Employment conditions and mental health of overseas female migrant domestic workers in Hong Kong: a parallel mediation analysis

BACKGROUND

Female migrant domestic workers (MDW), approximately 8.5 million globally, often live in their employer's home under vulnerable conditions. In Hong Kong, MDWs currently comprise 5% of the population. This study was conducted to assess the association between employment conditions and mental health, and the mediating roles stress and job satisfaction have, among female MDWs in Hong Kong.

METHODS

Participants completed an online cross-sectional survey. A total of 1,965 survey were collected between August 2020 and August 2021. Questions in the survey were related to MDWs background information, employment conditions, stress, job satisfaction, and two mental health outcomes: anxiety and depression. An employment conditions score was created to assess the cumulative effect poor employment conditions had on mental health. A multicategorical parallel mediation analysis was used to assess the direct effect employment conditions have on mental health and the indirect effects through stress and job satisfaction.

RESULTS

Overall, 17.7% of MDWs were reported to be suffering from anxiety and 30.8% from depression. An increase in poor employment conditions was statistically associated with an increase in both outcomes, while stress levels and job satisfaction mediated this association.

CONCLUSIONS

The findings call for increased scrutiny of employment conditions and mental well-being of MDWs.

Determinants of COVID-19 Vaccine Uptake among Female Foreign Domestic Workers in Hong Kong: A Cross-Sectional Quantitative Survey

Globally, minority groups and non-citizens may not be sufficiently included in the COVID-19 vaccine coverage. This study seeks to understand determinants of vaccine uptake among female foreign domestic workers (FDWs) in Hong Kong. We conducted a cross-sectional study of female FDWs (n = 581) from June to August 2021. Respondents completed an online survey obtaining sociodemographic, employment, and health status information. Based upon the socio-ecological model, we obtained individual, interpersonal, and socio-structural factors that may be associated with COVID-19 vaccine uptake. Multivariable logistic regression analysis was used to examine factors associated with having received at least one dose of a COVID-19 vaccine. At the individual level, agreeing that taking COVID-19 vaccines can contribute to COVID-19 control in Hong Kong (OR 6.11, 95% CI 2.27–16.43) was associated with increased vaccine uptake, while being worried of severe side-effects from vaccination (OR 0.29, 95% CI 0.16–0.55) was associated with decreased uptake. At the interpersonal level, those being encouraged by their employer (OR 2.05, 95% CI 1.06–3.95) and family members (OR 2.27, 95% CI 1.17–4.38) were more likely to be vaccinated, while at the socio-structural level, believing vaccination would violate religious beliefs (OR 0.19, 95% CI 0.06–0.65) was associated with decreased uptake. The government can formulate a multi-level approach according to our findings to target the remaining unvaccinated FDW population.

Differential associations among social support, health promoting behaviors, health-related quality of life and subjective well-being in older and younger persons: a structural equation modelling approach

Background

Extensive studies have confirmed social support as a critical protective factor of people’s health-related quality of life (HRQoL) and subjective well-being (SWB). However, health promoting behaviors as a potential mechanism and age differences in this mechanism has received fewer attention. This study aims to examine the associations among social support, health promoting behaviors, HRQoL and SWB in older and younger persons in Hong Kong.

Method

A convenience sample of both younger (12–35 years old) and older persons (55 years old and above) were recruited from three non-government organizations to complete a survey. Structural Equation Model (SEM) was conducted to test both the measurement model and structural models to examine the relationship between social support, health promoting behaviors, HRQoL and SWB. Multi-group SEM was also performed and compared to test whether there were significant age differences in the pathways between the key variables.

Results

A final sample of 408 participants (older-persons: N = 200 (mean age: 71.63 (8.16); 180/200 female), younger-persons: N = 208 (mean age: 18.10 (5.04); 155/208 female) were included in the final analysis. Results showed that social support was positively associated with SWB directly and indirectly through health promoting behaviors for the whole sample (CFI = .95, IFI = .94, RMSEA = .07, SRMR = 0.056). Results suggested that the association between the variables differed across age samples. While social support showed a positive association with health promoting behaviors for both younger and older persons, how each of them associated with HRQoL and SWB was different.

Conclusion

Findings suggest that the pathway which social support linked with HRQoL and SWB might differ across age groups. Age-specific strategies should be considered when promoting HRQoL and SWB among the younger and older population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-01931-z.

Sociodemographic moderation of the association between depression and stroke incidence in a retrospective cohort of 0.4 million primary care recipients with hypertension

BACKGROUND

Previous research has suggested an association between depression and subsequent acute stroke incidence, but few studies have examined any effect modification by sociodemographic factors. In addition, no studies have investigated this association among primary care recipients with hypertension.

METHODS

We examined the anonymized records of all public general outpatient visits by patients aged 45+ during January 2007-December 2010 in Hong Kong to extract primary care patients with hypertension for analysis. We took the last consultation date as the baseline and followed them up for 4 years (until 2011-2014) to observe any subsequent acute hospitalization due to stroke. Mixed-effects Cox models (random intercept across 74 included clinics) were implemented to examine the association between depression (ICPC diagnosis or anti-depressant prescription) at baseline and the hazard of acute stroke (ICD-9: 430-437.9). Effect modification by age, sex, and recipient status of social security assistance was examined in extended models with respective interaction terms specified.

RESULTS

In total, 396 858 eligible patients were included, with 9099 (2.3%) having depression, and 10 851 (2.7%) eventually hospitalized for stroke. From the adjusted analysis, baseline depression was associated with a 17% increased hazard of acute stroke hospitalization [95% confidence interval (CI) 1.03-1.32]. This association was suggested to be even stronger among men than among women (hazard ratio = 1.29, 95% CI 1.00-1.67).

CONCLUSION

Depression is more strongly associated with acute stroke incidence among male than female primary care patients with hypertension. More integrated services are warranted to address their needs.

Socioeconomic Patterns of COVID-19 Clusters in Low-Incidence City, Hong Kong

Although coronavirus disease (COVID-19) outbreaks have been relatively well controlled in Hong Kong, containment remains challenging among socioeconomically disadvantaged persons. They are at higher risk for widespread COVID-19 transmission through sizable clustering, probably because of exposure to social settings in which existing mitigation policies had differential socioeconomic effects.

Comparing Multimorbidity Patterns Among Discharged Middle-Aged and Older Inpatients Between Hong Kong and Zurich: A Hierarchical Agglomerative Clustering Analysis of Routine Hospital Records

Background: Multimorbidity, defined as the co-occurrence of ≥2 chronic conditions, is clinically diverse. Such complexity hinders the development of integrated/collaborative care for multimorbid patients. In addition, the universality of multimorbidity patterns is unclear given scarce research comparing multimorbidity profiles across populations. This study aims to derive and compare multimorbidity profiles in Hong Kong (HK, PRC) and Zurich (ZH, Switzerland).

Methods: Stratified by sites, hierarchical agglomerative clustering analysis (dissimilarity measured by Jaccard index) was conducted with the objective of grouping inpatients into clinically meaningful clusters based on age, sex, and 30 chronic conditions among 20,000 randomly selected discharged multimorbid inpatients (10,000 from each site) aged ≥ 45 years. The elbow point method based on average within-cluster dissimilarity, complemented with a qualitative clinical examination of disease prevalence, was used to determine the number of clusters.

Results: Nine clusters were derived for each site. Both similarities and dissimilarities of multimorbidity patterns were observed. There was one stroke-oriented cluster (3.9% in HK; 6.5% in ZH) and one chronic kidney disease-oriented cluster (13.1% in HK; 11.5% ZH) in each site. Examples of site-specific multimorbidity patterns, on the other hand, included a myocardial infarction-oriented cluster in ZH (2.3%) and several clusters in HK with high prevalence of heart failure (>65%) and chronic pain (>20%).

Conclusion: This is the first study using hierarchical agglomerative clustering analysis to profile multimorbid inpatients from two different populations to identify universalities and differences of multimorbidity patterns. Our findings may inform the coordination of integrated/collaborative healthcare services.

Socioeconomic disadvantages over the life-course and their influence on obesity among older Hong Kong Chinese adults

BACKGROUND

The life-course perspective on socioeconomic inequality in health is a burgeoning field of research. Nonetheless, the three classic life-course models (i.e. sensitive period, cumulative risk and social mobility models) have rarely been simultaneously applied to studies on obesity. Therefore, this study examined the associations of socioeconomic positions (SEPs) across life stages and their associated life-course models with both general and abdominal obesity.

METHODS

Face-to-face interviews were conducted among 1077 community-dwelling adults aged 50 or above during 2014-15 in Hong Kong. Experiences of poverty, educational attainment and deprivation of necessities represented respondents' SEP in childhood, early adulthood and late adulthood, respectively. General and abdominal obesity were defined as body mass index ≥25 kg m-2 and waist-to-height ratio >0.5. Multivariable modified Poisson regression with a robust error variance was performed.

RESULTS

Respondents with low childhood SEP tended to have reduced risk of general obesity [relative risk (RR) = 0.85; 95% confidence interval (CI) = 0.72-1.00], whereas those with low childhood SEP and low late-adulthood SEP tended to have increased risk of abdominal obesity (RR = 1.10; 95% CI = 1.00-1.21 and RR = 1.14; 95% CI = 1.03-1.26, respectively). Cumulative socioeconomic disadvantages showed a dose-response relationship with abdominal obesity. Also, those with upward socioeconomic mobility had lower risk of abdominal obesity, whereas those with downward socioeconomic mobility had greater risk.

CONCLUSIONS

Low SEP, especially in childhood, exerted contrasting effects on general and abdominal obesity among older Hong Kong Chinese adults. The three life-course models operated simultaneously in determining the risk of abdominal obesity, while support for cumulative risk and social mobility models was weak in general obesity.

Association between antipsychotic use and acute ischemic heart disease in women but not in men: a retrospective cohort study of over one million primary care patients

BACKGROUND

Research comparing sex differences in the effects of antipsychotic medications on acute ischemic heart disease (IHD) is limited and the findings ambiguous. This study aimed to investigate these associations within a primary care setting.

METHODS

Hong Kong public general outpatient electronic records of patients aged 45+ during 2007-2010 were extracted, with the last consultation date as the baseline for a 4-year follow-up period to observe acute IHD hospitalizations (2011-2014). Antipsychotic use was defined as any prescription over the previous 12 months from a list of 16 antipsychotics, while acute IHD was defined by ICD-9: 410.00-411.89. Both sex-specific and sex-combined (both sexes) mixed-effects Cox models (random intercept across 74 clinics) were implemented to examine the association and test the interaction between antipsychotics and sex.

RESULTS

Among 1,043,236 included patients, 17,780 (1.7%) were prescribed antipsychotics, and 8342 (0.8%) developed IHD. In sex-specific analyses, antipsychotic prescription was associated with a 32% increased hazard rate of acute IHD among women (95% CI 1.05-1.67) but not among men. A likelihood ratio test comparing sex-combined models with and without the interaction between antipsychotic use and sex suggested significant interaction (χ² = 4.72, P = 0.030). The association between antipsychotic use and IHD among women attenuated and became non-significant when haloperidol was omitted from the operationalization of antipsychotic use (HR = 1.23, 95% CI 0.95-1.60).

CONCLUSION

Our results suggest that antipsychotic prescription is moderately associated with an increased risk of acute IHD among women in primary care and this relationship may be explained by specific antipsychotics. Further research should observe and capture the potential intermediary mechanisms and the dose-response relationship of this association to provide more rigorous evidence to establish causality and inform clinical practices.

Knowledge, attitudes and binge drinking among urban Chinese university students in Hong Kong

Background

Although dormitory residents have been identified as a high-risk group for alcohol misuse in Chinese university settings, the factors associated with their drinking behaviors has not be characterized.

Methods

A cross-sectional study was conducted among hostel residents in two Hong Kong universities (n = 1455) using self-administered, anonymous surveys. In addition to examining the knowledge levels and drinking-related attitudes, we examined the factors associated with binge drinking in this population using multivariable regression analysis.

Results

Among university dormitory residents, the prevalence of past-month binge drinking was 26.8% among males and 12.8% among females. It was noted that although respondents demonstrated attitudes conducive towards alcohol-free socialization, they exhibited low levels of alcohol-related knowledge (mean knowledge score: 3.3/ 10, SD = 2.0). While about 59% were aware that alcohol is a carcinogen and that some medications should not be taken with alcohol, only 10.4% were familiar with symptoms of alcohol poisoning and only 23% were familiar with relative amounts of alcohol in different beverage categories. Of the respondents the factors independently associated with past-month binge drinking were: male sex, older age, full-time hostel residence, drinking roommates, drinking romantic partner, participation in drinking games, and having pro-alcohol attitudes (OR ranging from 1.33-3.69). Alcohol-related knowledge was not associated with binge drinking.

Conclusions

Although southern China is a low alcohol consumption area, binge drinking is common among university residents and requires multi-prong interventions. Heavy drinking is a neglected health problem among urban Chinese university students. Interventions targeting binge drinkers need to counteract pro-alcohol attitudes and peer effects. Increasing alcohol knowledge may additionally help to reduce alcohol-related harms in this age group.

Key messages

Urban Chinese university dormitory residents demonstrate low levels of alcohol knowledge. Pro-alcohol attitudes and peers effects need to be addressed in university anti-binge drinking interventions.

Second-hand harms of alcohol use in urban Chinese university students: A study from Hong Kong

Background

Although second-harms alcohol harms, harms caused by the drinking of others, may contribute significantly to the public health burden of alcohol, these harms are an understudied area of public health research. This study aims to examine second-hand alcohol harms in among urban Chinese university students residing on campus who are were previously identified as a high risk group for alcohol misuse.

Methods

A cross-sectional study was conducted among hostel residents in two Hong Kong universities (n = 1455) using self-administered, anonymous surveys. We examined the prevalance and the factors associated with second-hand alcohol harms this population using multivariable regression analysis.

Results

Approximately 2/3 of the university residents experienced at least one second-hand drinking harm in the past year while 1/5 experienced 4 or more harms. The harms reported were: 1) inconveniences/disturbances (46.2%), psychological distress/anxiety/depression (32.9%), home arguments (28.3%), conflicts/arguments/insults in public (25.3%), worsened productivity/academics (22.2%), property damage/monetary loss (13.2%), accidents/injury/assault (11.7%) and having to deal with authorities/law enforcement (11.5%). Only 9.1% reported these harms to authorities. Participation in drinking games (OR = 1.44), having drinking roomates (OR = 1.37) or drinking romantic partner (OR = 1.89) were independently associated with likelihood of second-hand alcohol harms (p < 0.05).

Conclusions

Although southern China is a low alcohol consumption region, there is a high prevalence of second-hand alcohol harms among university dorm residents. Universities in the region should rectify the near absence of alcohol-related topics in university health promotion.

Key messages

Harms from the drinking of others is a commonplace but underappreciated phenomenon among university campus residents. University health promotion in the region should include alcohol harms reduction topics.

Prospective Association of Obesity Patterns with Subclinical Carotid Plaque Development in Early Postmenopausal Chinese Women

OBJECTIVE

This study aimed to examine the prospective associations of general and abdominal obesity patterns with carotid plaque development among early postmenopausal Chinese women.

METHODS

A total of 518 postmenopausal women aged 50 to 64 years were recruited between 2002 and 2004 and were followed up at 3 years and 5 years. Carotid plaque was measured using B-mode ultrasonography, whereas general and abdominal obesity were defined as BMI ≥ 25 kg/m² and waist-hip ratio ≥ 0.85, respectively. Sociodemographic, lifestyle, mental health, disease history, and clinical measurements were also assessed for confounding control. Multivariable binary logistic regression analyses on plaque development at 5 years were performed among 322 women with no carotid plaque at baseline.

RESULTS

Over the 5-year follow-up period, 70 women (21.7%) developed carotid plaque. Baseline abdominal obesity independently predicted plaque development (adjusted odds ratio = 2.30; 95% CI: 1.15-4.60), but general obesity did not. Women with normal-weight abdominal obesity were more than twice as likely to develop carotid plaque (adjusted odds ratio = 2.43; 95% CI: 1.02-5.75) compared with women with no obesity, with their risk comparable to women with both general and abdominal obesity.

CONCLUSIONS

Abdominal obesity was a critical predictor of subclinical carotid plaque development among early postmenopausal Chinese women. Policy makers should recognize the need to identify high-risk midlife women with normal-weight abdominal obesity in public health and clinical practice.

Educational inequality in physician-diagnosed hypertension widened and persisted among women from 1999 to 2014 in Hong Kong

Gender differences in the trend of educational inequality in hypertension have been observed especially in the Asian populations, indicating the increasing importance of education as a social determinant of hypertension among women. This study examined the gender-specific trends of educational inequality in physician-diagnosed hypertension in Hong Kong between 1999 and 2014. Based on a series of eight government-led territory-wide household surveys conducted between 1999 and 2014, 97,481 community-dwelling Hong Kong Chinese adults aged 45 or above were analysed. The extent and trend of gender-specific educational inequality in self-reported physician-diagnosed hypertension were estimated by regression-based Relative Index of Inequality and age-standardised Slope Index of Inequality. Over the study period, age-standardised prevalence of self-reported hypertension increased in both genders, with the greatest prevalence among the least educated women. Educational inequalities in hypertension significantly widened in female from 1999 to 2009 and persisted thereafter; nonetheless, the respective inequality was negligible in male. Further adjustment for household income did not attenuate the observed inequality. To conclude, a widened and then persistent discrepancy in hypertension across education levels was observed among women, but not among men, in Hong Kong. The gender perspective should be carefully considered when designing hypertension prevention strategies and related health policies.

Multimorbidity in middle age predicts more subsequent hospital admissions than in older age: A nine-year retrospective cohort study of 121,188 discharged in-patients

BACKGROUND

Previous research has suggested a differential short-term effect of multimorbidity on hospitalization by age, with younger groups affected more. This study compares the nine-year hospitalization pattern by age and multimorbidity status in a retrospective cohort of discharged in-patients, who represent a high-need portion of the population.

METHODS

We examined routine clinical records of all patients aged 45+ years with chronic conditions discharged from public general hospitals in 2005 in Hong Kong. Patterns of annual frequencies of hospital admissions and number of hospitalized days over nine years (2005-2014) were compared by multimorbidity status (1, 2, 3+ conditions) and age group (45-64, 65-74, 75+).

RESULTS

Among 121,188 included patients, 33.9% had 2+ conditions and 12.3% had 3+. Hospitalization patterns varied by age and multimorbidity status. For those having only 1 condition, annual number of admissions was similar by age, but older patients had more hospitalized days (4.40 days per person-year for the 45-64 group versus 10.29 for the 75+ group in the 5th year). For those with 3+ conditions, younger patients had more admissions (4.39 admissions per person-year for the 45-64 group versus 1.87 for the 75+ group in the 5th year) but similar number of hospitalized days with older patients. Interaction analysis showed effect of multimorbidity on hospitalization was stronger in younger groups (P < 0.05).

CONCLUSION

Middle-aged discharged in-patients with multimorbidity are admitted more often than their older counterparts and have similar total hospitalized days per year. Further research is needed to investigate chronic care needs of younger people with multimorbidity.

Sex-specific intergenerational trends in morbidity burden and multimorbidity status in Hong Kong community: an age-period-cohort analysis of repeated population surveys

OBJECTIVES

Prevalence of multimorbidity has been increasing worldwide. While population ageing undoubtedly contributes, secular trends have seldom been decomposed into age, period and cohort effects to investigate intergenerational differences. This study examines the birth cohort effect on morbidity burden and multimorbidity in Hong Kong community.

DESIGN

Sex-specific age-period-cohort analysis with repeated cross-sectional surveys.

SETTING

A territory-wide population survey database.

PARTICIPANTS

69 636 adults aged 35 or above who participated in the surveys in 1999, 2001, 2005 or 2008.

MAIN OUTCOME MEASURES

Morbidity burden was operationalised as number of chronic conditions from a list of 14, while multimorbidity was defined as a dichotomous status of whether participants had two or more conditions.

RESULTS

For both sexes, there was an upward inflection (positive change) of risk of increased morbidity burden starting from cohort 1955-1959. For men born after 1945-1954, there was a trend of lower risk (relative risk=0.63, 95% CI 0.50 to 0.80 for 1950-1954 vs 1935-1939) which continued through subsequent cohorts but with no further declines. In women, there had been a gradual increase of risk, although only significant for cohort 1970-1974 (relative risk=1.90, 95% CI 1.08 to 1.34 vs 1935-1939). Similar results were found for dichotomous multimorbidity status.

CONCLUSIONS

The trend of lower risk starting from men born in 1945-1954 may be due to a persistent decline in smoking rates since the 1980s. On the other hand, the childhood obesity epidemic starting from the late 1950s coincided with the observed upward inflection of risk for both sexes, that is, notably more drastic increase of risk in women and the levelling-off of the decline of risk in men. These findings highlight that the cohort effects on morbidity burden and multimorbidity may be sex-specific and contextual. By examining such effects in different world populations, localised sex-specific and generation-specific risk factors can be identified to inform policy-making.

Abuse and depression among Filipino foreign domestic helpers. A cross-sectional survey in Hong Kong

OBJECTIVES

The objectives of this study are to (1) explore physical and verbal abuse experience, perpetrators of abuse and abuse reporting behaviours of Filipino foreign domestic helpers in Hong Kong and (2) examine associations between their abuse experience and depression level.

STUDY DESIGN

A cross-sectional survey METHODS: We purposively sampled participants at the Statue Square of Hong Kong on three Sunday afternoons between June and August 2017. Using a self-administered questionnaire, measures include sociodemographic and housing environment variables, physical and verbal abuse experience and depression level measured using the Depression Subscale of Depression Anxiety Stress Scale 21 (DASS-21-D). Multiple linear regression was performed to identify factors associated with the DASS-21-D score.

RESULTS

The response rate was 86.1% and 105 participants completed the questionnaire. Overall, 20.5% and 34.4% had experienced physical and verbal abuse, respectively, in the past 12 months. Majority of perpetrators were female employers and children. Meanwhile, 16.7% of the abuse victims did not report their cases. Among those who reported, only a few (19.4%) reported their cases to formal organizations (agency and police). Factors significantly associated with the DASS-21-D score include physical abuse (unstandardized beta coefficient [B] = 1.68, 95% confidence interval [95% CI] = 0.12-3.34), verbal abuse (B = 1.58, 95% CI = 0.16-3.00), non-disclosure of physical abuse experience (B = 5.68, 95% CI = 0.18-11.18) and living space satisfaction (B = -1.50, 95% CI = -2.12 to -0.88).

CONCLUSIONS

Physical and verbal abuse among foreign domestic workers in Hong Kong were underreported to formal organizations and were associated with depression. Legislative enforcement of a comprehensive abuse reporting mechanism and mental health service should be considered.

Benefits and limitations of implementing Chronic Care Model (CCM) in primary care programs: A systematic review

BACKGROUND

Chronic Care Model (CCM) has been developed to improve patients' health care by restructuring health systems in a multidimensional manner. This systematic review aims to summarize and analyse programs specifically designed and conducted for the fulfilment of multiple CCM components. We have focused on programs targeting diabetes mellitus, hypertension and cardiovascular disease.

METHOD AND RESULTS

This review was based on a comprehensive literature search of articles in the PubMed database that reported clinical outcomes. We included a total of 25 eligible articles. Evidence of improvement in medical outcomes and the compliance of patients with medical treatment were reported in 18 and 14 studies, respectively. Two studies demonstrated a reduction of the medical burden in terms of health service utilization, and another two studies reported the effectiveness of the programs in reducing the risk of heart failure and other cardiovascular diseases. However, CCMs were still restricted by limited academic robustness and social constraints when they were implemented in primary care. Higher professional recognition, tighter system collaborations and increased financial support may be necessary to overcome the limitations of, and barriers to CCM implementation.

CONCLUSION

This review has identified the benefits of implementing CCM, and recommended suggestions for the future development of CCM.

Collaborate across silos: Perceived barriers to integration of care for the elderly from the perspectives of service providers

PURPOSE

To examine the barriers that hinder collaboration between health care and social care services and to report recommendations for effective collaboration to meet the growing support and care needs of our ageing population.

METHODS

Data for this qualitative study were obtained from interviews with 7 key informants (n = 42) and 22 focus groups (n = 117) consisting of service providers who were from the health care or social care sectors and supporting elderly patients with multiple chronic diseases or long-term care needs. Data collection was conducted from 2015 to 2016. The data were analysed using an inductive approach on the basis of thematic analysis.

FINDINGS

Qualitative analysis reviewed a number of factors that play a significant role in setting up barriers at the operational level, including fragmentation and lack of sustainability of discharge programmes provided by non-governmental organisations, lack of capacity of homes for the elderly, limitation of time and resources, and variation of roles in supporting end-of-life care decisions between the medical and social sectors. Other barriers are those of communication to be found at the structural level and perceptual ones that exist between professionals. Of these, perceptual barriers affect attitudes and create mistrust and interprofessional stereotypes and a hierarchy between the health care and social care sectors.

CONCLUSION

Health care and social care service providers recognise the need for collaborative work to enhance continuity of care and ageing in place; however, their efforts are hindered by the identified barriers that need to be dealt with in practical terms and by a change of policy.

Integrated care for older populations and its implementation facilitators and barriers: A rapid scoping review

Purpose

Inform health system improvements by summarizing components of integrated care in older populations. Identify key implementation barriers and facilitators.

Data sources

A scoping review was undertaken for evidence from MEDLINE, the Cochrane Library, organizational websites and internet searches. Eligible publications included reviews, reports, individual studies and policy documents published from 2005 to February 2017.

Study selection

Initial eligible documents were reviews or reports concerning integrated care approaches in older/frail populations. Other documents were later sourced to identify and contextualize implementation issues.

Data extraction

Study findings and implementation barriers and facilitators were charted and thematically synthesized.

Results of data synthesis

Thematic synthesis using 30 publications identified 8 important components for integrated care in elderly and frail populations: (i) care continuity/transitions; (ii) enabling policies/governance; (iii) shared values/goals; (iv) person-centred care; (v) multi-/inter-disciplinary services; (vi) effective communication; (vii) case management; (viii) needs assessments for care and discharge planning. Intervention outcomes and implementation issues (barriers or facilitators) tend to depend heavily on the context and programme objectives. Implementation issues in four main areas were observed: (i) Macro-level contextual factors; (ii) Miso-level system organization (funding, leadership, service structure and culture); (iii) Miso-level intervention organization (characteristics, resources and credibility) and (iv) Micro-level factors (shared values, engagement and communication).

Conclusion

Improving integration in care requires many components. However, local barriers and facilitators need to be considered. Changes are expected to occur slowly and are more likely to be successful where elements of integrated care are well incorporated into local settings.

A Pilot Cross-Sectional Study of Postpartum Wrist Pain in an Urban Chinese Population: Its Prevalence and Risk Factors

BACKGROUND

Wrist pain after childbirth is commonly encountered in clinical practice. Little is known about the prevalence of this musculoskeletal disorder which is important to overall maternal health.

OBJECTIVE

To examine the prevalence of and risk factors for de novo wrist pain in women after childbirth.

STUDY DESIGN

A pilot cross-sectional survey.

SETTING

A telephone interview was conducted 2 months after childbirth among women who delivered at a tertiary hospital in Hong Kong.

METHODS

The prevalence of de novo wrist pain was recorded; its severity was rated using the numerical rating scale and Patient-Rated Wrist Evaluation (PRWE) with pain and functional subscale scores.

RESULTS

In total, 259 women aged 32.8 ± 4.0 years participated; 149 women (57.5%) developed wrist pain after childbirth and 125 (84%) had persistent wrist pain 2 months postpartum. The majority had moderate (43.5%) to severe (21%) wrist pain. Bilateral involvement was common (56.8%), with most of the pain (59.3%) located on the radial side of the wrist. Primiparity was associated with wrist pain development (odds ratio 2.62, 95% confidence interval 1.33 - 5.16, P = 0.01); pain intensity was negatively correlated with the baby's birth weight (beta = -1.059, P = 0.013). Mean PRWE pain and function scores were 22.8 ± 10.3 and 15.6 ± 10.7, respectively.

LIMITATIONS

Cross-sectional survey is prone to volunteer bias, though recent literature indicates that the bias may not substantially affect the internal validity of the study.

CONCLUSIONS

Wrist pain is prevalent after childbirth; future studies may consider looking into its exact pathology, long-term consequences, and overall effect on maternal health.

KEY WORDS

Wrist pain, DeQuervain disease, postpartum, childbirth, mothers, prevalence, cross sectional study, survey.

Regular Source of Care for the Elderly: A Cross-National Comparative Study of Hong Kong With 11 Developed Countries

OBJECTIVE

This study aimed to give an international perspective of health service gaps for caring for elderly individuals and explore the role of primary care for caring for elderly individuals with chronic conditions in Hong Kong.

DESIGN

Cross-sectional, telephone survey.

SETTING

Hong Kong.

PARTICIPANT

A sample of 1000 Chinese participants in Hong Kong aged 60 or older.

MEASUREMENTS

Questionnaire extracted from the Commonwealth Fund 2014 International Health Policy Survey of Older Adults.

RESULTS

Similar to the 11 countries, more than half (about 65%) of Hong Kong respondents suffered from chronic conditions, whereas approximately one-third of them had at least 2 chronic conditions. US respondents had highest rate of having chronic conditions. Only 65% of Hong Kong respondents reported having a regular source of care and a higher proportion of elderly reported having poor self-rated health when compared with overseas counterparts. However, the proportion of elderly individuals who could access same-day or next-day medical care was higher compared with findings of other countries. Both Hong Kong and US respondents were more likely to report cost-related problems when accessing care. Waiting time for specialists in Hong Kong was much longer and coordination between regular doctors was poorer than in all other countries. Although half of Hong Kong respondents had a management plan for chronic conditions, a smaller proportion of them considered it helpful.

CONCLUSIONS

Hong Kong has the lowest rate of regular source of care when compared with 11 developed countries, although people in Hong Kong were more likely to be able to access same-day or next-day medical care. To cope with increasing needs of chronic disease care, there may be a need to further develop the provision of regular source of care for elderly individuals, including the development of quality primary care in Hong Kong.

Care Toward the End of Life in Older Populations and Its Implementation Facilitators and Barriers: A Scoping Review

PURPOSE

To inform health system improvements for care of elderly populations approaching the end of life (EOL) by identifying important elements of care and implementation barriers and facilitators.

DESIGN

A scoping review was carried out to identify key themes in EOL care. Articles were identified from MEDLINE, the Cochrane Library, organizational websites, and internet searches. Eligible publications included reviews, reports, and policy documents published between 2005 and 2016. Initially, eligible documents included reviews or reports concerning effective or important models or components of EOL care in older populations, and evidence was thematically synthesized. Later, other documents were identified to contextualize implementation issues.

RESULTS

Thematic synthesis using 35 reports identified key features in EOL care: (1) enabling policies and environments; (2) care pathways and models; (3) assessment and prognostication; (4) advance care planning and advance directives; (5) palliative and hospice care; (6) integrated and multidisciplinary care; (7) effective communication; (8) staff training and experience; (9) emotional and spiritual support; (10) personalized care; and (11) resources. Barriers in implementing EOL care include fragmented services, poor communication, difficult prognostication, difficulty in accepting prognosis, and the curative focus in medical care.

CONCLUSIONS

Quality EOL care for older populations requires many core components but the local context and implementation issues may ultimately determine if these elements can be incorporated into the system to improve care. Changes at the macro-level (system/national), meso-level (organizational), and micro-level (individual) will be required to successfully implement service changes to provide holistic and person-centered EOL care for elderly populations.

The association between types of regular primary care and hospitalization among people with and without multimorbidity: A household survey on 25,780 Chinese

Using data collected from 25,780 Hong Kong citizens in a household survey, this study aimed to investigate the association between having regular source of primary care and hospitalization amongst people with and without multimorbidity (two or more chronic conditions). Potential interaction effects of regular primary care with multimorbidity were also examined. Results revealed a significant association between having regular source of primary care from General Practitioners and reduced hospitalization amongst respondents with multimorbidity (RR = 0.772; 95% CI = 0.667-0.894), adjusting for other potential confounding factors (i.e., socio-demographic factors and medical insurance and benefits). In contrast, having regular Specialist care was significantly associated with increased risk of hospitalization among both people with multimorbidity (RR = 1.619; 95% CI = 1.256-2.087) and without multimorbidity (RR = 1.981; 95% CI = 1.246-3.149), adjusting for potential confounders. A dose-response relationship between the number of chronic diseases and hospitalization was also observed, regardless of whether participants had regular source of primary care or not; relative risks and predicted probabilities for hospitalization were generally greater for those without regular source of primary care. Further studies are warranted to explore the role of healthcare system, informatics, organizational and practice-related factors on healthcare and functional outcomes.

COHORT EFFECTS OF SUICIDE MORTALITY ARE SEX SPECIFIC IN THE RAPIDLY DEVELOPED HONG KONG CHINESE POPULATION, 1976-2010

BACKGROUND

To examine temporal variations of age, period, and cohort on suicide mortality rate in Hong Kong (HK) from 1976 to 2010, and speculate the macroenvironmental mechanisms of the observed trends.

METHODS

Poisson age-period-cohort modeling was used to delineate the effects of age, period, and cohort on suicide mortality. Analysis by sex was also conducted to examine if gender difference exists for suicidal behaviours.

RESULTS

Age-cohort model provides the best fit to the mortality data, implying that the cohort effect is likely to explain more of the contributions to HK's suicide mortality pattern than the period effect. Risk of suicide mortality increases nonlinearly with age and accelerates after age 65-69 for both sexes. Moreover, the cohort effects differ between the sexes-risk of mortality increases continually for men born after 1961, but no change is observed for women since the 1941 cohort.

CONCLUSIONS

With increased risk of suicide mortality in younger cohorts and the age effect of suicide mortality, we may see future increase in suicide mortality as these younger cohorts age. Further studies are needed to clarify plausible associations between broader sociohistorical changes in the population impacting psychological risk factors and suicidal behaviour to better inform suicide prevention strategies.

Socioeconomic Determinants of Multimorbidity: A Population-Based Household Survey of Hong Kong Chinese

INTRODUCTION

Multimorbidity has been well researched in terms of consequences and healthcare implications. Nevertheless, its risk factors and determinants, especially in the Asian context, remain understudied. We tested the hypothesis of a negative relationship between socioeconomic status and multimorbidity, with contextually different patterns from those observed in the West.

METHODS

We conducted our study in the general Hong Kong (HK) population. Data on current health conditions, health behaviours, socio-demographic and socioeconomic characteristics was obtained from HK Government's Thematic Household Survey. 25,780 individuals aged 15 or above were sampled. Binary logistic and negative binomial regression analyses were conducted to identify risk factors for presence of multimorbidity and number of chronic conditions, respectively. Sub-analysis of possible mediation effect through financial burden borne by private housing residents on multimorbidity was also conducted.

RESULTS

Unadjusted and adjusted models showed that being female, being 25 years or above, having an education level of primary schooling or below, having less than HK$15,000 monthly household income, being jobless or retired, and being past daily smoker were significant risk factors for the presence of multimorbidity and increased number of chronic diseases. Living in private housing was significantly associated with higher chance of multimorbidity and increased number of chronic diseases only after adjustments.

CONCLUSIONS

Less advantaged people tend to have higher risks of multimorbidity and utilize healthcare from the public sector with poorer primary healthcare experience. Moreover, middle-class people who are not eligible for government subsidized public housing may be of higher risk of multimorbidity due to psychosocial stress from paying for the severely unaffordable private housing.

Is Alcohol Use Disorder Identification Test (AUDIT) or its shorter versions more useful to identify risky drinkers in a Chinese population? A diagnostic study

Objective

To examine the diagnostic performance of shorter versions of Alcohol Use Disorder Identification Test (AUDIT), including Alcohol Consumption (AUDIT-C), in identifying risky drinkers in primary care settings using conventional performance measures, supplemented by decision curve analysis and reclassification table.

Study design and Setting

A cross-sectional study of adult males in general outpatient clinics in Hong Kong. The study included only patients who reported at least sometimes drinking alcoholic beverages. Timeline follow back alcohol consumption assessment method was used as the reference standard. A Chinese translated and validated 10-item AUDIT (Ch-AUDIT) was used as a screening tool of risky drinking.

Results

Of the participants, 21.7% were classified as risky drinkers. AUDIT-C has the best overall performance among the shorter versions of Ch-AUDIT. The AUC of AUDIT-C was comparable to Ch-AUDIT (0.898 vs 0.901, p-value = 0.959). Decision curve analysis revealed that when the threshold probability ranged from 15–30%, the AUDIT-C had a higher net-benefit than all other screens. AUDIT-C improved the reclassification of risky drinking when compared to Ch-AUDIT (net reclassification improvement = 0.167). The optimal cut-off of AUDIT-C was at ≥5.

Conclusion

Given the rising levels of alcohol consumption in the Chinese regions, this Chinese translated 3-item instrument provides convenient and time-efficient risky drinking screening and may become an increasingly useful tool.

Inequalities in health status among rural residents: EQ-5D findings from household survey China

Introduction

This study analyzed inequalities in health status among different socioeconomic and demographic rural residents covered by the New Rural Cooperative Medical System in China.

Methods

A cross-sectional study was conducted in Lian Yungang City, China. A total of 337 respondents, who were selected by using a multistage stratified systematic random sampling method, completed the surveys. A questionnaire consisting of EQ-5D and demographic and socioeconomic information was adopted for data collection, and was administered by face-to-face interviews. Multiple regression models were employed to examine the differences in the Visual Analogue Scale (VAS) score and the EQ-5D dimensions.

Results

Compared with those with lower education attainment, the respondents with higher education levels tended to report a higher VAS score (β = 2.666, 95% CI: 0.978 to 6.310), and were less likely to suffer from pain/discomfort (OR = 3.968; 95% CI: 1.447 to 10.880). The singles were more likely than the married to report moderate or extreme problems in usual activities (OR = 4.583; 95% CI: 1.188 to 17.676) and mobility (OR = 10.666; 95% CI: 2.464 to 6.171). However, no statistically significant differences were identified between the respondents with different income levels in the VAS score and EQ-5D dimensions.

Conclusions

This study suggests that the singles and the people with lower education levels are high-risk groups for poorer health status in the Chinese rural population. The findings from this study warrant further investigation.

Lower urinary tract symptoms (LUTS) as a risk factor for depressive symptoms in elderly men: results from a large prospective study in Southern Chinese men

A cross-sectional relationship between lower urinary tract symptoms (LUTS) and depressive symptoms was previously reported among Southern Chinese men; however, the temporal relationship was unclear. Our objective is to evaluate the temporal relationship between moderate to severe lower urinary tract symptoms and clinically significant depressive symptoms in elderly Chinese men aged 65 in a prospective manner. In a prospective cohort of 2,000 Chinese men aged 65 to 92 years in Hong Kong, we studied the association of having moderate to severe LUTS at baseline and having clinically relevant depressive symptoms at year 2 follow-up. After excluding men with prostate or bladder cancer or surgery (n = 20) and lost to follow-up (n = 254), data on 1,726 subjects were analyzed. LUTS were measured by the International Prostate Symptom score; and clinically relevant depressive symptoms were measured by the Geriatric Depression Scale. The multiple logistic regressions showed that the presence of moderate-to-severe LUTS at baseline were significantly associated with increased risk for being depressed at two-year follow-up, with adjustments for demographic, lifestyle, medical factors, weight status and stressful life events (OR = 2.97; CI: 1.70-5.20). Association remained significant with additional adjustments for baseline GDS score (OR = 1.88; CI: 1.03-3.41). LUTS are important risk factors in predicting the presence of clinically relevant depressive symptoms. In elderly men, increased awareness and possible screening are needed to detect the increased risk of clinically relevant depressive symptoms.

How does socioeconomic development affect risk of mortality? An age-period-cohort analysis from a recently transitioned population in China

During the 20th century, the Hong Kong Chinese population experienced 2 abrupt but temporally distinct macroenvironmental changes: The transition from essentially preindustrial living conditions to a rapidly developing economy through mass migration in the late 1940s was followed by the emergence of an infant and childhood adiposity epidemic in the 1960s. The authors aimed to delineate the effects of these 2 aspects of economic development on mortality, thus providing a sentinel for other rapidly developing economies. Sex-specific Poisson models were used to estimate effects of age, calendar period, and birth cohort on Hong Kong adult mortality between 1976 and 2005. All-cause and cause-specific mortality, including mortality from ischemic heart disease (IHD), cardiovascular disease excluding IHD, lung cancer, other cancers, and respiratory disease, were considered. Male mortality from IHD and female mortality from other cancers increased with birth into a more economically developed environment. Cardiovascular disease mortality increased with birth after the start of the infant and childhood adiposity epidemic, particularly for men. Macroenvironmental changes associated with economic development had sex-specific effects over the life course, probably originating in early life. The full population health consequences of these changes are unlikely to manifest until persons who have spent their early lives in such environments reach an age at which they become vulnerable to chronic diseases.

Socioeconomic disparities in air pollution-associated mortality

This study aimed to determine whether individuals with lower socioeconomic status (SES) were more susceptible to the acute effects of ambient air pollution than those with higher SES. We included 24,357 Hong Kong Chinese aged 30 or above who died of natural causes in 1998. Information on individual socioeconomic characteristics was obtained by interviewing proxy informants with a standardized questionnaire in all four death registries. Individual SES was indicated by three measures: type of housing, occupational group and education attainment. Poisson regression was performed to assess the short-term effects of ambient air pollution measured by PM(10), NO(2), SO(2) and O(3) on mortality for each SES group. The differences in the effects between SES groups were estimated by the interaction between air pollution and SES. We found that PM(10) and NO(2) were associated with greater risk of mortality on people living in public rental housing than in private housing. The effects of all four pollutants were significantly greater in blue-collar workers than the never-employed and white-collar groups (p<0.05). However, we found no compelling evidence of effect modification by education attainment. Our results provide new evidence on the role of individual's SES as effect modifiers of the short-term effects of air pollution on mortality. The reduction of risks associated with air pollution for socially disadvantaged populations should be a high priority in public health and environmental policies.

Does regular exercise protect against air pollution-associated mortality?

OBJECTIVES

To examine whether habitual exercise would modify the effects of air pollution on mortality.

METHODS

This study included 24,053 Hong Kong Chinese who died at the age of 30 years or older in 1998. Individual information on frequency of exercise was obtained by interviewing their relatives at all four death registries. The deceased subjects were categorized as never-exercise (<once/month) and exercise (> or =once/month). Excess risks (ER) of mortality per 10 microg/m(3) increase of air pollutant were estimated separately by a Poisson regression model in the exercise and never-exercise groups. An interaction model was used to estimate the difference in ER between the two groups.

RESULTS

In people aged 65 years or older and categorized as never-exercise group, there were significant ER of mortality for all natural causes attributed to nitrogen dioxide (p<0.05), ozone (p<0.05) and particulate matter with an aerodynamic diameter of 10 mum or smaller (p<0.01). When compared to the exercise group, the ER were significantly higher by 4.31% (95% confidence interval: 2.57%, 6.03%), 1.75% (0.25%, 3.23%), and 3.06% (1.74%, 4.37%), respectively. The estimates were insensitive to adjustment for socioeconomic, smoking and health status, and were non-linear by different exercise levels.

CONCLUSIONS

The results of this study provide evidence that habitual exercise may prevent premature death attributable to air pollution.

Management outcomes for ruptured and unruptured aneurysms in the elderly

OBJECTIVE

In a patient older than 70 years, the decision to treat an intracranial aneurysm remains difficult whether it is ruptured or unruptured. We sought to review our institutional risks of treatment of such lesions in the context of the risks of rupture and its associated morbidity and mortality in this age group.

METHODS

One hundred twenty-nine consecutive patients aged 70 years or older, who were treated at a single institution for an intracranial aneurysm, were retrospectively reviewed. Forty patients were treated for unruptured aneurysms, and 89 patients presented after subarachnoid hemorrhage. Seven additional patients in this age group who had solely intracavernous lesions, as well as one patient with a dolichoectatic fusiform basilar lesion, were excluded. Management outcomes were assessed using a modification of the Glasgow Outcome Scale, and additional physical and functional disability was assessed using the Barthel index and the Reintegration to Normal Living index.

RESULTS

Six-month outcomes for the unruptured group were: excellent, 70%; good, 15%; fair, 5%; poor, 7.5%; and death (2.5%). Outcomes for all patients with ruptured lesions (including those not offered aggressive therapy) were: excellent, 34%; good, 9%; fair, 5.6%; poor, 3.4%; and death, 45%. Long-term follow-up was performed by questionnaire to assess physical and functional disability. Although physical disability (Barthel index) was similar among survivors, the Reintegration to Normal Living index, a global assessment of function, was significantly higher in patients with unruptured aneurysms (84.8 versus 70.1; P = 0.05), which highlights the disabling effects of hemorrhage.

CONCLUSION

On the basis of an individual treatment center's management risks, annual aneurysmal rupture rates can be estimated that justify treatment in this difficult patient population. Despite recent controversy regarding aneurysmal hemorrhage rates, we think that symptomatic unruptured aneurysms should be treated and good results can be achieved, even in older patients.

B-myb promoter retargeting of herpes simplex virus gamma34.5 gene-mediated virulence toward tumor and cycling cells

Deletion of the gamma34.5 gene coding for virulence markedly reduces cytotoxicity mediated by herpes simplex virus type 1 (HSV-1) (J. M. Markert et al., Neurosurgery 32:597-603, 1993; N. S. Markovitz et al. , J. Virol. 71:5560-5569, 1997). To target lytic virulence to tumors, we have created a novel HSV-1 mutant, designated Myb34.5. This viral mutant is characterized by a deletion of the gene for infected cell polypeptide 6 (ICP6; also known as UL39 or ribonucleotide reductase) and of the two endogenous copies of the gamma34.5 gene (RL1) and by reintroduction of one copy of gamma34.5 under control of the E2F-responsive, cellular B-myb promoter. On direct intracerebral inoculation in BALB/c mice, the 50% lethal dose (LD(50)) for Myb34.5 was 2.7 x 10(7) PFU while that for HSVs with mutations in the gamma34.5 gene could not be technically achieved with available viral stocks and it was estimated as >1 x 10(7) PFU. The LD(50) for an HSV with a single defect in ICP6 function was 1.3 x 10(6) PFU. Conversely, Myb34.5's oncolytic efficacy against a variety of human glioma cells in culture and in vivo was enhanced compared to that of HSVs with gamma34.5 mutations, and in fact, it was comparable to that of the wild-type F strain and of viral mutants that possess a wild-type gamma34.5 gene. The characteristic shutoff of host protein synthesis, occurring after infection of human SK-N-SH neuroblastoma cells by gamma34.5 mutant viruses (J. Chou and B. Roizman, Proc. Natl. Acad. Sci. USA 89:3266-3270, 1992), was not present after infection with Myb34.5. There was an increase of almost 3 logarithmic units in the production of progeny virus in arrested fibroblasts compared to that in cycling fibroblasts infected with Myb34.5. These results suggest that transcriptional regulation of gamma34.5 by cell cycle-regulated promoters can be used to target HSV-1 virulence toward tumors while maintaining the desirable neuroattenuated phenotype of a gamma34.5 mutant.

Gene therapy for tumors of the central nervous system

Primary central nervous system tumors, consisting mainly of malignant gliomas, represent a unique system for the study of gene transfer techniques. Exogenous transgenes have been delivered using retroviral, adenoviral, and herpes simplex virus vectors. A number of strategies have been developed, including: (1) delivery of prodrug activating genes, (2) replacement of tumor suppressor genes, (3) cytokine-mediated enhancement of antitumor immune responses, and (4) antisense cDNA delivery to block the action of growth factors, cell cycle proteins, and drug resistance mechanisms. Efforts to disrupt the blood brain barrier may facilitate tumor gene delivery.

An oncolytic viral mutant that delivers the CYP2B1 transgene and augments cyclophosphamide chemotherapy

Herpes simplex viruses type 1 (HSV-1) with an inactivated viral ribonucleotide reductase (Hsrr, ICP6) were designed to target tumor cells with upregulated mammalian ribonucleotide reductase (mRR), an enzyme whose expression is regulated by the p16/pRB tumor suppressor pathway. A recombinant HSV-1 was generated by knock-out of Hsrr and insertion of the rat CYP2B1 transgene responsible for the bioactivation of the prodrugs, cyclophosphamide and ifosfamide. The mutant virus replicated selectively in rat and human tumor cells that express mRR. Addition of cyclophosphamide potentiated oncolytic effects against cultured tumor cells and subcutaneous tumor xenografts established in athymic mice.

Comparative study of p53 gene and protein alterations in human astrocytic tumors

The p53 gene is a tumor suppressor gene involved in many common malignancies, including astrocytomas. Genetic analysis of the p53 gene and immunohistochemistry of the p53 protein have each been used to screen astrocytomas. To compare these methods, we performed immunohistochemistry with the monoclonal antibody PAb 1801 and single-strand conformational polymorphism (SSCP) with sequence analysis on 34 astrocytic tumors (WHO grades II, III and IV). Seven cases had detectable p53 protein and gene mutations, while twelve cases had neither detectable protein nor gene mutations. Four tumors had frameshift mutations in the p53 gene that were not revealed by immunohistochemistry. One tumor had a genetic polymorphism and no detectable p53 protein. Ten tumors had p53 protein accumulation but no mutations by SSCP; these cases may represent p53 mutations outside of the conserved exons or elevated levels of wild-type p53 protein. Thus, some p53 mutations are missed with PAb 1801 immunohistochemistry alone. p53 immunohistochemistry, however, may reveal p53 accumulation independent of mutations in the conserved portions of the gene. Finally, we suggest that glioblastomas with p53 mutations in the conserved region of the gene may be a subset that are more common in women and in younger patients.

Repression of the basal c-fos promoter by wild-type p53

Mutations in the p53 gene are the most common genetic alterations observed in many inherited and sporadic forms of human cancer. Recent studies indicate that wild-type p53 may be involved in the regulation of gene expression. In the present report we examined the effect of p53 on the human c-fos promoter. Using a transient co-transfection assay we show that wild-type human p53, but not a transforming mutant of p53, negatively regulates the activity of the c-fos promoter in a dose-dependent manner. Promoter deletion analysis maps a sequence conferring p53 repression to the basal promoter region between nucleotides -53 and +42 relative to the cap site. In contrast, p53 strongly stimulates transcription when a sequence previously reported to bind p53 (TGCCT repeat) was inserted in front of the HSV-TK promoter driving CAT. These findings raise the question as to whether p53 may mediate its inhibitory effect on c-fos gene expression by interfering, directly or indirectly, with components of the basal transcriptional machinery.

Association of epidermal growth factor receptor gene amplification with loss of chromosome 10 in human glioblastoma multiforme

Although the loss of tumor suppressor genes and the activation of oncogenes have been established as two of the fundamental mechanisms of tumorigenesis in human cancer, little is known about the possible interactions between these two mechanisms. Loss of genetic material on chromosome 10 and amplification of the epidermal growth factor receptor (EGFR) gene are the most frequently reported genetic abnormalities in glioblastoma multiforme. In order to examine a possible correlation between these two genetic aberrations, the authors studied 106 gliomas (58 glioblastomas, 14 anaplastic astrocytomas, five astrocytomas, nine pilocytic astrocytomas, seven mixed gliomas, six oligodendrogliomas, two ependymomas, one subependymoma, one subependymal giant-cell astrocytoma, and three gangliogliomas) with Southern blot analysis for loss of heterozygosity on both arms of chromosome 10 and for amplification of the EGFR gene. Both the loss of genetic material on chromosome 10 and EGFR gene amplification were restricted to the glioblastomas. Of the 58 glioblastoma patients, 72% showed loss of chromosome 10 and 38% showed EGFR gene amplification. The remaining 28% had neither loss of chromosome 10 nor EGFR gene amplification. Without exception, the glioblastomas that exhibited EGFR gene amplification had also lost genetic material on chromosome 10 (p less than 0.001). This invariable association suggests a relationship between the two genetic events. Moreover, the presence of 15 cases of glioblastoma with loss of chromosome 10 but without EGFR gene amplification may further imply that the loss of a tumor suppressor gene (or genes) on chromosome 10 precedes EGFR gene amplification in glioblastoma tumorigenesis.

p53 mutations are associated with 17p allelic loss in grade II and grade III astrocytoma

Loss of genetic material on the short arm of chromosome 17 is observed in approximately 40% of human astrocytomas (WHO grades II and III) and in approximately 30% of cases of glioblastoma multiforme (WHO grade IV). Previous studies of glioblastoma multiforme have shown that the p53 gene, located on the short arm of chromosome 17, is frequently mutated in these glioblastomas. To explore whether lower-grade astrocytomas are also associated with corresponding mutations of the p53 gene, we have investigated a series of 22 human astrocytomas of WHO grades II and III both for loss of heterozygosity on chromosome 17p and for p53 mutations. Mutations in the conserved regions of the p53 gene were identified by single strand conformation polymorphism analysis of exons 5, 6, 7, and 8 and were verified by direct DNA sequencing of the polymerase chain reaction products. p53 mutations were observed in 3 of 8 grade II astrocytomas and 4 of 14 grade II astrocytomas. In all 22 tumors, allelic loss of the short arm of chromosome 17 was investigated by restriction fragment length polymorphism analysis. One-half of the grade II astrocytomas (4 of 8) and grade III astrocytomas (7 of 14) exhibited allelic loss on chromosome 17p. Mutations in the p53 gene were exclusively observed in tumors with allelic loss on 17p. Our results show that p53 mutations are not restricted to glioblastoma multiforme and may be important in the tumorigenesis of lower-grade astrocytomas and that p53 mutations in lower-grade astrocytomas are associated with loss of chromosome 17p. These findings are consistent with a recessive mechanism of action of p53 in WHO grade II and III astrocytoma tumorigenesis.

Chromosome 17p deletions and p53 gene mutations associated with the formation of malignant neurofibrosarcomas in von Recklinghausen neurofibromatosis

von Recklinghausen neurofibromatosis (NF1) is a common hereditary disorder characterized by neural crest-derived tumors, particularly benign neurofibromas whose malignant transformation to neurofibrosarcomas can be fatal. The NF1 gene has been mapped to a small region of chromosome 17q, but neither the nature of the primary defect nor the mechanisms involved in tumor progression are understood. We have tested whether NF1 might be caused by the inactivation of a tumor suppressor gene on 17q, analogous to that on chromosome 22 in NF2, by searching for deletions of chromosome 17 in NF1-derived tumor specimens. Both neurofibrosarcomas from patients with "atypical" NF and 5 of 6 neurofibrosarcomas from NF1 patients displayed loss of alleles for polymorphic DNA markers on chromosome 17. However, the common region of deletion was on 17p and did not include the NF1 region of 17q. Since no loss of markers on chromosome 17 was observed in any of 30 benign tumors from NF1 patients, the 17p deletions seen in neurofibrosarcomas are probably associated with tumor progression and/or malignancy. This region contains a candidate gene for tumor progression, p53, which has recently been implicated in the progression of a broad array of human cancers. In a preliminary search for p53 aberrations by direct sequencing of polymerase chain reaction-amplified DNA from 7 neurofibrosarcomas, 2 tumors that contained point mutations in exon 4 of the p53 gene were found, suggesting a role for this gene in at least some neurofibrosarcomas. Thus the formation of malignant neurofibrosarcomas may result from several independent genetic events including mutation of the NF1 gene, whose mechanism of tumorigenesis remains uncertain, and subsequent loss of a "tumor suppressor" gene on 17p, most likely p53.

Loss of distinct regions on the short arm of chromosome 17 associated with tumorigenesis of human astrocytomas

Astrocytomas, including glioblastoma multiforme, represent the most frequent and deadly primary neoplasms of the human nervous system. Despite a number of previous cytogenetic and oncogene studies primarily focusing on malignant astrocytomas, the primary mechanism of tumor initiation has remained obscure. The loss or inactivation of "tumor suppressor" genes are thought to play a fundamental role in the development of many human cancers. Thus, we have analyzed astrocytomas of various histological malignancy grades with polymorphic DNA markers to search for specific chromosomal deletions potentially pointing to loci containing tumor suppressor genes. Loss of constitutional heterozygosity indicating chromosomal loss or deletions was most frequently seen for markers on the short arm of chromosome 17 in 50% of the informative tumors (5 of 10 informative cases) and, to a lesser extent, for markers on chromosomes 1 and 10. Deletions on chromosome 17p were seen in both low-grade and high-grade malignant astrocytomas, suggesting that this chromosome may contain a tumor suppressor gene associated with the early events in tumorigenesis. The common region of deletions on the short arm of chromosome 17 is, therefore, clearly distinct from the gene causing von Recklinghausen neurofibromatosis (NF1), a tumor syndrome associated with glial tumors that maps to the long arm of chromosome 17. The search for progressively smaller deletions on chromosome 17p in astrocytomas may be the way to clone and characterize this locus, thus leading to insights into normal and abnormal growth and differentiation of glial cells.

Edinger-Westphal nucleus: cells that project to spinal cord contain corticotropin-releasing factor

Combined retrograde transport and immunocytochemical methods were used to determine whether neurons in the Edinger-Westphal complex (EW) that project to the spinal cord also demonstrate corticotropin-releasing factor-like immunoreactivity (CRF-LI). Large injections of horseradish peroxidase (HRP) into cervical spinal cord retrogradely labeled cells throughout the extent of the EW complex. Most retrogradely labeled EW neurons also exhibited CRF-LI, evidence that EW is the origin of a direct CRF-containing pathway which links the rostral mesencephalon with spinal cord.

Suppression of the jaw-opening reflex by periaqueductal gray stimulation is decreased by paramedian brainstem lesions

Electrical stimulation of the midbrain periaqueductal gray region (PAG) suppresses the tooth pulp-evoked jaw-opening reflex (TP-JOR). In the present study the pathways that mediate this suppression were investigated by placing brainstem lesions in lightly anesthetized cats. Parasagittal lesions that interrupted the afferent and efferent connections of the medullary and pontine raphe nuclei attenuated (but did not abolish) suppression of the TP-JOR evoked by PAG stimulation. This result provides further evidence that medial brainstem structures partially mediate the effects of PAG stimulation in the trigeminal system.