Differential interplay between multimorbidity patterns and frailty and their mutual mediation effect on mortality in old age.

BACKGROUND: Multimorbidity and frailty often concurrently occur among older adults. OBJECTIVES: To assess the reciprocal association between multimorbidity (condition count and patterns) and frailty and examine the mutual mediation effect of multimorbidity and frailty in their associations with mortality among Chinese older adults. METHODS: This nationwide population-based longitudinal study included 16,563 participants aged ≥65 years in the Chinese Longitudinal Healthy Longevity Survey who were surveyed in 2008 and followed up in 2011, 2014, and 2018. Frailty phenotype was assessed by the modified Fried criteria and vital status was ascertained from family members. Cross-lagged panel model (CLPM) was used to test bidirectional associations between multimorbidity and frailty. The direct and indirect effects of multimorbidity and frailty on mortality were evaluated using the combined CLPM with survival analysis. RESULTS: Three multimorbidity patterns were identified: cardiometabolic diseases, cognitive-sensory disorder, and arthritis-digestive-respiratory diseases. The number of chronic conditions and cognitive-sensory disease pattern showed bidirectional associations with frailty across waves (range for ß: 0.046-0.109; all P < 0.001), while cardiometabolic and arthritis-digestive-respiratory patterns unidirectionally predicted frailty change. Furthermore, frailty mediated 23%-27% of the association between multimorbidity and mortality. Only the number of conditions and cognitive-sensory disease pattern were significant mediators in the association between frailty and mortality, with the proportion of mediation ranging 4%-12%. CONCLUSIONS: Multimorbidity measures including condition count and cognitive-sensory disease pattern are bi-directionally associated with frailty in older adults. These multimorbidity measures and frailty partially mediated each other's association with mortality, with frailty acting as a more prominent pathway in the association between multimorbidity and mortality.

A circumpolar study unveils a positive non-linear effect of temperature on arctic arthropod availability that may reduce the risk of warming-induced trophic mismatch for breeding shorebirds.

Seasonally abundant arthropods are a crucial food source for many migratory birds that breed in the Arctic. In cold environments, the growth and emergence of arthropods are particularly tied to temperature. Thus, the phenology of arthropods is anticipated to undergo a rapid change in response to a warming climate, potentially leading to a trophic mismatch between migratory insectivorous birds and their prey. Using data from 19 sites spanning a wide temperature gradient from the Subarctic to the High Arctic, we investigated the effects of temperature on the phenology and biomass of arthropods available to shorebirds during their short breeding season at high latitudes. We hypothesized that prolonged exposure to warmer summer temperatures would generate earlier peaks in arthropod biomass, as well as higher peak and seasonal biomass. Across the temperature gradient encompassed by our study sites (>10°C in average summer temperatures), we found a 3-day shift in average peak date for every increment of 80 cumulative thawing degree-days. Interestingly, we found a linear relationship between temperature and arthropod biomass only below temperature thresholds. Higher temperatures were associated with higher peak and seasonal biomass below 106 and 177 cumulative thawing degree-days, respectively, between June 5 and July 15. Beyond these thresholds, no relationship was observed between temperature and arthropod biomass. Our results suggest that prolonged exposure to elevated temperatures can positively influence prey availability for some arctic birds. This positive effect could, in part, stem from changes in arthropod assemblages and may reduce the risk of trophic mismatch.

Effects of mindfulness-based cognitive therapy for Chinese adults with PTSD symptoms: protocol for a randomised controlled trial.

INTRODUCTION: Emerging evidence supports mindfulness as a potential psychotherapy for post-traumatic stress disorder (PTSD). Individuals with subthreshold PTSD experience significant impairment in their daily life and functioning due to PTSD symptoms, despite not meeting the full diagnostic criteria for PTSD in DSM-5. Mindfulness skills, including non-judgmental acceptance, attentional control and openness to experiences may help alleviate PTSD symptoms by targeting characteristics such as intensified memory processing, dysregulated hyperarousal, avoidance, and thought suppression. This trial aims to test the effects of mindfulness-based cognitive therapy (MBCT) when compared to an active control. METHOD AND ANALYSIS: This 1:1 randomised controlled trial will enroll 160 participants with PTSD symptoms in 2 arms (MBCT vs. Seeking Safety), with both interventions consisting of 8 weekly sessions lasting 2 h each week and led by certified instructors. Assessments will be conducted at baseline (T0), post-intervention (T1), and 3 months post-intervention (T2), with the primary outcome being PTSD symptoms measured by the PTSD checklist for DSM-5 (PCL-5) at T1. Secondary outcomes include depression, anxiety, attention, experimental avoidance, rumination, mindfulness, and coping skills. Both intention-to-treat and per-protocol analyses will be performed. Mediation analysis will investigate whether attention, experimental avoidance, and rumination mediate the effect of mindfulness on PTSD symptoms. DISCUSSION: The proposed study will assess the effectiveness of MBCT in improving PTSD symptoms. The findings are anticipated to have implications for various areas of healthcare and contribute to the enhancement of existing intervention guidelines for PTSD. TRIAL REGISTRATION NUMBER: ChiCTR2200061863.

Determinants of health-related quality of life in older people with chronic musculoskeletal pain: a cross-sectional study.

BACKGROUND: This study aimed to identify the significant physical, psychological, and social determinants associated with EuroQuol-5D (EQ-5D) among Chinese older people with chronic musculoskeletal pain, and to evaluate how these determinants affected the five dimensions of EQ-5D. METHOD: This is a cross-sectional study. Data were collected through a cohort involving 946 community-dwelling older people aged ≥ 60 with chronic musculoskeletal pain in Hong Kong. Selected independent variables were categorized into physical, psychological, and social domains. Physical variables included age, sex, body mass index (BMI), pain severity score, number of pain regions, the most painful site, and the number of comorbidities. Psychological variables included depression level measured using the 9-question Patient Health Questionnaire (PHQ-9), and anxiety level measured using the Generalized Anxiety Disorder Assessment (GAD-7). Social variables included living, marital, and social welfare recipient's status. The dependent variables comprised the index scores and the five dimensions of the EQ-5D descriptive system. Ordinal least squares (OLS) model and logistic regression model were used for data analysis. RESULTS: The mean age of the participants was 67.1 (SD = 5.1), with 77.6% being female. Higher pain severity scores (beta (ß) coefficient =-0.044, P < 0.001), depression scores (ß=-0.007, P < 0.001) and higher anxiety scores (ß=-0.01, P < 0.001) were associated with lower EQ-5D index scores. Specifically, knee pain (ß=-0.061, P < 0.001) was significantly associated with lower EQ-5D index scores. Participants with higher pain severity and depression scores were more likely to report problems in most EQ-5D dimensions. Participants with anxiety primarily faced challenges related to mood, and those with knee pain were more likely to have problems with mobility and daily activities. CONCLUSION: Among the selected determinants in our study, pain intensity, depression, anxiety, and knee pain were identified as key determinants associated with reduced HRQoL in older Chinese people with chronic musculoskeletal pain. Each of these determinants showed distinct associations with different dimensions of the EQ-5D, potentially informed resource allocation and the development of targeted interventions to improve the overall HRQoL of this specific population.

"Shame on Me": Exploring the Role of Self-Stigma in Psychological Outcomes Among Type 2 Diabetes Patients in Hong Kong.

BACKGROUND: Studies have suggested that type 2 diabetes mellitus (T2DM) are at risk of self-stigmatization (i.e., internalized sense of shame about having diabetes). Self-stigma has been found to be associated with poorer psychological outcomes among chronic disease patients; relevant studies examining such an association and its psychosocial mechanisms are scarce among Chinese T2DM patients. This study aimed to examine the association between self-stigma and psychological outcomes among T2DM patients in Hong Kong. Self-stigma was hypothesized to be associated with higher psychological distress and lower quality of life (QoL). Such associations were also hypothesized to be mediated by lower perceived social support, lower self-care self-efficacy, plus higher self-perceived burden to significant others. METHODS: T2DM patients (N = 206) recruited from hospitals and clinics in Hong Kong were invited to complete a cross-sectional survey measuring the aforementioned variables. RESULTS: After controlling for covariates, multiple mediation analysis results indicated the indirect effects from self-stigma to psychological distress via increased self-perceived burden (ß = 0.07; 95% CI = 0.02, 0.15) and decreased self-care self-efficacy (ß = 0.05; 95% CI = 0.01, 0.11) were significant. Moreover, the indirect effect from self-stigma to QoL via decreased self-care self-efficacy was also significant (ß = -0.07; 95% CI = -0.14, -0.02). After considering the mediators, the direct effects from self-stigma to higher psychological distress and lower QoL remained significant (ßs = 0.15 and -0.15 respectively, ps < .05). CONCLUSIONS: Self-stigma could be linked to poorer psychological outcomes through increased self-perceived burden and decreased self-care self-efficacy among T2DM patients. Targeting those variables when designing interventions might facilitate those patients' psychological adjustments.

Assessment of Hypertension Complications and Health Service Use 5 Years After Implementation of a Multicomponent Intervention.

Importance: There is a lack of information regarding the impact of implementing a protocol-driven, team-based, multicomponent intervention in public primary care settings on hypertension-related complications and health care burden over the long term. Objective: To compare hypertension-related complications and health service use at 5 years among patients managed with Risk Assessment and Management Program for Hypertension (RAMP-HT) vs usual care. Design, Setting, and Participants: In this population-based prospective matched cohort study, patients were followed up until the date of all-cause mortality, an outcome event, or last follow-up appointment before October 2017, whichever occurred first. Participants included 212 707 adults with uncomplicated hypertension managed at 73 public general outpatient clinics in Hong Kong between 2011 and 2013. RAMP-HT participants were matched to patients receiving usual care using propensity score fine stratification weightings. Statistical analysis was conducted from January 2019 to March 2023. Interventions: Nurse-led risk assessment linked to electronic action reminder system, nurse intervention, and specialist consultation (as necessary), in addition to usual care. Main Outcomes and Measures: Hypertension-related complications (cardiovascular diseases, end-stage kidney disease), all-cause mortality, public health service use (overnight hospitalization, attendances at accident and emergency department, specialist outpatient clinic, and general outpatient clinic). Results: A total of 108 045 RAMP-HT participants (mean [SD] age: 66.3 [12.3] years; 62 277 [57.6%] female) and 104 662 patients receiving usual care (mean [SD] age 66.3 [13.5] years; 60 497 [57.8%] female) were included. After a median (IQR) follow-up of 5.4 (4.5-5.8) years, RAMP-HT participants had 8.0% absolute risk reduction in cardiovascular diseases, 1.6% absolute risk reduction in end-stage kidney disease, and 10.0% absolute risk reduction in all-cause mortality. After adjusting for baseline covariates, the RAMP-HT group was associated with lower risk of cardiovascular diseases (hazard ratio [HR], 0.62; 95% CI, 0.61-0.64), end-stage kidney disease (HR, 0.54; 95% CI, 0.50-0.59), and all-cause mortality (HR, 0.52; 95% CI, 0.50-0.54) compared with the usual care group. The number needed to treat to prevent 1 cardiovascular disease event, end-stage kidney disease, and all-cause mortality was 16, 106, and 17, respectively. RAMP-HT participants had lower hospital-based health service use (incidence rate ratios ranging from 0.60 to 0.87) but more general outpatient clinic attendances (IRR, 1.06; 95% CI, 1.06-1.06) compared with usual care patients. Conclusions and Relevance: In this prospective matched cohort study involving 212 707 primary care patients with hypertension, participation in RAMP-HT was associated with statistically significant reductions in all-cause mortality, hypertension-related complications, and hospital-based health service use after 5 years.

Safety, Feasibility, and Acceptability of Telemedicine for Hypertension in Primary Care: A Proof-of-concept and Pilot Randomized Controlled Trial (SATE-HT).

Hypertension (HT) continues to be a leading cause of cardiovascular death and an enormous burden on the healthcare system. Although telemedicine may provide improved blood pressure (BP) monitoring and control, it remains unclear whether it could replace face-to-face consultations in patients with optimal BP control. We hypothesized that an automatic drug refill coupled with a telemedicine system tailored to patients with optimal BP would lead to non-inferior BP control. In this pilot, multicenter, randomized control trial (RCT), participants receiving anti-HT medications were randomly assigned (1:1) to either the telemedicine or usual care group. Patients in the telemedicine group measured and transmitted their home BP readings to the clinic. The medications were refilled without consultation when optimal control (BP < 135/85 mmHg) was confirmed. The primary outcome of this trial was the feasibility of using the telemedicine app. Office and ambulatory BP readings were compared between the two groups at the study endpoint. Acceptability was assessed through interviews with the telemedicine study participants. Overall, 49 participants were recruited in 6 months and retention rate was 98%. Participants from both groups had similar BP control (daytime systolic BP: 128.2 versus 126.9 mmHg [telemedicine vs. usual care], p = 0.41) and no adverse events. Participants in the telemedicine group had fewer general outpatient clinic attendances (0.8 vs. 2, p < 0.001). Interviewees reported that the system was convenient, timesaving, cost saving, and educational. The system could be safely used. However, the results must be verified in an adequately powered RCT. Trial registration: NCT04542564.

Enhancing Subjective Well-Being Through Qigong: A Randomized Controlled Trial in Older Adults in Hong Kong With Chronic Physical Illness.

Context: Eight-section Brocades, a qigong protocol, has been shown to reduce depressive symptoms in older adults with chronic physical illness, but its positive effects on quality of life, such as subjective well-being, aren't known. Objective: This study intended to evaluate the efficacy of qigong for increasing subjective well-being in older adults with chronic physical illness. Design: A randomized controlled trial was conducted. Setting: A governmental family clinic in Hong Kong. Participants: Participants were 47 older adults, 19 males and 28 females, with chronic physical illness. Intervention: Participants were randomly assigned to an Eight-section Brocades group (n = 25) or a cognitive training group (n = 22). The groups received 12 weeks of the Eight-section Brocades intervention or of cognitive training, respectively. Outcome Measures: The primary outcome-subjective well-being-and the secondary outcomes-functional independence, sleep quality, mobility, and hand grip strength-were assessed at baseline, postintervention, and at a one-month follow-up. Results: No significant between-group differences were observed in improvements in subjective well-being or any of the secondary outcomes. Significant improvements in subjective sleep quality and decreases in daytime dysfunction over time were reported by participants in both groups. Conclusions: The findings didn't support 12 weeks of Eight-section Brocades qigong as an effective treatment to enhance the subjective well-being of older adults with chronic physical illness. These null findings may be due to the possibilities that: (1) the treatment may have minimal effects on positive psychology outcomes; (2) the primary outcome measure showed possible ceiling effects for the groups; (3) the current study used an active control condition that may have had more benefits than the control conditions used in previous studies; (4) the current study may have been underpowered; (5) more than 12 weeks (24 sessions) of qigong may be required to impact well-being; or (6) some combination of these factors may have affected the results.

Impact of the Use of Oral Antiviral Agents on the Risk of Hospitalization in Community Coronavirus Disease 2019 Patients (COVID-19).

BACKGROUND: We examined the effectiveness of molnupiravir and nirmatrelvir/ritonavir in reducing hospitalization and deaths in a real-world cohort of nonhospitalized patients with coronavirus disease 2019 (COVID-19). METHODS: This was a territory-wide retrospective cohort study in Hong Kong. Nonhospitalized COVID-19 patients who attended designated outpatient clinics between 16 February and 31 March 2022 were identified. Patients hospitalized on the day of the first clinic appointment or used both oral antivirals were excluded. The primary endpoint was hospitalization. The secondary endpoint was a composite of intensive care unit admission, invasive mechanical ventilation use, and/or death. RESULTS: Of 93 883 patients, 83 154 (88.6%), 5808 (6.2%), and 4921 (5.2%) were oral antiviral nonusers, molnupiravir users, and nirmatrelvir/ritonavir users, respectively. Compared with nonusers, oral antiviral users were older and had more comorbidities, lower complete vaccination rate, and more hospitalizations in the previous year. Molnupiravir users were older and had more comorbidities, lower complete vaccination rate, and more hospitalizations in the previous year than nirmatrelvir/ritonavir users. At a median follow-up of 30 days, 1931 (2.1%) patients were hospitalized and 225 (0.2%) patients developed the secondary endpoint. After propensity score weighting, nirmatrelvir/ritonavir use (weighted hazard ratio 0.79; 95% confidence interval [CI], 0.65-0.95; P = .011) but not molnupiravir use (weighted hazard ratio 1.17; 95% CI, 0.99-1.39; P = .062) was associated with a reduced risk of hospitalization than nonusers. The use of molnupiravir or nirmatrelvir/ritonavir was not associated with a lower risk of the secondary endpoint as compared with nonusers. CONCLUSION: Use of nirmatrelvir/ritonavir but not molnupiravir was associated with a reduced risk of hospitalization in real-world nonhospitalized patients with COVID-19.

PUMA screening tool to detect COPD in high-risk patients in Chinese primary care-A validation study.

The early stage of chronic obstructive pulmonary disease (COPD) is not easily recognized. Screening tools can help to identify high-risk patients in primary care settings for spirometry and may be helpful in the early detection in COPD and management. This study aims to validate the PUMA questionnaire for use in Chinese primary care settings. This cross-sectional study recruited participants (≥40 years old, current or former smoker with ≥10 packs of cigarette per year) in primary health care clinics in Hong Kong. The Chinese version of the PUMA questionnaire was administered by trained research staff to participants awaiting consultation. COPD diagnosis was confirmed by spirometry (post-bronchodilator FEV1/FVC <0.70). A total 377 patients were recruited of which 373 completed the spirometry. The percentage of participants diagnosed with COPD (post-bronchodilator FEV1/FVC <0.70) was 27.1%. A higher PUMA score was more likely to have an advanced stage of GOLD classification (P = 0.013). The area under the ROC curve of the PUMA score was 0.753 (95%CI 0.698-0.807). The best cut-point according to Youden's index for PUMA score was ≥6 with sensitivity 76.5%, specificity 63.3% and negative predictive value (NPV) 63.3%. A cut-off point of PUMA score ≥5 was selected due to higher sensitivity of 91.2%, specificity of 42.6% and high NPV of 92.7%. PUMA score performed better than CDQ and COPD-PS in the area under the ROC curve (0.753 versus 0.658 and 0.612 respectively), had higher sensitivity than COPD-PS (91.2% versus 61%) and had higher specificity than CDQ (42.6% versus 13.1%). The use of PUMA as a screening tool was feasible in Chinese primary care and can be conducted by trained staff and health professionals. The validation results showed high sensitivity and high NPV to identify high risk patient with COPD at cut-off point of ≥5. It can be useful for early detection and management of COPD.

The association of glycemic control and fall risk in diabetic elderly: a cross-sectional study in Hong Kong.

BACKGROUND: Many foreign studies investigated glycemic control and fall risk. However, there was insufficient study on this topic in Hong Kong. This study aims to find out the association of glycemic control and fall risk in the diabetic elderly in a general outpatient clinic in the North District of Hong Kong. Their frequency of falls and other associated risk factors of fall were also studied. METHODS: A cross-sectional questionnaire survey was conducted on 442 diabetic patients aged 65 years-old or above with regular follow-up in a general outpatient clinic. Main outcome measure was the number of falls in the past one year from the interview date. Recurrent falls was defined as two or more falls in the past one year from the interview date. Subjects were asked about experience of hypoglycemic symptoms. HbA1c level, chronic illness, retinopathy etc. were obtained through computerized medical record review. Chi square test and logistic regression were used to assess the association between outcomes and the explanatory variables. RESULTS: In the past one year, 23.3% participants experienced at least one fall and 8.6% had recurrent falls. Hypoglycemic symptoms, and lower visual acuity < 0.6 were significantly associated with fall (OR 2.42, p = 0.007 and OR 1.75, p = 0.038 respectively). Age 75-79 years-old had a higher likelihood of fall than the 65-69 age group (OR 2.23, p = 0.044). Patients with HbA1c 7.0-7.4% had a lower risk of recurrent falls when compared to those with intensive control (OR 0.32, p = 0.044). Other risk factors that increased risk of recurrent falls were hypoglycemic symptoms (OR 6.64, p < 0.001) and history of cerebral vascular accident (OR 4.24, p = 0.003). CONCLUSIONS: Hypoglycemic symptoms had a very strong association with falls. Less stringent HbA1c control reduced the risk of recurrent falls. Healthcare professionals need to take a more proactive approach in enquiring about hypoglycemia. There should be individualized diabetic treatment target for the diabetic elderly.

Morbidity Patterns in Primary Care in Hong Kong: Protocol for a Practice-Based Morbidity Survey.

BACKGROUND: Up-to-date and accurate information about the health problems encountered by primary care doctors is essential to understanding the morbidity pattern of the community to better inform health care policy and practice. Morbidity surveys of doctors allow documentation of actual consultations, reflecting the patient's reason for seeking care as well as the doctor's diagnostic interpretation of the illness and management approach. Such surveys are particularly critical in the absence of a centralized primary care electronic medical record database. OBJECTIVE: With the changing sociodemographic profile of the population and implementation of health care initiatives in the past 10 years, the aim of this study is to determine the morbidity and management patterns in Hong Kong primary care during a pandemic and compare the results with the last survey conducted in 2007-2008. METHODS: This will be a prospective, practice-based survey of Hong Kong primary care doctors. Participants will be recruited by convenience and targeted sampling from both public and private sectors. Participating doctors will record the health problems and corresponding management activities for consecutive patient encounters during one designated week in each season of the year. Coding of health problems will follow the International Classification of Primary Care, Second Edition. Descriptive statistics will be used to calculate the prevalence of health problems and diseases as well as the rates of management activities (referral, investigation, prescription, preventive care). Nonlinear mixed effects models will assess the differences between the private and public sectors as well as factors associated with morbidity and management patterns in primary care. RESULTS: The data collection will last from March 1, 2021, to August 31, 2022. As of April 2022, 176 doctor-weeks of data have been collected. CONCLUSIONS: The results will provide information about the health of the community and inform the planning and allocation of health care resources. TRIAL REGISTRATION: ClinicalTrials.gov NCT04736992; https://clinicaltrials.gov/ct2/show/NCT04736992. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37334.

Impact of society and national guidelines on patient selection for lung cancer surgery in the United Kingdom.

OBJECTIVES: We sought to evaluate the impact of different national clinical guidelines (with consistent and conflicting recommendations) on clinician's practice in the UK. METHODS: In this cohort study, we analysed data from National Lung Cancer Audit comprising all patients diagnosed with lung cancer between 2008 and 2013 within England and Wales for consistent (British Thoracic Society and National Institute of Clinical Excellence) recommendations for lower/more permissive lung function but opposing stage (N2) selection parameters for surgery. RESULTS: From 2008 to 2013, data from 167 192 patients with primary lung cancers were included. The proportion of patients undergoing surgery for lung cancer increased from 9.5% to 20.5% in 2013 (P < 0.001) as the number of general thoracic surgeons in the UK increased from 40 to 81 in the corresponding timeframe. Mean forced expiratory volume in 1 s of surgical patients increased from 76% (22) to 81% (22) in 2013 (P < 0.001). Of the patients undergoing surgery, the proportion of patients with N2 disease across the 6-year interval was broadly consistent between 8% and 11% without any evidence of trend (P = 0.125). CONCLUSIONS: Within 3 years of new clinical guideline recommendations, we did not observe any overall change suggesting greater selection for surgery on lower levels of lung function. When presented with conflicting recommendation, no observable change in selection was noted on surgery for N2 disease. The observed increase in surgical resection rates is more likely due to greater access to surgery (by increasing number of surgeons) rather than any impact of guideline recommendations.

Prevalence of major electrocardiographic abnormalities in patients with hypertension in a primary care clinic in Hong Kong.

BACKGROUND: Hypertension is strongly associated with cardiovascular events. Studies have shown that electrocardiographic (ECG) abnormalities were associated with increased risks for cardiovascular events. However local data is limited. The objectives of this study were: (1) to determine the prevalence of major electrocardiographic abnormalities in patients with hypertension in primary care in Hong Kong, and (2) to determine the association of major electrocardiographic abnormalities with patients' socio-economical background, cardiovascular disease and cardiovascular risk factors. METHODS: This was a cross-sectional study. Subjects were hypertensive patients aged between 18 and 80 who were enrolled in the Risk Assessment and Management Programme (RAMP) in a general outpatient clinic in Hong Kong. Outcome measures were prevalence of probable ischaemic heart disease (IHD), complete left bundle branch block (LBBB), left ventricular hypertrophy (LVH) and atrial fibrillation (AF) in patients with hypertension. The Pearson Chi-square test, independent t-test and Mantel-Haenszel test were used to measure the association between socioeconomic characteristics and cardiovascular risk factors, and ECG abnormalities. RESULTS: 504 hypertensive patients aged 18-80 were recruited in a general outpatient clinic. 6.3% had probable IHD, 0.4% had complete LBBB, 4.0% had LVH and 1.0% had AF. Probable IHD was associated with smoking (P = 0.032), hypercholesterolaemia (P = 0.037) and higher 10-year CV risk (P = 0.04). Complete LBBB was associated with smoking (P = 0.021) and hypercholesterolaemia (P = 0.022). LVH was associated with male gender (P = 0.001) and longer duration of hypertension (P = 0.035). AF was not significantly associated with any of the clinical or sociodemographic parameters. CONCLUSIONS: This study showed that a significant proportion of patients with hypertension at the primary care setting in Hong Kong had probable ischaemic heart disease, left ventricular hypertrophy and atrial fibrillation. This finding is consistent with both overseas data and historic data in Hong Kong. The detection of electrocardiographic abnormalities is helpful in hypertension management by improving risk stratification.

Long term clinical outcomes of patients with ischemic stroke in primary care - a 9-year retrospective study.

BACKGROUND: We aim to document the long-term outcomes of ischemic stroke patients and explore the potential risk factors for recurrent cardiovascular events and all-cause mortality in primary care. METHODS: A retrospective cohort study performed at two general out-patient clinics (GOPCs) under Hospital Authority (HA) in Hong Kong (HK). Ischemic stroke patients with at least two consecutive follow-up visits during the recruitment period (1/1-30/6/2010) were included. Patients were followed up regularly till the date of recurrent stroke, cardiovascular event, death or 31/12/2018. The primary outcome was the occurrence of recurrent cerebrovascular event including transient ischemic stroke (TIA), ischemic stroke or hemorrhagic stroke. The secondary outcomes were all-cause mortality and coronary artery disease (CAD). We fit cox proportional hazard model adjusting death as competing risk factor to estimate the cause-specific hazard ratio (csHR). RESULTS: A total of 466 patients (mean age, 71.5 years) were included. During a median follow-up period of 8.7 years, 158 patients (33.9%) died. Eighty patients (17.2%) had recurrent stroke and 57 (12.2%) patients developed CAD. Age was an independent risk factor for recurrent stroke, CAD and death. Statin therapy at baseline had a protective effect for recurrent stroke (csHR = 0.476; 95% confidence interval [CI] 0.285-0.796, P = 0.005) after adjusting death as a competing risk factor and all-cause mortality (HR = 0.693, 95% CI 0.486-0.968, P = 0.043). In addition, female sex, antiplatelet and a higher diastolic blood pressure (DBP) at baseline were also independent predictors for survival. CONCLUSIONS: Long term prognosis of ischemic stroke patients in primary care is favorable. Use of statin was associated with a significant decrease in stroke recurrence and mortality. Patients who died had a significant lower DBP at baseline, highlighted the need to consider both systolic and diastolic blood pressure in our daily practice.

Qualitative Analysis of the "Healthy Growing at School Program" - Vision of Health Professionals, School Community and Family / Análise Qualitativa do Programa Crescer Saudável na Escola - Visão dos Profissionais de Saúde, da Comunidade Escolar e da Família

INTRODUCTION: At present, school institutions exert a great influence on the diet of their pupils, since they usually remain for a long time in these places. The Food and Nutrition Education can help in the creation of healthy eating habits among children. OBJECTIVE: To analyze the results of the Healthy Growing in School Program with regard to encouraging healthy eating habits among preschoolers at a school in São Paulo (São Paulo, Brazil). METHODS: The Program lasted 1 academic year. The sample consisted of 108 children of both sexes, aged 4 to 6 years. A questionnaire was applied to those responsible for characterization and questions to measure the level of knowledge about balanced eating (score 0-37 points) at the beginning and end of the Program. Eighteen play activities were carried out with the children, and two with the parents. This study was approved by the Ethics Committee of the São Camilo University Center (No.2,450,931). RESULTS: Most of the parents or guardians have a high school education, receive from 1-3 minimum salaries and have a nutritional diagnosis of eutrophic. The average score of the food knowledge questionnaire was 27.0±2.5 at the beginning of the Program and did not show a significant difference at the end (p=0,322). From the development of educational activities, it was possible to observe that the preschoolers acquired more knowledge about the fruits, vegetables and vegetables most commonly consumed in São Paulo. The vision of the school community and families was positive about the Program. CONCLUSION: The Program provided has increased interest in healthy eating practices among children.

INTRODUÇÃO: Atualmente, as instituições escolares exercem grande influência na alimentação dos alunos, pois, geralmente, permanecem longo período nestes locais. A Educação Alimentar e Nutricional pode auxiliar numa possível criação de hábitos alimentares saudáveis entre as crianças. OBJETIVO: Analisar os resultados do Programa Crescer Saudável na Escola no que se refere ao estímulo de hábitos alimentares saudáveis entre os pré-escolares em uma escola municipal em São Paulo (SP, Brasil). MÉTODO: O Programa teve duração de 1 ano letivo. A amostra foi composta por 108 crianças de ambos os sexos, com idade de 4 a 6 anos. Foi aplicado um questionário aos responsáveis para caracterização e medir o nível de conhecimento sobre alimentação equilibrada (0-37 pontos) no início e no final do Programa. Foram realizadas dezoito atividades com as crianças, e duas com os pais. Este estudo foi aprovado pelo Comitê de Ética. RESULTADOS: A maioria dos pais tem ensino médio, recebem de 1-3 salários mínimos e apresentam diagnóstico nutricional de eutrofia. A pontuação média do questionário foi de 27,0±2,5 no início do Programa, e não apresentou diferença significativa no final (p=0,322). A partir do desenvolvimento das atividades educativas foi possível observar que os pré-escolares adquiriram maior conhecimento sobre frutas, verduras e legumes mais comumente consumidos em SP. As percepções da comunidade escolar e das famílias foram positivas. CONCLUSÃO: O Programa proporcionou aumento do interesse sobre práticas alimentares saudáveis entre as crianças.

Exercise Intervention to Normalize Blood Pressure and Nocturnal Dipping in HyperTensive Patients (END-HT): Protocol of a Randomized Controlled Trial.

BACKGROUND: Lack of decrease (≤10%) in systolic blood pressure (BP) during sleep, referred to as non-dipping (ND), independently predicts cardiovascular events and mortality. There has been no prospective and adequately powered randomized controlled trial (RCT) to determine whether exercise, when compared with standard treatment, can normalize ND in patients with hypertension (HT). Further, most patients do not sustain an exercise program by 12 months. METHODS: A 2-arm, assessor-blinded RCT, involving 198 hypertensive Chinese patients who have ND will be conducted to evaluate the effectiveness of a combined exercise (aerobic exercise and resistance training) program to normalize ND. The combined exercise program, "exercise is medicine" (EIM), was developed to maintain exercise habit using a variety of techniques (e.g. 12-week exercise classes, mobile application, wrist trackers, self-scheduling, monitoring, regular feedback, and motivational interviewing). Eligible patients will be randomized to EIM plus usual care or to usual care in 1:1 ratio by stratified randomization according to age and sex. The randomization sequence is blinded to the investigators and allocation is disclosed only after valid consent. Ambulatory BP measurements will be performed at baseline, 3, and 12 months. The primary outcome is proportion of participants with ND at 3 months; secondary outcomes include proportion of participants with ND at 12 months, absolute BP values at 3 and 12 months. Exercise level will be detected by validated questionnaire and compared between 2 arms at 3 and 12 months. CONCLUSION: The trial will examine the efficacy of treating ND and HT by an exercise program.

Blood-based circulating tumor DNA mutations as a diagnostic and prognostic biomarker for lung cancer.

BACKGROUND: The objectives of the current study were to develop an initial blood-based circulating tumor DNA (ctDNA) gene signature and to validate the clinical test performance in patients with early primary and secondary lung cancer. METHODS: Between January 2009 and October 2014, a total of 211 patients with known or suspected lung cancer donated their blood prior to surgery and were followed up to May 2018. ctDNA was extracted from plasma and from corresponding formalin-fixed, paraffin-embedded tissues. The blood was analyzed in a blinded manner and pathology reports were issued that were blinded to the blood test results. The reference standard was histopathology confirmed cancer in the resected surgical specimens as reported according to World Health Organization criteria and staged using the eighth edition of the TNM Classification of Malignant Tumors criteria. RESULTS: Of 211 consenting patients, 19 (9.0%) were excluded, leaving 192 participants, consisting of 95 men (49%) and with a mean age of 63 years (SD, 15 years). The clinical test performance for the blood-based diagnostic signature demonstrated a sensitivity of 75% (95% CI, 67%-81%), specificity of 89% (95% CI, 70%-98%), positive predictive value of 98% (95% CI, 93%-100%), and negative predictive value of 35% (95% CI, 24%-48%) when compared with conventional clinical histopathology reporting of the resected tissue. CONCLUSIONS: The results of the current study suggested that blood-based ctDNA analysis of cancer mutations is a specific, noninvasive test for the diagnosis of cancer.