injury outcome indicators that would be useful for monitoring injury trends and burdens in Hong Kong.

A Family-Centered, Multidisciplinary Clinic for Early Diagnosis of Neurodevelopmental Impairment and Cerebral Palsy in China-A Pilot Observation.

Background: Comprehensive multidisciplinary assessment of neurodevelopmental outcomes of high-risk neonates may have significant challenges in low- and middle-income countries, in addition to socio-cultural barriers. We aimed to compare the time to diagnosis of neurodevelopmental impairment (NDI) and cerebral palsy (CP) in preterm neonates (<29 weeks) at a multidisciplinary assessment and care (MDAC) clinic with that of a conventional high-risk infant follow-up clinic in China. Methods: All eligible surviving very preterm neonates born at <29 weeks gestation at the University of Hong Kong-Shenzhen Hospital between January 2015 and December 2019 were followed up in conventional (2015-2017) and MDAC (2018-2020) clinics up to 2 years corrected age with clinical demographic information collected in a prospective database. The MDAC team used standardized developmental assessments. The rates and timing of diagnosing NDI and CP in two epochs were compared. Results: The rates of NDI and CP were not different in two epochs [NDI: 12 (50%) vs. 12 (41%); CP: 3 (12%) vs. 2 (7%) of 24 and 29 surviving infants assessed in conventional and MDAC clinics, respectively]. Infants in the MDAC clinic were diagnosed with NDI and CP earlier than those in the pre-MDAC epoch (6 vs. 14 months corrected age, respectively, P < 0.05). Conclusion: High-risk preterm neonates can be followed more effectively in a family-centered, child-friendly multidisciplinary clinic, leading to an earlier diagnosis of NDI and CP. Early counseling and interventions could be implemented accordingly.

Vulnerability and resilience in children during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is having a profound impact on the health and development of children worldwide. There is limited evidence on the impact of COVID-19 and its related school closures and disease-containment measures on the psychosocial wellbeing of children; little research has been done on the characteristics of vulnerable groups and factors that promote resilience. METHODS: We conducted a large-scale cross-sectional population study of Hong Kong families with children aged 2-12 years. Parents completed an online survey on family demographics, child psychosocial wellbeing, functioning and lifestyle habits, parent-child interactions, and parental stress during school closures due to COVID-19. We used simple and multiple linear regression analyses to explore factors associated with child psychosocial problems and parental stress during the pandemic. RESULTS: The study included 29,202 individual families; of which 12,163 had children aged 2-5 years and 17,029 had children aged 6-12 years. The risk of child psychosocial problems was higher in children with special educational needs, and/or acute or chronic disease, mothers with mental illness, single-parent families, and low-income families. Delayed bedtime and/or inadequate sleep or exercise duration, extended use of electronic devices were associated with significantly higher parental stress and more psychosocial problems among pre-schoolers. CONCLUSIONS: This study identifies vulnerable groups of children and highlights the importance of strengthening family coherence, adequate sleep and exercise, and responsible use of electronic devices in promoting psychosocial wellbeing during the COVID-19 pandemic.

Family-centered care management strategies for term and near-term neonates with brief hospitalization in a level III NICU in Shenzhen, China during the time of COVID-19 pandemic.

BACKGROUND: Adopting the family-centered care (FCC) approach in the neonatal care has been shown to improve breastfeeding rate and parental satisfaction. To minimize the transmission of COVID-19, family visit in neonatal intensive care unit (NICU) was suspended in China. In order to maintain the benefits of FCC, the Hong Kong University-Shenzhen Hospital NICU modified FCC strategies. We evaluated the effects of new strategies and aimed to share our results and experience with other NICUs during the COVID-19 pandemic. METHODS: Using prospectively collected hospital databases, we retrospectively compared the demographic and clinical data of neonates, rates of breastfeeding at discharge, nosocomial infection and parental satisfaction one month before (open group) and after (closed group) the implementation of alternative FCC management strategies when family visit was suspended during COVID-19 pandemic. RESULTS: During the COVID-19 pandemic, we organized a multidisciplinary task force and adopted strategies of triage and screening, management of suspected infants, and breastfeeding promotion with effective communication. The nosocomial infection rate and parental satisfaction for open and closed groups (144 and 108 term and near-term neonates with brief hospitalization, respectively) were not different (1% vs. 0%, p = 1.00; 98.6 vs. 98.8, p = .80; respectively). Breastfeeding rate at discharge decreased but the difference was not significant (74% vs. 80%, p = .29). CONCLUSIONS: In our experience, in term and near-term neonates with brief hospitalization, the alternative FCC strategies maintained high parental satisfaction without increased nosocomial infection rate, but strong support for breastfeeding was needed. Through multidisciplinary collaboration, the continuation of "modified" FCC in a level III NICU is feasible in the context of COVID-19 pandemic with reduced family visitation and participation in the care.

CTNNB1-related neurodevelopmental disorder in a Chinese population: A case series.

CTNNB1-related disorder is an autosomal dominant neurodevelopmental disorder characterized by a variable degree of cognitive impairment, microcephaly, truncal hypotonia, peripheral spasticity, visual defects, and dysmorphic features. In this case series, we report the clinical and molecular findings of nine Chinese patients affected by CTNNB1-related disorders. The facial features of these affected individuals appear to resemble what had been previously described, with thin upper lip (77.8%) and hypoplastic alae nasi (77.8%) being the most common. Frequently reported clinical characteristics in our cohort include developmental delay (100%), peripheral spasticity (88.9%), truncal hypotonia (66.7%), microcephaly (66.7%), and dystonia (44.4%). While various eye manifestations were reported, two affected individuals (22.2%) in our cohort had familial exudative vitreoretinopathy. One of the affected individuals had craniosynostosis, a feature not reported in the literature before. To our knowledge, this is the first reported Chinese case series of CTNNB1-related neurodevelopmental disorders. Further studies are required to look into whether ethnic differences play a role in phenotypic variations.

The estimated age-group specific influenza vaccine coverage rates in Hong Kong and the impact of the school outreach vaccination program.

Previous studies have shown that seasonal influenza strikes annually causing millions to fall sick and several hundred thousand to die globally. Hence, universal vaccination is a public health aim to control influenza. The Hong Kong Government started to introduce the School Outreach Vaccination (SOV) program in 2018 to increase vaccination rates in children. This study looked at the impact this had on hospital admissions and estimated vaccination rates in the total population, using a questionnaire-based tool. The SOV program significantly increased vaccination coverage rates with a 1% increase associated with a reduction of 4.3 influenza-related hospital admissions of school-aged children. The estimation of vaccine coverage rates among the under 5-year olds (48.5%), primary school children (69.3%) and over 65-year olds (45.7%), through the questionnaire-based tool, was within the 95% confidence interval of the coverage rates published by the Center for Health Protection of the Hong Kong Government, 47.4%, 68.1% and 45.8%, respectively. Extension of the SOV program should be considered in secondary schools to increase the coverage rates in adolescents. The questionnaire survey may inform government how to achieve universal vaccination for specific age groups.

Epidemiology of Acute Myocarditis/Pericarditis in Hong Kong Adolescents Following Comirnaty Vaccination.

BACKGROUND: Age-specific incidence of acute myocarditis/pericarditis in adolescents following Comirnaty vaccination in Asia is lacking. This study aimed to study the clinical characteristics and incidence of acute myocarditis/pericarditis among Hong Kong adolescents following Comirnaty vaccination. METHODS: This is a population cohort study in Hong Kong that monitored adverse events following immunization through a pharmacovigilance system for coronavirus disease 2019 (COVID-19) vaccines. All adolescents aged between 12 and 17 years following Comirnaty vaccination were monitored under the COVID-19 vaccine adverse event response and evaluation program. The clinical characteristics and overall incidence of acute myocarditis/pericarditis in adolescents following Comirnaty vaccination were analyzed. RESULTS: Between 14 June 2021 and 4 September 2021, 33 Chinese adolescents who developed acute myocarditis/pericarditis following Comirnaty vaccination were identified. In total, 29 (87.88%) were male and 4 (12.12%) were female, with a median age of 15.25 years. And 27 (81.82%) and 6 (18.18%) cases developed acute myocarditis/pericarditis after receiving the second and first dose, respectively. All cases are mild and required only conservative management. The overall incidence of acute myocarditis/pericarditis was 18.52 (95% confidence interval [CI], 11.67-29.01) per 100 000 persons vaccinated. The incidence after the first and second doses were 3.37 (95% CI, 1.12-9.51) and 21.22 (95% CI, 13.78-32.28 per 100 000 persons vaccinated, respectively. Among male adolescents, the incidence after the first and second doses were 5.57 (95% CI, 2.38-12.53) and 37.32 (95% CI, 26.98-51.25) per 100 000 persons vaccinated. CONCLUSIONS: There is a significant increase in the risk of acute myocarditis/pericarditis following Comirnaty vaccination among Chinese male adolescents, especially after the second dose.

An Internet Quiz Game Intervention for Adolescent Alcohol Drinking: A Clustered RCT.

BACKGROUND AND OBJECTIVES: Interventions on adolescent drinking have yielded mixed results. We assessed the effectiveness of an Internet quiz game intervention compared to conventional health education. METHODS: In this cluster randomized controlled trial with parallel group design, we randomly allocated 30 participating schools to the Internet quiz game intervention or the conventional health education (comparison) group, with 1:1 ratio. Students of Hong Kong secondary schools (aged 12-15 years) were recruited. The intervention was a 4-week Web-based quiz game competition in which participating students answered 1000 alcohol-related multiple-choice quiz questions. The comparison group received a printed promotional leaflet and hyperlinks to alcohol-related information. RESULTS: Of 30 eligible schools, 15 (4294 students) were randomly assigned to the Internet quiz game intervention group and 15 (3498 students) to the comparison group. Average age of participants was 13.30 years. No significant between-group differences were identified at baseline. Overall retention rate for students was 86.0%. At 1-month follow-up, fewer students in the intervention group reported drinking (9.8% vs 12.1%, risk ratio 0.79, 95% confidence interval [CI] 0.68 to 0.92; P = .003), and those who drank reported drinking less alcohol (standardized difference ß -0.06, 95% CI -0.11 to -0.01; P = .02). Between-group differences remained statistically significant at 3-month follow-up (10.4% vs 11.6%, risk ratio 0.86, 95% CI 0.74 to 0.999; P = .048; ß -0.06, 95% CI -0.11 to -0.01; P = .02). CONCLUSIONS: The Internet quiz game intervention reduced underage drinking by 21% at 1-month and 14% at 3-month follow-up compared with conventional health education.

Clinical Characteristics and Transmission of COVID-19 in Children and Youths During 3 Waves of Outbreaks in Hong Kong.

Importance: Schools were closed intermittently across Hong Kong to control the COVID-19 outbreak, which led to significant physical and psychosocial problems among children and youths. Objective: To compare the clinical characteristics and sources of infection among children and youths with COVID-19 during the 3 waves of outbreaks in Hong Kong in 2020. Design, Setting, and Participants: This cross-sectional study involved children and youths aged 18 years or younger with COVID-19 in the 3 waves of outbreaks from January 23 through December 2, 2020. Data were analyzed from December 2020 through January 2021. Main Outcomes and Measures: Demographic characteristics, travel and contact histories, lengths of hospital stay, and symptoms were captured through the central electronic database. Individuals who were infected without recent international travel were defined as having domestic infections. Results: Among 397 children and youths confirmed with COVID-19 infections, the mean (SD) age was 9.95 (5.34) years, 220 individuals (55.4%) were male, and 154 individuals (38.8%) were asymptomatic. There were significantly more individuals who were infected without symptoms in the second wave (59 of 118 individuals [50.0%]) and third wave (94 of 265 individuals [35.5%]) than in the first wave (1 of 14 individuals [7.1%]) (P = .001). Significantly fewer individuals who were infected in the second and third waves, compared with the first wave, had fever (first wave: 10 individuals [71.4%]; second wave: 22 individuals [18.5%]; third wave: 98 individuals [37.0%]; P < .001) or cough (first wave: 6 individuals [42.9%]; second wave: 15 individuals [12.7%]; third wave: 52 individuals [19.6%]; P = .02). Among all individuals, 394 individuals (99.2%) had mild illness. One patient developed chilblains (ie, COVID toes), 1 patient developed multisystem inflammatory syndrome in children, and 1 patient developed post-COVID-19 autoimmune hemolytic anemia. In all 3 waves, 204 patients with COVID-19 (51.4%) had domestic infections. Among these individuals, 186 (91.2%) reported having a contact history with another individual with COVID-19, of which most (183 individuals [90.0%]) were family members. In the third wave, 18 individuals with domestic infections had unknown contact histories. Three schoolmates were confirmed with COVID-19 on the same day and were reported to be close contacts. Conclusions and Relevance: This cross-sectional study found that nearly all children and youths with COVID-19 in Hong Kong had mild illness. These findings suggest that household transmission was the main source of infection for children and youths with domestic infections and that the risk of being infected at school was small.

Quantification of injury burden using multiple data sources: a longitudinal study.

Quantification of injury burden is vital for injury prevention, as it provides a guide for setting policies and priorities. This study generated a set of Hong Kong specific disability weights (DWs) derived from patient experiences and hospital records. Patients were recruited from the Accident and Emergency Department (AED) of three major trauma centers in Hong Kong between September 2014 and December 2015 and subsequently interviewed with a focus on health-related quality of life at most three times over a 12-month period. These patient-reported data were then used for estimation of DWs. The burden of injury was determined using the mortality and inpatient data from 2001 to 2012 and then compared with those reported in the UK Burden of Injury (UKBOI) and global burden of diseases (GBD) studies. There were 22,856 mortality cases and 817,953 morbidity cases caused by injuries, in total contributing to 1,027,641 disability-adjusted life years (DALYs) in the 12-year study timeframe. Estimates for DALYs per 100,000 in Hong Kong amounted to 1192, compared with 2924 in UKBOI and 3459 in GBD. Our findings support the use of multiple data sources including patient-reported data and hospital records for estimation of injury burden.

Risk of Child Maltreatment in Chinese Teenage and Young Mothers With Rapid Repeat Pregnancy: The Moderating Role of Family Cohesion and Support From Friends.

Rapid repeat pregnancy (RRP) often occurs in teenage and young mothers. Mothers with a history of RRP are more likely to experience high stress increasing their risk of child maltreatment. Despite these challenges, some mothers can continue to cope adaptively. Social support may play a role in empowering these mothers to overcome the childbearing difficulties. Although the protective effects of social support are well recognized, there has been little evidence on the relative importance of sources of support. For example, whether support from family and friends is equally important in relieving parenting stress remains unanswered. RRP, a social phenomenon encompassing various adverse living and parenting issues, provides an ideal research context to investigate the role of family and friends in preventing child maltreatment. This study examined whether family cohesion and friends' support moderated the association between RRP and child maltreatment in young mothers. We recruited 392 Chinese teenage and young mothers from a population-based integrated young mothers supporting program in Hong Kong. Questionnaires on pregnancy history, family cohesion, social support, and risk of child maltreatment were administered. Moderation analysis was conducted to examine the effect of RRP on child maltreatment as a function of family cohesion or friend support. Results showed that RRP was associated with a higher risk of child neglect (adjusted odds ratio [aOR] = 1.72, p < .05) and physical maltreatment (aOR = 1.91, p < .01), and that family cohesion was more important than friend support in mitigating the risk of child maltreatment for mothers with a history of RRP. Our findings suggest that interventions for young mothers, particularly those with a history of RRP, should be family-based so the whole family can be empowered to tackle the childrearing burden.

Disentangling the Effects of Exposure to Maternal Substance Misuse and Physical Abuse and Neglect on Child Behavioral Problems.

There is inconsistent evidence on the association between prenatal substance exposure and child behavioral problems. Children affected by maternal substance misuse are vulnerable to physical abuse and neglect. Few studies have examined factors contributing to internalizing and externalizing problems in these children. This study, with a focus on children with prenatal substance exposure, investigated whether family characteristics (the duration of maternal substance misuse postpartum or the existence of a sibling) moderated the association between adverse exposure (physical abuse or neglect) and behavior (internalizing or externalizing problems). We recruited 54 Hong Kong Chinese mothers with registered records of substance misuse during pregnancy and their children (2-9 years). Mothers completed questionnaires on drug use patterns during pregnancy and postpartum, abusive and neglectful parenting behaviors in the preceding year, and children's current behavioral problems. Moderated regression analyses tested whether abusive and neglectful parenting behavior interacted with family characteristics to affect child behavioral problems. The existence of a sibling moderated the relationship between neglect experience and internalizing problems, with a positive relationship observed only among single children (adjusted B [95% confidence interval] = 3.70 [0.98, 6.41], p = .012). The duration of maternal substance misuse postpartum moderated the relationship between physical abuse experience and externalizing problems, with a positive relationship observed only among children of mothers abusing substances beyond the child's infancy period (adjusted B [95% confidence interval] = 6.86 [2.34, 11.38], p = .008). The results show that the impact of physical abuse and neglect experiences depend on the type of behavior assessed and family and child characteristics. Positive sibling relationship and early detoxification in the mother can foster healthy behavioral development for children exposed prenatally to maternal substance misuse.

Early Risk Factors for Retinopathy of Prematurity in Very and Extremely Preterm Chinese Neonates.

Objective: To investigate the incidence and risk factors of retinopathy of prematurity (ROP) in very and extremely preterm (28+0- <32+0, and <28+0 weeks gestation, respectively) neonates, and the predictive factors for ROP in the early hours after birth and during hospitalization. Methods: Using a prospective database supplemented with a retrospective chart review, we identified preterm neonates born at gestation <32 weeks at the University of Hong Kong-Shenzhen Hospital between January 2015 and August 2018. Demographic and clinical variables were studied including indicators of disease acuity in the first 24 h after birth. We also compared the difference in risk factors between survivors with ROP and survivors without ROP. Results: During the study period, there were 529 preterm neonates admitted to our neonatal intensive care unit with 120 (23%) born at <32 weeks' gestation. Thirteen (11%) neonates died. Among the 107 survivors, 23 (21%) had ROP, of whom five (22%) received laser and/or medical therapy for severe ROP. Compared with survivors without ROP, infants with ROP had lower mean blood pressure in the first 12 and 24 h after birth, respectively. Using multivariate regression, gestation age, mean blood pressure in the first 12 h after birth, hospital length of stay, and total days of blood gases pH <7.2 were independent risk factors for ROP. Conclusions: In this small cohort of Chinese neonates born <32+0 weeks' gestation, survivors with ROP had a lower blood pressure in the early hours after birth, younger gestation, longer hospital stay, and duration of acidosis when compared to those without ROP.

COVID-19 in children across three Asian cosmopolitan regions.

ABSTRACT As another wave of COVID-19 outbreak has approached in July 2020, a larger scale COVID-19 pediatric Asian cohort summarizing the clinical observations is warranted. Children confirmed with COVID-19 infection from the Republic of Korea, the Hong Kong Special Administrative Region (HKSAR) and Wuhan, China, during their first waves of local outbreaks were included. Their clinical characteristics and the temporal sequences of the first waves of local paediatric outbreaks were compared. Four hundred and twenty three children with COVID-19 were analyzed. Wuhan had the earliest peak, followed by Korea and HKSAR. Compared with Korea and Wuhan, patients in HKSAR were significantly older (mean age: 12.9 vs. 10.8 vs. 6.6 years, p < 0.001, respectively) and had more imported cases (87.5% vs. 16.5% vs. 0%, p < 0.001, respectively). The imported cases were also older (13.4 vs. 7.6 years, p < 0.001). More cases in HKSAR were asymptomatic compared to Korea and Wuhan (45.5% vs. 22.0% vs. 20.9%, p < 0.001, respectively), and significantly more patients from Wuhan developed fever (40.6% vs. 29.7% vs. 21.6%, p=0.003, respectively). There were significantly less imported cases than domestic cases developing fever after adjusting for age and region of origin (p = 0.046). 5.4% to 10.8% of patients reported anosmia and ageusia. None developed pediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PMIS-TS). In general, adolescents were more likely to be asymptomatic and less likely to develop fever, but required longer hospital stays. In conclusion, majority patients in this pediatric Asian cohort had a mild disease. None developed PIMS-TS. Their clinical characteristics were influenced by travel history and age.

A Mobile Game (Safe City) Designed to Promote Children's Safety Knowledge and Behaviors: Protocol for a Randomized Controlled Trial.

BACKGROUND: Children have high levels of curiosity and eagerness to explore. This makes them more vulnerable to danger and hazards, and they thus have a higher risk of injury. Safety education such as teaching safety rules and tips is vital to prevent children from injuries. Although game-based approaches have the potential to capture children's attention and sustain their interest in learning, whether these new instructional approaches are more effective than traditional approaches in delivering safety messages to children remains uncertain. OBJECTIVE: The aim of this study is to test the effectiveness of a game-based intervention in promoting safety knowledge and behaviors among Hong Kong school children in Grades 4-6. It will also examine the potential effect of the game-based intervention on these children's functioning and psychosocial difficulties. METHODS: This study comprises the development of a city-based role-playing game Safe City, where players are immersed as safety inspectors to prevent dangerous situations and promote safety behavior in a virtual city environment. The usability and acceptability tests will be conducted with children in Grades 4-6 who will trial the gameplay on a mobile phone. Adjustments will be made based on their feedback. A 4-week randomized controlled trial with children studying in Grades 4-6 in Hong Kong elementary schools will be conducted to assess the effectiveness of the Safe City game-based intervention. In this trial, 504 children will play Safe City, and 504 children will receive traditional instructional materials (electronic and printed safety information). The evaluation will be conducted using both child self-report and parent proxy-report data. Specifically, child safety knowledge and behaviors will be assessed by a questionnaire involving items on knowledge and behaviors, respectively, for home safety, road safety, and sport-related safety; child functioning will be assessed by PedsQL Generic Core Scales; and psychosocial difficulties will be assessed by the Strength and Difficulties Questionnaire. These questionnaires will be administered at 3 time points: before, 1 month, and 3 months after the intervention. Game usage statistics will also be reviewed. RESULTS: This project was funded in September 2019. The design and development of the Safe City game are currently under way. Recruitment and data collection will begin from September 2020 and will continue up to March 1, 2021. Full analysis will be conducted after the end of the data collection period. CONCLUSIONS: If the Safe City game is found to be an effective tool to deliver safety education, it could be used to promote safety in children in the community and upgraded to incorporate more health-related topics to support education and empowerment for the larger public. TRIAL REGISTRATION: ClinicalTrials.gov NCT04096196; https://clinicaltrials.gov/ct2/show/NCT04096196. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/17756.

Geographical accessibility of community social services and incidence of self-harm.

OBJECTIVE: The study aimed to explore the association between area-based coverage of community services and the incidence of self-harm, which will provide an evaluation framework for the support of self-harm. METHODS: Enhanced two-Step floating catchment area method was used to estimate the centersto- population ratio and geographical accessibility adjusted by a distance-decay function. Spearman's rank coefficient was used to examine the association between the self-harm rate and adjusted accessibility index. RESULTS: There was a significant negative correlation between the accessibility index and selfharm rate in youth (rho = -0.87, P < 0.01) and older adults (rho = -0.87, P < 0.01). The survival curves showed no relationship between self-harm repetition and service accessibility in youth or older adults. CONCLUSIONS: The uneven spatial accessibility of community social service centers and the independence between spatial accessibility and self-harm highlights the need to explore personal barriers to community service utilization.