Vivian Wong

Psychological resilience and dysfunction among hospitalized survivors of the SARS epidemic in Hong Kong: a latent class approach.

OBJECTIVE To examine trajectories of psychological functioning using latent class analysis on a sample of hospitalized survivors of the 2003 severe acute respiratory syndrome (SARS) epidemic in Hong Kong. DESIGN A longitudinal study of 997 survivors, recruited from among 1,331 individuals hospitalized for SARS, were interviewed at 6, 12, and 18 months after hospitalization. MAIN OUTCOME MEASURES Psychological and physical functioning at each time point was measured using the 12-item Medical Outcome Study Short-Form Health Survey (SF-12). RESULTS Four latent classes were identified--chronic dysfunction, delayed dysfunction, recovery, and resilience. All groups had better physical health than the chronic group. Resilient and recovered individuals had greater social support and less SARS-related worry, and resilient individuals were more likely to be male. The resilient group also had greater social support than the delayed group and better physical functioning than the recovered group. CONCLUSION This study demonstrated that longitudinal outcome trajectories following a major health-threat event in an Asian sample bear close resemblance to prototypical trajectories observed in trauma studies using Western samples. Unique predictors of the trajectories included factors observed in previous studies, such as social support, as well as factors of particular relevance to a major disease outbreak, such as SARS-related worry.

Development and validation of stroke risk equation for Hong Kong Chinese patients with type 2 diabetes: the Hong Kong Diabetes Registry.

OBJECTIVE—We sought to develop stroke risk equations for Chinese patients with type 2 diabetes in Hong Kong. RESEARCH DESIGN AND METHODS—A total of 7,209 Hong Kong Chinese type 2 diabetic patients without a history of stroke at baseline were analyzed. The data were randomly and evenly divided into the training subsample and the test subsample. In the training subsample, stepwise Cox models were used to develop the risk equation. Validation of the U.K. Prospective Diabetes Study (UKPDS) stroke risk engine and the current stroke equation was performed in the test dataset. The life-table method was used to check calibration, and the area under the receiver operating characteristic curve (aROC) was used to check discrimination. RESULTS—A total of 372 patients developed incident stroke during a median of 5.37 years (interquartile range 2.88–7.78) of follow-up. Age, A1C, spot urine albumin-to-creatinine ratio (ACR), and history of coronary heart disease (CHD) were independent predictors. The performance of the UKPDS stroke engine was suboptimal in our cohort. The newly developed risk equation defined by these four predictors had adequate performance in the test subsample. The predicted stroke-free probability by the current equation was within the 95% CI of the observed probability. The aROC was 0.77 for predicting stroke within 5 years. The risk score was computed as follows: 0.0634 × age (years) + 0.0897 × A1C + 0.5314 × log10 (ACR) (mg/mmol) + 0.5636 × history of CHD (1 if yes). The 5-year stroke probability can be calculated by: 1 − 0.9707EXP (Risk Score − 4.5674). CONCLUSIONS—Although the risk equation performed reasonably well in Chinese type 2 diabetic patients, external validation is required in other populations.

Development and Validation of an All-Cause Mortality Risk Score in Type 2 Diabetes: The Hong Kong Diabetes Registry

BACKGROUND Diabetes reduces life expectancy by 10 to 12 years, but whether death can be predicted in type 2 diabetes mellitus remains uncertain. METHODS A prospective cohort of 7583 type 2 diabetic patients enrolled since 1995 were censored on July 30, 2005, or after 6 years of follow-up, whichever came first. A restricted cubic spline model was used to check data linearity and to develop linear-transforming formulas. Data were randomly assigned to a training data set and to a test data set. A Cox model was used to develop risk scores in the test data set. Calibration and discrimination were assessed in the test data set. RESULTS A total of 619 patients died during a median follow-up period of 5.51 years, resulting in a mortality rate of 18.69 per 1000 person-years. Age, sex, peripheral arterial disease, cancer history, insulin use, blood hemoglobin levels, linear-transformed body mass index, random spot urinary albumin-creatinine ratio, and estimated glomerular filtration rate at enrollment were predictors of all-cause death. A risk score for all-cause mortality was developed using these predictors. The predicted and observed death rates in the test data set were similar (P > .70). The area under the receiver operating characteristic curve was 0.85 for 5 years of follow-up. Using the risk score in ranking cause-specific deaths, the area under the receiver operating characteristic curve was 0.95 for genitourinary death, 0.85 for circulatory death, 0.85 for respiratory death, and 0.71 for neoplasm death. CONCLUSIONS Death in type 2 diabetes mellitus can be predicted using a risk score consisting of commonly measured clinical and biochemical variables. Further validation is needed before clinical use.

A systematic review on use of Chinese medicine and acupuncture for treatment of obesity

Obesity is a major health hazard and despite lifestyle modification, many patients frequently regain any lost body weight. The use of western anti‐obesity drugs has been limited by side effects including mood changes, suicidal thoughts, and gastrointestinal or cardiovascular complications. The effectiveness and safety of traditional Chinese medicine including Chinese herbal medicine (CHM) and acupuncture provide an alternative established therapy for this medical challenge. In this systematic review, we used standard methodologies to search, review, analyse and synthesize published data on the efficacy, safety and relapse of weight regain associated with use of CHM and acupuncture. We also examined the rationale, mechanisms and potential utility of these therapies. A total of 12 electronic databases, including Chinese, English, Korean and Japanese, were searched up to 28 February 2010. Randomized controlled trials (RCTs) for CHM and/or acupuncture with comparative controls were considered. We used the Jadad scale to assess methodological qualities, the random effect model in the pooled analysis of therapeutic efficacy to adjust for heterogeneity and funnel plots to explore publication bias. After screening 2,545 potential articles from the electronic databases, we identified 96 RCTs; comprising of 49 trials on CHM treatment, 44 trials on acupuncture treatment and 3 trials on combined therapy for appraisal. There were 4,861 subjects in the treatment groups and 3,821 in the control groups, with treatment duration ranging from 2 weeks to 4 months. Of the 77 publications written in Chinese, 75 had a Jadad score <3, while 16 of the 19 English publications had a Jadad score of >3. Efficacy was defined as body weight reduction ≥2 kg or body mass index (BMI) reduction ≥0.5 kg/m2. Compared with placebo or lifestyle modification, CHM and acupuncture exhibited respective ‘risk ratio’ (RR) of 1.84 (95% CI: 1.37–2.46) and 2.14 (95% CI: 1.58–2.90) in favour of body weight reduction, with a mean difference in body weight reduction of 4.03 kg (95% CI: 2.22–5.85) and 2.76 kg (95% CI: 1.61–3.83) and a mean difference in BMI reduction of 1.32 kg m–2 (95% CI: 0.78–1.85) and 2.02 kg m–2 (95% CI: 0.94–3.10), respectively. Compared with the pharmacological treatments of sibutramine, fenfluramine or orlistat, CHM and acupuncture exhibited an RR of 1.11 (95% CI: 0.96–1.28) and 1.14 (95% CI: 1.03–1.25) in body weight reduction, mean difference in body weight reduction of 0.08 kg (95% CI: −0.58 to 0.74) and 0.65 kg (95% CI: −0.61 to 1.91), and mean difference in BMI reduction of 0.18 kg m–2 (95% CI: −0.39 to 0.75) and 0.83 kg m–2 (95% CI: 0.29–1.37), respectively. There were fewer reports of adverse effects and relapses of weight regain in CHM intervention studies conducted in China than studies conducted outside China. CHM and acupuncture were more effective than placebo or lifestyle modification in reducing body weight. They had a similar efficacy as the Western anti‐obesity drugs but with fewer reported adverse effects. However, these conclusions were limited by small sample size and low quality of methodologies.

Risk factors in V‐shaped risk associations with all‐cause mortality in type 2 diabetes—The Hong Kong Diabetes Registry

Body mass index (BMI) is associated with death in a V‐shaped manner in general populations but it is unknown whether BMI or other risk factors also exhibit V‐shaped relationships with death in type 2 diabetic patients.

A systematic review of the effectiveness of qigong exercise in supportive cancer care

PurposeQigong as a complementary and alternative modality of traditional Chinese medicine is often used by cancer patients to manage their symptoms. The aim of this systematic review is to critically evaluate the effectiveness of qigong exercise in cancer care.MethodsThirteen databases were searched from their inceptions through November 2010. All controlled clinical trials of qigong exercise among cancer patients were included. The strength of the evidence was evaluated for all included studies using the Oxford Centre for Evidence-based Medicine Levels of Evidence. The validity of randomized controlled trials (RCTs) was also evaluated using the Jadad Scale.ResultsTwenty-three studies including eight RCTs and fifteen non-randomized controlled clinical trials (CCTs) were identified. The effects of qigong on physical and psychosocial outcomes were examined in 14 studies and the effects on biomedical outcomes were examined in 15 studies. For physical and psychosocial outcomes, it is difficult to draw a conclusion due to heterogeneity of outcome measures and variability of the results in the included studies. Among reviewed studies on biomedical outcomes, a consistent tendency appears to emerge which suggests that the patients treated with qigong exercise in combination with conventional methods had significant improvement in immune function than the patients treated with conventional methods alone.ConclusionsDue to high risk of bias and methodological problems in the majority of included studies, it is still too early to draw conclusive statements. Further vigorously designed large-scale RCTs with validated outcome measures are needed.

Impacts of chronic kidney disease and albuminuria on associations between coronary heart disease and its traditional risk factors in type 2 diabetic patients – the Hong Kong diabetes registry

BackgroundGlycated haemoglobin (HbA1c), blood pressure and body mass index (BMI) are risk factors for albuminuria, the latter in turn can lead to hyperlipidaemia. We used novel statistical analyses to examine how albuminuria and chronic kidney disease (CKD) may influence the effects of other risk factors on coronary heart disease (CHD).MethodsA prospective cohort of 7067 Chinese type 2 diabetic patients without history of CHD enrolled since 1995 were censored on July 30th, 2005. Cox proportional hazard regression with restricted cubic spline was used to auto-select predictors. Hazard ratio plots were used to examine the risk of CHD. Based on these plots, non-linear risk factors were categorised and the categorised variables were refitted into various Cox models in a stepwise manner to confirm the findings.ResultsAge, male gender, duration of diabetes, spot urinary albumin: creatinine ratio, estimated glomerular filtration rate, total cholesterol (TC), high density lipoprotein cholesterol (HDL-C) and current smoking status were risk factors of CHD. Linear association between TC and CHD was observed only in patients with albuminuria. Although in general, increased HDL-C was associated with decreased risk of CHD, full-range HDL-C was associated with CHD in an A-shaped manner with a zenith at 1.1 mmol/L. Albuminuria and CKD were the main contributors for the paradoxically positive association between HDL-C and CHD for HDL-C values less than 1.1 mmol/L.ConclusionIn type 2 diabetes, albuminuria plays a linking role between conventional risk factors and CHD. The onset of CKD changes risk associations between lipids and CHD.

Thresholds of risk factors for ischemic stroke in type 2 diabetic patients with and without albuminuria : A non-linear approach

OBJECTIVES Multiple risk factors in type 2 diabetes may explain their high risk for ischemic stroke (IS). However, it remains unknown whether these risk factors exhibit threshold characteristics and whether these relationships are influenced by albuminuria. The study aims to investigate whether risk factors exhibit any albuminuria specific threshold for IS. PATIENTS AND METHODS This is a prospective cohort study with 6969 Chinese type 2 diabetic patients without history of stroke after a median follow-up of 5.36 years. We identified thresholds of risk factors for IS using hazard ratio plots followed by confirmation using traditional Cox regression analysis. RESULTS In the non-albuminuric group (n=4008), IS risk started to increase rapidly at a body mass index threshold of 24 kg/m(2). The risk of IS declined with increasing blood hemoglobin reaching a threshold value of 14 g/dl. Using these threshold values as cutoff point, body mass index > or =24 kg/m(2) and hemoglobin <14 g/dl were associated with 2-fold increased risk of IS in these subjects. In the albuminuric group (n=2961). IS risk started to increase rapidly from a systolic blood pressure threshold of 135 mmHg and declined with increasing estimated glomerular filtration rate (eGFR) reaching a trough of 115 ml/min per 1.73 m(2). Using these values as cutoff points, patients with systolic blood pressure > or =135 mmHg and eGFR <115 ml/min per 1.73 m(2) had 2-fold increased risk of IS. CONCLUSION In type 2 diabetic patients, body mass index, hemoglobin, systolic blood pressure and eGFR exhibit different risk relationships and thresholds for IS contingent upon presence or absence of albuminuria.

Add-On Effect of Chinese Herbal Medicine on Mortality in Myocardial Infarction: Systematic Review and Meta-Analysis of Randomized Controlled Trials

In China, Chinese herbal medicine (CHM) is widely used as an adjunct to biomedicine (BM) in treating myocardial infarction (MI). This meta-analysis of RCTs evaluated the efficacy of combined CHM-BM in the treatment of MI, compared to BM alone. Sixty-five RCTs (12,022 patients) of moderate quality were identified. 6,036 patients were given CHM plus BM, and 5,986 patients used BM only. Combined results showed clear additional effect of CHM-BM treatment in reducing all-cause mortality (relative risk reduction (RRR) = 37%, 95% CI = 28%–45%, I 2 = 0.0%) and mortality of cardiac origin (RRR = 39%, 95% CI = 22%–52%, I 2 = 22.8). Benefits remained after random-effect trim and fill adjustment for publication bias (adjusted RRR for all-cause mortality = 29%, 95% CI = 16%–40%; adjusted RRR for cardiac death = 32%, 95% CI = 15%–46%). CHM is also found to be efficacious in lowering the risk of fatal and nonfatal cardiogenic shock, cardiac arrhythmia, myocardial reinfarction, heart failure, angina, and occurrence of total heart events. In conclusion, addition of CHM is very likely to be able to improve survival of MI patients who are already receiving BM. Further confirmatory evaluation via large blinded randomized trials is warranted.

Using Chinese Version of MYMOP in Chinese Medicine Evaluation: Validity, Responsiveness and Minimally Important Change

BackgroundMeasure Yourself Medical Outcome Profile (MYMOP) is a patient generated outcome instrument applicable in the evaluation of both allopathic and complementary medicine treatment. This study aims to adapt MYMOP into Chinese, and to assess its validity, responsiveness and minimally important change values in a sample of patients using Chinese medicine (CM) services.MethodsA Chinese version of MYMOP (CMYMOP) is developed by forward-backward-forward translation strategy, expert panel assessment and pilot testing amongst patients. 272 patients aged 18 or above with subjective symptoms in the past 2 weeks were recruited at a CM clinic, and were invited to complete a set of questionnaire containing CMYMOP and SF-36. Follow ups were performed at 2nd and 4th week after consultation, using the same set of questionnaire plus a global rating of change question. Criterion validity of CMYMOP was assessed by its correlation with SF-36 at baseline, and responsiveness was evaluated by calculating the Cohen effect size (ES) of change at two follow ups. Minimally important difference (MID) values were estimated via anchor based method, while minimally detectable difference (MDC) figures were calculated by distribution based method.ResultsCriterion validity of CMYMOP was demonstrated by negative correlation between CMYMOP Profile scores and all SF-36 domain and summary scores at baseline. For responsiveness between baseline and 4th week follow up, ES of CMYMOP Symptom 1, Activity and Profile reached the moderate change threshold (ES>0.5), while Symptom 2 and Wellbeing reached the weak change threshold (ES>0.2). None of the SF-36 scores reached the moderate change threshold, implying CMYMOPs stronger responsiveness in CM setting. At 2nd week follow up, MID values for Symptom 1, Symptom 2, Wellbeing and Profile items were 0.894, 0.580, 0.263 and 0.516 respectively. For Activity item, MDC figure of 0.808 was adopted to estimate MID.ConclusionsThe findings support the validity and responsiveness of CMYMOP for capturing patient centred clinical changes within 2 weeks in a CM clinical setting. Further researches are warranted (1) to estimate Activity item MID, (2) to assess the test-retest reliability of CMYMOP, and (3) to perform further MID evaluation using multiple, item specific anchor questions.