End of Life Experience of Symptom Cluster and Their Management in Hong Kong Chinese Patients with Lung Cancer Who Receive Palliative Radiotherapy

Breathlessness, fatigue, and anxiety are distressing symptoms for patients with advanced lung cancer, however, they are not relieved by palliative RT and are often viewed as neglected areas of clinical practice. This paper aims to review def initions of, and explore patients' experiences of, breathlessness, fatigue, and anxiety. Further, it will outline existing approaches, both pharmacological and non-pharmacological, to treat them. Current treatments and perceptions of these symptoms will be discussed in the context of Hong Kong health care service. The review of literature also shows that breathlessness, fatigue and anxiety appears to have similar emotional origins. A contemporary approach of using a common pyschoeducational intervention to treat these symptoms together as a cluster in end of life care will be discussed.

Developing an Evidence-Based Exercise Guideline on Improving Shoulder Motion and Lessening the Severity of Lymphedema for Breast Cancer Patients after Axillary Lymph-Node Dissection

Exercise is proven to be effective, safe and the preferred intervention for improving the range of shoulder motion of breast cancer patients who have undergone surgery for axillary lymph-node dissection. The application of evidence-based guidelines to clinical practice can help healthcare professionals to provide good quality care to patients and, in turn, produce better patient outcomes. The purpose of the present paper is to describe the development process of an evidenced-based guideline. Challenges in the implementation of evidence-based practice are identi.ed and strategies for tackling them discussed.

Self-care among older Chinese people with chronic heart failure： the roles of cognitive and psychosocial characteristics

Chronic heart failure （CHF） is a complex clinical syndrome resulting from inefficient myocardial pumping, and is characterised by a typical progressively deteriorating trajectory punctuated by serious episodes of acute disease decompensation.High prevalence of hospital admission has been reported.[2] However, around 40% of hospital admissions was avoidable if patients demonstrate consistent self-care.

Overview of the Shenzhen Emergency Medical Service Call Pattern

BACKGROUND：In Shenzhen, the Emergency Medical Service （EMS） system has been in service since 1997. This study aims to examine the operation of Shenzhen 120 EMS center and to identify the reasons of calling EMS.BACKGROUND：In this retrospective quantitative descriptive study, the data from the Shenzhen 120 EMS registry in 2011 were analyzed.RESULTS：Shenzhen 120 EMS center is a communication command center. When the number of 120 are dialed, it is forwarded to the closest appropriate hospital for ambulance dispatch. In 2011, the Shenzhen 120 EMS center received 153 160 ambulance calls, with an average of 420 calls per day. Calling emergency services was mainly due to traffic accidents. Trauma and other acute diseases constituted a majority of ambulance transports. The adult patients aged 15-60 years are the principal users of EMS. There are no recognized ＇paramedic＇ doctors and nurses. The pre-hospital emergency service is under the operation of emergency departments of hospitals. Shenzhen at present does not have specialized pre-hospital training for doctors and nurses in posttrauma management. Moreover, specialized pre-hospital training, financial support, and public health education on proper use of EMS should be emphasized.CONCLUSION：The Shenzhen 120 EMS center has its own epidemiology characteristics. Traumatic injury and traffic accident are the main reasons for calling ambulance service. In-depth study emphasizing the distribution and characteristics of trauma patients is crucial to the future development of EMS.

Evolvement of left ventricular assist device： the implications on heart failure management

Heart failure （HF） is a potentially fatal disease that affects increasing number of people worldwide. Although heart transplant is the ＂gold standard＂ therapy for HF, due to the limited availability of organs, many patients died when waiting for the transplant. Left ventricular assist device （LVAD）, as a mechanical circulatory support, has become a new light for patients with HF. With the technical advancements, LVADs work not only as a bridge to transplant, but also assist heart recovery and even as a destination therapy in long-term treatment. This observation paper reviewed the development of LVAD and its clinical roles. The challenges and possible solutions in nursing care for pa- tients with LVAD at different stage of implantation were discussed. The healthcare professionals could obtain a better understanding about the LVAD treatment for HF patients.

Assessing Sexual Function amongst Hong Kong Chinese Patients with Gynecological Cancer： Translation and Validation of the Sexual Function-Vaginal Changes Questionnaire （SVQ）

OBJECTIVE The study aims to translate the Sexual FunctionVaginal Changes Questionnaire （SVQ） into Chinese and to establish its psychometric properties.METHODS A Chinese SVQ was developed by the use of the Brislin model of translation. The content validity and semantic equivalence were assessed by an expert panel. The translated version of SVQ was administered to 75 Hong Kong Chinese women who were suffered from gynecological cancer to test its psychometric properties.RESULTS The Chinese version of SVQ was compared to the original study for factor analysis. Internal consistency, itemtoscale correlations and test-retest reliability were high. The convergent and divergent validities supported the Chinese SVQ to CONCLUSION We conclude that the Chinese SVQ appears to be a valid, reliable and feasible disease-specific tool for the assessment of sexual function among Chinese patients.

The Impact of COVID-19 on the Mental-Emotional Wellbeing of Primary Healthcare Professionals: A Descriptive Correlational Study

The present study aimed to examine work environment related factors and frontline primary healthcare profes-sionals’mental-emotional wellbeing during the COVID-19 pandemic in school communities of Hong Kong.A total of 61(20%)school health nurses(frontline primary healthcare professionals)participated in a cross-sec-tional online survey from March to June 2020.Outcomes of mental-emotional health were measured using the Mental Health Continuum-Short Form(14-item scale with three subscales related to emotional,social and psychological wellbeing);the Perceived Stress Scale(10-item scale with two subscales related to perceived help-lessness and lack of self-efficacy);and the Coping Orientation to Problems Experienced Inventory(Brief COPE),a 28-item inventory with two subscales related to adaptive and maladaptive strategies.Almost half(42.6%)of par-ticipants experienced mental health problems.Those employed in government subsidized schools had signifi-cantly lower scores in mental health wellbeing than those who worked in private schools.Factors relating to increased mental health problems included lack of emotional support,inadequate training relating to infection prevention and control measures,disengagement and self-blame.A variety of factors influencing school health nurses’social,emotional and psychological wellbeing in their work environment during the COVID-19 pandemic were also reported.The mental-emotional wellbeing of school nurses may relate to their subjective feeling of lone-liness as participants were the sole frontline primary healthcare professional working in the school community during the COVID-19 pandemic.Studyfindings provide relevant evidence for management teams to build a cul-ture of psychological and social support into workplace policies and procedures.Continuous staff development and adequate social support are important to promote the mental-emotional wellbeing of primary healthcare pro-fessionals in school communities as they play a significant role in safeguarding resources during pandemics.

Symptom clusters and quality of life among patients with advanced heart failure

Objectives To identify symptom clusters among patients with advanced heart failure （HF） and the independent relationships with their quality of life （QoL）. Methods This is the secondary data analysis of a cross-sectional study which interviewed 119 patients with advanced HF in the geriatric unit of a regional hospital in Hong Kong. The symptom profile and QoL were assessed by using the Edmonton Symptom Assessment Scale （ESAS） and the McGill QoL Questionnaire. Exploratory factor analysis was used to identify the symptom clusters. Hier- archical regression analysis was used to examine the independent relationships with their QoL, after adjusting the effects of age, gender, and comorbidities. Results The patients were at an advanced age （82.9± 6.5 years）. Three distinct symptom clusters were identified： they were the distress cluster （including shortness of breath, anxiety, and depression）, the decondition cluster （fatigue, drowsiness, nausea, and reduced appetite）, and the discomfort cluster （pain, and sense of generalized discomfort）. These three symptom clusters accounted for 63.25% of variance of the patients＇ symptom experience. The small to moderate correlations between these symptom clusters indicated that they were rather independent of one another. After adjusting the age, gender and comorbidities, the distress （β = -0.635, P 〈 0.001）, the decondition （β = -0.148, P = 0.01）, and the discomfort （β = -0.258, P 〈 0.001） symptom clusters independently predicted their QoL. Conclusions This study identified the distinctive symptom clusters among patients with advanced HF. The results shed light on the need to develop palliative care interventions for optimizing the symptom control for this life-limiting disease.

Quality of life and palliative care needs of elderly patients with advanced heart failure

Objective To examine the quality of life and palliative care needs of elderly patients with advanced heart failure （HF）. Methods This was a correlation descriptive study conducted at a 650-bed sub-acute hospital. Patients who were aged 65 or over, diagnosed with HF of New York Heart Association Class III or IV symptoms, and mentally sound were eligible to the study. The Edmonton Symptom Assessment Scale, the overall quality of life single item scale, and the McQill Quality of Life Questionnaire （MQoL）, were used for measurement. Multi- ple regression analysis was performed to determine factors for predicting quality of life. Results A convenience sample of 112 patients was recruited. Their age was 81.5 ± 8.5 years. The three most distressing symptoms reported by the patients were tiredness （5.96 ± 2.78）, drowsiness （5.47± 2.93）, and shortness of breath （5.34 ± 2.96）. Their mean overall quality of life single item scale score was 4.72 ± 2.06 out of 10. The mean MQoL physical subscale score was the lowest （4.20 ± 1.767）, whereas their mean psychological subscale was the highest （7.14 ±2.39）. However, in a multivariate analysis model, quality of life was significantly associated with existential wellbeing, physical wellbeing, psychological wellbeing and educational level. Conclusions The findings highlight that spiritual concerns are significant palliative care needs among elderly patients with advanced HF, in addition to symptom management. This is in line with the argument that palliative care that places great emphasis on holistic care should be integrated to the care of this group of patients.

Effects of a nurse-led heart failure clinic on hospital readmission and mortality in Hong Kong

Background Heart failure （HF） is a physically and socially debilitating disease that carries the burden of hospital re-admission and mortality. As an aging society, Hong Kong urgently needs to find ways to reduce the hospital readmission of HF patients. This study evaluates the effects of a nurse-led HF clinic on the hospital readmission and mortality rates among older HF patients in Hong Kong. Methods This study is a retrospective data analysis that compares HF patient in a nurse-led HF clinic in Hong Kong compared with HF patients who did not attend the clinic. The nurses of this clinic provide education on lifestyle modification and symptom monitoring, as well as titrate the medications and measure biochemical markers by following established protocols. This analysis used the socio-demographic and clinical data of HF patients who were aged 〉 65 years old and stayed in the clinic over a six-month period. Results The data of a total of 78 HF patients were included in this data analysis. The mean age of the patients was 77.38 ± 6.80 years. Approximately half of the HF patients were male （51.3%）, almost half were smokers （46.2%）, and the majority received 〈 six years of formal education. Most of the HF patients （87.2%） belonged to classes II and III of the New York Heart Association Functional Classification, with a mean ejection fraction of 47.15± 20.31 mL. The HF patients who attended the clinic （n = 38, 75.13 ± 5.89 years） were significantly younger than those who did not attend the clinic （n = 40, 79.53 ± 6.96 years） （P = 0.04）, and had lower recorded blood pressure. No other statistically significant difference existed between the socio-demographic and clinical characteristics of the two groups. The HF patients who did not attend the nurse-led HF clinic demonstrated a significantly higher risk of hospital readmission [odd ratio （OR）： 7.40; P 〈 0.01] than those who attended after adjusting for the effect of age and blood pressure. In addition, HF patients who attended the clinic had lower mortality （n = 4） than those who did not attend （n = 14）. However, such a difference did not reach statistical significance when the effects of age and blood pressure were adjusted. A signifi- cant reduction in systolic blood pressure IF （2, 94） = 3.39, P = 0.04] and diastolic blood pressure [F （2, 94） = 8.48, P 〈 0.01] was observed among the HF patients who attended the clinic during the six-month period. Conclusions The finding of this study suggests the important role of nurse-led HF clinics in reducing healthcare burden and improving patient outcomes among HF patients in Hong Kong.

Uptake of prostate cancer screening and associated factors among Chinese men aged 50 or more: a population-based survey

Objective: To investigate the uptake rate of prostate specific antigen(PSA) testing among Hong Kong Chinese males aged 50 or above, and identify factors associated with the likelihood of undergoing a PSA test.Methods: A population-based telephone survey was conducted in Hong Kong in 2007. The survey covered demographic information, perceived health status, use of complementary therapy, cancer screening behavior, perceived susceptibility to cancer and family history of cancer. Descriptive statistics, percentages and logistic regression analysis were used for data analysis.Results: A total of 1,002 men aged 50 or above took part in the study(response rate =67%), and the uptake rate of PSA testing was found to be 10%. Employment status, use of complementary therapy, perceiving regular visits to a doctor as good for health and the recommendations of health professionals were significant factors associated with PSA testing.Conclusion: The uptake rate of PSA testing in the study population was very low. Among all the factors identified, recommendations from health professionals had the strongest association with the uptake of PSA testing, and they should therefore take an active role in educating this population about cancer prevention and detection.

Needs assessment and expectations regarding evidence-based practice knowledge acquisition and training activities:A cross-sectional study of healthcare personnel in China

Objectives Evidence-based healthcare contributes to the improvement of healthcare quality and informs healthcare decision-making.The provision of timely high-quality evidence is always required to fulfil the ever-changing needs and expectations of healthcare personnel.This study aimed to assess the needs and expectations of healthcare personnel regarding evidence-based healthcare in China.Methods We conducted a cross-sectional online survey from December 8,2020 to January 15,2021 involving 901 participants across China.Healthcare providers,policy makers,researchers and educators,and full-time postgraduate medical and nursing students working/living in China were eligible to participate.A self-developed questionnaire was used.Results Participants generally agreed that health-related research evidence was beneficial.Evidence-based resources,such as Cochrane resources,were only known or used by about half of the respondents due to difficulties related to availability and accessibility.Various types of resources,topics of evidence,and themes of workshops were of particular interest to most of the participants.Conclusions The dissemination and translation of evidence,provision of more support in evidence availability,offering evidence-based training,and determining the most in-demand research areas have been identified as priority areas of work which could fulfil the needs and expectations of healthcare personnel in China.

Supportive care needs and health-related quality of life among Chinese lung cancer survivors

Purpose: The purpose of this study was to explore the supportive care needs and health-related quality of life (HRQoL) of lung cancer survivors, and to identify the association between patient characteristics, HRQoL and supportive care needs. Method: This was a sub-study of a larger scale survey of cancer survivors’ supportive care needs. A total of 48 lung cancer survivors were recruited from a regional teaching hospital, and a three-part structured questionnaire was used to collect 1) socio-demographic and clinical characteristics, 2) supportive care needs and 3) health-related quality of life data. Results: The three most commonly reported unmet needs were all in the health-system information domain: 1) being informed about your results as soon as possible (58%), 2) being informed about cancer which is under control or diminishing (50%), and 3) being informed about things you can do to help yourself get well (46%). The second most common unmet need domain was access to healthcare and ancillary support services. The survivors generally reported satisfactory HRQoL. However, household income and unmet physical and psychological needs were independently associated with HRQoL among these survivors. Conclusion: The high unmet needs in the health-system information area call for a review of the content and amount of information provided to lung cancer survivors. In addition, more attention should be given to lung cancer survivors with low incomes but high physical and psychological unmet needs, who require appropriate follow-up and long-term care of a physical, social and psychological kind.

A Scientometric Analysis and Critical Review of Internet Gaming Disorder Behaviours

There are increasing concerns about internet gaming disorder (IGD). No review of existing studies has systematicallyanalyzed and visualized the trends of IGD and those early identification of symptoms related to IGD behaviors.This critical review focuses on the emerging trends for early identification of symptoms related to IGDbehaviors in papers published in Web of Science Core Collection from 2009 to 2021 by scientometric analysisand critical review. Scientometric data analysis technique includes co-occurrence analysis, cluster analysis andburst analysis of authors, countries, keywords and co-citation to visualize those contributing and associated factorsto develop IGD behaviors and their relationships to mental-emotional symptoms. About 81.8% of the paperswere published in the following countries: United States, United Kingdom, Australia, China and South Korea. Thetop co-occurrence keywords were ‘children’, ‘depression’, ‘anxiety’ and ‘attention deficit hyperactivity disorder(ADHD)’, ‘scale’, identifying the population, characteristics and commonly used assessment tools that are susceptibleto certain symptoms relating to IGD of which influencing factors facilitate the understanding of the associationof sociodemographic characteristics. The main emerging topics were identified in this critical review afterconducted the scientometric analysis. The results identified five topics: game impulse, motivation, evaluationscale, mediating effects and diagnostic criteria. This study provides an overview of the research trends on theidentity and development of the IGD field of study.

Promoting International Students’Mental Health Unmet Needs:An Integrative Review

Background:There are increasing concerns about the mental health needs of international students.Previous studies report that international students experience additional challenges and higher levels of stress compared to domestic students.This integrative review aimed to identify perceived stressors,coping strategies and factors that contributed to accessing mental health services of international students.Methods:A systematic search was performed between January 2010 and December 2023 using PubMed,CINAHL,ProQuest,the Cochrane Library,Scopus and PsycINFO databases.A manual search was also performed that included reference lists of included articles;data was extracted and reviewed by three reviewers.A total of 21 studies were included in this review with a total of 4442 international students recruited,with ages between 17 to 43 years.Nineteen studies reported international students’gender,there were more females(n=2205)than males(n=1022).Ethnicity was reported in 18 studies.They included Asia,Europe,Latin America,North America,South America,Africa,the Middle East and Pacific Islands.This review adopted Whittemore and Knafl’s five-stage approach,with specific steps for problem identification,literature search,data evaluation,data analysis,and presentation.Results:The Health Belief Model was used to explain relationships among independent and dependent variables and guide the findings of this review.Three identified progressive themes emerged including Theme 1:understanding cultural variations with perceived stress;Theme 2:coping strategies in dealing with stress and challenges in the new environment;and Theme 3:perceived threats and stress affecting how international students perceived barriers and benefits to access counselling support services and mental health services.This integrative review presents an overview of mental health needs and factors contributing to the mental health and well-being of international students via the inclusion of studies with different designs,providing an in-depth understanding of the study phenomenon.The findings of this review may help university health providers,mental health professionals,academic institutions and policymakers better understand the multifaceted needs of international students.Conclusion:This review demonstrates the importance of increased cross-cultural interactions between international students and domestic student counterparts to enhance belongingness and connection to host countries.This may facilitate adaptation to new living and learning environments.It is crucial academic institutions offer programs that can be effectively implemented and sustained to meet the unmet mental health needs of international students.University orientation programs,student counselling and health services may integrate cultural events,social support groups,leadership programs and resilience models of acculturation to promote mental health and well-being among international students.While these studies show promising results,there is a need for further robust evaluative studies to develop culturally sensitive mental health promotion programs for international students.

Type D personality negatively associated with self-care in Chinese heart failure patients

Background Little is known about the association between type D personality and self-care behaviors in heart failure （HF） patients. We examined the effect of type D personality on self-care behaviors and self-efficacy among Chinese HF patients. Methods A cross-sectional study with a convenience sample was conducted. All participants completed the questionnaires of the self-care of HF index （V6） and type D personality scale. Demographic and clinical variables were obtained from medical records and patient interviews. The me- thods used for data analysis included descriptive analysis, independent-sample t-test, Z2 test, and multiple linear regression. Results A total of 127 HF patients were included and 61.4% of them were male. The average age for this study sample was 64.9± 12.34 years. The majority of the participants were in a New York Heart Association class III or IV （87%）, and the average length of living with HF was 38.24 ± 41.1 months. A total of 33.1% of the participants were identified as having type D personality. No significant differences were determined in the demographic and clinical variables between type D and non-type D patients, except for the mean age and the length of living with HF. Type D patients were younger and had a shorter time of living with HF than their non-type D counterparts. Multiple regression demonstrated significant associations between type D personality and self-care maintenance and self-efficacy after adjusting the demographic and clinical factors. However, type D personality was not significantly associated with self-care management behaviors. Conclusions Type D personality was negatively related to self-care maintenance and self-efficacy in Chinese HF patients. Future study is warranted to develop a tailored intervention to improve engagement in self-care behaviors in HF patients with type D personality.

Association between interleukin-21 gene rs907715 polymorphism and gastric precancerous lesions in a Chinese population

BACKGROUND The single nucleotide polymorphisms of interleukin-21(IL-21)gene were confirmed to be related to various diseases,but no studies have examined the possible role of IL-21 single nucleotide polymorphisms(SNPs)(rs907715,rs2221903,and rs12508721)in gastric precancerous lesions.AIM To explore the associations between SNPs of IL-21 gene(rs907715,rs2221903,and rs12508721)and gastric precancerous lesions in a Chinese population.METHODS Three SNPs of IL-21 were genotyped using polymerase chain reaction–ligase detection reaction in 588 cases and 290 healthy controls from May 2013 to December 2016 in northwestern China.Gastric precancerous lesions were confirmed by endoscopic examination and categorized as non-atrophic gastritis,atrophic gastritis,and intestinal metaplasia.Descriptive statistic and logistic regression were used for data analyses.RESULTS IL-21 rs907715 genotype CC and C frequencies were higher in in patients with gastric precancerous lesions than in the controls(OR=1.59,95%CI:1.06-2.38,P=0.013;OR=1.28,95%CI:1.01-2.22,P=0.044,respectively)after adjusting for confounding factors.For SNP rs907715 in intestinal metaplasia patients,significant differences between cases and controls were observed in the frequencies of genotype CC and C(OR=1.92,95%CI:1.24-2.98,P=0.004;OR=1.53,95%CI:1.04-2.24,P=0.028,respectively);for non-atrophic gastritis and atrophic gastritis patients,the CC and C genotypes showed no significant association with risk in all models.No association between either rs2221903 or rs12508721 and gastric precancerous lesions was found in the present study.In the haplotype analysis,the TC haplotype(rs907715 and rs12508721)and TT haplotype(rs2221903 and rs907715)were more frequent in the case group than control group(P<0.05).CONCLUSION Our findings indicate that SNP rs907715 of IL-21 gene is associated with gastric precancerous lesions.The TC haplotype(rs907715 and rs12508721)and TT haplotype(rs2221903 and rs907715)increased the risk of gastric precancerous lesions.If confirmed,these findings will shed light on the etiology of precancerous lesions.

座椅辅助阻力带运动对老年人身体功能、睡眠质量和抑郁的影响:系统评价

目的系统评价座椅辅助阻力带运动(chair-based resistance band exercise,CRBE)对长期护理机构老年人身体功能、睡眠质量和抑郁的影响。方法对AgeLine,CINAHL,PubMed,Embase,Cochrane Library,Scopus和Web of Science等数据库进行检索。检索时间为建库至2022年3月,纳入对慢性疾病老年人进行CRBE的随机对照试验研究。采用物理治疗证据数据库量表(the Physiotherapy Evidence Database,PEDro)对纳入文献进行质量评价,随机效应模型和固定效应模型用于生成集合效应量。结果共9篇文章符合纳入标准。结果显示,CRBE可促进日常生活活动(6项研究;SMD=0.30,P=0.001),肺活量(3项研究;MD=40.35,P<0.001),握力(5项研究;MD=2.17,P<0.001),上肢肌肉耐力(5项研究;MD=2.23,P=0.012),下肢肌肉耐力(4项研究;MD=1.32,P<0.001),上肢柔韧性(4项研究;MD=3.06,P=0.022),下体柔韧性(4项研究;MD=5.34,P<0.001),动态平衡(3项研究;MD=-0.35,P=0.011)、睡眠质量(2项研究;MD=-1.71,P<0.001),并减轻抑郁状况(2项研究;SMD=-0.33,P=0.035)。结论证据表明CRBE改善了长期慢性疾病老年人的身体功能参数、睡眠质量,并减轻抑郁状况。这项研究可用以敦促长期护理机构让行动不便的老年人参与体育活动。

Brassiere wearing and breast cancer risk:A systematic review and meta-analysis

AIM： To evaluate existing evidence for the association between different type of brassiere exposures and the risk of breast cancer.METHODS： Ovid Medline, CINAHL, Cochrane Data Base of Systematic Reviews, Pubmed, Scopus, Proquest, Sciencedirect, Wiley Online Library, WanFang Data, Hong Kong Index to Chinese Periodicals, China Journal Net, Chinese Medical Current Contents, Chinese Biomedical Literature Database, China Academic Journals Full-Text database, Taiwan Electronic Periodical Services and HyRead; reference lists of published studies; origi-nal research studies published in English or Chinese examining the association between type and duration of brassiere-wearing and breast cancer risk. Data were abstracted by a frst reviewer and verifed by a second. Study quality was rated according to predefned criteria. “Fair” or “good” quality studies were included. Results were summarised by meta-analysis whenever adequate material was available.RESULTS： Twelve case-control studies were included in the review. Meta-analysis showed brassiere wearing during sleep was associated with a two times ofincreased odds. CONCLUSION： The present review demonstrates insuffcient evidence to establish a positive association between the duration and type of brassiere wearing and breast cancer. Further research is essential; specifcally, a large-scale epidemiological study of a better design is needed to examine the association between various forms of brassiere exposure in detail and breast cancer risk, with adequate control of confounding variables.