Providing professional care and establishing a good rapport with patients is the mission of all health care workers. This relationship building is part of the patient-centred health care delivery model that is currently being advocated over a clinician- or disease-centred model.1 It is associated with better clinical outcomes and may reduce potential complaints due to miscommunication.2 3 4 In the intensive care setting where patients often cannot make their own decisions, either due to their illness or to the effect of medications,5 building a good relationship with the patients’ family is especially important. Furthermore, it has been recognised that families of patients admitted to the intensive care unit (ICU) are at higher risk of developing anxiety, depression, and post-traumatic stress disorder.6 7 They are suddenly subjected to an uncertain outcome for their loved ones, with associated emotional, social and financial consequences, and in a strange environment packed with complex technological advancements. The long-term psychological impact on the family after an ICU encounter is now termed as post-intensive care syndrome–family (PICS-F).7 This adds to the society’s health care burden and reduces the family ability to provide care. Evidence suggests that the risk of developing PICS-F is affected by the manner in which health care workers interact with the family.8 For these reasons, ICU quality measurement should include the families’ perspective and their satisfaction with the care process.9 10

In early 2012, the Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong (PYNICU) initiated the Family Satisfaction Enhancement (FAME) programme that aimed to improve family satisfaction with ICU care. A regular satisfaction survey was performed that intended to identify problem areas and make subsequent improvements. The current study was part of the FAME programme that evaluated the level of family satisfaction in a local ICU and its performance in comparison with international standards, and determined factors that are independently associated with a higher family satisfaction and could be used to plan future initiatives.

This was a questionnaire survey carried out at PYNICU, which is a mixed medical-surgical 22-bed adult ICU in a regional hospital with 1633 beds in Hong Kong. It is a closed ICU with 24-hour intensivist coverage.

The Family Satisfaction in the ICU (FS-ICU) questionnaire is a patient family satisfaction questionnaire originally developed in 2003 by a group of health care professionals in Canada: the Canadian Researchers at the End of Life Network (CARENET).5 The questionnaire has been validated for use in North America and Europe,11 12 13 14 and has been translated into other languages including Chinese. The questionnaire is accessible online (http://www.thecarenet.ca). The questionnaire consists of 37 items in two parts: satisfaction with overall ICU care, and satisfaction with decision-making around the care of critically ill patients; and three open-ended questions. Respondents were asked to provide baseline data (sex, age, relationship with the patient, prior experience with ICU, and whether they lived together before admission) at the start of the questionnaire. Corresponding patient data were retrieved from the Clinical Management System, electronic Patient Record, and Clinical Data Analysis and Reporting System.

Patients who were admitted to the ICU for 48 hours or more between 15 June 2012 and 31 January 2014, and were visited by their next-of-kin (NOK; defined as the key contact person nominated by the family and documented on the nursing chart on admission) during their stay in the ICU were eligible. Once an eligible patient was nearing ICU discharge (defined as an expected date of ICU discharge within the next 5 days as judged each morning by a senior clinician or nurse consultant), or had passed away in the ICU, his/her NOK was invited by an independent research assistant not involved in clinical care to participate in the survey. A minimum stay of 48 hours was used as in previous studies to ensure an adequate exposure of families to the ICU.15 16 A copy of the questionnaire and an envelope were given to the NOK to be completed based on his/her opinion. He/she was asked to return the questionnaire in the envelope provided, which was opened only by researchers. Those who failed to return the questionnaire were contacted by phone within 2 months of ICU discharge or death, and the questionnaire was sent to them with a stamped addressed envelope if they agreed to participate. All respondents were ensured of the confidentiality and anonymity of their response. For patients who were admitted to the ICU more than once within the same hospitalisation, only the last was analysed.

The study protocol was reviewed by the Hong Kong East Cluster Ethics Committee and the need for consent was waived.

Items in the FS-ICU questionnaire were scored as previously described12: each item was recoded into a linear scale ranging from 0 to 100, with 0 as very poor or very dissatisfied, and 100 as excellent or completely satisfied. Three items (“received appropriate amount of information”, “had enough time to think in decision-making process”, and “adequate time to address concerns and answer questions”) were recoded into dichotomous variables, while two items (“involved at right time in decision-making process”, and “given right amount of hope patient would recover”) were recoded into a 3-point Likert scale.12 A mean (± standard deviation [SD]) score was computed for each item. Subscores for satisfaction with overall ICU care (FS-ICU/Care) and satisfaction with role in decision-making (FS-ICU/DM), and a total score (FS-ICU/Total) were generated by averaging available items, provided that the respondent answered 70% or more of the items in the respective sections.12

Results were compared using Mann-Whitney U test with those of a multicentre Canadian database (written communication, Daren Heyland, Feb 2014) that comprised data captured from 2003 to 2006 at 12 Canadian sites.

Univariate analyses of satisfaction with overall ICU care and satisfaction with role in decision-making were conducted. Variables included the baseline respondent’s and patient’s characteristics, as well as items of part 1 or part 2 of FS-ICU, respectively. Continuous variables were categorised using their median, and questionnaire items were categorised into “completely satisfied” and “less than completely satisfied”. Factors with a P value of ≤0.1 were entered into multivariable logistic regression using stepwise backward elimination to identify independent factors associated with complete family satisfaction with overall ICU care and role in decision-making.

The independent factors thus identified by multivariable logistic regression were used in the construction of performance-importance plots to identify those factors that deserve more urgent attention because of their higher importance (regression weights above the median) but lower performance (percentage of that item being rated as “excellent” being below the median).

By applying the rule of 10 on logistic regression analysis of family satisfaction with overall ICU care, a target sample size was estimated to be 725 with 29 covariates with an estimated 40% of respondents being “completely satisfied” with overall care. All tests were two-sided, and a P value of <0.05 was considered statistically significant. All data were analysed using the Statistical Package for the Social Sciences (Windows version 20; SPSS Inc, Chicago [IL], US).

From 15 June 2012 to 31 January 2014, 961 patients were eligible and 822 families agreed to participate; 736 questionnaires were eventually returned, with a response rate of 76.6%. Excluding the three questions only applicable to families of patients who passed away in ICU and the three open-ended questions, 23 766 (95.0%) of the total 25 024 questions were completed. Baseline characteristics of the respondents and patients are shown in Table 1.

Our mean (± SD) FS-ICU/Total, FS-ICU/Care, and FS-ICU/DM scores were 78.1 ± 14.3, 78.0 ± 16.8, and 78.6 ± 13.6, respectively. Table 2 shows the percentage of responses and mean score for each questionnaire item.

When results were compared with the Canadian data (written communication, Daren Heyland, Feb 2014), the latter had a higher mean FS-ICU/Total, FS-ICU/Care, and FS-ICU/DM score of 82.9 ± 14.8, 83.5 ± 15.4, and 82.6 ± 16.0, respectively (P<0.001 for all three scores when compared with PYNICU). Table 2 shows the result for each FS-ICU item; PYNICU achieved a significantly higher mean score for item “control over care”. There was no significant difference in scores between the two databases for items “frequency of communication by physicians”, “atmosphere of ICU waiting room”, “involved at the right time in decision-making”, “received appropriate amount of information”, and “given right amount of hope”. The Canadian sites achieved higher scores for the remaining items.

In the univariate analysis of satisfaction with overall ICU care, none of the patient’s or respondent’s characteristics had a P≤0.1. Items “spiritual support for family”, “support from social workers”, and “support from pastors” were excluded since more than 30% of the responses were either missing or deemed not applicable. Thus, a total of 14 covariates were analysed in the multivariable analysis. The independent factors identified were “concern and caring for patients”, “agitation management”, “concern and caring for family”, “frequency of communication by nurses”, “physician skill and competence”, “atmosphere of ICU”, and “atmosphere of ICU waiting room” (Table 3). In the multivariable analysis of satisfaction with role in decision-making, 16 covariates including “age of respondent”, “sex of respondent” (with P values of 0.005 and 0.08, respectively in the univariate analysis), and all items in part two of the questionnaire excluding item “given right amount of hope” (P=0.214 in univariate analysis) were tested. Independent factors identified were “honesty of information”, “completeness of information”, “control over care”, “agreement within family regarding care patient received”, “satisfaction with amount of health care”, and “age of respondent ≥47 years” (Table 3).

Performance-importance plots identified the following items as being more important but performed less satisfactorily: “atmosphere of ICU waiting room”, “atmosphere of ICU”, “agitation management” (overall care), and “satisfaction with amount of health care” (decision-making) [Fig 1].

This is the first ICU family satisfaction survey published in Hong Kong, and was conducted following implementation of the FAME programme in 2012. Following a small-scale survey carried out by PYNICU in 2010 (written communication, HL Wu, 2012), staff awareness about the importance of family satisfaction has increased. Family satisfaction was added to the regular agenda at our weekly business meetings, where comments and feedback from NOKs were discussed. These discussions led to various measures to improve communication (unsolicited nurses’ update during visiting hours), access to information (information booklets in waiting rooms and noticeboard displays for families), and facilities (chairs for families at bedside, televisions for awake patients, and refurbishment of the waiting rooms). This survey showed high satisfaction scores in 2012 to 2014 that were similar to figures reported around the world (Fig 2 16 17 18 as well as the multicentre Canadian database—a German study reported their mean FS-ICU/Total, FS-ICU/Care, and FS-ICU/DM as 78.3 ± 14.3, 78.6 ± 14.3, and 77.8 ± 15.616; a Swiss study reported scores of 78 ± 14, 79 ± 14, and 77 ± 1517; and an American study achieved scores of 76.6 ± 20.6, 77.7 ± 20.6, and 75.2 ± 22.6, respectively.18 Nonetheless the Canadian centres were able to achieve a significantly better result in most items and in the summary scores. This might be explained by cross-cultural (different expectations from families), as well as administrative differences (nurse-patient and doctor-patient ratios), but it may also indicate room for further improvement.

Independent factors that affected satisfaction with overall care and identified by this study can be grouped into: care of the patient and family (concern and caring for the patient and family; agitation management), professional care (frequency of communication by nurses; physician skill and competence), and the ICU environment (atmosphere of the ICU and its waiting room). Consistent with prior studies, none of the patient’s or respondent’s characteristics, including the ICU survival status, was found to be independently associated with satisfaction of overall care.16 19 Setting professional skills aside, the perceived physician competence and amount of concern and care shown to patients and their families were largely affected by the communication skill of the health care providers and their manner when interacting with patients and families. The importance of communication has been emphasised by numerous studies.20 21 22 23 24 25 One study found that longer periods of communication between health care providers and families was associated with reduced anxiety among family members of ICU patients.24 They reported a median (range) time of staff contact as 10 (1-60) minutes. In addition to the duration, a proactive, structured, and multidisciplinary communication strategy that incorporated the five objectives in the mnemonic “VALUE” (to Value and appreciate what the family members said, to Acknowledge the family members’ emotions, to Listen, to ask open-ended questions that would allow the caregiver to Understand who the patient was as a person, and to Elicit questions from family members) was shown to lessen symptoms of anxiety, depression, and post-traumatic stress disorder.25 Education and training in communication skills, especially the power of listening and to allow families more opportunity to speak during conferences also improved family satisfaction in the ICU.26 It is also essential to diagnose the root cause of any communication problem.15 Removing barriers in the health care system that discourage communication, for example heavy workload rendering insufficient time spent with families and restrictive visiting policies, would be beneficial.27

Factors in the left upper quadrant of the performance-importance plots (Fig 1) had greater regression weights but performed less satisfactorily, and therefore warrant more urgent attention. Among these were the ICU and waiting room environment. The questionnaire items do not specify the particular areas of concern that individual families had in mind, but responses to the three open-ended questions were illuminating. Comments related to the ICU environment focused on the availability of facilities for patients (visual and audio entertainment devices) and their families (chairs and toilet), ICU noise level, room temperature, space, and privacy. In fact, the ICU environment has been repeatedly identified as a factor that affects satisfaction.13 18 19 One study found that migration of an ICU with multiple beds in one ward to another with single-room design significantly improved family and patient satisfaction.13 These findings offer opportunities for improvement, and also provide valuable information for administrators when designing a new ICU.

Agitation management also warranted more urgent attention (Fig 1a). Although evidence supports maintenance of a light rather than deep level of sedation in adult critically ill patients to shorten duration of mechanical ventilation and ICU length of stay,28 29 a balance needs to be struck to prevent excessive pain, agitation, or adverse experiences that are associated with a higher incidence of post-traumatic stress disorder in ICU survivors and could negatively impact their families.30 The revised 2013 version of Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult ICU Patients has recommended routine monitoring of the depth of sedation and targeted titration of preferably non-benzodiazepine sedatives.31

Our subscore for decision-making was higher than that for overall care, in contrast to the overseas counterparts.16 17 18 We do not know if this is unique to the Chinese population since no other Chinese survey is available for comparison. One interesting finding was that younger respondents were less satisfied with their role in decision-making than older respondents. A similar observation has been made before.32 In this information explosion era where electronic data are easily available, it can be understood that the younger generation wants to play a greater role in making decisions for their sick family member. A paternalistic approach will be less appealing to our future generation, and a deliberative model should therefore be adopted, with an emphasis on provision of complete and honest information to increase their sense of control over the care of their family member.

There are limitations to our study. First, the reason for refusal to participate in the survey was not documented and therefore we cannot rule out a response bias, where dissatisfied families might have declined participation in the survey, thus overestimating satisfaction. The high return rate compared with other studies (76.6% vs 27.8-75.4%15 16 17) would have lessened any effect of a response bias. Second, social desirability bias cannot be ruled out as most respondents completed the questionnaire while their sick family member was still under our care. We tried to minimise this by reassuring families of the confidentiality of their response and providing an envelope in which to return the completed questionnaire that was only opened by researchers at a later time. Third, questionnaires completed before ICU discharge might not reflect the whole ICU experience. Recruiting NOKs when the patient was nearing ICU discharge reduced premature data capture and prevented the otherwise increased administrative cost, increased recall bias, and anticipated lower response rate that would be involved when tracing eligible NOKs following ICU discharge. Fourth, FS-ICU has not been validated in the Chinese language. The Chinese (Taiwan) version provided by CARENET was modified by the co-authors wherein Taiwanese terms were replaced by ones familiar to the Hong Kong people and questions on the respondent’s demographics were added as in the original English questionnaire. This modified version was circulated to and approved by all co-authors to ensure face validity. The high return rate of the questionnaire and the high response rate to questions (95.0%) indicated feasibility of this modified Chinese version.11 Last, this was a single-centre study and thus generalisability of the results to other settings may not be appropriate.

Family satisfaction is an important measure of ICU quality. We found that families were satisfied with the ICU care we provided and with their role in decision-making. Their satisfaction was comparable with most overseas centres. Nonetheless there remains room for improvement when compared with the Canadian database. Future initiatives will focus on improving the ICU environment, agitation management, and enhancing communication with families.

We wish to thank all members of the FAME team including Dr Arthur CW Lau, Ms Nora LP Kwok, Ms L Lau, Ms CH Lee, and Ms HY Wong for their administrative advice and contribution in data collection and entry, and Ms CH Li, Ms WY So, and Ms PS Chiu for subject recruitment. We also wish to thank the Canadian Researchers at the End of Life Network for sharing their FS-ICU database. Current versions of the FS-ICU questionnaire can be found on their website <www.thecarenet.ca/57-researchers/our-projects/family-satisfaction-survey>.

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9. Flaatten H. The present use of quality indicators in the intensive care unit. Acta Anaesthesiol Scand 2012;56:1078-83. Crossref

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13. Jongerden IP, Slooter AJ, Peelen LM, et al. Effect of intensive care environment on family and patient satisfaction: a before-after study. Intensive Care Med 2013;39:1626-34. Crossref

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15. Heyland DK, Rocker GM, Dodek PM, et al. Family satisfaction with care in the intensive care unit: results of a multiple center study. Crit Care Med 2002;30:1413-8. Crossref

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Eczema or atopic dermatitis (AD) is a chronically relapsing dermatosis associated with atopy, and characterised by reduced skin hydration (SH), impaired skin integrity (transepidermal water loss [TEWL]), and poor quality of life as a result of deficient ceramides in the epidermis.1 Regular application of a moisturiser is the key step in its management. Moisturiser therapy for AD is significantly complicated by the diversity of disease manifestations and by a variety of complex immune abnormalities.1 Filaggrin (filament-aggregating protein) and related moisturising factors have an important function in epidermal differentiation and barrier function, and null mutations within the filaggrin gene are major risk factors for developing AD.2 3 4 5 6 Ceramides and related lipid products are also important components in skin barrier function.7 Recent advances in the understanding of the pathophysiological process of AD have led to the production of new moisturisers targeted at correcting the reduced amount of ceramides and natural moisturising factors in the stratum corneum with ceramides, pseudoceramides, or natural moisturising factors.7 Many proprietary products claim to have these ingredients, but have no or limited studies to document their clinical efficacy. Our group previously tested a number of these commercial products and found patient preference and acceptability may influence outcomes of topical treatment independent of the ingredients in these products.8 The purposes of this study were to investigate patient acceptability of a cream/cleanser combination containing lipid complex and shea butter extract with claimed antihistaminergic properties, and evaluate its efficacy in improving the clinical and biophysiological properties of the skin in AD patients. A MEDLINE search was also performed to evaluate whether evidence of efficacy of many of the proprietary moisturisers exists.

Consecutive patients with AD who were interested in trying a new moisturiser were recruited from the paediatric dermatology clinic at a university teaching hospital in Hong Kong. Diagnosis of AD was based on the UK working group criteria.9 In this study, SH and TEWL in the right forearm (2 cm below the antecubital flexure), and disease severity (SCORing Atopic Dermatitis [SCORAD] index) were measured. We have previously described our method of standardising measurements of SH and TEWL.10 After acclimatisation in the consultation room with the patient sitting comfortably in a chair for 20 to 30 minutes, SH (in arbitrary units) and TEWL (in g/m²/h) were then measured according to the manufacturer’s instructions with the Mobile Skin Center MSC 100 equipped with a Corneometer CM 825 (Courage + Khazaka electronic GmbH, Cologne, Germany), and a Tewameter TM 210 probe (Courage + Khazaka electronic GmbH). We documented that a site 2 cm distal to the right antecubital flexure was optimal for standardisation. Oozing and infected areas were avoided by moving the probe slightly sideways.10 The clinical severity of AD was assessed with the SCORAD index.11 12 The SCORAD index also scores pruritus and sleep loss/disturbance on a scale of 0 to 10 (0 being not affected and 10 being most severely affected).

Patients were given a liberal supply of a trial cream containing lipid complex with shea butter extract for eczema (Ezerra [E]; Hoe Pharma, Petaling Jaya, Malaysia) and body wash (E, Hoe Pharma). The moisturiser contained STIMU-TEX AS (Centerchem Inc, Norwalk [CT], US) and saccharide isomerate. The wash contained STIMU-TEX AS and Amisoft (Amisoft Technologies Ltd, Brentwood, UK). The patients were instructed not to use any other moisturiser or topical treatment. Use of any medications such as topical corticosteroid or oral antihistamine was documented. Patients were encouraged to use the test moisturiser at least twice daily on the flexures and areas with eczema. In case the emollient effect was not satisfactory, they could use their usual emollient and medications, but the frequency of such use was to be reported and they must continue with the E moisturiser. The patients were reviewed at the end of 4 weeks. Measurements of SCORAD index, Children’s Dermatology Life Quality Index (CDLQI), SH, and TEWL were repeated. Patients’ global or general acceptability of treatment (GAT) was recorded as ‘very good’, ‘good’, ‘fair’, or ‘poor’.8 13 Approval was obtained from the Clinical Research Ethics Committee of the Chinese University of Hong Kong and written informed consents were obtained from the guardian and patient.

Continuous data were expressed as mean and standard deviation. Mann-Whitney U test was used for intergroup comparison and Wilcoxon signed rank test for within-group comparison as a small number of patients was included. Categorical data were presented in counts. Chi squared test or Fisher’s exact test where appropriate was used to compare intergroup categorical data, while McNemar’s test was used to compare within-group categorical data. Fisher’s exact test was used to determine the GAT of previously used proprietary products and E moisturiser and wash. All comparisons were two-tailed, and P values of <0.05 were considered to be statistically significant. The results were also compared with the data for an emollient (C) containing ceramide-precursor lipids and moisturising factors (n=24).14

Between 1 April 2013 and 31 March 2014, 34 patients (56% boys; mean [± standard deviation] age, 12.1 ± 4.4 years) with AD were recruited and treated with applications of a moisturising cream (E). Compliance was good and patients generally managed to use the moisturiser daily. Among the patients, 74% reported ‘very good’ or ‘good’ acceptability, whereas 26% reported ‘fair’ or ‘poor’ acceptability of the moisturiser (Tables 1 and 2).

There were no intergroup differences in pre-usage clinical parameters of age, objective SCORAD index, pruritus, sleep loss, SH, TEWL, topical corticosteroid usage, oral antihistamine usage, or GAT of prior emollient (Table 2). Following use of the E cream, pruritus score and CDLQI were lower in the ‘very good’/‘good’ group than in the ‘fair’/‘poor’ group. Mean pruritus score decreased from 6.7 to 6.0 (P=0.036) and mean CDLQI improved from 10.0 to 8.0 (P=0.021) in the ‘very good’/‘good’ group (Table 2).

When analysed for the association of the rating of acceptability, the acceptability of E cleanser (P=0.526) and E cream (P=0.537) was not significantly associated with their respective pre-trial products (Table 1). Patients who preferred the trial moisturiser or wash might or might not have come from the group of poor/fair acceptability of their prior emollient or wash, and vice versa. Prior products included emulsifying ointment and various other proprietary products.

When compared historically with another product containing ceramide-precursor lipids (C) that we tested in a previous report,14 the present shea butter extract–containing cream showed similar efficacy and acceptability (Table 3). It appears that ceramide does not confer superiority in terms of acceptability and clinical efficacy.

A MEDLINE search was performed on selected common proprietary moisturisers/emollients for eczema using the following search terms in combinations: “eczema” OR “atopic dermatitis”, AND “emollient” OR “moisturizer” OR “barrier” OR “barrier repair” OR “natural moisturizing factor” OR “ceramide” OR “pseudoceramide”. We selected literature mainly from the past 10 years, but did not exclude commonly referenced and highly cited older articles. We included and described all randomised trials, case series, and bench studies in barrier repair therapy for eczema, with limits activated (Humans, Clinical Trial, Meta-Analysis, Randomized Controlled Trial, English, published in the past 10 years). Editorials, letters, practice guidelines, reviews, and animal studies were excluded. In addition, the bibliographies of the retrieved articles and our own research database were also hand searched. As of 23 April 2014, 18 articles were obtained (Table 413 27 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48). The common proprietary moisturisers were included. The publications generally provided limited evidence of efficacy and biophysical effects (such as SH and TEWL), but virtually no data on patient acceptability and effects on Staphylococcus aureus colonisation.

Atopic dermatitis is a chronically relapsing dermatosis characterised by pruritus, skin dryness, inflammation, secondary bacterial infection by S aureus, and poor quality of life.1 15 16 17 The stratum corneum normally consists of fully differentiated corneocytes surrounded by natural moisturising factor and a lipid-rich matrix containing cholesterol, free fatty acids, and ceramide. In AD, metabolism of lipid and filaggrin protein is abnormal, causing a deficiency of ceramide and natural moisturising factors and impairment of epidermal barrier function that leads to increased TEWL and abnormal skin integrity.1 4 7 18 19 20 21 Moisturisers form the first-line therapy as maintenance and therapeutic management in childhood-onset AD.1 22 23 Hydration of the skin helps to improve dryness, reduce pruritus, and restore disturbed barrier function. Bathing without the use of moisturiser may compromise SH.24 25 26

In this study, we explored clinical efficacy and acceptability of a proprietary moisturiser (E) containing shea butter extract. The cream was acceptable as ‘very good’ or ‘good’ in about three quarters of patients with AD who tried the moisturiser, and ameliorated their pruritus and improved their quality of life.

Compliance or adherence to usage of the moisturising cream was reflected by the GAT and reported frequency of usage (times per day).27 We did not calculate the amount of moisturising cream used because many parents/patients have discarded the tubes or failed to bring them back for weighing in previous trials. Topical steroid usage is also an important confounding factor in this study. We standardise treatment for all our patients by not changing their existing topical steroid (mometasone furoate) and other medications (ie oral antihistamine, topical immunomodulant, and Chinese medicine). In previous studies, we found that documentation of the exact amount of steroid usage (weight or frequency of usage) was difficult for similar reasons as those for moisturisers.28 Most parents are still concerned about topical steroid usage and tend to use the minimal amount of steroid as far as possible.29

Alternative explanations for the modest within-group changes in pruritus and CDLQI (Table 2) include regression to the mean, detection bias, or confounding by co-treatment with topical corticosteroid or usual emollients. Our study did not demonstrate any reduction in clinical severity or S aureus colonisation. When compared historically with another product (C) containing ceramide-precursor lipids that we tested in a previous report,14 although different patients were involved and the E or C products were not received by patients in the same period, the present E cream showed similar efficacy and acceptability with the use of a similar study protocol as the previous study. It appears that specific ceramide-precursor lipids do not confer superiority in terms of acceptability and clinical efficacy.

Regarding intra-group comparisons, the C cream reduced objective SCORAD index (P=0.027) and increased SH (P=0.015), whereas the E cream reduced pruritus and improved CDLQI only in the ‘very good’/‘good’ group (Table 3). Regarding intergroup comparisons, overall there were no significant differences between the pretreatment and post-treatment parameters for the two moisturisers. We note that in the subgroup analysis, pruritus and CDLQI could be the possible contributing factors for the acceptability in the ‘very good’/‘good’ group for the E cream.

Many proprietary emollients/moisturisers are available in the market.7 22 30 31 Despite claims about their efficacy, little evidence has demonstrated the short- or long-term usefulness of many of these proprietary products. Ceramides, pseudoceramides, or filaggrin protein products have been studied and added to commercial moisturisers to mimic natural skin lipids and moisturising factors.32 Anxious parents often consult their physicians for recommendation as to the choice of an ideal or perfect moisturiser for their child with AD. Physicians need to have some evidence-based understanding about these moisturisers in order to address issues raised by the parents. We performed a MEDLINE search and found that only a few of these products have published clinical data (Table 413 27 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48). The majority either do not have patient acceptability or clinical efficacy data in the scientific literature. The efficacy of ceramides and natural moisturiser factors is generally not scientifically documented. Larger-scale, properly conducted randomised controlled trials with recruitment of more study participants may validate subtle differences in clinical efficacy between different emollients. It is likely that there will be similar outcomes in efficacy if the tested emollient is compared with any other traditional emollient such as aqueous cream or Vaseline (Unilever, London, England). Commercial pharmaceutical companies are often unwilling to supply free samples of their product to compare with an inexpensive product, even if more validated and conclusive results may be obtained by increasing the sample size in clinical trials. That is perhaps why there are so few comparative clinical studies in the medical literature.

In a wider context, AD is a complex multifactorial atopic disease. Monotherapy targeting merely at replacement of ceramides, pseudoceramides, or filaggrin degradation products at the epidermis is often suboptimal. In particular, colonisation with S aureus must be adequately treated before emollient treatment can be optimised.17

The major hindrance to the efficacy of a moisturiser is the patient’s perception as to what an ideal moisturiser should be.8 Indeed, it is often not the product, but the patient’s acceptability that determines whether it may be used consistently. Therefore, the physician caring for a patient with AD must educate and guide the parents and the patient to choose the most acceptable formulation to ensure optimal compliance.

This open-label series confirms our previous experience in emollient research. First, patient acceptance of the strengths, types, and formulations of any novel products need to be studied, preferably in randomised controlled trials. Second, holistic efficacy studies of all clinical parameters (namely severity scores, quality-of-life indices, SH, TEWL, S aureus colonisation, and patient acceptance) must be included. Third, as AD is not a simple epidermal skin disease but rather a complex atopic disease, emollient alone is bound to be suboptimal in efficacy.

Well-designed, large-scale, randomised, placebo-controlled trials to document therapeutic effects on disease severity, skin biophysiological parameters, quality of life, and patient acceptability are needed. Patient’s acceptability of a certain product is pivotal for compliance and clinical outcome. Only few of the many proprietary moisturisers for AD have undergone clinical trials to evaluate clinical efficacy and patient acceptability.

Drs KL Hon and TF Leung have performed research on eczema therapeutics, and written about the subject matter of filaggrin, ceramides, and emollients.

We thank Hoe Pharma in Hong Kong for freely supplying the studied materials. The company, however, was not involved in the design or analysis of the research data. The products used in the present study could be examples of other similar products containing shea butter.

1. Leung AK, Hon KL, Robson WL. Atopic dermatitis. Adv Pediatr 2007;54:241-73. Crossref

2. Sandilands A, Terron-Kwiatkowski A, Hull PR, et al. Comprehensive analysis of the gene encoding filaggrin uncovers prevalent and rare mutations in ichthyosis vulgaris and atopic eczema. Nat Genet 2007;39:650-4. Crossref

3. Sandilands A, Smith FJ, Irvine AD, McLean WH. Filaggrin’s fuller figure: a glimpse into the genetic architecture of atopic dermatitis. J Invest Dermatol 2007;127:1282-4. Crossref

4. Enomoto H, Hirata K, Otsuka K, et al. Filaggrin null mutations are associated with atopic dermatitis and elevated levels of IgE in the Japanese population: a family and case-control study. J Hum Genet 2008;53:615-21. Crossref

5. Chamlin SL, Kao J, Frieden IJ, et al. Ceramide-dominant barrier repair lipids alleviate childhood atopic dermatitis: changes in barrier function provide a sensitive indicator of disease activity. J Am Acad Dermatol 2002;47:198-208. Crossref

6. Maintz L, Novak N. Getting more and more complex: the pathophysiology of atopic eczema. Eur J Dermatol 2007;17:267-83.

7. Hon KL, Leung AK. Use of ceramides and related products for childhood-onset eczema. Recent Pat Inflamm Allergy Drug Discov 2013;7:12-9. Crossref

8. Hon KL, Wang SS, Pong NH, Leung TF. The ideal moisturizer: a survey of parental expectations and practice in childhood-onset eczema. J Dermatolog Treat 2013;24:7-12. Crossref

9. Williams HC, Burney PG, Pembroke AC, Hay RJ. The U.K. Working Party’s Diagnostic Criteria for Atopic Dermatitis. III. Independent hospital validation. Br J Dermatol 1994;131:406-16. Crossref

10. Hon KL, Wong KY, Leung TF, Chow CM, Ng PC. Comparison of skin hydration evaluation sites and correlations among skin hydration, transepidermal water loss, SCORAD index, Nottingham Eczema Severity Score, and quality of life in patients with atopic dermatitis. Am J Clin Dermatol 2008;9:45-50. Crossref

11. Severity scoring of atopic dermatitis: the SCORAD index. Consensus Report of the European Task Force on Atopic Dermatitis. Dermatology 1993;186:23-31. Crossref

12. Kunz B, Oranje AP, Labreze L, Stalder JF, Ring J, Taieb A. Clinical validation and guidelines for the SCORAD index: consensus report of the European Task Force on Atopic Dermatitis. Dermatology 1997;195:10-9. Crossref

13. Hon KL, Wang SS, Lau Z, et al. Pseudoceramide for childhood eczema: does it work? Hong Kong Med J 2011;17:132-6.

14. Hon KL, Pong NH, Wang SS, Lee VW, Luk NM, Leung TF. Acceptability and efficacy of an emollient containing ceramide-precursor lipids and moisturizing factors for atopic dermatitis in pediatric patients. Drugs R D 2013;13:37-42. Crossref

15. Leung DY, Boguniewicz M, Howell MD, Nomura I, Hamid QA. New insights into atopic dermatitis. J Clin Invest 2004;113:651-7. Crossref

16. Hon KL, Lam MC, Leung TF, et al. Clinical features associated with nasal Staphylococcus aureus colonisation in Chinese children with moderate-to-severe atopic dermatitis. Ann Acad Med Singapore 2005;34:602-5.

17. Hon KL, Wang SS, Lee KK, Lee VW, Fan LT, Ip M. Combined antibiotic/corticosteroid cream in the empirical treatment of moderate to severe eczema: friend or foe? J Drugs Dermatol 2012;11:861-4.

18. Hanifin JM, Rajka RG. Diagnostic features of atopic dermatitis. Acta Derm Venereol (Stockh) 1980;2:44-7.

19. Hanifin JM. Atopic dermatitis. J Am Acad Dermatol 1982;6:1-13. Crossref

20. Candi E, Schmidt R, Melino G. The cornified envelope: a model of cell death in the skin. Nat Rev Mol Cell Biol 2005;6:328-40. Crossref

21. Leung DY, Nicklas RA, Li JT, et al. Disease management of atopic dermatitis: an updated practice parameter. Joint Task Force on Practice Parameters. Ann Allergy Asthma Immunol 2004;93(3 Suppl 2):S1-21. Crossref

22. Hon KL, Leung AK, Barankin B. Barrier repair therapy in atopic dermatitis: an overview. Am J Clin Dermatol 2013;14:389-99. Crossref

23. Krakowski AC, Eichenfield LF, Dohil MA. Management of atopic dermatitis in the pediatric population. Pediatrics 2008;122:812-24. Crossref

24. Lancaster W. Atopic eczema in infants and children. Community Pract 2009;82:36-7.

25. Tarr A, Iheanacho I. Should we use bath emollients for atopic eczema? BMJ 2009;339:b4273. Crossref

26. Hon KL, Leung TF, Wong Y, So HK, Li AM, Fok TF. A survey of bathing and showering practices in children with atopic eczema. Clin Exp Dermatol 2005;30:351-4. Crossref

27. Hon KL, Ching GK, Leung TF, Choi CY, Lee KK, Ng PC. Estimating emollient usage in patients with eczema. Clin Exp Dermatol 2010;35:22-6. Crossref

28. Hon KL, Leung TF, Ng PC, et al. Efficacy and tolerability of a Chinese herbal medicine concoction for treatment of atopic dermatitis: a randomized, double-blind, placebo-controlled study. Br J Dermatol 2007;157:357-63. Crossref

29. Hon KL, Kam WY, Leung TF, et al. Steroid fears in children with eczema. Acta Paediatr 2006;95:1451-5. Crossref

30. Roos TC, Geuer S, Roos S, Brost H. Recent advances in treatment strategies for atopic dermatitis. Drugs 2004;64:2639-66. Crossref

31. Baumer JH. Atopic eczema in children, NICE. Arch Dis Child Educ Pract Ed 2008;93:93-7.

32. Park KY, Kim DH, Jeong MS, Li K, Seo SJ. Changes of antimicrobial peptides and transepidermal water loss after topical application of tacrolimus and ceramide-dominant emollient in patients with atopic dermatitis. J Korean Med Sci 2010;25:766-71. Crossref

33. Mohammed D, Matts PJ, Hadgraft J, Lane ME. Influence of Aqueous Cream BP on corneocyte size, maturity, skin protease activity, protein content and transepidermal water loss. Br J Dermatol 2011;164:1304-10. Crossref

34. Tsang M, Guy RH. Effect of Aqueous Cream BP on human stratum corneum in vivo. Br J Dermatol 2010;163:954-8. Crossref

35. Simpson E, Böhling A, Bielfeldt S, Bosc C, Kerrouche N. Improvement of skin barrier function in atopic dermatitis patients with a new moisturizer containing a ceramide precursor. J Dermatolog Treat 2013;24:122-5. Crossref

36. Laquieze S, Czernielewski J, Baltas E. Beneficial use of Cetaphil moisturizing cream as part of a daily skin care regimen for individuals with rosacea. J Dermatolog Treat 2007;18:158-62. Crossref

37. Simpson E, Trookman NS, Rizer RL, et al. Safety and tolerability of a body wash and moisturizer when applied to infants and toddlers with a history of atopic dermatitis: results from an open-label study. Pediatr Dermatol 2012;29:590-7. Crossref

38. Miller MA, Borys D, Riggins M, Masneri DC, Levsky ME. Two cases of contact dermatitis resulting from use of body wash as a skin moisturizer. Am J Emerg Med 2008;26:246.e1-2.

39. Miller DW, Koch SB, Yentzer BA, et al. An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial. J Drugs Dermatol 2011;10:531-7.

40. Draelos ZD. The effect of ceramide-containing skin care products on eczema resolution duration. Cutis 2008;81:87-91.

41. Madaan A. Epiceram for the treatment of atopic dermatitis. Drugs Today (Barc) 2008;44:751-5. Crossref

42. Palatty PL, Azmidah A, Rao S, et al. Topical application of sandal wood oil and turmeric based cream prevents radiodermatitis in head and neck cancer patients undergoing external beam radiotherapy: a pilot study. Br J Radiol 2014;87:20130490. Crossref

43. Wang S, Kislalioglu MS, Breuer M. The effect of rheological properties of experimental moisturizing creams/lotions on their efficacy and perceptual attributes. Int J Cosmet Sci 1999;21:167-88. Crossref

44. Boffa MJ, Beck MH. Allergic contact dermatitis from quaternium 15 in Oilatum cream. Contact Dermatitis 1996;35:45-6. Crossref

45. Garfield SS. The beneficial effects of oilatum cream on hyperhydrosis. J Am Podiatry Assoc 1966;56:22-4. Crossref

46. Yilmaz E, Borchert HH. Effect of lipid-containing, positively charged nanoemulsions on skin hydration, elasticity and erythema—an in vivo study. Int J Pharm 2006;307:232-8. Crossref

47. Kemeny L, Koreck A, Kis K, et al. Endogenous phospholipid metabolite containing topical product inhibits ultraviolet light–induced inflammation and DNA damage in human skin. Skin Pharmacol Physiol 2007;20:155-61. Crossref

48. Dizon MV, Galzote C, Estanislao R, Mathew N, Sarkar R. Tolerance of baby cleansers in infants: a randomized controlled trial. Indian Pediatr 2010;47:959-63. Crossref

Since the introduction of locking plate fixation, there has been a tendency to manage distal radius fracture in elderly people with plate fixation over cast fixation. In the US, the rate of plate fixation in elderly people increased 5-fold from 3% in 1996 to 16% by 2005.1

Only a few recent studies have compared conservative versus operative management of distal radius fracture in elderly people. Some authors have concluded that, while grip strength was significantly better after operation, functional outcome did not improve.2 3

In Hong Kong, Chinese elderly people tend to have poorer bone quality than western people of the same age.4 Life expectancies in Hong Kong, however, are one of the longest in the world, at 80.9 years for men and 86.6 years for women in 2013.5 Moreover, an increasing number of people older than 60 years are still working and therefore the expectation for clinical outcomes after distal radius fracture will be higher than that in the past. As a result, it is imperative to investigate whether locking plate fixation is a good option in treating distal radius fracture in Chinese elderly people. The aim of this study was to compare the outcomes between locking plate fixation and cast immobilisation as treatment for displaced distal radius fracture with unstable fracture pattern in Chinese elderly people.

The hospital database was reviewed for elderly patients with distal radius fracture from 1 May 2010 to 31 October 2013. The study was approved by the Research Ethics Committee of the Hospital Authority, Hong Kong.

The operation rate for distal radius fracture decreased with age and elderly patients (>70 years) tended to prefer conservative management. The oldest patient who underwent locking plate fixation was 77 years. As a result, our inclusion criteria were: Chinese patients, aged 61 to 80 years, having displaced distal radius fracture with unstable fracture pattern (defined as having at least three out of five criteria of: initial dorsal angulation >20°, initial shortening >5 mm, >50% dorsal comminution, intra-articular fracture, and ulnar fracture6), and completion of a rehabilitation programme after either operative or conservative management.

The exclusion criteria were: operative management other than 2.4- or 3.5-mm locking compression plates (eg K-wire fixation, non-locking plate fixation, or external fixation), open fracture or neurovascular deficits requiring immediate operative management, concomitant same-side upper limb injury (eg elbow dislocation, shoulder dislocation, or humeral fracture) that affected the overall functional outcome, and a history of medical illness (eg stroke or dementia) that hindered the rehabilitation results.

A total of 57 patients were identified. All of the patients were active, independent in activities of daily living, and otherwise healthy. The patients were admitted to orthopaedic ward at Tseung Kwan O Hospital, Hong Kong from the Accident and Emergency Department. Initial closed reduction of distal radius fracture under local anaesthesia and immobilisation with a backslab were performed. Options of conservative management with cast immobilisation or operative management with locking plate fixation and the associated risks and complications were discussed with the patients. The patient made the final decision with written consent for either treatment.

For patients who opted for cast immobilisation, the reduced fracture was immobilised with a short arm cast for 6 weeks, followed by mobilisation and strengthening exercises. For patients who opted for locking plate fixation, the operation was done under general anaesthesia with an arm tourniquet. The modified Henry approach was used and the fracture was fixed with a 2.4- or 3.5-mm locking compression plate, followed by immediate mobilisation and then strengthening exercises. All patients were reviewed regularly in the orthopaedic out-patient clinic, with serial radiographs and rehabilitation until they reached the maximal improvement in range of motion and grip strength.

At the beginning of this retrospective study, the majority of the patients had been discharged from the clinic. In view of the technical difficulty of calling back elderly patients for physical assessment, the clinical parameters recorded in the last section of the rehabilitation programme were collected and the last radiographs taken in the clinic were retrieved for measurement. The duration from treatment to the last section of the rehabilitation programme averaged 10 months (range, 6-12 months) and the duration from treatment to the last radiographs averaged 9 months (range, 6-14 months).

Clinical parameters, including range of motion and grip strength of both hands, were measured by physiotherapists and occupational therapists not involved in this study. Radiographic parameters—including volar tilt, radial inclination, radial length, and ulnar variance—were measured by one of the investigators.

Functional outcome was assessed using the quick Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) score at a mean of 12 months (range, 6-24 months) after treatment; DASH score is a measure of a patient’s perceived disability. The quick DASH was chosen instead of the full DASH because the elderly patients generally had a low educational background, making completion of a comprehensive questionnaire difficult. The 11-question evaluation was completed by means of an interview in the clinic, a telephone interview, or answers to a mailed questionnaire. In summary, clinical, radiological, and functional outcomes were assessed at 9 to 12 months after treatment.

Data were assessed with different statistical tests. For categorical variables, Chi squared test (for sex and side of injury) and analysis of variance (for Orthopaedic Trauma Association classification) were used. For continuous variables, independent sample t test was used for normally distributed data (including grip strength and radiographic parameters) and Mann-Whitney U test for non-normally distributed data (including age, range of motion, and quick DASH score). A P value of ≤0.05 was considered statistically significant.

Of 57 patients enrolled in this study, 26 were treated with locking plate fixation and 31 were treated with cast immobilisation. The number of patients in the cast immobilisation group was low because many of them were either excluded due to stable fracture pattern (n=31) or were lost to follow-up in the rehabilitation programme (n=49). There were no statistically significant differences in characteristics between the two groups (Table 1).

Clinical outcomes are shown in Table 2. Grip strength was presented in the form of fraction of grip strength in the non-injured side as the denominator. The operative group did not achieve significantly better range of motion when compared with the cast immobilisation group, but grip strength was significantly better. Only one complication was documented, which was carpal tunnel syndrome after cast immobilisation. There was a statistically significant improvement in the radiographic parameters (except for radial length) after anatomical reduction in the operative group (Table 3). Regarding functional outcome, the operative group perceived significantly less disability than the cast immobilisation group (Table 4).

This study found that locking plate fixation for displaced, unstable distal radius fracture achieved significantly better grip strength, radiographic parameters, and functional outcome when compared with cast immobilisation in elderly people aged 61 to 80 years.

Whether anatomical reduction results in better functional outcome in elderly people with displaced distal radius fracture of unstable fracture pattern is still a controversial topic. Some authors have reported satisfactory functional outcome after cast immobilisation for displaced distal radius fracture in low-demand elderly people, regardless of the radiographic result.7 8 In the younger age-group, reconstruction of articular congruity of displaced intra-articular distal radius fractures by means of internal fixation and/or external fixation have long been known to improve functional outcome.9 Only a few studies in the literature have investigated this correlation in elderly patients.

One historical cohort study compared the outcomes of 90 patients older than 65 years who were treated either operatively with plate-and-screw fixation or external fixation, or conservatively with cast immobilisation.3 Grip strength and radiographic parameters were superior in the operative group, but there was no difference in other outcomes including DASH score.3 In one prospective randomised trial, 73 patients aged 65 years or older were randomised to receive open reduction internal fixation with volar locking plate or closed reduction and cast immobilisation.2 Similar results were reported. Lastly, in one diagnostic study examining 53 patients older than 55 years, operative intervention was found to have no influence on functional outcome.10

Our study has a discrepancy for functional outcome, although clinical and radiological outcomes were consistent with the previous studies. Our opinion is that the previous studies included some patients older than 80 years, for whom operation might not be suitable due to poorer premorbid status and lower functional demand than those aged 61 to 80 years. Therefore, the overall functional outcome did not improve after operation. We believe that locking plate fixation for active Chinese elderly people aged up to 80 years could achieve good clinical, radiological, and functional outcomes. However, the decision should not only be determined by chronological age but also be balanced with functional age and medical condition.

There are some limitations to this study. Since it is a non-randomised study, there might have been bias during discussion of the treatment options with the patients. Moreover, the two groups of patients were not blinded (and could not be blinded) to the therapists and investigator in assessing the clinical and radiological outcomes, which might have resulted in information bias. A substantial number of eligible patients defaulted the rehabilitation programme (four in the operative group, 49 in the cast immobilisation group) and were counted as loss to follow-up. Therefore, there was a possibility of self-selection bias among the remaining patients, who had better motivation for rehabilitation and regaining functions. Other confounding factors, such as differences in background characteristics and expectations of outcome, might have made the two groups of patients non-comparable. The follow-up duration was relatively short due to limitations of human resources. The times for assessing outcomes were not standardised due to the retrospective nature of this study. The sample size was relatively small due to the strict inclusion and exclusion criteria, especially after exclusion of patients older than 80 years, but this resulted in significantly better functional outcome. Lastly, the quick DASH score might have been affected by previous injury or degenerative arthritis of the same upper limb. Using a wrist-specific score such as the Mayo wrist score or Patient-Rated Wrist Evaluation, however, could not reflect how the whole upper limb compensates for the wrist function in elderly patients after distal radius fracture.

We advise operation with locking plate fixation for displaced distal radius fracture with unstable fracture pattern in active Chinese elderly patients aged 61 to 80 years. Nevertheless, further prospective study such as a randomised controlled trial is needed to resolve this controversy.

Special thanks to the many dedicated colleagues from the Physiotherapy and Occupational Therapy Departments of Tseung Kwan O Hospital.

1. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am 2009;91:1868-73. Crossref

2. Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am 2011;93:2146-53. Crossref

3. Egol KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N. Distal radial fractures in the elderly: operative compared with nonoperative treatment. J Bone Joint Surg Am 2010;92:1851-7. Crossref

4. Lau EM, Lynn H, Woo J, Melton LJ 3rd. Areal and volumetric bone density in Hong Kong Chinese: a comparison with Caucasians living in the United States. Osteoporos Int 2003;14:583-8. Crossref

5. Stoker S, editor. Hong Kong 2013. Information Services Department, Hong Kong Special Administrative Region Government; 2013.

6. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury 1989;20:208-10. Crossref

7. Anzarut A, Johnson JA, Rowe BH, Lambert RG, Blitz S, Majumdar SR. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures. J Hand Surg Am 2004;29:1121-7. Crossref

8. Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years. J Hand Surg Am 2000;25:19-28. Crossref

9. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg Am 1994;19:325-40. Crossref

10. Synn AJ, Makhni EC, Makhni MC, Rozental TD, Day CS. Distal radius fractures in older patients: is anatomic reduction necessary? Clin Orthop Relat Res 2009;467:1612-20. Crossref

Lumbar radiculopathy can be well-managed conservatively in the primary health care setting, but many patients with persistent disabling radicular pain need attention in a specialty clinic. The majority of patients first attend a public specialty clinic in Hong Kong with pain chronicity of more than 12 months, as they have had no significant clinical response to conservative management in primary health care, private medical specialists, traditional Chinese medicine, or alternative medicine, and they anticipate a long waiting time in a public hospital. Epidural steroid injection is commonly practised by orthopaedic surgeons, neurosurgeons, rehabilitation specialists, pain specialists, and interventional radiologists worldwide. The thresholds for offering epidural steroid injection by clinicians and acceptance by patients are variable, however.

Transforaminal epidural steroid injection (TFESI) is one of the more common approaches of epidural steroid injection, along with the interlaminar and caudal approaches. The technique is target-specific and the best route for delivering medication to the ventral epidural space (Fig 1a) and dorsal root ganglion,1 where most pathological changes occur.2 3 The least amount of drug with a relatively higher drug concentration is required to reach the primary site of pathology compared with interlaminar and caudal epidural steroid injections.4

Transforaminal epidural steroid injection is a useful procedure for lumbar radiculopathy.5 The technique provides neural blockade to anaesthetise the target nerve root for diagnostic purposes, and interrupts nociceptive input and self-sustaining activity of the neurons. Steroid provides anti-inflammatory effect (inhibition of pro-inflammatory synthesis and release of mediators) and produces longer-term pain relief, primarily for radiculopathy. The prognostic value of TFESI for surgical outcomes has been reported, with better surgical outcome in TFESI responders with chronic lumbar radiculopathy than in non-responders.6 The technique, however, does not alter the ultimate need for surgery.7

Underlying sepsis, malignant disease, and coagulopathy are considered to be contra-indications for spinal injection. The perceived benefits and threshold of offering TFESI as an adjunct to conservative treatment for patients with lumbar radiculopathy attributed to disc herniation or spinal stenosis are variable among orthopaedic surgeons, rehabilitation specialists, and pain specialists. The objective of this study was to identify the diagnostic, therapeutic, and prognostic values of TFESI for lumbar radiculopathy in Chinese patients in Hong Kong.

Patients were placed in the prone position on a radiolucent operating table. A 22-G spinal needle was inserted into the target neuroforamen with fluoroscopic image guidance. The target nerve root and its epidural space were outlined by water-soluble non-ionic contrast, ensuring epidural flow of contrast with no intravascular, intradural, or subcutaneous infiltration (Fig 1). A mixture of 1-mL methylprednisolone acetate 40 mg and 1-mL bupivacaine 0.5% was injected. Finally, the intact spinal needle was removed.

All patients who received TFESI for lumbar radiculopathy at Alice Ho Miu Ling Nethersole Hospital, Hong Kong from 1 January 2007 to 31 December 2011 (5 years) were identified by the electronic medical record system in the hospital. Retrospective review of all the medical records identified patients with numeric pain rating scale score (NPRS) of 4 to 7 (out of 10) who took less than three types of analgesics for at least 8 weeks as conservative treatment, or patients with persistent disabling pain with NPRS of >7 despite taking more than three types of analgesics for at least 1 week as conservative treatment. Patients with NPRS of <4, missing record of post-procedure response, or who had received previous lumbar spinal injection and lumbar spinal surgery were excluded.

The first part of the study assessed the response rate to diagnostic block by the local anaesthetic effect of TFESI for all patients with a clinical diagnosis of lumbar radiculopathy attributed to disc herniation or spinal stenosis, with compatible magnetic resonance imaging (MRI) findings of laterality and affected level. The second part of the study assessed the therapeutic and prognostic values of the steroid effect of TFESI as an adjunct to conservative treatment prior to assessment of surgical need.

The threshold for surgery for patients with lumbar radiculopathy attributed to prolapsed intervertebral disc (PID) and spinal stenosis, in general, considered factors of disabling pain resulting in inability to meet activity demands, clinical MRI findings compatible for laterality and site of compression, and medical fitness for general anaesthesia and major spinal surgery. Spinal fusion might be considered for patients with concomitant spondylolisthesis with instability or anticipated instability resulting from optimal surgical decompression in the lateral recess or foraminal stenosis and concomitant disabling discogenic low back pain that has not responded to conservative treatment.

An immediate response on the procedure day was considered to have a positive diagnostic value. Patients who reported pain reduction of greater than 50% at the first follow-up visit 4 weeks after TFESI were considered to have a positive therapeutic response to the steroid effects. The response duration, proportion of patients finally requiring surgery, whether decompression alone or spinal fusion besides decompression was needed, and risk factors that affected the response to TFESI were retrospectively reviewed.

Comparisons were carried out for all patients, as well as patients with PID or spinal stenosis only. Associations between responses to TFESI and risk factors for symptom chronicity and industrial injury were done by Fisher’s exact test or Mann-Whitney U test where appropriate. Non-parametric tests were done because some continuous variables were not normally distributed. The Statistical Package for the Social Sciences Windows version 20.0 (SPSS Inc, Chicago [IL], US) was used for all statistical analysis. A two-sided P value of ≤0.05 was considered statistically significant.

A total of 241 patients were recruited into this study. Nine patients were excluded for the following reasons: TFESI responders with PID and L5 radiculopathy had had symptom duration of less than 1 week and TFESI was not considered to be adequate first-line conservative treatment (n=3); and TFESI immediate responders did not return for first follow-up (n=2) and TFESI responses were not documented in the medical records (n=4) so the response durations for these six patients could not be verified. Therefore, the total number of eligible participants was 232 (110 men and 122 women; mean age ± standard deviation [SD]: 55.6 ± 14.3 years). The mean age of patients with PID and spinal stenosis were 37.4 ± 7.5 years and 60.3 ± 11.7 years, respectively. The symptom chronicity ranged from 8 days to 23 years with a median of 12.0 months, as well as 25th, 75th, and 90th percentiles being 7.0, 36.0, and 60.0 months, respectively in patients with lumbar radiculopathy. No statistically significant difference (P=0.402) in symptom chronicity between the PID and spinal stenosis groups was noted (median [interquartile range] duration: PID group 12.0 [8.0-24.0] months vs spinal stenosis group 12.0 [6.0-36.0] months). Fewer PID patients (n=48; 20.7%) needed TFESI than spinal stenosis patients (n=184; 79.3%) with lumbar radiculopathy in the study period.

L5 was the most commonly affected level of radiculopathy (n=150; 64.7%) regardless of whether a patient had single or multiple levels or underlying pathology of PID or spinal stenosis (Table 1). Therefore, post-ganglionic block of the L5 nerve root by L5-S1 TFESI was most commonly done.

The immediate response rate to TFESI was 80.2% in 186 patients with clinically diagnosed lumbar radiculopathy and MRI of the lumbar spine suggesting nerve root compression. Overall, 218 (94.0%) patients were affected at a single level and 14 (6.0%) were affected at multiple levels (Table 1). The immediate response rates to TFESI were 175 (80.3%) in the single-level radiculopathy group and 11 (78.6%) in the multiple-level radiculopathy group. There was no statistically significant difference in the immediate responder rate between patients with PID or spinal stenosis (P=0.877). No complications were reported.

The final need for surgery of TFESI immediate responders was noted in 10/39 (25.6%) patients in the PID group and 43/147 (29.3%) patients in the spinal stenosis group (Table 2).

Of the 232 patients, 106 (45.7%) were offered surgery, of whom 65 (61.3%) accepted surgery. The mean time from TFESI to uptake of surgery was 7.9 months. There was a statistically significant shorter median time to definitive surgery in the PID group (10.0 months) than in the spinal stenosis group (19.2 months) [P<0.01]. This reflects the fact that PID patients with failed first-line conservative treatment who needed TFESI for lumbar radiculopathy were likely to accept surgery earlier than patients with spinal stenosis. Patients with PID were younger (mean age, 37.0 years) than spinal stenosis patients (mean age, 59.2 years) undergoing surgery, which might be related to less daily activity demand, higher perceived operative risks, and older people being more psychologically reluctant to undergo surgery.

Of the 65 surgical patients, 23 (35.4%) underwent decompression surgery alone, with a mean time from TFESI of 5.45 months (SD, 5.25 months; median, 3.6 months; range, 8 days to 17.63 months). The remaining 42 (64.6%) patients required spinal fusion in addition to decompression surgery, with a mean time from TFESI of 9.37 months (SD, 7.23 months; median, 7.22 months; range, 14 days to 25.33 months). The difference in time to surgery for these two groups was statistically significant (P=0.012). More patients with a short-term response to TFESI underwent surgery (Fig 2) and TFESI was commonly used as a preoperative assessment tool.

The analgesic effect of TFESI lasted for less than 1 week (poor response) in 68 (29.3%) patients, for 1 to <3 weeks (short term) in 35 (15.1%) patients, for 3 to 12 weeks (intermediate) in 37 (15.9%) patients, and for more than 12 weeks (long term) in 92 (39.7%) patients. More patients with spinal stenosis underwent surgery in the short-term pain reduction group (1-<3 weeks), and the association between response to TFESI and surgery for spinal stenosis was significant (P<0.01), but no significance was noted for PID patients (P=0.067) [Table 3].

Poor response (mean, 34.3 ± 50.9 months) to TFESI (no immediate response and pain reduction duration of <1 week) was significantly associated with chronicity of symptoms (vs 23.1 ± 28.3 months in patients with positive response) [P=0.047]. Pain reduction duration had no significant association with symptom chronicity for pain reduction of less than 3 months and 3 months or more in the PID (P=0.225) and spinal stenosis (P=0.250) groups (Table 4).

Childhood injury is a major cause of death and disability in many countries, including Hong Kong.1 Although previous studies have reviewed general childhood injuries in Hong Kong children,1 2 dental injuries have not been specifically studied and reported. The oral region comprises 1% of the total body area, yet a population-based study in Sweden showed that it accounts for 5% of all body injuries at all ages.3 A recent study conducted by the Department of Health showed that injuries to orofacial areas accounted for 1.7% of all body injuries in children aged 14 years or below.1

Dental luxation and avulsion injuries account for 15% to 61% of all dental traumas to permanent teeth.4 It is an important public health concern as the treatment of such injuries is often complicated and requires specialist care.5 6 It also tends to occur at a young age during which growth and development take place and so long-term follow-up is needed.5 6 7 The average number of dental visits because of trauma to a permanent tooth during 1 year has been shown to be much higher than that required for a bodily injury.6 Information on how and where dental trauma occurs, and the associated risk factors are important data that can be used to plan a preventive strategy. There is, however, little information about the epidemiology of dental trauma in children residing in Hong Kong. The aims of this retrospective study were to identify the major causes and types of dental luxation and avulsion injuries, and their associated factors in primary school children attending a school dental clinic in Hong Kong.

This retrospective study was carried out at Fanling School Dental Clinic that provides care for approximately 30 000 primary school children in the Hong Kong New Territories East region. The study materials comprised dental records of patients with a history of dental luxation and/or avulsion injury between November 2005 and October 2012. All dental luxation and avulsion injuries were logged in the electronic records using specific codes: an electronic search of records was performed using the same dental condition codes (DC=concussion, DS=subluxation, DE=extrusion, DN=intrusion, DL=lateral luxation, and DA=avulsion). All cases were examined clinically by at least one of the three attending paediatric dentists at the clinic who were experienced in treating children with dental trauma. All records were reviewed by one single examiner, the paediatric dentist in-charge of the clinic. Information was recorded in Microsoft Excel and data analysis was carried out using the Chi squared test and multinomial logistic regression with PASW Statistics 18 software (SPSS Inc, Chicago [IL], US). The level of significance was set at P<0.05. To evaluate intra-examiner reliability, all selected records were reviewed by the same author 1 month after the original analysis and the findings of the two examinations compared for discrepancies.

Since November 2005, a standardised dental trauma form has been used in the clinic to facilitate follow-up care. The following parameters were recorded for patients who presented with dental luxation or avulsion injuries: date and time of injury, place where the injury occurred, cause of trauma, presence of other orofacial soft tissue injury, and the incisor relationship according to the British Standard Incisor Classification.8 The type of injury was classified according to the Andreasen modification of the World Health Organization classification,9 and included six types of injury to periodontal tissues (Table 1).

The adjacent apparently unaffected teeth on both sides were also included in the examination. For each tooth, objective clinical findings from the initial and follow-up examinations were recorded using the same standardised format and included the following: pulp sensitivity test; percussion tone; tenderness to percussion; tooth mobility; tooth colour; periodontal probing depths; and the presence of concomitant crown fractures and pulp exposure.

An anterior occlusal radiograph together with periapical radiographs of the affected teeth were taken at the initial examination. At each follow-up appointment, periapical radiographs were repeated for the affected teeth. All periapical radiographs were taken using a standard film holder (Dentsply Rinn, Elgin [IL], US).

All cases were followed up at regular intervals: 3 weeks, 6 to 8 weeks, 6 months, and then annually from the time of injury. Patients with dental avulsion were also seen on days 7 to 10 for splint removal and root canal treatment if indicated.

A total of 220 children with 355 teeth of dental luxation or avulsion injury were recorded during the study period. Their ages ranged from 6 to 14 years (mean age, 9.2 years; standard deviation, 1.7 years). To assess whether age was an important factor, children were divided into two age-groups: 58% (n=128) were aged 6 to 9 years and 42% (n=92) were 10 to 14 years at the time of injury. The male-to-female ratio was 1.8:1, with 141 boys and 79 girls. The gender difference in prevalence was more prominent in children aged 9 years or above. The peak occurrence was seen at the age of 9 years (n=46), followed by the age of 8 years (n=44) and 10 years (n=38). Only one tooth was traumatised in 117 (53%) children. The predominant traumatic dental injury was subluxation, followed by concussion (Table 2). Over 65% of teeth with concussion or subluxation also had crown fractures. Maxillary central incisors (295 teeth) were the most commonly affected, followed by maxillary lateral incisors (38 teeth) and mandibular incisors (20 teeth). The cause of injury was recorded in 219 cases (Table 3). Fall (62%) was the predominant cause in both genders and age-groups, followed by collision (18%) and cycling (15%). There were no incidents of injury caused by motor vehicle accidents or fights. Statistical analysis using Chi squared test showed no significant difference in the cause of injury between genders (P=0.108) or between the two age-groups (P=0.193). The place where the injury occurred was recorded in 217 cases: most occurred at school (Table 4). Statistical analysis using Chi squared test showed a significant difference in the place of occurrence between genders (Chi squared=15.6, degrees of freedom=6, P<0.05), but no significant difference between the two age-groups (P=0.078). Multivariate analysis using multinomial logistic regression was then performed with gender and age-group as independent variables and place of injury as a dependent variable. Because of the relatively small number of cases, injuries that occurred in the playground, street, swimming pool, and other places were grouped into one category named as other places in the analysis. Injury occurring at school was then compared with injuries that occurred at home, on a cycling path, or in other places. School was chosen as the reference because (1) it was the most common place where injury occurred; and (2) univariate analysis of individual places of injury using the Fisher’s exact test showed no significant difference between genders regarding injuries at school whereas there were significant gender differences in injuries that occurred at home and on a cycling path (P<0.05). The results of the regression showed that boys were more commonly affected than girls (P<0.05; odds ratio [OR]=2.97; 95% confidence interval [CI], 1.05-8.43) for injuries that occurred on a cycling path in comparison with injuries at school. In the same model, younger children were significantly less commonly affected than older children (P<0.05; OR=0.42; 95% CI, 0.21-0.85) for injuries that occurred in other places compared with injuries at school.

Incisor relationship was registered in 199 cases: most were Class I (63%) [Table 5]. Since such information was not available for the whole study, it was decided to use data from a previous study of the general Chinese population of children as a retrospective comparison group.10 Comparison of these two studies showed that there was a higher proportion of Class II and fewer Class III occlusions in the trauma group than in the general Chinese population. Statistical analysis showed a significant difference between the two population groups (Chi squared=36.1, degrees of freedom=2, P<0.0001). Soft tissue injury occurred in the orofacial region in 87 children, and lips were involved in most instances (82%). Intra-examiner reliability was evaluated and complete concordance of all data and parameters was found between the two evaluations that were 1 month apart.

The difference in the proportion of causes of traumatic dental injury depends on various factors including culture, age-group, and population.11 12 In some developing countries, the most common cause of dental injury in children is violence.9 In this study, fall against a hard object such as the ground was the cause in over 60% of cases. This finding is in agreement with most other studies of traumatic dental injury in children.7 11 12 13 14 15 16 17 18 19 20 In a study of New Zealand children, fall was the most common cause in children aged 5 to 7 years, but collision became more common in the 8- to 10-year-old group.21 Nonetheless, such a trend was not observed in this study. Although dental injury due to cycling accidents was not uncommon in this study, this finding may be confounded by the fact that New Territories East has one of the busiest cycling path networks in Hong Kong.2 The use of helmets offers little protection to the lower face and jaw.9 It has been suggested that modification of the helmet design to cover the lower face may be beneficial. There were few sports-related injuries observed in this study. This may be because high-risk contact sports, such as rugby and ice hockey,5 are not very popular among Hong Kong primary school children. Compulsory use of mouth guards in those who participate in such activities may also be a contributing factor. There was no case of trauma due to a road traffic accident; this may reflect the legal requirement in Hong Kong for all passengers to wear a car seatbelt.

In this study more boys than girls had dental luxation and avulsion injuries in accordance with the findings of most other studies.7 13 14 15 16 17 18 19 22 23 24 One probable reason for the gender difference is that boys take more risks and participate more in sports activities. Nonetheless this gender difference has narrowed in recent studies, possibly due to an increased interest in sports among girls, especially in western societies.5 11 21 In this study, a greater gender discrepancy in frequency of dental injury was observed in the older age-group, in accordance with the findings of Kania et al’s study of elementary school children in the US.24

Previous studies of dental trauma in children have shown that most injuries occur between the age of 6 and 12 years.7 16 17 18 The present study population comprised primary school children attending a regional school dental clinic. The age of most primary school children in Hong Kong falls within the range of 6 to 12 years, and so most of the dental injuries for this group of children could be registered in this study. The peak occurrence of injury was seen in 9-year-olds, again in agreement with previous studies where the highest frequency of trauma to permanent dentition was observed in 9- to 10-year-olds.12 19 Nonetheless in studies from New Zealand21 and Iraq,14 the highest frequency of dental injury occurred in 5- to 7-year-olds. Glendor et al9 observed a marked increase in the incidence of dental injury in boys aged 8 to 10 years, with the incidence rather stable in girls. The same trend was also seen in this study. This may reflect the more vigorous play characteristics of boys in this age-group than girls.9

The majority of dental injuries involve the anterior teeth, especially the maxillary central incisors. The maxillary lateral and mandibular incisors are affected less frequently.5 9 Similar findings were also observed in the present study. The more prominent position of the maxillary central incisors makes them more vulnerable to injury. In addition, Kania et al24 opined that maxillary incisors are more prone to injury than their mandibular counterparts because of the mandible’s non-rigid connection to the cranial base. Most of the children in this study experienced trauma to only one tooth. This concurs with the findings from previous studies of dental injury in children.9 11 14 23 24 Noori and Al-Obaidi14 opined that when one tooth is traumatised, the majority of the force is dispersed and so no more teeth will be injured.14 It has been suggested that multiple tooth injuries are seen more often in more serious accidents such as motor vehicle accidents and violence.8 9 24 Concussion and subluxation together accounted for 85% of the cases in this study, in accordance with the findings of most previous studies on luxation and avulsion injuries in children.7 16 17 19 21 As the force and direction of impact determines the resultant type of injury, the findings from this study seem to suggest that most periodontal tissue injuries in Hong Kong primary school children are caused by more trivial incidents.9 Increased overjet and consequent incompetent lip closure is a significant risk factor to traumatic dental injury.7 9 13 14 15 22 23 24 In a study conducted in Iraq, 70% of children who had a dental injury had increased overjet.14 In many other studies, most children who sustained a dental injury had normal overjet, yet the percentage of children with increased overjet was significantly higher in children with dental trauma than in the general population.7 9 13 22 23 24 Similar findings were also observed in the present study. The more prominent tooth position and the lack of a cushioning effect from the upper lip in Class II malocclusion make the maxillary incisors more prone to injury.14

In many previous studies, the predominant place of injury occurrence in school-aged children was home, followed by school and other public places.9 13 21 22 In the present study, most injuries occurred at school. The second and third most common places of occurrence were home and cycling paths, respectively. This finding was in agreement with the population bodily injury survey of children aged 14 years or below in Hong Kong.1 One probable reason is that school children in Hong Kong have relatively more play-time at school than at home. In this study, 40% of children with a traumatic dental injury also suffered soft tissue injury in the orofacial region. This percentage was of similar magnitude to another study that involved a large proportion of children with dental luxation and avulsion injuries,17 but higher than a study with a high proportion of minor dental trauma such as simple fracture.12 This discrepancy may be because incidents that resulted in dental luxation or avulsion were usually more severe and could lead to more soft tissue damage.

One of the limitations of this study is its retrospective design. It is, however, extremely difficult to perform prospective trauma studies on a population basis.25 ‘Grab’ sampling was employed in this retrospective study, ie all patients treated in one clinic for dental luxation and/or avulsion injury were used in the sample. The conclusions from this study may therefore not be applicable to other parts of Hong Kong. To avoid inter-examiner error, all the records were reviewed by the most senior paediatric dentist in the clinic. The use of a standardised trauma form helps improve the accuracy of data collected during treatment.25 With the aid of a standardised form, the cause of dental injury was recorded in all but one case, and the place of trauma in all but three. This illustrates the importance of a standardised registry of dental traumatology.

This is the first epidemiological study of traumatic dental injury in children resident in Hong Kong and our data provide an important baseline for future comparison. Very often, school teachers are often the first to deal with an acute dental injury and it may be beneficial to educate them about the emergency care of children with dental trauma. For example, with avulsion injuries, where immediate management is critical for optimal healing, the teachers should be taught how to replant the tooth on site. If that could not be done, they should know how to store the avulsed tooth in an appropriate medium to prevent damage to the periodontal tissue. The effects of various factors on healing will be investigated and reported in a subsequent paper.

Dental traumas have social and economic impacts with regard to the treatment required but it is difficult to prevent dental injuries that are not sports-related.6 21 One option is to improve environmental factors to prevent falling at school and at home. Environmental and behavioural factors, however, were not included in this study so it is difficult to make conclusive suggestions in this regard. Further studies are warranted.

The causes and types of dental luxation and avulsion injuries in this group of Hong Kong children were similar to those of other studies, except that more injuries happened at school than at home. Most dental luxation and avulsion injuries in Hong Kong primary school children were caused by fall. Boys were more commonly affected than girls, and Class II incisor relationship was a significant risk factor. Motor vehicle accident or fight was not a common risk factor for dental injury in children. As most of the injuries occurred at school, it may be beneficial to educate primary school teachers about the emergency care of children with dental trauma.

The author thanks Dr Denise Fung for her statistical advice in this study.

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