Virtual Multidisciplinary Stroke Care Clinic for Community-Dwelling Stroke Survivors: A Randomized Controlled Trial.

BACKGROUND: Stroke survivors constantly feel helpless and unprepared after discharge from hospitals. More flexible and pragmatic support are needed for their optimized recovery. We examined the effects of a virtual multidisciplinary stroke care clinic on survivors' health and self-management outcomes. METHODS: A randomized controlled trial was conducted. Survivors were recruited from 10 hospitals and randomized at 1:1 ratio into the intervention or the control groups. Intervention group participants received the Virtual Multidisciplinary Stroke Care Clinic service (monthly online consultations with a nurse, follow-up phone calls, and access to an online platform). Control group participants received the usual care. Outcomes of self-efficacy (stroke self-efficacy questionnaire; primary), self-management behaviors (Stroke Self-Management Behaviors Performance Scale), social participation (reintegration to normal living index), and depression (Geriatric Depression Scale; secondary) were measured at baseline, and 3 and 6 months after commencing the intervention (post-randomization). A generalized estimating equations model was used to compare the differential changes in outcomes at 3 and 6 months with respect to baseline between 2 groups. RESULTS: Between July 2019 and June 2022, 335 eligible participants were enrolled in the study. Participants (intervention group; n=166) showed significantly greater improvements in outcomes of self-efficacy (group-by-time interaction regression coefficient, B=4.60 [95% CI, 0.16 to 9.05]), social participation (B=5.07 [95% CI, 0.61 to 9.53]), and depression (B=-2.33 [95% CI, -4.06 to -0.61]), and no significant improvement in performance of self-management behaviors (B=3.45, [95% CI, -0.87 to 7.77]), compared with the control group (n=169) right after the intervention (6 months after its commencement). Hedges' g effect sizes of the intervention on outcomes: 0.19 to 0.36. CONCLUSIONS: The results provide some positive evidence on the usefulness of the Virtual Multidisciplinary Stroke Care Clinic service. The effect sizes are regarded as small to medium, which may not be of clinical relevance. The baseline levels in outcomes were in favor of the control group, the intervention effects might be overestimated. The service must be tested further to determine its effectiveness. REGISTRATION: URL: https://www.chictr.org.cn; Unique identifier: ChiCTR1800016101.

Provision of a personalized survivorship care plan and its impact on cancer-related health literacy among childhood cancer survivors in Hong Kong.

PURPOSE: To evaluate the short-term effectiveness of a personalized survivorship care plan (SCP) in improving cancer-related literacy among childhood cancer survivors, and to identify characteristics of survivors who demonstrated minimal gain from the intervention. METHODS: We recruited survivors diagnosed with cancer at ≤18 years old and were >2 years post treatment. The intervention included a personalized SCP and 30-minute health risk counseling. The participants' knowledge of their cancer diagnosis and potential treatment-related late effects (LEs) was assessed at baseline, immediately post intervention, and 1-3 months post intervention. Generalized estimating equation was used to test for changes in the awareness scores, with interacting terms (time*factor) added to identify differences in the score trajectory across clinically relevant subgroups. RESULTS: In total, 248 survivors completed the intervention (mean age: 19.4 [SD = 6.7] years; 54.1% male; 66.1% hematological malignancies), of whom 162 completed all assessments. There was significant increase in survivors' awareness of their cancer diagnoses (mean adjusted score: baseline 66.9, post intervention 86.3; p < .001) and potential LEs (baseline 30.9, post intervention 66.3; p < .001). The proportion of survivors who demonstrated awareness of their potential LEs increased from 9.7% to 54.3%. The interaction analysis showed that there was significantly less improvement in awareness among survivors of non-central nervous system (non-CNS) solid tumors (p = .032), lower socioeconomic status (p = .014), and parents of pediatric survivors (vs. adult survivors; p = .013). CONCLUSIONS: The provision of a personalized SCP showed preliminary effectiveness in improving survivors' understanding of their treatment-related LEs. Health counseling with SCP should be reinforced in vulnerable subgroups. Future work includes evaluating its long-term impact on lifestyle and health outcomes.

User Engagement on a Novel Educational Health Intervention Aimed at Increasing HPV Vaccine Uptake in Hong Kong: a Qualitative Study.

HPV vaccine uptake rates are suboptimal in Hong Kong. A multi-disciplinary school-based HPV health-promotion programme (MDL-SHPVP) aimed at raising HPV knowledge levels and increasing vaccine uptake has therefore been developed to address vaccine hesitancy. This qualitative study was conducted to collect user feedback and identify the strengths and limitations of the educational resources developed for the programme among key vaccination stakeholders including adolescent girls and their mothers. Twenty-six participants including eight mother-daughter dyads, four teachers, three social workers, two school principals and one school nurse were recruited. To cater to the diverse audience, ten educational videos, three animations, a digital game and one booklet were developed for the programme and distributed to the participants for viewing. Semi-structured interviews were then conducted to collect feedback on the acceptability and effectiveness of the resources. Interviews were audio-recorded, transcribed verbatim, and resulting data were thematically analysed. Three themes and six sub-themes emerged. The educational materials were well-received and effective in raising HPV-knowledge levels, generating confidence in vaccine safety and effectiveness, and boosting vaccination intention. Some doubts regarding vaccine necessity remained, and recommendations for improving resource presentation and accessibility were provided. Our findings suggest that the MDL-SHPVP has the potential to boost HPV vaccine uptake. Future studies may explore educational interventions which target to increase not only HPV vaccination intention but also the sense of urgency so as to encourage timely vaccination for adolescents at the ideal age. Study findings may also provide directions for the development of future health education interventions.

Multistakeholder knowledge levels and perspectives of human papillomavirus and its vaccination: An exploratory qualitative study.

OBJECTIVE: This qualitative study was an integral part in the development of a multidisciplinary team-led school-based human papillomavirus vaccination health-promotion programme (MDL-SHPVP) aiming to increase HPV vaccine uptake in Hong Kong. Study findings will inform the design of the MDL-SHPVP by drawing on interview data regarding the expectations and needs of key stakeholders and potential programme users. METHODS: Eight mother-daughter dyads, four secondary school teachers, two school principals, three social workers and one school nurse were interviewed. All interviews were audio-recorded and transcribed verbatim for thematic analysis. RESULTS: Most participants had misconceptions about HPV and the vaccine. Alhough there was no immediate perceived need for the vaccination, most participants had favourable attitudes towards HPV inoculation and vaccines in general. Factors affecting vaccine uptake included perceptions about risk of infection, vaccine availability, and cost. Participants were largely open to suggested MDL-SHPVP components (videos, digital game, and group discussions). CONCLUSION: Findings have highlighted knowledge gaps among potential users and key stakeholders and will be used to inform the design of the MDL-SHPVP to ensure that their needs and expectations are addressed. Study findings may also aid future HPV vaccine promotion efforts and boost HPV vaccine uptake among youth in the city.

Fostering gerontology students' competence in Interprofessional collaborative practice.

BACKGROUND: Interprofessional collaborative practice (IPCP) is increasingly recognised as being crucial for the provision of holistic care and optimising health outcomes among older adults, many with multiple complex health problems. However, little is known about the challenges of facilitating this in practice. Therefore, this study explores these issues from the perspective of different healthcare professionals and how this might inform interprofessional education curricula. METHODS: Sixteen different healthcare professionals working in a variety of aged care (acute, rehabilitative and community) settings were invited to participate in individual semi-structured in-depth interviews designed to: (i) explore the meaning of IPCP; (ii) explore the facilitators of and barriers to IPCP; and (iii) examine the opportunities and challenges in interprofessional gerontological education. All interviews were tape-recorded and transcribed verbatim with thematic analysis conducted by two independent researchers. RESULTS: Three major themes emerged from the interviews: the need for IPCP; role preparedness, scope and liability; and strategies for interprofessional education. Respondents shared a common belief that IPCP improves the quality of life of older adults in both hospital and community settings by improving person-centred coordinated care and decision making in care planning. However, respondents perceived major barriers to IPCP to be lack of knowledge about healthcare professionals' scope of practice, lack of training in interprofessional collaboration, professional culture and stereotypes, and liability issues. Suggested approaches to overcome these barriers included innovative teaching and learning approaches, engaging students early on in the curriculum of health professional degree programmes, and enhancing collaborative effective communication in health and social care settings. CONCLUSIONS: It is anticipated that these findings will be used to inform the development of a new interprofessional gerontological education curriculum that aims to enhance students' competence in IPCP.

Community pharmacists' perceptions about pharmaceutical service of over-the-counter traditional Chinese medicine: a survey study in Harbin of China.

BACKGROUND: This study aims to investigate community pharmacist's perception on the provision of over-the-counter (OTC) traditional Chinese medicine (TCM) pharmaceutical services; focusing on the areas of their attitude, general practice, perceived barriers and suggested improvements. METHODS: Questionnaire survey targeting community pharmacists in Harbin of China was applied in this study. Questionnaires were distributed and collected at community pharmacies. Data was analyzed by combining descriptive analysis and Chi-test. RESULTS: 280 valid questionnaires were collected, giving a response rate of 78%. Respondents generally showed positive attitude towards OTC TCM pharmaceutical services. However, they were uncertain about whether such pharmaceutical services should be considered as their primary responsibility. Respondents indicated that they acted proactively to find out all the medicines taken by their patients and to remind consumers of possible OTC TCM adverse reactions. However, they were less keen on recommending or re-directing consumers to suitable OTC TCM. The three main barriers hindering the provision of OTC TCM pharmaceutical service identified in this study were "insufficient professional knowledge" (54.6%), "ambiguity of the professional role of pharmacists" (54.6%) and "lack of scientific evidence of OTC TCM" (45.4%). The three main actions considered most relevant to improving pharmaceutical service of OTC TCM were "formulating or refining legislation to clarify the legal and professional role of pharmacists with respect to TCM" (60.7%), "strengthening training of pharmacists with respect to TCM" (57.9%), and "promoting public awareness of the pharmacist's role" (53.6%). According to the results of Chi-test, respondents' perceptions about the attitude, practice, perceived barriers, and improvement suggestions were significantly different depending on the education levels, certificate types and workloads of western medicine. CONCLUSIONS: The community pharmacists in Harbin, China were positive about the provision of OTC TCM pharmaceutical services. However, they were less certain about taking this duty as their primary responsibility. Insufficient knowledge and lack of role definition in the area of OTC TCM were found to be the major factors discouraging the provision of pharmaceutical service on OTC TCM by community pharmacists.

Cost-effectiveness analysis of left atrial appendage occlusion compared with pharmacological strategies for stroke prevention in atrial fibrillation.

BACKGROUND: Transcatheter left atrial appendage occlusion (LAAO) is a promising therapy for stroke prophylaxis in non-valvular atrial fibrillation (NVAF) but its cost-effectiveness remains understudied. This study evaluated the cost-effectiveness of LAAO for stroke prophylaxis in NVAF. METHODS: A Markov decision analytic model was used to compare the cost-effectiveness of LAAO with 7 pharmacological strategies: aspirin alone, clopidogrel plus aspirin, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban. Outcome measures included quality-adjusted life years (QALYs), lifetime costs and incremental cost-effectiveness ratios (ICERs). Base-case data were derived from ACTIVE, RE-LY, ARISTOTLE, ROCKET-AF, PROTECT-AF and PREVAIL trials. One-way sensitivity analysis varied by CHADS2 score, HAS-BLED score, time horizons, and LAAO costs; and probabilistic sensitivity analysis using 10,000 Monte Carlo simulations was conducted to assess parameter uncertainty. RESULTS: LAAO was considered cost-effective compared with aspirin, clopidogrel plus aspirin, and warfarin, with ICER of US$5,115, $2,447, and $6,298 per QALY gained, respectively. LAAO was dominant (i.e. less costly but more effective) compared to other strategies. Sensitivity analysis demonstrated favorable ICERs of LAAO against other strategies in varied CHADS2 score, HAS-BLED score, time horizons (5 to 15 years) and LAAO costs. LAAO was cost-effective in 86.24 % of 10,000 simulations using a threshold of US$50,000/QALY. CONCLUSIONS: Transcatheter LAAO is cost-effective for prevention of stroke in NVAF compared with 7 pharmacological strategies. The transcatheter left atrial appendage occlusion (LAAO) is considered cost-effective against the standard 7 oral pharmacological strategies including acetylsalicylic acid (ASA) alone, clopidogrel plus ASA, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban for stroke prophylaxis in non-valvular atrial fibrillation management.

Economic analysis between entecavir and lamivudine for the treatment of chronic hepatitis B in Hong Kong.

BACKGROUND AND AIM: Tremendous healthcare resources have been spent on the management of chronic hepatitis B (CHB) and its related complications. Therefore, a proper evaluation of the cost-effectiveness of pharmacotherapy is vital in aid of decision-making. The aim of the present study was to examine the long-term economic and clinical influence if lamivudine was replaced by entecavir in a group of CHB patients. METHODS: A recently published decision analytic model was adapted to study the cost-effectiveness of 2 years of treatment of entecavir in a hypothetical cohort of 1000 hepatitis B e antigen (HBeAg)-negative CHB patients from a public hospital perspective. Compensated cirrhosis (CC) and de-compensated cirrhosis (DC) and hepatocellular carcinoma (HCC) events were projected to 10 years. Hong Kong-specific health care costs were used. Quality Adjusted Life Years (QALYs) were calculated using the utility values obtained from a local study. RESULTS: In the base case analysis, compared with lamivudine, the use of entecavir was expected to reduce the incidences of CC, DC and HCC by 41.8%, 57.1% and 49.3%, respectively, and lead to a saving of $US 1.17 million in medical cost. The overall disease management cost for entecavir, which was 67.7% higher than lamivudine for 2 years treatment was reduced to 17.2% after projecting 2-year treatment duration to 10 years. The incremental cost per QALY gained for entecavir compared with lamivudine was $US 13 759. CONCLUSIONS: Based on the recommended cost-effectiveness threshold of the World Health Organization, entecavir is considered cost-effective compared with lamivudine in treating CHB in Hong Kong when long term medical consequences were considered.

Controlled-release oral melatonin supplementation for hypertension and nocturnal hypertension: A systematic review and meta-analysis.

Oral melatonin is a potential alternative treatment for hypertension and nocturnal hypertension. However, high-quality and relevant meta-analyses are lacking. This meta-analysis aimed to investigate whether oral melatonin supplementation reduces daytime/asleep blood pressure and cardiovascular risk, improves sleep quality, and is well-tolerated compared with placebo. Relevant articles were searched in multiple databases, including MEDLINE, EMBASE, CINAHL Complete, and the Cochrane Library, from their inception to June 2021. The included studies were randomized controlled trials recruiting patients with hypertension, using oral melatonin as the sole intervention, and investigating its effect on blood pressure. The mean out-of-office (including 24-h, daytime, and asleep) systolic and diastolic blood pressures, sleep quality, and side effects were compared between the melatonin and placebo arms using pairwise random-effect meta-analyses. A risk of bias assessment was performed using the Cochrane risk-of-bias tool. Four studies were included in the analysis and only one study was considered to have a low risk of bias. No study reported on cardiovascular risk or outcomes. Only controlled-release melatonin (not an immediate-release preparation) reduced asleep systolic blood pressure by 3.57 mm Hg (95% confidence interval: -7.88 to .73; I2  = 0%). It also reduced asleep and awake diastolic blood pressure, but these differences were not statistically significant. Melatonin improves sleep efficacy and total sleep time and is safe and well-tolerated. Due to the limited number of high-quality trials, the quality of evidence was low to very low. Therefore, adequately powered randomized controlled trials on melatonin are warranted.

Effects of a social participation-focused virtual reality intervention for community-dwelling stroke survivors with physical disabilities: a randomised controlled trial protocol.

INTRODUCTION: Studies show that stroke survivors encounter physical and psychological limitations that restrict their participation in social and community activities. Systematic reviews have yielded inconclusive evidence regarding the effectiveness of different interventions intended to support stroke survivors' social participation. Recent advances in virtual reality technology may offer promising solutions, although the optimal approach to enhance social participation among stroke survivors is yet to be determined. This trial aims to develop and evaluate the effectiveness of a social participation-focused virtual reality (SP-VR) intervention on the physical, psychological and social outcomes of community-dwelling stroke survivors with physical disabilities. METHODS AND ANALYSIS: A two-arm randomised, controlled, assessor-blind clinical trial will be conducted with 250 stroke survivor-caregiver dyads recruited from three acute and one rehabilitation hospitals, and three stroke nurse-led clinics. Participants will be survivors of a first or recurrent stroke within 6 months of stroke onset and able to remain in a sitting position without support, and their primary caregivers. Eligible participants will be randomly allocated to receive the SP-VR intervention or usual care which includes conventional physical therapy services. The intervention group will receive a newly developed 6-week novel custom-made SP-VR application comprising two sessions weekly. Three SP-VR modules will cover key aspects of survivors' social health needs, namely functional rehabilitation, social participation, and social interaction and recreation. The primary outcome for stroke survivors is social participation, and secondary outcomes include depressive symptoms, participation self-efficacy, physical function, functional mobility and social support. User satisfaction will be evaluated among both survivors and caregivers. Data will be collected in person at baseline, immediately after, and 3 months postintervention. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster Research Ethics Committee (Ref. No.: 2019.676). Study results will be disseminated through peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: ChiCTR2100050850.

Feasibility of a telephone-delivered educational intervention for knowledge transfer of COVID-19-related information to older adults in Hong Kong: a pre-post-pilot study.

BACKGROUND: During the COVID-19 pandemic, educational interventions have become necessary to prevent the spread of health-related misinformation among Hong Kong older adults. The primary objective of this study was to assess the feasibility of a student-led, telephone-delivered intervention to improve COVID-19-related health knowledge among Hong Kong older adults. The secondary objective was to evaluate the impact of the intervention on the student volunteers. METHODS: Twenty-five participants aged 65 or above who were able to communicate in Cantonese and had no hearing or cognitive impairments were recruited for this longitudinal pre-post-study from a community center in Hong Kong. The pilot telephone-delivered intervention consisted of five telephone call sessions conducted by 25 student volunteers. Each participant was paired with the same volunteer throughout the intervention. The first four sessions included pre-tests that assessed the participants' understanding of three COVID-19-related themes: medication safety, healthcare voucher scheme, and COVID-19 myth-busting. Standardized explanations of the pre-test questions were offered to participants during the phone calls. In the last session, a post-test on all the themes was conducted. The intervention's feasibility was assessed based on (a) percentage changes in the participants' test scores, (b) attrition rate, and (c) the acceptability of the intervention by the participants. The impact of the intervention on the student volunteers was evaluated based on a student feedback survey. There was no control group. RESULTS: Significant improvements in the participants' test scores (out of 100%) for all themes were observed after the intervention: from 76 to 95.2% for medication safety, from 64.0 to 88.8% for the healthcare voucher scheme, and from 78.0 to 93.2% for COVID-19 myth-busting. The average improvement in test scores of the three themes was 18.4% (95% CI 12.2 to 24.6%). Most participants were satisfied with the program. The student feedback survey suggested that the intervention enhanced students' communication skills and understanding of Hong Kong older adults. CONCLUSION: This pilot study offers initial evidence of the potential and feasibility of student-led, telephone-delivered educational interventions for the transfer of COVID-19-related knowledge to older adults and their benefits for the student volunteers. Future studies should include larger samples and a control group.

User engagement in the development of a home-based virtual multidisciplinary stroke care clinic for stroke survivors and caregivers: a qualitative descriptive study.

PURPOSE: To understand the user expectations and the facilitators and barriers of using a virtual multidisciplinary stroke care clinic ("virtual clinic"). METHODS: A qualitative descriptive study involving two rounds of face-to-face semi-structured interviews per participant was conducted. We purposively recruited ten participants in Hong Kong who were receiving traditional stroke rehabilitation. The first interview was conducted to explore participants' expectations. The second interview was conducted after a 4-week trial of the virtual clinic. Both interviews were analysed using thematic analysis. The findings were translated from Cantonese into English. RESULTS: Before using the virtual clinic, the participants perceived a need for (i) information communication technology guidance and support, (ii) familiar hardware and applications, and (iii) services to meet psychosocial needs. Facilitators identified by the participants included (i) feeling safe and supported, (ii) willingness to learn, adapt to, and use the new service, and (iii) ease of use with a flexible schedule. Issues relating to (i) internet connectivity, (ii) hardware, and (iii) interface and design were perceived barriers to the use of the clinic. CONCLUSION: This study provides findings of users' expectations of using telehealth services. Their perspectives on facilitators and barriers may increase the adoption of the newly developed telehealth service.Implications for rehabilitationTo implement telehealth as part of post-stroke care, it is important to ensure that stroke survivors and caregivers have the necessary information and communication technology support and infrastructure to engage in two-way interactions.Stroke survivors and caregivers may be inclined to use telehealth services due to ease of use, having flexibility in scheduling consultation sessions, do not need to travel to the clinic, useful online content, and remote blood pressure monitoring.Addressing the barriers of using telehealth services (e.g., hardware issues, internet connectivity issues, and user interface to facilitate the reading of information on the website) can improve the usability and acceptance to ensure the successful adoption of telehealth as part of post-stroke recovery.

May Measurement Month 2017-2019: A Community-Wide Opportunistic Blood Pressure Screening Campaign in Hong Kong.

INTRODUCTION: Hypertension is a modifiable risk factor for multiple cardiovascular diseases. Early identification and intervention of new cases are crucial to improve patients' outcomes. May Measurement Month (MMM) is an annual global synchronised blood pressure (BP) screening campaign. Participants can have their BP measured at the screening sites. It may be a possible way to identify undiagnosed hypertensive patients in the population. METHODS: It was a cross-sectional study of BP among Hong Kong adults. Multiple screening sites were set in local community pharmacies and on the campus of the Chinese University of Hong Kong. Participants were asked to fill in a questionnaire regarding their demographics, medical history, and social history. Then, they took at least one BP reading using an automated sphygmomanometer after sitting at for 5 minutes. Up to three BP readings were taken and recorded for each participant, with one-minute intervals between readings. RESULTS: A total of 3224 adults participated in MMM between 2017 and 2019. The average BP among the 3224 participants was 139.8/75.5 mmHg. The prevalence of hypertension was 2282 (70.8%), of which 635 (27.8%) were undiagnosed before MMM. Among the 1647 participants previously diagnosed with hypertension, 1007 (61.1%) had uncontrolled hypertension. CONCLUSION: A high number of cases can be identified with untreated, or treated but uncontrolled, hypertension from MMM. Citizens should be encouraged to check BP regularly and take follow-up actions if hypertension is suspected.

Effects of a multidisciplinary team-led school-based human papillomavirus vaccination health-promotion programme on improving vaccine acceptance and uptake among female adolescents: A cluster randomized controlled trial.

INTRODUCTION: Evidence has consistently shown the high efficacy of human papillomavirus (HPV) vaccines in preventing cervical cancers. However, the HPV vaccine uptake rate in Hong Kong is very low. We will develop and evaluate an innovative, theory-based multidisciplinary team-led school-based HPV vaccination health-promotion program (MDL-SHPVP), engaging female adolescents, parents/guardians, and secondary school personnel in multicomponent educational strategies and interactive discussions. METHODS AND ANALYSIS: A cluster randomized controlled trial is proposed. We will recruit 2520 female adolescents and their parents/guardians from 18 secondary day schools. The MDL-SHPVP is underpinned by the Health Belief Model and Precaution Adoption Process Model. Multicomponent interventions will be offered, including education sessions with small group dialogues with a registered nurse and trained healthcare and lay volunteers, and educational computer games. A team of volunteers will be established to raise HPV, cervical cancer, and HPV vaccine awareness. Outcomes include adolescents' uptake of the HPV vaccine, adolescents' intention to receive HPV vaccination, vaccine acceptance among parents/guardians, and parents'/guardians' and adolescents' HPV knowledge, attitudes, and beliefs. Data will be collected at baseline, 1 month, and 1 year after intervention. The generalized estimating equations analysis will be used for comparing the outcomes between the 2 groups. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (Ref. no.: 2019.055). We will disseminate the study findings via peer-reviewed publications and presentations at relevant events and international and local conferences. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT04438291.

Effectiveness and cost-effectiveness of a virtual multidisciplinary stroke care clinic for community-dwelling stroke survivors and caregivers: a randomised controlled trial protocol.

INTRODUCTION: The virtual multidisciplinary stroke care clinic (VMSCC) is the first nurse-led clinic developed to offer support to community-dwelling stroke survivors and caregivers, and to promote poststroke recovery. This two-arm randomised controlled trial will evaluate its effectiveness on survivors' self-efficacy (SE), survivors' and caregivers' health-related quality of life (HRQoL) and cost-effectiveness on emergency admissions and length of readmission hospital stay. METHODS AND ANALYSIS: A consecutive sample of 384 stroke survivor-caregiver dyads will be recruited from four hospitals. An online platform that embraces readily accessible and reliable information will be developed. Participants randomly assigned to the intervention group will receive usual care plus the VMSCC service. The service includes access to a tablet containing 30 videos demonstrating appropriate self-care strategies, communication with a registered nurse monthly through video and telephone calls and regular blood pressure monitoring. Primary outcomes include survivors' SE in self-management and survivors' and caregivers' HRQoL. Secondary outcomes include survivors' performance of self-management behaviours, depression and social participation; and caregivers' coping strategies, satisfaction with caring and depression. Data will be collected at baseline, and at 3 and 6 months after commencing the intervention. Survivors' and caregivers' satisfaction with the service will be assessed at 6-month follow-up. Multivariable regressions and generalised estimating equations model will be conducted. Survivors' emergency admissions and length of hospital stay will be evaluated during the 6-month follow-up period. Cost-effectiveness analysis will be performed on the average total cost incurred. DISCUSSION: The results will inform stakeholders about incorporating the VMSCC service into current stroke rehabilitation service. ETHICS AND DISSEMINATION: This protocol was approved by the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (CREC Ref. No.: 2017.660). All participants will provide written informed consent. Results will be disseminated through scientific publications, and presentations at local and international conferences. TRIAL REGISTRATION NUMBER: ChiCTR1800016101; Pre-results.

Combination of a cyclo-oxygenase-2 inhibitor and a proton-pump inhibitor for prevention of recurrent ulcer bleeding in patients at very high risk: a double-blind, randomised trial.

BACKGROUND: Guidelines on pain management recommend that patients at risk of ulcers receive either a cyclo-oxygenase (COX 2) inhibitor or a non-steroidal anti-inflammatory drug (NSAID) with a proton-pump inhibitor (PPI). These two treatments have similar effectiveness, but they are insufficient for protection of patients at very high risk for ulcer bleeding. We aimed to test the hypothesis that in patients with previous ulcer bleeding induced by non-selective NSAIDs, combined treatment with the COX 2 inhibitor celecoxib and the PPI esomeprazole would be better than celecoxib alone for prevention of recurrent ulcer bleeding. METHODS: 441 consecutively presenting patients who were taking non-selective NSAIDs for arthritis were recruited to our single-centre, prospective, randomised, double-blind trial after admission to hospital with upper-gastrointestinal bleeding. Patients were enrolled after their ulcers had healed and a histological test for Helicobacter pylori was negative. All patients were given 200 mg celecoxib twice daily. 137 patients were randomly assigned to receive 20 mg esomeprazole twice daily (combined-treatment group), and 136 to receive a placebo (control group) for 12 months. The primary endpoint was recurrent ulcer bleeding during treatment or within 1 month of the end of treatment. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00365313. FINDINGS: Combination treatment was more effective than celecoxib alone for prevention of ulcer bleeding in patients at high risk. The 13-month cumulative incidence of the primary endpoint was 0% in the combined-treatment group and 12 (8.9%) in the controls (95% CI difference, 4.1 to 13.7; p=0.0004). The median follow-up was 13 months (range 0.4-13.0). Discontinuation of treatment and the incidence of adverse events were similar in the two treatment groups. INTERPRETATION: Patients at very high risk for recurrent ulcer bleeding who need anti-inflammatory analgesics should receive combination treatment with a COX 2 inhibitor and a PPI. Our findings should encourage guideline committees to review their recommendations for patients at very high risk of recurrent ulcer bleeding.

Prevention of nitroglycerin tolerance in vitro by T0156, a selective phosphodiesterase type 5 inhibitor.

The efficacy of nitroglycerin as a vasodilator is limited by tolerance, which develops shortly after treatment begins. The present study aims to examine whether T0156, a newly developed potent and selective inhibitor of phosphodiesterase type 5 (PDE5), could attenuate the tolerance to nitroglycerin on rat aortas. Rat aortic rings were suspended in organ bath for the measurement of changes in isometric tension and nitrate tolerance was acutely induced by preceding exposure for 90 min to 30 microM nitroglycerin. Concentration-response curves to nitroglycerin were obtained on aortic rings pre-contracted with phenylephrine. Pre-exposure of rings with or without endothelium to nitroglycerin reduced the relaxations to nitroglycerin. The tissue levels of cyclic GMP were measured by enzyme immunoassay kit. Treatment with T0156 inhibited and prevented the reduced relaxation and cyclic GMP levels in response to nitroglycerin in tolerant rings. In contrast, nitroglycerin-induced tolerance was unaffected by cilostazol (PDE3 inhibitor) and rolipram (PDE4 inhibitor). Finally, incubation of aortic rings with thromboxane prostanoid receptor antagonist, cyclooxygenase inhibitor, or endothelin ET(A) receptor antagonist did not inhibit the development of tolerance. The present results suggest that nitroglycerin tolerance may involve an increased activity of PDE5 but not PDE3 or PDE4 isoforms in vascular smooth muscle cells since T0156 prevents the development of tolerance. Thromboxane A(2), cyclooxygenase (COX)-dependent prostaglandins and endothelin 1 play little role in the acute induction of nitroglycerin tolerance.

Clinical and Economic Analysis of Lipid Goal Attainments in Chinese Patients with Acute Coronary Syndrome Who Received Post-Percutaneous Coronary Intervention.

AIM: The recommended low-density lipoprotein cholesterol (LDL-C) levels of the guideline may be appropriate for Caucasian patients but not for other ethnic groups. METHODS: A cohort study was conducted in Hong Kong, and acute coronary syndrome (ACS) patients who received percutaneous coronary intervention (PCI) between 2005 and 2015 were enrolled. The primary outcomes of interest were the total cost of care and cardiovascular-related cost during one-year follow-up. The cost difference by lipid goal attainments was analyzed by Poisson regression with multivariate treatment effects. The clinical outcomes achieved by lipid goal attainments in terms of major adverse cardiovascular events were analyzed by multivariate Cox regression. RESULTS: Among the 4638 patients, 79.50%, 48.64%, and 36.14% attained the LDL-C goals of ＜2.6, ＜2.0, and ＜1.8 mmol/L for one year, respectively. Only about 16% patients achieved the ≥50% reduction from baseline. None of these lipid goals was associated with a significant reduction in the total cost of care. We only identified the clinical benefits associated with the lipid goal of ＜2.6 mmol/L. Other more stringent lipid goals seemed to bring a significant economic burden on cardiovascular-related cost, but their clinical benefits were uncertain. CONCLUSIONS: Lowering LDL-C to achieve the guideline-recommended target levels for post-PCI ACS patients may lead to fewer cardiovascular events, but it may not necessarily lead to economic benefits within one year of follow-up.

Effects of Acupuncture on the Recovery Outcomes of Stroke Survivors with Shoulder Pain: A Systematic Review.

BACKGROUND: Poststroke shoulder pain limits stroke survivors' physical functioning, impairs their ability to perform daily activities, and compromises their quality of life. The use of acupuncture to manage shoulder pain after a stroke is believed to free the blockage of energy flow and produce analgesic effects, but the evidence is unclear. We therefore conducted a systematic review to summarize the current evidence on the effects of acupuncture on the recovery outcomes of stroke survivors with shoulder pain. METHODS: Fourteen English and Chinese databases were searched for data from January 2009 to August 2017. The review included adult participants with a clinical diagnosis of ischemic or hemorrhagic stroke who had developed shoulder pain and had undergone conventional acupuncture, electroacupuncture, fire needle acupuncture, or warm needle acupuncture. The participants in the comparison group received the usual stroke care only. RESULTS: Twenty-nine randomized controlled trials were included. Most studies were assessed as having a substantial risk of bias. Moreover, due to the high heterogeneity of the acupuncture therapies examined, pooling the results in a meta-analysis was not appropriate. A narrative summary of the results is thus presented. The review showed that conventional acupuncture can be associated with benefits in reducing pain and edema and improving upper extremity function and physical function. The effects of conventional acupuncture on improving shoulder range of motion (ROM) are in doubt because this outcome was only examined in two trials. Electroacupuncture might be effective in reducing shoulder pain and improving upper extremity function, and conclusions on the effects of electroacupuncture on edema, shoulder ROM, and physical function cannot be drawn due to the limited number of eligible trials. The evidence to support the use of fire needle or warm needle acupuncture in stroke survivors with shoulder pain is also inconclusive due to the limited number of studies. CONCLUSION: Although most studies reviewed concluded that conventional and electroacupuncture could be effective for management of shoulder pain after stroke, the very high potential for bias should be considered. Further work in this area is needed that employs standardized acupuncture treatment modalities, endpoint assessments, and blinding of treatments.

Cost-effectiveness analysis of infant universal routine pneumococcal vaccination in Malaysia and Hong Kong.

Pneumococcal disease causes large morbidity, mortality and health care utilization and medical and non-medical costs, which can all be reduced by effective infant universal routine immunization programs with pneumococcal conjugate vaccines (PCV). We evaluated the clinical and economic benefits of such programs with either 10- or 13-valent PCVs in Malaysia and Hong Kong by using an age-stratified Markov cohort model with many country-specific inputs. The incremental cost per quality-adjusted life year (QALY) was calculated to compare PCV10 or PCV13 against no vaccination and PCV13 against PCV10 over a 10-year birth cohort's vaccination. Both payer and societal perspectives were used. PCV13 had better public health and economic outcomes than a PCV10 program across all scenarios considered. For example, in the base case scenario in Malaysia, PCV13 would reduce more cases of IPD (+2,296), pneumonia (+705,281), and acute otitis media (+376,967) and save more lives (+6,122) than PCV10. Similarly, in Hong Kong, PCV13 would reduce more cases of IPD cases (+529), pneumonia (+172,185), and acute otitis media (+37,727) and save more lives (+2,688) than PCV10. During the same time horizon, PCV13 would gain over 74,000 and 21,600 additional QALYs than PCV10 in Malaysia and Hong Kong, respectively. PCV13 would be cost saving when compared against similar program with PCV10, under both payer and societal perspective in both countries. PCV13 remained a better choice over PCV10 in multiple sensitivity, scenario, and probabilistic analyses. PCV13s broader serotype coverage in its formulation and herd effect compared against PCV10 were important drivers of differences in outcomes.