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ImportanceThe use of warfarin as an anticoagulant to prevent thromboembolism in patients with infective endocarditis (IE) remains controversial due to potentially increased bleeding risks.ObjectiveThis study compared the risks of ischemic stroke, death and bleeding in patients with IE with and without warfarin use.DesignProspective cohort study.SettingPopulation-based.ParticipantsPatients aged 18 or older and diagnosed with IE in Hong Kong between January 1st1997 and August 31st2020 were included. Patients with use of any anticoagulant 30 days before IE diagnosis were excluded. Patients initiated on warfarin within 14 days of IE diagnosis and patients without warfarin use were matched for baseline characteristics using 1:1 propensity score matching.ExposureWarfarin use within 14 days of IE diagnosis.Main outcomes and measuresPatients were followed up to 90 days for the outcomes of ischemic stroke, all-cause mortality, intracranial hemorrhage, and gastrointestinal bleeding. Cox regression was used to determine hazard ratios (HRs) [95% confidence intervals (CIs)] between treatment groups. Fine-Gray competing risk regression with all-cause mortality as the competing event was performed as a sensitivity analysis. In addition to 90-day analyses, landmark analyses were performed at 30 days of follow-up.ResultsThe matched cohort consisted of 675 warfarin users (57.0% male, age 59±16 years) and 675 warfarin non-users (53.5% male, age 61±19 years). From Cox regression, warfarin users had a 50% decreased 90-day risk in all-cause mortality (HR: 0.50 [0.39-0.65]), without significantly different 90-day risks of ischemic stroke (HR: 1.04 [0.70-1.53]), intracranial haemorrhage (HR: 1.25 [0.77-2.04]), and gastrointestinal bleeding (HR: 1.04 [0.60-1.78]). Thirty-day landmark analysis showed similar results. Competing risk regression showed significantly higher 30-day cumulative incidence of intracranial haemorrhage in warfarin users (sub-HR: 3.34 [1.34-8.31]), but not at 90-day (sub-HR: 1.63 [0.95-2.81]). Results from Fine-Gray regression were otherwise congruent with those from Cox regression.Conclusions and relevanceIn patients with IE, warfarin use initiated within 14 days of IE diagnosis may be associated with significantly decreased risks of mortality but higher risks of intracranial haemorrhage, with similar risks of ischemic stroke and gastrointestinal bleeding, compared with non-use of warfarin with 14 days of IE diagnosis.Key pointsQuestionIs warfarin, initiated within 14 days of a diagnosis of infective endocarditis (IE), efficacious and safe?FindingsIn this propensity score-matched, population-based, prospective cohort study from Hong Kong, warfarin use within 14 days of IE diagnosis was associated with a 50% decrease in the risk of all-cause mortality, albeit with higher risk of intracranial haemorrhage, and without significant differences in the risk of ischaemic stroke and gastrointestinal bleeding.MeaningIn patients with IE, warfarin use within 14 days of diagnosis may have mortality benefits, despite increased risks of intracranial haemorrhage.

Cancer patients may be susceptible to poorer outcomes in COVID-19 infection owing to the immunosuppressant effect of chemotherapy/radiotherapy and cancer growth, along with the potential for nosocomial transmission due to frequent hospital admissions.This was a population-based retrospective cohort study of COVID-19 patients who presented to Hong Kong public hospitals between 1 January 2020 and 8 December 2020. The primary outcome was a composite endpoint of requirement for intubation, ICU admission and 30-day mortality.The following study consisted of 6089 COVID-19 patients (median age 45.9 [27.8.1-62.7] years; 50% male), of which 142 were cancer subjects. COVID-19 cancer patients were older at baseline and tended to present with a higher frequency of comorbidities, including diabetes mellitus, hypertension, chronic obstructive pulmonary disease, ischemic heart disease, ventricular tachycardia/fibrillation and gastrointestinal bleeding (p 0.05). These subjects also likewise tended to present with higher serum levels of inflammatory markers, including D-dimer, lactate dehydrogenase, high sensitivity troponin-I and C-reactive protein. Multivariate Cox regression showed that any type of cancer presented with an almost four-fold increased risk of the primary outcome (HR: 3.77; 95% CI: 1.63-8.72; p 0.002) after adjusting for significant demographics, Charlson comorbidity index, number of comorbidities, past comorbidities and medication history. This association remained significant when assessing those with colorectal (HR: 5.07; 95% CI: 1.50-17.17; p 0.009) and gastrointestinal malignancies (HR: 3.79; 95% CI: 1.12-12.88; p 0.03), but not with lung, genitourinary, or breast malignancies, relative to their respective cancer-free COVID-19 counterparts.COVID-19 cancer patients are associated with a significantly higher risk of intubation, ICU admission and/or mortality.

Objective To compare the effects of sodium-glucose cotransporter 2 inhibitors (SGLT2Is) and dipeptidyl peptidase-4 inhibitors (DPP4Is) on adverse outcomes in diabetic patients in Hong Kong. Methods This was a retrospective population-based cohort study of type 2 diabetes mellitus patients (n = 72,746) treated with SGLT2I or DPP4I between January 1, 2015, and December 31, 2020, in Hong Kong. Patients with exposure to both DPP4I and SGLT2I therapy, without complete demographics or mortality data, or who had prior atrial fibrillation (AF) were excluded. The study outcomes were new-onset AF, stroke/transient ischemic attack, cardiovascular mortality and all-cause mortality. Propensity score matching (1:1 ratio) between SGLT2I and DPP4I users was performed. Results The unmatched study cohort included 21,713 SGLT2I users and 39,510 DPP4I users (total: n = 61,233 patients; 55.37% males, median age: 62.7 years [interquartile range (IQR): 54.6–71.9 years]). Over a median follow-up of 2030 (IQR: 1912–2117) days, 2496 patients (incidence rate [IR]: 4.07%) developed new-onset AF, 2179 patients (IR: 3.55%) developed stroke/transient ischemic attack, 1963 (IR: 3.20%) died from cardiovascular causes and 6607 patients (IR: 10.79%) suffered from all-cause mortality. After propensity score matching (SGLT2I: n = 21,713; DPP4I: n = 21,713), SGLT2I users showed lower incidence of new-onset AF (1.96% vs. 2.78%, standardized mean difference [SMD] = 0.05), stroke (1.80% vs. 3.52%, SMD = 0.11), cardiovascular mortality (0.47% vs. 1.56%, SMD = 0.11) and all-cause mortality (2.59% vs. 7.47%, SMD = 0.22) compared to DPP4I users. Cox regression found that SGLT2I users showed lower risk of new-onset AF (hazard ratio [HR]: 0.68, 95% confidence interval [CI]: [0.56, 0.83], P = 0.0001), stroke (HR: 0.64, 95% CI: [0.53, 0.79], P P P Conclusions Based on real-world data of type 2 diabetic patients in Hong Kong, SGLT2I use was associated with lower risk of incident AF, stroke/transient ischemic attack, and cardiovascular and all-cause mortality outcomes compared to DPP4I use.

PurposeThis study aimed to compare the effects of sodium glucose cotransporter 2 inhibitors (SGLT2I) and dipeptidyl peptidase-4 inhibitors (DPP4I) on new-onset hip fractures.MethodsThis was a retrospective population-based cohort study including type-2 diabetes mellitus patients treated with either SGLT2I or DPP4I between January 1st2015 and December 31st2020 in Hong Kong. The primary outcome was new-onset hip fracture and the secondary outcome was all-cause mortality. Propensity score matching (1:1 ratio) using the nearest neighbour search was performed. Univariable and multivariable Cox regression were applied to identify significant predictors. Competing risks models and multiple approaches using the propensity score were performed.ResultsThis cohort included 56393 patients with type-2 diabetes mellitus (median age: 62.1 years old [interquantile range, IQR]: 54.2-71.1; 57.45% males), of which 20432 patients ([incidence rate, IR]: 36.23%) used SGLT2I and 35961 patients (IR: 63.77%) used DPP4I. After the 1:1 propensity score matching, 449 (IR: 1.09%) patients had hip fractures, and 2012 patients (IR: 4.92%) died. SGLT2I was associated with significantly lower risks of hip fractures after adjusting for the demographics, past comorbidities, non-SGLT2I/DPP4I medications and laboratory results (hazard ratio: 0.55; 95% confidence interval: 0.42-0.89; P=0.0036). The results were consistent in the competing risk models and the different propensity matching approaches.ConclusionsSGLT2I was associated with lower risks of new-onset hip fractures after propensity score matching and adjustments.SummaryThis study compared the risks of hip fractures in between users of sodium glucose cotransporter 2 inhibitors (SGLT2I) and dipeptidyl peptidase-4 inhibitors in type-2 diabetes mellitus. After propensity score matching, SGLT2I was associated with lower risks of hip fractures adjusting for confounders (hazard ratio: 0.55; 95% confidence interval: 0.42-0.89; P=0.0036).

Object This study evaluates the association between antivirals (Molnupiravir and Nirmatrelvir-Ritonavir) and all-cause and respiratory mortality and organ dysfunction among high-risk COVID-19 patients during an Omicron outbreak. Methods Two cohorts, Nirmatrelvir-Ritonavir vs. control and Molnupiravir vs. control, were constructed with inverse probability treatment weighting to balance baseline characteristics. Cox proportional hazards models evaluated the association of their use with all-cause mortality, respiratory mortality, and all-cause sepsis (a composite of circulatory shock, respiratory failure, acute liver injury, coagulopathy, and acute liver impairment). Patients recruited were hospitalized and diagnosed with the COVID-19 Omicron variant between February 22, 2022 to April 15, 2022, and followed up until May 15, 2022. Results The study included 17,704 patients. There were 4.67 and 22.7 total mortalities per 1000 person-days in the Nirmatrelvir-Ritonavir and control groups respectively before adjustment (weighted incidence rate ratio, -18.1 [95%CI, -23.0 to -13.2]; hazard ratio, 0.18 [95%CI, 0.11–0.29]). There were 6.64 and 25.9 total mortalities per 1000 person-days in the Molnupiravir and control groups respectively before adjustment (weighted incidence rate ratio per 1000 person-days, -19.3 [95%CI, -22.6 to -15.9]; hazard ratio, 0.23 [95%CI, 0.18–0.30]). In all-cause sepsis, there were 13.7 and 35.4 organ dysfunction events per 1000 person-days in the Nirmatrelvir-Ritonavir and control groups respectively before adjustment (weighted incidence rate ratio per 1000 person-days, -21.7 [95%CI, -26.3 to -17.1]; hazard ratio, 0.44 [95%CI, 0.38–0.52]). There were 23.7 and 40.8 organ dysfunction events in the Molnupiravir and control groups respectively before adjustment (weighted incidence ratio per 1000 person-days, -17.1 [95%CI, -20.6 to -13.6]; hazard ratio, 0.63 [95%CI, 0.58–0.69]). Conclusions Among COVID-19 hospitalized patients, use of either Nirmatrelvir-Ritonavir or Molnupiravir compared with no antiviral use was associated with a significantly lower incidence of 28-day all-cause and respiratory mortality and sepsis.

Neutrophil-to-lymphocyte ratio (NLR) is a routinely available biomarker that reflects systemic inflammation. The study evaluated the predictive value of NLR for ischemic stroke and atrial fibrillation (AF) in patients with type 2 diabetes mellitus.This was a population-based cohort study of patients with type 2 diabetes mellitus and complete blood count tests at baseline between 1 January 1st, 2009, and 31 December, 2009, at government-funded hospitals/clinics in Hong Kong. Follow-up was until 31 December, 2019, or death.A total of 85,351 patients (age = 67.6 ± 13.2 years old, male = 48.8%, follow-up = 3101 ± 1441 days) were included. Univariable Cox regression found that increased NLR at quartiles 2, 3 and 4 was significantly associated with higher risks of new-onset ischemic stroke (hazard ratio [HR]: 1.28 [1.20-1.37], p .001, HR: 1.41 [1.32-1.51], p .001 and HR: 1.38 [1.29-1.47], p .001) and AF (HR: 1.09 [1.02-1.17], p .015; HR: 1.28 [1.20-1.37], p .001; HR: 1.39 [1.31-1.49], p .001) compared to quartile 1. On multivariable analysis, NLR remained a significant predictor of ischemic stroke risk for quartiles 2 and 3 (quartile 2: HR: 1.14 [1.05, 1.22], p = .001; quartile 3: HR: 1.14 [1.06, 1.23], p .001) but not quartile 4 (HR: 1.08 [0.994, 1.17], p = .070). NLR was not predictive of AF after adjusting for confounders (quartile 2: HR: 0.966 [0.874, 1.07], p = .499; quartile 3: HR: 0.978 [0.884, 1.08], p = .661; quartile 4: HR: 1.05 [0.935, 1.16], p = .462).NLR is a significant predictor of new-onset ischaemic stroke after adjusting for significant confounders in Chinese type 2 diabetes patients.

Introduction The present study examined the gender-specific prognostic value of blood pressure (BP) and its variability in the prediction of dementia risk and developed a score system for risk stratification. Materials and Methods This was a retrospective, observational population-based cohort study of patients admitted to government-funded family medicine clinics in Hong Kong between January 1, 2000 and March 31, 2002 with at least 3 blood pressure measurements. Gender-specific risk scores for dementia were developed and tested. Results The study consisted of 74 855 patients, of whom 3550 patients (incidence rate: 4.74%) developed dementia over a median follow-up of 112 months (IQR= [59.8–168]). Nonlinear associations between diastolic/systolic BP measurements and the time to dementia presentation were identified. Gender-specific dichotomized clinical scores were developed for males (age, hypertension, diastolic and systolic BP and their measures of variability) and females (age, prior cardiovascular, respiratory, gastrointestinal diseases, diabetes mellitus, hypertension, stroke, mean corpuscular volume, monocyte, neutrophil, urea, creatinine, diastolic and systolic BP and their measures of variability). They showed high predictive strengths for both male (hazard ratio [HR]: 12.83, 95% confidence interval [CI]: 11.15–14.33, P value Conclusion Gender-specific clinical risk scores incorporating BP variability can accurately predict incident dementia and can be applied clinically for early disease detection and optimized patient management.

BACKGROUND Healthcare avoidance in the COVID-19 Pandemic has been widely reported. Yet few studies have investigated the dynamics of hospital avoidance behaviour during pandemic waves and inferred its impact on excess non-COVID-19 death toll. OBJECTIVE To measure the impact of hospital avoidance behaviour on excess mortality using emergency department (ED) patient data from 2016 to 2021, during which Hong Kong experienced a unique COVID-19 pandemic with four distinct waves of case number surges. METHODS Our data is taken from the CDARS Hong Kong Hospital Authority administrative database, which oversees all local public hospitals and plays a prominent role in emergency care provision. To estimate excess mortality, two-stage least squares was utilised with daily tallies of ED visit and 28-day mortality. Elderly records were categorised by the residential care home for elderly status (RCHE) and comorbidities were used to explain the demographic and clinical attributes of excess 28-day mortality. RESULTS Compared with the average in 2016-2019 average there was a reduction in total ED visits in 2020 of 25·4%. During the same period, the 28-day mortality of non-COVID-19 ED deaths increased by 7·82% compared with 2016-2019. The estimated total elderly excess non-COVID 28-day death by reduced ED visits throughout 2020 to 2021 is 1,958 (1,100-2,820, no time lag). The actual excess death in 2020 and 2021 are 3,143 and 4,013 respectively, with 2016-2019 average as the benchmark. Death on Arrival (DOA)/ Death before Arrival (DBA) increased by 35·1% in 2020, while non-DOA/DBA mortalities increased only by a moderate 4·65%. In both DOA/DBA and non-DOA/DBA, the increases were higher during wave periods than in non-wave periods. Moreover, non-RCHE patients saw a greater reduction in ED visit than RCHE residents across all waves by more than 10%. Most of the subset comorbidities demonstrated an annualised reduction in visit in 2020. Renal diseases and severe liver diseases saw a notable death increase. CONCLUSIONS We demonstrated a statistical method to estimate hospital avoidance behaviour during a pandemic, and quantified the consequential excess 28-day mortality, with a focus on elderlies, who had high frequencies of ED visit and deaths. This study serves as an informed alert and possible investigation guideline to healthcare professionals about hospital avoidance behaviour and its consequences.

BackgroundBoth Coronavirus Disease-2019 (COVID-19) infection and COVID-19 vaccination have been associated with the development of acute myocardial infarction (AMI). This study compared the rates of AMI after COVID-19 infection and among the COVID-19 vaccinated populations in Hong Kong.MethodsThis was a population-based cohort study from Hong Kong, China. Patients with positive real time-polymerase chain reaction (RT-PCR) test for COVID-19 between January 1st, 2020 and June 30th, 2021 were included. The data of the vaccinated and unvaccinated population was obtained from the “Reference Data of Adverse Events in Public Hospitals” published by the local government. The individuals who were vaccinated with COVID-19 vaccination prior the observed period (December 6th, 2021 to January 2nd, 2022) in Hong Kong were also included. The vaccination data of other countries were obtained by searching PubMed using the terms [“COVID-19 vaccine” AND “Myocardial infarction”] from its inception to February 1st, 2022. The main exposures were COVID-19 test positivity or previous COVID-19 vaccination. The primary outcome was the development of AMI within 28 days observed period.ResultsThis study included 11441 COVID-19 patients, of whom 25 suffered from AMI within 28 days of exposure (rate per million: 2185; 95% confidence interval [CI]: 1481-3224). The rates of AMI were much higher than those who were not vaccinated by the COVID-19 vaccine before December 6th, 2021 (rate per million: 162; 95% CI: 147-162) with a rate ratio of 13.5 (95% CI: 9.01-20.2). Meanwhile, the rate of AMI was lower amongst the vaccinated population (rate per million: 47; 95% CI: 41.3-53.5) than COVID-19 infection with a rate ratio of 0.02 (0.01, 0.03). Regarding post-vaccination AMI, COVID-19 infection was associated with a significantly higher rate of AMI than post-COVID-19 vaccination AMI in other countries.ConclusionsCOVID-19 infection was associated with a higher rate of AMI than the vaccinated general population, and those immediately after COVID-19 vaccination.

BackgroundDiabetes mellitus is associated with the development of colorectal cancer (CRC). There have been a lack of study comparing the risk of colorectal cancer in sodium-glucose co-transporter 2 inhibitors (SGLT2i) and dipeptidyl peptidase 4 inhibitors (DPP4i), both of which commonly prescribed second line agents for diabetes.MethodsWe conducted a territory wide retrospective cohort study on patients with type 2 diabetes who was prescribed either of the two agents. Baseline demographics, use of other medications, comorbidities and biochemical parameters were extracted. Propensity score matching was performed to reduce the impacts of cofounders. Cause specific Cox regression was used to evaluate the risk of incident colorectal cancer in SGLT2i users, as compared to DPP4i users. Subgroup analyses based on age, gender and estimated glomerular filtration rate were performed.ResultsAfter propensity score matching, we included 13029 subjects who were prescribed SGLT2i and DPP4i respectively. Incidence rate ratio of CRC was 0.566 (0.418-0.766) in SGLT2i users. Overall, use of SGLT2i was associated with a lower risk of incident CRC (HR: 0.526; 95% CI: 0.382-0.724; P 2 (HR: 0.560; 95% CI: 0.395-0.792; P =0.001).ConclusionUse of SGLT2i may reduce risk of incident CRC as compared to use of DPP4i, especially in younger male patients with fairly preserved renal function.

Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may be associated with higher susceptibility of COVID-19 infection and adverse outcomes. We compared ACEI/ARB use and COVID-19 positivity in a case-control design, and severity in COVID-19 positive patients.Consecutive patients who attended Hong Kong's public hospitals or outpatient clinics between 1 January and 28 July 2020 for COVID-19 real time-PCR (RT-PCR) tests were included. Baseline demographics, past comorbidities, laboratory tests and use of different medications were compared between COVID-19 positive and negative patients. Severe endpoints for COVID-19 positive patients were 28-day mortality, need for intensive care admission or intubation.This study included 213 788 patients (COVID-19 positive: n = 2774 patients; negative: n = 211 014). In total, 162 COVID-19 positive patients (5.83%) met the severity outcome. The use of ACEI/ARB was significantly higher amongst cases than controls (n = 156/2774, 5.62 vs. n = 6708/211014, 3.17%; P 0.0001). Significant univariate predictors of COVID-19 positivity and severe COVID-19 disease were older age, higher Charlson score, comorbidities, use of ACEI/ARB, antidiabetic, lipid-lowering, anticoagulant and antiplatelet drugs and laboratory tests (odds ratio1, P 0.05). The relationship between the use of ACEI/ARB and COVID-19 positivity or severe disease remained significant after multivariable adjustment. No significant differences in COVID-19 positivity or disease severity between ACEI and ARB use were observed (P 0.05).There was a significant relationship between ACEI/ARB use and COVID-19 positivity and severe disease after adjusting for significant confounders.

Background: Commonly prescribed diabetic medications such as metformin and sulfonylurea may be associated with different arrhythmogenic risks. This study compared the risk of ventricular arrhythmia or sudden cardiac death (VA/SCD) between metformin and sulfonylurea in patients with type 2 diabetes. Methods: Patients aged 40 years or older who were diagnosed with type-2 diabetes mellitus or prescribed anti-diabetic agents in Hong Kong between 1st January 2009 and 31st December 2009 were included and followed up till 31st December 2019. Patients prescribed with both metformin and sulfonylurea or had prior myocardial infarction were excluded. The study outcome was a composite of VA/SCD. Metformin users and sulfonylurea users were matched at a 1:1 ratio by propensity score matching. Results: The study cohort consisted of 5756 metformin users (48.00% male, age 68±11 years, mean follow-up 5.04±2.57 years) and 5756 sulfonylurea users (50.30% male, age 69±11 years, mean follow-up 5.04±2.54 years). Sulfonylurea was associated with higher risk of VA/SCD than metformin (hazard ratio 1.84 [1.56 - 2.16], pConclusion: Sulfonylurea use is associated with higher risk of VA/SCD than metformin in patients with type 2 diabetes.

To gain insights on the cardiovascular effects of metformin and sulphonylurea, the present study compares the rates of incident atrial fibrillation, stroke, cardiovascular mortality and all-cause mortality between metformin and sulphonylurea users in type 2 diabetes mellitus. This was a retrospective population-based cohort study of type 2 diabetes mellitus patients receiving either sulphonylurea or metformin monotherapy between January 1, 2000, and December 31, 2019. The primary outcome was new-onset AF or stroke. Secondary outcomes were cardiovascular, non-cardiovascular and all-cause mortality. Propensity score matching (1:2 ratio) between sulphonylurea and metformin users was performed, based on demographics, CHA-DS-VASc score, past comorbidities and medication use. Cox regression was used to identify significant risk factors. Competing risk analysis was conducted using cause-specific and subdistribution hazard models. Sensitivity analyses using propensity score stratification, high-dimensional propensity score and inverse probability of treatment weighting were conducted. Subgroup analyses were conducted for age and gender in the matched cohort. A total of 36,228 sulphonylurea users and 72,456 metformin users were included in the propensity score-matched cohort. Multivariable Cox regression showed that sulphonylurea users had higher risks of incident AF (hazard ratio [HR]: 2.89, 95% confidence interval [CI]: 2.75-3.77; P

BackgroundDyslipidaemia is associated with adverse cardiovascular outcomes. However, the long-term prognostic value of visit-to-visit cholesterol variability for the risks of heart failure (HF) is uncertain. We investigated the associations between cholesterol variability and the risk of HF and adverse cardiovascular events.MethodsThis retrospective cohort study included patients attending family medicine clinics in Hong Kong during 2000-2003 with follow-up until 2019. Patients with at least three sets of blood cholesterol (low-density (LDL-C) and high-density (HDL-C) lipoprotein cholesterol) levels available at different visits were included. Patients with prior HF, myocardial infarction (MI), use of HF medications, and pregnancy were excluded. Visit-to-visit variability was calculated using standard deviation and coefficient of variation (CV). The primary outcome was HF. The secondary outcomes were cardiovascular mortality, and myocardial infarction.ResultsA total of 5662 patients were included (2152 males; mean age 63.3±12.4 years; mean follow-up 15.3±4.6 years). Higher variability of HDL-C (hazard ratio (HR) for CV: 13.757 [6.261, 30.226], pConclusionHigher visit-to-visit cholesterol variability was varyingly associated with significantly increased long-term risks of HF and adverse cardiovascular events. Such associations may be negated by using lipid-lowering medication(s).

BACKGROUND Engaging students in interprofessional education for higher order thinking and collaborative problem-solving skills is challenging. This study reports the development of Virtual ER, a serious game played on a virtual platform, and how it can be an innovative way for delivering interprofessional education to medical and nursing undergraduates. OBJECTIVE We report the development of a serious online game, Virtual ER, and evaluate its effect on teamwork enhancement and clinical competence. We also explore if Virtual ER can be an effective pedagogical tool to engage medical and nursing students with different learning styles. METHODS Virtual ER is a custom-made, learning outcome–driven, case-based web app. We developed a game performance scoring system with specific mechanisms to enhance serious gaming elements. Sixty-two students were recruited from our medical and nursing programs. They played the games in teams of 4 or 5, followed by an instructor-led debriefing for concept consolidation. Teamwork attitudes, as measured by the Human Factors Attitude Survey, were compared before and after the game. Learning style was measured with a modified Honey and Mumford learning style questionnaire. RESULTS Students were satisfied with Virtual ER (mean satisfaction score 5.44, SD 0.95, of a possible 7). Overall, Virtual ER enhanced teamwork attitude by 3.02 points (95% CI 1.15-4.88, P=.002). Students with higher scores as activists (estimate 9.09, 95% CI 5.17-13.02, PP=.01) had a significantly higher degree of teamwork attitude enhancement, while students with higher scores as theorists and reflectors did not demonstrate significant changes. However, there was no difference in game performance scores between students with different learning styles. CONCLUSIONS There was considerable teamwork enhancement after playing Virtual ER for interprofessional education, in particular for students who had activist or pragmatist learning styles. Serious online games have potential in interprofessional education for the development of 21st century life skills. Our findings also suggest that Virtual ER for interprofessional education delivery could be expanded locally and globally.

ObjectivesTo compare the rates of major cardiovascular adverse events in sodium-glucose cotransporter-2 inhibitors (SGLT2I) and dipeptidyl-peptidase-4 inhibitors (DPP4I) users in a Chinese population.BackgroundSGLT2I and DPP4I are increasingly prescribed for type 2 diabetes mellitus patients. However, few population-based studies are comparing their effects on incident heart failure or myocardial infarction.MethodsThis was a population-based retrospective cohort study using the electronic health record database in Hong Kong, including type 2 diabetes mellitus patients receiving either SGLT2I or DPP4I between January 1st, 2015, to December 31st, 2020. Propensity-score matching was performed in a 1:1 ratio based on demographics, past comorbidities, non-SGLT2I/DPP4I medications with nearest-neighbor matching (caliper=0.1). Univariable and multivariable Cox models were used to identify significant predictors for new onset heart failure, new onset myocardial infarction, cardiovascular mortality, and all-cause mortality. Sensitivity analyses with competing risk models and multiple propensity score matching approaches were conducted. Subgroup age and gender analyses were presented.ResultsA total of 41994 patients (58.89% males, median admission age at 58 years old, interquartile rage [IQR]: 51.2-65.3) were included in the study cohorts with a median follow-up duration of 5.6 years (IQR: 5.32-5.82). After adjusting for significant demographics, past comorbidities, medication prescriptions and biochemical results, SGLT2I users have a significantly lower risk for myocardial infarction (hazard ratio [HR]: 0.34, 95% confidence interval [CI]: [0.28, 0.41], P < 0.0001), cardiovascular mortality (HR: 0.53, 95% CI: [0.38, 0.74], P = 0.0002) and all-cause mortality (HR: 0.21, 95% CI: [0.18, 0.25], P= 0.0001) under multivariable Cox regression. However, the risk for heart failure is comparable (HR: 0.87, 95% CI: [0.73, 1.04], P= 0.1343).ConclusionsSGLT2 inhibitors are protective against adverse cardiovascular events compared to DPP4I. The prescription of SGLT2I is preferred especially for males and patients aged 65 or older to prevent cardiovascular risks.

Background: The aim of this study was to compare the risks of new-onset prostate cancer between metformin and sulfonylurea users with type 2 diabetes mellitus (T2DM). Methods: This population-based retrospective cohort study included male patients with T2DM presenting to public hospitals/clinics in Hong Kong between January 1, 2000, and December 31, 2009. We only included patients prescribed either, but not both, metformin or sulfonylurea. All patients were followed up until December 31, 2019. The primary outcome was new-onset prostate cancer and the secondary outcome was all-cause mortality. One-to-one propensity score matching was performed between metformin and sulfonylurea users based on demographics, comorbidities, antidiabetic and cardiovascular medications, fasting blood glucose level, and hemoglobin A1c level. Subgroup analyses based on age and use of androgen deprivation therapy were performed. Results: The final study cohort consisted of 25,695 metformin users (mean [SD] age, 65.2 [11.8] years) and 25,695 matched sulfonylurea users (mean [SD] age, 65.3 [11.8] years) with a median follow-up duration of 119.6 months (interquartile range, 91.7–139.6 months) after 1:1 propensity score matching of 66,411 patients. Metformin users had lower risks of new-onset prostate cancer (hazard ratio, 0.80; 95% CI, 0.69–0.93; P=.0031) and all-cause mortality (hazard ratio, 0.89; 95% CI, 0.86–0.92; PP for trend P for trend Conclusions: Metformin use was associated with significantly lower risks of new-onset prostate cancer and all-cause mortality than sulfonylurea use in male patients with T2DM.

This cohort study assesses the incidence of emergency department (ED) visits in Hong Kong, China, for sexual abuse among youth before and during the COVID-19 pandemic.

Triaging and prioritising patients for RT-PCR test had been essential in the management of COVID-19 in resource-scarce countries. In this study, we applied machine learning (ML) to the task of detection of SARS-CoV-2 infection using basic laboratory markers. We performed the statistical analysis and trained an ML model on a retrospective cohort of 5148 patients from 24 hospitals in Hong Kong to classify COVID-19 and other aetiology of pneumonia. We validated the model on three temporal validation sets from different waves of infection in Hong Kong. For predicting SARS-CoV-2 infection, the ML model achieved high AUCs and specificity but low sensitivity in all three validation sets (AUC: 89.9–95.8%; Sensitivity: 55.5–77.8%; Specificity: 91.5–98.3%). When used in adjunction with radiologist interpretations of chest radiographs, the sensitivity was over 90% while keeping moderate specificity. Our study showed that machine learning model based on readily available laboratory markers could achieve high accuracy in predicting SARS-CoV-2 infection.

The Students' Perceptions of Physician-Pharmacist Interprofessional Clinical Education and its revision (SPICE, SPICE-R) were designed to understand medicine and pharmacy students' perceptions of interprofessional education and collaborative practice in managing complex health problems. The SPICE-R authors, however, suggested for additional items for subscales "roles and responsibilities for collaborative care" and "patient outcomes from collaborative practice". We added two items and introduced SPICE-R3 to differentiate it from the 10-item SPICE-R2 and to adapt the scale to a wider range of healthcare members. We administered the SPICE-R3 to healthcare students at the height of the COVID-19 outbreak in Hong Kong in February 2020. Using data from 225 students from Chinese medicine, medicine, nursing, and pharmacy, confirmatory factor analysis indicated nine items having acceptable item coefficients. Our data obtained a good fit to the three-factor, nine-item model suggesting construct validity. Results of the between-network analysis suggest that the three subscales of SPICE-R3 correlated systematically with other theoretically relevant variables in the nomological network suggesting convergent validity. The SPICE-R3 is a valid measure to examine Hong Kong healthcare students' interprofessional attitudes in online interprofessional education even during the pandemic. Implications and directions for future research are provided.

Recent studies have reported numerous predictors for adverse outcomes in COVID-19 disease. However, there have been few simple clinical risk scores available for prompt risk stratification. The objective is to develop a simple risk score for predicting severe COVID-19 disease using territory-wide data based on simple clinical and laboratory variables. Consecutive patients admitted to Hong Kong’s public hospitals between 1 January and 22 August 2020 and diagnosed with COVID-19, as confirmed by RT-PCR, were included. The primary outcome was composite intensive care unit admission, need for intubation or death with follow-up until 8 September 2020. An external independent cohort from Wuhan was used for model validation. COVID-19 testing was performed in 237,493 patients and 4442 patients (median age 44.8 years old, 95% confidence interval (CI): [28.9, 60.8]); 50% males) were tested positive. Of these, 209 patients (4.8%) met the primary outcome. A risk score including the following components was derived from Cox regression: gender, age, diabetes mellitus, hypertension, atrial fibrillation, heart failure, ischemic heart disease, peripheral vascular disease, stroke, dementia, liver diseases, gastrointestinal bleeding, cancer, increases in neutrophil count, potassium, urea, creatinine, aspartate transaminase, alanine transaminase, bilirubin, D-dimer, high sensitive troponin-I, lactate dehydrogenase, activated partial thromboplastin time, prothrombin time, and C-reactive protein, as well as decreases in lymphocyte count, platelet, hematocrit, albumin, sodium, low-density lipoprotein, high-density lipoprotein, cholesterol, glucose, and base excess. The model based on test results taken on the day of admission demonstrated an excellent predictive value. Incorporation of test results on successive time points did not further improve risk prediction. The derived score system was evaluated with out-of-sample five-cross-validation (AUC: 0.86, 95% CI: 0.82–0.91) and external validation (N = 202, AUC: 0.89, 95% CI: 0.85–0.93). A simple clinical score accurately predicted severe COVID-19 disease, even without including symptoms, blood pressure or oxygen status on presentation, or chest radiograph results.

Little is still known about the clinical features associated with the occurrence of acute respiratory distress syndrome (ARDS) in hospitalized patients with Coronavirus disease 2019 (COVID-19). The aim of the present study was to describe the prevalence of pre-admission antithrombotic therapies in patients with COVID-19 and to investigate the potential association between antithrombotic therapy and ARDS, as disease clinical presentation, or in-hospital mortality. We enrolled 192 consecutive patients with laboratory-confirmed COVID-19 admitted to emergency department of five Italian hospitals. The study population was divided in two groups according to the evidence of ARDS at chest computed tomography at admission. Propensity score weighting adjusted regression analysis was performed to assess the risk ARDS at admission, and death during hospitalization, in patients treated or not with antiplatelet and anticoagulant agents. ARDS was reported in 73 cases (38 %), who showed more likely hypertension compared to those without ARDS (57.8 % vs 49.6 %; P = 0.005). Thirty-five patients (18.5 %) died during the hospitalization. Not survived COVID-19 patients showed a statistically significant increased age (77 ± 8.31 vs 65.57 ± 8.31; P = 0.001), hypertension (77.1 % vs 53.5 %; P = 0.018) and coronary artery disease prevalence (28.6 % vs 10.2 %; P = 0.009). Both unadjusted and adjusted regression analyses showed no difference in the risk of ARDS at admission, or death during hospitalization, between patients treated or not with antiplatelets or anticoagulants. Pre-admission antithrombotic therapy, both antiplatelet and anticoagulant, does not seem to show a protective effect in severe forms of COVID-19 with ARDS at presentation and rapidly evolving toward death.

The coronavirus disease 2019 (COVID-19) pandemic continues to cause significant morbidity and mortality worldwide. This study aims to identify specific lab markers, complications, and treatments that may be associated with increased mortality in COVID-19 patients. This study is retrospective in nature; it included 217 COVID-19 positive patients who were admitted to a ProMedica Health System hospital in Northwest Ohio, United States, between March 25 and June 16, 2020. We collected various laboratory values, complications, and treatment courses. T test and χ

Several studies have investigated the effectiveness and safety of nonvitamin K antagonist oral anticoagulants (NOACs) vs vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) and liver disease. Herein, we conducted a meta-analysis to compare the effect of NOACs with VKAs in patients with AF and liver disease. We also conducted a subsidiary analysis to compare the risk of liver injury between NOACs and VKA in AF patients. We systematically searched the PubMed and Embase databases from January 2009 to May 2020 for the relevant studies. Hazard ratios (HRs) with 95% confidence intervals (CIs) were selected and pooled using a random-effects model. A total of six cohorts were included. Compared with VKA use, the use of NOACs was associated with reduced risks of stroke or systemic embolism (HR 0.68, 95% CI 0.49-0.93), all-cause death (HR 0.69, 95% CI 0.63-0.75), and intracranial bleeding (HR 0.49, 95% CI 0.40-0.59), whereas the outcomes of major bleeding (HR 0.72, 95% CI 0.51-1.01) and gastrointestinal bleeding (HR 0.84, 95% CI 0.51-1.36) were not significantly different between groups in AF patients with liver disease. Moreover, compared with VKA use, the use of NOACs was associated with a reduced risk of liver injury (HR 0.72, 95% CI 0.61-0.84) in AF patients. Compared with VKAs, the use of NOACs was associated with reduced risks of stroke or systemic embolism, all-cause death, and intracranial bleeding in AF patients with liver disease, and associated with a reduced risk of liver injury in AF patients.

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

The three direct oral anticoagulants (DOAC), rivaroxaban, apixaban and dabigatran have been associated with lower risks of fractures compared to warfarin. However, no large scale studies have explored the associations with the newest DOAC, edoxaban, with fracture risk. The present study aims to elucidate the effects of edoxaban on the risk of hip fracture amongst elderly patients by comparing the incidence of new onset hip fracture between edoxaban and warfarin users in a Chinese population.This was a retrospective population-based cohort study of patients with edoxaban or warfarin use between January 1st, 2016 and December 31st, 2019 in Hong Kong, China. Patients with less than one-month exposure, medication switching between warfarin and edoxaban, those who died within 30 days after drug exposure, prior human immunodeficiency virus infection, age50 years old, and those with prior hip fractures were excluded. Propensity score matching (1:2) between edoxaban and warfarin users using the nearest neighbour method was performed based on demographics, prior comorbidities, and use of different medications. The study outcomes were new onset hip fractures, medically attended falls and all-cause mortality.A total of 5014 patients including 579 edoxaban users and 4435 warfarin users (median age: 70 years old [interquartile range (IQR): 62-79], 56.66% males) with a median follow-up of 637.5 (IQR: 320-1073) days were included. In the matched cohort, edoxaban users had significantly lower rates of new onset hip fractures, medically attended falls and all-cause mortality. The protective value of edoxaban use against new onset hip fracture (hazard ratio [HR]: 0.13, 95% confidence interval [CI]: [0.03-0.54], p = 0.0051), medically attended falls (HR: 0.47, [0.29-0.75], p = 0.0018) and all-cause mortality (HR: 0.61, [0.42-0.87], p = 0.0059) in comparison to warfarin use persisted after matching. The significant relationship between edoxaban use and lower fracture risk was preserved in all sensitivity analyses using different approaches using the propensity score.Edoxaban use is associated with lower risks of new onset hip fractures, medically attended falls and mortality risks compared to warfarin after propensity score matching.

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

Highlights • Compared with 2016 and 2017, the population stress level, prevalence of anxiety and the depression symptoms drastically increased during the COVID-19 outbreak. • Older and less educated respondents tended to have deteriorated mental health outcomes. • Public mental health interventions are urgently needed particularly for the vulnerable groups., Objectives To compare the mental health burden before and during the COVID-19 outbreak and identified vulnerable groups by sociodemographic factors. Methods We analyzed repeated cross-sectional data from Hong Kong Family and Health Information Trend Survey (FHInTS) in 2016 (N = 4036) and 2017 (N = 4051) and COVID-19 Health Information Survey (CoVHInS) in April 9 to 23, 2020 (N = 1501) using population-based random samples of general adults by landline telephone and online panel. Stress (Perceived Stress Scale 4), anxiety symptoms (General Anxiety Disorders 2), depression symptoms (Patient Health Questionnaire-2), subjective happiness (4-point Likert item), and sociodemographic were collected. Results Compared with 2016 and 2017, the stress level increased by 28.3%, prevalence of anxiety increased by 42.3% and the depression symptoms and unhappiness have doubled (all p for trends

OBJECTIVES: The objective was to research and develop a novel curriculum on administrative leadership development within the discipline of emergency medicine (EM) with the goal of establishing and implementing it through the world's EM professional organizations. METHODS: From 2016 to 2018 an assessment of different administrative and leadership programs was performed by researching and reviewing previously outlined curricula. Using the data from this assessment, a questionnaire was developed, that was subsequently sent to members of the International Federation for Emergency Medicine's (IFEM) listserv. RESULTS: A total of 377 people from 38 different countries participated in the survey. The majority of respondents identified themselves as EM specialists (81%, 306/377), while others identified themselves as EM resident physicians (9.5%, 36/377) and non‐EM specialist physicians (4.5%, 17/377). A large majority of respondents articulated that there was a paucity of developed curricula focusing on leadership, administrative, and management principles within their institution, training program, or professional organization. Across all topic areas, fewer than 30% of polled individuals indicated that they had formal education related to individual and programmatic leadership development, change management, assessment methodology, negotiation skills, financial analysis, media relations, and health care policy. Quality improvement (QI) was the only curricular element that a majority of respondents had integrated into their clinical practice (61%). Qualitative data analysis of the narrative comments was performed with further evaluation of thematic components. CONCLUSIONS: The results of this study further support the findings that the majority of EM providers queried do not have a longitudinal curriculum that fosters administrative and leadership development nor advocate for its importance in relation to the quality of care. Given this gap, we propose that medical education at all levels—medical schools, EM resident/specialty training programs, and professional organizations—should consider creating administrative and leadership development programs. Additionally, development of any curriculum should require a global understanding of health care systems and awareness of the unique contexts of a given location and its available resources.