Self-Administered Acupressure for Probable Knee Osteoarthritis in Middle-Aged and Older Adults: A Randomized Clinical Trial

Importance

The effects of self-administered acupressure (SAA) on knee osteoarthritis (OA) pain remain unclear.

Objective

To evaluate the effectiveness of SAA taught via a short training course on reducing knee OA pain in middle-aged and older adults.

Design, Setting, and Participants

This randomized clinical trial was conducted among community-dwelling individuals in Hong Kong who were aged 50 years or older with probable knee OA from September 2019 to May 2022.

Interventions

The intervention included 2 training sessions for SAA with a brief knee health education (KHE) session, in which participants practiced acupressure twice daily for 12 weeks. The control group (KHE only) received only education about maintaining knee health on the same schedule and duration.

Main Outcomes and Measures

The primary outcome was the numerical rating scale (NRS) pain score at 12 weeks. Other outcomes included Western Ontario and McMaster University Osteoarthritis Index, Short Form 6 Dimensions (SF-6D), Timed Up and Go, and Fast Gait Speed tests.

Results

A total of 314 participants (mean [SD] age, 62.7 [4.5] years; 246 [78.3%] female; mean [SD] knee pain duration, 7.3 [7.6] years) were randomized into intervention and KHE-only groups (each 157). At week 12, compared with the KHE-only group, the intervention group had a significantly greater reduction in NRS pain score (mean difference [MD], -0.54 points; 95% CI, -0.97 to -0.10 points; P = .02) and higher enhancement in SF-6D utility score (MD, 0.03 points; 95% CI, 0.003 to 0.01 points; P = .03) but did not have significant differences in other outcome measures. The cost-effectiveness acceptability curve demonstrated a greater than 90% probability that the intervention is cost-effective at a willingness to pay threshold of 1 GDP per capita.

Conclusions and Relevance

In this randomized clinical trial, SAA with a brief KHE program was efficacious and cost-effective in relieving knee pain and improving mobility in middle-aged and older adults with probable knee OA.

Trial Registration

ClinicalTrials.gov Identifier: NCT04191837.

Elevated risk of multimorbidity post-COVID-19 infection: protective effect of vaccination

BACKGROUND

It is unclear how the coronavirus disease 2019 (Covid-19) pandemic has affected multimorbidity incidence among those with one pre-existing chronic condition, as well as how vaccination could modify this association.

AIM

To examine the association of Covid-19 infection with multimorbidity incidence among people with one pre-existing chronic condition, including those with prior vaccination.

DESIGN

Nested case-control study.

METHODS

We conducted a territory-wide nested case-control study with incidence density sampling using Hong Kong electronic health records from public healthcare facilities and mandatory Covid-19 reports. People with one listed chronic condition (based on a list of 30) who developed multimorbidity during 1 January 2020-15 November 2022 were selected as case participants and randomly matched with up to 10 people of the same age, sex and with the same first chronic condition without having developed multimorbidity at that point. Conditional logistic regression was used to estimate adjusted odds ratios (aORs) of multimorbidity.

RESULTS

In total, 127 744 case participants were matched with 1 230 636 control participants. Adjusted analysis showed that there were 28%-increased odds of multimorbidity following Covid-19 [confidence interval (CI) 22% to 36%] but only 3% (non-significant) with prior full vaccination with BNT162b2 or CoronaVac (95% CI -2% to 7%). Similar associations were observed in men, women, older people aged 65 or more, and people aged 64 or younger.

CONCLUSIONS

We found a significantly elevated risk of multimorbidity following a Covid-19 episode among people with one pre-existing chronic condition. Full vaccination significantly reduced this risk increase.

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.

The impact of a complex school nutrition intervention on double burden of malnutrition among Thai primary school children: a 2-year quasi-experiment

OBJECTIVE

This study assessed the impacts of the Dekthai Kamsai programme on overweight/obesity, underweight and stunting among male and female primary school students.

STUDY DESIGN

A quasi-experiment was conducted in 16 intervention and 19 control schools across Thailand in 2018 and 2019. In total, 896 treated and 1779 control students from grades 1 to 3 were recruited. In intervention schools, a set of multifaceted intervention components were added into school routine practices. Anthropometric outcomes were measured at baseline and at the beginning and end of every school term.

METHODS

Propensity score matching with linear and Poisson difference-in-difference analyses were used to adjust for the non-randomisation and to analyse the intervention's effects over time.

RESULTS

Compared with controls, the increases in mean BMI-for-age Z-score (BAZ) and the incidence rate of overweight/obesity were lower in the intervention schools at the 3rd, 4th and 8th measurements and the 3rd measurement, respectively. The decrease in mean height-for-age Z-score (HAZ) was lower at the 4th measurement. The decrease in the incidence rate of wasting was lower at the 5th, 7th and 8th measurements. The favourable impacts on BAZ and HAZ were found in both sexes, while the favourable impact on overweight/obesity and unfavourable impact on wasting were found in girls.

CONCLUSIONS

This intervention might be effective in reducing BAZ, overweight/obesity, poor height gain, but not wasting. These findings highlight the benefits of a multifaceted school nutrition intervention and a need to incorporate tailor-made interventions for wasting to comprehensively address the double burden of malnutrition.

Adjuvant Chemotherapy in Older Patients with Gastric Cancer: A Population-Based Cohort Study

(1) Background: The effectiveness of adjuvant chemotherapy in older patients with gastric cancer after D2-gastrectomy is unclear. This study investigated the efficacy of adjuvant chemotherapy in elderly patients with stage II/III gastric cancer. (2) Methods: A real-world population-based retrospective cohort of patients aged ≥65 with stage II/III gastric cancer (n = 2616; median age: 73.5; 12.2% aged >80 years) treated between 1 January 1997 and 31 December 2020 were included. All data was retrieved from the Hong Kong Hospital Authority Clinical Management System (CMS). Clinical characteristics of those patients with and without adjuvant chemotherapy treatment were balanced after propensity score matching (PSM). In total, 732 patients treated with adjuvant chemotherapy were matched with 732 patients treated with surgery alone. Hazard ratios (HRs) estimated via Cox proportional hazards regression models were used to compare the overall survival (OS) and cancer-specific survival (CSS) of the two patient groups. (3) Results: Adjuvant chemotherapy was associated with better OS (37 vs. 25 months; HR: 0.80; 95% CI: 0.75-0.84; p < 0.001) than surgery alone. The OS benefit was observed in both the 65-80 (44 vs. 27 months; HR: 0.79; 95% CI: 0.74-0.84; p < 0.001) and >80 (14 vs. 11 months; HR: 0.82; 95% CI: 0.71-0.96; p < 0.001) age groups. A better CSS was observed in patients who received adjuvant chemotherapy than those who only had surgery (5-year CSS: 64.1% vs. 61.1%, HR: 0.85; 95% CI: 0.79-0.93; p < 0.001). (4) Conclusions: adjuvant chemotherapy significantly improved OS and CSS in older patients with stage II/III gastric cancer.

Non-Laboratory-Based Risk Prediction Tools for Undiagnosed Pre-Diabetes: A Systematic Review

Early detection of pre-diabetes (pre-DM) can prevent DM and related complications. This review examined studies on non-laboratory-based pre-DM risk prediction tools to identify important predictors and evaluate their performance. PubMed, Embase, MEDLINE, CINAHL were searched in February 2023. Studies that developed tools with: (1) pre-DM as a prediction outcome, (2) fasting/post-prandial blood glucose/HbA1c as outcome measures, and (3) non-laboratory predictors only were included. The studies’ quality was assessed using the CASP Clinical Prediction Rule Checklist. Data on pre-DM definitions, predictors, validation methods, performances of the tools were extracted for narrative synthesis. A total of 6398 titles were identified and screened. Twenty-four studies were included with satisfactory quality. Eight studies (33.3%) developed pre-DM risk tools and sixteen studies (66.7%) focused on pre-DM and DM risks. Age, family history of DM, diagnosed hypertension and obesity measured by BMI and/or WC were the most common non-laboratory predictors. Existing tools showed satisfactory internal discrimination (AUROC: 0.68–0.82), sensitivity (0.60–0.89), and specificity (0.50–0.74). Only twelve studies (50.0%) had validated their tools externally, with a variance in the external discrimination (AUROC: 0.31–0.79) and sensitivity (0.31–0.92). Most non-laboratory-based risk tools for pre-DM detection showed satisfactory performance in their study populations. The generalisability of these tools was unclear since most lacked external validation.

Effect of vaccine booster, vaccine type, and hybrid immunity on humoral and cellular immunity against SARS-CoV-2 ancestral strain and Omicron variant sublineages BA.2 and BA.5 among older adults with comorbidities: a cross sectional study

BACKGROUND

Vaccination reduces COVID-19-related hospitalization among older adults. However, how SARS-CoV-2 infection and vaccine regimens affect vaccine-elicited immunity remain unclear.

METHODS

This is a cross-sectional study recruiting adults aged ≥70 years with comorbidities in Hong Kong. Demographic and clinical information were collected using a questionnaire. Neutralizing antibody (nAb) titers (against ancestral and Omicron strains) and SARS-CoV-2-specific T cell response were analyzed according to infection and vaccination status. Multivariable regression analysis was performed to assess the associations of BNT162b2 and booster doses with higher nAb titers, with adjustment for comorbidities.

FINDINGS

In July 2022, 101 patients were recruited, of whom 25 (24%) had previous infection. Overall, the geometric mean titer (GMT) of BA.5 nAb was 2.8-fold lower than that against BA.2 (P < 0.0001). The ancestral strain and BA.2 titers were higher for the 3-4-dose-BNT162 group than the 2-dose-BNT162b2 group. Non-infected individuals in the 3-4-dose-CoronaVac group had a more robust T cell response than the 2-dose-CoronaVac group (P = 0.0181), but there was no significant difference between the 2-dose-BNT162b2 and 3-4-dose-BNT162b groups. Patients who had heterologous CoronaVac-BNT162b2 prime-boost regimen had 3.22-fold higher BA.5 nAb titers than those who were primed/boosted with CoronaVac (P = 0.0207). Patients with hybrid immunity had higher Omicron nAb titers than those with vaccine-only immunity. Multivariable analysis showed that BNT162b2 and booster doses were independently associated with higher ancestral strain nAb titers.

INTERPRETATION

Our data support the use of booster doses for older adults with or without prior infection. Non-infected individuals primed with CoronaVac will benefit from heterologous mRNA vaccine booster.

FUNDING

Richard and Carol Yu, May Tam Mak Mei Yin, The Shaw Foundation Hong Kong, Michael Tong, Marina Lee, Government Consultancy Service (See acknowledgements for full list).

Change in framingham cardiovascular disease risk between 2003 and 2014 in the hong kong population health survey

Background

The Framingham Risk model estimates a person's 10-year cardiovascular disease (CVD) risk.

Purpose

We aimed to calculate the change in sex-age specific Framingham CVD risk in the Hong Kong Population Health Survey (PHS) 2014/15 in comparison with the survey in 2003–05 (PHS2003/2004 & Heart Health Survey (HHS) 2004/2005).

Methods

Subjects aged 30–74 years from PHS2014/15 (n=1,662, n=4,445,869 after population weighing) and PHS2003/2004 & HHS2004/2005 (n=818, n=3,495,074 after population weighing) with complete data for the calculation of Framingham CVD predicted risk were included. The sex-specific CVD risks of participants were calculated based on their age, total cholesterol and high-density lipoprotein, mean systolic blood pressure, smoking habits, diabetic status, and treatment for hypertension. The mean sex-age specific CVD risks were then calculated, and the differences in CVD risk between the two surveys were analysed using ANOVA.

Results

There was no significant difference in 10-year CVD risks between the 2003–2005 and 2014/15 study populations (10.2% vs. 10.6%, p=0.29). After adjusting to a standard population (US Census 2000), the age-standardized CVD risk was lower in 2014–2015 than in 2003–05 (10.0% vs. 10.7%, p=0.017). More participants aged 65–74 were classified as high risk during 2003/04 (PHS2003/2004 & HHS2004/2005: 66.8% vs. PHS2014/15: 53.1%, p=0.026). This might be due to the decrease in the proportion of smokers among men (2003–2005: 30.5% vs. 24.0% in 2014–15, p&lt;0.001).

Conclusions

Between 2003/04 and 2014/15, there was a small decrease in age-standardized 10-year CVD risk, which might be related to the reduction in smoking. However, more effort in targeting multiple CVD risk factors simultaneously is needed to achieve a greater reduction in CVD risk.

Funding Acknowledgement

Type of funding sources: None.

Repurposing DPP-4 Inhibitors for Colorectal Cancer: A Retrospective and Single Center Study

Simple Summary

Colorectal cancer is one of the most common causes and the leading cause of cancer deaths worldwide. Its poor prognosis highlights the urgent need for more effective treatments. Repurposing approved drugs is a promising strategy as preclinical screenings can be minimized. The aim of our retrospective study was to investigate the potential of Dipeptidyl-peptidase 4 (DPP4)-inhibitors, which are safe Food and Drug Association (FDA)-approved drugs for treating diabetes, in treating CRC patients. Our findings conclude that CRC patients with diabetes and treated with DPP4-inhibitors in our hospital during 2006–2015, their 5-year prognosis following curative resection was significantly better than those treated with metformin. We further showed that their prognosis was associated with immune cell population features that associated with better prognosis, and immune cell profile is a biomarker for predicting the prognosis of DPP4-inhibitors treated CRC patients.

Abstract

Background: There have been studies reporting the crucial roles of Dipeptidyl-peptidase 4 (DPP4) in colorectal cancer (CRC) initiation and progression, whereas DPP4-inhibitors are safe Food and Drug Association (FDA)-approved drugs for treating diabetes. This study aims to investigate the association between DPP4-inhibitor treatment and the prognosis of CRC patients. Methods: Clinical data of CRC patients with diabetes and the prescription of DPP4-inhibitors who had undergone curative surgery in our hospital between January 2006 and December 2015 were retrieved. Their survival data and immune cell population in circulatory blood were compared to those treated with metformin. Results: The DPP4-inhibitor patient group showed a significantly better 5-year disease-free survival (median DFS = 1733 days, 95% CI = 1596 to 1870 days) when compared to the metformin group (p = 0.030, median DFS = 1382 days, 95% CI = 1246 to 1518 days). 33 out of the 92 patients in the metformin group showed recurrence whereas only 3 of the 26 patients in the DPP4-inhibitor group showed recurrence (p = 0.033). Cox regression analysis demonstrated that DPP4-inhibitor application is a favorable factor associated with a lower risk of recurrence (Hazard ratio = 0.200, p = 0.035). Furthermore, our results suggested that the immune cell profile of CRC patients is a potential biomarker for response to DPP4-inhibitor treatment. Conclusion: This study demonstrated the association of DPP4-inhibitor treatment with a better prognosis of CRC patients.

Acceptance of COVID-19 Vaccination in Cancer Patients in Hong Kong: Approaches to Improve the Vaccination Rate

Emerging efficacy and safety data have led to the authorization of COVID-19 vaccines worldwide, but most trials excluded patients with active malignancies. This study evaluates the intended acceptance of COVID-19 vaccination in cancer patients in Hong Kong. Methods: 660 adult cancer patients received a survey, in paper or electronic format, between 31 January 2021 and 15 February 2021. The survey included patient’s clinical characteristics, perceptions of COVID-19 and vaccination, vaccine knowledge, cancer health literacy, and Hospital Anxiety and Depression scale (HADS). The primary outcome was the intended acceptance of COVID-19 vaccine in cancer patients. Multivariable analysis was performed to identify factors associated with intended acceptance. Results: The intended acceptance of COVID-19 vaccination was 17.9%. A total of 487 (73.8%) believed that vaccination could prevent them from infection. Over 70% worried about vaccine negative effects on cancer and its side effects. Factors associated with intended acceptance included higher level of “belief in vaccine on preventing them from getting COVID-19”, less worry about long-term side effects of vaccine, lower level of cancer health literacy, and normal HADS (Depression scale). Conclusions: To improve vaccine acceptance rate, public education campaigns specific to cancer patients to gain their trust in efficacy and relieve their worries are needed.

Impact of COVID-19 on Child Maltreatment: Income Instability and Parenting Issues

Introduction: Children are widely recognized as a vulnerable population during disasters and emergencies. The COVID-19 pandemic, like a natural disaster, brought uncertainties and instability to the economic development of the society and social distancing, which might lead to child maltreatment. This study aims to investigate whether job loss, income reduction and parenting affect child maltreatment. Methods: We conducted a cross-sectional online survey of 600 randomly sampled parents aged 18 years or older who had and lived with a child under 10 years old in Hong Kong between 29 May to 16 June 2020. Participants were recruited from a random list of mobile phone numbers of a panel of parents. Of 779 recruited target parents, 600 parents completed the survey successfully via a web-based system after obtaining their online consent for participating in the survey. Results: Income reduction was found significantly associated with severe (OR = 3.29, 95% CI = 1.06, 10.25) and very severe physical assaults (OR = 7.69, 95% CI = 2.24, 26.41) towards children. Job loss or large income reduction were also significantly associated with severe (OR= 3.68, 95% CI = 1.33, 10.19) and very severe physical assaults (OR = 4.05, 95% CI = 1.17, 14.08) towards children. However, income reduction (OR = 0.29, 95% CI = 0.15, 0.53) and job loss (OR = 0.47, 95% CI = 0.28, 0.76) were significantly associated with less psychological aggression. Exposure to intimate partner violence between parents is a very strong and significant factor associated with all types of child maltreatment. Having higher levels of difficulty in discussing COVID-19 with children was significantly associated with more corporal punishment (OR = 1.19, 95% CI = 1.05, 1.34), whereas having higher level of confidence in managing preventive COVID-19 behaviors with children was negatively associated with corporal punishment (OR = 0.87, 95% CI = 0.76, 0.99) and very severe physical assaults (OR = 0.74, 95% CI = 0.58, 0.93). Conclusions: Income instability such as income reduction and job loss amplified the risk of severe and very severe child physical assaults but protected children from psychological aggression. Also, confidence in teaching COVID-19 and managing preventive COVID-19 behaviors with children was significantly negatively associated with corporal punishment during pandemic.

Cost-effectiveness of fine-needle aspiration cytology (FNAC) and watchful observation for incidental thyroid nodules

OBJECTIVES

A trial-based comparison of the use of resources, costs and health utility outcomes of fine-needle aspiration cytology (FNAC), and watchful observation for incidental small (< 2 cm) thyroid nodules was performed using data from the randomized controlled trial (RCT).

METHODS

Using data from 314 patients, healthcare-related use of resources, costs, health utility, and quality-adjusted life years (QALYs) were estimated at 12 months after first presentation of incidental thyroid nodule(s) on an intention-to-treat basis with adjustment for covariates. Uncertainty about the incremental cost-effectiveness ratio for FNAC versus watchful management at 12 months of follow-up was incorporated using bootstrapping. Multiple imputation methods were used to deal with missing data.

RESULTS

FNAC management was associated with greater use of healthcare resources and mean direct healthcare costs per patient (US$542.47 vs US$411.55). Lower mean 12-month QALYs per patient in FNAC was observed in comparison to watchful observation (0.752 versus 0.758). The probability that FNAC management was cost-effective compared with watchful management at a willingness-to-pay threshold of US50,000 per QALY gained was 26.5%.

CONCLUSION

Based on 12-month data from RCT, watchful observation appeared cost-saving compared to FNAC in patients with incidental thyroid nodules that have a low-suspicion sonographic pattern and measure between 1.0 and 2.0 cm from healthcare provider perspective. CLINICALTRIALS.

GOV IDENTIFIER

NCT02398721.

SGLT2i as fourth-line therapy and risk of mortality, end-stage renal diseases and cardiovascular diseases in patients with type 2 diabetes mellitus

AIM

Current guideline recommends insulin as fourth-line glucose-lowering medications. However, treatment effects of sodium glucose co-transporter-2 inhibitors (SGLT2i) on the risk of complications are uncertain. This study examines risks of all-cause mortality, cardiovascular diseases (CVD) and end-stage renal diseases (ESRD) in type 2 diabetes mellitus (T2DM) patients on triple oral glucose-lowering medications initiating SGLT2i, insulin or other oral medications.

METHODS

A population-based retrospective cohort of patients with T2DM between 2006-2017 was extracted from Hong Kong Hospital Authority database. Patients who were initiated a fourth-line therapy with SGLT2i, insulin or other oral medications were included. Hazard ratios (HRs) for all-cause mortality, CVD and ESRD were assessed using Cox proportional hazard models.

RESULTS

Over a median follow-up period of 18.5 months with 63,122 person-years, SGLT2i and insulin group had the lowest and highest incidence rate of all-cause mortality, CVD and ESRD (1.06, 0.65 and 0.61 vs 4.25, 5.58 and 4.39/100 person-years), respectively. Initiating SGLT2i as fourth-line medication had more benefits on CVD, in particular coronary heart disease and stroke. Insulin users had higher risks of CVD (HR=8.04, 95%CI=3.06-21.12) than SGLT2i users. SGLT2i was associated with insignificant reduction in ESRD (HR=4.62, 95%CI=0.73-29.09) and all-cause mortality (HR=3.06, 95%CI=0.75-12.45), and HF (HR=2.99, 95%CI=0.37-24.42) among patients without established HF.

CONCLUSION

Among T2DM patients initiating fourth-line therapy, SGLT2i users had significant benefits in lowering risk of CVD, and potential benefits in lowering risks of ESRD and all-cause mortality. SGLT2i was the preferred fourth-line glucose-lowering medication least likely to be associated with complication risks.

Prediction models for the risk of cardiovascular diseases in Chinese patients with type 2 diabetes mellitus: a systematic review

OBJECTIVES

Diabetes mellitus (DM) is a serious public health issue worldwide, and DM patients have higher risk of cardiovascular diseases (CVDs), which is the leading cause of DM-related deaths. China has the largest DM population, yet a robust model to predict CVDs in Chinese DM patients is still lacking. This systematic review is carried out to summarize existing models and identify potentially important predictors for CVDs in Chinese DM patients.

STUDY DESIGN

Systematic review.

METHODS

Medline and Embase were searched for data from April 1st, 2011 to May 31st, 2018. A study was eligible if it developed CVD (defined as total CVD or any major cardiovascular component) risk prediction models or explored potential predictors of CVD specifically for Chinese people with type 2 DM. Standardized forms were utilized to extract information, appraise applicability, risk of bias, and availabilities.

RESULTS

Five models and 29 studies focusing on potential predictors were identified. Models for a primary care setting, or to predict total CVD, are rare. A number of common predictors (e.g. age, sex, diabetes duration, smoking status, glycated hemoglobin (HbA1c), blood pressure, lipid profile, and treatment modalities) were observed in existing models, in which urine albumin:creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR) are highly recommended for the Chinese population. Variability of blood pressure (BP) and HbA1c should be included in prediction model development as novel factors. Meanwhile, interactions between age, sex, and risk factors should also be considered.

CONCLUSIONS

A 10-year prediction model for CVD risk in Chinese type 2 DM patients is lacking and urgently needed. There is insufficient evidence to support the inclusion of other novel predictors in CVDs risk prediction functions for routine clinical use.

SF-6D utility scores of smokers and ex-smokers with or without respiratory symptoms attending primary care clinics

Introduction

The aim of this paper is to find out generic preference-based Short-Form 6 Dimensions (SF-6D) utility scores of smokers and ex-smokers with varying cigarette exposure, with and without respiratory symptoms.

Methods

Seven hundred thirty one people aged ≥30 with a history of smoking who attended 5 public primary care clinics completed a cross-sectional survey using SF-6D utility score, Breathlessness, Cough, and Sputum Scale (BCSS©) and office spirometry.

Results

Most of the subjects were men (92.5%) in an older age group (mean age 62.2 ± 11.7 years). About half of them (48.3%) were current smokers while the other half (51.7%) were ex-smokers. More than half of them (54.2%) reported mild respiratory symptoms (mean BCSS score 0.95 ± 1.12). The most common symptoms were sputum (45.1%), followed by cough (34.2%) and breathlessness (6.0%). The SF-6D overall utility score was 0.850 ± 0.106. The subjects reported significantly lower SF-6D scores when they had breathlessness (0.752 ± 0.138; p = < 0.001), cough (0.836 ± 0.107; p = 0.007), sputum (0.838 ± 0.115; p = 0.004) or any of the above symptom (0.837 ± 0.113; p < 0.001). In both groups of current smokers and ex-smokers, there was no statistically significant difference in the scores among light, moderate or heavy smokers. In the Tobit regression model of factors affecting SF-6D utility score, subjects who reported more respiratory symptoms (i.e. higher BCSS©) had lower SF-6D scores (B = − 0.018 ± 0.007, p < 0.001), while men had higher SF-6D scores than women (B = 0.037 ± 0.031, p = 0.019). Subjects who attended middle or high school had higher SF-6D score than those attended the University or above. The presence of airflow obstruction was not associated with the score.

Conclusions

The study yielded SF-6D utility scores of smokers and ex-smokers with different reported cigarette exposure, which could be useful in future clinical studies and cost-effectiveness analysis.

Use of the International Prostate Symptom Score (IPSS) in Chinese male patients with benign prostatic hyperplasia

PURPOSE

To test the psychometric properties of the International Prostate Symptom Score (Hong Kong Chinese version 2) (IPSS) in Chinese male patients with benign prostatic hyperplasia (BPH) under secondary care.

METHODS

A prospective longitudinal study was done by interviewing subjects at baseline, at 2 week after baseline for assessing test-retest reliability and at 26 week after baseline for assessing responsiveness. All subjects were interviewed to complete a structured questionnaire including IPSS, Short Form-12 Health Survey version 2 (SF-12v2) and Depression Anxiety Stress Scale (DASS).

RESULTS

The IPSS HRQOL score had weak correlations with SF-12v2 summary and DASS domain scores. For reliability analysis, Cronbach's alpha coefficient was 0.90 for the seven symptom-related items. The intraclass correlation coefficients of the IPSS total symptom score and HRQOL score were 0.90 and 0.86, respectively. For sensitivity, statistically significant differences were detected between the subjects with BPH and those without for IPSS total symptom score (effect size = 0.68) but not the IPSS HRQOL score. The areas under ROC curves for the IPSS total symptom and HRQOL scores were 0.67 and 0.60, respectively.

CONCLUSIONS

The IPSS was valid, reliable instrument in Chinese patients with BPH. The IPSS total symptom score, but not the HRQOL score, is sensitive in differentiating subgroups.

Annual direct medical costs associated with diabetes-related complications in the event year and in subsequent years in Hong Kong

AIM

To develop models to estimate the direct medical costs associated with diabetes-related complications in the event year and in subsequent years.

METHODS

The public direct medical costs associated with 13 diabetes-related complications were estimated among a cohort of 128 353 people with diabetes over 5 years. Private direct medical costs were estimated from a cross-sectional survey among 1825 people with diabetes. We used panel data regression with fixed effects to investigate the impact of each complication on direct medical costs in the event year and subsequent years, adjusting for age and co-existing complications.

RESULTS

The expected annual public direct medical cost for the baseline case was US$1,521 (95% CI 1,518 to 1,525) or a 65-year-old person with diabetes without complications. A new lower limb ulcer was associated with the biggest increase, with a multiplier of 9.38 (95% CI 8.49 to 10.37). New end-stage renal disease and stroke increased the annual medical cost by 5.23 (95% CI 4.70 to 5.82) and 5.94 (95% CI 5.79 to 6.10) times, respectively. History of acute myocardial infarction, congestive heart failure, stroke, end-stage renal disease and lower limb ulcer increased the cost by 2-3 times. The expected annual private direct medical cost of the baseline case was US$187 (95% CI 135 to 258) for a 65-year-old man without complications. Heart disease, stroke, sight-threatening diabetic retinopathy and end-stage renal disease increased the private medical costs by 1.5 to 2.5 times.

CONCLUSIONS

Wide variations in direct medical cost in event year and subsequent years across different major complications were observed. Input of these data would be essential for economic evaluations of diabetes management programmes.

Effect of a structured diabetes education programme in primary care on hospitalizations and emergency department visits among people with Type 2 diabetes mellitus: results from the Patient Empowerment Programme

AIM

To assess whether a structured diabetes education programme, the Patient Empowerment Programme, was associated with a lower rate of all-cause hospitalization and emergency department visits in a population-based cohort of patients with Type 2 diabetes mellitus in primary care.

METHODS

A cohort of 24 250 patients was evaluated using a linked administrative database during 2009-2013. We selected 12 125 patients with Type 2 diabetes who had at least one Patient Empowerment Programme session attendance. Patients who did not participate in the Patient Empowerment Programme were matched one-to-one with patients who did, using the propensity score method. Hospitalization events and emergency department visits were the events of interest. Cox proportional hazard and negative binomial regressions were performed to estimate the hazard ratios for the initial event, and incidence rate ratios for the number of events.

RESULTS

During a median 30.5 months of follow-up, participants in the Patient Empowerment Programme had a lower incidence of an initial hospitalization event (22.1 vs 25.2%; hazard ratio 0.879; P < 0.001) and emergency department visit (40.5 vs 44%; hazard ratio 0.901; P < 0.001) than those who did not participate in the Patient Empowerment Programme. Participation in the Patient Empowerment Programme was associated with a significantly lower number of emergency department visits (incidence rate ratio 0.903; P < 0.001): 40.4 visits per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 36.2 per 100 patients annually in those who did. There were significantly fewer hospitalization episodes (incidence rate ratio 0.854; P < 0.001): 20.0 hospitalizations per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 16.9 hospitalizations per 100 patients annually in those who did.

CONCLUSIONS

Among patients with Type 2 diabetes, the Patient Empowerment Programme was shown to be effective in delaying the initial hospitalization event and in reducing their frequency.

Prevalence of undiagnosed airflow obstruction among people with a history of smoking in a primary care setting

Purpose

The purpose of this study was to define the prevalence of undiagnosed airflow obstruction (AO) among subjects with a history of smoking but no previous diagnosis of chronic lung disease. The finding of AO likely represents diagnosis of chronic obstructive pulmonary disease.

Patients

People aged ≥30 years with a history of smoking who attended public outpatient clinics for primary care services were included in this study.

Methods

A cross-sectional survey in five clinics in Hong Kong using the Breathlessness, Cough, and Sputum Scale, the Lung Function Questionnaire, and office spirometry was conducted.

Results

In total, 731 subjects (response rate =97.9%) completed the questionnaires and spirometry tests. Most of the subjects were men (92.5%) in the older age group (mean age =62.2 years; standard deviation =11.7). Of the 731 subjects, 107 had AO, giving a prevalence of 14.6% (95% confidence interval =12.1–17.2); 45 subjects with AO underwent a postbronchodilator test. By classifying the severity of chronic obstructive pulmonary disease using the Global Initiative for Chronic Obstructive Lung Disease, 27 (60%) were considered to be in mild category and 18 (40%) in moderate category. None of them belonged to the severe or very severe category. The total score of Lung Function Questionnaire showed that majority of the subjects with AO also had chronic cough, wheezing attack, or breathlessness, although most did not show any acute respiratory symptoms in accordance with the Breathlessness, Cough, and Sputum Scale. Diagnosis of AO was positively associated with the number of years of smoking (odds ratio =1.044, P=0.035) and being normal or underweight (odds ratio =1.605, P=0.046). It was negatively associated with a history of hypertension (odds ratio =0.491, P=0.003).

Conclusion

One-seventh of smokers have undiagnosed AO. Spirometry screening of smokers should be considered in order to diagnose AO at an early stage, with an emphasis on smoking cessation.

Psychological health and HIV transmission among female sex workers: a systematic review and meta-analysis

Current HIV prevention interventions for female sex workers (FSWs) have tended to target the cognitive factors in changing their behaviors, yet little attention has been paid to the psychological factors that influence the behavior of women in sex work. This review aimed to explore the associations between the psychological health of FSWs and HIV risk. A total of eight studies published in English before July 2013 were identified and reviewed. FSWs had reported psychological issues, including depression, suicidal thoughts as well as lower quality of life, and the pooled prevalence of probable depression was as high as 62.4%. The majority of studies showed that higher scores in psychological health problems were associated with increased HIV risk behavior, in particular inconsistent condom use, or sexually transmitted infections. Among the five studies which measured symptoms of depression, four documented that higher depression scores were significantly associated with inconsistent condom use among FSWs with their clients and/or partners. Meta-analysis using a fixed-effects model was performed to examine the association between depression and inconsistent condom use and found that higher scores in depression were significantly associated with inconsistent condom use (odds ratio = 2.57, p < .001). This review contends that future HIV preventive interventions should take psychological health of FSWs into consideration.

Patient Empowerment Programme in primary care reduced all-cause mortality and cardiovascular diseases in patients with type 2 diabetes mellitus: a population-based propensity-matched cohort study

AIMS

To assess whether a structured diabetes education programme, the Patient Empowerment Programme (PEP), was associated with a lower risk of first cardiovascular disease (CVD) event and all-cause mortality in a population-based cohort of patients with type 2 diabetes mellitus (T2DM) in primary care.

METHODS

A Chinese cohort of 27 278 patients with T2DM and without previous CVD events on or before the baseline study recruitment date was linked to the Hong Kong administrative database from 2008 to 2013. The PEP was provided to patients with T2DM treated at primary care outpatient clinics through community trained professional educators. PEP non-participants were matched one-to-one with the PEP participants using a propensity score method with respect to their baseline covariates. Cox proportional hazard regression was performed to estimate the associations of the PEP with the occurrence of first CVD event, coronary heart disease, stroke, heart failure and death from any cause, controlling for baseline characteristics.

RESULTS

During a median of 21.5 months follow-up, 795 (352 PEP participants and 443 PEP non-participants) patients experienced a first CVD event. After adjusting for confounding variables, PEP participants had a lower rate of all-cause mortality [hazard ratio (HR) 0.564, 95% confidence interval (CI) 0.445-0.715; p < 0.001], first CVD (HR 0.807, 95% CI 0.696-0.935; p = 0.004) and stroke (HR 0.702; 95% CI 0.569-0.867; p = 0.001) than those without PEP.

CONCLUSIONS

Enrolment in the PEP was associated with lower all-cause mortality and a lower number of first CVD events among patients with T2DM. The CVD benefit of PEP might be attributable to improving metabolic control through empowerment of self-care and the enhancement of quality of diabetes care in primary care.

Home blood pressure monitoring--a trial on the effect of a structured education program

BACKGROUND

This study aimed to assess whether a structured home blood pressure monitoring (HBPM) education program can improve blood pressure control in patients.

METHODS

A cluster randomised controlled trial in which half of 240 patients in the intervention group received an education program focused on using HBPM machines at home, while the other half had the usual care. The primary endpoints were mean systolic blood pressure and diastolic blood pressure.

RESULTS

Systolic blood pressure dropped 1.88 mmHg (p=0.372) and diastolic blood pressure significantly dropped 3.84 mmHg (p=0.004) in intervention group at 3 months. At 6 months, systolic blood pressure and diastolic blood pressure were still on a decreasing trend, but there was no significant difference in blood pressure changes between the two groups.

DISCUSSION

The structured HBPM education program has the potential to improve patient blood pressure control at short term, but such effect appears tailing off at medium terms. Additional components may be needed to maximise and sustain the benefit of HBPM.

Prevalence of undiagnosed diabetes mellitus and cardiovascular risk factors in Hong Kong professional drivers

AIMS

To investigate the prevalence of undiagnosed diabetes mellitus (DM) and cardiovascular risk factors among professional drivers in Hong Kong.

METHODS

Chinese professional drivers with no history of DM were invited to complete a questionnaire on their health status, followed by taking their body measurements, fasting blood glucose (FG) and lipids. 75g OGTT were performed when FG≥5.6 to <7.0mmol/L.

RESULTS

Of these 3376 drivers (male 92.6%, mean age 50.9±7.6 years), the prevalence of undiagnosed DM, prediabetes, and metabolic syndrome was 8.1% (272/3376, 95% CI 7.1-9.0%), 10.0% (337/3376, 95% CI 9.0-11.0%) and 26.8% (904/3376, 95% CI 25.3-28.3%) respectively, while the corresponding WHO Standard Population age-standardized prevalence was 7.8%, 9.0% and 24.7% respectively. Many of them were obese (51.2%), had hypertension (57.0%) and high cholesterol (58.7%), and a third had hypertriglyceridaemia (34.9%) and low HDL-cholesterol (29.3%). Their median working hours were 60.0 (IQR 14)h. Majority had exercise <1h/week (56.0%) and ate out ≥6times/week (54.9%).

CONCLUSIONS

Hong Kong professional drivers have higher prevalence of undiagnosed DM, cardiovascular risk factors and metabolic syndrome than the general population. Therefore, health care measures targeting against them should be taken to prevent and detect DM and cardiovascular diseases.