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The social context is crucial for the adolescent development of self-regulatory skills and social responsibility. To understand the role of social context in adolescent development, the present study examined family predictors (i.e., family cohesion and conflict) of social responsibility, with emotion regulation ability as a mediating process. A total of 828 Chinese adolescents (35.6% female; mean age = 13.92 years, SD = 1.34) were recruited from major Chinese cities, including Hong Kong and Macau. Path analysis revealed that emotion regulation ability mediated the relation between family factors (i.e., family cohesion and family conflict) and social responsibility. That is, the ability to regulate emotions serves as a process between family factors and social responsibility. More specifically, family cohesion was positively associated with emotion regulation ability, whereas family conflict was negatively associated with emotion regulation ability. In turn, emotion regulation ability was positively associated with social responsibility. The results suggested that the family environment and adolescent's emotion regulation ability are important contextual and intrapersonal factors contributing to their development of social responsibility. As an implication, policymakers and practitioners might allocate resources to enrich positive family interactions and cultivate emotional competency to support adolescents' development of social responsibility., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Cheng et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Aims/hypothesis: The aim of this study was to describe the metabolome in diabetic kidney disease (DKD) and its association with incident CVD in type 2 diabetes, and identify prognostic biomarkers., Methods: From a prospective cohort of individuals with type 2 diabetes, baseline sera (N=1991) were quantified for 170 metabolites using NMR spectroscopy with median 5.2 years of follow-up. Associations of chronic kidney disease (CKD, eGFR<60 ml/min per 1.73 m 2 ) or severely increased albuminuria with each metabolite were examined using linear regression, adjusted for confounders and multiplicity. Associations between DKD (CKD or severely increased albuminuria)-related metabolites and incident CVD were examined using Cox regressions. Metabolomic biomarkers were identified and assessed for CVD prediction and replicated in two independent cohorts., Results: At false discovery rate (FDR)<0.05, 156 metabolites were associated with DKD (151 for CKD and 128 for severely increased albuminuria), including apolipoprotein B-containing lipoproteins, HDL, fatty acids, phenylalanine, tyrosine, albumin and glycoprotein acetyls. Over 5.2 years of follow-up, 75 metabolites were associated with incident CVD at FDR<0.05. A model comprising age, sex and three metabolites (albumin, triglycerides in large HDL and phospholipids in small LDL) performed comparably to conventional risk factors (C statistic 0.765 vs 0.762, p=0.893) and adding the three metabolites further improved CVD prediction (C statistic from 0.762 to 0.797, p=0.014) and improved discrimination and reclassification. The 3-metabolite score was validated in independent Chinese and Dutch cohorts., Conclusions/interpretation: Altered metabolomic signatures in DKD are associated with incident CVD and improve CVD risk stratification., (© 2024. The Author(s).)

Background: It has been a long-standing tradition of using herbal tea for preventive and therapeutic healthcare in Hong Kong and South China and Five Flowers Tea is one of the most popular herbal teas. Based on the principle of traditional Chinese medicine, the pharmacological functions are to clear heat and dispel dampness in the body. Heat and dampness are thought to contribute to a range of health problems, especially during the hot and humid season in South China and Hong Kong. The most prevalent herbs in the formula contain bioactive compounds including flavonoids, alkaloids and terpenoids, which have a wide range of pharmacological properties including anti-inflammation, antivirus, antidiarrhoea, antibacteria, and antioxidation. However, with the composition varies widely, the ethnopharmacological benefits described may not be delivered uniformly. This study is to provide a comprehensive analysis on the composition of the Five Flowers Tea sold in Hong Kong and investigate the rationale behind the selection of herbs used in the formula. This study also provides information on the variation and quality of the Five Flowers Tea in the market., Methods: Thirty-three Five Flowers Tea samples were collected from various locations in Hong Kong. The size, texture, colour and organoleptic properties were documented. Macroscopic and molecular authentication methods were employed to identify the individual components., Results: Macroscopic identification revealed there were 23 herbs belonging to 18 plant families. The most prevalent herb was Bombax ceiba L., followed by Chrysanthemum morifolium. Ten adulterants and the existence of insect Lasioderma serricorne were confirmed by DNA barcoding techniques., Conclusion: This study employed a comprehensive approach to authenticate the herbs in Five Flowers Tea samples collected from various locations in Hong Kong. Macroscopic and molecular methods were used to identify the herbs and adulterants. The findings revealed the varied composition in Five Flowers Tea and the occurrence of adulterants in some samples. This shows that quality assurance of Five Flowers Tea is essential for the effective use of this popular folk medicine., (© 2024. The Author(s).)

Background: Clinical trials have demonstrated that remission of type 2 diabetes can be achieved following sustained weight loss. However, the feasibility of achieving diabetes remission through weight management in real-world settings remains unclear. In this study, we aimed to examine the association of weight change at 1 year after diabetes diagnosis with long-term incidence and sustainability of type 2 diabetes remission in real-world settings in Hong Kong., Methods and Findings: This was a population-based observational cohort study. The territory-wide Risk Assessment and Management Programme for Diabetes Mellitus (RAMP-DM) provides regular comprehensive assessments of metabolic control and complication screening for people with diabetes in Hong Kong. We included 37,326 people with newly diagnosed type 2 diabetes who were enrolled in the RAMP-DM between 2000 and 2017, followed until 2019. Diabetes remission was defined as 2 consecutive HbA1c <6.5% measurements at least 6 months apart in the absence of glucose-lowering drugs (GLDs) and with no record of GLDs at least 3 months before these measurements. During a median follow-up of 7.9 years, 6.1% (2,279) of people achieved diabetes remission, with an incidence rate of 7.8 (95% CI: 7.5, 8.1) per 1,000 person-years. After adjusting for age at diabetes diagnosis, sex, assessment year, body mass index, other metabolic indices, smoking, alcohol drinking, and medication use, the hazard ratio (HR) for diabetes remission was 3.28 (95% CI: 2.75, 3.92; p < 0.001) for people with ≥10% weight loss within 1 year of diagnosis, 2.29 (95% CI: 2.03, 2.59; p < 0.001) for those with 5% to 9.9% weight loss, and 1.34 (95% CI: 1.22, 1.47; p < 0.001) for those with 0% to 4.9% weight loss compared to people with weight gain. During a median follow-up of 3.1 years, 67.2% (1,531) of people who had achieved diabetes remission returned to hyperglycaemia, with an incidence rate of 184.8 (95% CI: 175.5, 194.0) per 1,000 person-years. The adjusted HR for returning to hyperglycaemia was 0.52 (95% CI: 0.41, 0.65; p < 0.001) for people with ≥10% weight loss, 0.78 (95% CI: 0.68, 0.92; p = 0.002) for those with 5% to 9.9% weight loss, and 0.90 (95% CI: 0.80, 1.01; p = 0.073) for those with 0% to 4.9% weight loss compared to people with weight gain. Diabetes remission was associated with a 31% (HR: 0.69, 95% CI: 0.52, 0.93; p = 0.014) decreased risk of all-cause mortality. The main limitation of the study is that the reliability of HbA1c used to define diabetes remission can be affected by other medical conditions. Furthermore, we did not have data on bariatric surgery., Conclusions: In this study, greater weight loss within the first year of diabetes diagnosis was associated with an increased likelihood of achieving diabetes remission and a decreased risk of returning to hyperglycaemia among those who had achieved diabetes remission. However, both the incidence of diabetes remission and the probability of its long-term sustainability were low with conventional management in real-world settings, in an era when the importance of weight loss was not fully appreciated. Our study provides evidence for policymakers to design and implement early weight management interventions and diabetes remission initiatives., Competing Interests: AOYL has received research grants or contracts from Amgen, AstraZeneca, Bayer, Biogen, Boehringer Ingelheim, Eli Lilly, Junshi, Lee Pharmaceutical, MSD, Novo Nordisk, Roche, Sanofi, Shanghai Junshi Biosciences, Sugardown, Takeda, received travel grants and honoraria for speaking from AstraZeneca, Boehringer Ingelheim, Eli Lilly, MSD. JCNC has received research grants through institutions and/or honoraria for consultancy and/or giving lectures from Applied Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, Hua Medicine, Lee Powder, Merck Serono, Merck Sharp & Dohme, Pfizer, Sanofi and Viatris. APSK has received research grants and/or speaker honoraria from Abbott, Astra Zeneca, Bayer, Boehringer Ingelheim, Eli-Lilly, Kyowa Kirin, Merck Serono, Nestle, Novo-Nordisk, Pfizer and Sanofi. RCWM has received research funding from AstraZeneca, Bayer, Merck Sharp & Dohme, Novo Nordisk, Pfizer, Roche Diagnostics and Tricida Inc. for carrying out clinical trials or studies, and from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo and Merck for speaker honoraria or consultancy in advisory boards. All proceeds have been donated to the Chinese University of Hong Kong to support diabetes research. RCMW is member of the editorial board of PLOS Medicine. Other authors have no competing interests to declare., (Copyright: © 2024 Wu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Continuity of care (COC) is associated with improved health outcomes in patients with hypertension. Team-based COC allows more flexibility in service delivery but there is a lack of research on its effectiveness for patients with hypertension., Aim: To investigate the effectiveness of team-based COC on the prevention of cardiovascular disease (CVD) and mortality in patients with hypertension., Design and Setting: A retrospective cohort study in a primary care setting in Hong Kong., Method: Eligible patients included those visiting public primary care clinics in Hong Kong from 2008 to 2018. The usual provider continuity index (UPCI) was used to measure the COC provided by the most visited physician team. Cox regression and restricted cubic splines were applied to model the association between the COC and the risk for CVDs and all-cause mortality., Results: This study included 421 640 eligible patients. Compared with participants in the lowest quartile of UPCI, the hazard ratios for overall CVD were 0.94 (95% CI = 0.92 to 0.96), 0.91(95% CI = 0.89 to 0.93), and 0.90 (95% CI = 0.88 to 0.92) in the second, third, and fourth quartiles, respectively. A greater effect size on CVD risk reduction was observed among the patients with unsatisfactory blood pressure control, patients aged <65 years, and those with a Charlson comorbidity index of <4 at baseline ( P interaction<0.05 in these subgroup analyses), but the effect was insignificant among the participants with an estimated glomerular filtration rate of <60 ml/ min/1.73 m 2 at baseline., Conclusion: Team-based COC via a coordinated physician team was associated with reduced risks of CVD and all-cause mortality among patients with hypertension, especially for the patients with unsatisfactory blood pressure control. Early initiation of team-based COC may also achieve extra benefits., (© The Authors.)

Background: Type 2 diabetes affects multiple systems. We aimed to compare age- and sex-specific rates of all-cause and cause-specific hospital bed-days between people with and without type 2 diabetes., Methods and Findings: Data were provided by the Hong Kong Hospital Authority. We included 1,516,508 one-to-one matched people with incident type 2 diabetes (n = 758,254) and those without diabetes during the entire follow-up period (n = 758,254) between 2002 and 2018, followed until 2019. People with type 2 diabetes and controls were matched for age at index date (±2 years), sex, and index year (±2 years). We defined hospital bed-day rate as total inpatient bed-days divided by follow-up time. We constructed negative binominal regression models to estimate hospital bed-day rate ratios (RRs) by age at diabetes diagnosis and sex. All RRs were stratified by sex and adjusted for age and index year. During a median of 7.8 years of follow-up, 60.5% (n = 459,440) of people with type 2 diabetes and 56.5% (n = 428,296) of controls had a hospital admission for any cause, with a hospital bed-day rate of 3,359 bed-days and 2,350 bed-days per 1,000 person-years, respectively. All-cause hospital bed-day rate increased with increasing age in controls, but showed a J-shaped relationship with age in people with type 2 diabetes, with 38.4% of bed-days in those diagnosed <40 years caused by mental health disorders. Type 2 diabetes was associated with increased risks for a wide range of medical conditions, with an RR of 1.75 (95% CI [confidence interval] [1.73, 1.76]; p < 0.001) for all-cause hospital bed-days in men and 1.87 (95% CI [1.85, 1.89]; p < 0.001) in women. The RRs were greater in people with diabetes diagnosed at a younger than older age and varied by sex according to medical conditions. Sex differences were most notable for a higher RR for urinary tract infection and peptic ulcer, and a lower RR for chronic kidney disease and pancreatic disease in women than men. The main limitation of the study was that young people without diabetes in the database were unlikely to be representative of those in the Hong Kong general population with potential selection bias due to inclusion of individuals in need of medical care., Conclusions: In this study, we observed that type 2 diabetes was associated with increased risks of hospital bed-days for a wide range of medical conditions, with an excess burden of mental health disorders in people diagnosed at a young age. Age and sex differences should be considered in planning preventive and therapeutic strategies for type 2 diabetes. Effective control of risk factors with a focus on mental health disorders are urgently needed in young people with type 2 diabetes. Healthcare systems and policymakers should consider allocating adequate resources and developing strategies to meet the mental health needs of young people with type 2 diabetes, including integrating mental health services into diabetes care., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: AOYL has received research grants or contracts from Amgen, AstraZeneca, Bayer, Biogen, Boehringer Ingelheim, Eli Lilly, Junshi, Lee Pharmaceutical, MSD, Novo Nordisk, Roche, Sanofi, Shanghai Junshi Biosciences, Sugardown, Takeda, received travel grants and honoraria for speaking from AstraZeneca, Boehringer Ingelheim, Eli Lilly, MSD. JCNC has received research grants through institutions and/or honoraria for consultancy and/or giving lectures from Applied Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, Hua Medicine, Lee Powder, Merck Serono, Merck Sharp & Dohme, Pfizer, Sanofi and Viatris. APSK has received research grants and/or speaker honoraria from Abbott, Astra Zeneca, Bayer, Boehringer Ingelheim, Eli-Lilly, Kyowa Kirin, Merck Serono, Nestle, Novo-Nordisk, Pfizer and Sanofi. RCWM has received research funding from AstraZeneca, Bayer, Merck Sharp & Dohme, Novo Nordisk, Pfizer, Roche Diagnostics and Tricida Inc. for carrying out clinical trials or studies, and from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo and Merck for speaker honoraria or consultancy in advisory boards. All proceeds have been donated to the Chinese University of Hong Kong to support diabetes research. RCMW is member of the editorial board of PLOS Medicine. Other authors have no competing interests to declare., (Copyright: © 2023 Wu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Problems with health-related quality of life can affect physicians' ability to work effectively. This study compared the health-related quality of life of Hong Kong physicians to the general population and explored the factors associated with mental and physical health-related quality of life., Methods: This cross-sectional study was conducted from January to April 2016. Medical graduates from the University of Hong Kong participated in a survey containing the Short Form-12 Item Health survey version 2, Patient Health Questionnaire-9, Copenhagen Burnout Inventory, and items on lifestyle behaviors, career satisfaction, and socio-demographics., Results: 496 responses were received. The mean physical component summary score was 53.2 (SD = 7.6), similar to the general population. The mean mental component summary score was 43.6 (SD = 11.8), significantly worse than the general population (P<0.01). Compared to the general population, all Short-Form 12 Health Survey version 2 domains were worse in doctors, aside from bodily pain and general health. Regular exercise was positively associated with physical component summary scores (Coeff 2.024; P = 0.047); but having children and higher personal burnout scores were negatively associated with it (Coeff -1.890; P = 0.036; and Coeff -0.045; P = 0.027, respectively). Poorer mental component summary scores correlated with worse personal (Coeff -0.284; P< 0.001), work-related (Coeff -0.135; P = 0.040), and patient-related burnout (Coeff -0.060; P = 0.041), and higher Patient Health Questionnaire-9 scores (Coeff -9.170; P<0.001). There were significant differences in mental health (P = 0.042) and mental component summary scores (P = 0.012) across age groups, but not with gender., Conclusion: Hong Kong physicians are less impacted by physical health than mental health. Compared to the general population, doctors' mental health has a more significant impact on their lives. Interventions aimed to improve burnout and depression rates in physicians may improve physicians' mental health-related quality of life., Competing Interests: The authors have declared that no competing interests exist, (Copyright: © 2023 Ng et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The prevalence of type 2 diabetes has increased in both young and old people. We examined age-specific associations and population attributable fractions (PAFs) of risk factors for all-cause and cause-specific mortality in people with type 2 diabetes., Methods and Findings: We analysed data from 360,202 Chinese with type 2 diabetes who participated in a territory-wide diabetes complication screening programme in Hong Kong between January 2000 and December 2019. We compared the hazard ratios and PAFs of eight risk factors, including three major comorbidities (cardiovascular disease [CVD], chronic kidney disease [CKD], all-site cancer) and five modifiable risk factors (suboptimal HbA1c, suboptimal blood pressure, suboptimal low-density lipoprotein cholesterol, smoking, and suboptimal weight), for mortality across four age groups (18 to 54, 55 to 64, 65 to 74, and ≥75 years). During a median 6.0 years of follow-up, 44,396 people died, with cancer, CVD, and pneumonia being the leading causes of death. Despite a higher absolute mortality risk in older people (crude all-cause mortality rate: 59.7 versus 596.2 per 10,000 person-years in people aged 18 to 54 years versus those aged ≥75 years), the relative risk of all-cause and cause-specific mortality associated with most risk factors was higher in younger than older people, after mutually adjusting for the eight risk factors and other potential confounders including sex, diabetes duration, lipid profile, and medication use. The eight risk factors explained a larger proportion of mortality events in the youngest (PAF: 51.6%, 95% confidence interval [CI] [39.1%, 64.0%], p < 0.001) than the oldest (PAF: 35.3%, 95% CI [27.2%, 43.4%], p < 0.001) age group. Suboptimal blood pressure (PAF: 16.9%, 95% CI [14.7%, 19.1%], p < 0.001) was the leading attributable risk factor for all-cause mortality in the youngest age group, while CKD (PAF: 15.2%, 95% CI [14.0%, 16.4%], p < 0.001) and CVD (PAF: 9.2%, 95% CI [8.3%, 10.1%], p < 0.001) were the leading attributable risk factors in the oldest age group. The analysis was restricted to Chinese, which might affect the generalisability to the global population with differences in risk profiles. Furthermore, PAFs were estimated under the assumption of a causal relationship between risk factors and mortality. However, reliable causality was difficult to establish in the observational study., Conclusions: Major comorbidities and modifiable risk factors were associated with a greater relative risk for mortality in younger than older people with type 2 diabetes and their associations with population mortality burden varied substantially by age. These findings highlight the importance of early control of blood pressure, which could reduce premature mortality in young people with type 2 diabetes and prevent the onset of later CKD and related mortality at older ages., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: R. C.W. M. is a Editorial Board member of Plos Medicine., (Copyright: © 2023 Wu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: High-density lipoproteins (HDL) comprise particles of different size, density and composition and their vasoprotective functions may differ. Diabetes modifies the composition and function of HDL. We assessed associations of HDL size-based subclasses with incident cardiovascular disease (CVD) and mortality and their prognostic utility., Research Design and Methods: HDL subclasses by nuclear magnetic resonance spectroscopy were determined in sera from 1991 fasted adults with type 2 diabetes (T2D) consecutively recruited from March 2014 to February 2015 in Hong Kong. HDL was divided into small, medium, large and very large subclasses. Associations (per SD increment) with outcomes were evaluated using multivariate Cox proportional hazards models. C-statistic, integrated discrimination index (IDI), and categorial and continuous net reclassification improvement (NRI) were used to assess predictive value., Results: Over median (IQR) 5.2 (5.0-5.4) years, 125 participants developed incident CVD and 90 participants died. Small HDL particles (HDL-P) were inversely associated with incident CVD [hazard ratio (HR) 0.65 (95% CI 0.52, 0.81)] and all-cause mortality [0.47 (0.38, 0.59)] (false discovery rate < 0.05). Very large HDL-P were positively associated with all-cause mortality [1.75 (1.19, 2.58)]. Small HDL-P improved prediction of mortality [C-statistic 0.034 (0.013, 0.055), IDI 0.052 (0.014, 0.103), categorical NRI 0.156 (0.006, 0.252), and continuous NRI 0.571 (0.246, 0.851)] and CVD [IDI 0.017 (0.003, 0.038) and continuous NRI 0.282 (0.088, 0.486)] over the RECODe model., Conclusion: Small HDL-P were inversely associated with incident CVD and all-cause mortality and improved risk stratification for adverse outcomes in people with T2D. HDL-P may be used as markers for residual risk in people with T2D., (© 2022. The Author(s).)

Rationale & Objective: Nonalbuminuric diabetic kidney disease (DKD) has become the prevailing DKD phenotype. We compared the risks of adverse outcomes among patients with this phenotype compared with other DKD phenotypes., Study Design: Multicenter prospective cohort study., Settings & Participants: 19,025 Chinese adults with type 2 diabetes enrolled in the Hong Kong Diabetes Biobank., Exposures: DKD phenotypes defined by baseline estimated glomerular filtration rate (eGFR) and albuminuria: no DKD (no decreased eGFR or albuminuria), albuminuria without decreased eGFR, decreased eGFR without albuminuria, and albuminuria with decreased eGFR., Outcomes: All-cause mortality, cardiovascular disease (CVD) events, hospitalization for heart failure (HF), and chronic kidney disease (CKD) progression (incident kidney failure or sustained eGFR reduction ≥40%)., Analytical Approach: Multivariable Cox proportional or cause-specific hazards models to estimate the relative risks of death, CVD, hospitalization for HF, and CKD progression. Multiple imputation was used for missing covariates., Results: Mean participant age was 61.1 years, 58.3% were male, and mean diabetes duration was 11.1 years. During 54,260 person-years of follow-up, 438 deaths, 1,076 CVD events, 298 hospitalizations for HF, and 1,161 episodes of CKD progression occurred. Compared with the no-DKD subgroup, the subgroup with decreased eGFR without albuminuria had higher risks of all-cause mortality (hazard ratio [HR], 1.59 [95% CI, 1.04-2.44]), hospitalization for HF (HR, 3.08 [95% CI, 1.82-5.21]), and CKD progression (HR, 2.37 [95% CI, 1.63-3.43]), but the risk of CVD was not significantly greater (HR, 1.14 [95% CI, 0.88-1.48]). The risks of death, CVD, hospitalization for HF, and CKD progression were higher in the setting of albuminuria with or without decreased eGFR. A sensitivity analysis that excluded participants with baseline eGFR <30 mL/min/1.73 m 2 yielded similar findings., Limitations: Potential misclassification because of drug use., Conclusions: Nonalbuminuric DKD was associated with higher risks of hospitalization for HF and of CKD progression than no DKD, regardless of baseline eGFR., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Diabetes mellitus (DM) is a major non-communicable disease with an increasing prevalence. Undiagnosed DM is not uncommon and can lead to severe complications and mortality. Identifying high-risk individuals at an earlier disease stage, that is, pre-diabetes (pre-DM), is crucial in delaying progression. Existing risk models mainly rely on non-modifiable factors to predict only the DM risk, and few apply to Chinese people. This study aims to develop and validate a risk prediction function that incorporates modifiable lifestyle factors to detect DM and pre-DM in Chinese adults in primary care., Methods and Analysis: A cross-sectional study to develop DM/Pre-DM risk prediction functions using data from the Hong Kong's Population Health Survey (PHS) 2014/2015 and a 12-month prospective study to validate the functions in case finding of individuals with DM/pre-DM. Data of 1857 Chinese adults without self-reported DM/Pre-DM will be extracted from the PHS 2014/2015 to develop DM/Pre-DM risk models using logistic regression and machine learning methods. 1014 Chinese adults without a known history of DM/Pre-DM will be recruited from public and private primary care clinics in Hong Kong. They will complete a questionnaire on relevant risk factors and blood tests on Oral Glucose Tolerance Test (OGTT) and haemoglobin A1C (HbA1c) on recruitment and, if the first blood test is negative, at 12 months. A positive case is DM/pre-DM defined by OGTT or HbA1c in any blood test. Area under receiver operating characteristic curve, sensitivity, specificity, positive predictive value and negative predictive value of the models in detecting DM/pre-DM will be calculated., Ethics and Dissemination: Ethics approval has been received from The University of Hong Kong/Hong Kong Hospital Authority Hong Kong West Cluster (UW19-831) and Hong Kong Hospital Authority Kowloon Central/Kowloon East Cluster (REC(KC/KE)-21-0042/ER-3). The study results will be submitted for publication in a peer-reviewed journal., Trial Registration Number: US ClinicalTrial.gov: NCT04881383; HKU clinical trials registry: HKUCTR-2808; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: Skin autofluorescence (SAF) can non-invasively assess the accumulation of tissue AGEs. We investigated the association between SAF and kidney dysfunction in participants with T2D., Methods: Of 4030 participants consecutively measured SAF at baseline, 3725 participants free of end-stage kidney disease (ESKD) were included in the analyses. The association of SAF with incident ESKD or ≥30% reduction in estimated glomerular filtration rate (eGFR) was examined with Cox regression, linear mixed-effects model for the association with annual eGFR decline, and mediation analyses for the mediating roles of renal markers., Results: During a median (IQR) 1.8 (1.1-3.1) years of follow-up, 411 participants developed the outcome. SAF was associated with progression of kidney disease (hazard ratio 1.15 per SD, 95% confidence interval [CI] [1.04, 1.28]) and annual decline in eGFR (β -0.39 per SD, 95% CI [-0.71, -0.07]) after adjustment for risk factors, including baseline eGFR and urinary albumin-creatinine ratio (UACR). Decreased eGFR (12.9%) and increased UACR (25.8%) accounted for 38.7% of the effect of SAF on renal outcome., Conclusions: SAF is independently associated with progression of kidney disease. More than half of its effect is independent of renal markers. SAF is of potential to be a prognostic marker for kidney dysfunction., Competing Interests: Declaration of competing interest This study was supported by the Research Grants Council Theme-based Research Scheme (T12-402/13N), and the Chinese University of Hong Kong-Shanghai Jiao Tong University Joint Research Fund, and the RGC Research Impact Fund (R4012-18). RCWM and AJJ acknowledge support from the Internationalization Faculty Mobility Schemes (Outbound Research Mobility Scheme 2015–2016 and Inbound Research Mobility Scheme 2015–2016, respectively) from the Office of Academic Links, Chinese University of Hong Kong. We acknowledge Diagnoptics and Chong Lap (H.K.) Co. Ltd for providing access to the AGE Reader. The funders or companies had no involvement or input into the study design, data analyses or manuscript preparation. RCWM received research funding from AstraZeneca, Bayer, Boehringer Ingelheim, Novo Nordisk, Pfizer, Sanofi and Tricida Inc. for carrying out clinical trials, speaker honorarium or consultancy in advisory boards. All proceeds have been donated to the Chinese University of Hong Kong to support diabetes research., (Copyright © 2021 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

Aims/hypothesis: Few large-scale prospective studies have investigated associations between relative leucocyte telomere length (rLTL) and kidney dysfunction in individuals with type 2 diabetes. We examined relationships between rLTL and incident end-stage kidney disease (ESKD) and the slope of eGFR decline in Chinese individuals with type 2 diabetes., Methods: We studied 4085 Chinese individuals with type 2 diabetes observed between 1995 and 2007 in the Hong Kong Diabetes Register with stored baseline DNA and available follow-up data. rLTL was measured using quantitative PCR. ESKD was diagnosed based on the ICD-9 code and eGFR., Results: In this cohort (mean ± SD age 54.3 ± 12.6 years) followed up for 14.1 ± 5.3 years, 564 individuals developed incident ESKD and had shorter rLTL at baseline (4.2 ± 1.2 vs 4.7 ± 1.2, p < 0.001) than the non-progressors (n = 3521). On Cox regression analysis, each ∆∆C t decrease in rLTL was associated with an increased risk of incident ESKD (HR 1.21 [95% CI 1.13, 1.30], p < 0.001); the association remained significant after adjusting for baseline age, sex, HbA 1c , lipids, renal function and other risk factors (HR 1.11 [95% CI 1.03, 1.19], p = 0.007). Shorter rLTL at baseline was associated with rapid decline in eGFR (>4% per year) during follow-up (unadjusted OR 1.22 [95% CI 1.15, 1.30], p < 0.001; adjusted OR 1.09 [95% CI 1.01, 1.17], p = 0.024)., Conclusions/interpretation: rLTL is independently associated with incident ESKD and rapid eGFR loss in individuals with type 2 diabetes. Telomere length may be a useful biomarker for the progression of kidney function and ESKD in type 2 diabetes., (© 2021. The Author(s).)

Depression amongst physicians can lead to poor individual and institutional outcomes. This study examined the prevalence and factors associated with depression and suicidal ideation amongst doctors in Hong Kong. Doctors who graduated from medical school at the University of Hong Kong between 1995 and 2014 were invited to participate in a survey measuring depressive symptoms, suicidal ideation and thoughts of self-harm, lifestyle behaviours, career satisfaction and socio-demographic characteristics. Data collection occurred between January and April 2016. The prevalence of screened-positive depression was 16.0% and 15.3% of respondents reported having suicidal ideation. Amongst those with positive depression screening scores, less than half reported having a diagnosed mood disorder. Sleeping fewer hours was associated with higher depression scores (P < 0.001) and an increased odds of meeting the cut-off for depression (P < 0.001). Factors associated with suicidal ideation included being unmarried (P = 0.012) and sleeping fewer hours (P = 0.022). Hong Kong doctors appear to have high rates of undiagnosed depression, and high levels of depressive symptoms and suicidal ideations. There is a need for greater awareness of the morbidity due to depression and to promote better mental health help-seeking among physicians. Barriers to mental health help-seeking need to be addressed and appropriate resources allocated to reduce suffering., (© 2021. The Author(s).)

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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Empirical research on the social psychological antecedents of collective action has been conducted almost exclusively in democratic societies, where activism is relatively safe. The present research examines the psychological predictors of collective action intentions in contexts where resistance is met with significant repression by the authorities. Combining recent advancements in the collective action literature, our model examines the unique predictive roles of emotion (anger and fear), political identity consolidation and participative efficacies, politicized identification, and moral obligation, over and above past participation. It further investigates how these variables are shaped by perceptions of risks attributable to repression. Four survey studies test this model among protesters in Russia ( N = 305), Ukraine ( N = 136), Hong Kong ( N = 115), and Turkey ( N = 296). Meta-analytic integration of the findings highlights that, unlike in most current accounts of collective action, protesters in these contexts are not primarily driven by political efficacy. Rather, their involvement is contingent upon beliefs in the ability of protest to build a movement (identity consolidation and participative efficacies) and motivated by outrage at state repression, identification with the social movement, and a sense of moral obligation to act on their behalf. Results also confirm that risks attributable to state repression spur rather than quell resistance by increasing outrage, politicized identification, identity consolidation and participative efficacies, and moral obligation. The implications of these findings for models of collective action and our understanding of the motives underlying engagement in repressive contexts are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Aims: Few studies have investigated the relationship between rLTL and mortality in patients with type 2 diabetes in a large prospective study, particularly in the Asian population. This study investigates the relationship between rLTL and the risk of death in Chinese patients with type 2 diabetes., Methods: Consecutive Chinese patients with type 2 diabetes (N = 5349) from the Hong Kong Diabetes Register with stored baseline DNA and available follow-up data were studied. rLTL was measured using a quantitative polymerase chain reaction. Mortality and clinical outcomes were obtained based on ICD-9 codes., Results: The mean (SD) age of the subjects was 57.5 (13.3) years and mean (SD) follow-up duration was 13.4 (5.5) years. Baseline rLTL was significantly shorter in the 1925 subjects who subsequently died compared with the remaining subjects (4.3 ± 1.2 vs. 4.7 ± 1.2, P < 0.001). Shorter rLTL was associated with a higher risk of mortality (HR: 1.19 (1.14-1.23), P < 0.001), which remained significant after adjusting for traditional risk factors., Conclusions: Shorter rLTL was significantly associated with an increased risk of all-cause and CVD mortality in patients with type 2 diabetes, independent of established risk factors. Telomere length may be a useful biomarker for mortality risk in patients with type 2 diabetes., Competing Interests: Declaration of Competing Interest A.O.L. has served as an advisory committee member for AstraZeneca, Boehringer Ingelheim, Sanofi and Amgen and has received research grants and travel grants from AstraZeneca, Boehringer Ingelheim, MSD, Novartis, Novo Nordisk, Sanofi and Amgen. A.P.K. has received research grants and/or speaker honoraria from Abbott, AstraZeneca, Eli-Lilly, Merck Serono, Nestle, Sanofi and Novo Nordisk. J.C.C. has received research grants and/or honoraria for consultancy or giving lectures, from AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Daiichi-Sankyo, Eli-Lilly, GlaxoSmithKline, Merck Serono, Merck Sharp & Dohme, Novo Nordisk, Pfizer and Sanofi. R.C.M. has received research grants for clinical trials from AstraZeneca, Bayer, MSD, Novo Nordisk, Sanofi, Tricida and honoraria for consultancy or lectures from AstraZeneca, and Boehringer Ingelheim. F.C., C.K.L., L.C., C.H.T., B.F., H.W., A.Y., E.S.L., A.C.N., E.C., H.M.L., A.C.K., M.V.J., W.Y.S., A.J.J., and A.A.H. do not have conflicts of interest to declare., (Copyright © 2021 Elsevier B.V. All rights reserved.)

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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims/hypothesis: Infection is an under-recognised but important complication in people with diabetes. Studies on temporal trends in incidence of infection in this population are limited. We report the trends in infection-related hospitalisation in people with diabetes and compared hospitalisation rates between people with and without diabetes in Hong Kong., Methods: Hospital admissions with infection, including pneumonia, influenza, tuberculosis, kidney infection, urinary tract infection, cellulitis, osteomyelitis, foot infection and sepsis, listed as principal diagnosis occurring between 2001 and 2016 were identified from people with diabetes in the electronic medical record system of the Hong Kong Hospital Authority. Data on hospitalisation for a subset of these infections in the general population between 2007 and 2016 were obtained from the Department of Health. The number of people with diabetes ranged between 117,322 in 2001 and 570,929 in 2016, and the number without diabetes ranged between 5,242,614 in 2007 and 5,593,153 in 2016. Joinpoint regression was used to describe the trends., Results: In people with diabetes, over a period of 16 years, the age-standardised annual rates of hospitalisation decreased for tuberculosis but increased for influenza; rates of hospitalisation for pneumonia increased up until 2004/2005 and declined in men and stabilised in women. The rates of hospitalisation for most infection types were unchanged or increased in the 20-44 year and 45-64 year age groups and decreased in those aged 65 years or above. Trends for most of the infections were similar when comparing sexes. Between 2007 and 2016, the rate ratios of hospitalisation for most infection types between people with and without diabetes were stable, and the rate ratios remained higher in people with diabetes, ranging from 1.3-1.4 for pneumonia to 3.2-4.9 for kidney infections in 2016 compared with non-diabetic individuals., Conclusions/interpretation: Despite advances in medical care, hospitalisation due to infections remains a major healthcare burden in people with diabetes. Graphical abstract.

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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: There has been a shift toward new classes of glucose-lowering drugs (GLDs) in the past decade but no improvements in glycemic control or hospitalization rates due to severe hypoglycemia (SH) in previous surveys. We examined trends in GLDs use, glycemic control, and SH rate among patients with diabetes in Hong Kong, which introduced a territory-wide, team-based diabetes care model since 2000., Research Design and Methods: Using population-based data from the Hong Kong Diabetes Surveillance Database, we estimated age- and sex-standardized proportion of GLD classes, mean hemoglobin A 1c (HbA 1c ) levels, and SH rates in 763,809 patients with diabetes aged ≥20 years between 2002 and 2016., Results: Between 2002 and 2016, use declined for sulfonylureas (62.9% to 35.3%) but increased for metformin (48.4% to 61.4%) and dipeptidyl peptidase 4 inhibitors (DPP-4is) (0.01% in 2007 to 8.3%). The proportion of patients with HbA 1c of 6.0-7.0% (42-53 mmol/mol) increased from 28.6% to 43.4%, while the SH rate declined from 4.2/100 person-years to 1.3/100 person-years. The main improvement in HbA 1c occurred between 2007 and 2014, decreasing from mean (SD) 7.6% (1.6) (59.5 [19.0] mmol/mol) to 7.2% (1.7) (54.8 [18.9] mmol/mol) ( P < 0.001). The 20-44 years age-group had the highest proportion of HbA 1c ≥9% (75 mmol/mol) and rising proportions not on GLDs (from 2.0% to 7.7%)., Conclusions: In this 15-year survey, the modest but important improvement in HbA 1c since 2007 coincided with diabetes service reforms, increase in metformin, decrease in sulfonylureas, and modest rise in DPP-4i use. Persistently poor glycemic control and underuse of GLDs in the youngest group calls for targeted action., (© 2020 by the American Diabetes Association.)

Aims/hypothesis: We aimed to describe trends in rates of hospitalisation for lower extremity amputation (LEA) and 1 year mortality rates after LEA in people with diabetes in Hong Kong between 2001 and 2016., Methods: The Hong Kong Diabetes Surveillance Database is a territory-wide population-based diabetes cohort (N = 770,078) identified from the Hong Kong Hospital Authority electronic medical system. We identified LEA events using ICD-9 procedure codes and 1 year mortality after LEA from linkage to the Hong Kong Death Registry. Joinpoint regression models were used to describe the trends., Results: Between 2001 and 2016, 6113 hospitalisations for LEAs in men and 4149 in women were recorded in the Hong Kong Diabetes Surveillance Database. The rates of minor LEAs declined by 48.6% (average annual per cent change [AAPC]: -3.8; 95% CI -5.7, -1.9) in men and by 59.5% (AAPC: -6.3; 95% CI -10.6, -1.8) in women. The rates of major LEAs declined by 77.9% (AAPC: -8.0; 95% CI -9.6, -6.5) in men and by 79.3% (AAPC: -10.4; 95% CI -13.1, -7.6) in women. The cumulative 1 year mortality rates after minor and major LEAs were 18.5% and 41.8% in men, and 21.3% and 42.0% in women, respectively, for the whole period. No change was detected in 1 year mortality rates during the surveillance in both sexes., Conclusions/interpretation: Although hospitalisation rates for LEAs have declined overall in people with diabetes, there were no improvements in 1 year mortality rates after LEA. Continuous efforts are needed to further prevent LEAs and improve the survival rate of people undergoing LEAs. Graphical abstract.

Objective: To estimate the prevalence and severity of burnout and explore the factors associated with burnout among Hong Kong medical graduates up to 20 years post-graduation., Design: Cross-sectional survey., Setting: Hong Kong., Participants: Doctors who graduated from the University of Hong Kong between 1995 and 2014., Primary and Secondary Outcome Measures: Burnout as measured by the Copenhagen Burnout Inventory (CBI), alcohol consumption as measured by the Alcohol Use Disorders Identification Test Version C, lifestyle behaviours (hours of sleep and work, exercise, smoking, substance use), career satisfaction and sociodemographic characteristics were obtained using paper or online questionnaires., Results: Response rate was 30.9% (496/1607). Prevalence of CBI burnout was 63.1% (personal), 55.9% (work-related) and 35.4% (patient-related). The mean CBI subscale scores were 57.4±21.4 (personal), 48.9±7.4 (work-related) and 41.5±21.8 (client-related). Factors associated with personal and patient-related burnout included age (coeff -0.437, 95% CI -0.779 to -0.095 and coeff -0.596, 95% CI -0.965 to -0.228, respectively), practice setting (coeff -5.759, 95% CI -10.665 to -0.853 and coeff -5.317, 95% CI -10.602 to -0.032, respectively) and regular exercise (coeff -6.855, 95% CI -11.102 to -2.608 and coeff -6.769, 95% CI -11.333 to -2.205, respectively). Gender (coeff 5.1, 95% CI 1.382 to 8.818), average hours of sleep per night (coeff -5.200, 95% CI -7.139 to -3.262) and work hours per week (coeff 0.226, 95% CI 0.099 to 0.353) were associated with personal burnout only. No factors were significantly associated with work-related burnout., Conclusion: Burnout is highly prevalent among Hong Kong medical graduates. Younger doctors, women and those working in the public sector appear to be at higher risk for burnout and may benefit from targeted interventions. Policymakers and healthcare authorities should consider measures to help reduce burnout by enabling adequate sleep, reducing work hours and encouraging exercise., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Diabetes outcomes are influenced by host factors, settings, and care processes. We examined the association of data-driven integrated care assisted by information and communications technology (ICT) with clinical outcomes in type 2 diabetes in public and private healthcare settings., Methods and Findings: The web-based Joint Asia Diabetes Evaluation (JADE) platform provides a protocol to guide data collection for issuing a personalized JADE report including risk categories (1-4, low-high), 5-year probabilities of cardiovascular-renal events, and trends and targets of 4 risk factors with tailored decision support. The JADE program is a prospective cohort study implemented in a naturalistic environment where patients underwent nurse-led structured evaluation (blood/urine/eye/feet) in public and private outpatient clinics and diabetes centers in Hong Kong. We retrospectively analyzed the data of 16,624 Han Chinese patients with type 2 diabetes who were enrolled in 2007-2015. In the public setting, the non-JADE group (n = 3,587) underwent structured evaluation for risk factors and complications only, while the JADE (n = 9,601) group received a JADE report with group empowerment by nurses. In a community-based, nurse-led, university-affiliated diabetes center (UDC), the JADE-Personalized (JADE-P) group (n = 3,436) received a JADE report, personalized empowerment, and annual telephone reminder for reevaluation and engagement. The primary composite outcome was time to the first occurrence of cardiovascular-renal diseases, all-site cancer, and/or death, based on hospitalization data censored on 30 June 2017. During 94,311 person-years of follow-up in 2007-2017, 7,779 primary events occurred. Compared with the JADE group (136.22 cases per 1,000 patient-years [95% CI 132.35-140.18]), the non-JADE group had higher (145.32 [95% CI 138.68-152.20]; P = 0.020) while the JADE-P group had lower event rates (70.94 [95% CI 67.12-74.91]; P < 0.001). The adjusted hazard ratios (aHRs) for the primary composite outcome were 1.22 (95% CI 1.15-1.30) and 0.70 (95% CI 0.66-0.75), respectively, independent of risk profiles, education levels, drug usage, self-care, and comorbidities at baseline. We reported consistent results in propensity-score-matched analyses and after accounting for loss to follow-up. Potential limitations include its nonrandomized design that precludes causal inference, residual confounding, and participation bias., Conclusions: ICT-assisted integrated care was associated with a reduction in clinical events, including death in type 2 diabetes in public and private healthcare settings., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: JCNC is the Chief Executive Officer (on a pro-bono basis) of ADF, a charitable foundation established under the CUHK Foundation for developing the JADE Technology. JCNC, WYS, and RCWM are co-founders of GemVCare, a biotechnology company, supported by the Hong Kong Government Technology Start-up Support Scheme for Universities, which licenses the JADE Technology to provide diabetes risk evaluation and management program, in collaboration with other healthcare organizations. RCWM is a member of the editorial board for PLOS Medicine. RCWM has received research grants for clinical trials from AstraZeneca, Bayer, MSD, Novo Nordisk, Sanofi, and Tricida and honoraria for consultancy or lectures from AstraZeneca and Boehringer Ingelheim.

Background: Lifetime glycemic exposure and its relationship with age at diagnosis in type 2 diabetes (T2D) are unknown. Pharmacologic glycemic management strategies for young-onset T2D (age at diagnosis <40 years) are poorly defined. We studied how age at diagnosis affects glycemic exposure, glycemic deterioration, and responses to oral glucose-lowering drugs (OGLDs)., Methods and Findings: In a population-based cohort (n = 328,199; 47.2% women; mean age 34.6 and 59.3 years, respectively, for young-onset and usual-onset [age at diagnosis ≥40 years] T2D; 2002-2016), we used linear mixed-effects models to estimate the association between age at diagnosis and A1C slope (glycemic deterioration) and tested for an interaction between age at diagnosis and responses to various combinations of OGLDs during the first decade after diagnosis. In a register-based cohort (n = 21,016; 47.1% women; mean age 43.8 and 58.9 years, respectively, for young- and usual-onset T2D; 2000-2015), we estimated the glycemic exposure from diagnosis until age 75 years. People with young-onset T2D had a higher mean A1C (8.0% [standard deviation 0.15%]) versus usual-onset T2D (7.6% [0.03%]) throughout the life span (p < 0.001). The cumulative glycemic exposure was >3 times higher for young-onset versus usual-onset T2D (41.0 [95% confidence interval 39.1-42.8] versus 12.1 [11.8-12.3] A1C-years [1 A1C-year = 1 year with 8% average A1C]). Younger age at diagnosis was associated with faster glycemic deterioration (A1C slope over time +0.08% [0.078-0.084%] per year for age at diagnosis 20 years versus +0.02% [0.016-0.018%] per year for age at diagnosis 50 years; p-value for interaction <0.001). Age at diagnosis ≥60 years was associated with glycemic improvement (-0.004% [-0.005 to -0.004%] and -0.02% [-0.027 to -0.0244%] per year for ages 60 and 70 years at diagnosis, respectively; p-value for interaction <0.001). Responses to OGLDs differed by age at diagnosis (p-value for interaction <0.001). Those with young-onset T2D had smaller A1C decrements for metformin-based combinations versus usual-onset T2D (metformin alone: young-onset -0.15% [-0.105 to -0.080%], usual-onset -0.17% [-0.179 to -0.169%]; metformin, sulfonylurea, and dipeptidyl peptidase-4 inhibitor: young-onset -0.44% [-0.476 to -0.405%], usual-onset -0.48% [-0.498 to -0.459%]; metformin and α-glucosidase inhibitor: young-onset -0.40% [-0.660 to -0.144%], usual-onset -0.25% [-0.420 to -0.077%]) but greater responses to other combinations containing sulfonylureas (sulfonylurea alone: young-onset -0.08% [-0.099 to -0.065%], usual-onset +0.06% [+0.059 to +0.072%]; sulfonylurea and α-glucosidase inhibitor: young-onset -0.10% [-0.266 to 0.064%], usual-onset: 0.25% [+0.196% to +0.312%]). Limitations include possible residual confounding and unknown generalizability outside Hong Kong., Conclusions: In this study, we observed excess glycemic exposure and rapid glycemic deterioration in young-onset T2D, indicating that improved treatment strategies are needed in this setting. The differential responses to OGLDs between young- and usual-onset T2D suggest that better disease classification could guide personalized therapy., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: RCWM acknowledges receiving research support (outside of this work) from AstraZeneca, Bayer, and Pfizer for conducting clinical trials and honoraria or consultancy fees from AstraZeneca and Boehringer Ingelheim, all of which has been donated to the Chinese University of Hong Kong to support diabetes research. RCWM is a member of the Editorial Board of PLOS Medicine. AOYL acknowledges receiving research support (outside of this work) from Boehringer Ingelheim, MSD, Sanofi, and Amgen and travel grants from travel grant from AstraZeneca, Boehringer Ingelheim, MSD, Novartis, Novo Nordisk, and Sanofi. JCNC and RCWM are cofounders of GemVCare, a diabetes genetic testing laboratory, which was established through support from the Technology Start-up Support Scheme for Universities (TSSSU) from the Hong Kong Government Innovation and Technology Commission (ITC). JCNC is the Chief Executive Officer, on a pro bono basis, of the Asia Diabetes Foundation (ADF), which is a nonprofit research organization which designed and implemented the Joint Asia Diabetes Evaluation (JADE) Technology as an extension to the HKDR, under the governance of the CUHK Foundation. The HKDR was established as a research-driven quality improvement program initiated by the Chinese University of Hong Kong (CUHK)-Prince of Wales Hospital Diabetes Care and Research Team, supported by the Hong Kong Foundation for Research and Development in Diabetes established at CUHK. In 2007, this was merged with the web-based JADE Technology, complete with care protocols, risk stratification, personalized reporting, and decision support. The JADE Technology was designed and implemented by the ADF to enable other clinics and hospitals to establish diabetes registers and contribute anonymized data for research purposes. The ADF was set up as a charitable research organization governed by the CUHK Foundation.

Objective: Several studies support potential links between relative leukocyte telomere length (rLTL), a biomarker of biological aging, and type 2 diabetes. This study investigates relationships between rLTL and incident cardiovascular disease (CVD) in patients with type 2 diabetes., Research Design and Methods: Consecutive Chinese patients with type 2 diabetes ( N = 5,349) from the Hong Kong Diabetes Register for whom DNA obtained at baseline was stored and follow-up data were available were studied. rLTL was measured by using quantitative PCR. CVD was diagnosed on the basis of ICD-9 code., Results: Mean follow-up was 13.4 years (SD 5.5 years). rLTL was correlated inversely with age, diabetes duration, blood pressure, HbA 1c , and urine albumin-to-creatinine ratio (ACR), and positively with estimated glomerular filtration rate (eGFR) (all P < 0.001). Subjects with CVD at baseline had a shorter rLTL (4.3 ± 1.2 ΔΔCt) than did subjects without CVD (4.6 ± 1.2 ΔΔCt) ( P < 0.001). Of the 4,541 CVD-free subjects at baseline, the 1,140 who developed CVD during follow-up had a shorter rLTL (4.3 ± 1.2 ΔΔCt) than those who remained CVD-free after adjusting for age, sex, smoking, and albuminuria status (4.7 ± 1.2 ΔΔCt) ( P < 0.001). In Cox regression models, shorter rLTL was associated with higher risk of incident CVD (for each unit decrease, hazard ratio 1.252 [95% CI 1.195-1.311], P < 0.001), which remained significant after adjusting for age, sex, BMI, systolic blood pressure, LDL cholesterol, HbA 1c , eGFR, and ACR (hazard ratio 1.141 [95% CI 1.084-1.200], P < 0.001)., Conclusions: rLTL is significantly shorter in patients with type 2 diabetes and CVD, is associated with cardiometabolic risk factors, and is independently associated with incident CVD. Telomere length may be a useful biomarker for CVD risk in patients with type 2 diabetes., (© 2020 by the American Diabetes Association.)

Objective: The relative effects of various cardiovascular diseases (CVDs) and varying severity of chronic kidney disease (CKD) on mortality risk, direct medical cost, and life expectancy in patients with diabetes are unclear. The aim of this study was to evaluate these associations., Research Design and Methods: This was a retrospective cohort study that included 208,792 adults with diabetes stratified into 12 disease status groups with varying combinations of heart disease, stroke, moderate CKD (estimated glomerular filtration rate [eGFR] 30-59 mL/min/1.73 m 2 ) and severe CKD (eGFR <30 mL/min/1.73 m 2 ) in 2008-2010. The effect of risk of mortality, annual direct medical costs, and life expectancy were assessed using Cox regression, gamma generalized linear method with log-link function, and flexible parametric survival models., Results: Over a median follow-up of 8.5 years (1.6 million patient-years), 50,154 deaths were recorded. Mortality risks for patients with only a single condition among heart disease, stroke, and moderate CKD were similar. The mortality risks were 1.75 times, 2.63 times, and 3.58 times greater for patients with one, two, and all three conditions (consisting of stroke, heart disease, and moderate CKD), compared with patients without these diseases, suggesting an independent and individually additive effect for any combination. A similar trend was observed in annual public health care costs with 2.91-, 3.90-, and 3.88-fold increased costs for patients with one, two, and three conditions, respectively. Increases in the number of conditions reduced life expectancy greatly, particularly in younger patients. Reduction in life expectancy for a 40-year-old with one, two, and three conditions was 20, 25, and 30 years for men and 25, 30, and 35 years, respectively, for women. A similar trend of greater magnitude was observed for severe CKD., Conclusions: The effects of heart diseases, stroke, CKD, and the combination of these conditions on all-cause mortality and direct medical costs are independent and cumulative. CKD, especially severe CKD, appears to have a particularly significant impact on life expectancy and direct medical costs in patients with diabetes. These findings support the importance of preventing both CVD and CKD in patients with diabetes., (© 2020 by the American Diabetes Association.)

Background: Type 2 diabetes (T2D) is a progressive disease whereby there is often deterioration in glucose control despite escalation in treatment. There is significant heterogeneity to this progression of glycemia after onset of diabetes, yet the factors that influence glycemic progression are not well understood. Given the tremendous burden of diabetes in the Chinese population, and limited knowledge on factors that influence glycemia, we aim to identify the clinical and genetic predictors for glycemic progression in Chinese patients with T2D., Methods and Findings: In 1995-2007, 7,091 insulin-naïve Chinese patients (mean age 56.8 ± 13.3 [SD] years; mean age of T2D onset 51.1 ± 12.7 years; 47% men; 28.4% current or ex-smokers; median duration of diabetes 4 [IQR: 1-9] years; mean HbA1c 7.4% ± 1.7%; mean body mass index [BMI] 25.3 ± 4.0 kg/m2) were followed prospectively in the Hong Kong Diabetes Register. We examined associations of BMI and other clinical and genetic factors with glycemic progression defined as requirement of continuous insulin treatment, or 2 consecutive HbA1c ≥8.5% while on ≥2 oral glucose-lowering drugs (OGLDs), with validation in another multicenter cohort of Hong Kong Diabetes Biobank. During a median follow-up period of 8.8 (IQR: 4.8-13.3) years, incidence of glycemic progression was 48.0 (95% confidence interval [CI] 46.3-49.8) per 1,000 person-years with 2,519 patients started on insulin. Among the latter, 33.2% had a lag period of 1.3 years before insulin was initiated. Risk of progression was associated with extremes of BMI and high HbA1c. On multivariate Cox analysis, early age at diagnosis, microvascular complications, high triglyceride levels, and tobacco use were additional independent predictors for glycemic progression. A polygenic risk score (PRS) including 123 known risk variants for T2D also predicted rapid progression to insulin therapy (hazard ratio [HR]: 1.07 [95% CI 1.03-1.12] per SD; P = 0.001), with validation in the replication cohort (HR: 1.24 [95% CI 1.06-1.46] per SD; P = 0.008). A PRS using 63 BMI-related variants predicted BMI (beta [SE] = 0.312 [0.057] per SD; P = 5.84 × 10-8) but not glycemic progression (HR: 1.01 [95% CI 0.96-1.05] per SD; P = 0.747). Limitations of this study include potential misdiagnosis of T2D and lack of detailed data of drug use during follow-up in the replication cohort., Conclusions: Our results show that approximately 5% of patients with T2D failed OGLDs annually in this clinic-based cohort. The independent associations of modifiable and genetic risk factors allow more precise identification of high-risk patients for early intensive control of multiple risk factors to prevent glycemic progression., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: RCWM acknowledges receiving research support (outside of this work) from AstraZeneca, Bayer, and Pfizer and honoraria or consultancy fees from AstraZeneca and Boehringer Ingelheim, all of which have been donated to the Chinese University of Hong Kong to support diabetes research. CKPL, WYS, JCNC, and RCWM are cofounders of GemVCare, a diabetes genetic testing laboratory, which was established through support from the Technology Start-up Support Scheme for Universities (TSSSU) from the Hong Kong Government Innovation and Technology Commission (ITC). RCWM is a member of the editorial board of PLOS Medicine. JCNC has received research grants and/or honoraria for consultancy or giving lectures, from AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Daiichi-Sankyo, Eli-Lilly, GlaxoSmithKline, Merck Serono, Merck Sharp & Dohme, Novo Nordisk, Pfizer, and Sanofi. APSK has received research grants and/or speaker honoraria from Abbott, AstraZeneca, Eli-Lilly, Merck Serono, Nestle, Sanofi, and Novo Nordisk. AOL has served as an advisory committee member for AstraZeneca, Boehringer Ingelheim, Sanofi, and Amgen and has received research grants and travel grants from AstraZeneca, Boehringer Ingelheim, MSD, Novartis, Novo Nordisk, Sanofi, and Amgen.

Background The relationship between systolic blood pressure (SBP) and cardiovascular disease (CVD) among patients with diabetes mellitus remains unclear. The study aimed to explore age-specific associations between SBP and CVD. Methods and Results A population-based retrospective cohort study was conducted on 180 492 Chinese adults with type 2 diabetes mellitus in 2008-2010, with follow-up to 2017. Age-specific associations (<50, 50-59, 60-69, and 70-79 years) between the average SBP in the previous 2 years and CVD risk were assessed by adjusted Cox proportional hazards regression with age-specific regression dilution ratios and patient characteristics stratified by subgroups. During a median follow-up of 9.3 years (1.5 million person-years), 32 545 patients developed a CVD, with an incidence rate of 23.4 per 1000 person-years. A positive and log-linear association between SBP and CVD risk was observed among the 4 age groups without evidence of a threshold down to 120 mm Hg, but the magnitude of SBP effect on CVD attenuated with increased age. The CVD risk in the age group <50 years was ≈22% higher than the age group 70 to 79 years (hazard ratio [HR], 1.33 [95% CI, 1.26-1.41] versus HR, 1.09 [95% CI, 1.07-1.11]). Each 10-mm Hg higher SBP was associated with 12% (HR, 1.12 [95% CI, 1.10-1.13]), 11% (HR, 1.11 [95% CI, 1.10-1.13]), and 20% (HR, 1.20 [95% CI, 1.17-1.22]) higher risk of all composite CVD events, individual CVD, and CVD mortality, respectively. Conclusions There is a significant log-linear relationship between baseline SBP and the risk of CVD among patients with diabetes mellitus in China. The risk increases from an SBP of 120 mm Hg onward. Age influences this relationship significantly, with younger patients (<50 years) having a greater risk of CVD for a similar rise in SBP as compared with those who are older. These findings suggest that differential target blood pressures stratified by age maybe useful.

Background: Nationwide studies on contemporary trends in incidence of diabetes-related complications in Asia are lacking. We describe trends in incident coronary heart disease (CHD), stroke, heart failure, hyperglycaemic crisis, and lower-extremity amputation (LEA) in people with diabetes in Hong Kong between 2001 and 2016., Methods: The Hong Kong Diabetes Surveillance Database (HKDSD) is a territory-wide diabetes cohort identified from Hong Kong Hospital Authority electronic medical record system. We identified events of CHD, stroke, heart failure and hyperglycaemic crisis using hospital principal diagnosis codes at discharge and that of LEA using inpatient procedure codes. We used Joinpoint regression analysis to describe incidence trends by age and sex., Results: Between 2001 and 2016, a total of 390,071 men and 380,007 women aged 20 years or older with diabetes were included in the HKDSD. Event rates of CHD, stroke, heart failure, hyperglycaemic crisis and LEA declined by 69.4% (average annual percent change: - 7.6, 95% CI - 10.2, - 5.0), 70.3% (- 8.7, 95% CI - 9.8, - 7.5), 63.6% (- 6.4, 95% CI - 8.0, - 4.7), 59.1% (- 6.6, 95% CI - 12.4, - 0.44), and 67.5% (- 5.8, 95% CI - 7.2, - 4.4), in men and by 77.5% (- 9.9, 95% CI - 11.8, - 7.9), 74.5% (- 9.0, 95% CI - 9.6, - 8.4), 65.8% (- 7.0, 95% CI - 8.0, - 6.0), 81.7% (- 8.5, 95% CI - 10.5, - 6.5), and 72.7% (- 9.1. 95% CI - 12.2, - 5.8) in women, respectively, over a 16-year period in people with diabetes in Hong Kong. Joinpoint analysis identified greater declines in event rates of the five diabetes-related complications in the earlier one-third of study period and slowed down but remained significant until 2016. Event rates decreased for all age groups above 45 years for both sexes. There was no significant change in event rates in the group aged 20-44 years except for decline in hyperglycaemic crisis., Conclusions: The event rates of diabetes-related complications have declined substantially with no evidence of stabilization or increase in Hong Kong up to 2016. Improvements in outcome were observed for all age subgroups but not in young people with diabetes, calling for urgent action to improve quality of care to prevent complications in young people at risk.

Purpose: To estimate the prevalence of lower urinary tract symptoms (LUTS) in primary care using the International Continence Society symptom definition; to evaluate the association between LUTS and health-related quality of life (HRQOL); and to evaluate the treatment gaps., Methods: Patients aged 40 and above were randomly recruited in a Hong Kong public primary care. Patients were asked (i) how often they experienced 18 individual LUTS during the past 4 weeks and (ii) whether they had sought treatments for their LUTS. The 12-Item Short Form Health Survey version 2 (SF-12 v2) and the modified Incontinence Impact Questionnaire-Short Form (IIQ-7) were used to measure HRQOL., Results: 500 patients completed the survey. 75.8% of the patients had at least one LUTS "at least sometimes", with patients with a combination of storage, voiding, and post-micturition symptoms being the most prevalent (22.2%), followed by a combination of voiding and storage symptoms (14%). Only 14% of LUTS patients had sought treatments for their LUTS. LUTS was associated with a negative effect in all domains of the SF-12 v2 and IIQ-7 and patients with a combination of storage, voiding, and post-micturition symptoms had the worst HRQOL. Finally, having a combination of storage, voiding, and post-micturition symptoms and poorer HRQOL were factors associated with having sought treatments for LUTS., Conclusion: A high prevalence of LUTS but low treatment-seeking rates implied possible unmet needs of LUTS patients in primary care, suggesting the potential for more active interventions to alleviate the negative impact of LUTS on patients' HRQOL.

In Hong Kong, there is a cattle population of ~1,200 individuals of uncertain origin and genetic diversity. This population shows heterogeneous morphology, both in body type and pigmentation. Once used as draught animals by the local farmers, they were abandoned around the 1970s due to changes in the economy, and since then have lived as feral populations. To explore the origins of these cattle, we analysed ~50k genotype data of 21 Hong Kong feral cattle, along with data from 703 individuals of 36 cattle populations of European, African taurine, and Asian origin, the wild x domestic hybrid gayal, plus two wild bovine species, gaur and banteng. To reduce the effect of ascertainment bias ~4k loci that are polymorphic in the two wild species were selected for further analysis. The stringent SNP selection we applied resulted in increased heterozygosity across all populations studies, compared with the full panel of SNP, thus reducing the impact of ascertainment bias and facilitating the comparison of divergent breeds of cattle. Our results showed that Hong Kong feral cattle have relatively high levels of genetic distinctiveness, possibly due to the low level of artificial selection, and a likely common ancestry with wild species. We found signs of a putative taurine introgression, probably dating to the import of north European breeds during the British colonialism of Hong Kong. We showed that Hong Kong feral cattle, are distinct from Bos taurus and Bos indicus breeds. Our results highlight the distinctiveness of Hong Kong feral cattle and stress the conservation value of this indigenous breed that is likely to harbour adaptive genetic variation, which is a fundamental livestock resource in the face of climate change and diversifying market demands., Competing Interests: The authors have declared that no competing interests exist.

Aims/hypothesis: The aim of the study was to describe trends in all-cause and cause-specific mortality rates in Hong Kong Chinese people with diabetes from 2001 to 2016., Methods: The Hong Kong Diabetes Surveillance Database (HKDSD) is a territory-wide diabetes cohort identified from the Hong Kong Hospital Authority electronic medical record system. Deaths between 2001 and 2016 were identified from linkage to the Hong Kong Death Registry. We used Joinpoint regression analysis to describe mortality patterns among people with diabetes by age and sex, and standardised mortality ratios (SMRs) to compare all-cause mortality rates in people with and without diabetes., Results: Between 2001 and 2016, a total of 390,071 men and 380,007 women aged 20 years or older with diabetes were included in the HKDSD. There were 96,645 deaths among men and 88,437 deaths among women. Mortality rates for all-cause, cardiovascular disease and cancer among people with diabetes declined by 52.3%, 72.2% and 65.1% in men, respectively, and by 53.5%, 78.5% and 59.6% in women, respectively. Pneumonia mortality rates remained stable. The leading cause of death in people with diabetes has shifted from cardiovascular disease to pneumonia in the oldest age group, with cancer remaining the most common cause of death in people aged 45-74 years. The all-cause SMRs for men declined from 2.82 (95% CI 2.72, 2.94) to 1.50 (95% CI 1.46, 1.54), and for women, they declined from 3.28 (95% CI 3.15, 3.41) to 1.67 (95% CI 1.62, 1.72). However, among people aged 20-44 years, the declines in all-cause mortality rates over the study period were not statistically significant for both men (average annual per cent change [AAPC]: -3.2% [95% CI -7.3%, 1.0%]) and women (AAPC: -1.2% [95% CI -6.5%, 4.4%]). The SMRs in people aged 20-44 years fluctuated over time, between 7.86 (95% CI 5.74, 10.5) in men and 6.10 (95% CI 3.68, 9.45) in women in 2001, and 4.95 (95% CI 3.72, 6.45) in men and 4.92 (95% CI 3.25, 7.12) in women in 2016., Conclusions/interpretation: Absolute and relative mortality has declined overall in people with diabetes in Hong Kong, with less marked improvements in people under 45 years of age, calling for urgent action to improve care in young people with diabetes.

Background: Validated algorithms to classify type 1 and 2 diabetes (T1D, T2D) are mostly limited to white pediatric populations. We conducted a large study in Hong Kong among children and adults with diabetes to develop and validate algorithms using electronic health records (EHRs) to classify diabetes type against clinical assessment as the reference standard, and to evaluate performance by age at diagnosis., Methods: We included all people with diabetes (age at diagnosis 1.5-100 years during 2002-15) in the Hong Kong Diabetes Register and randomized them to derivation and validation cohorts. We developed candidate algorithms to identify diabetes types using encounter codes, prescriptions, and combinations of these criteria ("combination algorithms"). We identified 3 algorithms with the highest sensitivity, positive predictive value (PPV), and kappa coefficient, and evaluated performance by age at diagnosis in the validation cohort., Results: There were 10,196 (T1D n = 60, T2D n = 10,136) and 5101 (T1D n = 43, T2D n = 5058) people in the derivation and validation cohorts (mean age at diagnosis 22.7, 55.9 years; 53.3, 43.9% female; for T1D and T2D respectively). Algorithms using codes or prescriptions classified T1D well for age at diagnosis < 20 years, but sensitivity and PPV dropped for older ages at diagnosis. Combination algorithms maximized sensitivity or PPV, but not both. The "high sensitivity for type 1" algorithm (ratio of type 1 to type 2 codes ≥ 4, or at least 1 insulin prescription within 90 days) had a sensitivity of 95.3% (95% confidence interval 84.2-99.4%; PPV 12.8%, 9.3-16.9%), while the "high PPV for type 1" algorithm (ratio of type 1 to type 2 codes ≥ 4, and multiple daily injections with no other glucose-lowering medication prescription) had a PPV of 100.0% (79.4-100.0%; sensitivity 37.2%, 23.0-53.3%), and the "optimized" algorithm (ratio of type 1 to type 2 codes ≥ 4, and at least 1 insulin prescription within 90 days) had a sensitivity of 65.1% (49.1-79.0%) and PPV of 75.7% (58.8-88.2%) across all ages. Accuracy of T2D classification was high for all algorithms., Conclusions: Our validated set of algorithms accurately classifies T1D and T2D using EHRs for Hong Kong residents enrolled in a diabetes register. The choice of algorithm should be tailored to the unique requirements of each study question.

Background: There is very limited data on the time trend of diabetes incidence in Asia. Using population-level data, we report the secular trend of the incidence of type 1 and type 2 diabetes in Hong Kong between 2002 and 2015., Methods and Findings: The Hong Kong Diabetes Surveillance Database hosts clinical information on people with diabetes receiving care under the Hong Kong Hospital Authority, a statutory body that governs all public hospitals and clinics. Sex-specific incidence rates were standardised to the age structure of the World Health Organization population. Joinpoint regression analysis was used to describe incidence trends. A total of 562,022 cases of incident diabetes (type 1 diabetes [n = 2,426]: mean age at diagnosis is 32.5 years, 48.4% men; type 2 diabetes [n = 559,596]: mean age at diagnosis is 61.8 years, 51.9% men) were included. Among people aged <20 years, incidence of both type 1 and type 2 diabetes increased. For type 1 diabetes, the incidence increased from 3.5 (95% CI 2.2-4.9) to 5.3 (95% CI 3.4-7.1) per 100,000 person-years (average annual percentage change [AAPC] 3.6% [95% CI 0.2-7.1], p < 0.05) in boys and from 4.3 (95% CI 2.7-5.8) to 6.4 (95% CI 4.3-8.4) per 100,000 person-years (AAPC 4.7% [95% CI 1.7-7.7], p < 0.05] in girls; for type 2 diabetes, the incidence increased from 4.6 (95% CI 3.2-6.0) to 7.5 (95% CI 5.5-9.6) per 100,000 person-years (AAPC 5.9% [95% CI 3.4-8.5], p < 0.05) in boys and from 5.9 (95% CI 4.3-7.6) to 8.5 (95% CI 6.2-10.8) per 100,000 person-years (AAPC 4.8% [95% CI 2.7-7.0], p < 0.05) in girls. In people aged 20 to <40 years, incidence of type 1 diabetes remained stable, but incidence of type 2 diabetes increased over time from 75.4 (95% CI 70.1-80.7) to 110.8 (95% CI 104.1-117.5) per 100,000 person-years (AAPC 4.2% [95% CI 3.1-5.3], p < 0.05) in men and from 45.0 (95% CI 41.4-48.6) to 62.1 (95% CI 57.8-66.3) per 100,000 person-years (AAPC 3.3% [95% CI 2.3-4.2], p < 0.05) in women. In people aged 40 to <60 years, incidence of type 2 diabetes increased until 2011/2012 and then flattened. In people aged ≥60 years, incidence was stable in men and declined in women after 2011. No trend was identified in the incidence of type 1 diabetes in people aged ≥20 years. The present study is limited by its reliance on electronic medical records for identification of people with diabetes, which may result in incomplete capture of diabetes cases. The differentiation of type 1 and type 2 diabetes was based on an algorithm subject to potential misclassification., Conclusions: There was an increase in incidence of type 2 diabetes in people aged <40 years and stabilisation in people aged ≥40 years. Incidence of type 1 diabetes continued to climb in people aged <20 years but remained constant in other age groups., Competing Interests: RCWM acknowledges receiving research support (outside of this work) from AstraZeneca, Bayer, Pfizer for conducting clinical trials and honoraria or consultancy fees from AstraZeneca and Boehringer Ingelheim, all of which has been donated to the Chinese University of Hong Kong to support diabetes research. RCWM is a member of the Editorial Board of PLoS Medicine. AOYL acknowledges receiving research support (outside of this work) from Boehringer Ingelheim, MSD, Sanofi, Amgen and travel grants from travel grant from AstraZeneca, Boehringer Ingelheim, MSD, Novartis, Novo Nordisk, Sanofi. JCNC and RCWM are cofounders of GemVCare, a diabetes genetic testing laboratory, which was established through support from the Technology Start-up Support Scheme for Universities (TSSSU) from the Hong Kong Government Innovation and Technology Commission (ITC).

Background: Empathy is an important clinical attribute to be assessed during clinical examinations. While simulated patients (SPs) are well positioned to assess empathy in such settings, clinician-examiners are objective observers who are also experts in assessment. In this study, the assessments of student empathy from both examiners and SPs in clinical examinations were compared. Methods: The 10-item CARE measure were used for the assessment of empathy in 158 medical students in the Family Medicine specialty clerkship clinical competency test. The ratings from examiners and SPs were analyzed together with genders of students, examiners and patients, and the examination results. Results: SPs empathy ratings were higher than those from examiners across all ten items of CARE. A weak positive correlation was found between both ratings. Female SPs were more likely to give higher ratings, and examiners were more likely to give higher ratings to female students. SPs rating was moderately correlated with student examination score, while the correlation with examiners rating was strong. Conclusion: Although the inter-rater reliability was weak between the empathy rating from simulated patients and examiners, the evaluation of empathy from the patient's perspective was seen to be more authentic as they are in interaction with the students.

Background: Even though the negative impacts of nocturia on sleep quality and health-related quality of life (HRQOL) have been documented in previous research, their interrelationship has been poorly studied. This study aimed to explore whether nocturia would affect sleep quality, which in turn affects HRQOL., Methods: Participants aged 40 and above were randomly recruited from a Hong Kong public primary care clinic. Participants were asked to report the average number of nocturia (waking up at night to void) pisodes per night over a 1-month period. The Pittsburgh Sleep Quality Index (PSQI) and the 12-Item Short Form Health Survey version 2 (SF-12 v2) were administered. The mediation analysis was tested using multistage regression approach and bootstrap method., Results: Of the 500 subjects who completed the survey, 31.2% reported symptomatic nocturia (having ≥2 nocturia episodes per night), and 60.4% experienced poor sleep quality (a PSQI global score > 5). Respondents with symptomatic nocturia had a poorer HRQOL in the domains of physical functioning (PF), role physical (RP) and social functioning (SF), general health (GH), vitality (VT) and physical component summary (PCS) of the SF-12 v2 than those without. Compared with the respondents without poor sleep quality, those with poor sleep quality had poorer HRQOL across all domains and summaries of the SF-12 v2. Mediation analysis found that sleep quality fully mediated the association between nocturia and the PF, RP and SF domains of the SF-12 v2, respectively, and partially mediated the association between nocturia and the GH, VT and PCS domains of the SF-12 v2, respectively., Conclusions: We found that sleep quality mediated the association between nocturia and HRQOL. To enhance the HRQOL of patients with nocturia, clinicians should not only focus on nocturia symptoms, but also on their sleep quality.

In 1995, the Hong Kong Diabetes Register (HKDR) was established by a doctor-nurse team at a university-affiliated, publicly funded, hospital-based diabetes center using a structured protocol for gathering data to stratify risk, triage care, empower patients, and individualize treatment. This research-driven quality improvement program has motivated the introduction of a territory-wide diabetes risk assessment and management program provided by 18 hospital-based diabetes centers since 2000. By linking the data-rich HKDR to the territory-wide electronic medical record, risk equations were developed and validated to predict clinical outcomes. In 2007, the HKDR protocol was digitalized to establish the web-based Joint Asia Diabetes Evaluation (JADE) Program complete with risk levels and algorithms for issuance of personalized reports to reduce clinical inertia and empower self-management. Through this technologically assisted, integrated diabetes care program, we have generated big data to track secular trends, identify unmet needs, and verify interventions in a naturalistic environment. In 2009, the JADE Program was adapted to form the Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) in the publicly funded primary care clinics, which reduced all major events by 30-60% in patients without complications. Meanwhile, a JADE-assisted assessment and empowerment program provided by a university-affiliated, self-funded, nurse-coordinated diabetes center, aimed at complementing medical care in the community, also reduced all major events by 30-50% in patients with different risk levels. By combining universal health coverage, public-private partnerships, and data-driven integrated care, the Hong Kong experience provides a possible solution than can be adapted elsewhere to make quality diabetes care accessible, affordable, and sustainable., (© 2019 by the American Diabetes Association.)

Background: The Burden of Treatment Questionnaire (TBQ) assesses the impact of a patient's treatment workload on their quality of life., Objectives: The aim was to translate and validate the TBQ on Chinese primary care patients with multi-morbidity., Methods: The English TBQ was translated and back-translated using professional translators. Cognitive debriefing interviews were performed on 15 patients. The resulting instrument was tested on 200 primary care patients with multi-morbidity (>1 chronic disease) to examine its psychometric performance including exploratory factor analysis, confirmatory factor analysis, internal consistency and reliability. The EuroQol Five-Dimension Five-Level Questionnaire (EQ-5D-5L), Short-Form Six-Dimension (SF-6D), WONCA COOP Charts and the Global Health Rating Scale were used to assess convergent and divergent validity., Results: Median age of the respondents was 62 years (range 22-95 years) with a median of four conditions. The median TBQ total score was 16 (interquartile range 7.25-30). There was a significant floor effect (>15%) observed for all items. Spearman's correlations was >0.4 for all items demonstrating adequate internal construct validity. TBQ global score correlated with number of conditions (P = 0.034), EQ-5D-5L (P < 0.001), SF-6D (P < 0.001) and the feelings (P = 0.004), daily activities (P = 0.003) and social activities (P < 0.001) domains of the WONCA COOP. There was no significant correlation between global health rating and TBQ global scores (P = 0.298). Factor analysis demonstrated a three-factor structure. There was good internal consistency (Cronbach's alpha = 0.842) and good test-retest reliability (intra-class correlation coefficient = 0.830)., Conclusion: The newly translated Chinese version of the TBQ appears to be valid and reliable for use in Cantonese-speaking, adult primary care patients with multi-morbidity., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)

Background: The relative effects of combinations of CKD, heart disease, and stroke on risk of mortality, direct medical costs, and life expectancy are unknown., Methods: In a retrospective cohort study of 506,849 Chinese adults in Hong Kong with hypertension, we used Cox regressions to examine associations between all-cause mortality and combinations of moderate CKD (eGFR of 30-59 ml/min per 1.73 m 2 ), severe CKD (eGFR of 15-29 ml/min per 1.73 m 2 ), heart disease (coronary heart disease or heart failure), and stroke, and modeling to estimate annual public direct medical costs and life expectancy., Results: Over a median follow-up of 5.8 years (2.73 million person-years), 55,666 deaths occurred. Having an increasing number of comorbidities was associated with incremental increases in mortality risk and medical costs and reductions in life expectancy. Compared with patients who had neither CKD nor cardiovascular disease, patients with one, two, or three conditions (heart disease, stroke, and moderate CKD) had relative risk of mortality increased by about 70%, 160%, and 290%, respectively; direct medical costs increased by about 70%, 160%, and 280%, respectively; and life expectancy at age 60 years decreased by about 5, 10, and 15 years, respectively. Burdens were higher with severe CKD., Conclusions: This study demonstrated extremely high mortality risk and medical cost increases for severe CKD, exceeding the combined effects from heart disease and stroke. Mortality risks and costs for moderate CKD, heart disease, and stroke were similar individually and roughly multiplicative for any combination. These findings suggest that to reduce mortality and health care costs in patients with hypertension, CKD prevention and intervention merits priority equal to that of cardiovascular disease., (Copyright © 2019 by the American Society of Nephrology.)

The association between systolic blood pressure, cardiovascular disease, and chronic kidney disease remains unclear. This study aimed to evaluate these relationships. A population-based cohort of 267 469 adult patients with hypertension but without diabetes mellitus, cardiovascular disease, or chronic kidney disease were identified. Using baseline and repeated systolic blood pressure (average of all systolic blood pressure measurements in the past 5 years), the risks of cardiovascular disease and chronic kidney disease associated with systolic blood pressure were evaluated by Cox regression. Subgroup analyses were conducted by baseline characteristics. Over 1.4 million person-years follow-up (median 6 years), 29 500 cardiovascular disease and 30 993 chronic kidney disease events diagnosed. A J-shape association between baseline systolic blood pressure and risks of cardiovascular disease and chronic kidney disease was observed. Using repeated systolic blood pressure, a positive and log-linear association was identified. There was no evidence of a threshold down to the repeated systolic blood pressure of 120 mm Hg. Increases of 10 mm Hg of repeated systolic blood pressure was associated with a 16% (hazard ratio, 1.15; [95% CI, 1.13-1.16]), 11% (1.11; [1.08-1.13]), and 22% (1.22; [1.20-1.24]) higher risk of composite of cardiovascular disease and chronic kidney disease, individual cardiovascular disease and chronic kidney disease, respectively. Strength of the associations was similar across different subpopulations. This study showed that hypertensive patients with elevated repeated systolic blood pressure are at increased risk of cardiovascular disease or chronic kidney disease, irrespective of different characteristics. Very low single measurement of systolic blood pressure may be a potential indicator for poor health, but there seems to be no threshold for usual systolic blood pressure.

Study Objectives: Insomnia is associated with insulin resistance and type 2 diabetes (T2D) in the general population. However, the associations between insomnia and glycemic control in T2D population are not consistently reported. In this study, we aimed to examine the associations between insomnia and glycemic control, and gender differences in these associations among Hong Kong Chinese patients with T2D., Methods: This was a cross-sectional study involving T2D patients recruited from the Hong Kong Diabetes Registry between July 2010 and June 2015. Glycemic control was estimated by fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c). Participants with the Insomnia Severity Index score > 14 were considered as having insomnia., Results: A total of 3753 patients were recruited. Compared with patients without insomnia, patients with insomnia had higher levels of FPG and HbA1c. After adjustment for potential confounding factors, insomnia was associated with higher FPG and HbA1c in the entire cohort. There were significant interactions between insomnia and gender for FPG (p = 0.001) and HbA1c (p = 0.025) in the full model. Subgroup analyses found that men with insomnia had higher FPG [8.23 (7.85-8.61) mmol/L versus 7.50 (7.39-7.61) mmol/L, p < 0.001] and HbA1c [7.79 (7.57-8.02)% versus 7.45 (7.39-7.52)%, p = 0.005] than men without insomnia after adjusted for confounding factors, whereas such difference was not observed in women., Conclusions: T2D patients with insomnia had worse glycemic control than the patients without insomnia. The associations were particularly pronounced in men., (© Sleep Research Society 2019. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.)

Background: Type 2 diabetes (T2D) increases hospitalization risk. Young-onset T2D (YOD) (defined as onset before age 40 years) is associated with excess morbidity and mortality, but its effect on hospitalizations is unknown., Objective: To determine hospitalization rates among persons with YOD and to examine the effect of age at onset on hospitalization risk., Design: Prospective cohort study., Setting: Hong Kong., Participants: Adults aged 20 to 75 years in population-based (2002 to 2014; n = 422 908) and registry-based (2000 to 2014; n = 20 886) T2D cohorts., Measurements: All-cause and cause-specific hospitalization rates. Negative binomial regression models estimated effect of age at onset on hospitalization rate and cumulative bed-days from onset to age 75 years for YOD., Results: Patients with YOD had the highest hospitalization rates by attained age. In the registry cohort, 36.8% of YOD bed-days before age 40 years were due to mental illness. The adjusted rate ratios showed increased hospitalization in YOD versus usual-onset T2D (onset at age ≥40 years) (all-cause, 1.8 [95% CI, 1.7 to 2.0]; renal, 6.7 [CI, 4.2 to 10.6]; diabetes, 3.7 [CI, 3.0 to 4.6]; cardiovascular, 2.1 [CI, 1.8 to 2.5]; infection, 1.7 [CI, 1.4 to 2.1]; P < 0.001 for all). Models estimated that intensified risk factor control in YOD (hemoglobin A1c level <6.2%, systolic blood pressure <120 mm Hg, low-density lipoprotein cholesterol level <2.0 mmol/L [<77.3 mg/dL], triglyceride level <1.3 mmol/L [<115.1 mg/dL], waist circumference of 85 cm [men] or 80 cm [women], and smoking cessation) was associated with a one-third reduction in cumulative bed-days from onset to age 75 years (97 to 65 bed-days)., Limitation: Possible residual confounding., Conclusion: Adults with YOD have excess hospitalizations across their lifespan compared with persons with usual-onset T2D, including an unexpectedly large burden of mental illness in young adulthood. Efforts to prevent YOD and intensify cardiometabolic risk factor control while focusing on mental health are urgently needed., Primary Funding Source: Asia Diabetes Foundation.

Background: The aim of this study was to explore the relationship between patient self-reported Patient Health Questionnaire-9 (PHQ-9) symptoms and doctor diagnosis of depression using a tree analysis approach., Methods: This was a secondary analysis on a dataset obtained from 10 179 adult primary care patients and 59 primary care physicians (PCPs) across Hong Kong. Patients completed a waiting room survey collecting data on socio-demographics and the PHQ-9. Blinded doctors documented whether they thought the patient had depression. Data were analyzed using multiple logistic regression and conditional inference decision tree modeling., Results: PCPs diagnosed 594 patients with depression. Logistic regression identified gender, age, employment status, past history of depression, family history of mental illness and recent doctor visit as factors associated with a depression diagnosis. Tree analyses revealed different pathways of association between PHQ-9 symptoms and depression diagnosis for patients with and without past depression. The PHQ-9 symptom model revealed low mood, sense of worthlessness, fatigue, sleep disturbance and functional impairment as early classifiers. The PHQ-9 total score model revealed cut-off scores of &gt;12 and &gt;15 were most frequently associated with depression diagnoses in patients with and without past depression., Conclusions: A past history of depression is the most significant factor associated with the diagnosis of depression. PCPs appear to utilize a hypothetical-deductive problem-solving approach incorporating pre-test probability, with different associated factors for patients with and without past depression. Diagnostic thresholds may be too low for patients with past depression and too high for those without, potentially leading to over and under diagnosis of depression.

Diabetes is a major cause of end stage renal disease (ESRD), yet the natural history of diabetic kidney disease is not well understood. We aimed to identify patterns of estimated GFR (eGFR) trajectory and to determine the clinical and genetic factors and their associations of these different patterns with all-cause mortality in patients with type 2 diabetes. Among 6330 patients with baseline eGFR >60 ml/min per 1.73 m 2 in the Hong Kong Diabetes Register, a total of 456 patients (7.2%) developed Stage 5 chronic kidney disease or ESRD over a median follow-up of 13 years (incidence rate 5.6 per 1000 person-years). Joint latent class modeling was used to identify different patterns of eGFR trajectory. Four distinct and non-linear trajectories of eGFR were identified: slow decline (84.3% of patients), curvilinear decline (6.5%), progressive decline (6.1%) and accelerated decline (3.1%). Microalbuminuria and retinopathy were associated with accelerated eGFR decline, which was itself associated with all-cause mortality (odds ratio [OR] 6.9; 95% confidence interval [CI]: 5.6-8.4 for comparison with slow eGFR decline). Of 68 candidate genetic loci evaluated, the inclusion of five loci (rs11803049, rs911119, rs1933182, rs11123170, and rs889472) improved the prediction of eGFR trajectories (net reclassification improvement 0.232; 95% CI: 0.057--0.406). Our study highlights substantial heterogeneity in the patterns of eGFR decline among patients with diabetic kidney disease, and identifies associated clinical and genetic factors that may help to identify those who are more likely to experience an accelerated decline in kidney function., (Copyright © 2018 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

Introduction: Diabetes mellitus (DM) is a major disease burden worldwide because it is associated with disabling and lethal complications. DM complication risk assessment and stratification is key to cost-effective management and tertiary prevention for patients with diabetes in primary care. Existing risk prediction functions were found to be inaccurate in Chinese patients with diabetes in primary care. This study aims to develop 10-year risk prediction models for total cardiovascular diseases (CVD) and all-cause mortality among Chinese patients with DM in primary care., Methods and Analysis: A 10-year cohort study on a population-based primary care cohort of Chinese patients with diabetes, who were receiving care in the Hospital Authority General Outpatient Clinic on or before 1 January 2008, were identified from the clinical management system database of the Hospital Authority. All patients with complete baseline risk factors will be included and followed from 1 January 2008 to 31 December 2017 for the development and validation of prediction models. The analyses will be carried out separately for men and women. Two-thirds of subjects will be randomly selected as the training sample for model development. Cox regressions will be used to develop 10-year risk prediction models of total CVD and all-cause mortality. The validity of models will be tested on the remaining one-third of subjects by Harrell's C-statistics and calibration plot. Risk prediction models for diabetic complications specific to Chinese patients in primary care will enable accurate risk stratification, prioritisation of resources and more cost-effective interventions for patients with DM in primary care., Ethics and Dissemination: The study was approved by the Institutional Review Board of the University of Hong Kong-the Hospital Authority Hong Kong West Cluster (reference number: UW 15-258)., Trial Registration Number: NCT03299010; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Infection occurs more commonly in diabetic patients compared with the general population and is an under-recognised but important morbidity in patients with diabetes. We examined the impact of glycaemic control on hospitalisation for infection in a large prospective cohort of Chinese adults with type 2 diabetes., Methods: Between July 1994 and June 2014, 22 846 patients with type 2 diabetes underwent detailed assessment of metabolic control and diabetes complications. Patients were followed for occurrence of infection requiring hospitalisation as identified using discharge diagnosis codes., Results: Over a median follow-up of 4.8 years, 20.3% of patients were hospitalised for any infection type, with respiratory tract, genitourinary tract, and skin being the most commonly affected sites. In multivariate Cox regression, time-dependent HbA1c was associated with all-site infection (hazard ratio [HR] 1.07 [95% confidence interval {CI}:1.05-1.09, P < 0.001]), genitourinary tract infection (HR 1.09 [95% CI: 1.04-1.14], P < 0.001), and skin infection (HR 1.16 [95% CI 1.12-1.21]. P < 0.001), but not infection of respiratory tract, and was independent of age, gender, disease duration, smoking, body mass index, glomerular filtration rate, haemoglobin, history of stroke, congestive heart failure, coronary heart disease, peripheral artery disease, diabetic neuropathy and cancer, and baseline drug use. Against an arbitrary HbA1c interval of >7.0-8.0% (53-64 mmol/mol), patients with HbA1c ≤6.0% (42 mmol/mol) and >8.0% (64 mmol/mol) had excess risks of infection-related hospitalisation adjusted for other factors., Conclusions: In patients with type 2 diabetes, burden of serious infection is high. In the diabetic population, a U-shape relationship between glycaemia and infection-related hospitalisation was detected., (Copyright © 2017 John Wiley & Sons, Ltd.)

Objective: Nationwide studies on secular trends of diabetes complications are not available in Asia. We examined changes in risk factor control and incidence of complications from diabetes and death in a large longitudinal cohort of Chinese adults with type 2 diabetes in Hong Kong., Research Design and Methods: Between 1 January 2000 and 31 December 2012, 338,908 Chinese adults with type 2 diabetes underwent metabolic and complication assessment in 16 diabetes centers operated by Hong Kong Hospital Authority that provided care to a large majority of diagnosed patients. Patients were followed for incident acute myocardial infarction (AMI), stroke, end-stage renal disease (ESRD), and death until 31 December 2012. Risk factor levels between enrollment periods were compared. Incidence of clinical events, stratified by diabetes duration, was examined over time., Results: Incidence of complications from diabetes and death declined over the observation period in patients at varying disease duration. Among the high-risk group with diabetes for at least 15 years, crude incidence of AMI decreased from 8.7 to 5.8, stroke from 13.5 to 10.1, ESRD from 25.8 to 22.5, and death from 29.0 to 26.6 per 1,000 person-year between the periods 2000 to 2002 and 2010 to 2012. Improvements in levels of metabolic risk factors were detected. Proportion of patients achieving HbA 1c <7.0% (53 mmol/mol) was increased from 32.9 to 50.0%, blood pressure ≤130/80 mmHg from 24.7 to 30.7%, and LDL cholesterol <2.6 mmol/L from 25.8 to 38.1%., Conclusions: From this territory-wide Hong Kong Diabetes Database, we observed decreases in incidence of cardiovascular-renal complications and death and corresponding improvements in risk factor control over a 13-year period., (© 2017 by the American Diabetes Association.)

Aims: This study aimed to develop and validate an all-cause mortality risk prediction model for Chinese primary care patients with type 2 diabetes mellitus(T2DM) in Hong Kong., Methods: A population-based retrospective cohort study was conducted on 132,462 Chinese patients who had received public primary care services during 2010. Each gender sample was randomly split on a 2:1 basis into derivation and validation cohorts and was followed-up for a median period of 5years. Gender-specific mortality risk prediction models showing the interaction effect between predictors and age were derived using Cox proportional hazards regression with forward stepwise approach. Developed models were compared with pre-existing models by Harrell's C-statistic and calibration plot using validation cohort., Results: Common predictors of increased mortality risk in both genders included: age; smoking habit; diabetes duration; use of anti-hypertensive agents, insulin and lipid-lowering drugs; body mass index; hemoglobin A1c; systolic blood pressure(BP); total cholesterol to high-density lipoprotein-cholesterol ratio; urine albumin to creatinine ratio(urine ACR); and estimated glomerular filtration rate(eGFR). Prediction models showed better discrimination with Harrell"'s C-statistics of 0.768(males) and 0.782(females) and calibration power from the plots than previously established models., Conclusions: Our newly developed gender-specific models provide a more accurate predicted 5-year mortality risk for Chinese diabetic patients than other established models., (Copyright © 2017 Elsevier Inc. All rights reserved.)