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OBJECTIVES This study aimed to evaluate the most updated worldwide distribution, risk factors, and temporal trends of cervical cancer for different countries and age groups. METHODS The Global Cancer Observatory database was retrieved for the age-standardized rates (ASRs, per 100,000 persons) for incidence and mortality of cervical cancer in 2018. The associations with risk factors were examined by multivariable regression analysis, adjusting for human development index (HDI) and gross domestic products (GDP) per capita. Joinpoint regression analysis was used to calculate the 10-year annual average percent change (AAPC) for incidence and mortality. RESULTS A total of 568,847 new cases (ASR, 13.1) and 311,365 deaths (ASR, 6.9) of cervical cancer were reported globally in 2018. The highest incidence and mortality were observed in Southern Africa (ASRs, 43.1 and 20.0) and countries with low HDI (ASRs, 29.8 and 23.0). Countries with higher incidence and mortality had lower HDI (β = -8.19, 95% CI -11.32 to -5.06, p

Background: We aimed to examine the global disease burden and trends of prostate cancer incidence and mortality by age, and their associations with gross domestic product (GDP), human development index (HDI), smoking, and alcohol drinking. Materials and Methods: We retrieved the Global Cancer Observatory (GLOBOCAN) database for the incidence and mortality of prostate cancer in 2020; the World Bank for GDP per capita; the United Nations for HDI; the WHO Global Health Observatory for prevalence of smoking and alcohol drinking; the Cancer Incidence in 5 Continents (CI5), WHO mortality database, for trend analysis. We presented the prostate cancer incidence and mortality using age-standardized rates. We examined their associations with GDP, HDI, smoking, and alcohol drinking by Spearman's correlations and multivariable regression. We estimated the 10-year trend of incidence and mortality by joinpoint regression analysis with average annual percent change with 95% confidence intervals in different age groups. Results: A wide variation in the burden of prostate cancer with the highest mortality found in low-income countries while the highest incidence was observed in high-income countries. We found moderate to high positive correlations for GDP, HDI, and alcohol drinking with prostate cancer incidence, whilst a low negative correlation was observed for smoking. Globally, there was an increasing incidence but decreasing mortality of prostate cancer, and such trends were particularly prominent in Europe. Notably, the incidence increase was also found in the younger population aged

BACKGROUND Pneumococcal infection is a leading cause of disability and death globally. The Hong Kong Government has launched two programmes for pneumococcal vaccination - The Vaccination Subsidy Scheme (VSS) and the Government Vaccination Programme (GVP). This study aimed to examine the enabling factors, obstacles and perception of pneumococcal vaccination, and their association with its uptake in a general Chinese population. METHODS We performed a population-based, telephone survey in the general public aged 65 or above via simple random sampling. A validated survey based on the Health Belief Model (HBM) was used. Their socio-demographic information; history of previous participation in the GVP or VSS; and self-perceived health status were captured. Binary logistic regression models were constructed to examine the factors independently associated with vaccination. RESULTS A total of 1,000 respondents were enrolled in the study, with 402 (40.2%) respondents having intention to join the GVP/VSS in 12 months. Respondents with long-term medical consultant and medication (adjusted odds ratios [aOR] = 1.541, 95% confidence interval (CI): 1.008-2.356, p = 0.046); high levels of perceived susceptibility of infections (aOR = 3.624, 95 %CI: 2.318-5.665, p

Background The World Health Organization (WHO) declared coronavirus disease-19 (COVID-19) as a pandemic on March 11, 2020. The impact of COVID-19 on urological services in different geographical areas is unknown. Objective To investigate the global impact of COVID-19 on urological providers and the provision of urological patient care. Design, setting, and participants A cross-sectional, web-based survey was conducted from March 30, 2020 to April 7, 2020. A 55-item questionnaire was developed to investigate the impact of COVID-19 on various aspects of urological services. Target respondents were practising urologists, urology trainees, and urology nurses/advanced practice providers. Outcome measurements and statistical analysis The primary outcome was the degree of reduction in urological services, which was further stratified by the geographical location, degree of outbreak, and nature and urgency of urological conditions. The secondary outcome was the duration of delay in urological services. Results and limitations A total of 1004 participants responded to our survey, and they were mostly based in Asia, Europe, North America, and South America. Worldwide, 41% of the respondents reported that their hospital staff members had been diagnosed with COVID-19 infection, 27% reported personnel shortage, and 26% had to be deployed to take care of COVID-19 patients. Globally, only 33% of the respondents felt that they were given adequate personal protective equipment, and many providers expressed fear of going to work (47%). It was of concerning that 13% of the respondents were advised not to wear a surgical face mask for the fear of scaring their patients, and 21% of the respondents were advised not to discuss COVID-19 issues or concerns on media. COVID-19 had a global impact on the cut-down of urological services, including outpatient clinic appointments, outpatient investigations and procedures, and urological surgeries. The degree of cut-down of urological services increased with the degree of COVID-19 outbreak. On average, 28% of outpatient clinics, 30% of outpatient investigations and procedures, and 31% of urological surgeries had a delay of >8 wk. Urological services for benign conditions were more affected than those for malignant conditions. Finally, 47% of the respondents believed that the accumulated workload could be dealt with in a timely manner after the COVID-19 outbreak, but 50% thought the postponement of urological services would affect the treatment and survival outcomes of their patients. One of the limitations of this study is that Africa, Australia, and New Zealand were under-represented. Conclusions COVID-19 had a profound global impact on urological care and urology providers. The degree of cut-down of urological services increased with the degree of COVID-19 outbreak and was greater for benign than for malignant conditions. One-fourth of urological providers were deployed to assist with COVID-19 care. Many providers reported insufficient personal protective equipment and support from hospital administration. Patient summary Coronavirus disease-19 (COVID-19) has led to significant delay in outpatient care and surgery in urology, particularly in regions with the most COVID-19 cases. A considerable proportion of urology health care professionals have been deployed to assist in COVID-19 care, despite the perception of insufficient training and protective equipment., Take Home Message The coronavirus disease-19 (COVID-19) pandemic has imposed great challenges to the urological community globally. The impact of COVID-19 on urological services increased with the degree of outbreak, and resulted in significant delay in the delivery of urological care.

Background and Aims: \ud This systematic review and meta-analysis aims to compare the pooled diagnostic accuracy of the currently available esophageal squamous cell carcinoma (ESCC) screening tests.\ud \ud Methods: \ud A comprehensive literature search of Embase and Medline (up to October 31, 2020) was performed to identify eligible studies. We pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) for ESCC screening tools using a bivariate random-effects model. The summary receiver operating characteristic (sROC) curves with area under the curve (AUC) were plotted for each screening test.\ud \ud Results: \ud We included 161 studies conducted in 81 research articles involving 32,209 subjects. The pooled sensitivity, specificity, and AUC (95% CIs) of the major screening tools were: (1). Endoscopy (per-oral endoscopy): 0.94 (0.87-0.97), 0.92 (0.87-0.95), and 0.97 (0.96-0.99); (2) Endoscopy (transnasal endoscopy): 0.85 (0.70-0.93), 0.96 (0.91-0.98), and 0.97 (0.95, -0.98); (3). MicroRNA: 0.77 (0.75-0.80), 0.78 (0.75-0.80), and 0.85 (0.81-0.87); (4). Autoantibody: 0.45 (0.36-0.53), 0.91 (0.89-0.93), and 0.84 (0.81-0.87); and (5). Cytology: 0.82 (0.60-0.93), 0.97 (0.88-0.99), and 0.97 (0.95-0.98). There was high heterogeneity.\ud \ud Conclusions: \ud The diagnostic accuracy seems comparable between Cytology and endoscopy, whilst autoantibody and microRNAs bear potential as future non-invasive screening tools for ESCC. To reduce ESCC-related death in the high-risk populations, it is important to develop a more accurate and less invasive screening test.

Objectives To examine severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant replacement in association with containment capacity and changes in case fatality at country level. Methods Altogether, 69 571 full SARS-CoV-2 genomes collected globally within the first 6 months of the pandemic were examined. The correlation between variant replacement and containment capacity was examined by logistic regression models using the WHO International Health Regulation (IHR) score, the Oxford COVID-19 Government Response Tracker (OxCGRT) and the vulnerability index INFORM as proxies, while correlation with changes in monthly crude case fatality ratios was examined by a mixed effect model. Results At the global level, variant lineage G∗, characterized by the S-D614G mutation, replaced the older lineages L and S in March 2020. European countries—including Finland, France and Italy—were the first to reach a 50% increment of G∗, whereas only Singapore and South Korea had non-G∗ persisting throughout the first 6 months. Countries with higher IHR scores (β-coefficient –0.001, 95%CI –0.016, –0.001; p 0.034) and higher stringency indexes (OxCGRT) (β-coefficient –0.011, 95%CI –0.020, –0.001; p 0.035) were associated with lower levels of G∗ replacement, whereas higher vulnerability indexes (INFORM) (β-coefficient 0.049, 95%CI 0.001, 0.097; p 0.044) were associated with higher replacement levels. Crude case fatality ratio showed a positive correlation with G∗ replacement (β-coefficient: 0.034, 95%CI 0.011, 0.058; p 0.004), even after adjusting for testing capacity and other country-specific characteristics. Conclusions SARS-CoV-2 variant lineage G∗ (S-D614G) replaced older lineages more efficiently in countries with lower containment capacity, and its possible association with increased disease severity deserves further investigation.

Background: Sessile serrated adenoma/polyp is notorious for its malignancy potential and the difficulty to be detected and distinguished under endoscopy. This systematic review and meta-analysis aimed to evaluate endoscopic characteristics of SSA/P and delineate features that inform distinction between SSA/P and other types of lesions, including hyperplasitc polyp (HP) and conventional adenoma. Methods: MEDLINE, Embase and Cochrane Library from the inception to September 9, 2020 were searched for cohort, cross-sectional or case-control studies comparing endoscopic characteristics of SSA/P and other polyps. The primary outcome measure was the odds of finding specific endoscopic characteristics in patients with SSA/P compared with other types of polys in patients undergoing colorectal cancer screening. Findings: We included 74 studies from 16 countries comprising 34,535 SSA/P. Compared with HP, SSA/P was more likely to be in the right colon (OR 5.45; 95% CI 4.13-7.17; P 5mm vs.

Background Fibroblast growth factor 21 is a signalling protein involved in cell differentiation, morphogenesis, proliferation and metabolism. Recent studies have associated increased levels of FGF21 in the development of cardiovascular diseases, whereas others have reported no significant associations. Therefore, this systematic review and meta-analysis evaluated the value in predicting the risk of cardio-metabolic disorders and mortality. Methods PubMed and EMBASE were searched until 5th September 2017 for studies that evaluated the roles of FGF21 levels in cardio-metabolic disorders. Results A total of 183 and 301 entries were retrieved; 24 studies met the inclusion criteria. Four studies were identified by an additional search. Therefore, 28 studies were included in the final meta-analysis. High FGF21 levels significantly predicted the incidence of coronary artery disease (hazard ratio [HR]: 1.29; 95% confidence interval [CI]: 1.06–1.55; P Conclusion FGF21 significantly predicts the incidence of coronary artery disease, the risks of metabolic syndrome, diabetes mellitus and renal progression in diabetes. It also predicted all-cause and cardiovascular mortality.

Background and objectives Congenital long QT syndrome (LQTS) predisposes affected individuals to ventricular tachycardia/fibrillation (VF/VF), potentially resulting in sudden cardiac death. The Tpeak–Tend interval and the Tpeak–Tend/QT ratio, electrocardiographic markers of dispersion of ventricular repolarization, were proposed for risk stratification but their predictive values in LQTS have been controversial. A systematic review and meta-analysis was conducted to examine the value of Tpeak–Tend intervals and Tpeak–Tend/QT ratios in predicting arrhythmic and mortality outcomes in congenital LQTS. Method PubMed and Embase databases were searched until 9th May 2017, identifying 199 studies. Results Five studies on long QT syndrome were included in the final meta-analysis. Tpeak–Tend intervals were longer (mean difference [MD]: 13 ms, standard error [SE]: 4 ms, P = 0.002; I2 = 34%) in congenital LQTS patients with adverse events [syncope, ventricular arrhythmias or sudden cardiac death] compared to LQTS patients without such events. By contrast, Tpeak–Tend/QT ratios were not significantly different between the two groups (MD: 0.02, SE: 0.02, P = 0.26; I2 = 0%). Conclusion This meta-analysis showed that Tpeak–Tend interval is significant higher in individuals who are at elevated risk of adverse events in congenital LQTS, offering incremental value for risk stratification.

Impact of percutaneous coronary interventions (PCI) on health-related quality of life (HRQOL) is important but under-reported in elderly patients.To evaluate long-term health status in elderly patients who underwent PCI.Consecutive patients who underwent PCI at a university-affiliated hospital from September 2009 to June 2012 were prospectively enrolled with HRQOL assessment at baseline (up to 2 weeks before PCI) and at 6-, 12-, and 36-month follow-up using the EuroQol five-dimensional questionnaire descriptive profile and visual analogue scale (VAS). Minimally important benefit (MIB) in HRQOL was defined as greater than half an SD improvement in the baseline VAS score.Of 1957 patients, 49.9%, 29.1%, and 21.0% were aged younger than 65 years, 65 to 74 years, and 75 years and older, respectively. Mean VAS scores at baseline (50.1 ± 20.5 vs. 51.6 ± 20.5 vs. 52.6 ± 21.8; P = 0.09) and at 36 months (72.9 ± 14.0 vs. 72.8 ± 16.1 vs. 72.0 ± 14.8; P = 0.77) were similar between the three age groups, respectively. MIB at 36 months was observed in 65.7%, 61.9%, and 61.2% of patients in each age group, respectively. Proportion of patients aged 75 years and older reporting problems in pain/discomfort and self-care reduced from 91.2% and 24.8% at baseline to 41.4% and 10.1% at 36 months, respectively (both P0.01). Independent predictors of MIB in HRQOL at 36 months in patients 75 years and older included poor baseline HRQOL, MIB at 6 months, and presentation with myocardial infarction (all P0.01).Elderly patients experienced sustained long-term improvement in quality of life comparable with younger patients after PCI. Our findings suggest that age per se should not deter against revascularization because of sustained benefit in HRQOL.

Background Pancreatic cancer has been associated with lifestyle factors, but few comparative studies were conducted among countries of different culture and lifestyle habits. This study compared the trends of pancreatic cancer incidence and birth cohort effects in the United States and urban China and explored the potential discrepancies of risk patterns. Materials and methods Age-standardized incidence rates (ASIRs) were calculated using data from national or regional cancer registries of the United States and two large cities of China (Shanghai, Hong Kong). The temporal trends of incidence were assessed by joinpoint regression. The effects of birth cohort and calendar period were identified through age–period–cohort modeling. Results The ASIR in the United States from 1976 to 2015 was 8.26/100 000, which was higher than that in Hong Kong (4.29/100 000) and Shanghai of China (6.63/100 000). Shanghai had lower incidence (4.41/100 000) in 1976-1980 but increased annually by 1.38% in males and 1.67% in females, with a sharper upward trend than the United States and Hong Kong. Males had higher risks than females, with a male-to-female ratio of 1.34, 1.44, and 1.37 in the United States, Hong Kong, and Shanghai, respectively. A significant and prominent increase in incidence rate was observed among successive generations in China particularly for Shanghai, but such a pattern was not apparent in the United States. Conclusions The differences in pancreatic cancer incidence by sex may be multi-factorial involving known risk factors like tobacco smoking and alcohol consumption. The significant birth cohort effects among recent and early generations in the Shanghai population were in line with a society in socioeconomic transition and adoption of Western lifestyle mainly including consumption of calorie-rich foods and physical inactivity. Differences in these risk patterns will have implications on health care efforts and policies for cancer control., Highlights • The ASIR of pancreatic cancer in the U.S. is higher than that in urban China. • Higher risk of pancreatic cancer was observed in the youth of urban China, but this pattern was not prominent in the U.S. • The disparities of birth cohort effects are consistent with a society in socioeconomic transition.

Aim The mortality risk attributable to the classifications of chronic obstructive pulmonary disease (COPD) remains unclear. We investigated the associations of mortality with COPD classifications and reduced lung function in a large longitudinal cohort in Taiwan. Methods A total of 388,401 adults (≥25 years of age) were recruited between 1996 and 2016 underwent 834,491 medical examinations including spirometry. We used the Global Initiative for Chronic Obstructive Lung Disease (GOLD) to establish the COPD classifications. A time-dependent Cox regression model was used to investigate the associations between the morality risk and COPD classifications. We also examined the associations between mortality and lung function. Results The mean age of the participants was 42.1 years, and the median follow-up duration was 16.2 years. We identified 28,283 natural-cause deaths, and the mortality rate was 4.7 per 1,000 person-years. The hazard ratios (HRs) [95%confidence interval (95%CI)] of mortality in the participants with restrictive spirometry pattern and COPD GOLD Ⅰ–Ⅳ were 1.31 (1.27–1.35), 1.18 (1.00–1.39), 1.43 (1.35–1.51), 1.78 (1.66–1.90), and 2.13 (1.94–2.34), respectively, with reference to the participants with normal lung function. The natural-cause mortality risk increased by 33% [HR(95%CI): 1.33 (1.28–1.39)] for participants with COPD. Reduced lung function was also associated with a higher mortality risk. Conclusions A more advanced classification of COPD was associated with a greater increase in the mortality risk. Our study suggests that early detection of COPD and slowing the disease progress in patients with COPD are crucial for mortality prevention.

Background & Aims We studied incidence and mortality trends of colorectal cancer (CRC) in 39 countries according to age, sex, and anatomic location (colon vs rectum). Methods We retrieved incidence data from registries from 36 countries. The registries included the following: Cancer Incidence in 5 Continents volumes I to XI; the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute; and the Nordic Cancer Registries from Europe. We obtained mortality data from 39 countries of the World Health Organization database. We evaluated average annual percentage changes in CRC incidence and mortality in the past decade using joinpoint regression analysis. Results From 2007 to 2016, 2006 to 2015, or 2005 to 2014, depending on the availability of the data, the incidence of colon cancer increased in 10 of 36 countries analyzed (all in Asia or Europe); India had the greatest increase, followed by Poland. All 10 of these countries have medium to high Human Development Index (HDI) scores. Six countries had a decrease in colon cancer incidence; these countries had the highest HDI scores; the United States had the greatest decrease, followed by Israel. Seven countries (including all countries from Northern America) had a decrease in incidence among persons older than 50 years. Eight countries had an increase in colon cancer incidence among persons younger than 50 years, including the United Kingdom and India. Countries with a decreased or stable incidence among persons 50 years or older but a significant increase in persons younger than 50 years, included Germany, Australia, the United States, Sweden, Canada, and the United Kingdom. Only Italy had a decrease in CRC incidence among persons younger than 50 years. Among women, 12 of 36 countries (all from Asia and Europe) had an increase in colon cancer incidence and 7 countries had a decrease; India had the greatest increase followed by Slovenia. Five of 36 countries had an increase in incidence of rectal cancer and 8 countries had a decrease; Ecuador and Thailand had the greatest increases in incidence. The incidence of rectal cancer among persons younger than 50 years increased significantly in Finland, Australia, Canada, the United States, and The Netherlands. Four countries had an increase in the incidence of rectal cancer in women; Ecuador had the greatest increase followed by Thailand. The incidence of rectal cancer in women decreased in 8 countries. Among women younger than 50 years, rectal cancer incidence increased, despite a decrease in women older than 50 years, in Costa Rica, Slovenia, Japan, Slovakia, Canada, and the United States there was an increase in incidence, although their elder population had a stable or decreased incidence. Twenty-four countries reported a reduction in CRC mortality, including North America, Oceania, and most European countries. Nevertheless, some countries from Asia, Latin America, and Southern Europe had significant increases in CRC mortality. Conclusions In an analysis of incidence and mortality databases from 39 countries, we found that the incidence of colon and rectal cancers has continued to increase in countries with medium to high HDI and in younger populations. Preventive strategies are needed for countries with increasing CRC and rectal cancer incidence and mortality.

Background: \ud \ud Prostate cancer (PCa) is a leading cause of mortality and morbidity globally, but its specific geographic patterns and temporal trends are under-researched.\ud \ud Objective: \ud \ud To test the hypotheses that PCa incidence is higher and PCa mortality is lower in countries with higher socioeconomic development, and that temporal trends for PCa incidence have increased while mortality has decreased over time.\ud \ud Design, setting, and participants: \ud \ud Data on age-standardized incidence and mortality rates in 2012 were retrieved from the GLOBOCAN database. Temporal patterns were assessed for 36 countries using data obtained from Cancer incidence in five continents volumes I–X and the World Health Organization mortality database. Correlations between incidence or mortality rates and socioeconomic indicators (human development index [HDI] and gross domestic product [GDP]) were evaluated.\ud \ud Outcome measurements and statistical analysis: \ud \ud The average annual percent change in PCa incidence and mortality in the most recent 10 yr according to join-point regression.\ud \ud Results and limitations: \ud \ud Reported PCa incidence rates varied more than 25-fold worldwide in 2012, with the highest incidence rates observed in Micronesia/Polynesia, the USA, and European countries. Mortality rates paralleled the incidence rates except for Africa, where PCa mortality rates were the highest. Countries with higher HDI (r = 0.58) and per capita GDP (r = 0.62) reported greater incidence rates. According to the most recent 10-yr temporal data available, most countries experienced increases in incidence, with sharp rises in incidence rates in Asia and Northern and Western Europe. A substantial reduction in mortality rates was reported in most countries, except in some Asian countries and Eastern Europe, where mortality increased. Data in regional registries could be underestimated.\ud \ud Conclusions: \ud \ud PCa incidence has increased while PCa mortality has decreased in most countries. The reported incidence was higher in countries with higher socioeconomic development.\ud \ud Patient summary: \ud \ud The incidence of prostate cancer has shown high variations geographically and over time, with smaller variations in mortality.

Background Given the regular winter recurrence of influenza epidemics and the biologically plausible association between seasonal influenza and cardiovascular events, researchers assumed a valid and reliable influenza forecast could envision the timing and burden of winter surge in cardiovascular (CVD) hospitalizations. This, however, is well justified only in temperate regions. In this study, we aim to investigate the temporal association between ambient temperature, seasonal influenza and risk of cardiovascular events in a subtropical city. Methods Generalized additive model was used in conjunction with distributed-lag non-linear model of quasi-Poisson family to estimate the association of interest with daily CVD admissions as outcome and daily influenza admissions as predictor, while controlling for meteorological factors (i.e. temperature, relative humidity, wind speed and total rainfall) and respiratory pollutants (i.e. nitrogen dioxide, sulphur dioxide, ozone and PM10). Results were expressed in the form of relative risk (RR). Results Using median as the reference value, a U-shaped association was observed between CVD admissions and temperature. A slight decrease in RR was detected mainly towards the lower end of the temperature scale after adjusting for influenza admissions. Risk of CVD admission was found to be positively associated with the number of influenza hospitalization cases; this association remained consistent and statistically significant across subgroups of age except for those aged 5–49 years. Conclusion The slight reduction in CVD admission risk towards the lower end of the temperature scale after controlling for influenza activity might be attributed to the winter peaks of influenza, meaning that the effect of low temperature on CVD admissions might be partly mediated by influenza infection. In summary, this study reassures us that ambient temperature is independently associated with CVD hospital admissions and offers support for a positive association between seasonal influenza activity and cardiovascular events in Hong Kong.

Background: Information on the association between long-term exposure to PM2.5 and gastrointestinal cancer mortality is scarce. Objectives: This study investigated the association between long-term exposure to PM2.5 and deaths from gastrointestinal cancer and its subtypes in adults in Taiwan. Methods: A total of 385,650 Taiwanese adults (≥18 years old) jointed a standard medical examination program between 2001 and 2014 and were followed up until 2016. Their vital data were obtained from the National Death Registry maintained by the Ministry of Health and Welfare in Taiwan. We estimated the ambient PM2.5 concentration at individual’s address utilising a satellite-based spatiotemporal model at a resolution of 1 km2. Cox proportional hazard regression model was used to investigate the associations between ambient PM2.5 and deaths from gastrointestinal, stomach, colorectal and liver cancers. Results: We found that each 10 µg/m3 increase in PM2.5 was associated with an increased hazard risk (HR) of 1.09 (95% confidence interval (CI): 1.03–1.16) and 1.13 (95%CI: 1.02–1.24) in deaths from gastrointestinal and liver cancers, respectively. The association between PM2.5 and death from colorectal cancer was marginally statistically significant [HR: 1.13 (95%CI: 1.00–1.26)]. We did not find significant associations between PM2.5 and mortality from stomach cancer. Conclusions: Long-term exposure to ambient PM2.5 was associated with an increased risk of deaths from gastrointestinal cancers, liver cancer and also potentially colorectal cancer. Air pollution control strategies are necessary to reduce the burden of gastrointestinal cancer. Keywords: Long-term exposure, PM2.5 air pollution, Gastrointestinal cancer mortality, Live cancer mortality, Taiwan

Background & Aims Most colorectal cancers (CRC) arise from colorectal adenomas, yet there is not enough information on global prevalence to inform health care policy. We examined the prevalence of any type of adenomas, advanced adenomas (AADs), and CRC according to age, sex, ethnicity, geographic regions, and anatomic location (proximal vs distal). Methods MEDLINE and Embase were searched from their inception through May 1, 2018, to identify population-based, observational studies that reported the prevalence of colorectal neoplasia. Studies on participants 15 years or older, with a sample size of 500 persons or more, were included. Metaprop (College Station, TX) was used to model within-study variability by binomial distribution and Freeman–Tukey Double Arcsine Transformation to stabilize the variances. The prevalence figures were presented by proportions and their 95% CIs using random-effects models. Results Our meta-analysis included 70 studies involving 637,414 individuals. The overall prevalence rates of adenoma (23.9%; 95% CI, 22.2%–25.8%), AAD (4.6%; 95% CI, 3.8%–5.5%), and CRC (0.4%, 95% CI, 0.3%–0.5%) were calculated. Subgroup analysis indicated that prevalence values (adenomas, AADs, and CRCs) were higher among men (29.7%, 6.5%, and 0.8%, respectively) than women (19.3%, 3.8% and 0.4%, respectively), among older adults (25.9%, 5.2%, and 0.6%, respectively) than younger adults (14.6%, 1.6%, and 0.1%, respectively), among Caucasians (23.7%, 6.6%, and 0.5%, respectively) than other ethnicities, in European countries (25.9%, 8.4%, and 0.8%, respectively) than other countries, and among patients with proximal (25.9%, 5.3%, and 0.1%, respectively) vs distal neoplasia. Conclusions In a systematic review and meta-analysis, we found a high prevalence of colorectal neoplasia among some populations. This indicates a need to expand CRC screening programs for these groups. The pooled prevalence estimates can be used as quality indicators for established CRC screening programs.

The idea of targeted screening for colorectal cancer based on risk profiles originates from its benefits to improve detection yield and optimize screening efficiency. Clinically, it allows individuals to be more aware of their own risk and make informed decisions on screening choice. From a public health perspective, the implementation of risk stratification strategies may better justify utilization of colonoscopic resources, and facilitate resource-planning in the formulation of population-based screening programmes. There are several at-risk groups who should receive earlier screening, and colonoscopy is more preferred. This review summarizes the currently recommended CRC screening strategies among subjects with different risk factors, and introduces existing risk scoring systems. Additional genetic, epidemiological, and clinical parameters may be needed to enhance their performance to risk-stratify screening participants. Future research studies should refine these scoring systems, and explore the adaptability, feasibility, acceptability, and user-friendliness of their use in clinical practice among different population groups.

Background & Aims We compared the accuracy of a qualitative fecal immunochemical test (FIT) in identifying patients with proximal vs distal advanced neoplasia and evaluated whether analysis of 2 specimens performed better than analysis of 1 specimen. Distal advanced neoplasia was defined as colorectal cancer (CRC), any colorectal adenoma ≥10 mm in diameter, high-grade dysplasia, or a lesion with villous or tubulovillous histologic characteristics in a location distal to the splenic flexure, including the descending colon, the rectosigmoid, and the rectum. Methods We collected data from 5343 subjects (50−70 years old) who received 2 FITs (Hemosure; cutoff value, 10 μg hemoglobin/g feces) before colonoscopy in an invitational CRC screening program in Hong Kong from 2008 through 2012. We calculated the FIT's sensitivity, specificity, positive predictive value (PPV), and negative predictive value in detecting colorectal neoplasia. Results Of the participants, 13.6%, 12.2%, and 6.0% had distal, proximal, and synchronous distal or proximal neoplasia, respectively. Advanced neoplasia was detected in 291 subjects (5.4%); 22 (0.4%) had CRC. FIT detected distal advanced adenoma with 39.7% sensitivity (95% confidence interval [CI], 32.0%−48.0%) vs proximal advanced adenoma with 25.0% sensitivity (95% CI, 17.3%−34.6%; P = .014), distal advanced neoplasia with 40.0% sensitivity (95% CI, 32.5%−47.9%) vs proximal advanced neoplasia with 27.9% sensitivity (95% CI, 20.0%−37.4%; P = .039), and any distal adenoma ≥10 mm, irrespective of other lesion characteristics, with 39.5% sensitivity (95% CI, 31.0%−48.7%) vs proximal adenoma with 25.3% sensitivity (95% CI, 16.5%−36.6%; P = .038). The specificity of FIT in detecting CRC was similar between the proximal and distal colon. FIT detected distal lesions with higher PPV than proximal lesions. One FIT detected advanced neoplasia with 31.8% sensitivity (95% CI, 25.9%−38.4%) and 92.4% specificity (95% CI, 91.6%−93.2%), whereas 2 FITs detected advanced neoplasia with 34.1% sensitivity (95% CI, 28.0%−40.8%; P = .617) and 91.9% specificity (95% CI, 91.0%−92.7%; P = .327). FIT detected distal advanced neoplasia with greater sensitivity and higher PPV than proximal advanced neoplasia. Conclusions In an analysis of data from subjects who underwent CRC screening in Hong Kong, FIT detected distal advanced neoplasia with higher sensitivity than proximal advanced neoplasia. Analysis of 1 vs 2 specimens by FIT identified advanced neoplasia with similar test characteristics.

Lisinopril and perindopril are two commonly used first-line antihypertensive agents. Few studies compared their effectiveness in reducing the incidence of renal diseases and diabetes.Adult patients who received new prescriptions of lisinopril or perindopril from 2001 to 2005 in all public hospitals and clinics in Hong Kong were included, and followed up for at least 2 years. Patients prescribed the angiotensin converting enzyme inhibitors (ACEIs) for1 month were excluded. The incidence of admissions due to renal diseases and diabetes was evaluated. We used Cox proportional hazard regression models to assess hospital admissions as the outcome measures, adjusting for age, sex, socioeconomic status, service types, and the proportion of days covered as a measure of medication adherence. The regression models were constructed with propensity score matching to minimize indication biases.20,252 eligible patients with an average age of 64.5 years (SD 15.0) were included. The admission rates 24 months within the date of index prescription due to renal diseases were 3.1% (lisinopril) and 2.3% (perindopril); and 9.6% (lisinopril) and 7.2% (perindopril) for diabetes. Except for admissions due to diabetes at 6 months, lisinopril users were significantly more likely to be admitted due to renal diseases (adjusted hazard ratios: 1.304 to 1.378) and diabetes (1.146 to 1.231) than perindopril users at all time points.Patients prescribed different ACEIs might have a different incidence of hospital admissions. Future studies should be conducted to evaluate the comparative effectiveness of different ACEIs on various patient-centered outcomes by head-to-head randomized controlled trials.

Objectives To explore the feasibility of using the FRAIL scale in community screening of older Chinese people aged 65 years and older, followed by clinical validation by comprehensive geriatric assessment of those classified as pre-frail or frail. Design Two-phase study: screening of people aged 65 years and older by trained volunteers, followed by comprehensive geriatric assessment by multidisciplinary staff for those classified as pre-frail or frail. Setting Elderly Centers in the New Territories East Region of Hong Kong SAR China. Participants A total of 816 members of elderly centers attending by themselves or accompanied by relatives. Measurements For phase 1, questionnaire (including demographic, lifestyle, chronic diseases) and screening tools were administered by trained volunteers. These consist of the FRAIL scale, SARC-F to screen for sarcopenia, and mild cognitive impairment using the abbreviated screening for mild cognitive impairment (Abbreviated Memory Inventory for the Chinese). Blood pressure, body mass index, and grip strength were recorded. For phase 2, comprehensive geriatric assessment include questionnaires assessing lifestyle domain (physical activity, nutritional status using the Mini-Nutritional Assessment-Short Form), the physical domain (number of diseases and number of drugs, activities of daily living and instrumental activities of daily living disabilities, geriatric syndromes, self-rated health, sleep quality), cognitive and psychological domain (Mini-Mental State Examination, Geriatric Depression Scale), and social domain (income, housing, living satisfaction, family support). Results The prevalence of pre-frailty and frailty were 52.4% and 12.5%, respectively. The prevalence for frailty increasing with age from 5.1% for those aged 65–69 years to 16.8% for those ≥75, being greater in women compared with men (13.9% vs 4.2%). Of those who were pre-frail or frail (n = 529), 42.5% had sarcopenia and 60.7% had mild cognitive impairment. Among those who were frail (n = 102), sarcopenia and mild cognitive impairment were also frequently present: 12.8% had sarcopenia, 14.7% had mild cognitive impairment, 63.7% had both sarcopenia and mild cognitive impairment, and only 8.8% had neither. In phase 2, participants who were classified as pre-frail or frail (n = 529) were invited for further interviews; 255 participants (48.2%) returned. Compared with the pre-frail group, those in the frail group were less physically active, had higher number of chronic diseases, were taking more medications (more were taking sleeping pills), reported more falls, rated their health as poor, had higher prevalence of depressive symptoms and mild cognitive impairment, had higher prevalence of sarcopenia, and a high number of activities of daily living and instrumental activities of daily living disabilities. Conclusion The FRAIL scale may be used as the first step in a step care approach to detecting frailty in the community, allowing targeted intervention to potentially retard decline and future disability.

Background Certain subgroups have higher rates of false fecal immunochemical test (FIT) results, yet few studies have addressed this topic. Objective To identify demographic factors associated with false-positive and false-negative FIT results in colorectal cancer screening. Design Retrospective database review of prospectively collected data. Setting A bowel cancer screening center in Hong Kong invited participants for colorectal cancer screening (2008-2012). Patients Study participants who underwent both FIT and colonoscopy in the first year (n = 4482) and underwent colonoscopy after negative FIT results for 3 consecutive years (n = 857). Main Outcome Measurements The diagnostic accuracy and predictive values of FIT according to participant characteristics. Results The sensitivity, specificity, positive predictive values, and negative predictive values for advanced neoplasia were 33.1%, 91.9%, 19.0%, and 96.0%, respectively. Participants 66 to 70 years of age had higher sensitivity, whereas older age, smoking, and use of aspirin/nonsteroidal anti-inflammatory drugs were associated with lower specificity. The rates of false-positive and false-negative results were 8.1% and 66.9%, respectively. Older age (66-70 years; adjusted odds ratio [AOR] 1.95; 95% confidence interval [CI], 1.35-2.81; P P = .020), and the presence of polypoid adenoma (AOR 1.71; 95% CI, 1.14-2.57; P = .009) were associated with false-positive results. Younger participants (AOR for elderly participants 0.31) and the use of aspirin/nonsteroidal anti-inflammatory drugs (AOR 4.44) in participants with 1 FIT with negative results and the absence of high-grade dysplasia (AOR for presence 0.41) were associated with false-negative results. Limitations Self-referred participants who received one type of qualitative FIT. Conclusion These findings could be used to target screening more toward those with a higher risk of false-negative results and those with a lower risk of false-positive results for earlier colonoscopy.

Despite effective treatments, suboptimal medication adherence substantially hinders blood pressure (BP) control among hypertensive patients. This study aimed to evaluate the determinants of medication adherence and BP control among hypertensive patients in Hong Kong.A cross-sectional study was conducted. Adult patients aged18years taking at least one type of antihypertensive drugs were recruited from four clinics in Hong Kong. Each patient completed a self-administered questionnaire, including socio-demographic variables and items related to knowledge, illness perception and medication adherence. Medication adherence was measured by the eight-item Morisky Medication Adherence Scale (MMAS-8), with a score6 defined as "good adherence". BP was measured, and optimal control was defined as systolic BP140mmHg and diastolic BP90mmHg.Among 2445 patients, 55.1% and 52.5% had optimal medication adherence and BP control, respectively. Binary logistic regression analyses were conducted with optimal medication adherence and BP control, respectively, as the outcome variables. Advanced age (adjusted odds ratio [aOR] 1.012, 95% CI 1.002-1.022, p=0.014), unemployment (aOR for employed 0.782, 95% CI 0.628-0.975, p=0.029), and good self-perceived health status (aOR 2.155, 95% CI 1.711-2.714, p0.001) were associated with good adherence; whereas being married (aOR 1.265, 95% CI 1.038-1.542, p=0.020) and having no co-morbidity (aOR for morbidity count 0.713, 95% CI 0.639-0.796, p0.001) were associated with optimal BP control.Evidence-based, adherence-enhancing interventions should be targeted on younger subjects; employed patients; and those with poor self-perceived health status. Patients who are single and those with comorbidities should be closely monitored for their BP control.

Optimal adherence with antihypertensive medications is crucial to prevent hypertension-related complications. This study evaluated whether the duration of initial antihypertensive prescription is associated with better medication adherence in a large sample of Chinese hypertensive patients.From a validated clinical database which consists of all patients in the public healthcare sector in Hong Kong, all patients on their first-ever antihypertensive agent from 2001 to 2005 (N=203,259) were included and followed-up for 12 months (and up to 5 years in separate analyses). The average age was 58.7 years (SD 17.3), and the overall rate of optimal adherence (as measured by having the Proportion of Days Covered≥0.80) was 32.4%. The proportion of patients whose initial prescriptions lasted for ≤6 days; 7-14 days; 15-28 days and ≥29 days was 23.7%, 24.3%, 15.1% and 37.0%, respectively. The corresponding proportion of optimal adherence was 18.1%, 20.1%, 31.0% and 50.3%. The binary logistic regression analysis showed that after controlling for age, sex, socioeconomic status, service type, drug class, and district of residence, those whose initial prescription was 7-14 days (adjusted odds ratio [AOR]=1.17, 95% C.I. 1.12-1.22); 15-28 days (AOR=1.90, 95% C.I. 1.82-1.99) and ≥29 days (AOR=4.13, 95% C.I. 3.96-4.31) were significantly more likely to be adherent than those who were prescribed for ≤6 days (all p0.001). These findings remained significant in separate analyses where the period of follow-up was extended to 5 years.Shorter duration of first antihypertensive prescriptions was associated with poorer medication adherence, and this practice should be avoided if possible.

Current evidence is mixed regarding the association between antihypertensive prescriptions and cancer mortality. We evaluated this association in a large Chinese hypertensive population. We followed for five years all patients who were prescribed their first-ever antihypertensive agents between 2001 and 2005 in a public healthcare sector of Hong Kong. The association between antihypertensive drug class and cancer mortality was evaluated by Cox proportional hazard models with propensity score matching. Age, gender, socioeconomic status, service settings, district of residence, proportion of days covered reflecting medication adherence, and the number of comorbidities were adjusted. From 217,910 eligible patients, 9500 (4.4%) died from cancer within five years after their first-ever antihypertensive prescription. Most cancer deaths occurred in the digestive (38.9%) and respiratory system (30.4%); the breast (6.2%); and the lympho-hematopoietic tissues (5.3%). The proportion of patients who died from cancer was the highest in the calcium channel blocker (CCB) group (6.5%), followed by thiazide diuretics (4.4%), angiotensin converting enzyme inhibitors (4.2%) and β-blockers (2.6%). When compared with β-blockers, patients prescribed CCBs (Adjusted Hazard Ratio [AHR] = 1.406, 95% C.I. 1.334–1.482, p < 0.001) were more likely to die from cancer. Thiazide users were also more likely to suffer from cancer deaths (AHR = 1.364, 95% C.I. 1.255–1.483, p < 0.001), but became insignificant in stratified analysis. The association between cancer mortality and use of CCB, and perhaps thaizide, may alert physicians to the need for more meticulous and comprehensive care of these patients in clinical practice. We recommend prospective studies to evaluate cause-and-effect relationships of these associations.

Flexible sigmoidoscopy (FS) and colonoscopy are two commonly used screening tools for colorectal cancer (CRC), and FS mainly detects distal lesions. Colonoscopy resource is limited, yet there is no definite evidence on when flexible sigmoidoscopy is suitable as a screening alternative. This study evaluated the optimal cut-off score from a validated risk stratification system which best predicts proximal advanced neoplasia (PAN) by comparing the sensitivity, specificity and relative risk of PAN according to various cut-off scores. 5819 asymptomatic subjects aged between 50 and 70years (average age 57.7years, standard deviation (SD) 4.9) received colonoscopy between 2008 and 2014 in Hong Kong. Their prevalence of PAN was evaluated according to a prediction tool for colorectal neoplasia based on age, gender, smoking status, family history of CRC, body mass index (BMI) and diabetes (ranging from 0 to 6). One binary logistic regression model was performed with PAN as the outcome variable and the risk score as the variable tested for association. In multivariate regression analysis, risk score ⩾3 was associated with significantly higher risk of PAN (3.4-9.1%; AOR=3.18-8.09, p0.001) when compared with those scoring 0. Risk scores 0-2 were associated with either insignificant or lower risks of PAN compared to the overall risk. Applying FS for screening those who scored 0-2 and colonoscopy for those who scored ⩾3 led to a very small proportion of PAN being missed (1.60%), whilst maintaining a high level of specificity (81.9%). Clinicians may use this scoring system to inform subjects and facilitate their choice between colonoscopy and FS.

Multimorbidity has become the norm worldwide as populations age. It remains, however, infrequently researched. This study evaluated factors associated with multimorbidity in a predominantly Chinese hypertensive population. We included all adult patients prescribed their first antihypertensive agents in the entire public sector in Hong Kong from a validated database. Multimorbidity was defined as having one or more medical conditions (cardiovascular diseases; respiratory diseases; diabetes or impaired fasting glucose; renal disease) in addition to hypertension. We studied the prevalence of multimorbidity and performed multinomial regression analyses to evaluate factors independently associated with multimorbidity. 223,286 hypertensive patients (average age of 59.9 years, SD 17.6) were included. The prevalence of having 0, 1 and ≥ 2 additional conditions was 59.6%, 32.8% and 7.5%, respectively. The most common conditions were cardiovascular disease (24.2%) and diabetes (23.0%), followed by respiratory disorders (14.6%) and renal disease (10.9%). Older age (>50 years), male sex, lower household income, receipt of social security allowance and suboptimal blood pressure control (>140 mmHg or >90 mmHg; >130 mmHg or >80 mmHg for diabetes patients; AOR = 3.38-4.49) were significantly associated with multimorbidity. There exists a synergistic effect among these variables as older (≥ 70 years), male patients receiving security allowance had substantially higher prevalence of multimorbidity (19.9% vs 7.5% among all patients). Multimorbidity is very common in hypertensive patients and its prevalence increased markedly with the presence of risk factors identified in this study. Hypertensive patients with multimorbidities should receive more meticulous clinical care as their blood pressure control tends to be poorer.

Background The Asia-Pacific Colorectal Screening (APCS) score based on age, gender, family history, and smoking is useful to predict advanced colorectal neoplasia (ACN) in asymptomatic Asian subjects. Purpose To evaluate the factors in addition to those of APCS associated with ACN colonoscopic findings. Methods Data from 5,220 asymptomatic subjects aged between 50 and 70 years who underwent screening colonoscopy in a community center between 2008 and 2012 were analyzed. One binary logistic regression analysis was conducted in 2013 with the presence of ACN or cancer as the outcome, controlling for APCS score, alcohol consumption, BMI, hypertension, and other chronic diseases as independent variables. Results The average participant age was 57.7 years (SD=4.9) and 47.5% were men. Advanced neoplasms or cancers were identified at colonoscopy in 5.6% of all screening participants. From multivariate regression analysis, APCS score≥4 (adjusted OR [AOR]=1.74, 95% CI=1.34, 2.25, p p =0.007); obesity (BMI≥25, AOR=1.56, 95% CI=1.15, 2.10, p =0.004); hypertension (AOR=1.58, 95% CI=1.21, 2.06, p =0.001); and alcohol consumption (AOR=1.47, 95% CI=1.05, 2.06, p =0.025) were associated with ACN. The c-statistic of APCS score alone was 0.560 (95% CI=0.524, 0.595, p =0.001) and that of APCS score plus BMI, hypertension, and alcohol consumption was 0.613 (95% CI=0.578, 0.648, p Conclusions Alcohol consumption, hypertension, and BMI are independent predictors of ACN, which could be incorporated into the APCS for prioritizing Asian asymptomatic subjects for colorectal cancer screening.

Background Colorectal cancer is the third most commonly diagnosed cancer and the second leading cause of cancer mortality globally. Colorectal adenomas are recognised as precursors in most new cases of colorectal cancer. However, few studies reported the prevalence of different types of colorectal neoplasia among the Chinese population. This systematic review and meta-analysis estimated the prevalence of any type of adenomas, advanced adenomas, and colorectal cancer according to age and gender among average-risk Chinese populations. Methods We did a PRISMA-compliant search in MEDLINE, Embase, CNKI, and Wanfang Database to identify studies reporting the prevalence of colorectal neoplasia among asymptomatic Chinese individuals receiving direct colonoscopy for colorectal cancer screening, from database inception until May 29, 2019, including studies published in English and Chinese. Metaprop was used to model within-study variability by binomial distribution and Freeman-Tukey Double Arcsine Transformation to stabilise the variances in the meta-analysis. Heterogeneity was measure by I2 statistic. The prevalence data were presented by proportions and their 95% CIs using random-effects models. Findings This meta-analysis included 16 studies reporting on a total of 81 262 people between 1996 and 2015. The overall prevalence of adenomas was 8699 people (21·1% [95% CI 17·3–25·1]), 1855 people (4·0% [3·1–5·1]) for advanced adenomas, and 210 (0·4% [0·2–0·6]) for colorectal cancer. Subgroup analysis indicated prevalence of adenomas, advanced adenomas, and colorectal cancer was higher among men (25·0%, 4·3%, and 0·1%, respectively) than women (15·5% [p=0·14], 2·7% [p Interpretation The high prevalence of colorectal neoplasia among Chinese men and older adults highlighted the need to expand colorectal cancer screening programmes for these groups. The pooled prevalence estimates can be used as quality indicators for established colorectal cancer screening programmes. Future research should investigate its time-trend prevalence that could provide important data to inform health policy making. Funding None.

Background Screening for colorectal cancer can reduce mortality, yet, participation rate is suboptimal in various countries. We aimed to evaluate the effectiveness of a pilot programme for colorectal cancer screening on increasing the enabling factors of screening in a large Chinese population, and identified factors associated with its participation based on variables pertinent to the Health Belief Model. Methods We collected data from 3600 screening participants who were randomly selected using a telephone list for 2016, 2017, and 2018, from the government colorectal cancer screening programme. We also collected data from 3600 non-screening participants through a telephone survey via simple random sampling of telephone numbers in a territory-wide directory for the years 2016, 2017, and 2018. We collected sociodemographic factors, the enabling factors of screening (such as knowledge levels of colorectal cancer, perceptions of colorectal cancer screening, cues to actions), and barriers of screening. We constructed a logistic regression model to identify the association between these factors and participation in colorectal cancer screening adjusted for age, gender, educational level, and household income. The study was approved by the Joint Chinese University of Hong Kong − New Territories East Cluster Clinical Research Ethics Committee (reference number 2016.485). Verbal consent was obtained from the study participants. Findings The knowledge level of colorectal cancer screening tools (from 67·9% to 85·4%, p Interpretation These findings demonstrate the effectiveness of the screening programme on increasing the enabling factors and identify the target groups such as younger individuals, females, and more affluent people among whom more intensive educational initiatives are needed to enhance their participation. Funding Health and Medical Research Fund (No. 6904168), Food and Health Bureau, Hong Kong, China.

Summary Objectives The current study was conducted to use a developed framework to appraise the public primary care response to pandemic 2009 influenza A H1N1 virus in Hong Kong in 2009. Methods A cross-sectional survey was conducted of 300 doctors working in public primary care clinics. In addition, a qualitative study was conducted in two selected general outpatient clinics (GOPCs) with 10 doctors between September and December 2009. Results We found that there was an increase in clinical service demand for public primary care doctors and that there was lower compliance with hand washing as compared to the wearing of masks among GOPC doctors during the study period. Conclusions Since hand hygiene and influenza vaccination are effective methods to prevent the spread of influenza infection, future studies should explore the reasons for non-compliance with these preventive behaviors among doctors. More education and training in dealing with influenza A H1N1 infection may be needed.

This study examined the rates of discontinuation of Oral Hypoglycemic Agents (OHAs) in diabetes patients, and to evaluate the associations between discontinuation of OHAs, socioeconomic status and the number of comorbidities.A cohort study from January 2004 to June 2007 was conducted and followed up through December 2007. We included all primary care clinics in one large territories of Hong Kong involving 28,773 Chinese diabetes patients. Multivariate regression analyses controlled for age, gender, payment status (fee-payers vs. fee waivers; fee-waivers represented those less able to pay for consultation fees and were regarded as having lower socioeconomic status), service type delivered by the clinics, district of residence, visit type (new vs. follow-up), the number of comorbidities and the drug class (sulphonylureas vs. biguanide vs. combination therapy).9.9% discontinued their medications within 180 days of their prescriptions. Fee waivers (adjusted odds ratio [AOR] for fee payers=0.81, 95% C.I. 0.73-0.89, p0.001) and the absence of comorbidities (AOR for ≥one morbidity=0.59-0.62, p0.001) were associated with medication discontinuation.Diabetes patients with lower ability to pay and without comorbidities were significantly associated with OHAs discontinuation. They should be the target groups for medication counseling programmes.