Changes in Emergency Department Visits, Diagnostic Groups, and 28-Day Mortality Associated With the COVID-19 Pandemic: A Territory-Wide, Retrospective, Cohort Study

Association between stringency of lockdown measures and emergency department visits during the COVID-19 pandemic: A Dutch multicentre study

INTRODUCTION

The COVID-19 outbreak disrupted regular health care, including the Emergency Department (ED), and resulted in insufficient ICU capacity. Lockdown measures were taken to prevent disease spread and hospital overcrowding. Little is known about the relationship of stringency of lockdown measures on ED utilization.

OBJECTIVE

This study aimed to compare the frequency and characteristics of ED visits during the COVID-19 outbreak in 2020 to 2019, and their relation to stringency of lockdown measures.

MATERIAL AND METHODS

A retrospective multicentre study among five Dutch hospitals was performed. The primary outcome was the absolute number of ED visits (year 2018 and 2019 compared to 2020). Secondary outcomes were age, sex, triage category, way of transportation, referral, disposition, and treating medical specialty. The relation between stringency of lockdown measures, measured with the Oxford Stringency Index (OSI) and number and characteristics of ED visits was analysed.

RESULTS

The total number of ED visits in the five hospitals in 2019 was 165,894, whereas the total number of visits in 2020 was 135,762, which was a decrease of 18.2% (range per hospital: 10.5%-30.7%). The reduction in ED visits was greater during periods of high stringency lockdown measures, as indicated by OSI.

CONCLUSION

The number of ED visits in the Netherlands has significantly dropped during the first year of the COVID-19 pandemic, with a clear association between decreasing ED visits and increasing lockdown measures. The OSI could be used as an indicator in the management of ED visits during a future pandemic.

Health care utilization and mortality for people with epilepsy during COVID-19: A population study

OBJECTIVE

This study was undertaken to characterize changes in health care utilization and mortality for people with epilepsy (PWE) during the COVID-19 pandemic.

METHODS

We performed a retrospective study using linked, individual-level, population-scale anonymized health data from the Secure Anonymised Information Linkage databank. We identified PWE living in Wales during the study "pandemic period" (January 1, 2020-June 30, 2021) and during a "prepandemic" period (January 1, 2016-December 31, 2019). We compared prepandemic health care utilization, status epilepticus, and mortality rates with corresponding pandemic rates for PWE and people without epilepsy (PWOE). We performed subgroup analyses on children (<18 years old), older people (>65 years old), those with intellectual disability, and those living in the most deprived areas. We used Poisson models to calculate adjusted rate ratios (RRs).

RESULTS

We identified 27 279 PWE who had significantly higher rates of hospital (50.3 visits/1000 patient months), emergency department (55.7), and outpatient attendance (172.4) when compared to PWOE (corresponding figures: 25.7, 25.2, and 87.0) in the prepandemic period. Hospital and epilepsy-related hospital admissions, and emergency department and outpatient attendances all reduced significantly for PWE (and all subgroups) during the pandemic period. RRs [95% confidence intervals (CIs)] for pandemic versus prepandemic periods were .70 [.69-.72], .77 [.73-.81], .78 [.77-.79], and .80 [.79-.81]. The corresponding rates also reduced for PWOE. New epilepsy diagnosis rates decreased during the pandemic compared with the prepandemic period (2.3/100 000/month cf. 3.1/100 000/month, RR = .73, 95% CI = .68-.78). Both all-cause deaths and deaths with epilepsy recorded on the death certificate increased for PWE during the pandemic (RR = 1.07, 95% CI = .997-1.145 and RR = 2.44, 95% CI = 2.12-2.81). When removing COVID deaths, RRs were .88 (95% CI = .81-.95) and 1.29 (95% CI = 1.08-1.53). Status epilepticus rates did not change significantly during the pandemic (RR = .95, 95% CI = .78-1.15).

SIGNIFICANCE

All-cause non-COVID deaths did not increase but non-COVID deaths associated with epilepsy did increase for PWE during the COVID-19 pandemic. The longer term effects of the decrease in new epilepsy diagnoses and health care utilization and increase in deaths associated with epilepsy need further research.

The Effect of the COVID-19 Pandemic on Non-COVID-19 Deaths: Population-Wide Retrospective Cohort Study

BACKGROUND

Health care avoidance in the COVID-19 pandemic has been widely reported. Yet few studies have investigated the dynamics of hospital avoidance behavior during pandemic waves and inferred its impact on excess non-COVID-19 deaths.

OBJECTIVE

This study aimed to measure the impact of hospital avoidance on excess non-COVID-19 deaths in public hospitals in Hong Kong.

METHODS

This was a retrospective cohort study involving 11,966,786 patients examined between January 1, 2016, and December 31, 2021, in Hong Kong. All data were linked to service, treatment, and outcomes. To estimate excess mortality, the 2-stage least squares method was used with daily tallies of emergency department (ED) visits and 28-day mortality. Records for older people were categorized by long-term care (LTC) home status, and comorbidities were used to explain the demographic and clinical attributes of excess 28-day mortality. The primary outcome was actual excess death in 2020 and 2021. The 2-stage least squares method was used to estimate the daily excess 28-day mortality by daily reduced visits.

RESULTS

Compared with the prepandemic (2016-2019) average, there was a reduction in total ED visits in 2020 of 25.4% (548,116/2,142,609). During the same period, the 28-day mortality of non-COVID-19 ED deaths increased by 7.82% (2689/34,370) compared with 2016-2019. The actual excess deaths in 2020 and 2021 were 3143 and 4013, respectively. The estimated total excess non-COVID-19 28-day deaths among older people in 2020 to 2021 were 1958 (95% CI 1100-2820; no time lag). Deaths on arrival (DOAs) or deaths before arrival (DBAs) increased by 33.6% (1457/4336) in 2020, while non-DOA/DBAs increased only by a moderate 4.97% (1202/24,204). In both types of deaths, the increases were higher during wave periods than in nonwave periods. Moreover, non-LTC patients saw a greater reduction in ED visits than LTC patients across all waves, by more than 10% (non-LTC: 93,896/363,879, 25.8%; LTC: 7,956/67,090, 11.9%). Most of the comorbidity subsets demonstrated an annualized reduction in visits in 2020. Renal diseases and severe liver diseases saw notable increases in deaths.

CONCLUSIONS

We demonstrated a statistical method to estimate hospital avoidance behavior during a pandemic and quantified the consequent excess 28-day mortality with a focus on older people, who had high frequencies of ED visits and deaths. This study serves as an informed alert and possible investigational guideline for health care professionals for hospital avoidance behavior and its consequences.

Effects of socioeconomic status and greenspace on respiratory emergency department visits under short-term temperature variations: An age-stratified case time-series study

INTRODUCTION

Neighborhood socioeconomic status (SES) and greenspace can affect respiratory health. However, it is unclear whether effects of neighborhood SES and greenspace on respiratory health still exist regardless of temperature variations.

METHODS

This paper conducted a two-stage, age-stratified case time-series study. The first goal is to examine the associations between two temperature metrics (daily mean temperature [DMT] and diurnal temperature range [DTR]) and respiratory emergency department (ED) visits among four age groups in New York City. The second goal is to evaluate whether neighborhood SES and greenspace would be determinants of respiratory ED visits independent from temperature varying factors. A distributed lag nonlinear model was applied on ED data from 135 zip codes (October 2016 - February 2020).

RESULTS

Our first-stage analysis indicated that older adults aged 65+ had higher risk of ED visits (RR=2.78, 95% eCI: 2.41, 3.22; with 7 days of lag) on days with low DMT (-10°C), followed by adults aged 18-64 (RR=2.48, 95% eCI: 2.32, 2.65), children and youth aged 5-17 (RR=1.38, 95% eCI: 1.24, 1.53), and young children aged 0-4 (RR=1.04, 95% eCI: 0.96, 1.13). However, no excess respiratory ED visits were observed on days with high DMT (30°C). Higher DTR was associated with higher risk, with children and youth more susceptible when DTR was high (DTR 20°C; RR=5.70, 95% eCI: 3.42, 9.49; with 7 days of lag). The second-stage analysis indicated neighborhood SES and greenspace had significant associations with respiratory ED visits regardless of temperature variations. Specifically, Higher income and greenspace exposure were negatively associated with ED visits among all age groups.

CONCLUSIONS

Neighborhood SES and greenspace could affect respiratory morbidity regardless of weather conditions. Daily temperature variations accelerated the short-term risk among population subgroups under different weather conditions (e.g., higher risk of days with low DMT among older adults, higher risk of days with high DTR among children and youth aged 5-17), which could create co-effects with neighborhood SES and greenspace on respiratory health.

Demand for emergency services during the COVID-19 pandemic and disease burden: a case study in Portugal

Background

The COVID-19 pandemic brought changes in the pattern of care use. A significant increase in the volume of emergencies was expected. However, a significant decrease was observed worldwide.

Methods

An observational, analytical and cross-sectional study of all records of emergency episodes of patients aged 18 years or older admitted to the emergency services of the University of Porto Hospital Centre (2018-2022) were analysed.

Results

During the pandemic, a significant reduction in emergency episode admissions (up to 40% during lockdowns), an increase in pre-emergency services, and discharges from Infectious Diseases and Internal Medicine was observed. The discharges from General Practice and General Practice and Family Medicine were residual.

Conclusion

The lower use and type of use of emergency services during the COVID-19 pandemic had a negative impact on the disease burden. This could be prevented in future pandemics through the development of strategies to promote confidence in the use of health resources and establishing contingency plans for virtual assistance.

Evaluating the Patient Boarding during Omicron Surge in Hong Kong: Time Series Analysis

The fifth wave of COVID-19 outbreaks in Hong Kong (HK) from January to March 2022 has the highest confirmed cases and deaths compared with previous waves. Severe hospital boarding (to inpatient wards) was noted in various Emergency Departments (EDs). Our objective is to identify factors associated with hospital boarding during Omicron surge in HK. We conducted a retrospective cohort study including all ED visits and inpatient (IP) ward admissions from January 1st to March 31st, 2022. Vector Autoregression model evaluated the effects of a single variable on the targeted hospital boarding variables. Admissions from elderly homes with 6 lag days held the highest positive value of statistical significance (t-stat = 2.827, P < .05) caused prolonged admission waiting time, while medical patients with 4 lag days had the highest statistical significance (t-stat = 2.530, P < .05) caused an increased number of boarding patients. Within one week after impulses, medical occupancy's influence on the waiting time varied from 0.289 on the 1st day to -0.315 on the 7th day. While occupancy of medical wards always positively affected blocked number of patients, and its response was maximized at 0.309 on the 2nd day. Number of confirmed COVID-19 cases was not the sole significant contributor, while occupancy of medical wards was still a critical factor associated with patient boarding. Increasing ward capacity and controlling occupancy were suggested during the outbreak. Moreover, streamlining elderly patients in ED could be an approach to relieve pressure on the healthcare system.

Temporal trends in cardiovascular burden among patients with prostate cancer receiving androgen deprivation therapy: a population-based cohort study

BACKGROUND

Although androgen deprivation therapy (ADT) is associated with cardiovascular risks, the extent and temporal trends of cardiovascular burden amongst patients with prostate cancer receiving ADT are unclear.

METHODS

This retrospective cohort study analyzed adults with PCa receiving ADT between 1993-2021 in Hong Kong, with follow-up until 31/9/2021 for the primary outcome of major adverse cardiovascular events (MACE; composite of cardiovascular mortality, myocardial infarction, stroke, and heart failure), and the secondary outcome of mortality. Patients were stratified into four groups by the year of ADT initiation for comparisons.

RESULTS

Altogether, 13,537 patients were included (mean age 75.5 ± 8.5 years old; mean follow-up 4.7 ± 4.3 years). More recent recipients of ADT had more cardiovascular risk factors and used more cardiovascular or antidiabetic medications. More recent recipients of ADT had higher risk of MACE (most recent (2015-2021) vs least recent (1993-2000) group: hazard ratio 1.33 [1.11, 1.59], P = 0.002; Ptrend < 0.001), but lower risk of mortality (hazard ratio 0.76 [0.70, 0.83], P < 0.001; Ptrend < 0.001). The 5-year risk of MACE and mortality for the most recent group were 22.5% [20.9%, 24.2%] and 52.9% [51.3%, 54.6%], respectively.

CONCLUSIONS

Cardiovascular risk factors were increasingly prevalent amongst patients with prostate cancer receiving ADT, with increasing risk of MACE despite decreasing mortality.

Exposure-response relationship between COVID-19 incidence rate and incidence and survival of out-of-hospital cardiac arrest (OHCA)

Aim

We aimed to report the epidemiology of OHCA, bystander CPR pattern and other Utstein factors in a region in Hong Kong during the COVID-19 pandemic. In particular, we studied the relationship between COVID-19 incidence, OHCA incidence and survival outcome.

Methods

This was a retrospective cohort study that used data from our registry to compare features of OHCA during pre-pandemic (Jan 2018 to Dec 2019), low-incidence pandemic (Jan 2020 to Dec 2021) and high-incidence pandemic (Jan to Mar 2022). We used multivariable logistic regression to identify survival predictors.

Results

Incidence of OHCA increased dramatically with surging COVID-19 incidence (65.9 vs 74.2 vs 159.2 per 100,000 population per year, p < 0.001). During the pandemic, there were more indoor OHCA (89.3% vs 92.6% vs 97.4%, p < 0.001), fewer witnessed arrest (38.5% vs 38.3% vs 29.6%, p = 0.001), and longer median time to basic life support upon receiving call (9 min vs 10 min vs 14 min, p < 0.001). There was a higher proportion of OHCA cases with bystander-CPR (26.1% vs 31.3% vs 35.3%, p < 0.001). The proportion of cases with survival to admission (STA) (30.8% vs 22.2% vs 15.4%, p < 0.001) and survival to discharge (STD) (2.2% vs 1.0% vs 0.2%, p = 0.001) were lowered. After controlling for confounders, the odds of STA was reduced by 33% and 55% during the low-incidence and high-incidence pandemic respectively.

Conclusion

The increase in COVID-19 incidence had an exposure-response relationship with an increased incidence of OHCA and worsened survival outcomes.

Association of Molnupiravir and Nirmatrelvir-Ritonavir with reduced mortality and sepsis in hospitalized omicron patients: a territory-wide study

This study evaluates the association between antivirals (Molnupiravir and Nirmatrelvir-Ritonavir) and all-cause and respiratory mortality and organ dysfunction among high-risk COVID-19 patients during an Omicron outbreak. Two cohorts, Nirmatrelvir-Ritonavir versus control and Molnupiravir versus control, were constructed with inverse probability treatment weighting to balance baseline characteristics. Cox proportional hazards models evaluated the association of their use with all-cause mortality, respiratory mortality, and all-cause sepsis (a composite of circulatory shock, respiratory failure, acute liver injury, coagulopathy, and acute liver impairment). Patients recruited were hospitalized and diagnosed with the COVID-19 Omicron variant between February 22, 2022 and April 15, 2022, and followed up until May 15, 2022. The study included 17,704 patients. There were 4.67 and 22.7 total mortalities per 1000 person-days in the Nirmatrelvir-Ritonavir and control groups respectively before adjustment (weighted incidence rate ratio, - 18.1 [95% CI - 23.0 to - 13.2]; hazard ratio, 0.18 [95% CI, 0.11-0.29]). There were 6.64 and 25.9 total mortalities per 1000 person-days in the Molnupiravir and control groups respectively before adjustment (weighted incidence rate ratio per 1000 person-days, - 19.3 [95% CI - 22.6 to - 15.9]; hazard ratio, 0.23 [95% CI 0.18-0.30]). In all-cause sepsis, there were 13.7 and 35.4 organ dysfunction events per 1000 person-days in the Nirmatrelvir-Ritonavir and control groups respectively before adjustment (weighted incidence rate ratio per 1000 person-days, - 21.7 [95% CI - 26.3 to - 17.1]; hazard ratio, 0.44 [95% CI 0.38-0.52]). There were 23.7 and 40.8 organ dysfunction events in the Molnupiravir and control groups respectively before adjustment (weighted incidence ratio per 1000 person-days, - 17.1 [95% CI, - 20.6 to - 13.6]; hazard ratio, 0.63 [95% CI 0.58-0.69]). Among COVID-19 hospitalized patients, use of either Nirmatrelvir-Ritonavir or Molnupiravir compared with no antiviral use was associated with a significantly lower incidence of 28-days all-cause and respiratory mortality and sepsis.

Long-term prognostic impact of cardiovascular comorbidities in patients with prostate cancer receiving androgen deprivation therapy: A population-based competing risk analysis

Our study investigated how adverse cardiovascular outcomes are impacted by cardiovascular comorbidities in patients with prostate cancer treated by androgen deprivation therapy (ADT). Using prospective, population-based data, all Hong Kong patients with prostate cancer who received ADT during 1 January 1993 to 3 March 2021 were identified and followed up for the endpoint of cardiovascular hospitalization/mortality until 31 September 2021, whichever earlier. Multivariable competing risk regression was used to compare the endpoint's cumulative incidence between different combinations of major cardiovascular comorbidities (heart failure [HF], myocardial infarction [MI], stroke and/or arrhythmia), with noncardiovascular death as competing event. Altogether, 13 537 patients were included (median age 75.9 [interquartile range 70.0-81.5] years old; median follow-up 3.3 [1.5-6.7] years). Compared to those with none of prior HF/MI/stroke/arrhythmia, the incidence of the endpoint was not different in those with only stroke (subhazard ratio [SHR] 1.06 [95% confidence interval (CI): 0.92-1.23], P = .391), but was higher in those with only HF (SHR 1.67 [1.37-2.02], P < .001), arrhythmia (SHR 1.63 [1.35-1.98], P < .001) or MI (SHR 1.43 [1.14-1.79], P = .002). Those with ≥2 of HF/MI/stroke/arrhythmia had the highest incidence of the endpoint (SHR 1.94 [1.62-2.33], P < .001), among whom different major cardiovascular comorbidities had similar prognostic impacts, with the number of comorbidities present being significantly prognostic instead. In conclusion, in patients with prostate cancer receiving ADT, the sole presence of HF, MI or arrhythmia, but not stroke, may be associated with elevated cardiovascular risks. In those with ≥2 of HF/MI/stroke/arrhythmia, the number of major cardiovascular comorbidities may be prognostically more important than the type of comorbidities.

Risk of diabetes mellitus among users of immune checkpoint inhibitors: A population-based cohort study

BACKGROUND

Immune checkpoint inhibitors (ICIs) are increasingly established cancer therapeutics, but they are associated with new-onset diabetes mellitus (DM). Such risks have not been adequately quantified, and between-class and -sex differences remain unexplored.

METHODS

This was a prospective cohort study of cancer patients receiving any ICI in Hong Kong between 2013 and 2021. Patients with known DM were excluded. Due to few patients using other ICIs, only programmed cell death 1 inhibitors (PD-1i) and programmed death ligand 1 inhibitors (PD-L1i) were compared, alongside between-sex comparison. When comparing PD-1i against PD-L1i, patients with the use of other ICIs or both PD-1i and PD-L1 were further excluded. Inverse probability treatment weighting (IPTW) was used to minimize between-group covariate imbalances.

RESULTS

Altogether, 3375 patients were analyzed (65.2% males, median age 62.2 [interquartile range 53.8-69.5] years old). Over a median follow-up of 1.0 [0.4-2.4] years, new-onset DM occurred in 457 patients (13.5%), with a 3-year risk of 14.5% [95% confidence interval 13.3%, 15.8%]. IPTW achieve acceptable covariate balance between sexes, and between PD-1i (N = 622) and PD-L1i (N = 2426) users. Males had significantly higher risk of new-onset DM (hazard ratio 1.35 [1.09, 1.67], p = 0.006), while PD-1i and PD-L1i users did not have significantly different risks (hazard ratio vs PD-L1i 0.81 [0.59, 1.11], p = 0.182). These were consistent in those with at least 1 year of follow-up, and on competing risk regression.

CONCLUSION

Users of ICI may have a substantial risk of new-onset DM, which may be higher in males but did not differ between PD-1i and PD-L1i.

HbA1c Variability and Cardiovascular Events in Patients with Prostate Cancer Receiving Androgen Deprivation Therapy

Background

Androgen deprivation therapy (ADT) worsens glycaemic control and cardiovascular outcomes. The prognostic value of visit-to-visit HbA1c variability (VVHV) has been unexplored in prostate cancer (PCa) patients receiving ADT.

Objective

To explore the effect of ADT on VVHV and the cardiovascular prognostic value of VVHV.

Design setting and participants

PCa patients receiving ADT in Hong Kong between January 1, 1993 and March 31, 2021 were included in this retrospective cohort study. Those with fewer than three HbA1c results available within 3 yr after ADT initiation, <6 mo of ADT, missing baseline HbA1c, prior diagnosis of any component of major adverse cardiovascular events (MACEs), and MACEs occurring within 3 yr were excluded. Patients were followed up until September 31, 2021.

Outcome measurements and statistical analysis

The outcome was MACEs (composite of heart failure, myocardial infarction, stroke, and cardiovascular mortality). VVHV was calculated from HbA1c levels within 3 yr after and, separately where available, before ADT initiation using coefficient of variation (CV; standard deviation [SD] divided by mean) and average real variability (ARV; average difference between consecutive measurements).

Results and limitations

Altogether, 1065 patients were analysed (median age 74.4 yr old [interquartile range 68.3-79.5 yr]). In 709 patients with VVHV available before and after ADT initiation, VVHV increased after ADT initiation (p < 0.001), with 473 (66.2%) and 474 (66.9%) having increased CV and ARV, respectively. Over a median follow-up of 4.3 yr (2.8-6.7 yr), higher VVHV was associated with a higher risk of MACEs (adjusted hazard ratio [per SD] for CV 1.21 [95% confidence interval: 1.02, 1.43], p = 0.029; ARV 1.25 [1.06, 1.48], p = 0.008). Limitations included residual confounding and selection bias.

Conclusions

In PCa patients receiving ADT, VVHV increased after ADT initiation. Higher VVHV was associated with an increased risk of MACEs.

Patient summary

In prostate cancer patients receiving androgen deprivation therapy (ADT), glycaemic control is less stable after initiating ADT, which was associated with an increased cardiovascular risk.

Predictive value of neutrophil-to-lymphocyte ratio for atrial fibrillation and stroke in type 2 diabetes mellitus: The Hong Kong Diabetes Study

INTRODUCTION

Neutrophil-to-lymphocyte ratio (NLR) is a routinely available biomarker that reflects systemic inflammation. The study evaluated the predictive value of NLR for ischemic stroke and atrial fibrillation (AF) in patients with type 2 diabetes mellitus.

METHODS

This was a population-based cohort study of patients with type 2 diabetes mellitus and complete blood count tests at baseline between 1 January 1st, 2009, and 31 December, 2009, at government-funded hospitals/clinics in Hong Kong. Follow-up was until 31 December, 2019, or death.

RESULTS

A total of 85,351 patients (age = 67.6 ± 13.2 years old, male = 48.8%, follow-up = 3101 ± 1441 days) were included. Univariable Cox regression found that increased NLR at quartiles 2, 3 and 4 was significantly associated with higher risks of new-onset ischemic stroke (hazard ratio [HR]: 1.28 [1.20-1.37], p < .001, HR: 1.41 [1.32-1.51], p < .001 and HR: 1.38 [1.29-1.47], p < .001) and AF (HR: 1.09 [1.02-1.17], p < .015; HR: 1.28 [1.20-1.37], p < .001; HR: 1.39 [1.31-1.49], p < .001) compared to quartile 1. On multivariable analysis, NLR remained a significant predictor of ischemic stroke risk for quartiles 2 and 3 (quartile 2: HR: 1.14 [1.05, 1.22], p = .001; quartile 3: HR: 1.14 [1.06, 1.23], p < .001) but not quartile 4 (HR: 1.08 [0.994, 1.17], p = .070). NLR was not predictive of AF after adjusting for confounders (quartile 2: HR: 0.966 [0.874, 1.07], p = .499; quartile 3: HR: 0.978 [0.884, 1.08], p = .661; quartile 4: HR: 1.05 [0.935, 1.16], p = .462).

CONCLUSION

NLR is a significant predictor of new-onset ischaemic stroke after adjusting for significant confounders in Chinese type 2 diabetes patients.

The Impact of Cardiac Comorbidity Sequence at Baseline and Mortality Risk in Type 2 Diabetes Mellitus: A Retrospective Population-Based Cohort Study

Introduction: The presence of multiple comorbidities increases the risk of all-cause mortality, but the effects of the comorbidity sequence before the baseline date on mortality remain unexplored. This study investigated the relationship between coronary heart disease (CHD), atrial fibrillation (AF) and heart failure (HF) through their sequence of development and the effect on all-cause mortality risk in type 2 diabetes mellitus. Methods: This study included patients with type 2 diabetes mellitus prescribed antidiabetic/cardiovascular medications in public hospitals of Hong Kong between 1 January 2009 and 31 December 2009, with follow-up until death or 31 December 2019. The Cox regression was used to identify comorbidity sequences predicting all-cause mortality in patients with different medication subgroups. Results: A total of 249,291 patients (age: 66.0 ± 12.4 years, 47.4% male) were included. At baseline, 7564, 10,900 and 25,589 patients had AF, HF and CHD, respectively. Over follow-up (3524 ± 1218 days), 85,870 patients died (mortality rate: 35.7 per 1000 person-years). Sulphonylurea users with CHD developing later and insulin users with CHD developing earlier in the disease course had lower mortality risks. Amongst insulin users with two of the three comorbidities, those with CHD with preceding AF (hazard ratio (HR): 3.06, 95% CI: [2.60−3.61], p < 0.001) or HF (HR: 3.84 [3.47−4.24], p < 0.001) had a higher mortality. In users of lipid-lowering agents with all three comorbidities, those with preceding AF had a higher risk of mortality (AF-CHD-HF: HR: 3.22, [2.24−4.61], p < 0.001; AF-HF-CHD: HR: 3.71, [2.66−5.16], p < 0.001). Conclusions: The sequence of comorbidity development affects the risk of all-cause mortality to varying degrees in diabetic patients on different antidiabetic/cardiovascular medications.

Global Excess Mortality during COVID-19 Pandemic: A Systematic Review and Meta-Analysis

Background: Currently, reported COVID-19 deaths are inadequate to assess the impact of the pandemic on global excess mortality. All-cause excess mortality is a WHO-recommended index for assessing the death burden of COVID-19. However, the global excess mortality assessed by this index remains unclear. We aimed to assess the global excess mortality during the COVID-19 pandemic. Methods: We searched PubMed, EMBASE, and Web of Science for studies published in English between 1 January 2020, and 21 May 2022. Cross-sectional and cohort studies that reported data about excess mortality during the pandemic were included. Two researchers independently searched the published studies, extracted data, and assessed quality. The Mantel–Haenszel random-effects method was adopted to estimate pooled risk difference (RD) and their 95% confidence intervals (CIs). Results: A total of 79 countries from twenty studies were included. During the COVID-19 pandemic, of 2,228,109,318 individuals, 17,974,051 all-cause deaths were reported, and 15,498,145 deaths were expected. The pooled global excess mortality was 104.84 (95% CI 85.56–124.13) per 100,000. South America had the highest pooled excess mortality [134.02 (95% CI: 68.24–199.80) per 100,000], while Oceania had the lowest [−32.15 (95% CI: −60.53–−3.77) per 100,000]. Developing countries had higher excess mortality [135.80 (95% CI: 107.83–163.76) per 100,000] than developed countries [68.08 (95% CI: 42.61–93.55) per 100,000]. Lower middle-income countries [133.45 (95% CI: 75.10–191.81) per 100,000] and upper-middle-income countries [149.88 (110.35–189.38) per 100,000] had higher excess mortality than high-income countries [75.54 (95% CI: 53.44–97.64) per 100,000]. Males had higher excess mortality [130.10 (95% CI: 94.15–166.05) per 100,000] than females [102.16 (95% CI: 85.76–118.56) per 100,000]. The population aged ≥ 60 years had the highest excess mortality [781.74 (95% CI: 626.24–937.24) per 100,000]. Conclusions: The pooled global excess mortality was 104.84 deaths per 100,000, and the number of reported all-cause deaths was higher than expected deaths during the global COVID-19 pandemic. In South America, developing and middle-income countries, male populations, and individuals aged ≥ 60 years had a heavier excess mortality burden.

Incidence of Emergency Department Visits for Sexual Abuse Among Youth in Hong Kong Before and During the COVID-19 Pandemic

This cohort study assesses the incidence of emergency department (ED) visits in Hong Kong, China, for sexual abuse among youth before and during the COVID-19 pandemic.

Comparison of outcomes in emergency department revisiting patients before and after coronavirus disease 2019 epidemic

BACKGROUND AND IMPORTANCE

The outbreak of COVID-19 challenged the global health system and specifically impacted the emergency departments (EDs). Studying the quality indicators of ED care under COVID-19 has been a necessary task, and ED revisits have been used as an indicator to monitor ED performance.

OBJECTIVES

The study investigated whether discrepancies existed among ED revisiting cases before and after COVID-19 and whether the COVID-19 epidemic was a predictor of poor outcomes of ED revisits.

DESIGN

Retrospective study.

SETTINGS AND PARTICIPANTS

We used electronic health records data from a tertiary medical center. Data of patients with 72-h ED revisit after the COVID-19 epidemic were collected from February 2020 to June 2020 and compared with those of patients before COVID-19, from February 2019 to June 2019.

OUTCOME MEASURES AND ANALYSIS

The investigated outcomes included hospital admission, ICU admission, out-of-hospital cardiac arrest, and subsequent inhospital mortality. Univariate and multivariate logistic regression models were used to identify independent predictors of 72-h ED revisit outcomes.

MAIN RESULTS

In total, 1786 patients were enrolled in our study - 765 in the COVID group and 1021 in the non-COVID group. Compared with the non-COVID group, patients in the COVID group were younger (53.9 vs. 56.1 years old; P = 0.002) and more often female (66.1% vs. 47.3%; P < 0.001) and had less escalation of triage level (11.6% vs. 15.0%; P = 0.041). The hospital admission and inhospital mortality rates in the COVID and non-COVID groups were 33.9% vs. 32.0% and 2.7% vs. 1.5%, respectively. In the logistic regression model, the COVID-19 period was significantly associated with inhospital mortality (adjusted odds ratio, 2.289; 95% confidence interval, 1.059-4.948; P = 0.035).

CONCLUSION

Patients with 72-h ED revisits showed distinct demographic and clinical patterns before and after the COVID-19 epidemic; the COVID-19 period was an independent predictor of increased inhospital mortality.

Hong Kong poison information centre: Annual report 2020

Background:

The Hong Kong Poison Information Centre has provided consultation service to healthcare professionals and collected epidemiological data on poisoning in Hong Kong since 2005.

Objective:

To analyse and report the poisoning data of Hong Kong Poison Information Centre in 2020 during the COVID-19 pandemic.

Methods:

A retrospective review of all poisoning cases recorded in the Poison Information and Clinical Management System of Hong Kong Poison Information Centre in 2020.

Results:

A total of 3633 poisoning cases were analysed. Compared to 2019 (pre-COVID era), there was a reduction of ~10% of total poisoning cases recorded (383 cases), with a majority (> 90%) of reduction from poisoning cases with no clinical effect (353 cases). A greater proportion of reduction was observed among the children (0–12 years), patients with general unintentional poisoning, poisoning due to therapeutic error and food poisoning. An increased number of cases was noted from abusive use, adverse herb/proprietary Chinese medicine reaction and poisoning related to household bleaches. Teenage (13–19 years) poisoning seemed to be unaffected by the COVID-19 pandemic and the previously observed increasing trend continued (up to 11.8% of total poisoning cases this year). Despite a total reduction in poisoning cases recorded, the number of deaths increased by 37% from 35 in 2019 to 48 in 2020 (mortality rate 1.5%). A total of seven interesting cases were discussed.

Conclusion:

This 15th annual report provides updated epidemiological information on poisoning patterns in Hong Kong during the COVID-19 pandemic. It also highlighted important changes and possible effects of the COVID-19 pandemic on poisoning in Hong Kong in comparison with our previous reports.

Association between visit-to-visit lipid variability and incident cancer: a population-based cohort study

Dyslipidaemia is associated with increased cancer risk. However, the prognostic value of visit-to-visit lipid variability (VVLV) is unexplored in this regard. To investigate the associations between VVLV and the risk of incident cancer, we conducted a retrospective cohort study on adult patients attending a family medicine clinic in Hong Kong during 2000-2003, excluding those with <3 tests for low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, and total cholesterol (TC) each, those with prior cancer diagnosis, and those with <1 year of follow-up. Visit-to-visit LDL-C, HDL-C, TC, and triglycerides variabilities were measured by the coefficient of variation (CV). Patients were followed up until 31^st December 2019 for the primary outcome of incident cancer. Altogether, 69,186 patients were included (26,679 males (38.6%); mean age 60±13 years; mean follow-up 16±3 years); 7958 patients (11.5%) had incident cancer. Higher variability of LDL-C, HDL-C, TC, and TG was associated with higher risk of incident cancer. Patients in the third tercile of the CV of LDL-C (adjusted hazard ratio (aHR) against first tercile 1.06 [1.00, 1.12], p=0.049), HDL-C (aHR 1.37 [1.29, 1.44], p<0.001), TC (aHR 1.10 [1.04, 1.17], p=0.001), and TG (aHR 1.11 [1.06, 1.18], p<0.001) had the highest risks of incident cancer. Among these, only HDL-C variability remained associated with the risk of incident cancer in users of statins/fibrates. To conclude, higher VVLV was associated with significantly higher long-term risks of incident cancer. VVLV may be a clinically useful tool for cancer risk stratification.

Cardiovascular outcomes and hospitalizations in Asian patients receiving immune checkpoint inhibitors: a population-based study

Immune checkpoint inhibitors (ICI) have known associations with cardiotoxicity. However, a representative quantification of the adverse cardiovascular events and cardiovascular attendances amongst Asian users of ICI has been lacking. This retrospective cohort study identified all ICI users in Hong Kong, China, between 2013-2021. All patients were followed up until the end of 2021 for the primary outcome of major adverse cardiovascular event (MACE; a composite of cardiovascular mortality, myocardial infarction, heart failure, and stroke). Patients with prior diagnosis of any component of MACE were excluded from all MACE analyses. In total, 4324 patients were analysed (2905 (67.2%) males; median age 63.5 years old (interquartile range 55.4-70.7 years old); median follow-up 1.0 year (interquartile range 0.4-2.3 years)), of whom 153 were excluded from MACE analyses due to prior events. MACE occurred in 116 (2.8%) with an incidence rate (IR) of 1.7 [95% confidence interval: 1.4, 2.0] events per 100 patient-years; IR was higher within the first year of follow-up (2.9 [2.3, 3.5] events per 100 patient-years). Cardiovascular hospitalization(s) occurred in 188 (4.4%) with 254 episodes (0.5% of all episodes) and 1555 days of hospitalization (1.3% of all hospitalized days), for whom the IR of cardiovascular hospitalization was 5.6 [4.6, 6.9] episodes per 100 person-years with 52.9 [39.8, 70.3] days' stay per 100 person-years. Amongst Asian users of ICI, MACE was uncommon, and a small proportion of hospitalizations was cardiovascular in nature. Most MACE and cardiovascular hospitalizations occurred during the first year after initiating ICI.

Surfing-Related Craniofacial Injuries: A NEISS Database Study

INTRODUCTION

Surfing is a popular pastime in coastal areas around the world with increasing numbers of participants. There is a lack of detailed data in the literature regarding surfing-related head and neck (HN) injuries.

MATERIALS AND METHODS

We queried the National Electronic Injury Surveillance System (NEISS) database to characterize patient demographics, injury types, injury subsite, and emergency department (ED) disposition status associated with surfing-related HN injuries between 2009 and 2020 in the United States.

RESULTS

A total of 54,978 estimated national cases were reported from 2009 to 2020. Injuries to the head (36.0%) and neck (35.8%) were most common. Young adults (ages 18-35) made up most ED visits, whereas older adults (>35) made up most (63.5%) admissions. Laceration (46.1%) was the most common injury among ED visits, whereas fracture (30.5%) and internal injury (29.2%) were most common in admitted patients. Concussions represented 7.5% of injuries overall, 9.1% of pediatric injuries, and 9.9% of young adult injuries.

CONCLUSIONS

When treating a patient who presents with injury suffered during surfing, a thorough examination of the HN should be performed. Specific attention should be given to evaluation of lacerations, fractures, internal ear injuries, and concussions. Pediatric and young adult patients are at increased risk of concussion. The majority of surfing injuries can be treated in an outpatient context.