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AIMS: To develop a culturally relevant conceptual map to discover perceptions of a statutory form of advance directive (AD) for Hong Kong Chinese. DESIGN: This was the first study on AD using a concept mapping approach with two phases. METHODS: The data collection of the two phases was conducted from February 2016-February 2017. In Phase I, 96 participants were recruited using purposive sampling. In Phase II, multi-dimensional scaling and hierarchical cluster analysis were used to create a concept map based on quantitative data. RESULTS: The map depicted six clusters of factors affecting the acceptance of AD, with their importance rating in decreasing order: Conditional factor, value system, process of AD, physical and illness factor, personal situation factor, and socio-cultural factor. CONCLUSION: The study adopted a comprehensive approach to unfolding the multi-faceted factors affecting the acceptance of ADs by stakeholders. Strategies targeting the clusters could be developed to facilitate the discussion and completion of AD.

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BACKGROUND: Pressure injury is a common clinical parameter of patient care outcome. Various risk factors increase the risk of palliative care patients to pressure injuries and difficult wound healing. Healthcare professionals are aware that wound healing is difficult, but they still focus on this process instead of providing the needs of patients with unhealed wounds. METHODS: This study aims to identify the clinical parameters of pressure injuries in relation to patients with advanced illness. A retrospective analysis of the records of patients with pressure injuries admitted over 18 months was performed. Descriptive analysis and Spearman's correlation coefficient were used. RESULTS: A total of 127 clinical records were reviewed. The study revealed that patients of old age, high creatinine level, advanced wound age, reduced palliative performance scale (PPS) and low Norton scores are prone to suffer from unhealed wounds. CONCLUSIONS: Pressure injuries are prone to non-healing in patients with old age, high creatinine level, advanced wound stage, low PPS and low Norton scores. Further studies involving patients in earlier stage can be considered.

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OBJECTIVE: An advance directive (AD) is a document that allows mentally competent individuals to make healthcare decisions about their condition that they might no longer be able to make in the future. This study aimed to explore the perceptions of AD decision-making of various stakeholders in the Chinese palliative care setting. METHODS: Patients with life-limiting diseases, family members, health professionals, and hospital volunteers were recruited in the palliative care unit of two hospitals in Hong Kong by purposive sampling on age and sex. Qualitative semi-structured individual interviews were conducted. RESULTS: A total of 96 participants, including 24 participants from each group, completed the study. Most participants were willing to discuss AD but had not heard about it before the interview. Patients regarded the decisions made in the AD as a way to reduce their future sufferings, while they also considered the welfare of their family. Family members were concerned about the psychological burden when discussing about the AD. Health professionals emphasized the logistic and process of the AD. Hospital volunteers pointed out the impact of Chinese culture on AD acceptance and the lack of AD promotion in the community. CONCLUSIONS: The findings of the study indicated the need for more promotion of AD in the society. It is important to consider the opinion of a patient's family during AD discussions in a Chinese culture. Health professionals may need to identify the best timing for the discussion of AD with patients and their families.

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Advance directives (AD) can be used for the communication of healthcare decisions that may be required in the future when individuals have lost their capacity to make such decisions. The aim of this study is to examine the prevalence, perception, and predictors of AD completion in the Hong Kong general population with a diverse culture. Through random-digit dialing, a population-based telephone survey was conducted with participants aged 18 or above. Socio-demographic characteristics, self-perception and health status, prevalence of AD, and perceptions related to AD were assessed. The acceptance on completing AD was measured by the summed score on the level of agreement in making AD. In total, 2002 participants completed the survey, with only 0.5% having made AD. However, the majority of those who had heard about AD had made or intended to make AD (80.2%). Multivariable regression analysis showed that being religious, being optimistic, and agreeing to respect patients' wishes are independently associated with higher AD acceptance. Being a student is associated with lower AD acceptance. The extremely low completion rate of AD, but high acceptance of AD urges for more active promotion of AD to the public and education on end-of-life care among university students.

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BACKGROUND: Millions of workers are exposed to dust containing silica. Chronic and over-exposure to silica will lead to silicosis, which is an irreversible and sometimes fatal lung disease. The disordered physiological processes of silicosis consist of accumulation of silica particles in the alveoli of the lung. Then, the ingestion of the silica particles by macrophages was followed by an inflammatory response. Up till now, the chest radiographs remain the key tool in diagnosing and assessing the extent of silicosis. However, concerns exist regarding the sensitivity and specificity of the technique. Therefore, there is still a need to develop a biomarker for silicosis for early detection of silicosis. METHOD: In this study, RNA-Seq was applied to detect the gene expression changes when silica was exposed to macrophages at different time intervals. RNA-Seq provides a broader dynamic range, increased specificity and sensitivity, and easier detection of rare and low-abundance transcripts. Bioinformatics tools such as the Database for Annotation, Visualization and Integrated Discovery (DAVID) and Gene Functional Classification Tool and Search Tool for the Retrieval of Interacting Genes (STRING) were applied for data analysis. Quantitative PCR was used to validate the results. RESULTS: Our results showed that regulation of transcription factors was the dominant activated pathway in early exposure of silica to macrophages, followed by inflammatory responses which were the main mechanisms in silicosis. One of the findings was the upregulation of activating transcription factor 3 (ATF3) during silica exposure. When ATF3 expression was inhibited by siRNA, the production of cytokines IL-1ß, IL-6 and TNF was further increased. CONCLUSION: This indicated that ATF3 may be a potential early diagnostic biomarker for silicosis and ATF3 acts as a repressor in inflammatory responses induced by silica.

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Silicosis is a prolonged, irreversible and incurable occupational disease, and there is a significant number of newly diagnosed cases every year in Hong Kong. Due to the long latency of the disease, the diagnosis can be missed until detailed clinical examination at a later stage. For a better control of this deadly disease, detailing the pro-inflammatory and fibrotic events in the macrophage would be instrumental in understanding the pathogenesis of the disease and essential for the significant biomarkers discovery. In this in vitro study, human cell line model A549 lung epithelial cells were used. The immediate molecular events underneath the activation of quartz silica polymorphs were followed in a time course of 0, 0.5, 2, 8, 16 and 24 h. The transcriptome library was prepared and subjected to RNA-Seq analysis. Data analysis was performed by pathway analysis tools and verified by real-time PCR. The results showed that triggered genes were mainly found in the immune response and inflammatory pathways. An interesting finding was the association of the DNA-binding protein inhibitor (ID) family in the silica exposure to lung cells. The linkage of ID1, ID2 and ID3 to cancer may rationalize themselves to be the markers indicating an early response of silicosis. However, further studies are required to consolidate the roles of these genes in silicosis. Copyright © 2017 John Wiley & Sons, Ltd.

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AIMS AND OBJECTIVES: To report on the effectiveness of an eight-week palliative care programme in Hong Kong. BACKGROUND: A recent survey reported that the quality of palliative care services in Hong Kong ranked the 20th among 40 countries and it is far behind other Asian countries. There are disagreement and inadequate communication in clinical decision-making among patients, families and healthcare professionals, and that the nurses lack sufficient knowledge and skills in providing palliative care and advance care planning. DESIGN: A pretest post-test design and semi-structured interviews were adopted. METHODS: A total of 108 home care patients with life-limiting disease and their family caregivers in Hong Kong were recruited to complete a set of questionnaire including The McGill Quality of Life Questionnaire for Hong Kong Chinese and the Family Satisfaction Scale before and after they attended an eight-week programme. The programme comprised the elements of symptom management, intensive communication on advance care planning and psychosocial intervention. RESULTS: Pearson's chi-square tests and Wilcoxon matched paired tests show a general trend that the patients' quality of life was improved after the programme. Their understanding and active participation in advance care planning was also improved. The hospital readmission rate and the days of hospital stays were significantly reduced. In qualitative interview, four major themes were identified that are as follows: improvement in the communication of treatment plans and after-death arrangements, symptom management, emotional support and suggested areas of improvement. CONCLUSION: The study supports the benefit of implementing a palliative care programme to patients with life-limiting disease. Patients demonstrated improved understanding and changed behaviour as regards the preparation for death and dying after the eight-week programme. RELEVANCE TO CLINICAL PRACTICE: The programme could be replicated in other hospitals and infirmaries that offer home care services.

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Methadone has been used as an alternative strong opioid to morphine in the management of cancer pain. The conversion of morphine to methadone is not straightforward because of the high individual variability and unpredictability in the pharmacokinetics of methadone. An ad libitum schedule for conversion of morphine to methadone was used in 37 cancer patients who had intolerable morphine-related side effects or had pain not satisfactorily controlled by morphine. Oral morphine was discontinued on the day of conversion. Methadone was given at a dose calculated as one-twelfth of the total daily dose of morphine, up to a maximum of 30 mg/dose. Methadone was administered at patient-controlled intervals not more frequent than three hours, the need of which was indicated by the presence of pain of moderate intensity or above as rated by a verbal rating scale. When the demand for methadone was stabilized, the total daily dose was given regularly in divided doses. Pain control on day 7 was taken as the primary endpoint. Twenty-seven patients completed the study. Twenty-four patients (88.9%) were in good pain control on day 7, and all reached good pain control by day 11. The median time required to achieve good pain control was three days (range 1-11 days). A majority (88.6%) of morphine-related adverse effects improved or resolved after conversion to methadone. This ad libitum schedule is effective in conversion of morphine to methadone in these patients.

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