Causal association of genetically determined caffeine intake from tea or coffee with bone health: a two-sample Mendelian randomization study

BACKGROUND

Relationship of caffeine intake and consumption of caffeinated beverages, such as tea and coffee, with bone health remains controversial. This study aimed to evaluate whether genetically determined caffeine intake from tea or coffee has causal effects on overall total body bone mineral density (TB-BMD) and fracture. We also assessed the association with TB-BMD in five age strata.

METHODS

Using two-sample Mendelian randomization approach, summary statistics were retrieved from genome-wide association studies (GWAS)/GWAS meta-analyses of caffeine intake from tea (n = 395 866)/coffee (n = 373 522), TB-BMD (n = 66 628), and fracture (n = 426 795). Inverse variance weighted method was adopted as the main univariable analysis. Multivariable analysis was conducted to evaluate whether the causal effect is independent.

RESULTS

In univariable analysis, genetically determined caffeine intake from tea had positive association with overall TB-BMD (per SD increase in genetically determined caffeine intake, beta of TB-BMD [in SD]: 0.166; 95% confidence interval (CI): 0.006-0.326) and inverse association with fracture (OR = 0.79; 95% CI: 0.654-0.954). Genetically determined caffeine intake from coffee was also positively associated with overall TB-BMD (beta = 0.231; 95% CI: 0.093-0.369). The association remained significant after adjustment for smoking in multivariable analysis. Genetically determined caffeine intake from tea or coffee was both positively associated with TB-BMD in the age strata of 45-60 years, but we lacked evidence of association in other strata.

CONCLUSIONS

Genetically, caffeine intake from tea or coffee may be beneficial to bone health. Due to the ascertainment method of caffeine intake from tea, our study also implied genetically higher tea consumption may improve TB-BMD and lower fracture risk.

Low Bone Mineral Density as a Risk Factor for Liver Cirrhosis: A Prospective Cohort Study

CONTEXT

Bone metabolism interplays with liver metabolism, also known as the liver-bone axis. Osteoporosis is a common complication of cirrhosis, but whether bone mineral density (BMD) can predict cirrhosis development is unknown.

OBJECTIVE

This study aims to investigate the relationship between BMD and the risk of incident cirrhosis in the Hong Kong Osteoporosis Study (HKOS).

METHODS

BMD was measured at the lumbar spine, femoral neck, total hip, and trochanter of 7,752 participants by the dual-energy X-ray absorptiometer (DXA), and the incidence of cirrhosis and mortality were followed by linking to the territory-wide electronic health records database. Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% CI.

RESULTS

With a median follow-up of 18.43 years, 42 incident cirrhosis were identified. Higher BMD T-scores at the femoral neck, total hip and trochanter were significantly associated with a reduced risk of cirrhosis (femoral neck: HR 0.56, 95% CI 0.39 to 0.82; total hip: HR 0.60, 95% CI 0.44 to 0.82; trochanter: HR 0.63, 95% CI 0.46 to 0.88). Similar associations were observed in participants without risk factors of cirrhosis at the baseline and further adjusting for the baseline level of alkaline phosphatase, albumin, and alanine transaminase. Consistent relationships in multiple sensitivity analyses suggest the robustness of the results.

CONCLUSION

Low BMD could be a novel risk factor and early predictor for cirrhosis, with consistent associations observed in multiple sensitivity analyses.

The trends in lung cancer prevalence, incidence, and survival in Hong Kong over the past two decades (2002-2021): a population-based study

Background

Over the past decades, significant progress in lung cancer management has been made. However, the trends in prevalence and survival of lung cancer in the Chinese population over the last decade remain unexplored. This study utilised a territory-wide electronic medical database in Hong Kong to provide the most up-to-date and comprehensive analysis of the trends in prevalence, incidence, and survival over the past two decades.

Methods

Descriptive epidemiology study using a retrospective cohort of lung cancer patients from the Clinical Data Analysis and Reporting System (CDARS). 10-year limited-duration prevalence, incidence, and relative period survival were calculated between 2002 and 2021. Sub-groups of age, sex, and comorbidity were examined. The annual percent change (APC) and average annual percent change (AAPC) were estimated using joinpoint regression.

Findings

This study included 87,259 incident cases between 2002 and 2021. The 10-year limited duration prevalence (per 100,000 persons) of lung cancer increased from 153.4 to 228.7 (AAPC: 3.08%). Crude incidence (per 100,000 persons) increased from 55.0 to 70.3 (APC: 1.23%), while age-standardised incidence decreased from 42.9 to 33.2 (APC: -1.32%). The 1-year and 5-year relative period survivals showed an increasing trend but remained low. Disparity in trends was observed among different sex and age groups.

Interpretation

Lung cancer burden has been increasing partly due to population ageing. Although survival showed improvement over the years, it remained low, highlighting the potential need for interventions. Further study exploring the disparity in sex-specific trends is warranted.

Funding

The Innovation and Technology Commission, Hong Kong.

Risk of Incident Thyroid Dysfunction in the Post-Acute Phase of COVID-19: A Population-Based Cohort Study in Hong Kong

OBJECTIVE

The evidence of thyroid dysfunction in the post-acute phase of SARS-CoV-2 infection is limited. This study aimed to evaluate the risk of incident thyroid dysfunction in the post-acute phase of COVID-19.

METHODS

This retrospective, propensity-score matched, population-based study included COVID-19 patients and non-COVID-19 individuals between January 2020 and March 2022, identified from the electronic medical records of the Hong Kong Hospital Authority. The cohort was followed up until the occurrence of outcomes, death, or 31 January 2023, whichever came first. Patients with COVID-19 were 1:1 matched to controls based on various variables. The primary outcome was a composite of thyroid dysfunction (hyperthyroidism, hypothyroidism, initiation of antithyroid drug or levothyroxine, and thyroiditis). Cox regression was employed to evaluate the risk of incident thyroid dysfunction during the post-acute phase.

RESULTS

A total of 84 034 COVID-19 survivors and 84 034 matched controls were identified. Upon a median follow-up of 303 days, there was no significant increase in the risk of diagnosed thyroid dysfunction in the post-acute phase of COVID-19 (hazard ratio [HR] 1.058, 95% confidence interval 0.979-1.144, P = .154). Regarding the secondary outcomes, patients with COVID-19 did not have increased risk of hyperthyroidism (HR 1.061, P = .345), hypothyroidism (HR 1.062, P = .255), initiation of antithyroid drug (HR 1.302, P = .070), initiation of levothyroxine (HR 1.086, P = .426), or thyroiditis (P = .252). Subgroup and sensitivity analyses were largely consistent with the main analyses.

CONCLUSION

Our population-based cohort study provided important reassuring data that COVID-19 was unlikely to be associated with persistent effects on thyroid function.

Risks of incident major osteoporotic fractures following SARS-CoV-2 infection among older individuals: a population-based cohort study in Hong Kong

Population-based epidemiological studies on post-acute phase COVID-19-related fractures in older adults are lacking. This study aims to examine the risk of incident major osteoporotic fractures following COVID-19 infection among individuals aged ≥50, compared to individuals without COVID-19. It was a retrospective, propensity-score matched, population-based cohort study of COVID-19 patients and non-COVID individuals identified from the electronic database of the Hong Kong Hospital Authority from January 2020 to March 2022. The primary outcome was a composite of major osteoporotic fractures (hip, clinical vertebral, and upper limb). COVID-19 patients were 1:1 matched to controls using propensity-score according to age, sex, vaccination status, medical comorbidities and baseline medications. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression models. A total of 429 459 COVID-19 patients were included, 1:1 matched to non-COVID individuals. Upon median follow-up of 11 months, COVID-19 patients had higher risks of major osteoporotic fractures (5.08 vs 3.95 per 1000 persons; HR 1.22 95%CI [1.15-1.31]), hip fractures (2.71 vs 1.94; 1.33 [1.22-1.46]), clinical vertebral fractures (0.42 vs 0.31; 1.29 [1.03-1.62]) and falls (13.83 vs 10.36; 1.28 [1.23-1.33]). Subgroup analyses revealed no significant interaction. In acute (within 30 days) and post-acute phases (beyond 30 days) following SARS-CoV-2 infection, we consistently observed a significant increase in fractures and falls risks. Our study demonstrated increased risk of major osteoporotic fractures after SARS-CoV-2 infection in both acute and post-acute phases in older adults, partly due to increased fall risk. Clinicians should be aware of musculoskeletal health of COVID-19 survivors.

Elevated risk of multimorbidity post-COVID-19 infection: protective effect of vaccination

BACKGROUND

It is unclear how the coronavirus disease 2019 (Covid-19) pandemic has affected multimorbidity incidence among those with one pre-existing chronic condition, as well as how vaccination could modify this association.

AIM

To examine the association of Covid-19 infection with multimorbidity incidence among people with one pre-existing chronic condition, including those with prior vaccination.

DESIGN

Nested case-control study.

METHODS

We conducted a territory-wide nested case-control study with incidence density sampling using Hong Kong electronic health records from public healthcare facilities and mandatory Covid-19 reports. People with one listed chronic condition (based on a list of 30) who developed multimorbidity during 1 January 2020-15 November 2022 were selected as case participants and randomly matched with up to 10 people of the same age, sex and with the same first chronic condition without having developed multimorbidity at that point. Conditional logistic regression was used to estimate adjusted odds ratios (aORs) of multimorbidity.

RESULTS

In total, 127 744 case participants were matched with 1 230 636 control participants. Adjusted analysis showed that there were 28%-increased odds of multimorbidity following Covid-19 [confidence interval (CI) 22% to 36%] but only 3% (non-significant) with prior full vaccination with BNT162b2 or CoronaVac (95% CI -2% to 7%). Similar associations were observed in men, women, older people aged 65 or more, and people aged 64 or younger.

CONCLUSIONS

We found a significantly elevated risk of multimorbidity following a Covid-19 episode among people with one pre-existing chronic condition. Full vaccination significantly reduced this risk increase.

Effectiveness and Respiratory Adverse Events Following Inactivated and mRNA COVID-19 Vaccines in Patients with COPD and Asthma: A Chinese Population-Based Study

INTRODUCTION

Effectiveness and respiratory adverse events following coronavirus disease-2019 (COVID-19) vaccines have not been well investigated in Chinese patients with chronic obstructive pulmonary disease (COPD) and asthma.

METHODS

Using electronic health care records in Hong Kong, we included adults with COPD or asthma or both and hospitalised for severe respiratory exacerbation in a self-controlled case series (SCCS) study between 23/02/2021 and 30/11/2022. Conditional Poisson regression models were used to estimate the incidence of outcomes within exposure periods (28 days after each dose) compared with baseline periods. Cox proportional hazard models evaluated vaccine effectiveness (VE) against COVID-related mortality, hospitalisation, and severe complications, including admission to intensive care units or ventilatory support. The VE assessment was based on vaccine types and the number of doses.

RESULTS

In the SCCS, 343 CoronaVac recipients and 212 BNT162b2 recipients were included. No increased risk of outcomes was observed within the exposure periods. In the cohort study, 108,423 and 83,323 patients received ≥ 2 doses of CoronaVac and BNT162b2, respectively. The VE (95% CI) against COVID-related mortality, hospitalisation, and severe complications after two-dose CoronaVac was 77% (74-80%), 18% (6-23%), and 29% (12-43%), respectively, while for the two-dose regimen of BNT162b2, it was 92% (91-94%), 33% (30-37%), and 57% (45-66%), respectively. Higher VE against COVID-related mortality, hospitalisation, and severe complications was found for the three-dose regimen of CoronaVac (94%, 40%, and 71%) and BNT162b2 (98%, 65%, and 83%). Administering a fourth dose of either vaccine showed additional reductions in COVID-related outcomes.

CONCLUSIONS

Among people with COPD and asthma, the COVID-19 vaccines CoronaVac and BNT162b2 did not increase severe exacerbations and achieved moderate-to-high effectiveness against COVID-related outcomes. COVID-19 vaccination remains essential and should be encouraged to protect this vulnerable population in future epidemic waves.

Bone-targeting agents in major solid tumour metastases: a multinational cohort study

OBJECTIVE

To describe the epidemiology, clinical characteristics and utilisation patterns of bone-targeting agents (BTAs) in patients with bone metastases from breast, prostate and lung cancer.

METHODS

This is a multinational retrospective cohort study including patients with three major solid tumours (breast, prostate and lung cancer) and newly initiated on BTAs (ie, denosumab, zoledronic acid and pamidronate). Records were retrieved from nationwide health databases from Hong Kong and Taiwan (HK and TW: 2013-2017) and Korea (KR: 2012-2016). Descriptive analyses included the annual incidence rates of bone metastases and the cumulative incidence curves of BTA initiation. We used Sankey diagrams to visualise the dynamic BTA utilisation patterns.

RESULTS

The annual incidence rate of bone metastases ranged from 3.5% to 4.5% in TW, from 9.6% to 10.3% in HK and from 2.9% to 3.8% in KR. We identified 14.1% (5127), 9.3% (883) and 9.4% (4800) of patients with bone metastases newly initiated on BTAs in TW, HK and KR, respectively. The most frequently used BTA in TW (67.1%) and HK (51.9%) was denosumab, while in KR (84.8%) it was zoledronic acid. Sankey diagrams indicated the proportion of patients remaining on denosumab was highest in TW and HK, while it was zoledronic acid in KR. Specifically, in TW, patients who were on bisphosphonates or had discontinued treatment frequently switched to or reinitiated denosumab.

CONCLUSIONS

We found the rate of BTA utilisation remained low across all sites and tumour types in recent years. The dynamic utilisation patterns of BTAs provide better understanding of the treatment landscape for future evaluation of associated outcomes of patients.

Association of Bone Mineral Density and Bone Turnover Markers with the Risk of Diabetes: Hong Kong Osteoporosis Study and Mendelian Randomization

Preclinical studies demonstrated that bone plays a central role in energy metabolism. However, how bone metabolism is related to the risk of diabetes in humans is unknown. We investigated the association of bone health (bone mineral density [BMD] and bone turnover markers) with incident type-2 diabetes mellitus (T2DM) based on the Hong Kong Osteoporosis Study (HKOS). A total of 993 and 7160 participants from the HKOS were studied for the cross-sectional and prospective analyses, respectively. The cross-sectional study evaluated the association of BMD and bone biomarkers with fasting glucose and glycated hemoglobin (HbA1c ) levels, whereas the prospective study examined the associations between BMD at study sites and the risk of T2DM by following subjects a median of 16.8 years. Body mass index (BMI) was adjusted in all full models. Mendelian randomization (MR) was conducted for causal inference. In the cross-sectional analysis, lower levels of circulating bone turnover markers and higher BMD were significantly associated with increased fasting glucose and HbA1c levels. In the prospective analysis, higher BMD (0.1 g/cm2 ) at the femoral neck and total hip was associated with increased risk of T2DM with hazard ratios (HRs) of 1.10 (95% confidence interval [CI], 1.03 to 1.18) and 1.14 (95% CI, 1.08 to 1.21), respectively. The presence of osteoporosis was associated with a 30% reduction in risk of T2DM compared to those with normal BMD (HR = 0.70; 95% CI, 0.55 to 0.90). The MR results indicate a robust genetic causal association of estimated BMD (eBMD) with 2-h glucose level after an oral glucose challenge test (estimate = 0.043; 95% CI, 0.007 to 0.079) and T2DM (odds ratio = 1.064; 95% CI, 1.036 to 1.093). Higher BMD and lower levels of circulating bone biomarkers were cross-sectionally associated with poor glycemic control. Moreover, higher BMD was associated with a higher risk of incident T2DM and the association is probably causal. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Levothyroxine Treatment Among Pregnant Women and Risk of Seizure in Children: A Population-Based Cohort Study

INTRODUCTION AND OBJECTIVE

The risk of seizure in offspring following prenatal exposure to levothyroxine is not well investigated. This study aimed to evaluate the association between levothyroxine treatment among pregnant women and the risk of seizure in their offspring.

METHODS

This population-based cohort study included all pregnant women who delivered a live birth between January 2001 to January 2018, with a follow-up to December 2020, using data from the Hong Kong Clinical Data Analysis and Reporting System. Propensity score fine-stratification weighted hazard ratios (wHR) with 95% confidence intervals (CIs) were presented to assess the association between maternal levothyroxine use during pregnancy and seizures in children.

RESULTS

Among 528,343 included mother-child pairs, 3044 children were prenatally exposed to levothyroxine at any time during the pregnancy period. A significantly increased risk of seizure was observed in children of the prenatally exposed group compared with the prenatally unexposed group (wHR 1.12, 95% CI 1.02-1.22). An increased risk of seizure was observed when comparing the prenatally exposed group with euthyroid mothers who had no history of thyroid-related diagnosis or prescriptions (wHR 1.12, 95% CI 1.02-1.23). However, no significant difference was observed between the prenatally exposed group and those previously exposed to levothyroxine but had stopped during pregnancy (wHR 0.97, 95% CI 0.66-1.44). No significant difference was observed in the sibling-matched analysis either (wHR 1.23, 95% CI 0.76-2.01).

CONCLUSION

The observed increased risk of seizure in children born from mothers exposed to levothyroxine during pregnancy might be due to residual confounding by maternal thyroid disease. The findings support the current guidelines on the safe use of levothyroxine treatment during pregnancy.

Validation of diagnostic coding for bronchiectasis in an electronic health record system in Hong Kong

BACKGROUND AND OBJECTIVE

Electronic medical record (EMR) databases can facilitate epidemiology research in various diseases including bronchiectasis. Given the diagnostic challenges of bronchiectasis, the validity of the coding in EMR requires clarification. We aimed to assess the validity of International Classification of Diseases, 9th Revision (ICD-9) code algorithms for identifying bronchiectasis in the territory-wide electronic medical health record system of Clinical Data Analysis and Reporting System (CDARS) in Hong Kong.

MATERIALS AND METHODS

Adult patients who had the diagnosis of bronchiectasis input from Queen Mary Hospital in 2011-2020 were identified using the ICD-9 code of 494 by CDARS. All patients who had high resolution computed tomography (HRCT) were reviewed by respiratory specialists to confirm the presence of bronchiectasis on HRCT.

RESULTS

A total of 19 617 patients who had the diagnostic code of bronchiectasis among all public hospitals in Hong Kong and 1866 in Queen Mary Hospital in the same period. Six hundred and forty-eight cases were randomly selected and validated using medical record and HRCT review by a respiratory specialist. The overall positive predictive value (PPV) was 92.7% (95% CI 90.7-94.7).

CONCLUSIONS

This was the first ICD-9 coding validation for bronchiectasis in Hong Kong CDARS. Our study demonstrated that using ICD-9 code of 494 was reliable to support utility of CDARS database for further clinical research on bronchiectasis.

GWAS meta-analysis of over 29,000 people with epilepsy identifies 26 risk loci and subtype-specific genetic architecture

Epilepsy is a highly heritable disorder affecting over 50 million people worldwide, of which about one-third are resistant to current treatments. Here we report a multi-ancestry genome-wide association study including 29,944 cases, stratified into three broad categories and seven subtypes of epilepsy, and 52,538 controls. We identify 26 genome-wide significant loci, 19 of which are specific to genetic generalized epilepsy (GGE). We implicate 29 likely causal genes underlying these 26 loci. SNP-based heritability analyses show that common variants explain between 39.6% and 90% of genetic risk for GGE and its subtypes. Subtype analysis revealed markedly different genetic architectures between focal and generalized epilepsies. Gene-set analyses of GGE signals implicate synaptic processes in both excitatory and inhibitory neurons in the brain. Prioritized candidate genes overlap with monogenic epilepsy genes and with targets of current antiseizure medications. Finally, we leverage our results to identify alternate drugs with predicted efficacy if repurposed for epilepsy treatment.

Illicit drug use is associated with lower bone mineral density and bone strength

Objectives

To evaluate the association of illicit drug use with bone mineral density (BMD) and hip geometric parameters at the narrow neck.

Methods

This is a cross-sectional matched cohort study conducted in the Hong Kong Chinese population. Associations with illicit drug use were estimated using linear regression for BMD (lumbar spine and femoral neck) and hip geometrical parameters (cross-sectional area [CSA], cross-sectional moment of inertia [CSMI], section modulus [SM], average cortical thickness [ACT] and BMD at the narrow neck) after adjusting for age, body mass index (BMI), smoking status, drinking status, physical activity, and history of antipsychotic and antidepressant use. Mean difference and 95% confidence intervals (95% CI) were calculated between 108 illicit drug users and 108 controls using an adjusted linear model and cluster-robust standard errors after matching by age and sex. The false discovery rate was used to correct for multiple testing.

Results

Illicit drug users had a significantly lower BMD (g/cm2) at the lumbar spine (mean difference: -0.062; 95% CI: -0.108 to -0.015), and femoral neck (mean difference: -0.058; 95% CI: -0.106 to -0.010) in the fully adjusted model. Illicit drug users also had a significantly lower CSA (mean difference: -0.238 cm2; 95% CI: -0.462 to -0.013), ACT (mean difference: -0.018 cm; 95% CI: -0.030 to -0.006) and BMD (mean difference: -0.070 g/cm2; 95% CI: -0.128 to -0.012) at the narrow neck.

Conclusions

Illicit drug use is associated with lower BMD and bone strength. Future studies evaluating the risk of illicit drug use with fragility fracture are warranted.

COVID-19 and cognitive performance: a Mendelian randomization study

Background

A substantial proportion of individuals with COVID-19 experienced cognitive impairment after resolution of SARS-CoV-2 infection. We aimed to evaluate whether genetic liability to SARS-CoV-2 infection per se, or more severe COVID-19, is causally linked to cognitive deficit.

Methods

We firstly performed univariable Mendelian randomization (MR) analysis to examine whether genetic liability to SARS-CoV-2 infection, hospitalized and severe COVID-19 is causally associated with cognitive performance. To dissect the causal pathway, multivariable MR (MVMR) analysis was conducted by adjusting for five inflammatory markers [C-reactive protein, interleukin (IL)-1β, IL-6, IL-8, and tumour necrosis factor α, as proxies of systemic inflammation].

Results

In univariable MR analysis, host genetic liability to SARS-CoV-2 infection was associated with lower cognitive performance [inverse variance weighted (IVW) analysis, estimate: -0.023; 95% Confidence Interval (CI): -0.038 to -0.009]. Such causal association was attenuated in MVMR analysis when we adjusted for the five correlated inflammatory markers in one analysis (IVW analysis, estimate: -0.022; 95% CI: -0.049 to 0.004). There was insufficient evidence of association for genetic liability to hospitalized and severe COVID-19 with cognitive performance.

Conclusion

The causal effect of host genetic liability to SARS-CoV-2 infection on reduced cognitive performance may be mediated by systemic inflammation. Future studies examining whether anti-inflammatory agents could alleviate cognitive impairment in SARS-CoV-2-infected individuals are warranted.

Global Epidemiology of Hip Fractures: Secular Trends in Incidence Rate, Post-Fracture Treatment, and All-Cause Mortality

In this international study, we examined the incidence of hip fractures, postfracture treatment, and all-cause mortality following hip fractures, based on demographics, geography, and calendar year. We used patient-level healthcare data from 19 countries and regions to identify patients aged 50 years and older hospitalized with a hip fracture from 2005 to 2018. The age- and sex-standardized incidence rates of hip fractures, post-hip fracture treatment (defined as the proportion of patients receiving anti-osteoporosis medication with various mechanisms of action [bisphosphonates, denosumab, raloxifene, strontium ranelate, or teriparatide] following a hip fracture), and the all-cause mortality rates after hip fractures were estimated using a standardized protocol and common data model. The number of hip fractures in 2050 was projected based on trends in the incidence and estimated future population demographics. In total, 4,115,046 hip fractures were identified from 20 databases. The reported age- and sex-standardized incidence rates of hip fractures ranged from 95.1 (95% confidence interval [CI] 94.8-95.4) in Brazil to 315.9 (95% CI 314.0-317.7) in Denmark per 100,000 population. Incidence rates decreased over the study period in most countries; however, the estimated total annual number of hip fractures nearly doubled from 2018 to 2050. Within 1 year following a hip fracture, post-hip fracture treatment ranged from 11.5% (95% CI 11.1% to 11.9%) in Germany to 50.3% (95% CI 50.0% to 50.7%) in the United Kingdom, and all-cause mortality rates ranged from 14.4% (95% CI 14.0% to 14.8%) in Singapore to 28.3% (95% CI 28.0% to 28.6%) in the United Kingdom. Males had lower use of anti-osteoporosis medication than females, higher rates of all-cause mortality, and a larger increase in the projected number of hip fractures by 2050. Substantial variations exist in the global epidemiology of hip fractures and postfracture outcomes. Our findings inform possible actions to reduce the projected public health burden of osteoporotic fractures among the aging population. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Incidence of diabetes following COVID-19 vaccination and SARS-CoV-2 infection in Hong Kong: A population-based cohort study

BACKGROUND

The risk of incident diabetes following Coronavirus Disease 2019 (COVID-19) vaccination remains to be elucidated. Also, it is unclear whether the risk of incident diabetes after Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is modified by vaccination status or differs by SARS-CoV-2 variants. We evaluated the incidence of diabetes following mRNA (BNT162b2), inactivated (CoronaVac) COVID-19 vaccines, and after SARS-CoV-2 infection.

METHODS AND FINDINGS

In this population-based cohort study, individuals without known diabetes were identified from an electronic health database in Hong Kong. The first cohort included people who received ≥1 dose of COVID-19 vaccine and those who did not receive any COVID-19 vaccines up to September 2021. The second cohort consisted of confirmed COVID-19 patients and people who were never infected up to March 2022. Both cohorts were followed until August 15, 2022. A total of 325,715 COVID-19 vaccine recipients (CoronaVac: 167,337; BNT162b2: 158,378) and 145,199 COVID-19 patients were 1:1 matched to their respective controls using propensity score for various baseline characteristics. We also adjusted for previous SARS-CoV-2 infection when estimating the conditional probability of receiving vaccinations, and vaccination status when estimating the conditional probability of contracting SARS-CoV-2 infection. Hazard ratios (HRs) and 95% confidence intervals (CIs) for incident diabetes were estimated using Cox regression models. In the first cohort, we identified 5,760 and 4,411 diabetes cases after receiving CoronaVac and BNT162b2 vaccines, respectively. Upon a median follow-up of 384 to 386 days, there was no evidence of increased risks of incident diabetes following CoronaVac or BNT162b2 vaccination (CoronaVac: 9.08 versus 9.10 per 100,000 person-days, HR = 0.998 [95% CI 0.962 to 1.035]; BNT162b2: 7.41 versus 8.58, HR = 0.862 [0.828 to 0.897]), regardless of diabetes type. In the second cohort, we observed 2,109 cases of diabetes following SARS-CoV-2 infection. Upon a median follow-up of 164 days, SARS-CoV-2 infection was associated with significantly higher risk of incident diabetes (9.04 versus 7.38, HR = 1.225 [1.150 to 1.305])-mainly type 2 diabetes-regardless of predominant circulating variants, albeit lower with Omicron variants (p for interaction = 0.009). The number needed to harm at 6 months was 406 for 1 additional diabetes case. Subgroup analysis revealed no evidence of increased risk of incident diabetes among fully vaccinated COVID-19 survivors. Main limitations of our study included possible misclassification bias as type 1 diabetes was identified through diagnostic coding and possible residual confounders due to its observational nature.

CONCLUSIONS

There was no evidence of increased risks of incident diabetes following COVID-19 vaccination. The risk of incident diabetes increased following SARS-CoV-2 infection, mainly type 2 diabetes. The excess risk was lower, but still statistically significant, for Omicron variants. Fully vaccinated individuals might be protected from risks of incident diabetes following SARS-CoV-2 infection.

Effectiveness of BNT162b2 after extending the primary series dosing interval in children and adolescents aged 5-17

Extended intervals between the first and second doses of mRNA Covid-19 vaccines may reduce the risk of myocarditis in children and adolescents. However, vaccine effectiveness after this extension remains unclear. To examine this potential variable effectiveness, we conducted a population-based nested case-control study of children and adolescents aged 5-17 years who had received two doses of BNT162b2 in Hong Kong. From January 1 to August 15, 2022, 5396 Covid-19 cases and 202 Covid-19 related hospitalizations were identified and matched with 21,577 and 808 controls, respectively. For vaccine recipients with extended intervals [≥28 days, adjusted odds ratio 0.718, 95% Confidence Interval: 0.619, 0.833] there was a 29.2%-reduced risk of Covid-19 infection compared to those with regular intervals (21-27 days). If the threshold was set at eight weeks, the risk reduction was estimated at 43.5% (aOR 0.565, 95% CI: 0.456, 0.700). In conclusion, longer dosing intervals for children and adolescents should be considered.

Development and validation of sex-specific hip fracture prediction models using electronic health records: a retrospective, population-based cohort study

BACKGROUND

Hip fracture is associated with immobility, morbidity, mortality, and high medical cost. Due to limited availability of dual-energy X-ray absorptiometry (DXA), hip fracture prediction models without using bone mineral density (BMD) data are essential. We aimed to develop and validate 10-year sex-specific hip fracture prediction models using electronic health records (EHR) without BMD.

METHODS

In this retrospective, population-based cohort study, anonymized medical records were retrieved from the Clinical Data Analysis and Reporting System for public healthcare service users in Hong Kong aged ≥60 years as of 31 December 2005. A total of 161,051 individuals (91,926 female; 69,125 male) with complete follow-up from 1 January 2006 till the study end date on 31 December 2015 were included in the derivation cohort. The sex-stratified derivation cohort was randomly divided into 80% training and 20% internal testing datasets. An independent validation cohort comprised 3046 community-dwelling participants aged ≥60 years as of 31 December 2005 from the Hong Kong Osteoporosis Study, a prospective cohort which recruited participants between 1995 and 2010. With 395 potential predictors (age, diagnosis, and drug prescription records from EHR), 10-year sex-specific hip fracture prediction models were developed using stepwise selection by logistic regression (LR) and four machine learning (ML) algorithms (gradient boosting machine, random forest, eXtreme gradient boosting, and single-layer neural networks) in the training cohort. Model performance was evaluated in both internal and independent validation cohorts.

FINDINGS

In female, the LR model had the highest AUC (0.815; 95% Confidence Interval [CI]: 0.805-0.825) and adequate calibration in internal validation. Reclassification metrics showed the LR model had better discrimination and classification performance than the ML algorithms. Similar performance was attained by the LR model in independent validation, with high AUC (0.841; 95% CI: 0.807-0.87) comparable to other ML algorithms. In internal validation for male, LR model had high AUC (0.818; 95% CI: 0.801-0.834) and it outperformed all ML models as indicated by reclassification metrics, with adequate calibration. In independent validation, the LR model had high AUC (0.898; 95% CI: 0.857-0.939) comparable to ML algorithms. Reclassification metrics demonstrated that LR model had the best discrimination performance.

INTERPRETATION

Even without using BMD data, the 10-year hip fracture prediction models developed by conventional LR had better discrimination performance than the models developed by ML algorithms. Upon further validation in independent cohorts, the LR models could be integrated into the routine clinical workflow, aiding the identification of people at high risk for DXA scan.

FUNDING

Health and Medical Research Fund, Health Bureau, Hong Kong SAR Government (reference: 17181381).

Treatment with methylphenidate and the risk of fractures among children and young people: a systematic review and self-controlled case series study

INTRODUCTION

Animal studies suggest that methylphenidate treatment for around 3 months may lead to less mineralized and weaker appendicular bones. A systematic review was conducted to summarize the evidence from observational studies, and a self-controlled case series study was used to compare the risk before and after treatment initiation.

METHODS

Literature search was conducted using PubMed, Embase, and the Cochrane Library to identify observational studies on methylphenidate and fractures. We also conducted a self-controlled case series study with individuals aged from 5-24 years who received methylphenidate treatment and experienced fractures from 2001-2020 in Hong Kong. Incidence rate ratios and 95% confidence intervals were calculated by comparing the incidence rate in the methylphenidate-exposed period compared to non-exposed period.

RESULTS

Six cohort studies and two case-control studies were included. For all-cause fractures, studies found a 39-74% lower risk in treated-ADHD group compared with untreated-ADHD, but no difference between stimulants and non-stimulants. Differences between sexes and treatment duration were also found - significant results were shown in males and those with longer treatment duration. Among 43,841 individuals with ADHD medication before year 2020, 2,203 were included in the self-controlled case series analysis. The risks of fractures were lower by 32-41% in the different treatment periods when compared with 6-month before treatment initiation.

CONCLUSION

In conclusion, methylphenidate treatment may lower the risk of all-cause fractures from both study designs, however, further evidence is needed about the treatment duration and sex effect. Conclusions on stress fractures are not yet established and further research is required.

Development and validation of the Chinese osteoporosis screening algorithm (COSA) in identification of people with high risk of osteoporosis

Objectives

To enhance the public awareness and facilitate diagnosis of osteoporosis, we aim to develop a new Chinese Osteoporosis Screening Algorithm (COSA) to identify people at high risk of osteoporosis.

Methods

A total of 4747 postmenopausal women and men aged ≥ 50 from the Hong Kong Osteoporosis Study were randomly split into a development (N = 2373) and an internal validation cohort (N = 2374). An external validation cohort comprising 1876 community-dwelling subjects was used to evaluate the positive predictive value (PPV).

Results

Among 11 predictors included, age, sex, weight, and history of fracture were significantly associated with osteoporosis after correction for multiple testing. Age- and sex-stratified models were developed due to the presence of significant sex and age interactions. The area under the curve of the COSA in the internal validation cohort was 0.761 (95% CI, 0.711-0.811), 0.822 (95% CI, 0.792-0.851), and 0.946 (95% CI, 0.908-0.984) for women aged < 65, women aged ≥ 65, and men, respectively. The COSA demonstrated improved reclassification performance when compared to Osteoporosis Self-Assessment Tool for Asians. In the external validation cohort, the PPV of COSA was 40.6%, 59.4%, and 19.4% for women aged < 65, women aged ≥ 65, and men, respectively. In addition, COSA > 0 was associated with an increased 10-year risk of hip fracture in women ≥ 65 (OR, 4.65; 95% CI, 2.24-9.65) and men (OR, 11.51; 95% CI, 4.16-31.81).

Conclusions

We have developed and validated a new osteoporosis screening algorithm, COSA, specific for Hong Kong Chinese.

Validation of Diagnostic Coding for Asthma in an Electronic Health Record System in Hong Kong

Background

Electronic health record (EHR) databases can facilitate epidemiology research into various diseases including asthma. Given the diagnostic challenges of asthma, the validity of the coding in EHR requires clarification. We aimed to assess the validity of International Classification of Diseases, 9th Revision (ICD-9) code algorithms for identifying asthma in the territory-wide electronic medical health record system of the Clinical Data Analysis and Reporting System (CDARS) in Hong Kong.

Methods

Adult patients who had the diagnosis of asthma input from all public hospitals in Hong Kong and those from Queen Mary Hospital in 2011-2020 were identified using the ICD-9 code of 493 (493.0, 493.1, 493.2, and 493.9) by CDARS. Patients' clinical record and spirometry were reviewed by two respiratory specialists to confirm the presence of asthma in the randomly selected cases.

Results

There were 43,454 patients who had the diagnostic code of asthma among all public hospitals in Hong Kong and 1852 in Queen Mary Hospital in the same period. A total of 200 cases were randomly selected and validated using medical record and spirometry review by a respiratory specialist. The overall positive predictive value (PPV) was 85.0% (95% CI 80.1-89.9%).

Conclusion

This was the first ICD-9 code validation for CDARS (EHR) in Hong Kong on asthma. Our study demonstrated that using ICD-9 code (493.0, 493.1, 493.2 and 493.9) to identify asthma can result in a PPV that was reliable to support the utility of the CDARS database for further research on asthma among the Hong Kong population.

Association of Sodium-Glucose Cotransporter 2 Inhibitor vs Dipeptidyl Peptidase-4 Inhibitor Use With Risk of Incident Obstructive Airway Disease and Exacerbation Events Among Patients With Type 2 Diabetes in Hong Kong

IMPORTANCE

Patients with diabetes are at higher risk for obstructive airway disease (OAD). In recent meta-analyses of post hoc analyses of cardiorenal trials, sodium-glucose cotransporter 2 inhibitors (SGLT2Is) were suggested to reduce the risk of OAD adverse events. However, a clinical investigation of this association is warranted.

OBJECTIVE

This study aimed to investigate the association of SGLT2I use vs dipeptidyl peptidase-4 inhibitor (DPP4I) use with OAD incidence and exacerbation events in patients with type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study used electronic health data from a territory-wide electronic medical database in Hong Kong. Data were collected for patients with type 2 diabetes who were prescribed SGLT2Is or DPP4Is between January 1, 2015, and December 31, 2018. Patients were followed for a median of 2.2 years between January 1, 2015, and December 31, 2020. A prevalent new-user design was adopted to match patients based on previous exposure to the study drugs. Propensity score matching was used to balance baseline characteristics.

EXPOSURES

Patients with type 2 diabetes using SGLT2Is (exposure of interest) or DPP4Is (active comparator).

MAIN OUTCOMES AND MEASURES

The main outcomes were the first incidence of OAD and the count of OAD exacerbations. The risk of incident OAD was estimated using a Cox proportional hazards regression model. The rate of exacerbations was estimated using zero-inflated Poisson regression. Statistical analysis was performed on November 13, 2022.

RESULTS

This study included 30 385 patients. The propensity score-matched non-OAD cohort (incidence analysis) consisted of 5696 SGLT2I users and 22 784 DPP4I users, while the matched OAD cohort (exacerbations analysis) comprised 381 SGLT2I users and 1524 DPP4I users. At baseline, 56% of patients in the non-OAD cohort were men and the mean (SD) age was 61.2 (9.9) years; 51% of patients in the OAD cohort were men and the mean age was 62.2 (10.8) years. Compared with DPP4I use, SGLT2I use was associated with a lower risk of incident OAD (hazard ratio, 0.65 [95% CI, 0.54-0.79]; P < .001) and a lower rate of exacerbations (rate ratio, 0.54 [95% CI, 0.36-0.83]; P = .01). The associations were consistent in sex subgroup analysis.

CONCLUSIONS AND RELEVANCE

The findings of this retrospective cohort study of patients with type 2 diabetes in Hong Kong suggest that SGLT2I use was associated with a reduced risk of incident OAD and a lower rate of exacerbations in a clinical setting compared with DPP4I use. These findings further suggest that SGLT2Is may provide additional protective effects against OAD for patients with type 2 diabetes and that further investigation is warranted.

Unravelling genetic causality of haematopoiesis on bone metabolism in human

OBJECTIVE

Haematopoiesis was shown to regulate bone metabolism in in vivo studies. However, whether haematopoiesis has causal effects on bone health has never been investigated in humans. We aimed to evaluate the causal relationships of blood traits with bone mineral density (BMD) and fracture.

DESIGN AND METHODS

Using two-sample Mendelian randomization, causal relationship of 29 blood traits with estimated BMD (eBMD), total body BMD (TBBMD), lumbar spine BMD (LSBMD), femoral neck BMD (FNBMD) and fracture were evaluated by inverse-variance weighted (IVW) method and multiple sensitivity analyses. Relevant genetic data were obtained from the largest possible publicly available genome-wide association studies.

RESULTS

Eight genetically determined red blood cell traits showed positive causal effects on eBMD, with beta estimates ranging from 0.009 (mean corpuscular haemoglobin) to 0.057 (haemoglobin concentration), while three white blood cell traits, including lymphocyte count (beta: -0.020; 95% CI: -0.033 to -0.007), neutrophil count (beta: -0.020; 95% CI: -0.035 to -0.006) and white blood cell count (beta: -0.027; 95% CI: -0.039 to -0.014), were inversely associated with eBMD. Causal effects for six of these blood traits were validated on TBBMD, LSBMD, FNBMD and/or fracture. The association of reticulocyte count (beta: 0.040; 95% CI: 0.016 to 0.063), haemoglobin (beta: 0.058; 95% CI: 0.021 to 0.094) and mean corpuscular haemoglobin concentration (beta: 0.030; 95% CI: 0.007 to 0.054) with eBMD remained significant in multivariable IVW analyses adjusted for other blood traits.

CONCLUSION

This study provided evidence that haematopoietic system might regulate the skeletal system in humans and suggested the possible pathophysiology of bone diseases among people with haematological diseases.

SIGNIFICANCE STATEMENT

We conducted a novel Mendelian randomization study investigating the causal relationship of blood cells with bone mineral density. Red and white blood cell traits have positive and inverse causal relationship with bone mineral density, respectively, suggesting a potential link of haematopoietic system with the skeletal system in humans. Current findings suggest individuals with related haematological diseases, such as anaemia and leukocytosis, may have a lifelong increased risk of osteoporosis and/or fracture. Given that complete blood count is commonly performed in clinical setting, whether complete blood count can be used to predict fracture risk warrants further investigation.

Sodium-Glucose Cotransporter 2 Inhibitors and the Risk of Pneumonia and Septic Shock

CONTEXT

Individuals with type 2 diabetes mellitus (DM) have an increased risk of pneumonia and septic shock. Traditional glucose-lowering drugs have recently been found to be associated with a higher risk of infections. It remains unclear whether sodium-glucose cotransporter 2 inhibitors (SGLT2is), which have pleiotropic/anti-inflammatory effects, may reduce the risk of pneumonia and septic shock in DM.

METHODS

MEDLINE, Embase, and ClinicalTrials.gov were searched from inception up to May 19, 2022, for randomized, placebo-controlled trials of SGLT2i that included patients with DM and reported outcomes of interest (pneumonia and/or septic shock). Study selection, data extraction, and quality assessment (using the Cochrane Risk of Bias Assessment Tool) were conducted by independent authors. A fixed-effects model was used to pool the relative risk (RRs) and 95% CI across trials.

RESULTS

Out of 4568 citations, 26 trials with a total of 59 264 patients (1.9% developed pneumonia and 0.2% developed septic shock) were included. Compared with placebo, SGLT2is significantly reduced the risk of pneumonia (pooled RR 0.87, 95% CI 0.78-0.98) and septic shock (pooled RR 0.65, 95% CI 0.44-0.95). There was no significant heterogeneity of effect size among trials. Subgroup analyses according to the type of SGLT2i used, baseline comorbidities, glycemic control, duration of DM, and trial follow-up showed consistent results without evidence of significant treatment-by-subgroup heterogeneity (all Pheterogeneity > .10).

CONCLUSION

Among DM patients, SGLT2is reduced the risk of pneumonia and septic shock compared with placebo. Our findings should be viewed as hypothesis generating, with concepts requiring validation in future studies.

Association of maternal levothyroxine use during pregnancy with offspring birth and neurodevelopmental outcomes: a population-based cohort study

BACKGROUND

The influence of maternal levothyroxine treatment during pregnancy remains unclear. This study aimed to evaluate the associations of maternal levothyroxine treatment during pregnancy with the birth and neurodevelopmental outcomes in offspring.

METHODS

This population-based cohort study was conducted among pregnant women using the Hong Kong Clinical Data Analysis and Reporting System. Mother-child pairs in Hong Kong from 2001 to 2015 were included and children were followed up till 2020. We defined the exposure group as mothers who were exposed to levothyroxine during pregnancy. Preterm birth and small for gestational age (SGA) were included as birth outcomes. Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) were included as neurodevelopmental outcomes. Odds ratios (OR) or hazard ratios (HRs) with a 95% confidence interval (CI) were evaluated to assess the association of gestational levothyroxine use with offspring birth and neurodevelopmental outcomes respectively, using propensity score fine-stratification weighting and a Cox proportional hazards regression model.

RESULTS

Among 422,156 mother-child pairs, 2125 children were born from mothers exposed to levothyroxine during pregnancy. A significantly increased risk of preterm birth was observed in children with maternal levothyroxine exposure during pregnancy, when compared to mothers who had no history of thyroid-related diagnoses or prescriptions (weighted OR [wOR]: 1.22, 95% CI: 1.07, 1.39). Similarly, an increased risk of preterm birth was found among children of gestational levothyroxine users, when compared to children of mothers who had used levothyroxine before but stopped during pregnancy (wOR: 2.16, 95% CI: 1.09, 4.25). Sensitivity analysis, by excluding mothers exposed to psychotropic or antiepileptic medications before or during pregnancy, also indicated a similar increased risk of preterm birth regarding the gestational use of levothyroxine (wOR: 1.26, 95% CI: 1.10, 1.45). No significant association was observed for the risk of SGA, ADHD, and ASD.

CONCLUSIONS

There is no evidence that gestational use of levothyroxine is associated with SGA, ADHD, or ASD in offspring. Gestational levothyroxine treatment is associated with a higher risk of preterm birth. Such risk might be confounded by the underlying maternal thyroid disease itself, however, we cannot completely exclude the possible effect of gestational L-T4 treatment on offspring preterm birth. Our findings provided support to the current guidelines on the cautious use of levothyroxine treatment during pregnancy.

COVID-19 and Thyroid Function: A Bi-Directional Two-Sample Mendelian Randomization Study

Background: Thyroid dysfunction has been observed among some patients with coronavirus disease (COVID-19). It is unclear whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (or its severity) leads to the development of thyroid dysfunction, or vice versa. In this study, we examined the bi-directional causal relationship between host genetic liability to three COVID-19 phenotypes (including SARS-CoV-2 infection, hospitalized and severe COVID-19) and three thyroid dysfunction traits (including hyperthyroidism, hypothyroidism, and autoimmune thyroid disease [AITD]) and three continuous traits of thyroid hormones (including thyrotropin [TSH] and free thyroxine [fT4] within reference range, and TSH in full range). Methods: Summary statistics from the largest available meta-analyses of human genome-wide association studies were retrieved for the following variables: SARS-CoV-2 infection (n = 1,348,701), COVID-19 hospitalization (n = 1,557,411), severe COVID-19 (n = 1,059,456), hyperthyroidism (n = 51,823), hypothyroidism (n = 53,423), AITD (n = 755,406), TSH within reference range (n = 54,288), fT4 within reference range (n = 49,269), and TSH in full range (n = 119,715). Using a two-sample Mendelian randomization (MR) approach, the inverse-variance weighted (IVW) method was adopted as the main MR analysis. Weighted median, contamination mixture, MR-Egger, and MR pleiotropy residual sum and outlier (MR-PRESSO) methods were applied as sensitivity analyses. Results: Host genetic susceptibility to SARS-CoV-2 infection was causally associated with hypothyroidism in the main IVW analysis (per doubling in prevalence of SARS-CoV-2 infection, odds ratio [OR] = 1.335; 95% confidence interval [CI]: 1.167-1.526; p = 2.4 × 10^-5, surpassing the Bonferroni multiple-testing threshold). Similar causal estimates were observed in the sensitivity analyses (weighted median: OR = 1.296; CI: 1.066-1.575; p = 9 × 10^-3; contamination mixture: OR = 1.356; CI: 1.095-1.818; p = 0.013; MR-Egger: OR = 1.712; CI: 1.202-2.439; p = 2.92 × 10^-3, and MR-PRESSO: OR = 1.335; CI: 1.156-1.542; p = 5.73 × 10^-4). Host genetic liability to hospitalized or severe COVID-19 was not associated with thyroid dysfunction or thyroid hormone levels. In the reverse direction, there was no evidence to suggest that genetic predisposition to thyroid dysfunction or genetically determined thyroid hormone levels altered the risk of the COVID-19 outcomes. Conclusions: This bi-directional MR study supports that host response to SARS-CoV-2 viral infection plays a role in the causal association with increased risk of hypothyroidism. Long-term follow-up studies are needed to confirm the expected increased hypothyroidism risk.

Hip Fracture as a Predictive Marker for the Risk of Dementia: A Population-Based Cohort Study

OBJECTIVES

This study aimed to investigate the association between hip fracture and the risk of dementia.

DESIGN

A retrospective real-world propensity score-matched cohort study was conducted using the real-world hip fracture cohort (RHFC).

SETTING AND PARTICIPANTS

Electronic health record data from the Clinical Data Analysis and Reporting System (CDARS) in Hong Kong were used. A total of 52,848 patients aged ≥65 years and with at least an event of fall from 2006 to 2015 were included in the RHFC.

METHODS

The incidence of fall, hip fracture, and dementia was determined using their International Classification of Diseases, Ninth Revision (ICD-9) codes. Competing risk regression models were used to estimate hazard ratios (HRs) and 95% CIs.

RESULTS

Hip fracture was associated with an increased risk of dementia (HR 1.09, 95% CI 1.04-1.15, P < .001). The subgroup analysis showed that association was significant in women but not in men.

CONCLUSIONS AND IMPLICATIONS

Hip fracture was associated with the increased risk of dementia among older adults. Further studies investigating the potential roles of hip fracture in the development of dementia could benefit the management of both conditions in older adults.

Thromboembolic events and hemorrhagic stroke after mRNA (BNT162b2) and inactivated (CoronaVac) covid-19 vaccination: A self-controlled case series study

BACKGROUND

This study aims to evaluate the association between thromboembolic events and hemorrhagic stroke following BNT162b2 and CoronaVac vaccination.

METHODS

Patients with incident thromboembolic events or hemorrhagic stroke within 28 days of covid-19 vaccination or SARS-CoV-2 positive test during 23 February to 30 September 2021 were included. The incidence per 100,000 covid-19 vaccine doses administered and SARS-CoV-2 test positive cases were estimated. A modified self-controlled case series (SCCS) analysis using the data from the Hong Kong territory-wide electronic health and vaccination records. Seasonal effect was adjusted by month.

FINDINGS

A total of 5,526,547 doses of BNT162b2 and 3,146,741 doses of CoronaVac were administered. A total of 334 and 402 thromboembolic events, and 57 and 49 hemorrhagic stroke cases occurred within 28 days after BNT162b2 and CoronaVac vaccination, respectively. The crude incidence of thromboembolic events and hemorrhagic stroke per 100,000 doses administered for both covid-19 vaccines were smaller than that per 100,000 SARS-CoV-2 test positive cases. The modified SCCS detected an increased risk of hemorrhagic stroke in BNT162b2 14-27 days after first dose with adjusted IRR of 2.53 (95% CI 1.48-4.34), and 0-13 days after second dose with adjusted IRR 2.69 (95% CI 1.54-4.69). No statistically significant risk was observed for thromboembolic events for both vaccines.

INTERPRETATION

We detected a possible safety signal for hemorrhagic stroke following BNT162b2 vaccination. The incidence of thromboembolic event or hemorrhagic stroke following vaccination is lower than that among SARS-CoV-2 test positive cases; therefore, vaccination against covid-19 remains an important public health intervention.

FUNDING

This study was funded by a research grant from the Food and Health Bureau, The Government of the Hong Kong Special Administrative Region (reference COVID19F01).

Osteoporosis is a novel risk factor of infections and sepsis: A cohort study

BACKGROUND

Accumulating evidence suggests the interaction of bone metabolism and the immune system, but how bone health is associated with the risk of infections remains unknown.

METHODS

This study aimed to investigate the relationship of bone mineral density (BMD) with the risk of common infections and sepsis in Hong Kong Osteoporosis Study (HKOS). A prospective cohort study, initiated in 1995 and followed until 31 December 2020, of 5,717 participants examined the association of BMD at three skeletal sites (lumbar spine, femoral neck, and total hip) with common infections - pneumonia, urinary tract infection (UTI), skin infection, and sepsis. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI).

FINDINGS

During the median follow-up of 17 years, higher BMD T-scores at the femoral neck and total hip were significantly associated with the reduced risk of pneumonia (HRs 0.89 and 0.87; 95% CIs 0.82 to 0.98 and 0.81 to 0.95), UTI (HRs 0.85 and 0.86; 95% CIs 0.76 to 0.94 and 0.78 to 0.95), skin infection (HRs 0.85 and 0.82; 95% CIs 0.74 to 0.97 and 0.73 to 0.93), and sepsis (HRs 0.83 and 0.82; 95% CIs 0.71 to 0.97 and 0.72 to 0.94). A significant association was observed for the lumbar spine BMD T-score with the risk of skin infection (HR 0.86; 95% CI: 0.78 to 0.95) but not with other infections and sepsis. Similarly, participants with osteoporosis, but not osteopenia, were significantly associated with an increased risk of infections and sepsis compared to those with normal BMD.

INTERPRETATION

BMD is a novel risk factor of infections and sepsis. People with low BMD, particularly those with osteoporosis, are at higher risk of infections and sepsis than those with normal BMD. Further studies on whether improving bone health can reduce the risk of infections and sepsis are warranted.

FUNDING

None.

Evaluation of bi-directional causal association between depression and cardiovascular diseases: a Mendelian randomization study

BACKGROUND

Depression and cardiovascular disease (CVD) are associated with each other but their relationship remains unclear. We aim to determine whether genetic predisposition to depression are causally linked to CVD [including coronary artery disease (CAD), myocardial infarction (MI), stroke and atrial fibrillation (AF)].

METHODS

Using summary statistics from the largest genome-wide association studies (GWAS) or GWAS meta-analysis of depression (primary analysis: n = 500 199), broad depression (help-seeking behavior for problems with nerves, anxiety, tension or depression; secondary analysis: n = 322 580), CAD (n = 184 305), MI (n = 171 875), stroke (n = 446 696) and AF (n = 1 030 836), genetic correlation was tested between two depression phenotypes and CVD [MI, stroke and AF (not CAD as its correlation was previously confirmed)]. Causality was inferred between correlated traits by Mendelian Randomization analyses.

RESULTS

Both depression phenotypes were genetically correlated with MI (depression: r_G = 0.169; p = 9.03 × 10^-9; broad depression: r_G = 0.123; p = 1 × 10^-4) and AF (depression: r_G = 0.112; p = 7.80 × 10^-6; broad depression: r_G = 0.126; p = 3.62 × 10^-6). Genetically doubling the odds of depression was causally associated with increased risk of CAD (OR = 1.099; 95% CI 1.031-1.170; p = 0.004) and MI (OR = 1.146; 95% CI 1.070-1.228; p = 1.05 × 10^-4). Adjustment for blood lipid levels/smoking status attenuated the causality between depression and CAD/MI. Null causal association was observed for CVD on depression. A similar pattern of results was observed in the secondary analysis for broad depression.

CONCLUSIONS

Genetic predisposition to depression may have positive causal roles on CAD/MI. Genetic susceptibility to self-awareness of mood problems may be a strong causal risk factor of CAD/MI. Blood lipid levels and smoking may potentially mediate the causal pathway. Prevention and early diagnosis of depression are important in the management of CAD/MI.

Immunity-enhancing Micronutrients and Community Pharmacists: An Opportunity to Expand Self-Care Practices among the Public

Background: The urban lifestyle and environment pose a constant immune challenge to city dwellers. A major such challenge is influenza, which creates substantial public health and socio-economic burdens. The global healthcare paradigm has begun emphasizing the importance and cost-effectiveness of self-care in partnership with healthcare professionals such as community pharmacists for the management of mild ailments. For the general public, micronutrient supplementation is an affordable and potentially feasible self-care strategy for immunity enhancement and disease management. At the same time, micronutrient deficiencies are a serious public health concern in both developing and developed areas. Objective: This review focuses on the clinical evidence for the efficacy and safety of three key micronutrients — vitamins C, D and zinc — on respiratory infections. Key findings: These micronutrients are important for optimal immune function through their complementary roles in supporting both innate and adaptive immunity, as well as epithelial barriers. The need to improve public awareness of self-care in prevention and health management is highlighted by recent public health issues and the global fight against antimicrobial resistance. Community pharmacists could play a crucial role in empowering patient autonomy. Conclusion: With this review we aim to offer insights into the supplementation of these micronutrients as a self-care approach to the management of immune health.

Association Between SGLT2 Inhibitors vs DPP4 Inhibitors and Renal Outcomes Among Patients With Type 2 Diabetes

CONTEXT

Diabetic kidney disease is a major burden among diabetic patients. Sodium-glucose cotransporter 2 inhibitors (SGLT2is) were shown to reduce renal outcomes in clinical trials and real-world studies. However, head-to-head comparisons with individual classes of glucose-lowering agents warranted further investigation.

OBJECTIVE

This work aimed to investigate the associations between SGLT2is use vs dipeptidyl peptidase-4 inhibitors (DPP4is) use and 4 renal outcomes: end-stage renal disease (ESRD), albuminuria, acute renal failure (ARF), and the rate of estimated glomerular filtration rate (eGFR) change using a territory-wide electronic medical database in Hong Kong.

METHODS

For this retrospective cohort study, the "prevalent new-user" design was adopted to account for previous exposure to study drugs. Propensity score matching was used to balance baseline characteristics. Electronic health data of type 2 diabetes patients using SGLT2is and DPP4is between 2015 and 2018 were collected.

RESULTS

The matched cohort consisted of 6333 SGLT2is users and 25 332 DPP4is users, with a median follow-up of 3.8 years. Compared to DPP4is, SGLT2is use was associated with lower risks of ESRD (hazard ratio [HR]: 0.51; 95% CI, 0.42-0.62; P < .001) and ARF (HR: 0.59; 95% CI, 0.48-0.73; P < .001), and a slower decline in eGFR. The associations remained statistically significant among patients with or without rapid eGFR decline and patients who added or switched to SGLT2is from DPP4is. The association with albuminuria was inconsistent across analyses.

CONCLUSION

Compared to DPP4is, SGLT2is use was associated with reduced risks of ESRD and ARF, and a slower eGFR decline in a real-world setting. The associations remained statistically significant in patients with or without preindex rapid eGFR decline.

Effects of statins on the inducible degrader of low-density lipoprotein receptor in familial hypercholesterolemia

The inducible degrader of low-density lipoprotein receptor (IDOL) is an E3 ubiquitin ligase involved in the post-transcriptional regulation of LDL receptor (LDLR). Statins lower plasma LDL by activating transcription of hepatic LDLR expression, and we have determined whether statins modulate IDOL expression and influence LDLR protein abundance. IDOL expression in monocytes and serum IDOL level was determined in statin-treated familial hypercholesterolemia (FH) patients and compared with control subjects. Serum IDOL level was also evaluated in a group of untreated FH patients before and after the initiation of statin. The mechanism underlying the inhibitory effect of statin on IDOL expression was investigated in vitro. In statin-treated FH patients, serum IDOL level and its expression in monocytes was reduced compared with control (P < 0.05). In contrast, untreated FH patients had higher serum levels of IDOL and proprotein convertase subtilisin/kexintype 9 (PCSK9) than control (P < 0.05), and serum IDOL level decreased after statin therapy (P < 0.05) whereas an increase was observed in PCSK9 level (P < 0.01). In vitro, atorvastatin significantly decreased IDOL abundance in a dose-dependent manner in cultured macrophages and hepatocytes with a concomitant increase in LDLR expression. The transcription of IDOL was restored by adding either an LXR agonist T0901317 or oxysterol 22(R)-hydroxycholesterol, indicating that statin inhibited IDOL expression by reducing LXR activation. The LXR-IDOL-LDLR axis can be modulated by statins in vitro and in vivo. Statins inhibit IDOL expression by reducing LXR activation and upregulate LDLR, and statins exert the opposite effect on IDOL and PCSK9.

COVID-19 and platelet traits: A bidirectional Mendelian randomization study

This study aimed to evaluate the host genetic liability of coronavirus disease 2019 (covid‐19) with platelet traits using the Mendelian randomization (MR) approach. We conducted a bidirectional two‐sample MR using summary statistics from the largest genome‐wide association study of three variables, covid‐19 severity (severe acute respiratory syndrome coronavirus 2 [SARS‐CoV‐2] infection, covid‐19 hospitalization, and severe covid‐19, N = ~1 059 456–1 557 411) and four platelet traits (mean platelet volume [MPV], plateletcrit, platelet distribution width, and platelet count; N = 408 112). Inverse‐variance weighted (IVW), median weighted, MR‐Egger, and contamination mixture methods were used to estimate the causal association. Null and inconsistent associations in the IVW and sensitivity analyses were observed for SARS‐CoV‐2 infection and covid‐19 hospitalization with platelet traits. For severe covid‐19, significant associations with MPV and platelet count were observed in the IVW and sensitivity analyses, with the beta_IVW of 0.01 (95% confidence interval [CI]: 0.005–0.016, p = 3.51 × 10⁻⁴) and −0.009 (95% CI: −0.015 to −0.002, p = 0.008) per doubling in odds of severe covid‐19, respectively. Conversely, null associations were observed for platelet traits with covid‐19 traits. In conclusion, host genetic liability to severe covid‐19 was causally associated with increased MPV and reduced platelet count, which may provide insights into evaluating hypercoagulability and thromboembolic events in covid‐19 patients.

Temporal trends and patterns of infective endocarditis in a Chinese population: A territory-wide study in Hong Kong (2002–2019)

Background

The characteristics of infective endocarditis (IE) in Asians are poorly understood. Therefore, we aim to describe the epidemiological trends and clinical features of IE in Hong Kong.

Methods

All patients with incident IE from 2002–2019 in a territory-wide clinical database in Hong Kong were identified. We studied the age- and sex-adjusted and one-year mortality of IE between 2002 and 2019 and identified significant contributors to 1-year all-cause death using the attributable fraction. We used propensity score and inverse propensity of treatment weighting to study the association of surgery with mortality.

Findings

A total of 5139 patients (60.4 ± 18.2years, 37% women) were included. The overall incidence of IE was 4.9 per 100,000 person-year, which did not change over time (P = 0.17). Patients in 2019 were older and more comorbid than those in 2002. The one-year crude mortality rate was 30% in 2002, which did not change significantly over time (P = 0.10). Between 2002 and 2019, the rate of surgery increased and was associated with a 51% risk reduction in 1-year all-cause mortality (Hazard Ratio 0.49 [0.28–0.87], P = 0.015). Advanced age (attributable fraction 19%) and comorbidities (attributable fraction 15%) were significant contributors to death.

Interpretation

The incidence of IE in Hong Kong did not change between 2002 and 2019. Patients with IE in 2019 were older and had more comorbidities than those in 2002. Mortality of IE remains persistently high in Hong Kong. Together, these data can guide public health strategies to improve the outcomes of patients with IE.

Funding

This work was supported by Sanming Project of Medicine in Shenzhen, China [No. SZSM201911020] and HKU-SZH Fund for Shenzhen Key Medical Discipline [No. SZXK2020081].

Association Between SGLT2 Inhibitors vs DPP-4 Inhibitors and Risk of Pneumonia Among Patients With Type 2 Diabetes

CONTEXT

Patients with diabetes are at a higher risk of pneumonia and pneumonia mortality. Sodium glucose co-transporter 2 inhibitors (SGLT2is), the latest class of glucose-lowering agents, were shown to reduce the risk of pneumonia in clinical trials. However, the real-world effectiveness of SGLT2is on the risk of pneumonia is largely unknown.

OBJECTIVE

To investigate the associations between SGLT2is use and the risk of pneumonia and pneumonia mortality compared with dipeptidyl peptidase-4 inhibitors (DPP4is) using an electronic medical database in Hong Kong.

DESIGN

A retrospective cohort study. The "prevalent new-user" design was adopted to account for the previous exposure to the study drugs being compared. Propensity score (PS) matching (1:4) was used to balance the baseline characteristics of the 2 groups.

SETTING AND PARTICIPANTS

Electronic health data of type 2 diabetes patients using SGLT2is and DPP4is between 2015 and 2018 was collected from the Clinical Data Analysis and Reporting System.

MAIN OUTCOME MEASURES

Pneumonia incidence and mortality.

RESULTS

The PS-matched cohort consisted of 6664 users of SGLT2is and 26 656 users of DPP4is, with a mean follow-up of 3.8 years. Poisson regression showed that SGLT2is use was associated with lower risk of pneumonia compared with DPP4is with an absolute rate difference of 4.05 per 1000 person-years (95% CI, 2.61-5.51). The corresponding incidence rate ratio was 0.71 (95% CI, 0.62-0.81). Similar reduction in risk of pneumonia death was observed (hazard ratio 0.57; 95% CI, 0.42-0.77).

CONCLUSION

Compared with DPP4is, SGLT2is use was associated with a reduced risk of pneumonia and pneumonia mortality in a real-world setting.

Prevalence of Childhood Obesity in the United States in 1999-2018: A 20-Year Analysis

INTRODUCTION

Obesity is a public health crisis in the USA. This study aimed to estimate the prevalence of obesity and severe obesity in US children and adolescents and identify novel targetable risk factors associated with childhood obesity.

METHODS

From the US National Health and Nutrition Examination Survey from 1999 to 2018, 35,907 children aged 2-19 with body mass index (BMI) data were included. Obesity and severe obesity were defined as BMI ≥95th percentile and ≥120% of 95th percentile of US Centers for Disease Control and Prevention growth charts, respectively. Trends in the prevalence of obesity and subgroup analyses according to socioeconomic factors and language used in the interview were analyzed.

RESULTS

The prevalence of obesity and severe obesity increased from 14.7 [95% confidence interval: 12.9-17.0]% to 19.2 [17.2-21.0]% and 3.9 [2.9-5.0]% to 6.1 [4.8-8.0]% in 1999-2018, respectively (p = 0.001 and p = 0.014, respectively). In 2017-2018, the prevalence of obesity among children from Spanish-speaking households was 24.4 [22.4-27.0]%, higher than children from English-speaking households (p = 0.027).

CONCLUSION

The prevalence of childhood obesity kept increasing in 1999-2018. The problem is worse in children from Spanish-speaking households. Novel and targeted public health intervention strategies are urgently warranted to effectively halt the rising epidemic of childhood obesity.

Association between the liver fat score (LFS) and cardiovascular diseases in the national health and nutrition examination survey 1999-2016

BACKGROUND

The liver fat score (LFS) has been proposed to be a simple non-invasive marker of non-alcoholic fatty liver disease (NAFLD), which is highly prevalent in the general population. We tested its association with cardiovascular diseases (CVDs) and prognosis.

METHODS

17,244 adult participants from the National Health and Nutrition Examination Survey 1999-2016 were included. LFS is calculated from variables including serum aspartate transaminase/alanine transaminase (AST/ALT) ratio, fasting serum aspartate transaminase (AST) level, fasting serum insulin level, presence of metabolic syndrome and diabetes mellitus. In cross-sectional analysis, logistic regression was used to examine the association of the LFS with coronary heart disease (CHD), myocardial infarction (MI), congestive heart failure (CHF), stroke and angina pectoris. Mortality during follow-up was analysed using Cox proportional hazard regression.

RESULTS

LFS was associated with CHD (adjusted odds ratio [OR]: 1.09 per standard deviation [SD], 95% confidence interval [95% CI]: 1.03-1.15) (p = .003), CHF (1.11, 1.04-1.18) (p = .003) and angina pectoris (1.08, 1.02-1.13) (p = .005). LFS was not associated with MI or stroke, but was associated with increased all-cause and cardiovascular mortality with hazard ratios (HRs) of 1.10 (95% CI: 1.07-1.13) (p < .001) and 1.12 (95% CI: 1.06-1.17) (p < .001), respectively.

CONCLUSIONS

NAFLD is usually asymptomatic, but this large study of a large general population shows that LFS is associated with CHD, CHF, angina pectoris, cardiovascular and all-cause mortality. Determining the LFS is worthwhile, as it identifies people with NAFLD, who may also be at increased cardiovascular risk.Key MessagesLiver fat score (LFS), a non-invasive marker of non-alcoholic fatty liver disease (NAFLD), is associated with coronary heart disease (CHD), congestive heart failure (CHF) and angina.LFS is also associated with increased cardiovascular and all-cause mortality.Determining the LFS is worthwhile as it identifies people with NAFLD as well as increased cardiovascular risk.

Genetically Determined TSH Level Within Reference Range Is Inversely Associated With Alzheimer Disease

CONTEXT

Contradictory findings were reported in observational studies on the association of thyroid function (thyrotropin [TSH] and free thyroxine [FT4] levels) with Alzheimer disease (AD).

OBJECTIVE

This work aims to determine whether genetically determined TSH/FT4 levels within reference range are causally associated with AD.

METHODS

A bidirectional, 2-sample mendelian randomization (MR) study was conducted. With summary statistics from the largest genome-wide association studies (GWAS)/GWAS meta-analysis of TSH level(n ≥ 54 288), FT4 level(n = 49 269), and AD (71 880 cases; 383 378 controls), we used an MR approach to evaluate the bidirectional causal relationship between TSH/FT4 levels and AD. The inverse-variance weighted method was adopted as the main analysis.

RESULTS

One SD increase in genetically determined TSH level within reference range was causally associated with a reduced risk of AD (odds ratio: 0.988; 95% CI, 0.977-0.998). A similar inverse association was observed in sex-specific analysis. The causal association was attenuated after adjustment for atrial fibrillation and blood pressure, suggesting they may mediate the causal pathway. A positive causal effect of AD on TSH level was detected only in male participants. This male-specific feedback loop may explain why the largest cohort study to date (Rotterdam Study) demonstrated a null observational association in men. Null association was observed between FT4 level and AD in both directions.

CONCLUSION

Genetic predisposition to increased TSH level, even within reference range, may lower the risk of AD, with atrial fibrillation, systolic, and diastolic blood pressure as possible mediators. Given the higher magnitude of risk reduction observed in the Rotterdam Study, whether the causal estimates derived from this MR study are underestimated warrants further investigation.

Immediate Risk for Cardiovascular Events in Hip Fracture Patients: A Population-Based Cohort Study

BACKGROUND

Emerging evidence showed that bone metabolism and cardiovascular diseases (CVD) are closely related. We previously observed a potential immediate risk of cardiovascular mortality after hip fracture. However, whether there is an immediate risk of cardiovascular events after hip fracture is unclear. The aim of this study was to evaluate the risk for major adverse cardiovascular events (MACEs) between patients having experienced falls with and without hip fracture.

METHODS

This retrospective population-based cohort study used data from a centralized electronic health record database managed by Hong Kong Hospital Authority. Patients having experienced falls with and without hip fracture were matched by propensity score (PS) at a 1:1 ratio. Adjusted associations between hip fracture and risk of MACEs were evaluated using competing risk regression after accounting for competing risk of death.

RESULTS

Competing risk regression showed that hip fracture was associated with increased one-year risk of MACEs (hazard ratio [HR], 1.27; 95% CI, 1.21 to 1.33; p<0.001), with a 1-year cumulative incidence difference of 2.40% (1.94% to 2.87%). The HR was the highest in the first 90-day after hip fracture (HR of 1.32), and such an estimate was continuously reduced in 180-day, 270-day, and 1-year after hip fracture.

CONCLUSIONS

Hip fracture was associated with increased immediate risk of MACEs. This study suggested that a prompt evaluation of MACE among older adults aged 65 years and older who are diagnosed with hip fracture irrespectively of cardiovascular risk factors may be important, as early management may reduce subsequent risk of MACE.

Prevalence of metabolic syndrome in the United States National Health and Nutrition Examination Survey (nhanes) 2011–2018

Background

Metabolic syndrome (MetS) is a cluster of risk factors presaging the development of cardiovascular disease and diabetes. It is a risk factor for severe coronavirus disease 2019 (COVID-19).

Purpose

To estimate the prevalence of MetS in the US National Health and Nutrition Examination Survey (NHANES) 2011–2018.

Methods

This cohort study included 22370 eligible participants aged ≥20 years from the NHANES 2011–2018. MetS was defined as the presence of at least three of these components: central obesity, reduced high-density lipoprotein, elevated triglycerides, elevated blood pressure and elevated fasting blood glucose. The prevalence of MetS was estimated taking into account the complex sampling. The time trend was evaluated using logistic regression. Annual percentage changes (APC) were measured trend in MetS prevalence.

Results

The prevalence of MetS was 36.2% (95% CI, 32.3–40.3), 34.8% (95% CI, 32.3–37.4), 39.9% (95% CI, 36.6–43.2) and 38.3% (95% CI, 35.3–41.3) in 2011–2, 2013–4, 2015–6, 2017–8, respectively (P for trend = 0.08). Among the MetS components, the prevalence of elevated glucose increased from 48.7% (95% CI, 45.9–51.5) in 2011–2 to 64.3% (95% CI, 61.0–67.4) in 2017–8 [P for trend &lt;0.001; APC=11.7, (95% CI, 3.5–21.0)]. The prevalence of MetS in non-Hispanic Asian increased from 21.8% (95% CI, 16.7–28.0) in 2011–2 to 31.2% (95% CI, 27.4–35.3) in 2017–8 [P for trend &lt;0.001; APC=14.6, (95% CI, 2.5–34.8)].

Conclusions

The prevalence of MetS remained stable during 2011 to 2018. Lifestyle modification is needed, especially among non-Hispanic Asians to prevent the metabolic syndrome and the associated risks of diabetes and cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

Secular trends in fall-related hospitalizations in adolescents, youth and adults: a population-based study

Background

Falls are one of the major causes of injury globally. However, there is a lack of population-based studies on falls among adolescents, young and middle-aged adults. We therefore aimed to conduct a large-scale population study on the secular trend in incidence of fall-related hospitalization.

Methods

A population-wide electronic database, Hong Kong's Clinical Data Analysis and Reporting System (CDARS), was used in this retrospective cohort study. Patients aged≥10, hospitalized with diagnosis of accidental falls (ICD-9-CM E880-E888) from 2005-2018, were included. Outcome measures included the number, age- and sex-standardized incidence rate of fall-related hospital admissions, their length of stay (LOS) and 1-year all-cause mortality. Linear regression and average annual percentage change (AAPC) using joinpoint regression were computed for trend analysis.

Findings

From 2005 to 2018, a total of 336,439 patients aged≥10 were identified with fall-related hospitalization. Among these fall patients, 33.7% occurred at age<60. The number of fall-related hospital admissions episodes increased significantly by 83.7% during the study period. The standardized incidence rate of falls per 1000 person-years increased from 3.67 (95% CI 3.62-3.72) in 2005 to 4.79 (95% CI 4.74-4.84) in 2018. Although the total hospitalized bed-days increased from 178,723 days in 2005, to 299,273 days in 2018 (+67.5%,p<.0001), the median length of stay per episode of falls decreased from 4.90 days to 3.79 days (p<.0001).

Interpretation

Continuous increase in the incidence of fall-related hospitalization in people aged≥10 was observed. This suggested that falls are a public health issue in all ages. Further studies on the differences in the underlying risk factors and comorbidities between younger and older fall patients are warranted.

Funding

None.

Global epidemiology of hip fractures: a study protocol using a common analytical platform among multiple countries

INTRODUCTION

Hip fractures are associated with a high burden of morbidity and mortality. Globally, there is wide variation in the incidence of hip fracture in people aged 50 years and older. Longitudinal and cross-geographical comparisons of health data can provide insights on aetiology, risk factors, and healthcare practices. However, systematic reviews of studies that use different methods and study periods do not permit direct comparison across geographical regions. Thus, the objective of this study is to investigate global secular trends in hip fracture incidence, mortality and use of postfracture pharmacological treatment across Asia, Oceania, North and South America, and Western and Northern Europe using a unified methodology applied to health records.

METHODS AND ANALYSIS

This retrospective cohort study will use a common protocol and an analytical common data model approach to examine incidence of hip fracture across population-based databases in different geographical regions and healthcare settings. The study period will be from 2005 to 2018 subject to data availability in study sites. Patients aged 50 years and older and hospitalised due to hip fracture during the study period will be included. The primary outcome will be expressed as the annual incidence of hip fracture. Secondary outcomes will be the pharmacological treatment rate and mortality within 12 months following initial hip fracture by year. For the primary outcome, crude and standardised incidence of hip fracture will be reported. Linear regression will be used to test for time trends in the annual incidence. For secondary outcomes, the crude mortality and standardised mortality incidence will be reported.

ETHICS AND DISSEMINATION

Each participating site will follow the relevant local ethics and regulatory frameworks for study approval. The results of the study will be submitted for peer-reviewed scientific publications and presented at scientific conferences.

Hip fractures are preventable: a proposal for osteoporosis screening and fall prevention in older people

Osteoporosis is highly prevalent but underdiagnosed and undertreated in Hong Kong. Fragility fractures associated with osteoporosis often result in loss of independence and increased mortality for home-dwelling patients, imposing a high socio-economic burden on society. This issue requires urgent attention given the rapid growth of the elderly population in Hong Kong by approximately 4.3% each year. To address this situation, a group of experts convened to discuss practical ways to reduce the burden of fractures and formulated three recommendations: first, all men (aged ≥70 years) and women (aged ≥65 years) should receive universal dual-energy X-ray absorptiometry assessment for osteoporosis. Second, all men (aged ≥70 years) and women (aged ≥65 years) with a fracture-risk assessment-derived 10-year risk (hip fracture with bone mineral density) ≥3% should receive ≥3 years of anti-osteoporotic treatment. Third, comprehensive structured assessment (including dual-energy X-ray absorptiometry) should be conducted in older patients with a history of falling. By implementing these recommendations, we estimate that we could prevent 5234 hip fractures in 10 years, an annual incidence reduction of approximately 7%, and save HK$425 million in direct medical costs plus substantial indirect savings. Ample clinical and cost-effectiveness data support these recommendations, and studies in Hong Kong and abroad could serve as models on how to implement them. We are confident that by applying these recommendations rigorously and systematically, a significant reduction in hip fractures in Hong Kong is achievable.

Long-term Outcome of Short-course High-dose Glucocorticoids for Severe Acute Respiratory Syndrome (SARS): A 17-Year Follow-up in SARS Survivors

Use of high-dose glucocorticoids for coronavirus disease 2019 (COVID-19; caused by SARS-CoV-2) is controversial because of safety concerns. We examined long-term consequences in severe acute respiratory syndrome (SARS; caused by SARS-CoV-1) survivors. Results showed that high-dose glucocorticoids greatly increased long-term risk of avascular necrosis, but not other major diseases.

Prevalence of Childhood Obesity in the United States 1999 - 2018: A 20-Year Analysis

Introduction: Obesity is a public health crisis in the US. Childhood obesity is associated with multiple comorbidities in the adulthood, including metabolic syndrome, cardiovascular diseases, and premature death. A recent study found that the prevalence of childhood obesity varied according to age and ethnicity. This study aims to evaluate the long-term trends and the underexplored socioeconomic factors associated with childhood obesity.

Method: From the US National Health and Nutrition Examination Survey from 1999 to 2018, 35 907 children aged 2–19 with body mass index (BMI) data were included. Prevalence of obesity and severe obesity, defined as BMI ≥95th percentile and ≥120% of 95th percentile of US Centers for Disease Control and Prevention growth charts, respectively. Trends in prevalence of obesity and subgroup analyses according to age group, sex, ethnicity, language used in interview, household education level, and household income level, were analyzed. Data analysis was performed using the R statistical package “survey” (version 3.6.3).

Results: The prevalence of obesity and severe obesity increased from 14.7 [95% CI: 12.9–17.0] % to 19.2 [17.2–21.0] % and 3.9 [2.9–5.0] % to 6.1 [4.8–8.0] % in 1999–2018, respectively (p=0.001 and p=0.014 for obesity and severe obesity, respectively). In 2017–8, the prevalence of obesity among children from Spanish-speaking households was 24.4 [22.4–27.0] %, higher than children from English-speaking households (p=0.027). Children from households with high education level and high income level had a lower prevalence of obesity compared to those with low education level and low income level (p=0.003 and p=0.002 for education level and income level, respectively). Compared to girls, boys had higher prevalence of obesity (p=0.002) and severe obesity (p=0.004).

Conclusion: The prevalence of childhood obesity in America kept increasing during the period 1999–2018 despite various public health initiatives. The problem is worse in children with lower socioeconomic status, and in children from Spanish-speaking households. Public health interventions are urgently needed to halt the rising trend of childhood obesity, and measures specifically catering to children from Spanish-speaking families should be put in place.

Positive effects of low LDL-C and statins on bone mineral density: an integrated epidemiological observation analysis and Mendelian randomization study

BACKGROUND

Low-density lipoprotein cholesterol (LDL-C) is suggested to play a role in osteoporosis but its association with bone metabolism remains unclear. Effects of LDL-C-lowering drugs on bone are also controversial. We aim to determine whether LDL-C is linked causally to bone mineral density (BMD) and assess the effects of LDL-C-lowering drugs on BMD.

METHODS

Association between blood lipid levels and BMD was examined by epidemiological observation analyses in a US representative cohort NHANES III (n = 3638) and the Hong Kong Osteoporosis Study (HKOS; n = 1128). Two-sample Mendelian randomization (MR), employing genetic data from a large-scale genome-wide association study (GWAS) of blood lipids (n = 188 577), total body BMD (TB-BMD) (n = 66 628) and estimated BMD (eBMD) (n= 142 487), was performed to infer causality between LDL-C and BMD. Genetic proxies for LDL-C-lowering drugs were used to examine the drugs' effects on BMD.

RESULTS

In the NHANES III cohort, each standard deviation (SD) decrease in LDL-C was associated with a 0.045 SD increase in femoral neck BMD (95% CI: 0.009 - 0.081; P = 0.015). A similar increase in BMD was observed in the HKOS at femoral neck and lumbar spine. In MR analysis, a decrease in genetically predicted LDL-C was associated with an increase in TB-BMD {estimate per SD decrease, 0.038 [95% confidence interval (CI): 0.002 - 0.074]; P = 0.038} and eBMD [0.076 (0.042 - 0.111); P = 1.20x10-5]. Reduction in TB-BMD was causally associated with increased LDL-C [0.035 (0.033 - 0.066); P = 0.034]. Statins' LDL-C-lowering proxies were associated with increased TB-BMD [0.18 (0.044 - 0.316); P = 9.600x10-3] and eBMD [0.143 (0.062 - 0.223); P = 5.165x10-4].

CONCLUSIONS

Negative causal association exists between LDL-C level and BMD. Statins' LDL-C-lowering effect increases BMD, suggesting their protective effect on bone.