Edward M. F. Leung

Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Older

BACKGROUND A trial involving adults 50 years of age or older (ZOE-50) showed that the herpes zoster subunit vaccine (HZ/su) containing recombinant varicella-zoster virus glycoprotein E and the AS01B adjuvant system was associated with a risk of herpes zoster that was 97.2% lower than that associated with placebo. A second trial was performed concurrently at the same sites and examined the safety and efficacy of HZ/su in adults 70 years of age or older (ZOE-70). METHODS This randomized, placebo-controlled, phase 3 trial was conducted in 18 countries and involved adults 70 years of age or older. Participants received two doses of HZ/su or placebo (assigned in a 1:1 ratio) administered intramuscularly 2 months apart. Vaccine efficacy against herpes zoster and postherpetic neuralgia was assessed in participants from ZOE-70 and in participants pooled from ZOE-70 and ZOE-50. RESULTS In ZOE-70, 13,900 participants who could be evaluated (mean age, 75.6 years) received either HZ/su (6950 participants) or placebo (6950 participants). During a mean follow-up period of 3.7 years, herpes zoster occurred in 23 HZ/su recipients and in 223 placebo recipients (0.9 vs. 9.2 per 1000 person-years). Vaccine efficacy against herpes zoster was 89.8% (95% confidence interval [CI], 84.2 to 93.7; P<0.001) and was similar in participants 70 to 79 years of age (90.0%) and participants 80 years of age or older (89.1%). In pooled analyses of data from participants 70 years of age or older in ZOE-50 and ZOE-70 (16,596 participants), vaccine efficacy against herpes zoster was 91.3% (95% CI, 86.8 to 94.5; P<0.001), and vaccine efficacy against postherpetic neuralgia was 88.8% (95% CI, 68.7 to 97.1; P<0.001). Solicited reports of injection-site and systemic reactions within 7 days after injection were more frequent among HZ/su recipients than among placebo recipients (79.0% vs. 29.5%). Serious adverse events, potential immune-mediated diseases, and deaths occurred with similar frequencies in the two study groups. CONCLUSIONS In our trial, HZ/su was found to reduce the risks of herpes zoster and postherpetic neuralgia among adults 70 years of age or older. (Funded by GlaxoSmithKline Biologicals; ZOE-50 and ZOE-70 ClinicalTrials.gov numbers, NCT01165177 and NCT01165229 .).

Social Exchanges and Subjective Well-being: Do Sources of Positive and Negative Exchanges Matter?

OBJECTIVES To decompose the effects of positive and negative social exchanges on well-being in terms of relationship type (vertically extended family, horizontally extended family, or nonfamily) and subjective closeness (close vs. peripheral). METHODS One thousand and five Chinese older adults rated each network member on positive and negative exchanges, which were aggregated for each relationship type and closeness category. Regression analyses estimated the influences of positive and negative exchanges on well-being, controlling for network size, health, and demographic factors. RESULTS Social exchanges with close and peripheral vertical family members as well as close horizontal family members were associated with well-being, whereas exchanges with nonkin did not contribute independent effects. These results were similar for both positive and negative exchanges. DISCUSSION Well-being is determined not just by social exchanges but also by where they come from. In this regard, the vertical family, the horizontal family, and the nonfamily represent a hierarchy of preference for Chinese older adults, which, to some extent, reflects the influence of familism.

The Asia-Pacific clinical practice guidelines for the management of frailty

OBJECTIVE To develop Clinical Practice Guidelines for the screening, assessment and management of the geriatric condition of frailty. METHODS An adapted Grading of Recommendations, Assessment, Development, and Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation. RECOMMENDATIONS Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan. CONCLUSIONS The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines.

One-week ranitidine bismuth citrate versus colloidal bismuth subcitrate-based anti-Helicobacter triple therapy: a prospective randomized controlled trial

OBJECTIVE:The efficacy of 1 wk bismuth triple therapy is adversely influenced by the presence of metronidazole resistance. In vitro studies suggest that ranitidine bismuth citrate (RBC) plus metronidazole exhibit synergistic activity against metronidazole resistant strains of Helicobacter pylori (H. pylori). Whether this confers a superior clinical efficacy remains unproven. This study compared the efficacy of RBC-based triple therapy with bismuth triple therapy in eradication of H. pylori.METHODS:Patients with H. pylori-related ulcer disease or gastritis were randomized to receive either 400/mg of RBC twice daily plus 400/mg of metronidazole and 500/mg of tetracycline four times daily for 1 wk (RMT) or 120/mg of colloidal bismuth subcitrate, 400/mg of metronidazole, and 500/mg of tetracycline, all given four times daily for 1 wk (BMT). Metronidazole susceptibility was determined by the E-test and pretreatment resistance was defined as minimum inhibitory concentration ≥32/mg/L.RESULTS:Of 100 consecutive patients randomized, two patients were lost to follow-up in each group. Forty-three of 85 (51%) H. pylori isolates were metronidazole resistant. Perprotocol cure rate for RMT and BMT was 40 of 41 (98%) and 37 of 44 (84%), respectively (p= 0.058). Intent-to-treat cure rate for RMT and BMT was 46 of 50 and 41 of 50, respectively (92%vs 82%, p= 0.23). A significantly higher eradication of metronidazole resistant H. pylori was observed in the RMT group (25 of 25, 100%) than in the BMT group (12 of 16, 75%), (p= 0.018). Side effects observed in the two treatment groups were comparable.CONCLUSIONS:One week of RBC triple therapy with metronidazole and tetracycline is an effective anti-Helicobacter therapy. This regimen is more appropriate in areas of high prevalence of metronidazole resistance.

Would Older Adults with Mild Cognitive Impairment Adhere to and Benefit from a Structured Lifestyle Activity Intervention to Enhance Cognition?: A Cluster Randomized Controlled Trial

Background Epidemiologic evidence suggests that cognitive and physical activities are associated with better cognition in late life. The present study was conducted to examine the possible benefits of four structured lifestyle activity interventions and compare their effectiveness in optimizing cognition for older adults with mild cognitive impairment (MCI). Method and Findings This was a 12-month cluster randomized controlled trial. 555 community-dwelling Chinese older adults with MCI (295 with multiple-domain deficits (mdMCI), 260 with single-domain deficit (sdMCI)) were recruited. Participants were randomized into physical exercise (P), cognitive activity (C), integrated cognitive and physical exercise (CP), and social activity (S, active control) groups. Interventions comprised of one-hour structured activities three times per week. Primary outcome was Clinical Dementia Rating sum of boxes (CDR-SOB) scores. Secondary outcomes included Chinese versions of Alzheimer’s Disease Assessment Scale - Cognitive subscale (ADAS-Cog), delayed recall, Mini-Mental State Examination, Category Verbal Fluency Test (CVFT) and Disability Assessment for Dementia – Instrumental Activities of Daily Living (DAD-IADL). Percentage adherence to programs and factors affecting adherence were also examined. At 12th month, 423 (76.2%) completed final assessment. There was no change in CDR-SOB and DAD-IADL scores across time and intervention groups. Multilevel normal model and linear link function showed improvement in ADAS-Cog, delayed recall and CVFT with time (p<0.05). Post-hoc subgroup analyses showed that the CP group, compared with other intervention groups, had more significant improvements of ADAS-Cog, delayed recall and CVFT performance with sdMCI participants (p<0.05). Overall adherence rate was 73.3%. Improvements in ADAS-Cog and delayed recall scores were associated with adherence after controlling for age, education, and intervention groups (univariate analyses). Conclusions Structured lifestyle activity interventions were not associated with changes in everyday functioning, albeit with some improvements in cognitive scores across time. Higher adherence was associated with greater improvement in cognitive scores. Factors to enhance adherence should be specially considered in the design of psychosocial interventions for older adults with cognitive decline. Trial Registration ClinicalTrials.gov ChiCTR-TRC-11001359

Psychometric properties of the Chinese version of the European Heart Failure Self-care Behaviour Scale

BACKGROUND Effective self-care is the cornerstone of the successful management of heart failure (HF). The European Heart Failure Self-care Behaviour Scale is a brief, reliable and valid scale to measure this important construct among patients with HF. Although the EHFScBS has been translated to different languages, no Chinese version is available. Indeed, previous findings investigating the psychometric properties of EHFScBS indicated ambiguity of the conceptual structure of this scale. AIM The aim of this study was to translate the European Heart Failure Self-care Behaviour Scale (EHFScBS) into Chinese and to test its psychometric properties in the Chinese patients with HF. METHODS The EHFScBS (English Version) was translated to Chinese using Brislins forward and backward translation method. Panel review was used to examine its semantic equivalence and content validity. The EHFScBS (Chinese Version) was then tested with a convenience sample of 143 Chinese HF patients who attended a specialist clinic from January to September 2007. RESULTS The content validity index (CVI) of the EHFScBS (Chinese version) was satisfactory (Item CVI=0.96; Scale CVI=0.89), with Cronbachs alpha 0.82. Convergent validity was supported by a moderate relationship, statistical significant with a measure for social support (r=-0.36, p<0.001). However, the findings did not support the hypothesised three-factor structure of the EHFScBS (Chinese Version). Instead, all items except one fit well a two-factor structure to measure help-seeking and regimen-complying behaviours. CONCLUSION The adequate psychometric properties and clear conceptual structure of EHFScBS (Chinese Version) warrant its use in Chinese patients with HF.

Childlessness and Subjective Well-being in Chinese Widowed Persons

OBJECTIVES This study examined the effect of childlessness on psychological well-being in widowhood taking into account the influences of social network variables. METHOD A total of 273 Chinese widowed individuals who were community dwelling formed the sample of this study. Sixteen percent (n = 44) were childless. Social network variables, instrumental activities of daily living, chronic illnesses, depressive symptoms, life satisfaction, positive affect, and negative affect were assessed. RESULTS Childlessness was significantly associated with all outcomes of psychological well-being even after controlling for network size. After positive and negative exchanges were taken into account, the effect of childlessness on depression and life satisfaction became nonsignificant but remained significant on positive and negative affect. Furthermore, the effects of childlessness on depression and life satisfaction were significantly stronger in women than in men. Childlessness also had a stronger association with depression in those with functional impairments. DISCUSSION Findings support the importance of children, and supportive exchanges with them, for the subjective well-being of Chinese widowed persons. Being women and having physical dependencies might amplify the effects of childlessness.

Changing Needs and Changing Service Delivery for Long-Term Care in Hong Kong

Summary Both the need for and delivery of long-term care in Hong Kong are shaped by the interaction of the traditional and modern. Rapid social change is affecting traditional family structures and roles in care of the elderly, resulting in increased demand for formal care, which to date has been provided mainly by way of residential care. This growth of demand will escalate with rapid population aging in coming decades. In response to this burgeoning demand, current planning is seeking to reshape the established service system and tackle problems in service delivery in ways that will address the bias towards residential care and improve quality of care.

Physical and Social Activities Mediate the Associations Between Social Network Types and Ventilatory Function in Chinese Older Adults

OBJECTIVE This study examined the associations between social network types and peak expiratory flow (PEF), and whether these associations were mediated by social and physical activities and mood. METHOD Nine hundred twenty-four community-dwelling Chinese older adults, who were classified into five network types (diverse, friend-focused, family-focused, distant family, and restricted), provided data on demographics, social and physical activities, mood, smoking, chronic diseases, and instrumental activities of daily living. PEF and biological covariates, including blood lipids and glucose, blood pressure, and height and weight, were assessed. Two measures of PEF were analyzed: the raw reading in L/min and the reading expressed as percentage of predicted normal value on the basis of age, sex, and height. Diverse, friend-focused, and distant family networks were hypothesized to have better PEF values compared with restricted networks, through higher physical and/or social activities. No relative advantage was predicted for family-focused networks because such networks tend to be associated with lower physical activity. RESULTS Older adults with diverse, friend-focused, and distant family networks had significantly better PEF measures than those with restricted networks. The associations between diverse network and PEF measures were partially mediated by physical exercise and socializing activity. The associations between friend-focused network and PEF measures were partially mediated by socializing activity. No significant PEF differences between family-focused and restricted networks were found. CONCLUSIONS Findings suggest that social network types are associated with PEF in older adults, and that network-type differences in physical and socializing activity is partly responsible for this relationship.

Residential Care Policy for Elderly People in Hong Kong

This article examines the policy on residential care for the elderly in Hong Kong. The argument is founded on an empirical study which involved a review of relevant policy documents, a survey research, and personal interviews. The study shows that the provision of residential home places in Hong Kong is grossly inadequate. This is illustrated by the long list of applicants awaiting residential places. The relatively poor psychological state of those elderly people who could not secure proper placement is another indicator to reflect the inadequacy of elderly home places. The main problem of elderly care rests with the system of provision, to which improvements should and could be made. However, in the final analysis, it is the lack of government commitment to this area of service that has presented the most important obstacle to the development of a well thought out and well implemented policy for the elderly in the territory.