Publications by authors named "Carlos King Ho Wong"

87 Publications

Comorbid depression and obesity, and its transition on the risk of functional disability among middle-aged and older Chinese: a cohort study.

BMC Geriatr 2022 Apr 3;22(1):275. Epub 2022 Apr 3.

Department of Epidemiology, School of Public Health, Sun Yat-sen University, 74 Zhongshan Second Road, Guangzhou, 510080, Guangdong, China.

Background: Evidence has indicated that depression and obesity were associated with functional disability, independently. However, little is known about the detrimental impact of comorbid depression and obesity, as well as its transition on functional disability. This study investigated the association of baseline depression-obesity status and its dynamic change with incident functional disability among middle-aged and older Chinese.

Methods: This cohort study included 5507 participants aged ≥45 years from the 2011 and 2015 waves of China Health and Retirement Longitudinal Study. Depression was defined with a score ≥ 10 using the 10-item Centre for Epidemiologic Studies Depression Scale. Obesity was defined as body mass index ≥28 kg/m. Participants were cross-classified by depression and obesity status at baseline, and its change during follow-up. Logistic regression models were constructed to evaluate the association of baseline depression-obesity status and its transition with incident functional disability defined by the Katz index of activities of daily living scale.

Results: Over four-year follow-up, 510 (9.3%) participants developed functional disability. Individuals with baseline comorbid depression and obesity had the highest risk of functional disability (OR = 2.84, 95% CI: 1.95-4.15) than non-depressive participants without obesity, or those with depression or obesity alone. When investigating the dynamic changes of depression-obesity status on functional disability incidence, those with stable comorbidity throughout two surveys had the greatest risk of functional disability (OR = 4.06, 95% CI: 2.11-7.80). Progression of depression-obesity status was associated with increased risk of functional disability, while regression from baseline to follow-up was linked to attenuated risk estimates.

Conclusions: Among middle-aged and older Chinese adults, the risk of functional disability was exaggerated with comorbid depression and obesity. Our data further suggest that transitions of depression and obesity over time are associated with the risk of developing functional disability.
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http://dx.doi.org/10.1186/s12877-022-02972-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8976974PMC
April 2022

Impact of a delayed second dose of mRNA vaccine (BNT162b2) and inactivated SARS-CoV-2 vaccine (CoronaVac) on risks of all-cause mortality, emergency department visit, and unscheduled hospitalization.

BMC Med 2022 03 17;20(1):119. Epub 2022 Mar 17.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China.

Background: Safety after the second dose of the SARS-CoV-2 vaccine remains to be elucidated, especially among individuals reporting adverse events after their first dose. This study aims to evaluate the impact of a delayed second dose on all-cause mortality and emergency services.

Methods: A territory-wide, retrospective cohort of people who had completed two doses of mRNA (BNT162b2) or inactivated SARS-CoV-2 (CoronaVac) vaccine between February 23 and July 3, 2021, in Hong Kong was analyzed, with linkage to electronic health records retrieved from the Hong Kong Hospital Authority. Vaccine recipients were classified as receiving a second dose within recommended intervals (21-28 days for BNT162b2; 14-28 days for CoronaVac) or delayed. Study outcomes were all-cause mortality, emergency department (ED) visits, and unscheduled hospitalizations within 28 days after the second dose of vaccination.

Results: Among 417,497 BNT162b2 and 354,283 CoronaVac second dose recipients, 3.8% and 28.5% received the second dose beyond the recommended intervals (mean 34.4 and 31.8 days), respectively. During the study period, there were < 5 daily new cases of COVID-19 infections in the community. Delaying the second dose was not associated with all-cause mortality (hazard ratio [HR] = 1.185, 95% CI 0.478-2.937, P = 0.714), risk of ED visit (HR = 0.966, 95% CI 0.926-1.008, P = 0.113), and risk of unscheduled hospitalization (HR = 0.956, 95% CI 0.878-1.040, P = 0.294) compared to that within the recommended interval for CoronaVac recipients. No statistically significant differences in all-cause mortality (HR = 4.438, 95% CI 0.951-20.701, P = 0.058), ED visit (HR = 1.037, 95% CI 0.951-1.130, P = 0.411), and unscheduled hospitalization (HR = 1.054, 95% CI 0.867-1.281, P = 0.597) were identified between people who received a second dose of BNT162b2 within and beyond the recommended intervals.

Conclusions: No significant association between delayed second dose of BNT162b2 or CoronaVac and all-cause mortality, ED visit, and unscheduled hospitalization was observed in the present cohort. Regardless of the recommended or delayed schedule for SARS-CoV-2 vaccination, a second dose of both vaccines should be administered to obtain better protection against infection and serious disease. The second dose should be administered within the recommended interval following the manufacturer's product information, until further studies support the benefits of delaying vaccination outweighing the risks.
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http://dx.doi.org/10.1186/s12916-022-02321-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8926447PMC
March 2022

Non-laboratory-based risk assessment model for case detection of diabetes mellitus and pre-diabetes in primary care.

J Diabetes Investig 2022 Mar 16. Epub 2022 Mar 16.

Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.

Introduction: More than half of diabetes mellitus (DM) and pre-diabetes (pre-DM) cases remain undiagnosed, while existing risk assessment models are limited by focusing on diabetes mellitus only (omitting pre-DM) and often lack lifestyle factors such as sleep. This study aimed to develop a non-laboratory risk assessment model to detect undiagnosed diabetes mellitus and pre-diabetes mellitus in Chinese adults.

Methods: Based on a population-representative dataset, 1,857 participants aged 18-84 years without self-reported diabetes mellitus, pre-diabetes mellitus, and other major chronic diseases were included. The outcome was defined as a newly detected diabetes mellitus or pre-diabetes by a blood test. The risk models were developed using logistic regression (LR) and interpretable machine learning (ML) methods. Models were validated using area under the receiver-operating characteristic curve (AUC-ROC), precision-recall curve (AUC-PR), and calibration plots. Two existing diabetes mellitus risk models were included for comparison.

Results: The prevalence of newly diagnosed diabetes mellitus and pre-diabetes mellitus was 15.08%. In addition to known risk factors (age, BMI, WHR, SBP, waist circumference, and smoking status), we found that sleep duration, and vigorous recreational activity time were also significant risk factors of diabetes mellitus and pre-diabetes mellitus. Both LR (AUC-ROC = 0.812, AUC-PR = 0.448) and ML models (AUC-ROC = 0.822, AUC-PR = 0.496) performed well in the validation sample with the ML model showing better discrimination and calibration. The performance of the models was better than the two existing models.

Conclusions: Sleep duration and vigorous recreational activity time are modifiable risk factors of diabetes mellitus and pre-diabetes in Chinese adults. Non-laboratory-based risk assessment models that incorporate these lifestyle factors can enhance case detection of diabetes mellitus and pre-diabetes.
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http://dx.doi.org/10.1111/jdi.13790DOI Listing
March 2022

Adverse events of special interest following the use of BNT162b2 in adolescents: a population-based retrospective cohort study.

Emerg Microbes Infect 2022 Dec;11(1):885-893

Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China.

Accruing evidence suggests an increased risk of myocarditis in adolescents from messenger RNA COVID-19 vaccines. However, other potential adverse events remain under-researched. We conducted a retrospective cohort study of adolescents aged 12-18 with a territory-wide electronic healthcare database of the Hong Kong population linked with population-based vaccination records and supplemented with age- and sex-specific population numbers. Two age- and sex-matched retrospective cohorts were formed to observe 28 days following the first and second doses of BNT162b2 and estimate the age- and sex-adjusted incidence rate ratios between the vaccinated and unvaccinated. Thirty AESIs adapted from the World Health Organization's Global Advisory Committee on Vaccine Safety were examined. Eventually, the first-dose cohort comprised 274,881 adolescents (50.25% received the first dose) and the second-dose cohort 237,964 (50.29% received the second dose). Ninety-four (34.2 per 100,000 persons) adolescents in the first-dose cohort and 130 (54.6 per 100,000 persons) in the second-dose cohort experienced ≥1 AESIs. There were no statistically significant differences in the risk of any AESI associated with BNT162b2 except myocarditis [first-dose cohort: incidence rate ratio (IRR) = 9.15, 95% confidence interval (CI) 1.14-73.16; second-dose cohort: IRR = 29.61, 95% CI 4.04-217.07] and sleeping disturbances/disorders after the second dose (IRR = 2.06, 95% CI 1.01-4.24). Sensitivity analysis showed that, with myocarditis excluded as AESIs, no significantly elevated risk of AESIs as a composite outcome associated with vaccination was observed (= 0.195). To conclude, the overall absolute risk of AESIs was low with no evidence of an increased risk of AESIs except myocarditis and sleeping disturbances/disorders.
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http://dx.doi.org/10.1080/22221751.2022.2050952DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8942549PMC
December 2022

Safety of Inactivated and mRNA COVID-19 Vaccination Among Patients Treated for Hypothyroidism: A Population-Based Cohort Study.

Thyroid 2022 May 7;32(5):505-514. Epub 2022 Apr 7.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

Thyroiditis and Graves' disease have been reported after coronavirus disease 2019 (COVID-19) vaccination. We evaluated the risks of adverse events after COVID-19 vaccination among patients treated for hypothyroidism. In this retrospective population-based cohort study of Hong Kong Hospital Authority electronic health records with the Department of Health vaccination records linkage, levothyroxine (LT4) users were categorized into unvaccinated, vaccinated with BNT162b2 (mRNA vaccine), or CoronaVac (inactivated vaccine) between February 23, 2021, and September 9, 2021. Study outcomes were dosage reduction or escalation in LT4, emergency department (ED) visit, unscheduled hospitalization, adverse events of special interest (AESI) according to the World Health Organization's Global Advisory Committee on Vaccine Safety, and all-cause mortality. Inverse probability of treatment weighting for propensity score was applied to balance baseline patient characteristics among the three groups. Hazard ratios (HR) were estimated using Cox regression models. Patients were observed from the index date until the occurrence of study outcome, death, or censored on September 30, 2021, whichever came first. In total, 47,086 LT4 users were identified (BNT162b2:  = 12,310; CoronaVac:  = 11,353; and unvaccinated:  = 23,423). COVID-19 vaccination was not associated with increased risks of LT4 dosage reduction (BNT162b2: HR = 0.971 [confidence interval; CI 0.892-1.058]; CoronaVac: HR = 0.968 [CI 0.904-1.037]) or escalation (BNT162b2: HR = 0.779 [CI 0.519-1.169]; CoronaVac: HR = 0.715 [CI 0.481-1.062]). Besides, COVID-19 vaccination was not associated with a higher risk of ED visits (BNT162b2: HR = 0.944 [CI 0.700-1.273]; CoronaVac: HR = 0.851 [CI 0.647-1.120]) or unscheduled hospitalization (BNT162b2: HR = 0.905 [CI 0.539-1.520]; CoronaVac: HR = 0.735 [CI 0.448-1.207]). There were two (0.016%) deaths and six (0.062%) AESI recorded for BNT162b2 recipients, and one (0.009%) and three (0.035%) for CoronaVac recipients, respectively. BNT162b2 or CoronaVac vaccination is not associated with unstable thyroid status or an increased risk of adverse outcomes among patients treated for hypothyroidism in general. These reassuring data should encourage them to get vaccinated against COVID-19 for protection from potentially worse COVID-19-related outcomes.
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http://dx.doi.org/10.1089/thy.2021.0684DOI Listing
May 2022

Self-reported reactogenicity of CoronaVac (Sinovac) compared with Comirnaty (Pfizer-BioNTech): A prospective cohort study with intensive monitoring.

Vaccine 2022 03 7;40(10):1390-1396. Epub 2022 Feb 7.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong, China; Laboratory of Data Discovery for. Health (D(2)4H), Hong Kong Science and Technology Park, Hong Kong, China. Electronic address:

Objective: CoronaVac (Sinovac) Covid-19 vaccine has recently been approved for emergency use by the World Health Organization. However, data on its reactogenicity in real-world settings is scant. This study aimed to compare self-reported post-vaccination adverse reactions between CoronaVac and Comirnaty (Pfizer-BioNTech).

Methods: We adopted a prospective cohort study design using online surveys from the day of first-dose vaccination with intensive follow-up through two weeks after the second dose (11 time points). The primary outcome was adverse reactions (any versus none) and secondary outcomes were the sub-categories of adverse reactions (local, systemic, and severe allergic reactions). Potential effect modification across multimorbidity status, older age, and sex was examined.

Results: In total, 2,098 participants who were scheduled to complete the 14th-day survey were included, with 46.2% receiving Comirnaty. Retention rate two weeks after the second dose was 81.0% for the CoronaVac group and 83.6% for the Comirnaty group. Throughout the follow-up period, 801 (82.7%) of those receiving Comirnaty and 543 (48.1%) of those receiving CoronaVac reported adverse reactions. Adjusted analysis suggested that compared with Comirnaty, CoronaVac was associated with 83%-reduced odds of any adverse reactions [adjusted odds ratio (AOR) = 0.17, 95% confidence interval (CI) 0.15-0.20], 92%-reduced odds of local adverse reactions (AOR = 0.08, 95% CI 0.06-0.09), and 76%-reduced odds of systemic adverse reactions (AOR = 0.24, 95% CI 0.16-0.28). No significant effect modification was identified.

Conclusion: This post-marketing study comparing the reactogenicity of Covid-19 vaccines suggests a lower risk of self-reported adverse reactions following vaccination with CoronaVac compared with Comirnaty.
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http://dx.doi.org/10.1016/j.vaccine.2022.01.062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8818394PMC
March 2022

Lack of inflammatory bowel disease flare-up following two-dose BNT162b2 vaccine: a population-based cohort study.

Gut 2022 Feb 8. Epub 2022 Feb 8.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China

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http://dx.doi.org/10.1136/gutjnl-2021-326860DOI Listing
February 2022

Herpes zoster related hospitalization after inactivated (CoronaVac) and mRNA (BNT162b2) SARS-CoV-2 vaccination: A self-controlled case series and nested case-control study.

Lancet Reg Health West Pac 2022 Apr 2;21:100393. Epub 2022 Feb 2.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.

Background: Stimulation of immunity by vaccination may elicit adverse events. There is currently inconclusive evidence on the relationship between herpes zoster related hospitalization and COVID-19 vaccination. This study aimed to evaluate the effect of inactivated virus (CoronaVac, Sinovac) and mRNA (BNT162b2, BioNTech/Fosun Pharma) COVID-19 vaccine on the risk of herpes zoster related hospitalization.

Methods: Self-controlled case series (SCCS) analysis was conducted using the data from the electronic health records in Hospital Authority and COVID-19 vaccination records in the Department of Health in Hong Kong. We conducted the SCCS analysis including patients with a first primary diagnosis of herpes zoster in the hospital inpatient setting between February 23 and July 31, 2021. A confirmatory analysis by nested case-control method was also conducted. Each herpes zoster case was randomly matched with ten controls according to sex, age, Charlson comorbidity index, and date of hospital admission. Conditional Poisson regression and logistic regression models were used to assess the potential excess rates of herpes zoster after vaccination.

Findings: From February 23 to July 31, 2021, a total of 16 and 27 patients were identified with a first primary hospital diagnosis of herpes zoster within 28 days after CoronaVac and BNT162b2 vaccinations. The incidence of herpes zoster was 7.9 (95% Confidence interval [CI]: 5.2-11.5) for CoronaVac and 7.1 (95% CI: 4.1-11.5) for BNT162b2 per 1,000,000 doses administered. In SCCS analysis, CoronaVac vaccination was associated with significantly higher risk of herpes zoster within 14 days after first dose (adjusted incidence rate ratio [aIRR]=2.67, 95% CI: 1.08-6.59) but not in other periods afterwards compared to the baseline period. Regarding BNT162b2 vaccination, a significantly increased risk of herpes zoster was observed after first dose up to 14 days after second dose (0-13 days after first dose: aIRR=5.23, 95% CI: 1.61-17.03; 14-27 days after first dose: aIRR=5.82, 95% CI: 1.62-20.91; 0-13 days after second dose: aIRR=5.14, 95% CI: 1.29-20.47). Using these relative rates, we estimated that there has been an excess of approximately 5 and 7 cases of hospitalization as a result of herpes zoster after every 1,000,000 doses of CoronaVac and BNT162b2 vaccination, respectively. The findings in the nested case control analysis showed similar results.

Interpretation: We identified an increased risk of herpes zoster related hospitalization after CoronaVac and BNT162b2 vaccinations. However, the absolute risks of such adverse event after CoronaVac and BNT162b2 vaccinations were very low. In locations where COVID-19 is prevalent, the protective effects on COVID-19 from vaccinations will greatly outweigh the potential side effects of vaccination.

Funding: The project was funded by Research Grant from the Food and Health Bureau, The Government of the Hong Kong Special Administrative Region (Ref. No.COVID19F01). FTTL (Francisco Tsz Tsun Lai) and ICKW (Ian Chi Kei Wong)'s posts were partly funded by D4H; hence this work was partly supported by [email protected] administered by Innovation and Technology Commission.
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http://dx.doi.org/10.1016/j.lanwpc.2022.100393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8808060PMC
April 2022

Psychometric performance of proxy-reported EQ-5D youth version 5-level (EQ-5D-Y-5L) in comparison with three-level (EQ-5D-Y-3L) in children and adolescents with scoliosis.

Eur J Health Econ 2022 Feb 4. Epub 2022 Feb 4.

Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.

Objectives: To assess the psychometric performance of proxy-reported EQ-5D-Y-5L (Y-5L) in comparisons with EQ-5D-Y-3L (Y-3L) administered by caregivers of patients with juvenile (JIS) or adolescent idiopathic scoliosis (AIS).

Methods: A consecutive sample of caregivers of JIS or AIS patients were recruited. Redistribution property, ceiling effects, and discriminative power were examined. Known-group validity was determined by examining their ability to detect differences across clinical known groups. Test-retest reliability was assessed using intraclass correlation coefficient (ICC) for EQ-VAS score and Gwet's agreement coefficient (GAC) and percentage agreement (PA) for dimension responses. Furthermore, subgroups were analyzed for comparing test-retest reliability.

Results: A total of 130 caregivers were involved in the study. Consistencies between proxy-reported Y-3L and Y-5L were very high for all dimensions (93.8-99.2%). The ceiling effect in the Y-5L was slightly reduced in four dimensions (AR: 0.8-2.3%) whereas increased in "Having pain/discomfort". Greater informativity was found in the Y-5L than the Y-3L. In known-group comparisons of curvature magnitude, curvature type, and treatment modality, Y-5L and Y-3L dimension scales showed hypothesized results. For example, more full-health responses were found in the mild Cobb angle group (Y-5L: 63.1%; Y-3L: 62.2%) than the severe Cobb angle group (Y-5L: 55.6%, Y-3L: 55.6%). EQ-VAS score exhibited low test-retest reliability (ICC: 0.41), whereas dimension scales of both instruments showed satisfactory test-retest reliability (GAC ≥ 0.7 and PA ≥ 70% for all). In most known groups, hard-to-observe dimensions were more reliable for proxy-reported Y-5L than Y-3L.

Conclusion: Both the proxy-reported Y-5L and Y-3L are valid and reliable instruments for assessing the HRQoL of JIS or AIS patients.
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http://dx.doi.org/10.1007/s10198-022-01435-zDOI Listing
February 2022

COVID-19 vaccines and risks of hematological abnormalities: Nested case-control and self-controlled case series study.

Am J Hematol 2022 04 9;97(4):470-480. Epub 2022 Feb 9.

Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong Special Administrative Region, China.

Several studies reported hematological abnormalities after vaccination against the coronavirus disease 2019 (COVID-19). We evaluated the association between COVID-19 vaccines (CoronaVac and BNT162b2) and hematological abnormalities. We conducted nested case-control and self-controlled case series analyses using the data from the Hong Kong Hospital Authority and the Department of Health, HKSAR. Outcomes of interest were thrombocytopenia, leukopenia, and neutropenia. Adjusted odds ratios (aORs), incidence rate ratios (IRRs), and 95% confidence intervals (CIs) were estimated using conditional logistic regression. In total, 1 643 419 people received COVID-19 vaccination (738 609 CoronaVac; 904 810 BNT162b2). We identified 457 and 422 cases after CoronaVac and BNT162b2 vaccination, respectively. For CoronaVac, the incidence of thrombocytopenia, leukopenia, and neutropenia was 2.51, 1.08, and 0.15 per 10 000 doses. For BNT162b2, the corresponding incidence was 1.39, 1.17, and 0.26 per 10 000 doses. The incidence per 10 000 COVID-19 cases were 1254, 2341, and 884, respectively. We only observed an increased risk of leukopenia following the second dose of BNT162b2 (aOR 1.58, 95% CI 1.24-2.02; day 0-14, IRR 2.21; 95% CI 1.59-3.08). There was no increased risk of any hematological abnormalities after CoronaVac vaccination. We observed an increased risk of leukopenia shortly after the second dose of BNT162b2. However, the incidence was much lower than the incidence following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. There was no association between CoronaVac and hematological abnormalities. The benefits of vaccination against COVID-19 still outweigh the risk of hematological abnormalities.
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http://dx.doi.org/10.1002/ajh.26478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9011752PMC
April 2022

Carditis After COVID-19 Vaccination With a Messenger RNA Vaccine and an Inactivated Virus Vaccine : A Case-Control Study.

Ann Intern Med 2022 03 25;175(3):362-370. Epub 2022 Jan 25.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, and Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China, and Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom (I.C.K.).

Background: Case reports of carditis after BNT162b2 vaccination are accruing worldwide.

Objective: To examine the association of BNT162b2 and CoronaVac (Sinovac) vaccination with carditis.

Design: Case-control study with hospital control participants.

Setting: Territory-wide, public health care database with linkage to population-based vaccination records in Hong Kong.

Patients: Inpatients aged 12 years or older first diagnosed with carditis were selected as case patients. All other hospitalized patients without carditis were treated as control participants. Ten control participants were randomly matched with each case patient by age, sex, and admission date.

Intervention: Vaccination with BNT162b2 or CoronaVac.

Measurements: Incident diagnosis of carditis based on the International Classification of Diseases, Ninth Revision, and elevated troponin levels.

Results: A total of 160 case patients and 1533 control participants were included. Incidence of carditis per 100 000 doses of CoronaVac and BNT162b2 administered was estimated to be 0.31 (95% CI, 0.13 to 0.66) and 0.57 (CI, 0.36 to 0.90), respectively. Multivariable analyses showed that recipients of the BNT162b2 vaccine had higher odds of carditis (adjusted odds ratio [OR], 3.57 [CI, 1.93 to 6.60]) than unvaccinated persons. Stratified by sex, the OR was 4.68 (CI, 2.25 to 9.71) for males and 2.22 (CI, 0.57 to 8.69) for females receiving the BNT162b2 vaccine. The ORs for adults and adolescents receiving the BNT162b2 vaccine were 2.41 (CI, 1.18 to 4.90) and 13.79 (CI, 2.86 to 110.38), respectively. Subanalysis showed an OR of 9.29 (CI, 3.94 to 21.91) for myocarditis and 1.06 (CI, 0.35 to 3.22) for pericarditis associated with BNT162b2. The risk was mainly seen after the second dose of BNT162b2 rather than the first. No association between CoronaVac and carditis with a magnitude similar to that for BNT162b2 was seen.

Limitation: Limited sample size, absence of electrocardiography and other clinical investigative data, and unrecorded overseas vaccination exposure.

Conclusion: Despite a low absolute risk, there is an increased risk for carditis associated with BNT162b2 vaccination. This elevated risk should be weighed against the benefits of vaccination.

Primary Funding Source: Health and Medical Research Fund.
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http://dx.doi.org/10.7326/M21-3700DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8814917PMC
March 2022

Multimorbidity and adverse events of special interest associated with Covid-19 vaccines in Hong Kong.

Nat Commun 2022 01 20;13(1):411. Epub 2022 Jan 20.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.

Prior research using electronic health records for Covid-19 vaccine safety monitoring typically focuses on specific disease groups and excludes individuals with multimorbidity, defined as ≥2 chronic conditions. We examine the potential additional risk of adverse events 28 days after the first dose of CoronaVac or Comirnaty imposed by multimorbidity. Using a territory-wide public healthcare database with population-based vaccination records in Hong Kong, we analyze a retrospective cohort of patients with chronic conditions. Thirty adverse events of special interest according to the World Health Organization are examined. In total, 883,416 patients are included and 2,807 (0.3%) develop adverse events. Results suggest vaccinated patients have lower risks of adverse events than unvaccinated individuals, multimorbidity is associated with increased risks regardless of vaccination, and the association of vaccination with adverse events is not modified by multimorbidity. To conclude, we find no evidence that multimorbidity imposes extra risks of adverse events following Covid-19 vaccination.
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http://dx.doi.org/10.1038/s41467-022-28068-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8776841PMC
January 2022

Post-Covid-19-vaccination adverse events and healthcare utilization among individuals with or without previous SARS-CoV-2 infection.

J Intern Med 2022 Jun 1;291(6):864-869. Epub 2022 Feb 1.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

Background: Post-marketing pharmacovigilance data are scant on the safety of Covid-19 vaccines among people with previous SARS-CoV-2 infection compared with ordinary vaccine recipients. We compared the post-vaccination adverse events of special interests (AESI), accident and emergency room (A&E) visit, and hospitalization between these two groups.

Methods: We conducted a retrospective cohort study using a territory-wide public healthcare database with population-based vaccination records in Hong Kong.

Results: In total, 3922 vaccine recipients with previous SARS-CoV-2 infection and 1,137,583 vaccine recipients without previous SARS-CoV-2 infection were included. No significant association was observed between previous SARS-CoV-2 infection and AESI or hospitalization. Previous SARS-CoV-2 infection was significantly associated with a lower risk of A&E visit (CoronaVac: hazard ratios [HR] = 0.56, 95% confidence intervals [CI]: 0.32-0.99; Comirnaty: HR = 0.62, 95% CI: 0.47-0.82).

Conclusion: No safety signal of Covid-19 vaccination was detected from the comparison between vaccine recipients with previous SARS-CoV-2 infection and those without infection.
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http://dx.doi.org/10.1111/joim.13453DOI Listing
June 2022

Comparing self-reported reactogenicity between adolescents and adults following the use of BNT162b2 (Pfizer-BioNTech) messenger RNA COVID-19 vaccine: a prospective cohort study.

Int J Infect Dis 2022 Mar 26;116:47-50. Epub 2021 Dec 26.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong, China; Laboratory of Data Discovery for Health (D²4H), Hong Kong Science and Technology Park, Hong Kong, China. Electronic address:

Objectives: Although clinical data have shown that the BNT162b2 vaccine, which is widely used in many countries, is safe and effective as a protection against the SARS-CoV-2 infection, extant research in adverse reactions using real-world data of various sociodemographic characteristics is scant.

Methods: We conducted a prospective cohort study to compare age differences in self-reported reactogenicity of BNT162b2 in Hong Kong. A total of 1,516 participants were intensively followed up for two weeks following both doses of BNT162b2 vaccination, during which their basic demographic, health conditions, and medication information were collected.

Results: Results from the generalized mixed model showed that compared with adults aged 18 to 59 years, older adults aged 60 years or above had a lower risk of adverse reactions and adolescents aged 12 to 17 years had a moderately higher risk.

Conclusions: Results of this study should be informative to parents considering BNT162b2 vaccination for their children in that moderately increased reactogenicity compared with adults is anticipated.
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http://dx.doi.org/10.1016/j.ijid.2021.12.354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8710238PMC
March 2022

A pilot study on the validity and psychometric properties of the electronic EQ-5D-5L in routine clinical practice.

Health Qual Life Outcomes 2021 Dec 18;19(1):266. Epub 2021 Dec 18.

Department of Applied Health Research, Institute of Epidemiology and Health Care, University College London, London, UK.

Background: Electronic measurement of health-related quality of life (HRQOL) may facilitate timely and regular assessments in routine clinical practice. This study evaluated the validity and psychometric properties of an electronic version of the EQ-5D-5L (e-EQ-5D-5L) in Chinese patients with chronic knee and/or back problems.

Methods: 151 Chinese subjects completed an electronic version of the Chinese (Hong Kong) EQ-5D-5L when they attended a primary care or orthopedics specialist out-patient clinic in Hong Kong. They also completed the Chinese Western Ontario and McMaster University Osteoarthritis Index (WOMAC), a Pain Rating Scale, and a structured questionnaire on socio-demographics, co-morbidities and health service utilization. 32 subjects repeated the e-EQ-5D-5L two weeks after the baseline. 102 subjects completed e-EQ-5D-5L and 99 completed the Global Rating on Change Scale at three-month clinic follow up. Construct validity was assessed by the association of EQ-5D-5L scores with external criterion of WOMAC scores. We tested mean differences of WOMAC scores between adjacent response levels of the EQ-5D-5L dimensions by one-way ANOVA, test-retest reliability by intra-class correlation, sensitivity by known group comparisons and responsiveness by changes in EQ-5D-5L scores over 3 months.

Results: There was an association between EQ-5D-5L and WOMAC scores. Mean WOMAC scores increased with the increase in adjacent response levels of EQ-5D-5L dimensions. Test-retest intraclass correlation coefficient (ICC) of EQ-5D-5L utility and EQ-VAS scores were 0.76 and 0.83, respectively, indicating good reliability. There were significant differences in the proportions reporting limitations in the EQ-5D-5L dimensions, the utility and VAS scores between the mild and severe pain groups (utility = 0.28, p = 0.001; VAS = 11.46, p < 0.001), and between primary care and specialist out-patient clinic patients (utility = 0.15, p = 0.001; VAS = 10.21, p < 0.001), supporting sensitivity. Among those reporting 'better' global health at three-months, their EQ-5D-5L utility and EQ-VAS scores were significantly increased from baseline (utility = 0.18, p < 0.001; VAS = 10.75, p = 0.005).

Conclusions: The electronic version of the EQ-5D-5L is valid, reliable, sensitive and responsive in the measurement of HRQOL in Chinese patients with chronic knee or back pain in routine clinical practice.
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http://dx.doi.org/10.1186/s12955-021-01898-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8684117PMC
December 2021

Two-dose COVID-19 vaccination and possible arthritis flare among patients with rheumatoid arthritis in Hong Kong.

Ann Rheum Dis 2022 04 22;81(4):564-568. Epub 2021 Oct 22.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China

Objectives: To investigate the relationship between COVID-19 full vaccination (two completed doses) and possible arthritis flare.

Methods: Patients with rheumatoid arthritis (RA) were identified from population-based electronic medical records with vaccination linkage and categorised into BNT162b2 (mRNA vaccine), CoronaVac (inactive virus vaccine) and non-vaccinated groups. The risk of possible arthritis flare after vaccination was compared using a propensity-weighted cohort study design. We defined possible arthritis flare as hospitalisation and outpatient consultation related to RA or reactive arthritis, based on diagnosis records during the episode. Weekly prescriptions of rheumatic drugs since the launch of COVID-19 vaccination programme were compared to complement the findings from a diagnosis-based analysis.

Results: Among 5493 patients with RA (BNT162b2: 653; CoronaVac: 671; non-vaccinated: 4169), propensity-scored weighted Poisson regression showed no significant association between arthritis flare and COVID-19 vaccination ((BNT162b2: adjusted incidence rate ratio 0.86, 95% Confidence Interval 0.73 to 1.01); CoronaVac: 0.87 (0.74 to 1.02)). The distribution of weekly rheumatic drug prescriptions showed no significant differences among the three groups since the launch of the mass vaccination programme (all p values >0.1 from Kruskal-Wallis test).

Conclusions: Current evidence does not support that full vaccination of mRNA or inactivated virus COVID-19 vaccines is associated with possible arthritis flare.
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http://dx.doi.org/10.1136/annrheumdis-2021-221571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8550868PMC
April 2022

Cardio-renal outcomes and the direct medical cost of type 2 diabetes patients treated with sodium glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists: A population-based cohort study.

Diabetes Res Clin Pract 2021 Oct 27;180:109071. Epub 2021 Sep 27.

Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

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.
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http://dx.doi.org/10.1016/j.diabres.2021.109071DOI Listing
October 2021

Exploration of the psychometric properties of the Person-Centred Primary Care Measure (PCPCM) in a Chinese primary care population in Hong Kong: a cross-sectional validation study.

BMJ Open 2021 09 21;11(9):e052655. Epub 2021 Sep 21.

Center for Community Health Integration, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.

Objectives: To evaluate the validity and psychometric properties of the Chinese Person-Centred Primary Care Measure (PCPCM) in a Chinese-speaking population.

Design: A cross-sectional study.

Setting: A primary care clinic in Hong Kong.

Participants: 300 Chinese adult patients (150 males and 150 females) were recruited from a primary care clinic to complete a questionnaire containing the PCPCM, Consultation and Relational Empathy (CARE), Patient Enablement Index (PEI) and Adult (short version) Primary Care Assessment Tool (PCAT). The Chinese PCPCM was readministered to 118 participants after 14 days for test-retest reliability.

Outcome Measures: The construct validity, reliability and sensitivity of the Chinese PCPCM.

Results: The Chinese PCPCM was identified to have a one-factor construct, with good item fit and unidimensionality on Rasch analysis. Internal reliability was high (Cronbach's alpha >0.8) with moderate test-retest reliability (intraclass correlation coefficient=0.622, p<0.001). Significant correlations (0.58, 0.42, 0.48) between the PCPCM and CARE, PEI and Adult (short version) PCAT scores supported good convergent construct validity. PCPCM scores were higher among patients who had known their doctors for a longer period or who were more likely to be able to see the same doctor at every visit, and among those who self-reported to have 'better health' rather than 'worse health'.

Conclusion: The Chinese PCPCM appears to be a valid, reliable and sensitive instrument for evaluating the quality of person-centred care among primary care patients in Hong Kong. Further studies are needed to confirm the utility of this instrument in other Chinese-speaking populations around the world.
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http://dx.doi.org/10.1136/bmjopen-2021-052655DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8719180PMC
September 2021

Unintentional Injury Burden in Hong Kong: Results from a Representative Population-Based Survey.

Int J Environ Res Public Health 2021 08 21;18(16). Epub 2021 Aug 21.

Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China.

Unintentional injuries are major causes of mortality and morbidity. Although generally perceived as accidents, it is possible to identify those at higher risk and implement appropriate prevention measures. This study aims to investigate the common causes of unintentional injuries and their associated risk factors among a large representative sample. Data of 12,022 individuals who completed the Hong Kong Population Health Survey 2014/15 were extracted. The primary outcome was the prevalence of having unintentional injury(-ies) in the previous 12 months that was severe enough to limit daily activities. Multivariable logistic regression analyses were conducted to identify associations between injuries and sociodemographic, clinical and lifestyle factors. 14.5% of respondents reported episode(s) of unintentional injury in the past 12 months in the population level. The main causes of top three most severe unintentional injuries were sprains (24.0%), falls (19.9%) and being hit/struck (19.6%). 13.2% injury episodes were work-related among the most severe episode. Factors independently associated with significantly higher risks of injury included currently employed, homemaker or student, born in Hong Kong (as compared with immigrants), doctor-diagnosed chronic conditions, harmful alcohol consumption, insufficient sleep, and disturbed sleep. To summarize, unintentional injuries are highly prevalent and associated with harmful drinking, insufficient sleep, and disturbed sleep, which are potential modifiable risk factors for prevention.
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http://dx.doi.org/10.3390/ijerph18168826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8392553PMC
August 2021

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

Vaccines (Basel) 2021 Jul 16;9(7). Epub 2021 Jul 16.

Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China.

Emerging efficacy and safety data have led to the authorization of COVID-19 vaccines worldwide, but most trials excluded patients with active malignancies. This study evaluates the intended acceptance of COVID-19 vaccination in cancer patients in Hong Kong.

Methods: 660 adult cancer patients received a survey, in paper or electronic format, between 31 January 2021 and 15 February 2021. The survey included patient's clinical characteristics, perceptions of COVID-19 and vaccination, vaccine knowledge, cancer health literacy, and Hospital Anxiety and Depression scale (HADS). The primary outcome was the intended acceptance of COVID-19 vaccine in cancer patients. Multivariable analysis was performed to identify factors associated with intended acceptance.

Results: The intended acceptance of COVID-19 vaccination was 17.9%. A total of 487 (73.8%) believed that vaccination could prevent them from infection. Over 70% worried about vaccine negative effects on cancer and its side effects. Factors associated with intended acceptance included higher level of "belief in vaccine on preventing them from getting COVID-19", less worry about long-term side effects of vaccine, lower level of cancer health literacy, and normal HADS (Depression scale).

Conclusions: To improve vaccine acceptance rate, public education campaigns specific to cancer patients to gain their trust in efficacy and relieve their worries are needed.
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http://dx.doi.org/10.3390/vaccines9070792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310340PMC
July 2021

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

Cancers (Basel) 2021 Jul 17;13(14). Epub 2021 Jul 17.

Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong.

Background: There have been studies reporting the crucial roles of Dipeptidyl-peptidase 4 (DPP4) in colorectal cancer (CRC) initiation and progression, whereas DPP4-inhibitors are safe Food and Drug Association (FDA)-approved drugs for treating diabetes. This study aims to investigate the association between DPP4-inhibitor treatment and the prognosis of CRC patients.

Methods: Clinical data of CRC patients with diabetes and the prescription of DPP4-inhibitors who had undergone curative surgery in our hospital between January 2006 and December 2015 were retrieved. Their survival data and immune cell population in circulatory blood were compared to those treated with metformin.

Results: The DPP4-inhibitor patient group showed a significantly better 5-year disease-free survival (median DFS = 1733 days, 95% CI = 1596 to 1870 days) when compared to the metformin group ( = 0.030, median DFS = 1382 days, 95% CI = 1246 to 1518 days). 33 out of the 92 patients in the metformin group showed recurrence whereas only 3 of the 26 patients in the DPP4-inhibitor group showed recurrence ( = 0.033). Cox regression analysis demonstrated that DPP4-inhibitor application is a favorable factor associated with a lower risk of recurrence (Hazard ratio = 0.200, = 0.035). Furthermore, our results suggested that the immune cell profile of CRC patients is a potential biomarker for response to DPP4-inhibitor treatment.

Conclusion: This study demonstrated the association of DPP4-inhibitor treatment with a better prognosis of CRC patients.
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http://dx.doi.org/10.3390/cancers13143588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8306906PMC
July 2021

Association between health behaviours and cardiometabolic dysregulation: a population-based survey among healthy adults in Hong Kong.

BMJ Open 2021 07 9;11(7):e043503. Epub 2021 Jul 9.

Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong.

Objective: To explore the association between cardiometabolic dysregulation, an integral component of allostatic load, and health risk behaviours (HRBs) of the Hong Kong healthy adult population.

Design: Secondary analysis of cross-sectional anonymous data.

Setting: Data on sociodemographics, self-reported health status, HRBs and biomarkers were extracted from the Hong Kong Population Health Survey 2014/2015.

Participants: One thousand five hundred and fifty-one participants aged 18-64 years without self-reported diagnoses of hypertension, diabetes mellitus, hyperlipidaemia, cardiovascular disease, cognitive impairment or cancer.

Primary Outcome Measures: Cardiometabolic dysregulation index (CMDI), ranging from 0 to 6, was calculated by counting the number of biomarkers including systolic blood pressure, diastolic blood pressure, waist to hip ratio, glycated haemoglobin, total cholesterol to high-density lipoprotein cholesterol ratio, and triglycerides that were above the respective normal level suggested by international guidelines and literature. HRBs including smoking, dietary habits and sleeping hours were collected by self-report questionnaire. Alcohol consumption was assessed by the 10-item Alcohol Use Disorders Identification Test, while physical activity level was measured using the Global Physical Activity Questionnaire. A composite HRB score, ranging from 0 to 5, was calculated as the cumulative number of HRBs. The effect of HRB on CMDI was evaluated by negative binomial regression with adjustment for socioeconomic status, health awareness and comorbidities of the participants.

Results: The mean CMDI of the studied population was 1.6; 29.5% had a CMDI of 0, whereas 1.5% had a CMDI of 6. Significant difference was observed in mean CMDI between gender and different age groups. Sleeping less than 6 hours (incidence rate ratio (IRR)=1.26, p<0.001), smoking (IRR=1.15, p=0.027), insufficient physical activity (IRR=1.12, p=0.007) and higher composite HRB score (IRR=1.12, 95% CI 1.06 to 1.18) were significantly associated with higher CMDI.

Conclusion: Smoking, physical inactivity and inadequate sleep-an essential yet often overlooked health behaviour-were associated with higher CMDI in the Hong Kong healthy adult population.
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http://dx.doi.org/10.1136/bmjopen-2020-043503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8273464PMC
July 2021

Responsiveness of the EuroQoL 5-Dimension (EQ-5D) questionnaire in patients with spondyloarthritis.

BMC Musculoskelet Disord 2021 May 14;22(1):439. Epub 2021 May 14.

Department of Orthopaedics and Traumatology, The University of Hong Kong, Professorial Block, 5th Floor, 102 Pokfulam Road, Pokfulam, Hong Kong SAR, China.

Background: Spondyloarthritis (SpA) has a significant impact on patients' quality of life due to functional impairments. Generic health instruments like the EuroQoL 5-dimension (EQ-5D) is important for cost-utility analysis of health care interventions and calculation of quality-adjusted life-years. It has been validated in patients with SpA. However, its responsiveness property is unclear. Hence, the aim of study is to test the responsiveness properties of the EQ-5D health measure for Chinese patients with SpA.

Methods: Prospective and consecutive recruitment of 151 Chinese patients with SpA was conducted with follow-up assessments 6 months later. Demographic data including smoking and drinking habits, education level, income and occupation was collected. Disease-associated data including disease duration, presence of back pain, peripheral arthritis, dactylitis, enthesitis, uveitis, psoriasis, and inflammatory bowel disease was also recorded. Questionnaires regarding disease activity and functional disability (BASDAI, BASFI, BASGI, BASMI, ASDAS), mental health (HADS) and the EQ-5D scores were recorded. Responsiveness was tested against the global rating of change scale (GRC) and changes in disease activity using BASDAI and ASDAS-CRP.

Results: A total of 113 (74.8%) patients completed the follow-up assessments. Most patients (61.6%) had low disease activity level with BASDAI <4 and 39.7% of patients had inactive disease by ASDAS-CRP. EQ-5D scores was well discriminated along with BASDAI and BASFI scores. EQ-5D scores also correlated well with HADS. The GRC was not able to discriminate adequately. No significant ceiling or floor effect was observed.

Conclusions: EQ-5D demonstrates satisfactory responsiveness property for assessment of changes in SpA disease activity.

Level Of Evidence: II.
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http://dx.doi.org/10.1186/s12891-021-04315-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8122540PMC
May 2021

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

Int J Environ Res Public Health 2021 02 5;18(4). Epub 2021 Feb 5.

Department of Social and Behavioral Sciences, City University of Hong Kong, Hong Kong 999077, China.

: Children are widely recognized as a vulnerable population during disasters and emergencies. The COVID-19 pandemic, like a natural disaster, brought uncertainties and instability to the economic development of the society and social distancing, which might lead to child maltreatment. This study aims to investigate whether job loss, income reduction and parenting affect child maltreatment. We conducted a cross-sectional online survey of 600 randomly sampled parents aged 18 years or older who had and lived with a child under 10 years old in Hong Kong between 29 May to 16 June 2020. Participants were recruited from a random list of mobile phone numbers of a panel of parents. Of 779 recruited target parents, 600 parents completed the survey successfully via a web-based system after obtaining their online consent for participating in the survey. : Income reduction was found significantly associated with severe (OR = 3.29, 95% CI = 1.06, 10.25) and very severe physical assaults (OR = 7.69, 95% CI = 2.24, 26.41) towards children. Job loss or large income reduction were also significantly associated with severe (OR= 3.68, 95% CI = 1.33, 10.19) and very severe physical assaults (OR = 4.05, 95% CI = 1.17, 14.08) towards children. However, income reduction (OR = 0.29, 95% CI = 0.15, 0.53) and job loss (OR = 0.47, 95% CI = 0.28, 0.76) were significantly associated with less psychological aggression. Exposure to intimate partner violence between parents is a very strong and significant factor associated with all types of child maltreatment. Having higher levels of difficulty in discussing COVID-19 with children was significantly associated with more corporal punishment (OR = 1.19, 95% CI = 1.05, 1.34), whereas having higher level of confidence in managing preventive COVID-19 behaviors with children was negatively associated with corporal punishment (OR = 0.87, 95% CI = 0.76, 0.99) and very severe physical assaults (OR = 0.74, 95% CI = 0.58, 0.93). : Income instability such as income reduction and job loss amplified the risk of severe and very severe child physical assaults but protected children from psychological aggression. Also, confidence in teaching COVID-19 and managing preventive COVID-19 behaviors with children was significantly negatively associated with corporal punishment during pandemic.
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http://dx.doi.org/10.3390/ijerph18041501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7915078PMC
February 2021

Retrospective cohort study to investigate the 10-year trajectories of disease patterns in patients with hypertension and/or diabetes mellitus on subsequent cardiovascular outcomes and health service utilisation: a study protocol.

BMJ Open 2021 02 5;11(2):e038775. Epub 2021 Feb 5.

Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China.

Introduction: Hypertension (HT) and diabetes mellitus (DM) and are major disease burdens in all healthcare systems. Given their high impact on morbidity, premature death and direct medical costs, we need to optimise effectiveness and cost-effectiveness of primary care for patients with HT/DM. This study aims to find out the association of trajectories in disease patterns and treatment of patients with HT/DM including multimorbidity and continuity of care with disease outcomes and service utilisation over 10 years in order to identify better approaches to delivering primary care services.

Methods And Analysis: A 10-year retrospective cohort study on a population-based primary care cohort of Chinese patients with documented doctor-diagnosed HT and/or DM, managed in the Hong Kong Hospital Authority (HA) public primary care clinics from 1 January 2006 to 31 December 2019. Data will be extracted from the HA Clinical Management System to identify trajectory patterns of patients with HT/DM. Complications defined by ICPC-2/International Classification of Diseases-Ninth Revision, Clinical Modification diagnosis codes, all-cause mortality rates and public service utilisation rates are included as independent variables. Changes in clinical parameters will be investigated using a growth mixture modelling analysis with standard quadratic trajectories. Dependent variables including effects of multimorbidity, measured by (1) disease count and (2) Charlson's Comorbidity Index, and continuity of care, measured by the Usual Provide Continuity Index, on patient outcomes and health service utilisation will be investigated. Multivariable Cox proportional hazards regression will be conducted to estimate the effect of multimorbidity and continuity of care after stratification of patients into groups according to respective definitions.

Ethics And Dissemination: This study was approved by the institutional review board of the University of Hong Kong-the HA Hong Kong West Cluster, reference no: UW 19-329. The study findings will be disseminated through peer-reviewed publications and international conferences.

Trial Registration Number: NCT04302974.
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http://dx.doi.org/10.1136/bmjopen-2020-038775DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7925871PMC
February 2021

Cost analysis comparison between conventional microsurgical decompression and full-endoscopic interlaminar decompression for lumbar spinal stenosis surgery.

J Spine Surg 2020 Dec;6(4):721-728

Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.

Background: Two of the most commonly used techniques for treatment of lumbar spinal stenosis (LSS) include full-endoscopic interlaminar decompression (MIS) and conventional microsurgical decompression (CD). Although these procedures have proven efficacy for relief of stenotic symptoms, in this age of increased concerns for healthcare cost, weighing the respective accumulative costs is essential for deciding which approach to adopt. The aim of this study is to perform a cost analysis comparison between MIS and CD for LSS.

Methods: A decision analysis model comparing MIS and CD for patients with LSS over a 1-year time horizon was conducted. Relevant unit costs associated with each surgical procedure and each possible complication treatment were estimated. Regarding the respective complication rates for each procedure, data was retrieved from the literature. Reoperation was considered for epidural hematoma, inadequate decompression or iatrogenic instability requiring fusion. Nonoperative treatment for complications like infection was also considered.

Results: The average total costs for MIS and CD were found to be HKD$54,863 and HKD$52,748 respectively. Both procedures carried similar costs in terms of hospitalization, radiology and routine follow-up visits. A 3.9% (HKD$2,115) difference in total cost was largely due to the differences in cost of surgery and complications. MIS costs 5.7% more than CD for an operation but was 28.1% less costly than MIS for complications.

Conclusions: Given the similar clinical effectiveness of either procedure and only a small difference in overall cost, our findings suggest that surgeons should perform the procedure that they are competent with which guarantees adequacy of decompression.
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http://dx.doi.org/10.21037/jss-20-552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797801PMC
December 2020

Effectiveness of routine measurement of health-related quality of life in improving the outcomes of patients with musculoskeletal problems-a cluster randomised controlled trial: protocol paper.

BMJ Open 2020 12 15;10(12):e040373. Epub 2020 Dec 15.

Institute of Health Sciences, University of Leeds, Leeds, UK.

Introduction: Managing chronic musculoskeletal problems usually focuses on pain control using medications, but outcomes are often unsatisfactory and sometimes harmful. Information on a patient's health-related quality of life (HRQOL) may trigger a doctor to tailor management improving quality of life. The aim of this trial is to find out whether routine measurement and reporting of a patient's EuroQoL 5-Dimension 5-Level (EQ-5D-5L) HRQOL data using an electronic platform can improve HRQOL and pain in patients with chronic knee or back problems in primary care. We will also assess the acceptability of routine electronic measurements and reporting of the EQ-5D-5L in primary care settings.

Methods: This is a multicentre, prospective, cluster randomised controlled trial set in six public primary care clinics in Hong Kong. At the intervention clinics, subjects will complete an electronic EQ-5D-5L form at recruitment and at each clinic follow-up over 12 months. A report of the patient's longitudinal EQ-5D-5L data will be provided to the doctor. Subjects in the control clinics will receive care as usual. All subjects will complete the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a 10-point Pain Rating Scale and a structured questionnaire to collect sociodemographic information and data on morbidity and service utilisation at recruitment at baseline, 3, 6 and 12 months. Primary outcome is the change in WOMAC total score. Secondary outcomes are change in pain, other patient-reported outcome scores and doctor-rated severity of disease. Group differences in the changes in WOMAC and other outcome scores over time will be analysed using generalised estimating equation model with an intention-to-treat principle.

Ethics And Dissemination: Ethics approval has been obtained from The University of Hong Kong/Hospital Authority Hong Kong West Cluster (IRB reference number: UW 18-270). The results of the trial will be submitted for publication in a peer-reviewed journal.

Trial Registration Number: NCT03609762.
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http://dx.doi.org/10.1136/bmjopen-2020-040373DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745313PMC
December 2020

Association of Individual Health Literacy with Preventive Behaviours and Family Well-Being during COVID-19 Pandemic: Mediating Role of Family Information Sharing.

Int J Environ Res Public Health 2020 11 27;17(23). Epub 2020 Nov 27.

School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.

: We tested a model of individual health literacy information sharing with family members, personal preventive behaviours and family well-being during the Coronavirus Disease 2019 (COVID-19) pandemic in Hong Kong. : We analysed data of 1501 randomly selected Chinese adults from a cross-sectional survey in Hong Kong from 9 to 23 April, 2020. Individual health literacy about COVID-19 with the items extracted from the questionnaire in World Health Organization Risk Communication and Community Engagement (RCCE) Action Plan Guidance for COVID-19 preparedness and response, COVID-19 information sharing with family members, preventive behaviours against COVID-19 and family well-being were measured. Structural equation modelling analysis tested the proposed model. : COVID-19 information sharing with family members partially mediated the association between individual health literacy and personal preventive behaviours. The direct effect of 0.24 was shown, and the indirect effect through COVID-19 information sharing with family members was small at 0.03 (Z = 3.66, < 0.001). Family well-being was associated with personal preventive behaviours against COVID-19. The model was adjusted for sex, age, and socioeconomic status factors and had good fit with RMSEA = 0.04, CFI = 0.98, TLI = 0.96, and SRMR = 0.02. : COVID-19 information sharing with family members was a partial mediator between individual health literacy and personal preventive behaviours against COVID-19. Strategies for enhancing health literacy and preventive measures against COVID-19 are needed to promote family well-being in the pandemic.
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http://dx.doi.org/10.3390/ijerph17238838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7730256PMC
November 2020

Prevalence and prognostic impact of comorbidities and peripheral blood indices in sarcomas.

ESMO Open 2020 11;5(6):e001035

Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong SAR, China.

Background: The prognostic impact of comorbidities in patients with sarcomas is not well defined. The aims of this study were to examine the implications of comorbidities and abnormal peripheral blood indices in patients with sarcomas.

Methods: A population-based database was assembled to extract patients with sarcoma in Hong Kong between January 2004 and March 2018. Charlson's Comorbidity Index (CCI) score and prevalence of comorbidities, neutrophil, lymphocyte and platelet counts at diagnosis were assessed. The prognostic values of CCI, neutrophil-lymphocyte (NLR) and platelet-lymphocyte ratios (PLR) were estimated using Cox proportional hazard models. Restricted cubic spline plots were used to explore the association of baseline NLR and PLR with all-cause and cancer-specific mortality.

Results: Among 3358 eligible patients with sarcomas, 52.2% died after a median 26 months of follow-up. The most common comorbidities were diabetes mellitus (9.8%) and cerebrovascular disease (4.8%). Patients with higher CCI had higher mortality (CCI=3 vs CCI=2; HR 1.49; 95% CI 1.19 to 1.87; p<0.01; CCI ≥7 vs CCI =2; HR 3.20; 95% CI 2.62 to 3.92; p<0.001). Abnormal NLR and PLR levels were associated with higher all-cause mortality (NLR: HR 1.698, p<0.001, 95% CI 1.424 to 2.025; PLR: HR 1.346, p<0.001, 95% CI 1.164 to 1.555) and cancer-related mortality (NLR: HR 1.648, p<0.001, 95% CI 1.341 to 2.024; PLR: HR 1.430, p<0.001, 95% CI 1.205 to 1.697).

Conclusions: This is the largest population-based soft-tissue or bone sarcoma cohort worldwide. Comorbidities have significant negative prognostic impact on the survival of patients with sarcomas. Moreover, NLR and PLR are robust prognostic factors, and abnormal NLR and PLR have negative effects yet non-linear effects on survival.
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http://dx.doi.org/10.1136/esmoopen-2020-001035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678389PMC
November 2020

Development and pilot evaluation of a mobile app on parent-child exercises to improve physical activity and psychosocial outcomes of Hong Kong Chinese children.

BMC Public Health 2020 Oct 14;20(1):1544. Epub 2020 Oct 14.

Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Ap Lei Chau Main Street, Ap Lei Chau, Hong Kong, Hong Kong.

Background: Parent-child exercises involve children and parents to do workout together and have positive effects on physical and mental health. We developed a mobile app on parent-child exercises called Family Move, which combines coaching videos with game features such as points and level system to enhance the health and wellbeing of both children and parents through parent-child exercises. This pilot pre-post study investigated whether the Family Move app-based intervention had a positive effect on children's health-related quality of life (HRQOL), psychosocial wellbeing, and physical activity (PA) level.

Methods: We recruited 67 parent-child pairs. During the 8-week intervention, these pairs were invited to perform parent-child exercises using the Family Move app. Points were automatically added to the user account after viewing a coaching video. In-game ranking was available to enhance user engagement. Parent proxy-report questionnaires on children's HRQOL, psychosocial wellbeing, and PA were administered at baseline and 1- and 6-month follow-up. Paired samples t-tests were conducted to evaluate post-intervention changes in child outcomes (HRQOL, psychosocial wellbeing, and PA). Multiple linear regressions were used to examine these changes as a function of in-game ranking.

Results: 52 (78%) viewed at least one coaching video in the Family Move app. Children's PA level significantly increased at 1-month (d = 0.32, p = 0.030) and 6-month (d = 0.30, p = 0.042) follow-up, whereas their psychosocial problems declined at 6-month follow-up (d = 0.35, p = 0.005). Higher in-game ranking was significantly associated with fewer psychosocial problems at 1-month follow-up (β = - 0.15, p = 0.030).

Conclusions: Our findings suggest that the Family Move app could be a possible intervention to increase children's PA level and psychosocial wellbeing through parent-child exercise.

Trial Registration: ClinicalTrials.gov number, NCT03279354 , registered September 11, 2017 (Prospectively registered).
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http://dx.doi.org/10.1186/s12889-020-09655-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7556926PMC
October 2020
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