A Case report of Becker Muscular Dystrophy and Stroke who successfully regained Mobility with Robot Assisted Gait Training.

ABSTRACT: A 30-year-old patient with Becker Muscular Dystrophy presented with stroke. Background issues of proximal weakness, dilated cardiomyopathy and reduced endurance challenged the usual goal-setting and formulation of a stroke rehabilitation plan. We discuss the holistic rehabilitation program that this patient underwent, with a focus on the utilization of robot-assisted gait training that eventually led him to successfully regain mobility.

Hukou-based Discrimination and Migrant Adolescents' Adaptation: Migrant Pattern Differences among the Buffering Role of School Engagement.

While the detrimental consequences of racial/ethnic discrimination for adolescent adaptation are well established, little is known about the long-term impact of hukou-based discrimination from the hukou (household registration) system and the potential protective benefits of adolescents' internal capabilities; furthermore, there have been even fewer studies examining potential migrant pattern differences in the association. The current study addressed these gaps by investigating the longitudinal associations between hukou-based discrimination and migrant adolescents' adaptation outcomes (cognitive ability, depressive symptoms, and behavioral problems), as well as whether school engagement moderated these pathways, and whether this function varied by adolescents' migrant patterns. The data were obtained from 1226 migrant adolescents (51.31% male; 51.47% urban migrants, 48.53% rural migrants) aged 12 to 16 years (Mage = 13.56, SD = 0.69 at Wave 1) from the China Education Panel Survey in two waves separated by twelve months. Multilevel modeling revealed that hukou-based discrimination from peers and teachers was negatively related to cognitive abilities, but positively related to depressive symptoms and behavioral problems. School engagement served not only as a facilitator of adaptation but also as a protective factor against hukou-based discrimination. The moderating effect of school engagement was more pronounced in urban migrants than in rural migrants. The current study's findings highlight the role of hukou-based discrimination in adaptation disparities and shed light on the importance of internal capabilities in protecting migrant adolescents with different migration patterns from the detrimental impacts of discrimination on the adaptation process.

Socioeconomic inequality in the worsening of psychosocial wellbeing via disrupted social conditions during COVID-19 among adolescents in Hong Kong: self-resilience matters.

Background: Adolescents, especially the socioeconomically disadvantaged, are facing devastating psychosocial impact of the COVID-19 pandemic during their critical developmental period. This study aims to (i) examine the socioeconomic patterning of the worsening of psychosocial wellbeing, (ii) delineate the underlying mediating factors (i.e., overall worry about COVID-19, family's financial difficulty, learning problems, and loneliness), and (iii) explore the moderating effect of resilience in the inter-relationship among adolescents under COVID-19. Methods: Based on maximum variation sampling of 12 secondary schools of diverse socioeconomic background in Hong Kong, 1018 students aged 14-16 years were recruited and completed the online survey between September and October 2021. Multi-group structural equation modeling (SEM) by resilience levels was employed to delineate the pathways between socioeconomic position and the worsening of psychosocial wellbeing. Results: SEM analysis showed a significant total effect of socioeconomic ladder with the worsening of psychosocial wellbeing during the pandemic in the overall sample (ß = -0.149 [95% CI = -0.217 - -0.081], p < 0.001), which operated indirectly through learning problems and loneliness (both p < 0.001 for their indirect effects). Consistent pattern with stronger effect size was observed in the lower resilience group; nonetheless, the associations were substantially mitigated in the higher resilience group. Conclusion: In addition to facilitating self-directed learning and easing loneliness during the pandemic, evidence-based strategies to build up resilience among adolescents are critical to buffer against the adverse socioeconomic and psychosocial impacts of the pandemic or other potential catastrophic events in the future.

A network analysis of positive developmental assets of Hong Kong school-age children during the Covid-19 pandemic.

The ongoing COVID19 pandemic is having detrimental effects on the mental and emotional well-being of many adults and children. It is relevant therefore to explore the combination of personal strengths and attributes that can help an individual develop resilience to such stress. Little is known about how psychological strength assets such as social connectedness, grit, hope, life meaning, and life satisfaction are inter-related, and if certain factors play a central role. This study involved a sample of 1,405 school-aged children in Hong Kong (50% female) from seven schools that participated in an online survey of psychological strengths. Data were analyzed by constructing a psychological network that found strength factors are inter-connected, and that 'school connectedness' and 'agency thinking' are central to the network. The information gained can be of value in any schools that are planning to provide strength-based interventions to help students maintain their psychological well-being during and after the COVID-19 pandemic.

Adherence to the American Cancer Society Head and Neck Cancer Survivorship Care Guideline According to Chart Review: A Nested Retrospective Cohort Pilot Study.

OBJECTIVES: The purpose of this study was to explore adherence to the American Cancer Society (ACS) Head and Neck Cancer (HNC) Survivorship Care Guideline and their outlined 33 recommendations among posttreatment HNC survivors. METHODS: A bi-institutional, retrospective, nested cohort study of mucosal or salivary gland HNC survivors diagnosed in 2018 was designed. Guideline adherence was assessed via retrospective chart review between 0 and 13 months after completion of oncologic treatment according to 4 categories: (1) problem assessed, (2) problem diagnosed, (3) management offered; (4) problem treated. Adherence was defined as meeting a recommendation subcategory at least once over the 13-month period. RESULTS: Among 60 randomly selected HNC survivors, a total of 38 were included in the final cohort after exclusion of individuals with ineligible cancers and those who died or were lost to follow-up over the study period. Approximately 95% of HNC survivors were assessed for HNC recurrence and screened for lung cancer. Certain common problems such as xerostomia, dysphagia, and hypothyroidism were screened for and managed in ≥70% of eligible survivors. Conversely, screening for other second primary cancers and assessment of a majority of other physical and psychosocial harms occurred in <70% of survivors, and in many cases none to a slim minority of survivors (eg, sleep apnea and sleep disturbance, body and self-image concerns). Only 5% of survivors received a survivorship care plan. CONCLUSION: Overall adherence to the ACS HNC Survivorship Care Guideline in early posttreatment survivors was suboptimal. Interventions are needed to better implement and operationalize these guideline recommendations.

Optimising prescribing practices in older adults with multimorbidity: a scoping review of guidelines.

OBJECTIVE: Inappropriate polypharmacy occurs when multiple medications are prescribed without clear indications or where harms outweigh their benefits. The aims of this scoping review are to (1) identify prescribing guidelines that are available for older adults with multimorbidity and (2) to identify cross-cutting themes used in these guidelines. DESIGN: Scoping review. DATA SOURCES: PubMed, Embase, Web of Science, the Cochrane Library databases, Cumulative Index to Nursing and Allied Health Literature, grey literature sources, six key geriatrics journals, and reference lists of identified review papers. The search was conducted in November 2018 and updated in September 2019. STUDY SELECTION: General prescribing guidelines tailored to or for adults including older adults with multimorbidity. DATA EXTRACTION: Data for publication description, guideline characteristics, information for users and criteria were extracted. The synthesis contains summarised qualitative descriptions of the studies and guideline characteristics as well as identified cross-cutting themes. RESULTS: Our search strategy yielded 10 427 unique citations, of which 70 fulfilled the inclusion criteria for synthesis. Among these, there were 61 unique guidelines and tools which used implicit, explicit, mixed or other approaches in the prescriber decision-making process. There are 11 cross-cutting themes identified in the guidelines. Prescriber-related themes are: conduct a comprehensive assessment before prescribing, identify patients' needs, goals and priorities, adopt shared decision-making, consider evidence-based recommendations, use clinical prescribing tools, incorporate multidisciplinary inputs and embrace technology-enabled prescribing. Wider organisation-related and system-related themes related to education, training and the work environment are also identified. CONCLUSIONS: From guidelines and tools identified, eleven cross-cutting themes provide a usable knowledge base when seeking to optimise prescribing among older adults with multimorbidity. Incorporating these themes in an approach that uses mixed criteria and implementation information could facilitate greater uptake of published prescribing recommendations.

The Mediating Role of Different Types of Parental Support in the Social Disparity of Hope in Young Adulthood.

Research has shown hope to be associated with a person's well-being, but how it is affected by family factors is unclear. This study investigates whether family socio-economic status (SES) affects young adults' hope, and to what extent and how different types of parental support mediate this social disparity. The data is collected from a sample of Hong Kong youth (N = 760; 54.6% girls) which participated in a 7-year longitudinal study during age 15-22. The results from multiple regression models indicate that family SES significantly predicts hope. However, cultural and academic communication and career encouragement from parents in early years, and current parental emotional support fully mediate the relationship between family SES and hope, with parental emotional support being the strongest mediator. Implications for hope theory, practices for nurturing hope and further research are discussed to suggest possible actions.

COVID 19: prioritise autonomy, beneficence and conversations before score-based triage.

At the start of the COVID-19 pandemic, mounting demand overwhelmed critical care surge capacities, triggering implementation of triage protocols to determine ventilator allocation. Relying on triage scores to ration care, while relieving clinicians from making morally distressing decisions under high situational pressure, distracts clinicians from what is essentially deeply humanistic issues entrenched in this protracted public health crisis. Such an approach will become increasingly untenable as countries flatten their epidemic curves. Decisions regarding intensive care unit admission are particularly challenging in older people, who are most likely to require critical care, but for whom benefits are most uncertain. Before applying score-based triage, physicians must first discern if older people will benefit from critical care (beneficence) and second, if he wants critical care (autonomy). When deliberating beneficence, physicians should steer away from solely using age-stratified survival probabilities from epidemiological data. Instead, decisions must be based on individualised risk-stratification that encompasses evidence-based predictors of adverse outcomes specific to older adults. Survival will also need to be weighed against burden of treatment, as well as longer term functional deficits and quality-of-life. By identifying the robust older people who may benefit from critical care, clinicians should proceed to elicit his values and preferences that would determine the treatment most aligned with his best interest. During these dialogues, physicians must truthfully convey the emergent clinical reality, discern the older person's therapeutic goals and discuss the feasibility of achieving them. Given that COVID-19 is here to stay, these conversations aimed at achieving goal-cordant care must become a new clinical norm.

Higher rates of carbapenem-related seizures in older hospitalised adults.

Clinical experience suggests higher occurrence of carbapenem-associated seizures in the elderly than what is reported in the available literature (range between 0.2% and 0.7%). An audit of 1345 patients with age 60 years or older, who received imipenem, ertapenem or meropenem during their acute hospitalisation found 32 (2.4%) subjects developed seizures. Subjects with more than one central nervous system disorders were 11.6 times more likely to develop seizures (odds ratio 11.61, P < 0.001) and subjects with prior history of seizures is associated with four times greater risks (odds ratio 4.02, P = 0.005). Physicians should exercise caution when prescribing carbapenems in elderly, especially those with known epilepsy and a high number of intracranial pathologies.

Frailty in Hospitalized Older Adults: Comparing Different Frailty Measures in Predicting Short- and Long-term Patient Outcomes.

OBJECTIVES: Data for the assessment of frailty in acutely ill hospitalized older adults remains limited. Using the Frailty Index (FI) as "gold standard," we compared (1) the diagnostic performance of 3 frailty measures (FRAIL, Clinical Frailty Scale [CFS], and Tilburg Frailty Indicator [TFI]) in identifying frailty, and (2) their ability to predict negative outcomes at 12 months after enrollment. DESIGN: Prospective cohort study. PARTICIPANTS: We recruited 210 patients (mean age 89.4 ± 4.6 years, 69.5% female), admitted to the Department of Geriatric Medicine in a 1300-bed tertiary hospital. MEASUREMENTS: Premorbid frailty status was determined. Data on comorbidities, severity of illness, functional status, and cognitive status were gathered. We compared area under receiver operator characteristic curves (AUC) for each frailty measure against the reference FI. Multiple logistic regression was used to examine the independent association between frailty and the outcomes of interest. RESULTS: Frailty prevalence estimates were 87.1% (FI), 81.0% (CFS), 80.0% (TFI), and 50.0% (FRAIL). AUC against FI ranged from 0.81 (95% confidence interval [CI] 0.72-0.90: FRAIL) to 0.91 (95% CI 0.87-0.95: CFS). Only FRAIL was associated with higher in-hospital mortality (6.7% vs 1.0%, P = .031). FRAIL and CFS were significantly associated with increased length of hospitalization (10 [6.0-17.5] vs 8 [5.0-14.0] days, P = .043 and 9 [5.0-17.0] vs 7 [4.25-11.75] days, P = .036, respectively). CFS and FI were highly associated with mortality at 12-month (CFS, frail vs nonfrail: 32.9% vs 2.5%, P < .001, and FI, frail vs nonfrail: 30.6% vs 3.7%, P < .001). CFS also conferred the greatest risk of 12-month mortality (odds ratio [OR] 5.78, 95% CI 3.19-10.48, P < .001) and composite outcomes of institutionalization and/or mortality (OR 3.69, 95% CI 2.31-5.88, P < .001), adjusted for age, sex, and severity of illness. CONCLUSION: Our study affirms the utility of frailty assessment tools among older persons in acute care. FRAIL conferred highest risk of in-hospital mortality. However, CFS had greatest risk of mortality and institutionalization within 12 months.

Frailty and Risk of Adverse Outcomes in Hospitalized Older Adults: A Comparison of Different Frailty Measures.

OBJECTIVES: There is a paucity of data for the assessment of frailty in acutely ill hospitalized older adults. We aim to (1) compare the performance of frailty measures [5-item scale of fatigue, resistance, ambulation, illnesses, and loss of weight) (FRAIL), Tilburg Frailty Indicator (TFI), and Clinical Frailty Scale (CFS)] in identifying frailty, using the widely adopted Frailty Index (FI) as "gold standard," and (2) compare their ability to predict negative outcomes among hospitalized older adults. DESIGN: Prospective cohort study. SETTING: Acute inpatient care. PARTICIPANTS: A total of 210 patients (mean age 89.4 ± 4.6 years, 69.5% female) admitted to the Department of Geriatric Medicine. MEASUREMENTS: Premorbid frailty status was assessed by FI, FRAIL, TFI, and CFS. We collected data on comorbidities, severity of illness, functional status, and cognitive status. We compared area under receiver operator characteristic curves for FRAIL, TFI, and CFS against the reference FI. Multiple logistic regression was performed to examine the association between frailty and the primary outcome of in-hospital mortality. RESULTS: Frailty prevalence estimates were 87.1% (FI), 50% (FRAIL), 80% (TFI), and 81% (CFS). Area under receiver operator characteristics against FI ranged from 0.81 [95% confidence interval (CI) 0.72-0.90: FRAIL] to 0.91 (95% CI 0.87-0.95: CFS), with no significant difference on receiver operating characteristic curve contrast. Frailty, as defined by FRAIL score ≥3, was associated with higher in-hospital mortality (6.7% vs 1.0%, P = .031) and length of hospitalization [10 days (6.0-17.5) vs 8 days (5.0-14.0), P = .043]. FI [odds ratio (OR) = 1.15, 95% CI 1.00-1.33, P = .05], FRAIL (OR = 3.31, 95% CI 1.43-7.67, P = .005), and CFS (OR = 2.57, 95% CI 1.14-5.83, P = .023) independently predicted in-hospital mortality adjusted for age, sex, and severity of illness. CONCLUSIONS: FRAIL and CFS are simple frailty measures that may identify older adults at highest risk of adverse outcomes of hospitalization. FRAIL performed better in predicting in-hospital mortality.

Managing Ethical Dilemmas in End-Stage Neurodegenerative Diseases.

Neurodegenerative diseases are chronic, progressive and incurable illnesses that ultimately lead to death. The patient deteriorates inexorably towards the terminal phase of the disease when he becomes mentally and physically incapacitated. This article discusses the many ethical and moral dilemmas faced by the clinician and family members as they care for patients with neurodegenerative illnesses approaching the end of life. Topics discussed will include steps on how to assess mental capacity and decision-making capability, advance care planning, withholding and/or withdrawing treatment, food refusal, the do-not-resuscitate order and euthanasia. An approach to ethical decision-making incorporating Jonsen's 4-topic approach will also be discussed briefly.

Community-acquired pneumonia in adults and children.

This article provides an overview of community-acquired pneumonia in adults and children. The epidemiology, causes, clinical presentation, diagnostic testing, site-of-care decisions, treatment, possible complications, and prevention of pneumonia are discussed.

Report of two cases of adenoid cystic carcinoma of Bartholin's gland and review of literature.

OBJECTIVE: Primary adenoid cystic carcinoma (ACC) of Bartholin's gland is a rare gynecologic malignancy. We report two cases from primary treatment to recurrence and the adjuvant treatment. CASE REPORT: A woman aged 37 years presented with a mass on the right posterior labia minor and underwent right radical hemi-vulvectomy and right-side inguino-femoral node dissection. Final pathology showed ACC arising from Bartholin's gland with positive margins. She received adjuvant external beam radiation to the pelvis, right vulva, and groin area. However, distal metastasis occurred 42 months after initial treatment and she eventually died of multiple metastases. Another woman aged 48 years presented with a mass on the right posterior labia with intermittent pain. She underwent right hemi-vulvectomy and right inguino-femoral lymph node dissection only because pathology showed ACC of Bartholin's gland with negative surgical margins. Lung metastasis occurred 59 months after initial treatment. She took tamoxifen only and achieved stable disease status for 4 years. CONCLUSION: To date, about 70 cases have been reported. We treated our second patient with antiestrogen therapy for 4 years and achieved good quality of life and stable disease status. However, further study on hormone therapy for ACC of Bartholin's gland is needed.