Search

BackgroundRecent studies have reported numerous significant predictors for adverse outcomes in COVID-19 disease. However, there have been few simple clinical risk score for prompt risk stratification. The objective is to develop a simple risk score for severe COVID-19 disease using territory-wide healthcare data based on simple clinical and laboratory variables.MethodsConsecutive patients admitted to Hong Kong’s public hospitals between 1st January and 22nd August 2020 diagnosed with COVID-19, as confirmed by RT-PCR, were included. The primary outcome was composite intensive care unit admission, need for intubation or death with follow-up until 8th September 2020.ResultsCOVID-19 testing was performed in 237493 patients and 4445 patients (median age 44.8 years old, 95% CI: [28.9, 60.8]); 50% male) were tested positive. Of these, 212 patients (4.8%) met the primary outcome. A risk score including the following components was derived from Cox regression: gender, age, hypertension, stroke, diabetes mellitus, ischemic heart disease/heart failure, respiratory disease, renal disease, increases in neutrophil count, monocyte count, sodium, potassium, urea, alanine transaminase, alkaline phosphatase, high sensitive troponin-I, prothrombin time, activated partial thromboplastin time, D-dimer and C-reactive protein, as well as decreases in lymphocyte count, base excess and bicarbonate levels. The model based on test results taken on the day of admission demonstrated an excellent predictive value. Incorporation of test results on successive time points did not further improve risk prediction.ConclusionsA simple clinical score accurately predicted severe COVID-19 disease, even without including symptoms, blood pressure or oxygen status on presentation, or chest radiograph results.

Background Increasing evidence indicated that infection factors play important roles in stroke development. Human cytomegalovirus (HCMV) infection was positively associated with atherosclerosis and hypertension which are stroke risk factors. Therefore, we aimed to explore the relationship between HCMV infection and stroke using the data of US National Health and Nutrition Examination Survey (NHANES). Methods We analysed data on 2844 men and 3257 women in the NHANES 1999–2004. We included participants aged 20–49 years who had valid data on HCMV infection and stroke. Results 54.1% of participants had serological evidence of HCMV infection and 0.8% of them had a previous diagnosis of stroke. There were ethnic differences in the prevalence of HCMV seropositivity (p Conclusions We found a strong association between HCMV and stroke in women from the nationally representative population-based survey. This provide additional motivation for undertaking the difficult challenge to reduce the prevalence of stroke.

Whether newer P2Y12 inhibitors are more efficacious and safer than clopidogrel and whether there is a superior one remain uncertain. We compared the effect of P2Y12 inhibitors on clinical outcomes in patients with acute coronary syndrome (ACS). Randomized controlled trials comparing clopidogrel, prasugrel, ticagrelor, or cangrelor, in combination with aspirin were searched. Sixteen trials with altogether 77,896 patients were included. Compared to clopidogrel, cardiovascular mortality was reduced with prasugrel (OR 0.85, 95% CI 0.75–0.97) and ticagrelor (0.82, 0.73–0.93). Myocardial infarction (0.75, 0.63–0.89) and major adverse cardiovascular events (0.80, 0.69–0.94) were reduced by prasugrel. Stent thrombosis was reduced by prasugrel (0.49, 0.38–0.63), ticagrelor (0.72, 0.57–0.90), and cangrelor (0.59, 0.43–0.81). It was reduced more by prasugrel than ticagrelor (0.69, 0.51–0.93). There were more major bleeds with prasugrel (1.24, 1.05–1.48). Thrombolysis in Myocardial Infarction (TIMI) major bleeding was increased with prasugrel compared to clopidogrel (1.36, 1.11–1.66) and ticagrelor (1.33, 1.06–1.67). TIMI minor bleeding was increased with prasugrel (1.44, 1.16–1.77) and cangrelor (1.47, 1.01–2.16) compared to clopidogrel while it was increased with prasugrel compared to ticagrelor (1.32, 1.01–1.72). Prasugrel is preferable to those ACS patients at low bleeding risk to reduce cardiovascular events whereas ticagrelor is a relatively safe antiplatelet drug of choice for most patients.

Objectives Sarcopenia is recognized to be a health problem which is as serious as obesity, but its relevance to mortality is unclear. We conducted a meta-analysis of cohort studies on lean mass and mortality in populations with different health conditions. Methods In this study, a systematic search of PubMed, Cochrane Library and Embase was performed for cohort studies published before Dec 20, 2017 which examined the relationship between lean mass and mortality. We included studies reporting lean mass measurement by dual-energy X-ray absorptiometry, bioimpedance analysis or computed tomography, as continuous (per standard deviation [SD] decrease) or binary variables (using sarcopenia cutoffs). We excluded studies which used muscle mass surrogates, anthropometric measurement of muscle, rate of change in muscle mass, and sarcopenia defined by composite criteria. The primary study outcome was all-cause mortality. Pooled hazard ratio estimates were calculated using a random effects model. Results A total of 9602 articles were identified from the systematic search, and 188 studies with 98 468 participants from 34 countries were included in the meta-analysis. Of the 68 studies included in the present meta-analysis, the pooled HR was 1.36 and 1.74 for every SD decrease in lean mass and in people with low lean mass (cutoffs), respectively. Significant associations were also observed in elderly and all disease subgroups, irrespective of the measurement modalities. Conclusions Lower lean mass is robustly associated with increased mortality, regardless of health conditions and lean mass measurement modalities. This meta-analysis highlighted low lean mass as a key public health issue.

Objectives Muscle mass is one of the key components in defining sarcopenia and is known to be important for locomotion and body homeostasis. Lean mass is commonly used as a surrogate of muscle mass and has been shown to be associated with increased mortality. However, the relationship of lean mass with mortality may be affected by different clinical conditions, modalities used, cut-off point to define low or normal lean mass, and even types of cancer among cancer patients. Thus, we aim to perform a comprehensive meta-analysis of lean mass with mortality by considering all these factors. Methods Systematic search was done in PubMed, Cochrane Library and Embase for articles related to lean mass and mortality. Lean mass measured by dual X-ray absorptiometry, bioelectrical impedance analysis, and computerized tomography were included. Results The number of relevant studies has increased continuously since 2002. A total of 188 studies with 98 468 people were included in the meta-analysis. The association of lean mass with mortality was most studied in cancer patients, followed by people with renal diseases, liver diseases, elderly, people with cardiovascular disease, lung diseases, and other diseases. The meta-analysis can be further conducted in subgroups based on measurement modalities, site of measurements, definition of low lean mass adopted, and types of cancer for studies conducted in cancer patients. Conclusions This series of meta-analysis provided insight and evidence on the relationship between lean mass and mortality in all directions, which may be useful for further study and guideline development.

Use of high-dose glucocorticoids for COVID-19 (caused by SARS-CoV-2) is controversial because of safety concerns. We examined the long-term consequences of glucocorticoid use in severe acute respiratory syndrome (caused by SARS-CoV-1) survivors. Results showed that high-dose glucocorticoids greatly increased the long-term risk of avascular necrosis but not other major diseases.

Background Previous observational studies have not found a conclusive association between serum 25-hydroxyvitamin D (25(OH)D) levels and allergic rhinitis (AR) or allergic sensitization (AS). Objective To investigate a causal association between 25(OH)D levels with risk of AR and AS, using a two-sample Mendelian randomization (MR) approach. Methods Seven single nucleotide polymorphisms (SNPs), previously shown to be associated with serum 25(OH)D levels, were identified as instrumental variables. The primary outcome was AR, and the secondary outcomes were AS and non-allergic rhinitis (NAR). The genome-wide association (GWA) summary statistics of the outcomes were obtained from two cohort studies (EAGLE Consortium and UK Biobank). An MR analysis with random-effects inverse-variance weighted method was performed as the primary analysis to estimate overall effect size (odds ratio [OR] and 95% confidence interval [CI]). Sensitivity analysis using weighted median method and MR-Egger regression method was conducted. A subgroup analysis based on 25(OH)D synthesis-related SNPs was further applied. Results Serum 25(OH)D levels were not causally associated with risk of AR (OR: 0.960; 95% CI: 0.779-1.184), AS (OR: 1.059; 95% CI: 0.686 to 1.634) or NAR (OR: 0.937; 95% CI: 0.588-1.491). Subgroup analysis also showed null association between 25(OH)D synthesis-related SNPs and the outcomes. Sensitivity analyses yielded similar results. Conclusions and clinical relevance This MR study found no evidence supporting a causal association between serum 25(OH)D levels and risk of AR, AS and NAR in European-ancestry population. This argues against the previous postulation that vitamin D supplementation is effective in prevention of allergic diseases.

BackgroundObservational studies have found associations between salt intake with obesity, body shape and composition; but the findings may be biased by residual confounding.ObjectiveTo analyze the causal associations between salt intake and obesity measures in both sex-combined and sex-specific models.DesignsThis was a two-sample Mendelian randomization study. Genome-wide association (GWA) studies of urinary sodium secretion (UNa, a surrogate for salt intake), body mass index (BMI), BMI-adjusted waist-to-hip ratio (WHR), body fat (BF) percentage and estimated glomerular filtration rate (eGFR) were identified. We initially extracted fifty SNPs associated with UNa at GWA significance level of 5 × 10−8, but further removed those SNPs with potential horizontal pleiotropy. Univariable MR and multivariable MR with adjustment for eGFR were performed. Inverse-variance weighted MR was performed as the primary analysis, with MR-Egger methods as sensitivity analysis. The potential bidirectional association between BMI and UNa was investigated. All exposure and outcomes were continuous, and the effect measure was linear regression coefficients (beta) and their 95% confidence intervals (95%CI).ResultsUNa was causally associated with increased BMI in both men (eGFR-adjusted beta 0.443 (0.163 to 0.724)) and women (0.594 (0.333 to 0.855)). UNa caused BF percentage increase in men (0.622 (0.268 to 0.976)) and women (0.334 (0.007 to 0.662)). UNa significantly elevated BMI-adjusted WHR in men (0.321 (0.094 to 0.548)), but not in women (0.170 (−0.052 to 0.391)). Additionally, we found that BMI causally increased UNa (0.043 (0.023 to 0.063)).ConclusionsSalt intake increased BMI and BF percentage. Salt intake affects male body shape by increasing BMI-adjusted WHR, but showed no effects on female body shape. The bidirectional association between BMI and UNa suggested that salt reduction measures and weight reduction measures should be implemented simultaneously to break the vicious cycle and gain more health benefits.AbbreviationsALM: appendicular lean massBF: body fatBMI: body mass indexeGFR: estimated glomerular filtration rateGWA: genome-wide associationHC: hip circumferenceMR: Mendelian randomizationPRESSO test: Pleiotropy RESidual Sum and Outlier testSNP: single nucleotide polymorphismUNa: urinary sodium secretionWC: waist circumferenceWHR: waist-to-hip ratioWLM: whole body lean mass

The Risk Assessment and Management Program (RAMP) has successfully demonstrated a reduction of blood pressure (BP) and cardiovascular (CVD) risk of patients with hypertension. This study aimed to compare the blood pressure control rate of participants after attended RAMP group, with those attended RAMP individual from usual care. A prospective open cluster‐randomized controlled trial was performed in five public primary care clinics. Patients with uncontrolled hypertension were recruited. RAMP group consisted of multi‐disciplinary group education on knowledge of hypertension, lifestyle modification, and hands‐on home blood pressure monitoring (HBPM) training. Each participant was given a branchial HBPM device. An individual face‐to‐face nurse follow‐up was arranged 6 weeks later. Participants' office BP and clinical parameters were assessed at 6, 12, and 18 months. Three RAMP group and two RAMP‐individual clusters recruited 152 and 139 participants, respectively. The mean age was 67.0 (SD 9.9) year. After 18 months of treatment, there was a significantly higher BP control rate in the RAMP‐group participants than the RAMP‐individual participants (78.9% vs 36.5%, P

Background Metabolic syndrome (MetS) is common in China, which has a multi-ethnic population of 1·3 billion. We set out to determine the prevalence of MetS and its components in different ethnic groups. Methods This nationwide cross-sectional survey involved 24,796 participants from eight ethnicities in six provinces in China from 2008 to 2011. MetS was defined using the modified National Cholesterol Education Program Adult Treatment Panel III criteria. Results were analysed using SPSS version 22·0 in 2018. Logistic regression was used for deriving odds ratios and 95% confidence intervals of risk factors for the MetS. Results The prevalence of MetS increased with age from 3·60% to 21·68%. After age standardization, the prevalence of MetS, in descending order, was 35·42% (Korean), 22·82% (Hui), 19·80% (Han), 13·72% (Miao), 12·90% (Tujia), 12·04% (Li), 11·61% (Mongolian), 6·17% (Tibetan). Korean ethnicity was associated with a higher prevalence in five components of MetS, while Tibetan ethnicity was associated with lower prevalence except decreased HDL cholesterol. Logistic regression analyses showed that age, drinking and being non-Tibetan were associated with a higher risk of MetS. Conclusions Within one country, albeit a large one, the prevalence of MetS can vary greatly. Chinese of Korean ethnicity had a much higher prevalence than Tibetan ethnicity. Measures to tackle MetS should be tailored to the ethnic groups within a population.

Mercury is an environmental hazard. Organic mercury is biologically more toxic than inorganic mercury. Therefore, we studied recent trends in the blood levels of organic and inorganic mercury in the United States.A total of 56,445 participants that had blood mercury and urine mercury measurements in National Health and Nutrition Examination Survey (NHANES) 1999-2016 were included. The organic mercury level was obtained by subtracting the inorganic mercury level from the total mercury level. Results were analyzed using SPSS complex sample module version 25. Pregnant women, children ages20 years, and different ethnicities were analyzed as subgroups.Blood organic mercury level increased from (geometric mean [95% confidence interval]) 0.08 [0.07-0.10] to 0.17 [0.16-0.18] µg/L during 1999-2016. It increased significantly (P0.001) from 0.03 [0.02-0.03] to 0.07 [0.06-0.07] µg/L in children ages20 and from 0.14 [0.09-0.21] to 0.36 [0.16-0.83] µg/L in pregnant women in this period (P0.001). In 2013-2016, non-Hispanic Asians had the highest blood organic mercury level among different ethnicities, 0.93 [0.82-1.05] µg/L (P0.001). Blood inorganic mercury level decreased from 0.31 [0.31-0.31] in 1999-2000 to 0.21 [0.21-0.22] µg/L in 2015-2016 (P0.001). Urine mercury level decreased from 0.75 [0.71-0.80] in 1999-2000 to 0.16 [0.16-0.17] µg/L in 2015-2016 (P0.001).Blood organic mercury increased over the period 1999-2016 in the US population, including children and pregnant women, whereas there was a steady decline in both blood inorganic mercury and urine mercury levels.

Background To study the incidence of vancomycin-associated acute kidney injury (VA-AKI) in Hong Kong and identify risk factors for VA-AKI. Method Patients with vancomycin prescription and blood level measurement in 2012–2016 were identified using the Hong Kong Hospital Authority Clinical Data Analysis and Reporting System. Acute kidney injury was defined using KDIGO criteria. Patients without creatinine measurements, steady-state trough vancomycin level or who had vancomycin treatment Results One thousand four hundred fifty patients were identified as VA-AKI from 12,758 records in Hong Kong in 2012–2016. The incidence was respectively 10.6, 10.9, 11.3, 12.2, 11.2% from 2012 to 2016. The incidence of VA-AKI was 16.3, 12.2, 11.3 and 6.2% in patients aged 1–12, 12–60, elderly aged > 60 and newborn and infants, respectively. Baseline creatinine, serum trough vancomycin level, systematic disease history including respiratory failure, hypertension, congestive heart failure, chronic renal failure, anemia and type II diabetes, and concomitant diuretics, piperacillin-tazobactam (PTZ) and meropenem prescription were significantly higher in VA-AKI patients older than 12 years. Logistic regression showed that older age group, higher baseline creatinine, serum trough vancomycin level, respiratory failure, chronic renal failure and congestive heart failure, concomitant diuretics, PTZ and meropenem prescription, and longer hospital stay were all associated with increased risk of VA-AKI. Conclusion The incidence of VA-AKI in Hong Kong is low but shows no decline. Patients with higher baseline creatinine, multi-organ diseases and multiple drugs administration should have their vancomycin level monitored to decrease the risk of VA-AKI.

BACKGROUND: Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel is used for stroke prevention in patients with atrial fibrillation (AF) when patients refuse to use oral anticoagulants (OAC) in clinical practice. However, there are limited clinical data comparing these treatments.OBJECTIVE: To compare the clinical outcomes between DAPT and OAC in patients with AF.METHODS: Cohort study using a population-wide database of the Hong Kong Hospital Authority. New patients with AF during 2010-2014 and prescribed DAPT or OAC (warfarin or dabigatran) were followed until July 31, 2016. Outcomes were thromboembolism, bleeding, and death. Propensity score (PS) matching at 1:2 ratio was used to select DAPT users with similar characteristics to OAC users, analyzed using Poisson regression.RESULTS: Among 51,946 new patients with AF, 8,520 users of OAC and DAPT were identified. The likelihood of receiving DAPT over OAC increased with older age and previous intracranial hemorrhage. Among DAPT users, the incidences of thromboembolism, death, and bleeding per 100 patient-years were 15.8, 17.6, and 5.1 respectively. When compared to DAPT users, PS-matched analysis indicated a lower incidence of thromboembolism and/or death among OAC users (incidence rate ratio [IRR]=0.32, 95% confidence interval [CI]=0.19-0.55 for dabigatran and IRR=0.58, 95%CI=0.36-0.95 for warfarin), with no significant differences in bleeding events.CONCLUSIONS: DAPT users were at markedly increased risk of thromboembolism and death compared to OAC users. These findings indicate the need for improved stroke risk reduction strategies among patients taking DAPT and the opportunities of using OAC in high risk groups to prevent more events.

Introduction: Highly elevated blood lead levels (BLL) increase the risk of gout. It is unknown if this association still holds at lower BLLs, such as those in the general population. Methods: 21646 adult participants with blood lead measurements in NHANES 2007-2016 were included in this analysis. Gout was defined as a self-reported diagnosis of gout. Results were analysed using SPSS complex sample module version 22. Logistic regression was used to study the association between BLL and gout. Odds ratio (OR) and 95% confidence interval (95% CI) were estimated. Results: The prevalence of gout increased with BLL (prevalence [95% CI]: Quintile 1 (

Objective— In patients with stable coronary artery disease, conventional risk factors provide limited incremental predictive value for cardiovascular events. We sought to investigate whether a panel of cardiometabolic biomarkers alone or combined with conventional risk factors would exhibit incremental value in the prediction of cardiovascular events. Approach and Results— In the discovery cohort, we measured serum adiponectin, A-FABP (adipocyte fatty acid–binding protein), lipocalin-2, FGF (fibroblast growth factor)-19 and 21, plasminogen activator inhibitor-1, and retinol-binding protein-4 in 1166 Chinese coronary artery disease patients. After a median follow-up of 35 months, 170 patients developed new-onset major adverse cardiovascular events (MACE). In the model with age ≥65 years and conventional risk factors, area under the curve for predicting MACE was 0.68. Addition of lipocalin-2 to the age-clinical risk factor model improved predictive accuracy (area under the curve=0.73). Area under the curve further increased to 0.75 when a combination of lipocalin-2, A-FABP, and FGF-19 was added to yield age-biomarkers-clinical risk factor model. The adjusted hazard ratio on MACEs for lipocalin-2, A-FABP, and FGF-19 levels above optimal cutoffs were 2.23 (95% CI, 1.62–3.08), 1.99 (95% CI, 1.43–2.76), and 1.65 (95% CI, 1.15–2.35), respectively. In the validation cohort of 1262 coronary artery disease patients with type 2 diabetes mellitus, the age-biomarkers-clinical risk factor model was confirmed to provide good discrimination and calibration over the conventional risk factor alone for prediction of MACE. Conclusions— A combination of the 3 biomarkers, lipocalin-2, A-FABP, and FGF-19, with clinical risk factors to yield the age-biomarkers-clinical risk factor model provides an optimal and validated prediction of new-onset MACE in patients with stable coronary artery disease.

Background High-sensitivity troponin I (hs-Tnl) and B-type natriuretic peptide (BNP) are promising prognostic markers for coronary artery disease (CAD). This prospective cohort study investigated whether a combination of these cardiac biomarkers with conventional risk factors would add incremental value for the prediction of secondary major adverse cardiovascular events (MACEs) in patients with CAD, with and without type 2 diabetes mellitus (T2DM). Methods Baseline plasma level of hs-Tnl and BNP was measured in 2275 Chinese patients with stable CAD. Patients were monitored for new-onset of MACE over a median of 51 months. Cox proportional hazard model and area under the receiver operating characteristic curve (AUC) were used to assess the association of cardiac biomarkers with MACE and their predictive values in relationship with or without T2DM. Results During the follow up period 402 (18%) patients experienced a new-onset MACE with hs-Tnl and BNP level significantly higher than in those without MACE. In multivariable analyses, patients with elevated hs-Tnl (hazard ratio, 1.75 [95% CI 1.41–2.17]; P P = 0.001) were significantly associated with an increased risk of MACE after adjustment for variables of a risk factor model of age, sex, T2DM and hypertension. The risk factor model had an AUC of 0.64 for MACE prediction. The AUC significantly increased to 0.68 by the addition of hs-Tnl to the risk factor model. Subgroup analyses showed that hs-Tnl and BNP remained significant predictors of MACE in both patients with and without T2DM in multivariable models with higher risk of MACE evident in those without T2DM. Among patients without T2DM, addition of each biomarker yielded greater predictive accuracy than in T2DM patients, with AUC further increased to 0.75 when a combination of hs-Tnl and BNP was added to the risk factor model (age, sex and hypertension). Conclusions Elevated hs-Tnl and BNP level are independent predictors of new-onset MACE in CAD patients, irrespective of diabetes status. Among CAD patients without T2DM, a combination of cardiac biomarkers hs-Tnl and BNP yield the greatest predictive value beyond conventional risk factors.

Introduction: Obesity is a public health crisis in the US. Childhood obesity is associated with multiple comorbidities in the adulthood, including metabolic syndrome, cardiovascular diseases, and premature death. A recent study found that the prevalence of childhood obesity varied according to age and ethnicity. This study aims to evaluate the long-term trends and the underexplored socioeconomic factors associated with childhood obesity. Method: From the US National Health and Nutrition Examination Survey from 1999 to 2018, 35 907 children aged 2–19 with body mass index (BMI) data were included. Prevalence of obesity and severe obesity, defined as BMI ≥95th percentile and ≥120% of 95th percentile of US Centers for Disease Control and Prevention growth charts, respectively. Trends in prevalence of obesity and subgroup analyses according to age group, sex, ethnicity, language used in interview, household education level, and household income level, were analyzed. Data analysis was performed using the R statistical package “survey” (version 3.6.3). Results: The prevalence of obesity and severe obesity increased from 14.7 [95% CI: 12.9–17.0] % to 19.2 [17.2–21.0] % and 3.9 [2.9–5.0] % to 6.1 [4.8–8.0] % in 1999–2018, respectively (p=0.001 and p=0.014 for obesity and severe obesity, respectively). In 2017–8, the prevalence of obesity among children from Spanish-speaking households was 24.4 [22.4–27.0] %, higher than children from English-speaking households (p=0.027). Children from households with high education level and high income level had a lower prevalence of obesity compared to those with low education level and low income level (p=0.003 and p=0.002 for education level and income level, respectively). Compared to girls, boys had higher prevalence of obesity (p=0.002) and severe obesity (p=0.004). Conclusion: The prevalence of childhood obesity in America kept increasing during the period 1999–2018 despite various public health initiatives. The problem is worse in children with lower socioeconomic status, and in children from Spanish-speaking households. Public health interventions are urgently needed to halt the rising trend of childhood obesity, and measures specifically catering to children from Spanish-speaking families should be put in place.

Introduction: As guidelines evolve, lifestyle changes and new drugs are introduced, the long-term trends in cardiovascular risk in the general population are of interest. We evaluated the AHA-ACC-ASCVD risk score (ASCVD-RS) in the US population in the last 20 years. Methods: Participants in the National Health and Nutrition Examination Survey (NHANES) 1999–2018 aged 40–79 years were included. Pregnant participants and those with missing relevant laboratory/self-reported data were excluded. Temporal trends in ASCVD-RS and its components, and the proportions of participants at high risk (score ≥10%) were characterized using linear regression, adjusted for age, sex, and ethnicity. Data analysis was performed using the R statistical package “survey” (version 3.6.3). Results: Altogether 12744 NHANES participants (mean age 56.4 years; 55.9% male) were analyzed. From 1999–2018, the proportion of people with diabetes and taking antihypertensives increased significantly (both p Conclusions: Cardiovascular risk in the US population increased slightly in the past 20 years. Despite the increased treatment rate of hypertension and the decrease in total cholesterol, the prevalence of diabetes doubled. More effort should be directed at preventing diabetes through weight control and regular physical activity.

Aims To compare cardio-renal outcomes and incurred direct medical costs of patients initiating sodium glucose cotransporter-2 inhibitors (SGLT2i) versus glucagon-like peptide-1 receptor agonists (GLP-1RA). Methods A population-based cohort of patients with type 2 diabetes was identified from Hong Kong Hospital Authority. Patients who were free from cardiovascular and end-stage renal diseases at baseline, and newly treated with SGLT2i (n = 2,541) or GLP-1RA (n = 303), were included. Risks of developing cardio-renal complications, incurred direct medical costs, and changes in clinical parameters were assessed between groups. Results Over a median follow-up of 12.5 months in SGLT2i group and 25.5 months in GLP-1RA group, SGLT2i users were associated with significantly lower risk of heart failure compared with those on GLP-1RA [hazard ratio = 0.183, 95 %CI = (0.045, 0.745)]. 1-year change in clinical parameters also favored use of SGLT2i over GLP-1RA, where the former was associated with a larger reduction in fasting glucose level [difference-in-difference = −0.87 mmol/L, 95 %CI = (−1.42, −0.33), p = 0.002]. The two groups had comparable direct medical costs after 1-year of follow-up. Conclusion Patients initiating SGLT2i experienced a significantly lower risk of heart failure than those on GLP-1RA, alongside better glycemic control through a larger reduction in fasting glucose level over one-year follow-up, while direct medical cost incurred was comparable to that of GLP-1RA.

Aims Lipocalin-2 is a pro-inflammatory molecule characterized by a highly diversified pattern of expression and structure–functional relationships. In vivo, this molecule exists as multiple variants due to post-translational modifications and/or protein–protein interactions. Lipocalin-2 is modified by polyamination, which enhances the clearance of this protein from the circulation and prevents its excessive accumulation in tissues. On the other hand, animal studies suggest that non-polyaminated lipocalin-2 (npLcn2) plays a causal role in the pathogenesis of obesity-associated medical complications. The present study examined the presence of npLcn2 in samples from healthy volunteers or patients with cardiac abnormalities and evaluated npLcn2 as a biomarker for cardiometabolic risk assessment. Methods and results Immunoassays were developed to quantify npLcn2 in blood and urine samples collected from 100 volunteers (59 men and 41 women), or venous plasma and pericardial fluid samples obtained from 37 cardiothoracic surgery patients. In healthy volunteers, npLcn2 levels in serum are significantly higher in obese and overweight than in lean subjects. After adjustment for age, gender, smoking, and body mass index (BMI), serum npLcn2 levels are positively correlated with heart rate, circulating triglycerides, high-sensitivity C-reactive protein (hsCRP), and creatinine in plasma. The npLcn2 levels in urine are significantly increased in subjects with metabolic syndrome and positively correlated with BMI, heart rate, circulating triglycerides, and urinary aldosterone. In cardiothoracic surgery patients, the circulating concentrations of npLcn2 are higher (more than two-fold) than those of healthy volunteers and positively correlated with the accumulation of this protein in the pericardial fluid. Heart failure patients exhibit excessive expression and distribution of npLcn2 in mesothelial cells and adipocytes of the parietal pericardium, which are significantly correlated with the elevated plasma levels of npLcn2, total cholesterol, and creatinine. Conclusions Quantitative and qualitative evaluation of npLcn2 in human biofluid samples and tissue samples can be applied for risk assessment of healthy individuals and disease management of patients with obesity-related cardiometabolic and renal complications.

Fibroblast growth factor 21 (FGF21) is increasingly recognized as an important metabolic regulator of glucose homeostasis. Here, we conducted an exome-chip association analysis by genotyping 5,169 Chinese individuals from a community-based cohort and two clinic-based cohorts. A custom Asian exome-chip was used to detect genetic determinants influencing circulating FGF21 levels. Single-variant association analysis interrogating 70,444 single nucleotide polymorphisms identified a novel locus, GCKR, significantly associated with circulating FGF21 levels at genome-wide significance. In the combined analysis, the common missense variant of GCKR, rs1260326 (p.Pro446Leu), showed an association with FGF21 levels after adjustment for age and sex (P = 1.61 × 10−12; β [SE] = 0.14 [0.02]), which remained significant on further adjustment for BMI (P = 3.01 × 10−14; β [SE] = 0.15 [0.02]). GCKR Leu446 may influence FGF21 expression via its ability to increase glucokinase (GCK) activity. This can lead to enhanced FGF21 expression via elevated fatty acid synthesis, consequent to the inhibition of carnitine/palmitoyl-transferase by malonyl-CoA, and via increased glucose-6-phosphate–mediated activation of the carbohydrate response element binding protein, known to regulate FGF21 gene expression. Our findings shed new light on the genetic regulation of FGF21 levels. Further investigations to dissect the relationship between GCKR and FGF21, with respect to the risk of metabolic diseases, are warranted.

Purpose Drug-induced agranulocytosis is a rare but life-threatening adverse drug reaction. Its epidemiology in Chinese is largely unknown. This study aimed to estimate the incidence, mortality, and risk of the drugs associated with agranulocytosis in Hong Kong Chinese. Methods A population-based case-control study was conducted using the Clinical Data Analysis and Reporting System, a database managed by the Hong Kong Hospital Authority. Patients with drug-induced agranulocytosis from 1 January 2004 to 31 December 2013 were identified. World Health Organization causality assessment was used to evaluate the possible drug aetiology of each case. Odd ratios (ORs) of the drug exposure were calculated using exact conditional logistic regression. Results 155 cases of drug-induced agranulocytosis were identified. Mean age was 51.4 years and 95 cases were female. Incidence rate was estimated to be 2.2 cases per million person-years and the all-cause mortality of patients with drug-induced agranulocytosis was 3.9%. Among the cases, the most common associated drug groups were antithyroid drugs (41.9%), antimicrobials (20%), anticonvulsants (10.3%), and antipsychotics (6.5%). Carbimazole had the highest risk of agranulocytosis (adjusted OR 416.7, 95% Confidence Interval (CI) 51.5 – 3372.9) with an incidence of 9.2 (95% CI 6.9 - 12.1) per 10,000 users and 3.6 (95% CI 2.7 - 4.8) per 10,000 user-years. Other drugs with significant risk included cephalosporins, clozapine, penicillins, phenytoin, and propyl thiouracil. Conclusions The incidence and mortality in Hong Kong Chinese were relatively low compared to Caucasians. Antithyroid drugs were the most common Its epidemiology in Chinese is largely unknown. This study aimed to estimate the incidence, mortality, and risk of the drugs associated with agranulocytosis in Hong Kong Chinese. Methods A population-based case-control study was conducted using the Clinical Data Analysis and Reporting System, a database managed by the Hong Kong Hospital Authority. Patients with drug-induced agranulocytosis from 1 January 2004 to 31 December 2013 were identified. World Health Organization causality assessment was used to evaluate the possible drug aetiology of each case. Odd ratios (ORs) of the drug exposure were calculated using exact conditional logistic regression. Results 155 cases of drug-induced agranulocytosis were identified. Mean age was 51.4 years and 95 cases were female. Incidence rate was estimated to be 2.2 cases per million person-years and the all-cause mortality of patients with drug-induced agranulocytosis was 3.9%. Among the cases, the most common associated drug groups were antithyroid drugs (41.9%), antimicrobials (20%), anticonvulsants (10.3%), and antipsychotics (6.5%). Carbimazole had the highest risk of agranulocytosis (adjusted OR 416.7, 95% Confidence Interval (CI) 51.5 – 3372.9) with an incidence of 9.2 (95% CI 6.9 - 12.1) per 10,000 users and 3.6 (95% CI 2.7 - 4.8) per 10,000 user-years. Other drugs with significant risk included cephalosporins, clozapine, penicillins, phenytoin, and propyl thiouracil. Conclusions The incidence and mortality in Hong Kong Chinese were relatively low compared to Caucasians. Antithyroid drugs were the most common implicated drug class and carbimazole had the highest risk of agranulocytosis.

SummaryLow vitamin D levels have been associated with various cardiovascular diseases; however, whether it is associated with stroke remains inconclusive. We aimed to evaluate the association between serum 25-hydroxyvitamin D and risk of stroke. We conducted a cohort study consisting of 3,458 participants from the Hong Kong Osteoporosis Study aged ≥45 at baseline, examined between 1995 and 2010 and followed up using electronic medical records. Ischaemic and haemorrhagic stroke were defined using the ICD-9 code. In multivariable Cox-proportional hazard regression, quintiles 1 and 4 were significantly associated with increased risk of stroke when compared to the highest quintile (Quintile 1: HR, 1.78; 95 % CI, 1.16–2.74 and quintile 4: HR, 1.61; 95 % CI, 1.07–2.43). A similar association was observed in both men and women. In subgroup analysis, the association was specifically observed for ischaemic stroke, but not haemorrhagic stroke. Using a penalized regression spline, the association between vitamin D and risk of stroke was in a reverse J-shape, with the lowest risk of stroke being observed at 25(OH)D levels between 70 and 80 nmol/l. In conclusion, a low vitamin D level is associated with increased risk of ischaemic stroke; however, whether high vitamin D level is also associated with increased risk of stroke requires further study.Supplementary Material to this article is available at www.thrombosis-online.com.

More by accident than by design, a special themed issue on infectious disease in the Postgraduate Medical Journal was planned last year but comes out in this annus horribilis overshadowed by COVID-19. Although the Postgraduate Medical Journal champions many themes of contemporary relevance and significance, including equal opportunity,1 gender equality2 and burn-out,3 it has also been receiving many manuscripts and images related to infectious disease. Therefore, this is a good moment to focus on what is preoccupying people most in the world today. COVID-19 began in December 2019 as a mysterious cluster of atypical and life-threatening pneumonia in Wuhan,4 a modern commercial and industrial city of more than 11 million inhabitants (more than London, UK). These patients were not the typical frail and elderly patients with pneumonia, and they did not respond to antibiotics. The clinical picture resembled the atypical pneumonias caused by the SARS coronavirus 17 years ago. This time round, the virus was rapidly identified and its sequence was published in January 2020.5 On 3 January 2020, before the Chinese government publicly acknowledged an epidemic, the US Centres for Disease Control and Prevention was informed. The WHO initially thought that the outbreak was largely limited to China and there was no need for widespread panic. The WHO Collaborating Centre for Infectious Disease Epidemiology and Control, however, announced on Chinese New Year’s Day that the virus disease from Wuhan would rapidly involve cities within and outside China because of rail and air travel.6 This was only a mathematical projection, but nevertheless rang the alarm bells. There were already hundreds if not thousands of cases in Wuhan. The early epidemiology showed that the reproductive number (R) of the virus was around 2, which means that on average, each infected person would infect two other …

The Fellowship of Postgraduate Medicine (FPM) is partnering with its journals —Health Policy and Technology and the Postgraduate Medical Journal —to launch international awards for well-informed, clear writing on health matters in social media. Patients, members of the public, health professionals and policymakers increasingly use social media as a source for health information and to guide important decisions on choices and actions about prevention and treatment of disease. Where the information is accurate and easy to follow, this can be very helpful. However, we are increasingly at the mercy of a spectrum of unreliability, from incomplete or inaccurate reports, to claims that inconvenient truths are ‘fake news’. These are not new problems. …

Sir William Osler, born on 12th July 1849 and died on 29th December 1919, is often called the ‘Father of Modern Medicine’. Born and raised in Canada, he graduated from McGill University and took up important posts in Philadelphia, Baltimore and Oxford. He left his mark on all these places and so in the centenary of this death, he is commemorated widely for his legacy to the practice of medicine and the training of medical doctors. The Postgraduate Medical Journal is proud to dedicate the current issue to the memory of the great …

Aims/Introduction To develop a new non‐invasive risk score for undiagnosed diabetes in Chinese people, and to evaluate the incident diabetes risk in those with high‐risk scores, but no diabetes on initial testing. Materials and Methods A total of 2,609 participants with no known diabetes (aged 25–74 years) who underwent oral glucose tolerance tests in Hong Kong (HK) were investigated for independent risk factors of diabetes to develop a categorization point scoring system, the Non‐invasive Diabetes Score (NDS). This NDS was validated in a cross‐sectional study of 2,746 participants in Shaanxi, China. HK participants tested to not have diabetes at baseline were assessed for subsequent incident diabetes rates. Results In the HK cohort, hypertension, age and body mass index were the key independent risk factors selected to develop the NDS, with ≥28 out of 50 NDS points considered as high risk. The area under the receiver operating characteristic curve for undiagnosed diabetes was 0.818 and 0.720 for the HK and Shaanxi cohort, respectively. The negative predictive value was 97.4% (HK) and 95.8% (Shaanxi); the number needed to screen to identify one case of diabetes was five (HK) and 11 (Shaanxi), respectively. Among those that tested non‐diabetes at baseline, individuals with NDS ≥28 had a threefold risk of incident diabetes during the subsequent 20.9 years, compared with those with NDS, We described the development, validation and longitudinal evaluation of a simple diabetes risk score with the fewest number of variables for undiagnosed diabetes in Chinese people. This risk score might help in opportunistic screening of diabetes, and inform subsequent testing interval for high‐risk individuals after initial testing.

Objectives The aim of this study is to determine major adverse cardiovascular events (MACE) and all-cause mortality comparing between xanthine oxidase inhibitors (XOIs) and non-XOI users, and between allopurinol and febuxostat. Methods This is a retrospective cohort study of gout patients prescribed anti-hyperuricemic medications between 2013 and 2017 using a territory-wide administrative database. XOI users were matched 1:1 to XOI non-users using propensity scores. Febuxostat users were matched 1:3 to allopurinol users. Subgroup analyses were conducted based on colchicine use. Results Of the 13 997 eligible participants, 3607 (25.8%) were XOI users and 10 390 (74.2%) were XOI non-users. After propensity score matching, compared with non-users (n = 3607), XOI users (n = 3607) showed similar incidence of MACE (hazard ratio [HR]: 0.997, 95% CI, 0.879, 1.131; P>0.05) and all-cause mortality (HR = 0.972, 95% CI 0.886, 1.065, P=0.539). Febuxostat (n = 276) users showed a similar risk of MACE compared with allopurinol users (n = 828; HR: 0.672, 95% CI, 0.416, 1.085; P=0.104) with a tendency towards a lower risk of heart failure-related hospitalizations (HR = 0.529, 95% CI 0.272, 1.029; P=0.061). Concurrent colchicine use reduced the risk for all-cause mortality amongst XOI users (HR = 0.671, 95% 0.586, 0.768; P Conclusion In gout patients, XOI users showed similar risk of MACE and all-cause mortality compared with non-users. Compared with allopurinol users, febuxostat users showed similar MACE and all-cause mortality risks but lower heart failure-related hospitalizations.

In this issue of the Postgraduate Medical Journal , a blood pressure control rate of over 90% was reported by a teaching primary healthcare centre in Jordan.1 This is remarkable, if not miraculous, compared with blood pressure control rates in other parts of the world, including the USA.2 Admittedly, this was an observational study of only 286 patients with hypertension attending a well-run, round-the-clock primary healthcare centre serving university staff and their families, and university students. These patients with hypertension were therefore generally younger and healthier than typical subjects in epidemiological studies. They were also self-selecting in that they were registered …

Awareness is one of the first steps in a lifestyle modification process. Since older adults are at a higher risk of hypertension, maintaining low sodium intake is of utmost importance. Yet, it is uncertain if older adults have an awareness of their sodium intake. This study aimed to explore self-perceived sodium intake among older Chinese people and compare it with various measures of sodium intake. A cross-sectional study was conducted in Hong Kong in 2015. Data were collected from 24-h urinary sodium excretion (UNa24) measurements, dietary sodium intake by 24-h diet recalls and self-perceived salt intake levels among the older Hong Kong population. Kappa statistics and a paired t-test were used to compare the different measures. Fifty-nine participants provided complete 24-h urine samples. The mean (±SD) UNa24 of participants was 2846 ± 1253 mg, of which 74.6% exceeded the recommended daily sodium intake. About 87.8% of participants with UNa24 values >2000 mg perceived their sodium intake as too little or just right. The kappa statistic between UNa24 and self-perception was insignificantly different from zero (κ = −0.003, p-value = 0.909). The UNa24 estimates were significantly higher than those estimated from the 24-h diet recalls by 1203 mg ( p-value

SummaryObjective Fibroblast growth factor 21 (FGF21) improves glucose and lipid metabolism, but high circulating levels are found in type 2 diabetes, suggesting FGF21 resistance. Serum FGF21 predicts incident diabetes, but its performance compared to established and emerging predictors is not known. We aimed to study the performance of FGF21 in diabetes prediction, relative to other adipokines and established risk factors including 2-h plasma glucose (2hG) during the oral glucose tolerance test (OGTT). Design/Participants/Measurements We studied 1380 nondiabetic subjects from the Hong Kong Cardiovascular Risk Factor Prevalence Study using the second visit (2000–2004) as baseline when serum levels of FGF21 and other adipokines were measured. Glycaemic status was assessed by OGTT. Incident diabetes was defined as fasting glucose level (FG) ≥ 7 mmol/l or 2hG ≥ 11·1 mmol/l or use of antidiabetic agents, at subsequent visits. Results A total of 123 participants developed diabetes over 9·0 years (median). On multivariable logistic regression analysis, FGF21 (P = 0·003), adipocyte fatty acid-binding protein (P = 0·003) and adiponectin (P = 0·035) were independent predictors of incident diabetes. FGF21 had the best change in log likelihood when added to a diabetes prediction model (DP) based on age, family history, smoking, hypertension, BMI, dyslipidaemia and FG. It also improved the area under ROC curve (AUROC) of diabetes prediction (DP) from 0·797 to 0·819 (P = 0·0072), rendering its performance comparable to the ‘DP + 2hG’ model (AUROC=0·838, P = 0·19). Conclusions As a biomarker for diabetes prediction, serum FGF21 appeared to be superior to other adipokines and, on its own, could be considered as an alternative to the OGTT.

© 2015, The American Society for Clinical Pharmacology and Therapeutics.Thioamides antithyroid-drugs (ATDs) are important in hyperthyroid disease management. Identification of the susceptibility locus of ATD-induced agranulocytosis is important for clinical management. We performed a genome-wide association study (GWAS) involving 20 patients with ATD-induced agranulocytosis and 775 healthy controls. The top finding was further replicated. A single-nucleotide polymorphism (SNP), rs185386680, showed the strongest association with ATD-induced agranulocytosis in GWAS (odds ratio (OR) = 36.4; 95% confidence interval (CI) = 12.8-103.7; P = 1.3 × 10 -24) and replication (OR = 37; 95% CI = 3.7-367.4; P = 9.6 × 10 -7). HLA-B∗38:02:01 was in complete linkage disequilibrium with rs185386680. High-resolution HLA typing confirmed that HLA-B∗38:02:01 was associated with carbimazole (CMZ)/methimazole (MMI)-induced agranulocytosis (OR = 265.5; 95% CI = 27.9-2528.0; P = 2.5 × 10 -14), but not associated with propylthiouracil (PTU). The positive and negative predictive values of HLA-B∗38:02:01 in predicting CMZ/MMI-induced agranulocytosis were 0.07 and 0.999. Approximately 211 cases need to be screened to prevent one case. Screening for the risk allele will be useful in preventing agranulocytosis in populations in which the frequency of the risk allele is high.

The study aimed to prospectively evaluate if serum calcium is related to diabetes incidence in Hong Kong Chinese. The results showed that serum calcium has a significant association with increased risk of diabetes. The result of meta-analysis reinforced our findings. This study aimed to evaluate the association of serum calcium, including serum total calcium and albumin-corrected calcium, with incident diabetes in Hong Kong Chinese. We conducted a retrospective cohort study in 6096 participants aged 20 or above and free of diabetes at baseline. Serum calcium was measured at baseline. Incident diabetes was determined from several electronic databases. We also searched relevant databases for studies on serum calcium and incident diabetes and conducted a meta-analysis using fixed-effect modeling. During 59,130.9 person-years of follow-up, 631 participants developed diabetes. Serum total calcium and albumin-corrected calcium were associated with incident diabetes in the unadjusted model. After adjusting for demographic and clinical variables, the association remained significant only for serum total calcium (hazard ratio (HR), 1.32 (95 % confidence interval (CI), 1.02–1.70), highest vs. lowest quartile). In a meta-analysis of four studies including the current study, both serum total calcium (pooled risk ratio (RR), 1.38 (95 % CI, 1.15–1.65); I 2 = 5 %, comparing extreme quantiles) and albumin-corrected calcium (pooled RR, 1.29 (95 % CI, 1.03–1.61); I 2 = 0 %, comparing extreme quantiles) were associated with incident diabetes. Penalized regression splines showed that the association of incident diabetes with serum total calcium and albumin-correlated calcium was non-linear and linear, respectively. Elevated serum calcium concentration is associated with incident diabetes. The mechanism underlying this association warrants further investigation.

The objective of this review was to obtain a reliable estimate of the magnitude of the prospective association between gamma-glutamyltransferase (GGT) and risk of hypertension, and to characterize the nature of the dose-response relationship. We conducted a systematic review and dose-response meta-analysis of published prospective studies. Relevant studies were identified in a literature search of MEDLINE, EMBASE, and Web of Science databases up to May 2015. Study-specific relative risks (RRs) were meta-analyzed using random effects models. We examined a potential nonlinear relationship using restricted cubic splines. Of the 612 titles reviewed, we included 14 cohort studies with data on 44 582 participants and 5 270 hypertension cases. In a comparison of extreme thirds of baseline levels of GGT, RR for hypertension in pooled analysis of all 14 studies was 1.32 (95% confidence interval: 1.23-1.43). There was heterogeneity among the studies (P P for nonlinearity = 0.37). The pooled RR of hypertension per 5 U/l increment in GGT levels was 1.08 (95% confidence interval: 1.04-1.13). Baseline circulating GGT level is associated with an increased risk of hypertension in the general population, consistent with a linear dose-response relationship. Further investigation of any potential relevance of GGT in hypertension prevention is warranted.

The frequent answer to the question ‘Why do you want to study medicine’ at the medical school interview is ‘I want to save lives’. A scientist colleague used to greet me with the line ‘How many lives have you saved today?’ The truth is that while we can easily kill a patient if we are not careful, rarely can we intervene to turn the tide and save a life. As a clinical pharmacologist with an interest in medication errors, I know that a careful and alert doctor is better for the patient than a caring but tired doctor. Older doctors may recall with some fondness and pride that they used to be on call every other night and still came through. In the UK and European Union at least, it is now recognised that doctors, like airline pilots, must not overwork. Why, then, is burnout a growing problem in the medical profession? Can it be that we are not recruiting people with the ‘right stuff’ into the profession? In most countries, getting into medical school is extremely competitive. Only secondary school students with the highest grades and scores will …

Background Technological surrogate nursing (TSN) derives from the idea that nurse-caregiver substitutes can be created by technology to support chronic disease self-care. Objective This paper begins by arguing that TSN is a useful and viable approach to chronic disease self-care. The analysis then focuses on the empirical research question of testing and demonstrating the effectiveness and safety of prototype TSN supplied to patients with the typical complex chronic disease of coexisting type 2 diabetes and hypertension. At the policy level, it is shown that the data allow for a calibration of TSN technology augmentation, which can be readily applied to health care management. Methods A 24-week, parallel-group, randomized controlled trial (RCT) was designed and implemented among diabetic and hypertensive outpatients in two Hong Kong public hospitals. Participants were randomly assigned to an intervention group, supplied with a tablet-based TSN app prototype, or to a conventional self-managing control group. Primary indices—hemoglobin A1c, systolic blood pressure, and diastolic blood pressure—and secondary indices were measured at baseline and at 8, 12, 16, and 24 weeks after initiation, after which the data were applied to test TSN effectiveness and safety. Results A total of 299 participating patients were randomized to the intervention group (n=151) or the control group (n=148). Statistically significant outcomes that directly indicated TSN effectiveness in terms of hemoglobin 1c were found in both groups but not with regard to systolic and diastolic blood pressure. These findings also offered indirect empirical support for TSN safety. Statistically significant comparative changes in these primary indices were not observed between the groups but were suggestive of an operational calibration of TSN technology augmentation. Statistically significant changes in secondary indices were obtained in one or both groups, but not between the groups. Conclusions The RCT’s strong behavioral basis, as well as the importance of safety and effectiveness when complex chronic illness is proximately self-managed by layperson patients, prompted the formulation of the empirical joint hypothesis that TSN would improve patient self-care while satisfying the condition of patient self-safety. Statistical and decision analysis applied to the experimental outcomes offered support for this hypothesis. Policy relevance of the research is demonstrated by the derivation of a data-grounded operational calibration of TSN technology augmentation with ready application to health care management. Trial Registration ClinicalTrials.gov NCT02799953; https://clinicaltrials.gov/ct2/show/NCT02799953

Hypertension is a common chronic disease affecting a large section of the general population. Hypertension is highly prevalent in the elderly because blood pressure (BP) rises with age. The risk of developing hypertension increases with predisposing genes, intrauterine growth retardation, prematurity and childhood obesity. BP is easier to control in the young. Non-pharmacological treatment through lifestyle changes, such as weight control and leisure-time physical activity, is more likely to be successful in young people. Hypertension in older adults is more difficult to control, requiring the use of more than one antihypertensive drug. Adverse effects and compliance become problematic. Much research is now directed at novel ways of controlling BP such as denervation. The change in definition of hypertension in the American guideline highlights the need to identify and manage hypertension early, at a stage when it is potentially reversible.

Background: Conflicting and population-dependent findings have been reported from epidemiological studies on the associations of dietary intake of anti-oxidant vitamins with cardiovascular events. We investigated the prospective relationship between dietary intake of anti-oxidant vitamins and incident adverse cardiovascular outcomes amongst Hong Kong Chinese. Methods: In this prospective population-based study, baseline dietary intake of anti-oxidant vitamins (A, C, and E) were assessed using a food frequency questionnaire in 875 Chinese participants from the Hong Kong Cardiovascular Risk Factor Prevalence Study (CRISPS) in 1995&ndash, 1996. The adjusted hazard ratio (HR) of incident adverse cardiovascular outcomes, defined as the first recorded diagnosis of cardiovascular deaths, non-fatal myocardial infarction or non-fatal stroke, and coronary or other arterial revascularizations, was calculated per unit intake of each vitamin using multivariable Cox regression. Results: Over a median follow-up of 22 years, 85 participants (9.7%) developed adverse cardiovascular outcomes. Dietary intakes of vitamin A, C, and E were independently and inversely associated with incident adverse cardiovascular outcomes (HR 0.68, 95%CI 0.53&ndash, 0.88, p = 0.003 for vitamin A, HR 0.66, 95%CI 0.52&ndash, 0.85, p = 0.001 for vitamin C, and HR 0.57, 95%CI 0.38&ndash, 0.86, p = 0.017 for vitamin E) after adjustments for conventional cardiovascular risk factors at baseline. Conclusions: Dietary intakes of anti-oxidant vitamins A, C, and E reduced the risk of adverse cardiovascular outcomes in Hong Kong Chinese.

Summary Introduction The beneficial effect of vitamin D on the risk of non-musculoskeletal diseases has been investigated in observational studies and randomized clinical trials, but the findings were inconsistent. Identification of the metabolomic profile associated with vitamin D helps to identify novel biomarkers and increase the understanding of the biochemical and physiological role of vitamin D in different health conditions. Method Serum metabolomic profiling was performed using liquid chromatography/tandem mass spectrometry [LC/MS] and their association with serum 25(OH)D was evaluated using multivariable linear regression in the baseline cohort of 316 participants (aged 20 or above; 92 men, 224 women; mean age±SD: 48.1 ± 15.8 years) and in the follow-up cohort of 275 participants (aged 20 or above; 12 men, 263 women; mean age: 56.2 ± 9.6) of the Hong Kong Osteoporosis Study. We discovered and validated potential metabolites; and by meta-analysis of these associations in two cohorts, we identified metabolites that were significantly associated with serum 25(OH)D levels. Results Among 835 known metabolites, 102 metabolites showed significant correlation with 25(OH)D levels at baseline visit. Of these metabolites, 27 were validated in the follow-up visit. In meta-analysis of data from these two visits, 13 metabolites were highly correlated with 25(OH)D. The majority of metabolites identified were lipid in nature. Docosahexaenoylcarnitine and eicosapentaenoylcholine had the highest correlations, with effect estimates 0.2554 (p = 9.60 × 10−9) and 0.1682 (p = 4.94 × 10−7) respectively. Conclusion In Hong Kong Chinese at least, serum vitamin D level is closely related to lipid metabolism. Our finding highlights an important new direction in the study of vitamin D in different health conditions.

There is clinical trial evidence that lowering systolic blood pressure (SBP) to120 mm Hg is beneficial, and this has influenced the latest American guideline on hypertension. We therefore used network meta-analysis to study the association between SBP and cardiovascular outcomes.We searched for randomized controlled trials targeting different blood pressure levels that reported cardiovascular events. The mean achieved SBP in each trial was classified into 5 groups (110-119, 120-129, 130-139, 140-149, and 150-159 mm Hg). The primary variables of cardiovascular mortality, stroke, and myocardial infarction were assessed using frequentist and Bayesian approaches.Fourteen trials with altogether 44,015 patients were included. Stroke and major adverse cardiovascular events were reduced when lowering SBP to 120-129 mm Hg compared with 130-139 mm Hg (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.69-0.99 and OR 0.84, 95% CI 0.73-0.96), 140-149 mm Hg (OR 0.73, 95% CI 0.55-0.97 and OR 0.74, 95% CI 0.60-0.90), and 150-159 mm Hg (OR 0.43, 95% CI 0.26-0.71 and OR 0.41, 95% CI 0.30-0.57), respectively. More intensive control to120 mm Hg further reduced stroke (OR 0.58, 95% CI 0.38-0.87; OR 0.51, 95% CI 0.32-0.81; and OR 0.30, 95% CI 0.16-0.56). In contrast, SBP ≥ 150 mm Hg increased myocardial infarction and cardiovascular mortality compared with 120-129 mm Hg (OR 1.73, 95% CI 1.06-2.82 and OR 2.18, 95% CI 1.32-3.59) and 130-139 mm Hg (OR 1.53, 95% CI 1.01-2.32 and OR 1.71, 95% CI 1.11-2.61). No significant relationship between SBP and all-cause mortality was found.SBP130 mm Hg is associated with a lower risk of stroke and major adverse cardiovascular events. Further lowering to 120 mm Hg can be considered to reduce stroke risk if the therapy is tolerated. Long-term SBP should not exceed 150 mm Hg because of the increased risk of myocardial infarction and cardiac deaths.

China has the largest stroke population and at-risk population in the world. However, it has a lower thrombolytic therapy rate and longer onset-to-needle time/door-to-needle time for patients who had an acute stroke compared with developed countries, which might be due to redundant procedures or inefficient systems. Things are changing due to some new initiatives. Two years ago, a new emergency system in China, Stroke Emergency Map, was first launched as a regional emergency system in Shenzhen, the bustling metropolis just north of Hong Kong. As a result of the Stroke Emergency Map in Shenzhen, the number of thrombolytic cases increased in the last 2 years, from 568 to 809 annually. The Stroke Emergency Map, first pioneered in Shenzhen and now spreading to the rest of China, is a comprehensive and interdisciplinary system. The benefits are not just the immediate improvements in the acute stroke care because the continuous data collection and audit allows for improvements in logistics and future strategies.

BACKGROUND Sarcopenia is commonly defined as loss of muscle mass with limited muscle function or strength. Different cutpoints of low lean mass and slow gait speed have been proposed by different professional working groups. We compared the performance of different cutpoints of low lean mass and slow gait speed in predicting death. METHODS We analyzed data of participants aged 65 years or older from the continuous National Health and Nutrition Examination Survey 1999-2004 (N = 2,841), and the subsequent follow-up data on mortality up to December 31, 2006. For low lean mass, cutpoints based on appendicular lean mass (ALM) alone, ALM adjusted for body mass index (ALMBMI), and ALM adjusted for height squared (ALMH2) were evaluated. For slow gait speed, the cutpoints based on 0.8 and 1.0 m/s were evaluated. A Cox-proportional hazard regression model with adjustment for multiple confounding factors was used for the association analyses. RESULTS For low lean mass, the cutpoints based on ALMBMI (

Pericardial fat and lipoprotein abnormalities contribute to increased risk of cardiovascular disease (CVD). We investigated the relationship between pericardial fat volume and lipoprotein distribution, and whether the association of pericardial fat volume with subclinical atherosclerosis and incident CVD events differs according to lipoprotein distribution.We analyzed data from 5407 participants from the Multi-Ethnic Study of Atherosclerosis who had measurements of pericardial fat volume, lipoprotein distribution, carotid intima-media thickness (IMT), and coronary artery calcium (CAC). All participants were free of clinically apparent CVD at baseline. Incident CVD was defined as any adjudicated CVD event.After adjusting for demographic factors, traditional risk factors, and biomarkers of inflammation and hemostasis, a larger pericardial fat volume was associated with higher large VLDL particle (VLDL-P) concentration and small HDL particle (HDL-P) concentration, and smaller HDL-P size (regression coefficients = 0.585 nmol/L, 0.366 μmol/L, and -0.025 nm per SD increase in pericardial fat volume respectively, all P 0.05). The association of pericardial fat volume with large VLDL-P concentration and HDL-P size, but not small HDL-P concentration, remained significant after further adjusting for each other as well as LDL cholesterol, HDL cholesterol, and triglycerides. The relationship of pericardial fat volume with incident CVD events, carotid IMT, and prevalence and severity of CAC did not differ by quartiles of large VLDL-P concentration, small HDL-P concentration, or HDL-P size (P for interaction0.05).Pericardial fat is associated with atherogenic lipoprotein abnormalities. However, its relationship with subclinical atherosclerosis and incident CVD events does not differ according to lipoprotein distribution.