Publications by authors named "Benjamin H Yip"

47 Publications

Diagnostic accuracy of dementia screening tools in the Chinese population: a systematic review and meta-analysis of 167 diagnostic studies.

Age Ageing 2021 Feb 24. Epub 2021 Feb 24.

JC School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.

Background: The rate of undetected dementia is high in China. However, the performance of dementia screening tools may differ in the Chinese population due to the lower education level and cultural diversity. This study aimed to evaluate the diagnostic accuracy of dementia screening tools in the Chinese population.

Methods: Eleven electronic databases were searched for studies evaluating the diagnostic accuracy of dementia screening tools in older Chinese adults. The overall diagnostic accuracy was estimated using bivariate random-effects models, and the area under the summary receiver operating characteristic curve was presented.

Results: One hundred sixty-seven studies including 81 screening tools were identified. Only 134 studies qualified for the meta-analysis. The Mini-Mental State Examination (MMSE) was the most commonly studied tool, with a combined sensitivity (SENS) and specificity (SPEC) of 0.87 (95%CI 0.85-0.90) and 0.89 (95%CI 0.86-0.91), respectively. The Addenbrooke's Cognitive Examination-Revised (ACE-R) (SENS: 0.96, 95%CI 0.89-0.99; SPEC: 0.96, 95%CI 0.89-0.98) and Montreal Cognitive Assessment (MoCA) (SENS: 0.93, 95%CI 0.88-0.96; SPEC: 0.90, 95%CI 0.86-0.93) showed the highest performance. The General Practitioner Assessment of Cognition (GPCOG), Hasegawa's Dementia Scale and Cognitive Abilities Screening Instrument had performances comparable to that of the MMSE. The cut-off scores ranged widely across studies, especially for the MMSE (range: 15-27) and MoCA (range: 14-26).

Conclusions: A number of dementia screening tools were validated in the Chinese population after cultural and linguistical adaptations. The ACE-R and MoCA had the best diagnostic accuracy, whereas the GPCOG, with an administration time < 5 minutes, could be considered as a rapid screening tool.
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http://dx.doi.org/10.1093/ageing/afab005DOI Listing
February 2021

A pilot feasibility randomized controlled trial on combining mind-body physical exercise, cognitive training, and nurse-led risk factor modification to reduce cognitive decline among older adults with mild cognitive impairment in primary care.

PeerJ 2020 7;8:e9845. Epub 2020 Sep 7.

Division of Family Medicine and Primary Health Care, JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China.

Objectives: To examine the feasibility and preliminary effectiveness of (1) combining cognitive training, mind-body physical exercise, and nurse-led risk factor modification (CPR), (2) nurse-led risk factor modification (RFM), and (3) health advice (HA) on reducing cognitive decline among older adults with mild cognitive impairment (MCI).

Methods: It was a 3-arm open-labeled pilot randomized controlled trial in the primary care setting in Hong Kong. Nineteen older adults with MCI were randomized to either CPR ( = 6), RFM ( = 7), or HA ( = 6) for 6 months. The primary outcome was the feasibility of the study. Secondary outcomes included the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), the Montreal Cognitive Assessment Hong Kong version (HK-MoCA), the Clinical Dementia Rating (CDR), the Disability Assessment for Dementia (DAD), quality of life, depression, anxiety, physical activity, health service utilization, and diet.

Results: Nineteen out the 98 potential patients were recruited, with a recruitment rate of 19% (95% CI [12-29]%,  = 0.243). The adherence rate of risk factor modification was 89% (95% CI [65-98]%,  = 0.139) for CPR group and 86% (95% CI [63-96]%,  = 0.182) for RFM group. In the CPR group, 53% (95% CI [36-70]%,  = 0.038) of the Tai Chi exercise sessions and 54% (95% CI [37-71]%,  = 0.051) of cognitive sessions were completed. The overall dropout rate was 11% (95% CI [2-34]%,  = 0.456). Significant within group changes were observed in HK-MoCA in RFM (4.50 ± 2.59,  = 0.008), cost of health service utilization in CPR (-4000, quartiles: -6800 to -200,  = 0.043), fish and seafood in HA (-1.10 ± 1.02,  = 0.047), and sugar in HA (2.69 ± 1.80,  = 0.015). Group × time interactions were noted on HK-MoCA favoring the RFM group ( = 0.000), DAD score favoring CPR group ( = 0.027), GAS-20 favoring CPR group ( = 0.026), number of servings of fish and seafood ( = 0.004), and sugar ( < 0.001) ate per day.

Conclusions: In this pilot study, RFM and the multi-domain approach CPR were feasible and had preliminary beneficial effects in older adults with MCI in primary care setting in Hong Kong.

Trial Registration: Chinese Clinical Trial Registry (ChiCTR1800015324).
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http://dx.doi.org/10.7717/peerj.9845DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482623PMC
September 2020

Can voucher scheme enhance primary care provision for older adults: cross-sectional study in Hong Kong.

BMC Geriatr 2020 11 3;20(1):442. Epub 2020 Nov 3.

JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, Hong Kong.

Background: The Hong Kong government has launched the Elderly Health Care Voucher (EHCV) scheme to facilitate primary care in the private sector for older adults. This study aimed to examine whether voucher use was associated with a shift of healthcare burden from the public to the private sector, vaccine uptake and continuity of care.

Methods: This cross-sectional survey recruited older adults with ≥3 chronic diseases through convenience sampling from seven general outpatient clinics, seven geriatric day hospitals, and five specialist outpatient clinics of the public healthcare sector in Hong Kong. We used multiple logistic regression to address the study objective.

Results: A total of 1032 patients participated in the survey. We included 714 participants aged 70 or above in the analysis. EHCV use was associated with higher utilization of private primary care services, including general practitioner and family doctor (Adjusted Odds Ratio (AOR) 2.67, 95% Confidence Interval (95%CI) 1.51-4.72) and Chinese medicine clinic (AOR 3.53, 95%CI 1.47-8.49). There were no significant associations of EHCV use with public general outpatient clinic attendance, Accident & Emergency attendance, and hospitalization. Furthermore, EHCV users were more likely to receive pneumococcal vaccination (AOR 2.17, 95%CI 1.22-3.85) and were less likely to visit the same doctors for chronic disease management (AOR 0.10, 95%CI 0.01-0.73).

Conclusions: While the EHCV may promote private primary care utilization and preventive care, older patients continue to rely on public services and the EHCV may worsen continuity of care. Policy-makers should designate voucher usage for chronic disease management and continuity of care.
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http://dx.doi.org/10.1186/s12877-020-01851-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7640666PMC
November 2020

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.

BMC Med 2020 11 2;18(1):289. Epub 2020 Nov 2.

The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, New Territories, China.

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 (χ = 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.
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http://dx.doi.org/10.1186/s12916-020-01765-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604971PMC
November 2020

Behavioral activation with mindfulness in treating subthreshold depression in primary care: A cost-utility and cost-effectiveness analysis alongside a randomized controlled trial.

J Psychiatr Res 2021 01 16;132:111-115. Epub 2020 Oct 16.

The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China. Electronic address:

This study aimed to assess the cost-utility and cost-effectiveness of group-based behavioral activation with mindfulness (BAM) versus care as usual (CAU) for treating subthreshold depression in primary care. Adults aged 18 years or older with subthreshold depression were randomized into two arms and were followed up for 12 months. BAM group was provided with eight 2-h weekly treatment by trained allied healthcare workers. CAU group could access to usual medical care but did not receive extra interventions. The health service cost in the past 12 months was self-reported by the participants. Quality-adjusted Life Years (QALYs) and clinical outcome (incidence of major depressive disorder progression) were measured. Willingness-to-pay ratio for cost-utility analysis (CUA) and cost-effectiveness analysis (CEA) was US$50,000 per QALY and US$20,000 per prevented major depression case, respectively. These ratios were used in the cost-effective acceptability curve analyses to estimate the probability of cost-effectiveness of the estimated incremental cost effectiveness ratios (ICER) of BAM versus CAU. A total of 115 and 116 participants were included in the BAM group and CAU respectively. The estimated CUA ICER was US5,979 per QALY and had a probability of 0.93 that BAM was cost-effective when compared to CAU. Furthermore, when compared to CAU, BAM was cost-effective in preventing progression of major depression: the estimated CEA ICER was US$1046 per preventable case of major progression with a probability of 0.99 to be cost-effective. Group-based BAM is considered as a cost-effective alternative treatment for treating subthreshold depression by preventing major depressive disorder.
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http://dx.doi.org/10.1016/j.jpsychires.2020.10.006DOI Listing
January 2021

COVID-19 and Public Interest in Face Mask Use.

Am J Respir Crit Care Med 2020 08;202(3):453-455

Faculty of Medicine The Chinese University of Hong KongShatin, Hong Kong.

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http://dx.doi.org/10.1164/rccm.202004-1188LEDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7397798PMC
August 2020

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

Psychol Med 2020 Jun 11:1-9. Epub 2020 Jun 11.

The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, New Territories, Hong Kong, People's Republic of China.

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.
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http://dx.doi.org/10.1017/S0033291720001920DOI Listing
June 2020

Two-Year Clinical Trial of the Low-Concentration Atropine for Myopia Progression (LAMP) Study: Phase 2 Report.

Ophthalmology 2020 07 21;127(7):910-919. Epub 2019 Dec 21.

Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China.

Purpose: To evaluate the efficacy and safety of 0.05%, 0.025%, and 0.01% atropine eye drops over 2 years to determine which is the optimal concentration for longer-term myopia control.

Design: Randomized, double-masked trial extended from the Low-Concentration Atropine for Myopia Progression (LAMP) Study.

Participants: Three hundred eighty-three of 438 children (87%) aged 4 to 12 years with myopia of at least -1.0 diopter (D) originally randomized to receive atropine 0.05%, 0.025%, 0.01%, or placebo once daily in both eyes in the LAMP phase 1 study were continued in this extended trial (phase 2).

Methods: Children in the placebo group (phase 1) were switched to receive 0.05% atropine from the beginning of the second-year follow-up, whereas those in the 0.05%, 0.025%, and 0.01% atropine groups continued with the same regimen. Cycloplegic refraction, axial length (AL), accommodation amplitude, photopic and mesopic pupil diameter, and best-corrected visual acuity were measured at 4-month intervals.

Main Outcome Measures: Changes in spherical equivalent (SE) and AL and their differences between groups.

Results: Over the 2-year period, the mean SE progression was 0.55±0.86 D, 0.85±0.73 D, and 1.12±0.85 D in the 0.05%, 0.025%, and 0.01% atropine groups, respectively (P = 0.015, P < 0.001, and P = 0.02, respectively, for pairwise comparisons), with mean AL changes over 2 years of 0.39±0.35 mm, 0.50±0.33 mm, and 0.59±0.38 mm (P = 0.04, P < 0.001, and P = 0.10, respectively). Compared with the first year, the second-year efficacy of 0.05% and 0.025% atropine remained similar (P >0.1), but improved mildly in the 0.01% atropine group (P = 0.04). For the phase 1 placebo group, the myopia progression was reduced significantly after switching to 0.05% atropine (SE change, 0.18 D in second year vs. 0.82 D in first year [P < 0.001]; AL elongated 0.15 mm in second year vs. 0.43 mm in first year [P < 0.001]). Accommodation loss and change in pupil size in all concentrations remained similar to the first-year results and were well tolerated. Visual acuity and vision-related quality of life remained unaffected.

Conclusions: Over 2 years, the efficacy of 0.05% atropine observed was double that observed with 0.01% atropine, and it remained the optimal concentration among the studied atropine concentrations in slowing myopia progression.
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http://dx.doi.org/10.1016/j.ophtha.2019.12.011DOI Listing
July 2020

High prevalence of myopia in children and their parents in Hong Kong Chinese Population: the Hong Kong Children Eye Study.

Acta Ophthalmol 2020 Jan 24. Epub 2020 Jan 24.

Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Kowloon, Hong Kong.

Purpose: To determine the myopia prevalence in Hong Kong Chinese children and their parents.

Methods: It was a population-based cross-sectional study. A total of 4257 children aged 6-8 years, and 5880 parents were recruited in the Hong Kong Children Eye Study. Cycloplegic autorefraction was measured for children; and non-cycloplegic autorefraction for parents. Parental educational level, children's outdoor time, and near work were collected by validated questionnaires.

Results: In children aged 6-8 years, 25.0% were myopic, and among them, 12.7% for the 6-year-olds, 24.4% for the 7-year-olds and 36.1% for the 8-year-old. About 0.7% of children aged 8 years were high myopia. In all age groups, boys (their myopia rate: 13.9% at 6 years, 26.7% at 7 years, and 38.3% at 8 years) were more myopic than girls (11.3% at 6 years, 22.0% at 7 years, 33.4% at 8 years). Among parents, 72.2% were myopic (mother, 73.2%; father, 70.7%) and 13.5% high myopia (mother, 12.8%; father, 14.5%). It was observed that prevalence decreased with ages and increased with education level.

Conclusion: There is a strikingly high prevalence of myopia in Hong Kong children aged 6-8, much higher than that of other regions of China. Of note, the prevalence of children was similar to that in 15 years ago. Furthermore, the myopia prevalence of parents is high, and it had already increased in this cohort. Prevention of childhood myopia is important, likewise for visual complications from high myopia in adults.
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http://dx.doi.org/10.1111/aos.14350DOI Listing
January 2020

Can Classification and Regression Tree Analysis Help Identify Clinically Meaningful Risk Groups for Hip Fracture Prediction in Older American Men (The MrOS Cohort Study)?

JBMR Plus 2019 Oct 21;3(10):e10207. Epub 2019 Aug 21.

California Pacific Medical Center Research Institute San Francisco CA USA.

Although the WHO fracture risk algorithm (FRAX) is used to predict fracture, the utility of some simple machine-learning methods, such as classification and regression trees (CARTs) should be evaluated to determine their efficacy in fracture prediction. Follow-up time for the hip fracture analyses of 5977 community-dwelling American men aged ≥65 years old was truncated to 10 years. There were 172 (2.9%) men who had an incident nontraumatic hip fracture. The CARTs were developed using hip BMD and common clinical risk factors as follows: model 1 = using classification with continuous variables of age, total hip BMD, and femoral neck BMD, or together with common clinical risk factors; and model 2 = using classification with continuous variables of age, total hip BMD, femoral neck BMD, FRAX score, osteoporosis by -score at the hip, and common clinical risk factors. The predictive performance of risk models derived from CARTs was compared with the basic classification of FRAX at 3% (basic model). From model 1, discriminators selected by CART were total hip BMD, age, and femoral neck BMD; no other clinical risk factors were selected. From model 2, discriminators selected by CART were FRAX score, femoral neck BMD, and age. Compared with the basic model using only a high-risk group by FRAX ≥3%, no significantly improved predictive performance was demonstrated by model 1 or model 2 as identified by CART with the area under the receiver-operating characteristic curve for each model of 0.714 (95% CI, 0.676 to 0.751) or 0.726 (95% CI, 0.690 to 0.762) versus 0.703 (95% CI, 0.667 to 0.740), respectively. The improved overall net reclassification improvement index was 0.02 (95% CI, -0.04 to 0.08) and 0.05 (95% CI, -0.01 to 0.10), respectively. Although a FRAX category is a good clinical indicator for hip fracture risk, a simple classification by age and BMD may provide an alternative way to estimate a clinical risk level of 3.0%. © 2019 The Authors. is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.
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http://dx.doi.org/10.1002/jbm4.10207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820460PMC
October 2019

Combined nicotine patch with gum versus nicotine patch alone in smoking cessation in Hong Kong primary care clinics: a randomised controlled trial.

BMC Public Health 2019 Oct 16;19(1):1302. Epub 2019 Oct 16.

Department of Family Medicine and Primary Health Care, Kowloon East Cluster, Hospital Authority, Hong Kong, China.

Background: The prevalence of daily cigarette smoking has dropped to 10% in Hong Kong (HK) in 2017, however, smoking still kills 5700 persons per year. Studies suggest that abstinence rates are higher with combined NRT than single NRT, although local data on safety and benefits of combined NRT are lacking. The aim of this study is to compare the effectiveness of combined NRT with single NRT among HK Chinese.

Methods: This is a one-year, two-arm, parallel randomised trial. Five hundred sixty smokers, who smoked ≥10 cigarettes/day for ≥1 year, were randomized to combined and single NRT. Combined NRT group received counseling and nicotine patch & gum. Single NRT group received counselling and nicotine patch. Primary outcome was abstinence rate measured as self-reported 7-day point prevalence with CO validated at 52 weeks. Secondary outcomes included smoking abstinence rates at 4, 12, & 26 weeks. Crude odds ratio and p-value were reported from logistic regression without adjustment; for trend analysis, adjusted odds ratio (AOR) and p-value were reported from Generalized Estimating Equation (GEE) (controlling for time). All AORs were adjusted for age, sex, baseline CO and clusters.

Results: Abstinence rates at 4, 12, 26 and 52 weeks were all higher in the combined NRT group (35.8, 21.9, 16.8, 20.1%) compared with the single NRT group (28, 16.8, 11.2, 14.3%). At 4 weeks, combined NRT group was more likely to quit smoking (OR 1.43, 95% CI, 1.00 to 2.05) than the single NRT group. From GEE analysis, combined NRT group had a significantly higher abstinence rate (23.6%) than the single NRT group (17.6%) across repeated measures at all-time points. Combined NRT group was more likely to quit smoking (OR 1.43, 95% CI, 1.15 to 1.77). No significant difference in the side effect profile was detected between groups.

Conclusions: Smokers given 8 weeks of combined NRT were more likely to quit smoking at 4, 12, 26 and 52 weeks compared with single NRT. Combined NRT was as well tolerated as single NRT and it should be further promoted in our community.

Trial Registration: NCT03836560 from ClinicalTrial.gov , 9 Feb 2019.
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http://dx.doi.org/10.1186/s12889-019-7634-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6796337PMC
October 2019

Bone measurements at multiple skeletal sites in adolescent idiopathic scoliosis-an in vivo correlation study using DXA, HR-pQCT and QCT.

Arch Osteoporos 2019 06 27;14(1):70. Epub 2019 Jun 27.

Bone Quality and Health Centre, Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong, Hong Kong.

Significant correlations for bone mineral density and bone microstructure between spinal and non-spinal skeletal sites (distal radius and proximal femur) in adolescent idiopathic scoliosis (AIS) patients were observed, indicating that proximal femoral DXA and distal radial HR-pQCT could provide valid clinical assessments in patients with AIS.

Purpose: Low bone mass is an important feature of adolescent idiopathic scoliosis (AIS), which is a complex 3D spinal deformity that affects girls during puberty. However, no clinical imaging modality is suitable for regular monitoring on their spinal bone qualities in rapid growth period. Therefore, we investigated whether bone mineral density (BMD) and bone microstructure at non-spinal sites correlated with BMD and mechanical property in the spine in AIS patients.

Methods: Thirty-two AIS girls (16.7 ± 3.5 years old with mean Cobb angle of 67 ± 11°) who underwent pre-operative spine CT examination for navigation surgery were recruited. Volumetric BMD (vBMD) of lumbar spine (LS) was measured by quantitative computed tomography (QCT), vBMD and bone microstructure of distal radius (DR) by high-resolution peripheral QCT (HR-pQCT) and areal BMDs of total hip (TH) and femoral necks (FN) by dual-energy X-ray absorptiometry (DXA). Biomechanical properties of the DR and LS were estimated by finite element analysis (FEA). Pearson correlation was performed to study the correlation between bone parameters at these three sites.

Results: LS vBMD correlated significantly with both FN and TH aBMD (R = 0.663-0.725, both p < 0.01) and with DR microstructural parameters (R = 0.380-0.576, all p < 0.05). Mechanical properties of LS and DR were also correlated (R = 0.398, p = 0.039).

Conclusions: Bone measurement at proximal femur and distal radius could provide an additional predictive power in estimating the bone changes at spine, which is the primary site of deformity in AIS patients. Our result indicated that DXA and HR-pQCT could provide a valid surrogate for spine bone measurements in AIS patients.
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http://dx.doi.org/10.1007/s11657-019-0621-2DOI Listing
June 2019

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

BMJ Open 2019 01 25;9(1):e023927. Epub 2019 Jan 25.

The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong.

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.
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http://dx.doi.org/10.1136/bmjopen-2018-023927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347870PMC
January 2019

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.

Eur J Intern Med 2019 03 20;61:103-111. Epub 2018 Dec 20.

The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Sha Tin, New Territories, Hong Kong. Electronic address:

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.
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http://dx.doi.org/10.1016/j.ejim.2018.12.001DOI Listing
March 2019

Socioeconomic disparity in mortality risks widened across generations during rapid economic development in Hong Kong: an age-period-cohort analysis from 1976 to 2010.

Ann Epidemiol 2018 11 14;28(11):743-752.e4. Epub 2018 Jun 14.

The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, New Territories, Hong Kong, China.

Purpose: Hong Kong has been one of the fastest growing postwar economies with substantial decline in mortality risks during the past decades. Nevertheless, it is unclear whether there is a socioeconomic disparity in the trends of mortality risks across generations.

Methods: We conducted a series of sex-specific age-period-cohort analyses by neighborhood-level socioeconomic status (SES) using mortality data from 1976 to 2010 to examine the socioeconomic disparity of cohort effects. Outcomes included all-cause mortality and mortality from ischemic heart disease, other cardiovascular diseases (CVD), lung cancer, other cancers, respiratory diseases (RD), other medical causes, and external causes.

Results: Age-standardized mortality rates declined in both sexes, with generally higher rates observed in those of lower SES. Socioeconomic disparity in the risks of all mortality outcomes emerged and widened starting from cohorts born around the 1930s-1940s. These results suggested that mortality risks associated with lower SES did not decline across generations as much as those associated with higher SES.

Conclusions: The share of health benefits brought by economic growth was notably unequal by SES with greater benefits for those of higher SES. More attention should be paid to postwar baby boomers of lower SES.
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http://dx.doi.org/10.1016/j.annepidem.2018.06.004DOI Listing
November 2018

Utilization of psychiatric care and antidepressants among people with different severity of depression: a population-based cohort study in Stockholm, Sweden.

Soc Psychiatry Psychiatr Epidemiol 2018 Jun 12;53(6):607-615. Epub 2018 Apr 12.

Epidemiology and Public Health Intervention Research group (EPHIR), Department of Public Health Sciences, Karolinska Institutet, Widerströmska huset, 3rd floor, Tomtebodav 18A, 111 77, Stockholm, Sweden.

Purpose: To identify how severity of depression predicts future utilization of psychiatric care and antidepressants.

Methods: Data derived from a longitudinal population-based study in Stockholm, Sweden, include 10443 participants aged 20-64 years. Depression was assessed by Major Depression Inventory and divided into subsyndromal, mild, moderate and severe depression. Outcomes were the first time of hospitalization, specialized outpatient care and prescribed drugs obtained from national register records. The association between severity of depression and outcomes was tested by Cox regression analysis, after adjusting for gender, psychiatric treatment history and socio-environmental factors.

Results: The cumulative incidences of hospitalizations, outpatient care and antidepressants were 4.0, 11.2, and 21.9% respectively. Compared to the non-depressed group, people with different severity of depression (subsyndromal, mild, moderate and severe depression) all had significantly higher risk of all three psychiatric services (all log-rank test P < 0.001). Use of psychiatric care and antidepressants increased by rising severity of depression. Although the associations between severity of depression and psychiatric services were significant, the dose relationship was not present in people with previous psychiatric history or after adjusting for gender and other factors.

Conclusions: People with subsyndromal to severe depression all have increased future psychiatric service utilization compared to non-depressed people.
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http://dx.doi.org/10.1007/s00127-018-1515-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5959996PMC
June 2018

Treating Subthreshold Depression in Primary Care: A Randomized Controlled Trial of Behavioral Activation With Mindfulness.

Ann Fam Med 2018 03;16(2):111-119

The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China (Wong, Sun, T.Y. Chan, Yip); Fanling Family Medicine Centre, Hospital Authority, Hong Kong, China (Leung); United Christian Hospital, Hospital Authority, Hong Kong, China (Chao); Kowloon East Cluster, Hospital Authority, Hong Kong, China (Li); Kowloon Central Cluster, Hospital Authority, Hong Kong, China (K.H. Chan); Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong, China (Tang); School of Psychology and Speech Pathology, Curtin University, Perth, Western Australia (Mazzucchelli); Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong, China (Au).

Purpose: We undertook a randomized controlled trial to assess the efficacy of group-based behavioral activation with mindfulness (BAM) for treating subthreshold depression in primary care in Hong Kong.

Methods: We recruited adult patients aged 18 years or older with subthreshold depression from public primary care clinics and randomly assigned them to a BAM intervention group or a usual care group. The BAM group was provided with eight 2-hour weekly BAM sessions by trained allied health care workers. Patients in the usual care group received usual medical care with no additional psychological interventions. The primary outcome was depressive symptoms measured by the Beck Depression Inventory-II at 12 months. Secondary outcomes included incidence of major depressive disorder at 12 months. We assessed quality of life, activity and circumstances change, functional impairment, and anxiety at baseline, end of intervention, 5 months, and 12 months.

Results: We randomly allocated 115 patients to the BAM intervention and 116 patients to usual care. At 12 months, compared with usual care peers, BAM patients had a slightly more favorable change in levels of depressive symptoms on the Beck Depression Inventory-II (between-group mean difference in score = -3.85; 95% CI, -6.36 to -1.34; Cohen = -0.46, 95% CI, -0.76 to -0.16). Incidence of major depressive disorder was lower with BAM (10.8% vs 26.8%, = .01), whereas groups did not differ significantly on other secondary outcomes at 12 months.

Conclusions: Group BAM appears to be efficacious for decreasing depressive symptoms and reducing the incidence of major depression among patients with subthreshold depression in primary care, although generalizability of our findings may be limited.
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http://dx.doi.org/10.1370/afm.2206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5847348PMC
March 2018

Screening for latent and active tuberculosis infection in the elderly at admission to residential care homes: A cost-effectiveness analysis in an intermediate disease burden area.

PLoS One 2018 2;13(1):e0189531. Epub 2018 Jan 2.

Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China.

Background: Tuberculosis (TB) in the elderly remains a challenge in intermediate disease burden areas like Hong Kong. Given a higher TB burden in the elderly and limited impact of current case-finding strategy by patient-initiated pathway, proactive screening approaches for the high-risk group could be optimal and increasingly need targeted economic evaluations. In this study, we examined whether and under what circumstance the screening strategies are cost-effective compared with no screening strategy for the elderly at admission to residential care homes.

Methods: A decision analytic process based on Markov model was adopted to evaluate the cost-effectiveness of four strategies: (i) no screening, (ii) TB screening (CXR) and (iii) TB screening (Xpert) represent screening for TB in symptomatic elderly by chest X-ray and Xpert® MTB/RIF respectively, and (iv) LTBI/TB screening represents screening for latent and active TB infection by QuantiFERON®-TB Gold In-Tube and chest X-ray. The target population was a hypothetical cohort of 65-year-old people, using a health service provider perspective and a time horizon of 20 years. The outcomes were direct medical costs, life-years and quality-adjusted life-years (QALYs) measured by incremental cost-effectiveness ratio (ICER).

Results: In the base-case analysis, no screening was the most cost-saving; TB screening (CXR) was dominated by TB screening (Xpert); LTBI/TB screening resulted in more life-years and QALYs accrued. The ICERs of LTBI/TB screening were US$19,712 and US$29,951 per QALY gained compared with no screening and TB screening (Xpert), respectively. At the willingness-to-pay threshold of US$50,000 per QALY gained, LTBI/TB screening was the most cost-effective when the probability of annual LTBI reactivation was greater than 0.155% and acceptability of LTBI/TB screening was greater than 38%. In 1,000 iterations of Monte Carlo simulation, the probabilities of no screening, TB screening (CXR), TB screening (Xpert), and LTBI/TB screening to be cost-effective were 0, 1.3%, 20.1%, and 78.6% respectively.

Conclusions: Screening for latent and active TB infection in Hong Kong elderly people at admission to residential care homes appears to be highly effective and cost-effective. The key findings may be the next key factor to bring down TB endemic in the elderly population among intermediate TB burden areas.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0189531PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5749681PMC
February 2018

Incidence and mortality of kidney cancer: temporal patterns and global trends in 39 countries.

Sci Rep 2017 11 16;7(1):15698. Epub 2017 Nov 16.

Division of Urology, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.

We tested the hypotheses that kidney cancer incidence was increasing globally whilst its mortality was reducing; and its incidence was positively correlated with country-specific socioeconomic development. The incidence and mortality figures of each country were projected to 2030. Data on age-standardized incidence/mortality rates were retrieved from the GLOBOCAN in 2012. Temporal patterns were examined for 39 countries from the Cancer Incidence in Five Continents volumes I-X and other national registries. We evaluated the correlation between the incidence/mortality rates and Human Development Index (HDI)/Gross Domestic Product (GDP]). The average annual percent change of its incidence and mortality in the most recent 10 years was obtained from joinpoint regression. The highest incidence rates were observed in Eastern Europe and North America, while its mortality rates were the highest in European countries. Incidence was positively correlated with HDI and GDP per capita. Many countries experienced incidence rise over the most recent 10 years, and a substantial reduction in mortality rates was observed for a significant number of countries, yet increases in mortality rates were observed in Eastern Europe. By 2030, Brazil and Ecuador may have the greatest rise in incidence both in men and women, which requires urgent need for planning healthcare resources.
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http://dx.doi.org/10.1038/s41598-017-15922-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5691143PMC
November 2017

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

Pain Physician 2017 07;20(5):E711-E719

The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.

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.
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July 2017

Characteristics and Methodological Quality of Meta-Analyses on Hypertension Treatments-A Cross-Sectional Study.

J Clin Hypertens (Greenwich) 2017 Feb 6;19(2):137-142. Epub 2016 Aug 6.

Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.

Methodological quality of meta-analyses on hypertension treatments can affect treatment decision-making. The authors conducted a cross-sectional study to investigate the methodological quality of meta-analyses on hypertension treatments. One hundred and fifty-eight meta-analyses were identified. Overall, methodological quality was unsatisfactory in the following aspects: comprehensive reporting of financial support (1.9%), provision of included and excluded lists of studies (22.8%), inclusion of grey literature (27.2%), and inclusion of protocols (32.9%). The 126 non-Cochrane meta-analyses had poor performance on almost all the methodological items. Non-Cochrane meta-analyses focused on nonpharmacologic treatments were more likely to consider scientific quality of included studies when making conclusions. The 32 Cochrane meta-analyses generally had good methodological quality except for comprehensive reporting of the sources of support. These results highlight the need for cautious interpretation of these meta-analyses, especially among physicians and policy makers when guidelines are formulated. Future meta-analyses should pay attention to improving these methodological aspects.
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http://dx.doi.org/10.1111/jch.12889DOI Listing
February 2017

Epidemiological characteristics and methodological quality of meta-analyses on diabetes mellitus treatment: a systematic review.

Eur J Endocrinol 2016 Nov 4;175(5):353-60. Epub 2016 Aug 4.

Jockey Club School of Public Health and Primary Care Hong Kong Branch of the Chinese Cochrane Centre

Objective: Well-conducted meta-analyses (MAs) are considered as one of the best sources of clinical evidence for treatment decision. MA with methodological flaws may introduce bias and mislead evidence users. The aim of this study is to investigate the characteristics and methodological quality of MAs on diabetes mellitus (DM) treatments.

Design: Systematic review.

Methods: Cochrane Database of Systematic Review and Database of Abstract of Reviews of Effects were searched for relevant MAs. Assessing methodological quality of systematic reviews (AMSTAR) tool was used to evaluate the methodological quality of included MAs. Logistic regression analysis was used to identify association between characteristics of MA and AMSTAR results.

Results: A total of 252 MAs including 4999 primary studies and 13,577,025 patients were included. Over half of the MAs (65.1%) only included type 2 DM patients and 160 MAs (63.5%) focused on pharmacological treatments. About 89.7% MAs performed comprehensive literature search and 89.3% provided characteristics of included studies. Included MAs generally had poor performance on the remaining AMSTAR items, especially in assessing publication bias (39.3%), providing lists of studies (19.0%) and declaring source of support comprehensively (7.5%). Only 62.7% MAs mentioned about harm of interventions. MAs with corresponding author from Asia performed less well in providing MA protocol than those from Europe.

Conclusions: Methodological quality of MA on DM treatments was unsatisfactory. There is considerable room for improvement, especially in assessing publication bias, providing lists of studies and declaring source of support comprehensively. Also, there is an urgent need for MA authors to report treatment harm comprehensively.
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http://dx.doi.org/10.1530/EJE-16-0172DOI Listing
November 2016

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

Sci Rep 2016 07 20;6:29758. Epub 2016 Jul 20.

School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong.

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.
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http://dx.doi.org/10.1038/srep29758DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4951721PMC
July 2016

Electroacupuncture and splinting versus splinting alone to treat carpal tunnel syndrome: a randomized controlled trial.

CMAJ 2016 Sep 6;188(12):867-875. Epub 2016 Jun 6.

Jockey Club School of Public Health and Primary Care (Chong, Chung, Griffiths, Ho, Sit, Liu, Wong, Yip, Zee); Hong Kong Institute of Integrative Medicine (Chung, Lau, Sit, Wong, Wu); Department of Medicine and Therapeutics (Lau, Wu); School of Chinese Medicine (Leung), The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Institute of Global Health Innovation (Griffiths), Imperial College London, London, UK.

Background: The effectiveness of acupuncture for managing carpal tunnel syndrome is uncertain, particularly in patients already receiving conventional treatments (e.g., splinting). We aimed to assess the effects of electroacupuncture combined with splinting.

Methods: We conducted a randomized parallel-group assessor-blinded 2-arm trial on patients with clinically diagnosed primary carpal tunnel syndrome. The treatment group was offered 13 sessions of electroacupuncture over 17 weeks. The treatment and control groups both received continuous nocturnal wrist splinting.

Results: Of 181 participants randomly assigned to electroacupuncture combined with splinting (n = 90) or splinting alone (n = 91), 174 (96.1%) completed all follow-up. The electroacupuncture group showed greater improvements at 17 weeks in symptoms (primary outcome of Symptom Severity Scale score mean difference [MD] -0.20, 95% confidence interval [CI] -0.36 to -0.03), disability (Disability of Arm, Shoulder and Hand Questionnaire score MD -6.72, 95% CI -10.9 to -2.57), function (Functional Status Scale score MD -0.22, 95% CI -0.38 to -0.05), dexterity (time to complete blinded pick-up test MD -6.13 seconds, 95% CI -10.6 to -1.63) and maximal tip pinch strength (MD 1.17 lb, 95% CI 0.48 to 1.86). Differences between groups were small and clinically unimportant for reduction in pain (numerical rating scale -0.70, 95% CI -1.34 to -0.06), and not significant for sensation (first finger monofilament test -0.08 mm, 95% CI -0.22 to 0.06).

Interpretation: For patients with primary carpal tunnel syndrome, chronic mild to moderate symptoms and no indication for surgery, electroacupuncture produces small changes in symptoms, disability, function, dexterity and pinch strength when added to nocturnal splinting.

Trial Registration: Chinese Clinical Trial Register no. ChiCTR-TRC-11001655 (www.chictr.org.cn/showprojen.aspx?proj=7890); subsequently deposited in the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR-TRC-11001655).
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http://dx.doi.org/10.1503/cmaj.151003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008933PMC
September 2016

Patient Perceptions of Expression of Empathy From Chinese Medicine Clinicians in a Chinese Population: A Cross-Sectional Study.

Medicine (Baltimore) 2016 Apr;95(17):e3316

From the Jockey Club School of Public Health and Primary Care (VCHC, BHKY, ELMY, SL, RSTH, RWSS, SYSW), Hong Kong Institute of Integrative Medicine (VCHC, RWSS, JCYW, SYSW), and School of Chinese Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China (AWNL).

This study aims to examine the level of empathy perceived by patients receiving care from herbalists, acupuncturists and massage therapists and to investigate the factors that influence levels of perceived empathy.Participants who were 18 years or above; able to provide written informed consent; and able to read and write in Chinese without assistance were included. A total of 514 participants sampled from charity and semipublic Chinese medicine (CM) clinics in Hong Kong were recruited to assess levels of empathy perceived during various length of consultations (1-20 minutes) by the Chinese Consultation and Relational Empathy Measure (Chinese CARE). Multiple linear regressions were conducted to evaluate the associations between perceived levels of empathy and the type of CM practitioner consulted and participants' demographic and health characteristics.The average Chinese CARE total score for participants consulting CM practitioners was 34.3 of a maximum of 50. After adjusting for participants' health and demographic characteristics, acupuncturists received the highest ratings (P < 0.001), whereas massage therapists (P < 0.001) scored the lowest of the 3 modalities. Participants receiving social benefits (P = 0.013), those with longer waiting times (P = 0.002), and those with shorter consultation durations (P = 0.020) scored significantly lower on the Chinese CARE.The level of empathy perceived by participants using CM was similar to results found for those in conventional care, in contrast to findings in other geographical settings, where a high level of perceived empathy was a major motivator for participants to choose complementary medicine.
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http://dx.doi.org/10.1097/MD.0000000000003316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4998684PMC
April 2016

The Association of Types of Training and Practice Settings with Doctors' Empathy and Patient Enablement among Patients with Chronic Illness in Hong Kong.

PLoS One 2015 14;10(12):e0144492. Epub 2015 Dec 14.

School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, The People's Republic of China.

Background: The increase in non-communicable disease (NCD) is becoming a global health problem and there is an increasing need for primary care doctors to look after these patients although whether family doctors are adequately trained and prepared is unknown.

Objective: This study aimed to determine if doctors with family medicine (FM) training are associated with enhanced empathy in consultation and enablement for patients with chronic illness as compared to doctors with internal medicine training or without any postgraduate training in different clinic settings.

Methods: This was a cross-sectional questionnaire survey using the validated Chinese version of the Consultation and Relational Empathy (CARE) Measure as well as Patient Enablement Instrument (PEI) for evaluation of quality and outcome of care. 14 doctors from hospital specialist clinics (7 with family medicine training, and 7 with internal medicine training) and 13 doctors from primary care clinics (7 with family medicine training, and 6 without specialist training) were recruited. In total, they consulted 823 patients with chronic illness. The CARE Measure and PEI scores were compared amongst doctors in these clinics with different training background: family medicine training, internal medicine training and those without specialist training. Generalized estimation equation (GEE) was used to account for cluster effects of patients nested with doctors.

Results: Within similar clinic settings, FM trained doctors had higher CARE score than doctors with no FM training. In hospital clinics, the difference of the mean CARE score for doctors who had family medicine training (39.2, SD = 7.04) and internal medicine training (35.5, SD = 8.92) was statistically significant after adjusting for consultation time and gender of the patient. In the community care clinics, the mean CARE score for doctors with family medicine training and those without specialist training were 32.1 (SD = 7.95) and 29.2 (SD = 7.43) respectively, but the difference was not found to be significant. For PEI, patients receiving care from doctors in the hospital clinics scored significantly higher than those in the community clinics, but there was no significant difference in PEI between patients receiving care from doctors with different training backgrounds within similar clinic setting.

Conclusion: Family medicine training was associated with higher patient perceived empathy for chronic illness patients in the hospital clinics. Patient enablement appeared to be associated with clinic settings but not doctors' training background. Training in family medicine and a clinic environment that enables more patient doctor time might help in enhancing doctors' empathy and enablement for chronic illness patients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0144492PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4678047PMC
June 2016

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

PLoS One 2015 9;10(10):e0140040. Epub 2015 Oct 9.

School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.

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.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0140040PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4599799PMC
July 2016

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

PLoS One 2015 9;10(10):e0140040. Epub 2015 Oct 9.

School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.

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.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0140040PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4599799PMC
July 2016

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

PLoS One 2015 10;10(3):e0117721. Epub 2015 Mar 10.

Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China, Address: 4/F, School of Public Health Building, Prince of Wales Hospital, Shatin, Hong Kong, China.

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.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0117721PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4355485PMC
January 2016