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Influenza virus infections can lead to a number of secondary complications, including sepsis. We applied linear regression models to mortality and hospital admission data coded for septicaemia from 1998 to 2019 in Hong Kong, and estimated that septicaemia was associated with an annual average excess mortality rate of 0.23 (95% CI 0.04–0.40) per 100 000 persons per year and an excess septicaemia hospitalisation rate of 1.73 (95% CI 0.94–2.50) per 100 000 persons per year. The highest excess morbidity and mortality was found in older adults and young children, and during influenza A(H3N2) epidemics.
Lockdown during the pandemic has had significant impacts on public mental health. Previous studies suggest an increase in self-harm and suicide in children and adolescents. There has been little research on the roles of stringent lockdown.
To investigate the mediating and predictive roles of lockdown policy stringency measures in self-harm and emergency psychiatric presentations.
This was a retrospective cohort study. We analysed data of 2073 psychiatric emergency presentations of children and adolescents from 23 hospital catchment areas in ten countries, in March to April 2019 and 2020.
Lockdown measure stringency mediated the reduction in psychiatric emergency presentations (incidence rate ratio of the natural indirect effect [IRRNIE] = 0.41, 95% CI [0.35, 0.48]) and self-harm presentations (IRRNIE = 0.49, 95% CI [0.39, 0.60]) in 2020 compared with 2019. Self-harm presentations among male and looked after children were likely to increase in parallel with lockdown stringency. Self-harm presentations precipitated by social isolation increased with stringency, whereas school pressure and rows with a friend became less likely precipitants. Children from more deprived neighbourhoods were less likely to present to emergency departments when lockdown became more stringent,
Lockdown may produce differential effects among children and adolescents who self-harm. Development in community or remote mental health services is crucial to offset potential barriers to access to emergency psychiatric care, especially for the most deprived youths. Governments should aim to reduce unnecessary fear of help-seeking and keep lockdown as short as possible. Underlying mediation mechanisms of stringent measures and potential psychosocial inequalities warrant further research.
AU in days of therapy per 1,000 patient days and microbiologic data from 2015 and 2016 were collected from 26 hospitals. The prevalences of Pseudomonas aeruginosa, extended-spectrum β-lactamase (ESBL)–producing bacteria, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE) were calculated and compared to the average prevalence of all hospitals in the network. This proportion was used to calculate the adjusted AU (a-AU) for various categories of antimicrobials. For example, a-AU of antipseudomonal β-lactams (APBL) was the AU of APBL divided by (prevalence of P. aeruginosa at that hospital divided by the average prevalence of P. aeruginosa). Hospitals were categorized by bed size and ranked by AU and a-AU, and the rankings were compared.
Most hospitals in 2015 and 2016, respectively, moved ≥2 positions in the ranking using a-AU of APBL (15 of 24, 63%; 22 of 26, 85%), carbapenems (14 of 23, 61%; 22 of 25; 88%), anti-MRSA agents (13 of 23, 57%; 18 of 26, 69%), and anti-VRE agents (18 of 24, 75%; 15 of 26, 58%). Use of a-AU resulted in a shift in quartile of hospital ranking for 50% of APBL agents, 57% of carbapenems, 35% of anti-MRSA agents, and 75% of anti-VRE agents in 2015 and 50% of APBL agents, 28% of carbapenems, 50% of anti-MRSA agents, and 58% of anti-VRE agents in 2016.
The a-AU considerably changes how hospitals compare among each other within a network. Adjusting AU by microbiological burden allows for a more balanced comparison among hospitals with variable baseline rates of resistant bacteria.
Property-based random testing á la QuickCheck requires building efficient generators for well-distributed random data satisfying complex logical predicates, but writing these generators can be difficult and error prone. This chapter introduces a probabilistic domain-specific language in which generators are conveniently expressed by decorating predicates with lightweight annotations to control both the distribution of generated values and the amount of constraint solving that happens before each variable is instantiated. This language, called Luck, makes generators easier to write, read and maintain. We give Luck a probabilistic formal semantics and prove several fundamental properties, including the soundness and completeness of random generation with respect to a standard predicate semantics. We evaluate Luck on common examples from the property-based testing literature and on two significant case studies, showing that it can be used in complex domains with comparable bug-finding effectiveness and a significant reduction in testing code size compared to handwritten generators.
The risk of environmental contamination by severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in the intensive care unit (ICU) is unclear. We evaluated the extent of environmental contamination in the ICU and correlated this with patient and disease factors, including the impact of different ventilatory modalities.
In this observational study, surface environmental samples collected from ICU patient rooms and common areas were tested for SARS-CoV-2 by polymerase chain reaction (PCR). Select samples from the common area were tested by cell culture. Clinical data were collected and correlated to the presence of environmental contamination. Results were compared to historical data from a previous study in general wards.
In total, 200 samples from 20 patient rooms and 75 samples from common areas and the staff pantry were tested. The results showed that 14 rooms had at least 1 site contaminated, with an overall contamination rate of 14% (28 of 200 samples). Environmental contamination was not associated with day of illness, ventilatory mode, aerosol-generating procedures, or viral load. The frequency of environmental contamination was lower in the ICU than in general ward rooms. Eight samples from the common area were positive, though all were negative on cell culture.
Environmental contamination in the ICU was lower than in the general wards. The use of mechanical ventilation or high-flow nasal oxygen was not associated with greater surface contamination, supporting their use and safety from an infection control perspective. Transmission risk via environmental surfaces in the ICUs is likely to be low. Nonetheless, infection control practices should be strictly reinforced, and transmission risk via droplet or airborne spread remains.
The coronavirus disease 2019 (COVID-19) pandemic has led to significant strain on front-line healthcare workers.
In this multicentre study, we compared the psychological outcomes during the COVID-19 pandemic in various countries in the Asia-Pacific region and identified factors associated with adverse psychological outcomes.
From 29 April to 4 June 2020, the study recruited healthcare workers from major healthcare institutions in five countries in the Asia-Pacific region. A self-administrated survey that collected information on prior medical conditions, presence of symptoms, and scores on the Depression Anxiety Stress Scales and the Impact of Events Scale-Revised were used. The prevalence of depression, anxiety, stress and post-traumatic stress disorder (PTSD) relating to COVID-19 was compared, and multivariable logistic regression identified independent factors associated with adverse psychological outcomes within each country.
A total of 1146 participants from India, Indonesia, Singapore, Malaysia and Vietnam were studied. Despite having the lowest volume of cases, Vietnam displayed the highest prevalence of PTSD. In contrast, Singapore reported the highest case volume, but had a lower prevalence of depression and anxiety. In the multivariable analysis, we found that non-medically trained personnel, the presence of physical symptoms and presence of prior medical conditions were independent predictors across the participating countries.
This study highlights that the varied prevalence of psychological adversity among healthcare workers is independent of the burden of COVID-19 cases within each country. Early psychological interventions may be beneficial for the vulnerable groups of healthcare workers with presence of physical symptoms, prior medical conditions and those who are not medically trained.
Rapid detection and isolation of coronavirus disease 2019 (COVID-19) patients is the only means of reducing hospital transmission. We describe the impact of implementation of on-site severe acute respiratory coronavirus virus 2 (SARS-CoV-2) reverse-transcription polymerase chain reaction (RT-PCR) testing on reducing turnaround time, isolation duration, pathology test ordering, and antibiotic use in patients who do not have COVID-19.
Introducing common shocks is a popular dependence modelling approach, with some recent applications in loss reserving. The main advantage of this approach is the ability to capture structural dependence coming from known relationships. In addition, it helps with the parsimonious construction of correlation matrices of large dimensions. However, complications arise in the presence of “unbalanced data”, that is, when (expected) magnitude of observations over a single triangle, or between triangles, can vary substantially. Specifically, if a single common shock is applied to all of these cells, it can contribute insignificantly to the larger values and/or swamp the smaller ones, unless careful adjustments are made. This problem is further complicated in applications involving negative claim amounts. In this paper, we address this problem in the loss reserving context using a common shock Tweedie approach for unbalanced data. We show that the solution not only provides a much better balance of the common shock proportions relative to the unbalanced data, but it is also parsimonious. Finally, the common shock Tweedie model also provides distributional tractability.
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.
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.
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).
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.
Data localization is a phenomenon that is of increasing global significance, as a growing number of countries impose data localization requirements on data controllers. This paper discusses data localization in the ASEAN context. It proposes a schema of data localization laws which comprises two categories of data localization requirements. This schema is used to examine data localization laws within ASEAN, and it will be shown that there is presently a moderate level of data localization among ASEAN Member States. The paper then discusses how data localization is dealt with in the EU and in ASEAN, addressing some recent developments in the two regimes. It concludes with recommendations for ASEAN's approach to data localization, drawing from the EU regime.
Consumer recovery processes refer to social Connectedness, Hope, Identity, Meaning in life, and Empowerment (“CHIME”). This study examined if expectations of change in depression could mediate the relationship between CHIME recovery processes and depression severity. Participants were patients who consulted clinical psychologists at primary care clinics. Measures of depression change expectancy, CHIME recovery processes, and depression symptoms were administered. Change expectancy partially mediated the relationship between Hope and depression severity. The same was found for Identity, but Identity also mediated the relationship between change expectancy and depression. Thus, Hope may reduce depression by improving change expectancies, whereas Identity and change expectancy may have reciprocal influences that alter depression. Findings suggest that the CHIME recovery processes may facilitate recovery from depression.
This paper explains how the concept of personal data should be delimited. Certainty on this matter is crucial, as it determines the material scope of the data protection obligations. The primary boundary delimiting the scope of personal data is the requirement that personal data ‘relate to’ an individual. The courts of the UK and the EU have sought to delineate this boundary, but there are serious difficulties in the present approaches that have emerged thus far. Two possible ways forward are suggested, taking into account the implications of the direct application of the GDPR in the UK.
Statistical models are commonly employed in the estimation of influenza-associated excess mortality that, due to various reasons, is often underestimated by laboratory-confirmed influenza deaths reported by healthcare facilities. However, methodology for timely and reliable estimation of that impact remains limited because of the delay in mortality data reporting. We explored real-time estimation of influenza-associated excess mortality by types/subtypes in each year between 2012 and 2018 in Hong Kong using linear regression models fitted to historical mortality and influenza surveillance data. We could predict that during the winter of 2017/2018, there were ~634 (95% confidence interval (CI): (190, 1033)) influenza-associated excess all-cause deaths in Hong Kong in population ⩾18 years, compared to 259 reported laboratory-confirmed deaths. We estimated that influenza was associated with substantial excess deaths in older adults, suggesting the implementation of control measures, such as administration of antivirals and vaccination, in that age group. The approach that we developed appears to provide robust real-time estimates of the impact of influenza circulation and complement surveillance data on laboratory-confirmed deaths. These results improve our understanding of the impact of influenza epidemics and provide a practical approach for a timely estimation of the mortality burden of influenza circulation during an ongoing epidemic.
The Visual Cognitive Assessment Test (VCAT) is a language-neutral cognitive screening tool designed for use in culturally diverse populations without the need for translations or adaptations. While it has been established to be language-neutral, the VCAT’s construct validity has not been investigated.
471 participants were recruited, comprising 233 healthy comparisons, 117 mild cognitive impairment (MCI), and 121 mild Alzheimer’s disease (AD) patients. VCAT and domain-specific neuropsychological tests were administered in the same sitting. Construct validity was assessed by analyzing domain-specific associations between the VCAT and well-established cognitive assessments. Reliability (internal consistency) was measured by Cronbach’s alpha. Diagnostic ability (area under the curve) and recommended cutoffs were determined by receiver operating characteristic (ROC) analysis.
The VCAT and its subdomains demonstrated good construct validity in terms of both convergent and divergent validity and good internal consistency (α = .74). ROC analysis found that the VCAT was on par with the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) at distinguishing between healthy comparisons, MCI, and mild AD. Consistent with previous studies, VCAT scores were not affected by language of administration or ethnicity in our cohort. Findings suggest the following cutoffs: Dementia 0–19, MCI 20–24, Normal 25–30.
This study established the construct validity of the VCAT, which is vital to ensure its subdomains effectively measure the cognitive processes they were designed to. The VCAT is capable of detecting early cognitive impairments and allows for meaningful cross-cultural comparisons, especially useful for international collaborations and clinical trials, and for clinical use in diverse multiethnic populations.
OBJECTIVES/SPECIFIC AIMS: Examine data from PNID patients to evaluation the strength of associations between pre-operative and post-operative levels of pain, quality of life, and emotional reactions to pain to determine if one or more can serve as better predictors of surgical success than pain. METHODS/STUDY POPULATION: In our preliminary study, we gathered data from a pre-existing database of 464 PNID patients that contains self-reported visual analog scale scores (VAS) of pain intensity, QoL, and depression. We measured these variables at three time points: pre-operatively, post-operatively, and at the final visit. We used the Wilcoxon signed rank test to determine if each of these three variables differed significantly between the pre-operative visit and the post-operative visit period and from the pre-operative visit to the final visit. RESULTS/ANTICIPATED RESULTS: Median time from the pre-operative visit to surgery was 9 weeks; median time from surgery to the post-operative visit was 4 weeks; and median time from the post-operative visit to the final visit was 23.5 weeks. There was a clinically meaningful difference in pain scores between the pre-operative and post-operative visits (median difference 1.15; 95% CI 0.75-1.55). In the period between the post-operative visit and the final visit there was also a decrease in pain (0.90; 95% CI 0.55-1.30). The magnitude of change in median difference of 1.85 (95% CI 1.50-2.20) between the pre-operative visit and the final visit was larger than the change in median difference of 0.90 (95% CI 0.55-1.30) between the post-operative visit and the final visit. The pre-operative visit median QoL score was higher than the median score at the post-operative visit (1.65; 95% CI 1.25-2.10). The smallest median difference in QoL of occurred between the post-operative and the final visit (1.10; 95% CI 0.60-1.45). As seen with the pain scores, the magnitude of change in median difference of 2.50 (95% CI 2.20-2.85) for QoL was greatest between the pre-operative and the final visit. Depression scores showed the least amount of change amongst all the variables, between the pre-operative and the post-operative visit (1.00; 95% CI (0.70-1.40), and similarly between the post-operative visit and the final visit (0.15; 95% CI (0-.40). The median differences between the pre-operative and final visit were greatest in QoL (2.50; 95% CI 2.20-2.85), followed by pain scores (1.85; 95% CI 1.50-2.20), and finally, depression (1.05; 95% CI 0.70-1.40). DISCUSSION/SIGNIFICANCE OF IMPACT: Our results show that all three variables measured improve with surgery and continue to improve over the post-operative course to the final visit. This suggest that the relationships between pain, QoL, and depression should be further investigated. We are hopeful that elucidating how these variables interact in the PNID patient population, will encourage peripheral nerve surgeons to use these parameters in conjunction with pain intensity to measure outcomes. A follow-up study expanding on these results and including measures of anger and frustration in a larger sample is underway.
The paper is concerned with multiple claim arrays. In recognition of the extensive use by practitioners of large correlation matrices for the estimation of diversification benefits in capital modelling, we develop a methodology for the construction of such correlation structures (to any dimension). Indeed, the literature does not document any methodology by which practitioners, who often parameterise those correlations by means of informed guesswork, may do so in a disciplined and parsimonious manner.
We construct a broad and flexible family of models, where dependency is induced by common shock components. Models incorporate dependencies between observations both within arrays and between arrays. Arrays are of general shape (possibly with holes), but include the usual cases of claim triangles and trapezia that appear in the literature. General forms of dependency are considered with cell-, row-, column-, diagonal-wise, and other forms of dependency as special cases. Substantial effort is applied to practical interpretation of such matrices generated by the models constructed here.
Reasonably realistic examples are examined, in which an expression is obtained for the general entry in the correlation matrix in terms of a limited set of parameters, each of which has a straightforward intuitive meaning to the practitioner. This will maximise chance of obtaining a reliable matrix. This construction is illustrated by a numerical example.
We consider a profitable, risky setting with two separate, correlated asset and liability processes (first introduced by Gerber and Shiu, 2003). The company that is considered is allowed to distribute excess profits (traditionally referred to as dividends in the literature), but is regulated and is subject to particular regulatory (solvency) constraints. Because of the bivariate nature of the surplus formulation, such distributions of excess profits can take two alternative forms. These can originate from a reduction of assets (and hence a payment to owners), but also from an increase of liabilities (when these represent the wealth of owners, such as in pension funds). The latter is particularly relevant if distributions of assets do not make sense because of the context, such as in regulated pension funds where assets are locked until retirement. In this paper, we extend the model of Gerber and Shiu (2003) and consider recovery requirements for the distribution of excess funds. Such recovery requirements are an extension of the plain vanilla solvency constraints considered in Paulsen (2003), and require funds to reach a higher level of funding than the solvency level (if and after it is triggered) before excess funds can be distributed again. We obtain closed-form expressions for the expected present value of distributions (asset decrements or liability increments) when a distribution barrier is used.
The People's Action Party (PAP) has been at the helm of a one-party dominant state since Singapore became independent in 1965. From 1966 to 1981, PAP members of parliament (MPs) occupied every seat in Singapore's Westminster-style parliament. As a founding member of the PAP and the country's first prime minister (PM), Lee Kuan Yew presided over the transformation of the country from Third World to First World status. Goh Chok Tong (PM from 1990 to 2004) and Lee Hsien Loong (PM from 2004 to the present) built on that foundation to turn the small island nation into an economic powerhouse. Each of them is rightly proud of his government's contribution to the many and continuing achievements of the nation. Singapore's leaders have always been deeply convinced of their strong mandate to govern and their right to be obeyed, especially when they had to make unpopular decisions that they considered to be necessary.
However, in general elections held on May 7, 2011, the PAP garnered only 60.14 percent of the total votes and won 81 out of 87 seats. The PAP's five-member team fielded in the Aljunied Group Representation Constituency (GRC) was beaten by the Workers’ Party team, the first time that any of these team-contested multi-seat GRCs ever went to the opposition. The PAP's Aljunied team included Foreign Affairs Minister George Yeo and Singapore's first female cabinet minister Lim Hwee Hua. Widely held to be a watershed event, the election was atypical. Compared to past elections, it saw the largest number of seats contested and, in connection with this, the largest number of Singaporeans – up to 2.06 million – casting their votes, many for the very first time.
Just three months later, Singaporeans voted again in presidential elections held on August 27. Though required to be nonpartisan, three presidential candidates were previously PAP members and one had been a member of the opposition Singapore Democratic Party. Tony Tan, former deputy prime minister and PAP chairman as well as the government's preferred candidate, won 35.2 percent of the votes and was announced as president. He beat his closest rival Tan Cheng Bock by a narrow margin. The outspoken former PAP backbencher won 34.8 percent of the votes.
Research suggests that an 8-week mindfulness-based cognitive therapy
(MBCT) course may be effective for generalised anxiety disorder
To compare changes in anxiety levels among participants with GAD randomly
assigned to MBCT, cognitive–behavioural therapy-based psychoeducation and
In total, 182 participants with GAD were recruited (trial registration
number: CUHK_CCT00267) and assigned to the three groups and followed for
5 months after baseline assessment with the two intervention groups
followed for an additional 6 months. Primary outcomes were anxiety and
Linear mixed models demonstrated significant group × time interaction
(F(4,148) = 5.10, P = 0.001) effects
for decreased anxiety for both the intervention groups relative to usual
care. Significant group × time interaction effects were observed for
worry and depressive symptoms and mental health-related quality of life
for the psychoeducation group only.
These results suggest that both of the interventions appear to be
superior to usual care for the reduction of anxiety symptoms.
In the classical optimal dividends problem, dividend decisions are allowed to be made at any point in time — according to a continuous strategy. Depending on the surplus process that is considered and whether dividend payouts are bounded or not, optimal strategies are generally of a band, barrier or threshold type. In reality, while surpluses change continuously, dividends are generally paid on a periodic basis. Because of this, the actuarial literature has recently considered strategies where dividends are only allowed to be distributed at (random) discrete times — according to a periodic strategy.
In this paper, we focus on the Brownian risk model. In this context, the optimal continuous and periodic strategies have previously been shown (independently of one another) to be of barrier type. For the first time, we consider a model where both strategies are used. In such a hybrid strategy, decisions are allowed to be made either at any time (continuously), or periodically at a lower cost. This proves optimal in some cases. We also determine under which combination of parameters a pure continuous, pure periodic or hybrid (including both continuous and periodic dividend payments) barrier strategy is optimal. Interestingly, the hybrid strategy lies in-between periodic and continuous strategies, which provides some interesting insights. Results are illustrated.