Extended Paid Maternity Leave Associated With Improved Maternal Mental Health In Hong Kong

In July 2020, Hong Kong extended statutory paid maternity leave from ten weeks to fourteen weeks to align with International Labour Organization standards. We used the policy enactment as an observational natural experiment to assess the mental health implications of this policy change on probable postnatal depression (Edinburgh Postnatal Depression Scores of 10 or higher) and postpartum emotional well-being. Using an opportunistic observational study design, we recruited 1,414 survey respondents with births before (August 1-December 10, 2020) and after (December 11, 2020-July 18, 2022) policy implementation. Participants had a mean age of thirty-two, were majority primiparous, and were mostly working in skilled occupations. Our results show that the policy was associated with a 22 percent decrease in mothers experiencing postnatal depressive symptoms and a 33 percent decrease in postpartum emotional well-being interference. Even this modest change in policy, an additional four weeks of paid leave, was associated with significant mental health benefits. Policy makers should consider extending paid maternity leave to international norms to improve mental health among working mothers and to support workforce retention.

Exploring Hong Kong nurses' decision-making processes around presenteeism

BACKGROUND

Presenteeism among nurses is the common behaviour of being physically present at work when one should not be due to personal health and well-being, a stressful work environment, lack of work-life balance, or a sense of professional identity or obligation.

AIMS

To explore nurses' decision-making process related to presenteeism in a large Hong Kong public hospital.

METHODS

As part of a larger study on nurse presenteeism in Hong Kong, we conducted focus groups with nurses to understand their considerations related to working sick.

RESULTS

Eleven major themes emerged from the focus groups, which we grouped into three organizational domains reflecting nurses' decision-making process around presenteeism: consideration for colleagues, organizational factors and professional identity.

CONCLUSIONS

Presenteeism was a familiar behaviour among Hong Kong nurses in our study. We found both overlap and divergence with prior presenteeism research in the domains and themes identified. Loyalty to colleagues, written and unwritten rules and professional identity as nurses all seemed to encourage presenteeism among Hong Kong nurses. Organizations seeking to discourage presenteeism should evaluate policies such as sick leave certificates, ensure appropriate coverage for all nurse ranks and address subcultural norms encouraging presenteeism.

Acute intermittent hypoxia enhances regeneration of surgically repaired peripheral nerves in a manner akin to electrical stimulation

The intrinsic repair response of injured peripheral neurons is enhanced by brief electrical stimulation (ES) at time of surgical repair, resulting in improved regeneration in rodents and humans. However, ES is invasive. Acute intermittent hypoxia (AIH) - breathing alternate cycles of regular air and air with ~50% normal oxygen levels (11% O₂), considered mild hypoxia, is an emerging, promising non-invasive therapy that promotes motor function in spinal cord injured rats and humans. AIH can increase neural activity and under moderately severe hypoxic conditions improves repair of peripherally crushed nerves in mice. Thus, we posited an AIH paradigm similar to that used clinically for spinal cord injury, will improve surgically repaired peripheral nerves akin to ES, including an impact on regeneration-associated gene (RAG) expression-a predictor of growth states. Alterations in early RAG expression were examined in adult male Lewis rats that underwent tibial nerve coaptation repair with either 2 days AIH or normoxia control treatment begun on day 2 post-repair, or 1 h ES treatment (20 Hz) at time of repair. Three days post-repair, AIH or ES treatments effected significant and parallel elevated RAG expression relative to normoxia control at the level of injured sensory and motor neuron cell bodies and proximal axon front. These parallel impacts on RAG expression were coupled with significant improvements in later indices of regeneration, namely enhanced myelination and increased numbers of newly myelinated fibers detected 20 mm distal to the tibial nerve repair site or sensory and motor neurons retrogradely labeled 28 mm distal to the repair site, both at 25 days post nerve repair; and improved return of toe spread function 5-10 weeks post-repair. Collectively, AIH mirrors many beneficial effects of ES on peripheral nerve repair outcomes. This highlights its potential for clinical translation as a non-invasive means to effect improved regeneration of injured peripheral nerves.

Treatment-induced remission of medulloblastoma using a chemotherapeutic regimen devoid of vincristine in a child with Charcot-Marie-Tooth disease

Charcot-Marie-Tooth (cmt) disease is the most common form of inherited neuropathy. Core features include peripheral neuropathy and secondary axonal degeneration, with a noted distal predominance of limb-muscle wasting, weakness, and sensory loss. Given the significant prevalence of cmt, superimposed neoplastic disease can be encountered within this patient population. Malignancies that are treated with vincristine (a microtubule-targeting agent), even at low doses as part of standard treatment, pose a significant challenge for patients with cmt. Here, we present the case of a child with cmt who was successfully treated for medulloblastoma without vincristine, a standard drug used for treatment of that disease, to avoid the risk of severe debilitating neuropathy. This report is the first of a patient successfully treated for medulloblastoma without vincristine.

Demonstration of differences in colonic volumes, transit, chyme consistency, and response to psyllium between healthy and constipated subjects using magnetic resonance imaging

BACKGROUND

In functional gastrointestinal disorders a lack of objective biomarkers limits evaluation of underlying mechanisms. We aimed to demonstrate the utility of magnetic resonance imaging for this task using psyllium, an effective constipation treatment, in patients and controls.

METHODS

Two crossover studies: (i) adults without constipation (controls, n = 9) took three treatments in randomized order for 6 days - maltodextrin (placebo), psyllium 3.5 g t.d.s and 7 g t.d.s., (ii) adults with chronic constipation (patients, n = 20) took placebo and psyllium 7 g t.d.s. for 6 days. MRI was performed fasting and postprandially on day 6. Measurements included small bowel and ascending colon water content, colonic volume, transit time, and MR relaxometry (T1, T2) to assess colonic chyme. Stool water percentage was measured.

RESULTS

7 g psyllium t.d.s. increased fasting colonic volumes in controls from median 372 mL (IQR 284-601) to 578 mL (IQR 510-882), and in patients from median 831 mL (IQR 745-934) to 1104 mL (847-1316), P < .05. Mean postprandial small bowel water was higher in controls and patients after 7 g psyllium t.d.s. vs placebo. Whole gut transit was slower in patients than controls (P < .05). T1 of the descending colon chyme (fasting) was lower in patients (213 ms, 176-420) than controls (440 ms, 352-884, P < .05) on placebo, but increased by 7 g psyllium t.d.s. (590 ms, 446-1338), P < .001. Descending colon T1 correlated with baseline stool water content and stool frequency on treatment.

CONCLUSIONS AND INFERENCES

MRI measurements can objectively demonstrate the mode of action of therapy targeting intestinal fluid content in constipation.

A validation study of public health knowledge, skills, social responsibility and applied learning

OBJECTIVES

To design and validate a questionnaire to measure medical students' Public Health (PH) knowledge, skills, social responsibility and applied learning as indicated in the four domains recommended by the Association of Schools & Programmes of Public Health (ASPPH).

METHODS

A cross-sectional study was conducted to develop an evaluation tool for PH undergraduate education through item generation, reduction, refinement and validation. The 74 preliminary items derived from the existing literature were reduced to 55 items based on expert panel review which included those with expertise in PH, psychometrics and medical education, as well as medical students. Psychometric properties of the preliminary questionnaire were assessed as follows: frequency of endorsement for item variance; principal component analysis (PCA) with varimax rotation for item reduction and factor estimation; Cronbach's Alpha, item-total correlation and test-retest validity for internal consistency and reliability.

RESULTS

PCA yielded five factors: PH Learning Experience (6 items); PH Risk Assessment and Communication (5 items); Future Use of Evidence in Practice (6 items); Recognition of PH as a Scientific Discipline (4 items); and PH Skills Development (3 items), explaining 72.05% variance. Internal consistency and reliability tests were satisfactory (Cronbach's Alpha ranged from 0.87 to 0.90; item-total correlation > 0.59). Lower paired test-retest correlations reflected instability in a social science environment.

CONCLUSIONS

An evaluation tool for community-centred PH education has been developed and validated. The tool measures PH knowledge, skills, social responsibilities and applied learning as recommended by the internationally recognised Association of Schools & Programmes of Public Health (ASPPH).

Differences in the diagnosis and management of systemic lupus erythematosus by primary care and specialist providers in the American Indian/Alaska Native population

Objectives The objective of this study is to investigate differences in the diagnosis and management of systemic lupus erythematosus (SLE) by primary care and specialist physicians in a population-based registry. Methods This study includes individuals from the 2009 Indian Health Service lupus registry population with a diagnosis of SLE documented by either a primary care provider or specialist. SLE classification criteria, laboratory testing, and medication use at any time during the course of disease were determined by medical record abstraction. Results Of the 320 individuals with a diagnosis of SLE, 249 had the diagnosis documented by a specialist, with 71 documented by primary care. Individuals with a specialist diagnosis of SLE were more likely to have medical record documentation of meeting criteria for SLE by all criteria sets (American College of Rheumatology, 79% vs 22%; Boston Weighted, 82% vs 32%; and Systemic Lupus International Collaborating Clinics, 83% vs 35%; p < 0.001 for all comparisons). In addition, specialist diagnosis was associated with documentation of ever having been tested for anti-double-stranded DNA antibody and complement 3 and complement 4 ( p < 0.001). Documentation of ever receiving hydroxychloroquine was also more common with specialist diagnosis (86% vs 64%, p < 0.001). Conclusions Within the population studied, specialist diagnosis of SLE was associated with a higher likelihood of having SLE classification criteria documented, being tested for biomarkers of disease, and ever receiving treatment with hydroxychloroquine. These data support efforts both to increase specialist access for patients with suspected SLE and to provide lupus education to primary care providers.

Determining an optimal dose of linaclotide for use in Japanese patients with irritable bowel syndrome with constipation: A phase II randomized, double-blind, placebo-controlled study

BACKGROUND

Clinical testing to determine a suitable dose of linaclotide for Japanese patients with irritable bowel syndrome with constipation (IBS-C) was needed.

METHODS

This was a randomized, double-blind, placebo-controlled, dose-finding trial. Japanese patients with IBS-C diagnosed using Rome III criteria (n = 559, men/women: 49/510) were randomly assigned to 1 of 4 linaclotide doses (0.0625, 0.125, 0.25, or 0.5 mg) or placebo for the 12-week treatment period. The primary endpoint was responder rate of global assessment of relief of IBS symptoms during 12 weeks. The secondary endpoints included responder rates of complete spontaneous bowel movement (CSBM), SBM and abdominal pain/discomfort relief and others.

KEY RESULTS

The primary endpoint was 23.2%, 36.2%, 38.7%, 34.8%, and 38.3% in placebo (n = 112), 0.0625 (n = 116), 0.125 (n = 111), 0.25 (n = 112), and 0.5 (n = 107) mg of linaclotide groups with the difference from the placebo group in each linaclotide group (13.0%, 15.5%, 11.6%, 15.1%, P > .05). Monthly responder rate of global assessment of relief of IBS symptoms at month 3 (48.6%), responder rate of CSBM during 12 weeks (45.8%), and responder rate of abdominal pain/discomfort relief during 12 weeks (32.7%) in the 0.5 mg were significantly higher than those in placebo group (29.5%, P < .01; 25.9%, P < .01; and 18.8%, P < .05 respectively). The most frequent adverse event in the linaclotide groups was diarrhea.

CONCLUSIONS & INFERENCES

This study suggests that a linaclotide dose of 0.5 mg may be appropriate in Japanese patients with IBS-C.

Cohort Profile: FAMILY Cohort

The FAMILY Cohort is a longitudinal study of health, happiness and family harmony (the '3Hs') at individual, household and neighbourhood levels in Hong Kong. Using a family living in the same household as the sampling unit, the study (n = 20 279 households and 46 001 participants) consists of a composite sample from several sources, including: a population-representative random core sample (n = 8115 households and 19 533 participants); the first-degree relatives of this sample (n = 4658 households and 11 063 participants); and oversampling in three new towns (n = 2891 households and 7645 participants) and in three population subgroups with anticipated changes in family dynamics (n = 909 households and 2160 participants). Two household visits and five telephone- or web-based follow-ups were conducted over 2009-14. Data collected include socio-demographics, anthropometrics, lifestyle and behavioural factors, measures of social capital, and standardized instruments assessing the 3Hs. We also intend to collect biomaterials in future. The analytical plan includes multilevel inter-relations of the 3Hs for individuals, households, extended families and neighbourhoods. With Hong Kong's recent history of socioeconomic development, the FAMILY Cohort is therefore relevant to global urban populations currently experiencing similarly rapid economic growth. The FAMILY Cohort is currently set up as a supported access resource.

Cross-sectional associations of objectively assessed neighbourhood attributes with depressive symptoms in older adults of an ultra-dense urban environment: the Hong Kong ALECS study

OBJECTIVES

This study aimed to examine the associations between objectively assessed neighbourhood environmental attributes and depressive symptoms in Hong Kong Chinese older adults and the moderating effects of neighbourhood environmental attributes on the associations between living arrangements and depressive symptoms.

DESIGN

Cross-sectional observational study.

SETTING

Hong Kong.

PARTICIPANTS

909 Hong Kong Chinese community dwellers aged 65+ years residing in preselected areas stratified by walkability and socioeconomic status.

EXPOSURE AND OUTCOME MEASURES

Attributes of participants' neighbourhood environment were objectively assessed using geographic information systems and environmental audits. Depressive symptoms were measured using the Geriatric Depression Scale.

RESULTS

Overall, pedestrian infrastructure (OR=1.025; P=0.008), connectivity (OR=1.039; P=0.002) and prevalence of public transport stops (OR=1.056; P=0.012) were positively associated with the odds of reporting depressive symptoms. Older adults living alone were at higher risk of reporting any depressive symptoms than those living with others (OR=1.497; P=0.039). This association was moderated by neighbourhood crowdedness, perceptible pollution, access to destinations and presence of people. Residing in neighbourhoods with lower levels of these attributes was associated with increased deleterious effects of living alone. Living in neighbourhoods with lower public transport density also increased the deleterious effects of living alone on the number of depressive symptoms. Those living alone and residing in neighbourhoods with higher levels of connectivity tended to report more depressive symptoms than their counterparts.

CONCLUSIONS

The level of access to destinations and social networks across Hong Kong may be sufficiently high to reduce the risk of depressive symptoms in older adults. Yet, exposure to extreme levels of public transport density and associated traffic volumes may increase the risk of depressive symptoms. The provision of good access to a variety of destinations, public transport and public open spaces for socialising in the neighbourhood may help reduce the risk of depressive symptoms in older adults who live alone.

Diabetes incidence and prevalence in Hong Kong, China during 2006-2014

AIMS

To estimate recent secular changes in the incidence and prevalence of diabetes and pre-diabetes among Hong Kong Chinese adults, and thus show possible future trends for developing mainland China.

METHODS

Based on a complete census of the public sector health records of 6.4 million people from 2006 to 2014, diabetes cases were ascertained using different methods including the World Health Organization (WHO) 2011 guidelines (HbA_1c , fasting plasma glucose and glucose tolerance test), American Diabetes Association (ADA) 2015 guidelines (plus random plasma glucose), and additionally recorded diagnosis codes and medication dispensation. Pre-diabetes was defined using ADA 2015 guidelines.

RESULTS

We identified 697 201 people with diabetes (54.2% were incident cases); and 1 229 731 people with diabetes or pre-diabetes. In 2014, the overall incidence of diabetes was 9.46 per 1000 person-years [95% confidence interval (CI): 9.38 to 9.54], and overall prevalence was 10.29% (95% CI: 10.27% to 10.32%). Incidence of diabetes decreased significantly from 2007 to 2014 (quadratic trend, P < 0.001). From 2006 to 2014, the prevalence of diabetes increased significantly in both sexes and across all age groups (quadratic trend, P < 0.001). The overall incidence of pre-diabetes in 2014 was 18.88 per 1000 person-years (95% CI: 18.76 to 18.99), and the overall prevalence of pre-diabetes was 8.90% (95% CI: 8.87% to 8.92%).

CONCLUSIONS

Similar to other developed western and Asian populations, diabetes (and pre-diabetes) incidence in Hong Kong Chinese appeared to have stabilized and there have been small declines during the period of observation. Ageing and survivorship will likely drive a continued increase in the prevalence of diabetes and pre-diabetes, albeit with a decelerating growth rate if past trends persist.

Crystal structure of a bicupin protein HutD involved in histidine utilization in Pseudomonas

Cupins form one of the most functionally diverse superfamilies of proteins, with members performing a wide range of catalytic, non-catalytic, and regulatory functions. HutD is a predicted bicupin protein that is involved in histidine utilization (Hut) in Pseudomonas species. Previous genetic analyses have suggested that it limits the upper level of Hut pathway expression, but its mechanism of action is unknown. Here, we have determined the structure of PfluHutD at 1.74 Å resolution in several crystallization conditions, and identified N-formyl-l-glutamate (FG, a Hut pathway intermediate) as a potential ligand in vivo. Proteins 2017; 85:1580-1588. © 2017 Wiley Periodicals, Inc.

Associations between the neighbourhood environment characteristics and physical activity in older adults with specific types of chronic conditions: the ALECS cross-sectional study

Background

Neighbourhood characteristics may influence physical activity (PA), which has positive effects on the health of older adults. Older adults with chronic conditions are less active and possibly more affected by environmental factors than their peers. Understanding neighbourhood characteristics associated with PA specific to older adults with chronic conditions is currently lacking. This cross-sectional study aimed to assess the associations between the neighbourhood environment and various forms of PA in older adults with and without visual impairment, hearing impairment, musculoskeletal disease and/or genitourinary disease.

Methods

Neighbourhood environment and PA data were collected in Hong Kong older adults (N = 909) from 124 preselected neighbourhoods stratified for walkability and socioeconomic status. Generalized linear models and zero-inflated negative binomial models with robust standard errors were used to examine associations of perceived neighbourhood environment characteristics, and the moderating effects of having specific chronic conditions, with PA outcomes.

Results

Thirteen perceived neighbourhood characteristics were associated with older adults’ PA in the expected direction irrespective of their health condition. Nine neighbourhood characteristics had associations with PA that were dependent on hearing impairment, vision impairment, musculoskeletal disease or genitourinary disease. In general, they were stronger in participants with than without a specific chronic condition.

Conclusions

Maximizing the potential for PA in older adults who have lower levels of physical functionality due to chronic conditions may require neighbourhood characteristics specific to these groups.

Neighbourhood environment, physical activity, quality of life and depressive symptoms in Hong Kong older adults: a protocol for an observational study

INTRODUCTION

The neighbourhood environment can assist the adoption and maintenance of an active lifestyle and affect the physical and mental well-being of older adults. The psychosocial and behavioural mechanisms through which the environment may affect physical and mental well-being are currently poorly understood.

AIM

This observational study aims to examine associations between the physical and social neighbourhood environments, physical activity, quality of life and depressive symptoms in Chinese Hong Kong older adults.

METHODS AND ANALYSES

An observational study of the associations of measures of the physical and social neighbourhood environment, and psychosocial factors, with physical activity, quality of life and depressive symptoms in 900 Hong Kong older adults aged 65+ years is being conducted in 2012-2016. The study involves two assessments taken 6 months apart. Neighbourhood walkability and access to destinations are objectively measured using Geographic Information Systems and environmental audits. Demographics, socioeconomic status, walking for different purposes, perceived neighbourhood and home environments, psychosocial factors, health status, social networks, depressive symptoms and quality of life are being assessed using validated interviewer-administered self-report measures and medical records. Physical functionality is being assessed using the Short Physical Performance Battery. Physical activity and sedentary behaviours are also being objectively measured in approximately 45% of participants using accelerometers over a week. Physical activity, sedentary behaviours, quality of life and depressive symptoms are being assessed twice (6 months apart) to examine seasonality effects on behaviours and their associations with quality of life and depressive symptoms.

ETHICS AND DISSEMINATION

The study received ethical approval from the University of Hong Kong Human Research Ethics Committee for Non-Clinical Faculties (EA270211) and the Department of Health (Hong Kong SAR). Data are stored in a password-protected secure database for 10 years, accessible only to the named researchers. Findings will be submitted for publication in peer-reviewed journals.

Structure and validity of Family Harmony Scale: An instrument for measuring harmony

Culture plays a role in mental health, partly by defining the characteristics that are indicative of positive adjustment. In Chinese cultures, positive family relationships are considered central to well-being. The culturally emphasized characteristic of family harmony may be an important factor associated with psychopathology. This article presents the development and psychometric examination of the Family Harmony Scale (FHS), an indigenously developed 24-item instrument tapping family harmony in 17,461 Hong Kong residents from 7,791 households. A higher-order model with 1 second-order factor and 5 first-order factors fit the data well and showed factorial invariance across sex and participants in different family roles. A 5-item short form (FHS-5) was also developed, with 1 item from each first-order factor. The short scale showed, as expected, a single-factor structure with good fit. Both scales demonstrated high internal consistency, acceptable test-retest reliability, and good convergent and discriminant validity. The 24-item FHS was negatively associated with depressive symptoms after accounting for individual risk factors and general family function. Family harmony moderated the relationship between life stress and depressive symptoms such that those individuals who reported low family harmony had stronger associations between life stress and depressive symptoms. This study adds to the literature a systematically developed, multidimensional measure of family harmony, which may be an important psychological protective factor, in a large urban Chinese sample. The FHS-5 minimizes operational and respondent burdens, making it an attractive tool for large-scale epidemiological studies with Chinese populations in urban settings, where over half of China's 1.4 billion people reside.

Depression and health-seeking behaviour among migrant workers in Shenzhen

BACKGROUND

This study describes the prevalence of depression symptoms and its impact on health-seeking behaviour among Chinese migrant workers in a sample of 1,533 Shenzhen residents.

METHODS

A cross-sectional questionnaire survey was administered in Shenzhen with a random sample of 859 registered and 674 non-registered residents. The 20-item Centre for Epidemiologic Studies-Depression Scale (CES-D) scale was used to measure depression symptoms. Multivariate regression analysis was applied to assess healthcare services utilisation.

RESULTS

Non-registered residents were more likely to have clinically significant depressive symptoms (CES-D score ≥ 16) (odds ratio (OR) = 1.81; confidence interval (CI) = 1.18, 2.76). Despite this, depressed non-registered residents had no significant difference in health-seeking behaviour when compared to those without depression (OR = 2.86; CI = 0.98, 8.32), while in contrast, depressed registered residents had a positive and stronger association with healthcare services utilisation and/or self-medication (OR = 3.34; CI = 1.28, 8.71).

CONCLUSION

The findings suggest higher prevalence of depression but less utilisation of healthcare services or self-medication among migrant residents. That migrants with depression lack access to healthcare suggests healthcare inequality. Psychological disorders require careful management and treatment; the mismatch in their health needs and access to care may contribute to the Inverse-care law.

Neighbourhood environment, sitting time and motorised transport in older adults: a cross-sectional study in Hong Kong

OBJECTIVES

Sitting time is a public health concern. This study examined associations of objectively measured neighbourhood environmental attributes with non-transport sitting time and motorised transport in 484 Hong Kong older adults. Neighbourhood attributes encouraging walking may help older adults replace some sitting time at home and on motorised transport with light-to-moderate-intensity activities such as strolling around the neighbourhood or walking to/from neighbourhood destinations. Thus, we hypothesised environmental attributes found to be related to walking would show associations with non-transport sitting time and motorised transport opposite to those seen for walking.

DESIGN

Cross-sectional.

SETTING

Hong Kong, an ultradense urban environment.

PARTICIPANTS

484 ethnic Chinese Hong Kong residents aged 65+ recruited from membership lists of four Hong Kong Elderly Health Centres representing catchment areas of low and high transport-related walkability stratified by socioeconomic status (response rate: 78%).

PRIMARY AND SECONDARY OUTCOME MEASURES

Attributes of participants' neighbourhood environments were assessed by environmental audits, while non-transport sitting time and motorised transport were ascertained using the International Physical Activity Questionnaire-Long Form (Chinese version).

RESULTS

Daily non-transport sitting minutes were 283 (SD=128) and motorised transport 23 (SD=28). Prevalence of signs of crime/disorder, streetlights, public facilities (toilets and benches) and pedestrian safety were independently negatively related, and sloping streets positively related, to sitting outcomes. Places of worship in the neighbourhood were predictive of more, and prevalence of public transit points of less, non-transport sitting. Associations of either or both sitting outcomes with prevalence of food/grocery stores and presence of parks were moderated by path obstructions and signs of crime/disorder.

CONCLUSIONS

The findings suggest that access to specific destinations and relatively low-cost, minimal impact modifications to the urban form, such as street lighting, public toilets, benches and public transit points, could potentially reduce sitting time and associated negative health outcomes in Hong Kong older adults.

The impact of abdominal pain on global measures in patients with chronic idiopathic constipation, before and after treatment with linaclotide: a pooled analysis of two randomised, double-blind, placebo-controlled, phase 3 trials

BACKGROUND

Few clinical trials in chronic idiopathic constipation (CIC) patients have evaluated abdominal symptom severity and whether CIC patients with abdominal symptoms respond similarly to patients with limited abdominal symptoms.

AIMS

To examine abdominal symptom severity and relationships between symptoms and global measures at baseline; compare linaclotide's effect on symptoms in subpopulations with more or less abdominal pain; and assess relationships between symptom improvement and global measures in these two subpopulations.

METHODS

In two phase 3 trials, patients meeting modified Rome II CIC criteria were assigned to linaclotide 145 μg, 290 μg, or placebo once daily. Patients rated abdominal and bowel symptoms daily during 2-week pre-treatment and 12-week treatment periods. Linaclotide's effect on symptoms and global measures [constipation severity, health-related quality of life (HRQOL), treatment satisfaction] and their inter-relationships were assessed in post hoc analyses of abdominal pain subpopulations.

RESULTS

Of 1271 CIC patients, 23%, 32%, and 43% reported moderate-to-severe abdominal pain, discomfort, and bloating, respectively, during baseline. In more-severe abdominal pain patients, abdominal symptoms were more strongly correlated than bowel symptoms with global measures, but in less-severe abdominal pain patients, abdominal and bowel symptoms were similarly correlated with global measures, at baseline and post-treatment. Linaclotide significantly improved all symptoms and global measures in both subpopulations.

CONCLUSIONS

When abdominal pain is present in CIC, abdominal and not bowel symptoms may drive patient assessments of constipation severity, HRQOL, and treatment satisfaction. Linaclotide (145 μg and 290 μg) is an effective treatment for both abdominal and bowel symptoms, even in CIC patients with more severe abdominal pain at baseline. (Clinicaltrials.gov: NCT00765882, NCT00730015).

High-throughput screening identifies compounds that enhance lentiviral transduction

A difficulty in the field of gene therapy is the need to increase the susceptibility of hematopoietic stem cells (HSCs) to ex vivo genetic manipulation. To overcome this obstacle a high-throughput screen was performed to identify compounds that could enhance the transduction of target cells by lentiviral vectors. Of the 1280 compounds initially screened using the myeloid-erythroid-leukemic K562 cell line, 30 were identified as possible enhancers of viral transduction. Among the positive hits were known enhancers of transduction (camptothecin, etoposide and taxol), as well as the previously unidentified phorbol 12-myristate 13-acetate (PMA). The percentage of green fluorescent protein (GFP)-positive-expressing K562 cells was increased more than fourfold in the presence of PMA. In addition, the transduction of K562 cells with a lentiviral vector encoding fVIII was four times greater in the presence of PMA as determined by an increase in the levels of provirus in genetically modified cells. PMA did not enhance viral transduction of all cell types (for example, sca-1(+) mouse hematopoietic cells) but did enhance viral transduction of human bone marrow-derived CD34(+) cells. Notably, the percentage of GFP-positive CD34(+) cells was increased from 7% in the absence of PMA to greater than 22% in the presence of 1 nM PMA. PMA did not affect colony formation of CD34(+) cells or the expression of the hematopoietic markers CD34 and CD45. These data demonstrate that high-throughput screening can be used to identify compounds that increase the transduction efficiency of lentiviral vectors, identifying PMA as a potential enhancer of lentiviral HSC transduction.

Psychometric validation of symptom severity measures in irritable bowel syndrome with constipation

BACKGROUND

Historically, measures of symptom severity of irritable bowel syndrome with constipation (IBS-C) in clinical trials have not met the evidence requirements described in the FDA guidance on patient-reported outcomes (PROs), which describes the evidentiary requirements and review criteria for patient-reported outcome measures intended to support product approval or labelling claims.

AIM

Data from two phase 3 trials (N = 1608) of linaclotide for the treatment of IBS-C were analysed to evaluate the psychometric properties of patient-reported outcome measures assessing changes in the severity of abdominal and bowel symptoms.

METHODS

A set of patient-reported outcome assessments addressing abdominal and bowel symptoms, the IBS-C Symptom Severity Measures, were administered daily using interactive voice response system technology. Intraclass correlation coefficients (ICCs), Pearson correlations, factor analyses, F-tests and effect sizes were computed to evaluate the reliability, construct validity, discriminating ability and responsiveness of the IBS-C Symptom Severity Measures in a clinical trial context.

RESULTS

The IBS-C Symptom Severity Measures showed highly satisfactory test-retest reliability (ICCs ranging from 0.79 to 0.95) and construct validity. Factor analyses indicated one factor for abdominal symptoms and another for bowel symptoms. Known-groups F-tests comparing subgroups based on various responder definitions were statistically significant and in the expected direction, substantiating the discriminating ability of the IBS-C Symptom Severity Measures. Responsiveness statistics (ranging from 0.6 to 2.1) demonstrated these measures are also capable of detecting change.

CONCLUSIONS

The psychometric analysis results strongly support the reliability, construct validity, discriminating ability and responsiveness of the IBS-C Symptom Severity Measures and substantiate the conclusion of linaclotide treatment benefit.

Factors affecting implementation of accreditation programmes and the impact of the accreditation process on quality improvement in hospitals: a SWOT analysis

OBJECTIVES

The objectives of this review were to identify factors that influence implementation of hospital accreditation programmes and to assess the impact of the accreditation process on quality improvement in public hospitals.

DATA SOURCES

Two electronic databases, Medline (OvidSP) and PubMed, were systematically searched.

STUDY SELECTION

"Public hospital", "hospital accreditation", and "quality improvement" were used as the search terms. A total of 348 citations were initially identified. After critical appraisal and study selection, 26 articles were included in the review.

DATA EXTRACTION

The data were extracted and analysed using a SWOT (strengths, weaknesses, opportunities, threats) analysis.

DATA SYNTHESIS

Increased staff engagement and communication, multidisciplinary team building, positive changes in organisational culture, and enhanced leadership and staff awareness of continuous quality improvement were identified as strengths. Weaknesses included organisational resistance to change, increased staff workload, lack of awareness about continuous quality improvement, insufficient staff training and support for continuous quality improvement, lack of applicable accreditation standards for local use, and lack of performance outcome measures. Opportunities included identification of improvement areas, enhanced patient safety, additional funding, public recognition, and market advantage. Threats included opportunistic behaviours, funding cuts, lack of incentives for participation, and a regulatory approach to mandatory participation.

CONCLUSIONS

By relating the findings to the operational issues of accreditation, this review discussed the implications for successful implementation and how accreditation may drive quality improvement. These findings have implications for various stakeholders (government, the public, patients and health care providers), when it comes to embarking on accreditation exercises.

Responders vs clinical response: a critical analysis of data from linaclotide phase 3 clinical trials in IBS-C

BACKGROUND

US Food and Drug Administration (FDA) set a rigorous standard for defining patient responders in irritable bowel syndrome-C (IBS-C; i.e., FDA's Responder Endpoint) for regulatory approval. However, this endpoint's utility for health-care practitioners to assess clinical response has not been determined. We analyzed pooled IBS-C linaclotide trial data to evaluate clinically significant responses in linaclotide-treated patients who did not meet the FDA responder definition.

METHODS

Percentages of FDA non-responders reporting improvement in abdominal pain, bowel function and/or global relief measures were determined using pooled data from two linaclotide Phase 3 IBS-C trials.

KEY RESULTS

1602 IBS-C patients enrolled; 34% of linaclotide-treated and 17% of placebo-treated patients met the FDA Responder Endpoint (p < 0.0001). Among FDA non-responders at week 12, 63% of linaclotide-treated patients reported their abdominal pain was at least somewhat relieved, compared with 48% of placebo-treated patients. For stool frequency, 62% of linaclotide-treated patients reported that they were at least somewhat improved at week 12, compared with 46% of placebo-treated patients. For global IBS symptoms, 65% of linaclotide-treated patients reported at least some IBS-symptom relief, 43% reported adequate relief of IBS symptoms, and 57% reported being satisfied with linaclotide treatment, vs placebo rates of 48%, 34%, and 41% respectively.

CONCLUSIONS & INFERENCES

Most linaclotide-treated IBS-C patients who were FDA non-responders reported some improvement in abdominal pain and stool frequency, and global relief/satisfaction. In addition to the FDA Responder Endpoint, differing response thresholds and symptom-specific change from baseline should be considered by clinicians for a complete understanding of clinical response to linaclotide and other IBS-C therapies.

Ageing in an ultra-dense metropolis: perceived neighbourhood characteristics and utilitarian walking in Hong Kong elders

OBJECTIVE

The neighbourhood built environment may affect walking behaviour of elders. However, such effects remain underexplored, especially in an Asian context. We examined associations of perceived environmental attributes with overall and neighbourhood-specific walking for transport in a sample of Chinese elders residing in Hong Kong, an ultra-dense Chinese metropolis.

DESIGN

Cross-sectional observational study using a two-stage stratified sampling strategy.

SETTING

Hong Kong, China.

SUBJECTS

Chinese-speaking elders (n 484), with no cognitive impairment and able to walk without assistance, residing in thirty-two selected communities stratified by socio-economic status and walkability, were interviewer-administered validated measures of perceived neighbourhood environment and walking for transport.

RESULTS

Much higher levels of transport-related walking (mean 569 (sd 452) min/week) than found in Western samples were reported. The degree of perceived access to shops, crowdedness, presence of sitting facilities and easy access of residential entrance were independently positively related to both frequency of overall and within-neighbourhood walking for transportation. Infrastructure for walking and access to public transport were predictive of higher frequency of transport-related walking irrespective of location, while the perceived degree of land-use mix was predictive of higher levels of within-neighbourhood walking.

CONCLUSIONS

The provision of easy access to shops, residential entrances and sitting facilities in the neighbourhood may promote overall transport-related walking, while a good public transport network and pedestrian infrastructure linking destination-poor with destination-rich locations may compensate for the detrimental effects of living in less walkable neighbourhoods. Governmental investment in these micro- and macro-environmental features would help the promotion of an active lifestyle in elders.

Walking for transportation in Hong Kong Chinese urban elders: a cross-sectional study on what destinations matter and when

Background

Walking for transport can contribute to the accrual of health-enhancing levels of physical activity in elders. Identifying destinations and environmental conditions that facilitate this type of walking has public health significance. However, most findings are limited to Western, low-density locations, while a larger proportion of the global population resides in ultra-dense Asian metropolises. We investigated relationships of within-neighborhood objectively-measured destination categories and environmental attributes with walking for transport in 484 elders from an ultra-dense metropolis (Hong Kong).

Methods

We estimated relationships of diversity (number of different types) and prevalence of within-neighborhood destination categories (environmental audits of 400 m buffers surrounding residential addresses) with transport-related walking (interviewer–administered questionnaire) in 484 Chinese-speaking elders able to walk unassisted and living in 32 neighborhoods stratified by socio-economic status and transport-related walkability. We examined the moderating effects of safety and pedestrian infrastructure-related neighborhood attributes on destination-walking associations.

Results

Participants reported on average 569 and 254 min/week of overall and within-neighborhood walking for transport, respectively. The prevalence of public transit points and diversity of recreational destinations were positively related to overall walking for transport. The presence of a health clinic/service and place of worship, higher diversity in recreational destinations, and greater prevalence of non-food retails and services, food/grocery stores, and restaurants in the neighborhood were predictive of more within-neighborhood walking for transport. Neighborhood safety-related aspects moderated the relationship of overall walking for transport with the prevalence of public transit points, this being positive only in safe locations. Similar moderating effects of safety-related attributes were observed for the relationships of within-neighborhood walking for transport with diversity of recreational and entertainment destinations. Pedestrian-infrastructure attributes acted as moderators of associations of within-neighborhood walking for transport with prevalence of commercial destination categories. Composite destinations indices consisting of destination categories related to the specific measures of walking were positively associated with walking for transport.

Conclusions

The availability of both non-commercial and commercial destinations may promote within-neighborhood walking for transport, while recreational facilities and public transit points may facilitate overall walking for transport. However, destination-rich areas need to also provide adequate levels of personal safety and a physically-unchallenging pedestrian network.

An evaluation of the FDA responder endpoint for IBS-C clinical trials: analysis of data from linaclotide Phase 3 clinical trials

BACKGROUND

Our objective was to evaluate the performance of the Food and Drug Administration (FDA) Responder Endpoint for clinical trials in IBS-C, using data from two large Phase 3 clinical trials of linaclotide. The FDA interim endpoint requires that, for 50% of trial weeks, patients report ≥30% decrease in Abdominal Pain at its worst and (in the same week) an increase in Complete Spontaneous Bowel Movements (CSBMs) of ≥1 from baseline.

METHODS

Anchor-based methodology was used to estimate thresholds of clinically meaningful change using symptom-specific patient rating of change questions (PRCQs) and symptom severity questions. The diagnostic accuracy of the FDA Responder Endpoint was assessed using sensitivity/specificity-based methods.

KEY RESULTS

Using anchor-based methods, the estimates of the clinically meaningful improvement thresholds for Abdominal Pain ranged from 25.9% to 32.4% and thresholds for increase in weekly CSBM rate ranged from 1.4 to 1.6 CSBMs per week. Compared with the symptom-specific PRCQs for patient rating of relief, the FDA Responder Endpoint has a sensitivity of 60.7%, a specificity of 93.5%, and an accuracy of 82.0%. Changing the number of weeks required to be a responder or the percentage improvement in the Abdominal Pain criteria did not result in notable improvement in the accuracy of the FDA Responder Endpoint.

CONCLUSIONS & INFERENCES

The FDA Responder Endpoint for IBS-C clinical trials represents clinically meaningful improvements in IBS-C symptoms for patients with excellent specificity and reasonable sensitivity.

Effects of built environment on walking among Hong Kong older adults

1. Reliable and valid interviewer-administered questionnaires were developed to investigate associations of perceived neighbourhood attributes of Hong Kong older adults with their walking for transportation and recreation. 2. Access to and availability of different types of services and destinations, provision of facilities for resting/sitting in the neighbourhood, and easy access to/from residential buildings may help maintain an active lifestyle by facilitating walking for transport in the neighbourhood. 3. Access to services, indoor places for walking, environmental aesthetics, low traffic, and absence of physical barriers may promote recreational walking..

Randomised clinical trials: linaclotide phase 3 studies in IBS-C - a prespecified further analysis based on European Medicines Agency-specified endpoints

BACKGROUND

Treatment options that improve overall symptoms of irritable bowel syndrome with constipation (IBS-C) are lacking.

AIM

A prespecified further analysis to evaluate the efficacy and safety of linaclotide, a guanylate cyclase C agonist, in patients with IBS-C, based on efficacy parameters prespecified for European Medicines Agency (EMA) submission.

METHODS

Two randomised, double-blind, multicentre Phase 3 trials investigated once-daily linaclotide (290 μg) for 12 weeks (Trial 31) or 26 weeks (Trial 302) in patients with IBS-C. Prespecified primary endpoints were the EMA-recommended co-primary endpoints: (i) 12-week abdominal pain/discomfort responders [≥30% reduction in mean abdominal pain and/or discomfort score (11-point scales), with neither worsening from baseline, for ≥6 weeks] and (ii) 12-week IBS degree-of-relief responders (symptoms 'considerably' or 'completely' relieved for ≥6 weeks).

RESULTS

Overall, 803 (Trial 31) and 805 patients (Trial 302) were randomised. A significantly greater proportion of linaclotide-treated vs. placebo-treated patients were 12-week abdominal pain/discomfort responders (Trial 31: 54.8% vs. 41.8%; Trial 302: 54.1% vs. 38.5%; P < 0.001) and IBS degree-of-relief responders (Trial 31: 37.0% vs. 18.5%; Trial 302: 39.4% vs. 16.6%; P < 0.0001). Similarly, significantly more linaclotide- vs. placebo-treated patients were responders for ≥13 weeks in Trial 302 (abdominal pain/discomfort: 53.6% vs. 36.0%; IBS degree-of-relief: 37.2% vs. 16.9%; P < 0.0001). The proportion of sustained responders (co-primary endpoint responders plus responders for ≥2 of the last 4 weeks of treatment) was also significantly greater with linaclotide vs. placebo in both trials (P < 0.001).

CONCLUSION

Linaclotide treatment significantly improved abdominal pain/discomfort and degree-of-relief of IBS-C symptoms compared with placebo over 12 and 26 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov (identifiers: NCT00948818 and NCT00938717).

Health insurance and healthcare utilisation for Shenzhen residents: a tale of registrants and migrants?

BACKGROUND

Shenzhen's rapid growth and urbanisation has attracted a large, mobile, migrant working population. This article explores health protection through the means of social health insurance between migrants and registrants and their point of access to healthcare.

METHODS

A cross-sectional questionnaire survey was conducted in Shenzhen, with a random sample of 793 registered and 750 non-registered residents. Chi-square test and multivariate logistic regression were applied to analyse the association between health insurance coverage with Hukou registration status and healthcare utilisation.

RESULTS

Amongst 1543 respondents, 43.1% of non-registered residents were uninsured. Being non-registered strongly predicted for no insurance (OR = 5.00; CI 3.53,7.07) and have purchased additional/ private insurance (OR = 2.99; CI 1.66,5.37). Migrants who self-reported chronic health conditions were also more likely to utilise health services in general (OR = 2.77; CI 1.18,6.52).

CONCLUSIONS

Inadequate health insurance coverage for migrants as observed in Shenzhen remains a challenge for the Chinese health reform. Our results suggest that the current insurance system must seek to include migrants in order to achieve universal coverage and improved health protection for its population.

The nature of the stimulatory role of the supernatant fraction on triglyceride synthesis by the alpha-Glycerophosphate pathway

Evidence is presented as to the nature and mechanism of the stimulatory effect of the supernatant fraction on the biosynthesis of triglycerides via the alpha-glycerophosphate pathway in the intestinal mucosa. When microsomes are employed as the enzyme source, the major lipid formed from either labeled palmitic acid orL: -alpha-glycerophosphate is phosphatidic acid and only a limited amount of triglyceride is synthesized. The addition of the supernatant fraction to microsomes results in a stimulation of triglyceride biosynthesis at the expense of phosphatidic acid. Employing the same microsomal fraction, the reaction sequence was followed step by step and the intermediates were isolated. The results suggest that the stimulatory role of the supernatant fraction can be attributed to the presence ofL: -alpha-phosphatidate phosphohydrolase (EC 3.1.3.4). The hydrolysis of the biosynthesized microsomal phosphatidic acid by the supernatant enzyme occurs at a faster rate than the hydrolysis of added phosphatidic acid prepared from egg lecithin. The initial acylation steps in the biosynthesis of triglycerides or phosphatidic acid via the glycerophosphate pathway occur only in the presence of fatty acid and the cofactors necessary for its activation. Under these conditions, fatty acyl-CoA will not substitute for the fatty acid activation system.

Strategic and tactical limits of comparison studies

A comparison study is an experiment whose primary purpose is to compare directly (regardless of experimental design) at least two different procedures for changing behavior or two or more components of such a procedure. This paper argues that, in spite of their popularity, such studies typically lead to inappropriate inferences with poor generality based on improper evidence gathered in support of the wrong question, thus wasting the limited experimental resources. The discussion considers problems concerning the functions of comparison studies, the nature of the comparisons that are attempted, the generality of their findings, and the limited role that they can play in technological research.

Positive behavior support and applied behavior analysis

This article reviews the origins and characteristics of the positive behavior support (PBS) movement and examines those features in the context of the field of applied behavior analysis (ABA). We raise a number of concerns about PBS as an approach to delivery of behavioral services and its impact on how ABA is viewed by those in human services. We also consider the features of PBS that have facilitated its broad dissemination and how ABA might benefit from emulating certain practices of the PBS movement.

Distinguishing between applied research and practice

Behavior-analytic research is often viewed along a basic-applied continuum of research goals and methods. The applied portion of this continuum has evolved in ways that combine applied research and service delivery. Although these two facets of applied behavior analysis should be closely related, more clearly distinguishing between them, particularly in how we conceptualize and conduct applied research, may enhance the continuing development of each. This differentiation may improve the recruitment and training of graduate students.

Applying the least restrictive alternative principle to treatment decisions: A legal and behavioral analysis

The least restrictive alternative concept is widely used in mental health law. This paper addresses how the concept has been applied to treatment decisions. The paper offers both a legal and a behavioral analysis to some problems that have emerged in recent years concerning the selection of behavioral procedures used to change client behavior. The paper also offers ways of improving the application of the concept, which involve developing a more behaviorally functional perspective toward restrictiveness.

Logic, reasoning, and verbal behavior

This paper analyzes the traditional concepts of logic and reasoning from the perspective of radical behaviorism and in the terms of Skinner's treatment of verbal behavior. The topics covered in this analysis include the proposition, premises and conclusions, logicality and rules, and deductive and inductive reasoning.

Behavior analysis and the R&D paradigm

This paper considers research and development (R&D) as a style of investigation that holds promise for the field of behavior analysis. Contrasted with academic-style research, R&D tends to be highly targeted toward achievement of specific outcomes, which are determined by a user community. R&D is typically multidisciplinary in character and is coordinated by a funding source. R&D usually includes extensive field testing and systematically addresses technology transfer. A program of R&D focused on detector dogs serves as an exemplar of this approach for behavior analysis.