The evolving experience of illness for Chinese women with breast cancer: a qualitative study

The study of illness meaning in cancer in western communities has usually focused on causal attributions. We report a phenomenological study of 17 Hong Kong Chinese women with breast cancer, interviewed on completion of initial treatment, and describe how the illness experience and hence, meaning evolves for women in the Hong Kong Chinese culture. Themes arising from the identification and treatment of the disease include the difficulty of living in uncertainty and of maintaining and regaining normalcy in a superstitious society. The initial uncertainty of disease detection and the diagnostic process are characterized by shock and disbelief mingled with fear of death. Treatment choice presents women with difficulties arising from more uncertainty over the pressure to make quick decisions and the dilemma of death or mutilation. Following treatment, re-evaluation, re-prioritizing and positive life-re-evaluation occur. Changes in appearance proved problematic for those women who tried to hide their disease to protect themselves against stigmatization and social exclusion. In many ways, these findings parallel studies on western populations, suggesting that a common disease-medical care process is a predominant influence in shaping breast cancer experience. Implications for care are drawn from these data.

Voluntary HIV antibody testing amongst youth in Hong Kong

We performed a study to estimate the prevalence of and factors associated with human immunodeficiency virus (HIV) antibody-testing behaviour among youth in Hong Kong. It was a population-based cross-sectional study. Questions on HIV testing were asked as part of a youth sexuality study conducted in July to December 1996 among young adults in Hong Kong. A total of 517 (53.6%) males and 447 (46.4%) females aged 17 to 28 years completed an anonymous structured self-administered questionnaire. Respondents had good knowledge about correct modes of HIV transmission and prevention. 9.4% (95% confidence interval [CI]: 7.0, 12.3) of males and 6.4% (95% CI: 4.3, 9.1) of females had been tested for HIV through blood donation. Excluding blood donation, 3.7% (95% CI: 2.2, 5.7) of males and 3.6% (95% CI: 2.1, 5.9) of females had been tested (voluntary testing). 47.5% (95% CI: 44.4, 50.7) of subjects reported at least one major risk factor for HIV infection. In multivariate analyses, factors independently associated with both voluntary HIV testing and HIV testing by blood donation were age and having had sex with multiple partners. A higher educational level was a predictor of HIV testing by blood donation. Self-assessment of having sufficient sex education was also significantly associated with voluntary HIV testing. HIV testing is not widespread in Hong Kong and those at risk are more likely to have been tested. It is of concern, however, that many of those reporting risk factors have not been tested.

The mediating role of optimism on post-radiation quality of life in nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is prevalent in southern China. In non-welfare countries, eating difficulties after radiotherapy may hinder NPC patients' short-term quality of life (QoL) especially regarding work and finance. This study explored the positive mediating role of optimism on the relationship between eating ability and QoL of Chinese NPC patients who received radiotherapy in Hong Kong. A sample of 211 newly referred patients were recruited and followed-up face-to-face or by telephone at four (post-radiation 1) (FU 1) and eight (post-radiation 2) (FU 2) months from baseline. QoL was measured by the FACT-G (Chinese). Optimism and eating ability were measured by two 11-point self-rated items. Mediating effects were tested with a series of multiple regression models. After adjustment for pre-radiation QoL, socioeconomic status and cancer stage, optimism significantly mediated the relationship between eating ability at FU 1 and overall QoL at FU 2, in particular physical and social/family well-being. This study is the first to underpin the mediating role of optimism on QoL of NPC patients. Faced with aversive side-effects of radiotherapy, facilitating positive thinking in Chinese NPC patients may accelerate their short-term post-radiation adjustment.

Trends in breast cancer incidence in Hong Kong between 1973 and 1999: an age-period-cohort analysis

Hong Kong has the highest breast cancer incidence in Asia and studying secular changes in its rates may lead to hypotheses regarding disease aetiology and also predictions of future trends for China. We examined statistics from the Hong Kong Cancer Registry based on 26 566 cases of invasive breast cancer from 1973 to 1999. The trends in breast cancer incidence were studied using log-linear longitudinal models. We further analysed the independent effects of chronological age, time period and birth cohort on incidence trends using age-period-cohort modelling. The average annual per cent change of the age-standardised incidence was 3.6% during 1973-1999. Age-period-cohort modelling indicated the incidence development was predominantly a cohort effect, where the rise in relative risk was seemingly linear in successive birth cohorts, showing a 2-3-fold difference when comparing women born in the 1960's with those born around 1900. Our results suggest that direct and indirect consequences of westernisation may have been responsible for most of the observed increase in breast cancer incidence. As China moves towards a more westernised way of life, we can expect an emerging epidemic of breast cancer as Hong Kong's experience has demonstrated.

Patterns of cigarette smoking, alcohol use and other substance use among Chinese university students in Hong Kong

The pattern of tobacco, alcohol, and other substance use was assessed among 1,197 Chinese undergraduates in Hong Kong. Students reported their current and past use of tobacco (13%), alcohol (61%), marijuana (2%), and other illicit drugs (0.4%). Perceptions of risk from the use of different substances were low among those who use substances and among senior students. The rate of substance use was higher among males, residents of university hall, senior students, and among those who possessed a positive attitude towards substance use. There were significant associations between different substance uses among the respondents.

The development and evaluation of an integrated community-based, patient-centred learning activity at the University of Hong Kong

OBJECTIVE

To develop and evaluate the Patient Care Project (PCP), an integrated patient-centred, community-based learning activity, implemented at the University of Hong Kong since 1992.

DESIGN

The PCP, a required course in the first 2 preclinical years, is structured into four learning cycles over 9 months. Each cycle consists of a patient interview followed by a debriefing group tutorial. In-depth interviews with the same patient allow students to explore the impact of disease and patients' illness experience, as well as the contribution of the wider determinants of health to their condition. The debriefing tutorial frames empirical observations into theoretical models and its format reinforces habits of problem-based learning. The programme was evaluated using survey questionnaires completed by students, patients and tutors.

PARTICIPANTS

324 first- and second-year medical students.

RESULTS

Students, participating patients and tutors all rated the PCP positively in end-of-course evaluations. Specifically, 68% of students commented that the PCP had met all or most of its stated objectives, while there was nearly unanimous agreement among patients that students demonstrated understanding and empathy in the visits and interviews. Tutor appraisal of student performance also indicated the attainment of all stated aims and objectives overall.

CONCLUSIONS

The PCP is a valuable contribution to community-based learning and the promotion of the patient-centred clinical method.

Reasons for not using condoms among the Hong Kong Chinese population: implications for HIV and STD prevention

OBJECTIVE

To assess the prevalence and reasons for non-use of condoms among the Hong Kong Chinese population and obtain baseline data to monitor sexual behavioural change.

METHODS

Cross sectional self administered questionnaire surveys in convenience sampled groups of Hong Kong Chinese residents were carried out.

RESULTS

Of the 1508 respondents, 24% reported consistent condom use and 76% inconsistent use. Overall, 17% of respondents reported having sex with strangers. People who were at increased risk for inconsistent condom use included STD clinics attendees, those who never married, and those reporting low self efficacy for condom use or sex with strangers. Common reasons for not using condoms were trust in partner, use of other contraceptives, and reduced sensation while using condoms.

CONCLUSIONS

Given the reported high prevalence of travel and sexual contact with strangers, and misconceptions about condoms among the Hong Kong Chinese population, innovative condom social marketing campaigns are needed. Periodic monitoring of condom use behaviours should be an integral part of HIV/STD surveillance activity.

Risk factors for sexually transmitted diseases and casual sex among Chinese patients attending sexually transmitted disease clinics in Hong Kong

BACKGROUND

The risk factors for sexually transmitted diseases (STDs) and having casual sex among the Chinese people are unknown.

GOAL

The goal of the study was to estimate the prevalence of STDs and to develop a profile of risk behavior among patients attending STD clinics in Hong Kong.

STUDY DESIGN

In a clinic-based, cross-sectional study, 448 patients attending two government STD clinics were randomly sampled and interviewed by means of a structured questionnaire.

RESULTS

The prevalence of STDs was 51% (70% of men and 35% of women). Attendees who had STDs diagnosed were more likely to be male, never married, and smokers and alcohol users (ever) and to have had casual sex or sex during travel with someone not their usual partner. Those who did not always use condoms were more likely to be male and never married. Having had casual sex was reported by 63% of the respondents. Those who reported having had casual sexual encounters were more likely to have the following characteristics: male; never married; no religious belief; ever smoker and alcohol user; current STD; had sex during travel; history of STD; inconsistent condom user; and perception of being at low risk for STD. After adjustment, only male gender was associated with casual sexual encounters.

CONCLUSION

The results of this study indicated several risk factors among Chinese patients for the acquisition of STDs, for not using condoms, and for having casual sex. This information is useful in strengthening and evaluating currently available STD prevention and control strategies for the Chinese population in Hong Kong and elsewhere.

Physicians' attitudes towards the computerization of clinical practice in Hong Kong: a population study

OBJECTIVE

To identify the prevailing attitudes among physicians to use of computers in the clinical setting and specifically those attitudes that may be associated with the adoption of computers in practice.

DESIGN

A self-completed, 20-question postal questionnaire sent to 4850 randomly selected physicians. The questionnaire focused on details of the physicians' practice; actual computerization of or intention to computerize clinical and administrative functions; attitudes towards computerization; self-perceived computer ability and knowledge; and demographic information. The attitude statements were grouped under four themes according to a factor analysis.

RESULTS

The survey was completed by 897 physicians. Only physicians in 'individual' practices were included in the analysis. This group was further dichotomized into clinical users (those with one or more clinical functions computerized) and non-clinical users. Non-clinical users were older and had fewer specialist qualifications. Although there was strong support for the attitude statements among both groups with regard to the benefit of computerization to patient care, there was much less support for electronic medical records. Non-clinical users were concerned about the potentially negative impact of computerization on the clinical encounter and the perceived high cost of computerization.

DISCUSSION

The attitudes among current clinical users and non-users were substantially different. The most important disincentives to computerization were the potential for interference with the patient-physician encounter and the cost of computerizing multiple practice locations. Turning these disincentives into opportunities for change remains the challenge.

The impact of mastectomy, breast-conserving treatment and immediate breast reconstructions on the quality of life of Chinese women

BACKGROUND

The psychosocial impact of breast surgery has been extensively studied in the Western population. There is a relative paucity of comparable data in Oriental women who are increasingly affected by cancer of the breast. The present study investigates the effects that different types of breast surgery have on the quality of life of Chinese women.

METHODS

Forty-nine Chinese women with early breast cancer were interviewed at 6 months-2 years following their primary surgery (breast-conserving treatment (BCT, 17 patients), mastectomy (15 patients) and mastectomy with immediate breast reconstruction (17 patients)). Aspects of quality of life measured included general psychological well-being, body image, sexual functioning and social functioning.

RESULTS

Patients who received BCT had significantly better body image scores compared to mastectomy patients. They were less worried about their appearance, had more freedom in the choice of clothing, felt less upset by the change in their body and felt more accepted by their partners. The three groups did not differ significantly in the other aspects of quality of life measured.

CONCLUSIONS

Compared to mastectomy or mastectomy and immediate breast reconstruction, the most significant benefit of BCT is the preservation of a better body image.

The activity of low-clearance liposomal amikacin in experimental murine tuberculosis

Most of the amikacin in low-clearance liposomal amikacin is excreted very slowly, offering the possibility of maintaining effective treatment of pulmonary tuberculosis with widely separated supervised doses. As a preliminary to explorations in humans, its efficacy was assessed in acute experimental murine tuberculosis by weekly counts of viable bacilli in spleen and lungs over a 4 week period. Liposomal amikacin in dosages of 160, 80 and 40 mg/kg given iv three times a week was 2.4-5.0 times more active than free amikacin and 6.6-6.7 times more active than streptomycin with the non-liposomal drugs given im five times a week. When the free amikacin and the streptomycin were also given iv three times a week, liposomal amikacin was 2.7-2.9 times more active than free amikacin and 3.7-5.6 more active than streptomycin. In a model of chronic tuberculosis, initial BCG vaccination was followed by challenge with virulent Mycobacterium tuberculosis and a 2 week stabilization period. Thereafter, treatment with liposomal amikacin 160 and 80 mg/kg three times a week for the first 4 weeks and then once a week for a further 4 weeks, had greater initial bactericidal activity than free amikacin 160 mg/kg five times a week, but had less eventual sterilizing activity than five times a week oral isoniazid 25 mg/kg or rifampicin 15 mg/kg. Although low-clearance liposomes increased the safety, potency and dosing interval of amikacin in these models, all aminoglycosides, including liposomal amikacin, were only bactericidal in the presence of bacillary metabolism and growth.

Chinese nasopharyngeal carcinoma patients treated with radiotherapy: association between satisfaction with information provided and quality of life

BACKGROUND

Nasopharyngeal carcinoma (NPC) is highly prevalent in southern China. Prominent acute side effects of radiotherapy create problems in daily living and working that can generate considerable financial difficulties. A better adjustment to a diagnosis of NPC appears to be associated with an improved rate of recovery, a better quality of life (QoL), a quicker return to work, and normal functioning. Patient satisfaction with physician consultation and the way information is provided in particular may have significant bearing on QoL. The current study reports on short-term QoL after radiotherapy in NPC patients as a function of satisfaction with the information provided.

METHODS

Newly referred Hong Kong Chinese NPC patients (n = 211) completed interview measures at baseline before the initiation of radiotherapy, at 4 months after baseline (immediate posttreatment consultation) (FU 1), and again at 8 months (short-term postradiation period) after baseline (FU 2). Satisfaction with the information provided was measured by five items selected from the cognitive subscale of the Medical Interview Satisfaction Scale (MISS). QoL was measured by the Chinese version of the Functional Assessment of Cancer Therapy-General Scale (FACT-G (Ch)).

RESULTS

After adjustment for overall patient satisfaction (the PSQ-9), optimism, worry about family, anger, eating ability, subjective health, family income, and occupation at FU 1, treatment between baseline and FU 1, and disease recurrence after baseline, the 5-item MISS at FU 1 (beta = 0.21, P < 0.01) was found to significantly predict patient QoL at FU 2. Adjustment for baseline QoL and disease stage did not appear to alter this relation (beta = 0.20, P < 0.01).

CONCLUSIONS

To the authors' knowledge, there is very little research concerning NPC. The results of the current study reinforced the need to improve physicians' information provision during consultations with Chinese NPC patients shortly after the end of treatment.

Hong Kong: an epicenter of increasing risk for HIV transmission? Overview and response

Hong Kong, a Special Administrative Region (HKSAR) of the Peoples' Republic of China (PRC), has a low prevalence of HIV infection. This has been attributed to an extensive prevention and control program implemented by the Hong Kong government from the very beginning of the epidemic. Since the early 1990s, HIV-related surveys in Hong Kong have delineated the magnitude of the problem and identified particularly relevant cultural features that both increase and limit the risk of the transmission of HIV. Factors that may increase transmission include high rates of regional travel, cross-border mobility, and growing commercial sex industries nearby; the latter two are particularly important. Protective factors may include a later age for first sexual experience than in Western countries. More epidemiological research, and particularly intervention research, is needed in the HKSAR to identify new means to maintain the current low HIV/AIDS prevalence and to further strengthen prevention and control programs. Collaboration between government bodies, non-government organizations, and researchers is needed to assure that the best programs and policies are identified and implemented.

Preliminary evaluation of "interpreter" role plays in teaching communication skills to medical undergraduates

RATIONALE AND OBJECTIVES

Multiculturalism presents linguistic obstacles to health care provision. We explored the early introduction of "interpreter" role-play exercises in teaching medical undergraduates communication skills. The interpreter role creates a natural barrier in communication providing an active prompt for recognizing learning needs in this area.

METHODS

Bilingual Cantonese first-year medical students (n=160) were randomly allocated to either "Observer" or "Interpreter" role plays at a small-group introductory communication skills workshop using a quasi experimental design, counterbalanced across tutors. Students assessed their own skill competence before and, together with their perceptions of the different role plays' effectiveness, again after the workshop, using an anonymous 16 item Likert-type scale, analysed using ANOVA and MANOVA.

RESULTS

Students' assessments of their skills improved significantly following the workshop (F=73.19 [1,156], P=0.0009). Students in the observer group reported greater changes in their scores following the workshop than did students in the interpreter group (F=4.84 [1,156], P=0.029), largely due to improvement in perceived skill (F=4.38 [1,156], P=0.038) rather than perceived programme effectiveness (F=3.13 [1,156], P > 0.05). Subsequent MANOVA indicated no main effect of observer/interpreter conditions, indicating these differences could be attributed to chance alone (F=1.41 [16 141], P > 0.05).

CONCLUSION

The workshop positively influenced students' perceived communication skills, but the "Interpreter" role was less effective than the "Observer" role in achieving this. Future studies should examine whether interpreter role plays introduced later in the medical programme are beneficial.

Passive smoking at work: the short-term cost

STUDY OBJECTIVE

To estimate the impact of passive smoking at work on use of health care services and absenteeism.

DESIGN

Cross sectional survey.

SETTING

A workforce in Hong Kong.

PARTICIPANTS

5142 never-smoking police officers in a total sample of 9926.

MAIN RESULTS

A consistently strong association was found among men between length of time exposed to passive smoking at work and self reported consultations with a doctor, use of medicines and time off work. Results for women were similar but most were not statistically significant.

CONCLUSIONS

The exposure of healthy adults to passive smoking at work is related to utilisation of health care services and extra time off work. This results in costs to the health services, to employers and to those exposed.

Environmental tobacco smoke exposure among police officers in Hong Kong

CONTEXT

Few epidemiological studies have examined the relationship between chronic respiratory symptoms and exposure to environmental tobacco smoke (ETS) at work in adults, and none have shown clear dose-response relationships.

OBJECTIVE

To examine the respiratory effects of ETS exposure at home and at work among never-smoking adults.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional, self-administered questionnaire survey conducted in December 1995 and January 1996 among 4468 male and 728 female police officers in Hong Kong who were never-smokers.

MAIN OUTCOME MEASURES

Respiratory symptoms and physician consultation in the previous 14 days for such symptoms by presence and amount of ETS exposure at work.

RESULTS

Eighty percent of both men and women reported ETS exposure at work. Significant odds ratios (ORs) for respiratory symptoms were found among men with ETS exposure at work (for any respiratory symptoms, difference in absolute rate, 20.4%; OR, 2.33; 95% confidence interval [CI], 1.97-2.75; attributable risk, 57%) and physician consultation (difference in absolute rate, 4.5%; OR, 1.30; 95% CI, 1. 05-1.61; attributable risk, 23%). Trends were similar among women for any respiratory symptoms (difference in absolute rate, 15.4%; OR, 1.63; 95% CI, 1.04-2.56; attributable risk, 39%) and for physician consultation (difference in absolute rates, 2.8%; OR, 1.45; 95% CI, 0.87-2.41; attributable risk, 31%). Positive dose-response relationships with number of coworkers smoking nearby and amount of ETS exposure in the work place were found.

CONCLUSIONS

This study provides further evidence of the serious health hazards associated with ETS exposure at work. The findings support a ban on smoking in the workplace to protect all workers in both developed and developing countries. JAMA. 2000;284:756-763

Prevalence of travel related illness amongst a group of Chinese undergraduate students in Hong Kong

BACKGROUND

Regional and global travel by Asian residents is increasing. Young people seeking new experiences through travel may be particularly at risk of a wide spectrum of health problems. This study assesses travel-associated health risks and examines the prevalence and likely impact of pretravel health advice among Chinese undergraduate students in Hong Kong.

METHODS

Year 1 and year 3 undergraduate students of the University of Hong Kong were surveyed during September to December 1996, using a structured self-administered questionnaire. A total of 1,067 subjects were required to give a power of 95% (p =.50+/-3%).

RESULTS

Of 1,197 students (514 male and 680 female) surveyed, 52% had traveled outside Hong Kong at least once within the previous 12 months. Of these travelers (n = 578), 41% had developed one or more health problems, 7% had to consult a doctor and 2% needed hospitalization during travel, and 8% developed health problems within 2 weeks of returning for which they had to consult a doctor. Most (75%) took no pretravel health advice and 48% took no travel health precautions. About half (41%) of those who received advice received this from nonexpert sources. Those more likely to develop health problems were aged over 20 years (Odds Ratio, 1.49, 95% confidence interval, 1.06-2.10), in financial difficulties (1.60, 1.02-2.51), ever-smokers (1.69, 1.03-2.77), reporting poorer current health status (1.64, 1.04-2.57). Also, those who sought health advice from nonprofessional sources (2.13, 1.03-4.01) and took precautions (1.88, 1.33-2.63) were more likely to develop health problems.

CONCLUSIONS

This study demonstrated that young Chinese adults, with the benefits of higher education, are potentially at risk of a variety of avoidable travel-related health problems. Taking pretravel health advice from nonprofessional sources was common among respondents, but taking precautions did not reduce health problems. The comprehensibility and effectiveness of the advice and appropriateness of precautions taken need scrutiny in randomized trials. Specific topics for pretravel health education that will target higher risk travelers with preventive messages need to be identified and evaluated.

Measuring quality of life of Chinese cancer patients: A validation of the Chinese version of the Functional Assessment of Cancer Therapy-General (FACT-G) scale

BACKGROUND

Few cancer specific quality-of-life (QoL) measures from the West have been translated for use with Chinese-speaking patients, and no substantial validation of these translations with adequately large cohorts has been published previously, to the authors' knowledge. The Functional Assessment of Cancer Therapy-General (FACT-G) is a well-validated QoL instrument that is specific to cancer patients. The scale was translated into Chinese and the psychometric properties of this translated scale (FACT-G [Ch]) were tested with a Chinese sample in Hong Kong, China.

METHODS

A total of 1262 Chinese cancer patients were selected in 3 samples from 5 Hong Kong regional hospitals. Quantitative and qualitative data were used to assess the cultural equivalence, factor structure, reliability, and validity of the FACT-G (Ch).

RESULTS

Focus group discussions indicated that the FACT-G was seen as covering QoL domains identified as important and relevant to Chinese cancer patients, though in some respects it was seen as having limited scope in this sample. Psychometrically, the factor structure of the FACT-G deviated from that of the original work. The FACT-G (Ch) had acceptable reliability (Cronbach alpha 0.85). The convergent validity of the FACT-G (Ch) with a generic QoL measure (WHOQOL-BREF[HK]) was 0.72 (P < 0.001), and divergent validity showed low correlations of less than 0.15 (P < 0.05) with non-QoL measures.

CONCLUSIONS

Focus group data indicated that the FACT-G translation into Chinese was seen as a conceptually relevant and moderately sufficient QoL measure. Psychometrically, the instrument had acceptable properties, but conceptual differences from the original version were suggested. Although more work is needed to increase its adequacy, the translated scale has reasonable utility for use with Chinese populations in clinical settings.

Effects of assisted feeding on Wobbler mouse motoneuron disease and on serotonergic and peptidergic sprouting in the cervical spinal ventral horn

The Wobbler mouse is used as a model of human motoneuron disease (MND). During the disease progress, the significant loss of motoneurons in cervical spinal cord and cranial motor nuclei leads to the progressive loss of motor function in the forelimb, head, and neck regions. The loss of cutting and chewing ability that results in the inability to feed properly might lead to a lower mean body weight (b. wt.) that is generally one-half that of the normal phenotype littermate controls. Nutritional deficit might also influence neuronal processes sprouting in the cervical spinal ventral horn. To determine whether nutritional deficits contribute to the wt. loss, and influence the progress of MND as well as its sprouting phenomenon, Wobbler and normal phenotype control littermates were dropper-fed three times daily on a regular laboratory diet of Rat Chow. Weight measurements and behavioral tests were taken to monitor the disease. Immunocytochemisty of serotonin, substance P, and leucine enkephalin were conducted in the cervical spinal cord to investigate if any alteration occurred on the previously reported values in ad lib-fed animals. Organ wts. were measured to determine where nutritional benefit was incurred. Although mean wt. loss in Wobblers was reduced, wt. differed significantly from the control values after dropper feeding. However, the progress of the disease or alteration of neurotransmitters containing neuronal processes were not affected by nutritional factors. Therefore, nutritional intake affects wt. gain, but is not a primary consideration in the progress of MND. Behavioral deficits and neurotransmitter alterations are probably directly caused by motoneuron losses.

A novel behavioral method to detect motoneuron disease in Wobbler mice aged three to seven days old

The Wobbler mouse possesses an inherited autosomal recessive form of motoneuron disease. The most characteristic abnormality is the degeneration of motoneurons, mostly in the cervical spinal cord, and in the brain stem cranial motor nuclei. The underlying pathology shows up as symptoms that are only detectable confidently around the time of weaning (age 3 weeks). We now report a new method designed to identify presymptomatic Wobbler mice by behavioral and statistical approaches. We measured body weight, righting reflex (RR) and gender to examine whether these parameters have an impact on the status of the disease before age 3 weeks. Using a total of 341 NFR/wr strain pups, we found a strong association between RR and the Wobbler disease status (p<0.0001) between postnatal days 3 to 7, and achieved greater than 97% correct classification of Wobblers. Therefore the measurement of RR allows the early detection of the affected Wobbler (wr/wr) mice with a minimum of error. This method has been used in our laboratory for immunocytochemical studies that show the early sprouting of immunoreactive serotonin and peptidergic fibers in the cervical spinal ventral horn by postnatal days 7 and 12 respectively. The early detection of Wobbler mice thus facilitates significant new understanding regarding the pathogenesis of motoneuron disease. We can now examine potentially therapeutic approaches which may be more effective than when administered in the symptomatic weanlings (work in progress).

Travel, sexual behaviour, and the risk of contracting sexually transmitted diseases

This study investigates sexual behaviour and the risk of contracting sexually transmitted diseases among travellers departing from Hong Kong, with an aim supporting the design of local intervention in continuing health promotion. Travellers were interviewed by five trained multilingual interviewers in the departure lounge at Kai Tak International Airport, Hong Kong, between May and June 1996, by using a structured, pretested questionnaire. Forty-four percent (168/383) of the respondents who travelled at least once within the previous year had had sex with strangers during their travel and 37% (139/376) of the respondents reportedly do not use condoms during sexual intercourse. Middle-aged and married travellers were more likely to be in the high-risk group. These findings reflect the urgent need to target travellers in any strategy that is designed to prevent the spread of sexually transmitted diseases in Hong Kong and Asia Pacific region.

Strategies of information disclosure to Chinese cancer patients in an Asian community

There is little information available on strategies of information disclosure used by doctors in the care of patients with cancer. This report focuses on the style of disclosure used by doctors when giving diagnostic and prognostic information to patients with cancer. Among 46% of 133 surgeons and radiotherapists interviewed, disclosure of diagnosis involved a sudden approach (information given outright at one sitting). Less commonly used (19%) was a gradual disclosure style. Of the remainder who disclosed, more than half did so through the family or left it to the family to tell the patient. Doctors' specialty and patients' requests for prognostic information dictated disclosure style most frequently. Single people were more likely to have information disclosed to their families than were married people. While anecdotal accounts indicate negative reactions on the part of patients are a major reason for withholding such information, different disclosure style had little effect on doctors' reports of patient reactions to the bad news. Doctors perceived 25% of patients appeared to react 'with depression' but the remaining 75% appeared 'calm'. These results suggest patients are more likely to be told bad news suddenly, and that doctors do not perceive that this impacts too negatively on patients. The high levels of reported preference for information about cancer in Hong Kong (Fielding and Hung, 1996) conflict with actual prevalence patterns. It seems that commonly cited anecdotal reasons for withholding information from cancer patients in Hong Kong are not sustained by the data produced in these studies.

Evaluation of two videotape instruction programmes on how to break bad news--for Cantonese-speaking medical students in Hong Kong

OBJECTIVES

To evaluate a culture-specific videotape on how to 'break bad news' and another videotape produced by a western university, and to determine if the language of presentation influenced the students' perceived abilities to execute basic skills.

SUBJECTS

Third year medical students at the Faculty of Medicine, the University of Hong Kong.

DESIGN

Longitudinal study with experimental design.

INTERVENTION

Two instructional tapes on breaking bad news; one using Chinese speaking role models and one using English.

RESULTS

In both groups, self-efficacy summed scores increased from 26.8 (95% CI = 25.9-27.7) at the pre-test to 29.0 (95% CI = 28.4-29.6). The biggest changes occurred in perceived self-efficacy regarding specific skills. However, students using the Chinese tape rated skills as more useful than those using the English tape.

CONCLUSION

The videotapes were useful in teaching communication skills. Culturally relevant audiovisual materials were more effective.

A validation of the concept of current perceived health and the Current Perceived Health-42 (CPH-42) questionnaire

Perceived or self-rated general health in its trait form reliably predicts subsequent mortality among certain sections of the community. In an investigation of the predictive value of health status at the time of assessment, 574 cases drawn from five groups (police trainees, firemen, students, out-patients and in-patients) were used to validate what we have called current perceived health (CPH) and the CPH-42, a measure of CPH is described. Results indicate those rating CPH as poorer were more likely to consult a doctor (chi 2 = 45.9, df = 1, p < 0.0000) and use medication (chi 2 = 61.0, df = 1, p < 0.0000). In comparison, general perceived health ratings did not predict either consultation or medication use. The instrument has good psychometric properties, with high divergent validity from general mental health and general health, with a Guttman split-half reliability > 0.79. Discriminant analysis using the CPH-2 achieved high correct classification rates (up to 100%). Comparison of a scoring method based on canonical coefficients (83% correct classification) with that based on summative scores (74% correct classification) indicate the former method to be more accurate. Age, and among people 40 years or older, gender were significant independent predictors of current perceived health status, with older people rating their current health less positively than younger, and females over 40 years rating their current health less positively than their male counterparts.

Health care utilization as a function of subjective health status, job satisfaction and gender among health care workers in Guangzhou, southern China

Job satisfaction, subjective health and health care utilization was studied on 72 doctors and 127 nurses working at two hospitals in Guangzhou in the People's Republic of China (P.R.C.), along with medication use and consultations with physicians over the 14 days preceding data collection. Female doctors were, on average, ten years older than male doctors. Nurses (all female) were comparable to male doctors in terms of age. Current and general subjective health, and job satisfaction differed between doctors and nurses. Nurses were less satisfied than doctors and reported poorer perceived health, until gender and age were controlled. Female doctors had poorer ratings of general and current subjective health and lower job satisfaction than their male colleagues. Path analysis tested whether lower job satisfaction leads to decrements in perceived current health which in turn increased consultation with a physician and medication use. When male and female subjects were examined separately, job satisfaction was inversely related to consultation behaviour among males and positively related to perceived current health in both genders. Among females job satisfaction and consultation behaviour related to current perceived health but were not related to each other. The hypothesized path was upheld for nurses. Lack of power prevented the same path being significant for male or female doctors. In combination, doctors showed significant relationships between the four main variables studied.

The measurement of current perceived health among Chinese people in Guangzhou and Hong Kong, southern China

General perceived health might be considered as a trait measure of perceived health and has been shown to be a reliable predictor of mortality. Current perceived health might be thought of as a state measure and as such should be more sensitive to short-term changes in health status. This paper describes the development of an instrument, the CPH-42 which measures current perceived health among Chinese people. Over 1000 items associated with ill-health were collected after interviewing 90 subjects from out-patient and in-patient settings. To these were added 38 items from section 1 of the Nottingham Health Profile (NHP) and the Chinese Health Questionnaire (CHQ30), measures of functional status and mental health respectively. These items were administered to four groups of subjects and 42 items were extracted using discriminant analysis to create the CPH-42. Results show low levels of conceptual overlap between the CHQ30 and CPH-42, and slightly more overlap between the NHP and CPH-42. Subjects' health care utilization behaviour was linearly related to rated current perceived health. It is concluded that the instrument is both a valid and reliable tool (Guttman's split-half coefficient r = 0.85) which measures a distinct area of subjective health and is shown to predict health services utilization behaviour significantly better than general perceived health.

Doctor-shopping in Hong Kong: implications for quality of care

Doctor-shopping is defined as the changing of doctors without professional referral in the same illness episode. Two surveys on samples of patients attending Government Out-Patient Departments (GOPDs) in Hong Kong in 1989 (n = 869) and 1990 (n = 901) estimated the prevalence of shopping at nearly 40%, the main reason being a persistence of symptoms. Doctor-shoppers were likely to be younger with higher expectations of health care and who expressed dissatisfaction about aspects of the present service. In Hong Kong, patients perceive western medicine to be more effective and have high expectations of the effects of western drugs, in particular, in their administration by injection. Patients should be warned about iatrogenic health risks incurred from doctor-shopping; health education programmes are needed to modify unrealistic views about quality care. Health care providers in a mixed care system should promote greater continuity of care between doctors and both the public and private sectors, and identify and resolve problems which may be responsible for discontinuity of care.

Alteration in the levels of thyrotropin releasing hormone, substance P and enkephalins in the spinal cord, brainstem, hypothalamus and midbrain of the Wobbler mouse at different stages of the motoneuron disease

The present study was undertaken to quantify selected neuropeptides (thyrotropin releasing hormone, substance P, methionine and leucine enkephalin) in the cervical spinal cord and other regions of the central nervous system of Wobbler mice by radioimmunoassays during several stages of the motoneuron disease compared with age- and sex-matched normal phenotype littermates. In Wobbler spinal cord, thyrotropin releasing hormone is higher early in the disease, whereas in the brainstem it is higher at a later stage. Substance P in spinal cord is also higher late in the disease. Leucine enkephalin levels are greater at all stages in diseased spinal cord and brainstem, but methionine enkephalin increases only late in the disease. Highly significant increases of the peptides (except thyrotropin releasing hormone) appear in hypothalamus and midbrain only late in the motoneuron disease. Regression analyses show that thyrotropin releasing hormone in spinal cord and brainstem decreases normally with age in the control mice and at a faster rate related to the extent of motor impairment in Wobbler mice. Thyrotropin releasing hormone and methionine enkephalin in the Wobbler brainstem correlate (P less than 0.05) with the progress of the motoneuron disease. Methionine enkephalin increases faster in Wobbler brainstem and decreases faster in control spinal cord with age. The increase of leucine enkephalin in the Wobbler spinal cord correlates significantly with age and with the progress of the disease, but leucine enkephalin declines slightly with age in the controls. The changes of substance P in spinal cord and brainstem do not correlate significantly with the progress of the disease. In the hypothalamus, increasing values for substance P in control specimens and enkephalins in Wobbler specimens are significantly correlated with age. However, in the midbrain, higher methionine and leucine enkephalin levels are significantly associated with age only in the control mice. Alterations of neuropeptides in the Wobbler mouse spinal cord and brainstem may result from the degeneration of bulbospinal raphe neurons projecting to the ventral spinal cord, or from primary afferent or interneuronal nerve terminals. The data imply that the neuronal degeneration process in the Wobbler motoneuron disease is not limited to motoneurons. In the spinal cord, the data support our previous hypothesis that neuronal sprouting presynaptic to the motoneurons may account for increased neuropeptide concentrations. Alternatively, synthesis and/or degradation of these peptides may be altered. In addition, it is proposed that enkephalinergic neurons may develop abnormally in Wobbler mice. The early increase of leucine enkephalin in the Wobbler spinal cord possibly indicates its importance in the etiology of the motoneuron disease.

A comparison of case retrieval times: film versus picture archiving and communications systems

One of the advantages that a picture archiving and communications system (PACS) is supposed to provide over a film-based operation is improved performance in retrieving images. Although it seems self-evident that this should be so, this experiment was intended to verify this and to provide some time comparisons for the two methods. The experiment consisted of randomly selecting ultrasound and computed tomography cases and determining how long it took to retrieve files at a PACS workstation or in person from the file room. To simulate actual retrieval volumes, a total of 40 cases from current to 6 months old, 20 cases from the past year, and 10 cases more than 1 year old was selected. Results indicate that PACS retrieval can indeed be faster than file room retrieval. However, the difference is less for recent cases than for older cases. For cases 6 or fewer months old, the workstation retrieval was approximately 2.5 minutes faster per case than the film file room. This time difference increased markedly when extended to the 1-year and older-than-1-year groups. This report details the results of this study and provides information about the reliability of the two archives.

Effects of social interaction on distress and recovery from minor surgery in elective paediatric patients

Thirty-six children aged 2-10 years, the majority of whom were males admitted for urogenital surgery, were observed for level and frequency of distress and type of social interaction over the duration of hospitalization. The results indicate that high levels of observed distress were associated with longer post-operative hospital stays. Staff interactions were associated with higher levels of distress while peer caretaking interactions were associated with lower levels of distress. We tested the hypothesis that social interaction lowered distress, leading to a briefer hospital stay. Using path analysis, we found peer caretaking interactions accounted for a small but significant percentage of the observed variance in duration of post-operative hospital stay. These data illustrate the potential importance of social environments in the maintenance of reduction of distress before and after paediatric surgery. This raises the expectation that certain types of social environments could facilitate recovery from surgery.

Depression and acute myocardial infarction: a review and reinterpretation

Depression is widely accepted as occurring in response to acute myocardial infarction (AMI), and to be an important determinant of recovery. A review of the literature reveals that three categories of patients with depressive symptomatology may be identifiable. First, many patients show depressive symptoms before admission with AMI; these may intensify during hospitalisation. For these patients, the depressive symptoms may contribute etiologically to the onset of AMI or derive from a common source along with AMI. The second group constitute patients with a history of AMI, and who on readmission with chest pain or suspected AMI are more likely to report depressive symptoms. The third group of patients are non-depressed first time admissions for AMI. These patients appear to show transient depressive reactions, much of which it is argued, occurs as a reaction to hospitalisation and not to AMI per se. This review considers the theoretical context whereby depressive symptoms may arise from the same circumstances that generate the coronary heart disease which underlies AMI, and links this to the generation of helplessness and cardiopathic processes.

Leucine metabolism during fasting and exercise

Whole body leucine kinetics were examined in seven healthy young men while in a 14-h postabsorptive state (PAS) and after a 3.5-day fast (FS). Subjects received a primed constant intravenous infusion of L-[1-13C]leucine while resting for 3 h and then while exercising on a cycle ergometer at 45% maximal O2 uptake to exhaustion. Blood samples drawn during isotopic steady state were analyzed for 13C enrichment of leucine and alpha-ketoisocaproic acid, and expired gas samples were analyzed for 13CO2. Resting leucine flux was higher in the FS, and there was a slight increase in leucine oxidation. During exercise, leucine flux did not differ between PAS and FS but leucine oxidation rose markedly. In the FS, leucine oxidation was 25 +/- 7 (SD) mumol.kg-1.h-1 at rest and rose to 75 +/- 21 mumol.kg-1.h-1 during exercise; in the PAS, oxidation was 20 +/- 5 mumol.kg-1.h-1 at rest and 52 +/- 17 mumol.kg-1.h-1 during exercise. These data indicate that the high rate of leucine oxidation previously found during exercise was increased further by a 3.5-day fast.