Sociodemographic moderation of the association between depression and stroke incidence in a retrospective cohort of 0.4 million primary care recipients with hypertension.

BACKGROUND: Previous research has suggested an association between depression and subsequent acute stroke incidence, but few studies have examined any effect modification by sociodemographic factors. In addition, no studies have investigated this association among primary care recipients with hypertension. METHODS: We examined the anonymized records of all public general outpatient visits by patients aged 45+ during January 2007-December 2010 in Hong Kong to extract primary care patients with hypertension for analysis. We took the last consultation date as the baseline and followed them up for 4 years (until 2011-2014) to observe any subsequent acute hospitalization due to stroke. Mixed-effects Cox models (random intercept across 74 included clinics) were implemented to examine the association between depression (ICPC diagnosis or anti-depressant prescription) at baseline and the hazard of acute stroke (ICD-9: 430-437.9). Effect modification by age, sex, and recipient status of social security assistance was examined in extended models with respective interaction terms specified. RESULTS: In total, 396 858 eligible patients were included, with 9099 (2.3%) having depression, and 10 851 (2.7%) eventually hospitalized for stroke. From the adjusted analysis, baseline depression was associated with a 17% increased hazard of acute stroke hospitalization [95% confidence interval (CI) 1.03-1.32]. This association was suggested to be even stronger among men than among women (hazard ratio = 1.29, 95% CI 1.00-1.67). CONCLUSION: Depression is more strongly associated with acute stroke incidence among male than female primary care patients with hypertension. More integrated services are warranted to address their needs.

How common are Chinese patients with multimorbidity involved in decision-making and having a treatment plan? A cross-sectional study.

BACKGROUND: Creating a treatment plan (TP) through shared decision-making (SDM) with healthcare professionals is of paramount importance for patients with multimorbidity (MM). This study aims to estimate the prevalence of SDM and TP in patients with MM and study the association between SDM/TP with patients' confidence to manage their diseases and hospitalization within the previous 1 year. METHOD: This cross-sectional study used an internationally recognized survey. A total of 1032 patients aged 60 or above with MM were recruited from a specialist outpatient clinic, general outpatient clinic (GOPC) and a geriatric day hospital. The proportion of patients reported to have SDM and TP was estimated. Associations between the presence of SDM/TP and patients' demographic data, the confidence level to manage their illnesses and hospitalization in previous 1 year were then studied using logistic regression. RESULTS: The prevalence of SDM and TP was 35.8% and 82.1%, respectively. The presence of TP was associated with receiving healthcare from the same doctor or in the same facilities and being recruited from GOPC. The presence of SDM (OR = 1.352, P = .089) and TP (OR = 2.384, P < .001) was associated with enhanced confidence in dealing with diseases. CONCLUSION: Most people with MM had TP in Hong Kong, but fewer patients had SDM. PRACTICE IMPLICATIONS: Ways to promote SDM in HK are needed.

Association between antipsychotic use and acute ischemic heart disease in women but not in men: a retrospective cohort study of over one million primary care patients.

BACKGROUND: Research comparing sex differences in the effects of antipsychotic medications on acute ischemic heart disease (IHD) is limited and the findings ambiguous. This study aimed to investigate these associations within a primary care setting. METHODS: Hong Kong public general outpatient electronic records of patients aged 45+ during 2007-2010 were extracted, with the last consultation date as the baseline for a 4-year follow-up period to observe acute IHD hospitalizations (2011-2014). Antipsychotic use was defined as any prescription over the previous 12 months from a list of 16 antipsychotics, while acute IHD was defined by ICD-9: 410.00-411.89. Both sex-specific and sex-combined (both sexes) mixed-effects Cox models (random intercept across 74 clinics) were implemented to examine the association and test the interaction between antipsychotics and sex. RESULTS: Among 1,043,236 included patients, 17,780 (1.7%) were prescribed antipsychotics, and 8342 (0.8%) developed IHD. In sex-specific analyses, antipsychotic prescription was associated with a 32% increased hazard rate of acute IHD among women (95% CI 1.05-1.67) but not among men. A likelihood ratio test comparing sex-combined models with and without the interaction between antipsychotic use and sex suggested significant interaction (χ2 = 4.72, P = 0.030). The association between antipsychotic use and IHD among women attenuated and became non-significant when haloperidol was omitted from the operationalization of antipsychotic use (HR = 1.23, 95% CI 0.95-1.60). CONCLUSION: Our results suggest that antipsychotic prescription is moderately associated with an increased risk of acute IHD among women in primary care and this relationship may be explained by specific antipsychotics. Further research should observe and capture the potential intermediary mechanisms and the dose-response relationship of this association to provide more rigorous evidence to establish causality and inform clinical practices.

Dynamic Changes in Long-Term Exposure to Ambient Particulate Matter and Incidence of Hypertension in Adults.

Many countries dedicated in mitigation of air pollution in the past several decades. However, little is known about how air quality improvement affects health. Therefore, we conducted current study to investigate dynamic changes in long-term exposure to ambient particulate matter (PM2.5) and incidence of hypertension in a large longitudinal cohort. We recruited 134 978 adults aged 18 years or above between 2001 and 2014. All the participants received a series of standard medical examinations, including measurements of blood pressure. The PM2.5 concentration was estimated using a satellite-based spatiotemporal model at a high resolution (1×1 km2). The change in long-term exposure to PM2.5 (ΔPM2.5) was defined as the difference between the values measured during follow-up and during the immediately preceding visit, and a negative value indicated an improvement in PM2.5 air quality. Time-varying Cox model was used to examine the associations between ΔPM2.5 and the development of hypertension. The results show that PM2.5 concentrations increased in 2002, 2003, and 2004, but began to decrease in 2005. Every 5 µg/m3 change in exposure to PM2.5 (ie, a ΔPM2.5 of 5 µg/m3) was associated with a 16% change in the incidence of hypertension (hazard ratio, 0.84; 95% CI, 0.82-0.86). Both stratified and sensitivity analyses generally yielded similar results. We found that an improvement in PM2.5 exposure is associated with a decreased incidence of hypertension. Our findings demonstrate that air pollution mitigation is an effective strategy to reduce the risk of cardiovascular disease.

Epidemiology of abdominal aortic aneurysms in a Chinese population during introduction of endovascular repair, 1994 to 2013: A retrospective observational study.

The aim of this study was to examine changes in abdominal aortic aneurysm repair and mortality during a period when endovascular aneurysm repair (EVAR) was introduced.Open repair surgery was the mainstay of treatment for abdominal aortic aneurysm (AAA), but EVAR is increasingly utilized. Studies in the Western population have reported improved short-term or postoperative mortality and shorter length of hospital stay with EVAR. However, scant data are available in the Chinese population.We conducted a retrospective observational study using the database of the Hospital Authority, which provides public health care to most of the Hong Kong population. AAA patients admitted to public hospitals for intact repair or rupture from 1994 to 2013 were included in this study. We calculated the incidence of ruptured AAA, annual repair rates according to type of AAA and surgery, as well as death rates (operative and overall short-term). We calculated whether there were significant changes over time and compared short-term mortality between open surgery and EVAR.One thousand eight hundred eighty-five patients were admitted for intact repair and 1306 patients were admitted for AAA rupture, of whom 795 underwent rupture repair. Intact repair rates significantly increased in all age groups (7.3-37.8%, P < .001) over the study period.The incidence of ruptured AAA increased, in all age groups, except in < 64 years old. By 2013, 85% of intact repairs and 55.4% of rupture repair were done by EVAR. Over time, there was a significant decrease in operative mortality for intact repair (16.5 in 1994 to 7.1 in 2013, P = .01) and rupture repair (59.7 in 1994 to 30.8 in 2013, P = .003). Over the same time period, short-term AAA-related deaths decreased by more than half (73% in 1994 to 24% in 2013, P < .001), with a significant decline in all age groups, except < 64 years old. Short-term mortality was significantly lower for EVAR than for open repair (17.2% vs 40.3%, P < .01).Short-term AAA-related deaths have declined likely due to decreased operative mortality and rupture deaths during the period of EVAR introduction and expansion.

CALIPSO IIR Version 2 Level 1b calibrated radiances: analysis and reduction of residual biases in the Northern Hemisphere.

Version 2 of the Level 1b calibrated radiances of the Imaging Infrared Radiometer (IIR) on board the Cloud-Aerosol Lidar and Infrared Satellite Observation (CALIPSO) satellite has been released recently. This new version incorporates corrections of small but systematic seasonal calibration biases previously revealed in Version 1 data products mostly north of 30° N. These biases of different amplitudes in the three IIR channels 8.65 µm (IIR1), 10.6 µm (IIR2), and 12.05 µm (IIR3) were made apparent by a striping effect in images of IIR inter-channel brightness temperature differences (BTDs) and through seasonal warm biases of nighttime IIR brightness temperatures in the 30-60° N latitude range. The latter were highlighted through observed and simulated comparisons with similar channels of the Moderate Resolution Imaging Spectroradiometer (MODIS) on board the Aqua spacecraft. To characterize the calibration biases affecting Version 1 data, a semi-empirical approach is developed, which is based on the in-depth analysis of the IIR internal calibration procedure in conjunction with observations such as statistical comparisons with similar MODIS/Aqua channels. Two types of calibration biases are revealed: an equalization bias affecting part of the individual IIR images and a global bias affecting the radiometric level of each image. These biases are observed only when the temperature of the instrument increases, and they are found to be functions of elapsed time since night-to-day transition, regardless of the season. Correction coefficients of Version 1 radiances could thus be defined and implemented in the Version 2 code. As a result, the striping effect seen in Version 1 is significantly attenuated in Version 2. Systematic discrepancies between nighttime and daytime IIR-MODIS BTDs in the 30-60° N latitude range in summer are reduced from 0.2 K in Version 1 to 0.1 K in Version 2 for IIR1-MODIS29. For IIR2-MODIS31 and IIR3-MODIS32, they are reduced from 0.4 K to close to zero, except for IIR3-MODIS32 in June, where the night-minus-day difference is around -0.1 K.

CALIPSO Lidar Calibration at 532 nm: Version 4 Nighttime Algorithm.

Data products from the Cloud-Aerosol Lidar with Orthogonal Polarization (CALIOP) on board Cloud-Aerosol Lidar and Infrared Pathfinder Satellite Observations (CALIPSO) were recently updated following the implementation of new (version 4) calibration algorithms for all of the level 1 attenuated backscatter measurements. In this work we present the motivation for and the implementation of the version 4 nighttime 532 nm parallel channel calibration. The nighttime 532 nm calibration is the most fundamental calibration of CALIOP data, since all of CALIOP's other radiometric calibration procedures - i.e., the 532 nm daytime calibration and the 1064 nm calibrations during both nighttime and daytime - depend either directly or indirectly on the 532 nm nighttime calibration. The accuracy of the 532 nm nighttime calibration has been significantly improved by raising the molecular normalization altitude from 30-34 km to 36-39 km to substantially reduce stratospheric aerosol contamination. Due to the greatly reduced molecular number density and consequently reduced signal-to-noise ratio (SNR) at these higher altitudes, the signal is now averaged over a larger number of samples using data from multiple adjacent granules. As well, an enhanced strategy for filtering the radiation-induced noise from high energy particles was adopted. Further, the meteorological model used in the earlier versions has been replaced by the improved MERRA-2 model. An aerosol scattering ratio of 1.01 ± 0.01 is now explicitly used for the calibration altitude. These modifications lead to globally revised calibration coefficients which are, on average, 2-3% lower than in previous data releases. Further, the new calibration procedure is shown to eliminate biases at high altitudes that were present in earlier versions and consequently leads to an improved representation of stratospheric aerosols. Validation results using airborne lidar measurements are also presented. Biases relative to collocated measurements acquired by the Langley Research Center (LaRC) airborne high spectral resolution lidar (HSRL) are reduced from 3.6% ± 2.2% in the version 3 data set to 1.6% ± 2.4 % in the version 4 release.

Peer Education Group Intervention to Reduce Psychological Insulin Resistance: A Pilot Mixed-Method Study in a Chinese Population.

INTRODUCTION: Psychological insulin resistance (PIR) is common among type II diabetes (DM) patients. Although interventions to reduce PIR have been suggested, there is no standardized intervention to reduce PIR. This trial aimed to assess the preliminary effectiveness of a well-structured interventional patient group (for sample size calculation for larger trials), as well as the acceptability and feasibility of this intervention group. METHODS: This study used a quasi-experimental, mixed-method approach. Fifty-three patients with DM were recruited to an interventional group that included a general education of DM and insulin, an insulin pen demonstration, and an insulin-using peer sharing session. Each group consisted of around 15 participants and lasted for 2 h each. The validated Chinese version of the insulin treatment appraisal scale (C-ITAS) was administered before, immediately after, and 1 month after the intervention to measure any changes in the participants' PIR. Patients were interviewed to assess the acceptability of the intervention until data saturation. RESULTS: Repeated measures ANOVA showed that the post-intervention C-ITAS scores (immediately post group and at 1 month) were lower than the pre-intervention C-ITAS scores (p < 0.001). Changes in multiple attitudes toward insulin were detected before and after the group intervention. Ten patient interviews were conducted and found that the intervention was welcomed by all interviewees; no discomfort or adverse reactions were reported. CONCLUSION: Preliminary results showed that patient intervention groups with general education, insulin pen demonstration, and peer sharing appeared to be safe, acceptable, and effective in reducing PIR. Larger multicenter trials are needed to generalize these findings.

Translation and validation of the Insulin Treatment Appraisal Scale in Hong Kong primary care patients.

AIMS/INTRODUCTION: Patients with type 2 diabetes mellitus often delay the initiation or titration of insulin treatment due to psychological factors. This phenomenon is referred to as psychological insulin resistance (PIR). The Insulin Treatment Appraisal Scale (ITAS) is a 20-item instrument for assessing PIR. A previous Chinese version of the ITAS (C-ITAS) was found to be subject to problems arising from its translation. The present study aimed to translate and validate this instrument, which will facilitate research and aid in counseling in a clinical setting. MATERIALS AND METHODS: The C-ITAS was modified to develop the Hong Kong version of the C-ITAS (C-ITAS-HK) according to published guidelines for the translation of transcultural research. A total of 328 diabetes mellitus patients who were followed-up in 10 different publically funded primary care outpatient clinics were recruited for self-administration of the C-ITAS-HK. Demographic data were recorded, and clinical data (e.g., presence of diabetes mellitus complications) were obtained from case records. The C-ITAS-HK results were subjected to psychometric analysis, including the assessment of Cronbach's alpha, factor analysis and test-retest reliability. RESULTS: Factor analysis supported a two-factor structure with good internal consistency (whole scale 0.846, negative subscale 0.882, positive subscale 0.619). The test-retest reliability correlation coefficients for all items were positive, at 0.871, 0.782, and 0.692 for the whole scale, negative subscale and positive subscale, respectively. The ITAS scores differed significantly between participants with PIR and those without in the expected direction, suggesting good discriminant validity. CONCLUSIONS: The C-ITAS-HK is a valid tool for measuring and assessing PIR in the Hong Kong primary care diabetes mellitus population.

Psycholosocial factors associated with psychological insulin resistance in primary care patients in Hong Kong.

AIM: Patients with diabetes mellitus (DM) often delay the initiation of insulin treatment and titration due to psychological factors. This phenomenon is called psychological insulin resistance (PIR). The insulin treatment appraisal scale (ITAS) that was initially developed for Western populations has been translated and validated to measure PIR in Taiwanese populations (C-ITAS). This study aims to estimate the prevalence of PIR in primary care patients with DM in Hong Kong and to examine the relationship between PIR and psychosocial factors. METHOD: 402 DM patients from a government-funded general outpatient clinic completed the C-ITAS and a health questionnaire (the Patient Health Questionnaire-9, PHQ-9). Patient demographics were recorded and associations among C-ITAS scores, PHQ-9 scores and demographic data were evaluated. RESULTS: There was no relationship between the presence of depression and PIR. Furthermore, the prevalence of PIR was 47.2% in insulin-naive patients but only 8.7% in current insulin users. Tools such as the C-ITAS may help clinicians understand the etiology of PIR, which this study suggests is likely the result of multiple risk factors. Factors associated with a lower prevalence of PIR included current insulin use, a family history of insulin use, a high education level, male sex, and having received counseling from a physician about insulin within the previous 6 months.