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Meta‐analyses showed that non‐dipping of nocturnal blood pressure on ambulatory blood pressure monitoring (ABPM) was associated with adverse cardiovascular prognosis. However, these prognostic studies were mainly conducted in Caucasian and Japanese populations. Whether this association applies to Chinese patients remained uninvestigated. A total of 1199 Chinese patients with hypertension undergoing ABPM between January 2012 and December 2014 were recruited retrospectively from five public hypertension referral clinics in Hong Kong. Patients were followed up for a mean 6.42 years for cardiovascular morbidity and mortality and all‐cause mortality. Time to event of different dipping patterns was compared by Kaplan‐Meier curves. Hazard ratios (HR) were obtained by Cox proportional hazard models with patient demographics and confounding factors adjusted in multivariate regression. A total of 163 end point events occurred in the period. Normal dipping was observed in 446 patients (37.2%), non‐dipping in 490 (40.9%), reverse dipping in 161 (13.4%), and extreme dipping in 102 (8.5%). Kaplan‐Meier analyses showed inferior survival in non‐dippers and reverse dippers for total cardiovascular events and coronary events but not cerebrovascular events. After adjusting for confounding factors, Cox regressions showed HRs 1.166 (CI 0.770‐1.764) and 1.173 (CI 0.681‐2.021) in non‐dippers and reverse dippers for total cardiovascular events, and HRs 1.320 (CI 0.814‐2.141) and 1.476 (CI 0.783‐2.784) for coronary events. Nocturnal blood pressure non‐dipping, and to a greater extent reverse dipping, demonstrated adverse cardiovascular prognosis in a cohort of Chinese patients with hypertension in Hong Kong. Further focused studies on cerebrovascular events and reverse dippers were warranted to refine risk stratification.

Objectives To evaluate the impact of social distancing measures due to COVID-19 pandemic on glycemic and blood pressure control in primary care in Hong Kong. Methods This was a retrospective cross-sectional study. Diabetic patients with regular follow-up in 8 public primary care clinics in Hong Kong within the study period were recruited. The outcomes were to detect any difference of HbA1c levels and BP between pre-pandemic group (2019 group) and the 1-year post-pandemic group (2020 group) in all patients and in sub-group analysis of different age groups, sex, body mass index, presence of diabetic complications and different diabetic treatment. Results There was no statistically significant change in HbA1c level between 2020 and 2019 groups which was 0.019% (95% confidence interval [CI] -0.057% to 0.094%, p  = 0.632). There was also no statistically significant change in both systolic and diastolic BP between 2020 and 2019 groups which were -0.143 mmHg (95%CI -1.005 mmHg to 0.719 mmHg, p  = 0.745) and 0.148 mmHg (95%CI -0.422 mmHg to 0.718 mmHg, p  = 0.611). Subgroup analysis showed that female gender had statistically significant improvement in glycaemic control (HbA1c 6.92% in 2020 group versus HbA1c 7.03% in 2019 group, p  = 0.021). Patients with diabetic retinopathy had statistically significant lower diastolic BP (diastolic BP 73 mmHg in 2020 group versus diastolic BP 75 mmHg in 2019 group with p  = 0.011). Conclusions Despite the implementation of various social distancing measures resulting in significant change in lifestyle, COVID-19 pandemic did not worsen glycaemic and blood pressure control in T2DM patients. In fact, slight improvement in glycaemic control among female patients was found. Trial registration Not applicable.

Purpose The current gold standard for the diagnosis of white-coat effect is by the 24-h ambulatory blood pressure monitoring (ABPM) which may not be readily available in every primary care setting. Previous studies had shown that deep breathing, through modulating the baroreceptor reflex sensitivity to vagal stimulation over 30 to 60 s, was useful in detection of the white-coat effect. The aim of our study was to evaluate the diagnostic accuracy of the deep breathing test (DBT) as compared with the gold standard of ABPM in the diagnosis of hypertension with white-coat effect in Chinese patients in primary care. Methods This cross sectional study recruited 178 consecutive, eligible, consented, hypertensive patients receiving treatment at a local public primary care Hypertension Clinic. The diagnostic accuracy of the DBT in all recruited patients, patients not taking beta-adrenergic blockers and patients with different clinic SBP cut-off before the DBT by means of area under the receiver operating characteristic (ROC) curve, sensitivity, specificity, positive and negative predictive values was evaluated. Results The results for the ROC curves for systolic and diastolic BP changes after the DBT were statistically insignificant. The ROC curve was statistically significant for SBP change in patients not taking beta-adrenergic blockers and with pre-DBT clinic SBP ≥ 165 mmHg (ROC curve area of 0.719, 95% CI 0.53 to 0.91, p = 0.04). The corresponding sensitivity and specificity of the DBT were 40.9 and 90.9% respectively if SBP drop was > 30 mmHg. Conclusion The DBT, even though could not be clinically applied to all patients, was proven to be a potential screening and diagnostic test for white-coat effect in Chinese hypertensive patients with a pre-test SBP of ≥165 mmHg and who were not taking beta-adrenergic blockers. Trial registration This study was approved by Kowloon East Cluster/ Kowloon Central Cluster Research Ethics Committee/Institutional Review Board of Hospital Authority of Hong Kong under the registration KC/KE-16-0084/ER-3.

Objective The prevalence of atrial fibrillation (AF) in type 2 diabetes mellitus (DM) patients under primary care in Hong Kong was yet to be explored. We aimed to evaluate the prevalence of AF in patients with DM so as to provide evidence-based recommendations to incorporate AF screening as a component in regular diabetic risk and complication assessment. The performance of automated BP machine Microlife WatchBP Office AFIB as a screening tool for the detection of AF was also evaluated. Method This was a cross-sectional study. Patients with type 2 DM who attended the regular diabetic risk and complication assessment in the participating clinics from 24 August 2021 to 27 January 2022 were recruited. Blood pressure measurement by Microlife WatchBP Office AFIB and 12-lead ECGs were performed for AF screening. Results Among 2015 DM patients in primary care, the prevalence of AF was found to be 1.9% (95% confidence interval [CI] 1.3–2.6). The prevalence of AF increased with age, from 0.5% in patients aged < 65 years, to 2.2% in patients aged 65–74 years and 4.3% in patients aged ≥ 75 years. The sensitivity and specificity of Microlife WatchBP Office AFIB to detect AF were 80% (95% Cl 61.8–92.3) and 97.9%. (95% CI 97.3–98.5), respectively. The positive and negative predictive values were 32.8% (95% CI 21.9–45.1) and 99.7% (95% CI 99.5–99.9) respectively. Conclusions AF screening with the use of Microlife WatchBP Office AFIB is a simple procedure and can be considered as a standard assessment in the regular comprehensive diabetic risk and complication assessment in primary care setting.

Objective: To enhance the quality of COPD management in primary care via a two-phase clinical audit in Hong Kong. Methods: COPD patients aged 40 or above and had attended any of the 73 public primary care clinics under the Hospital Authority of Hong Kong (HAHK) for follow up (FU) during the audit period were included. Performance of six evidence-based audit criteria on COPD care was reviewed in phase 1 from 1st April 2017 to 31st March 2018. Service gaps were identified and a series of quality improvement strategies were executed in the one-year implementation phase. The outcome of the service enhancement was assessed in phase 2 from 1st April 2019 to 31st March 2020. Student's t-test and the chi-square test were used to examine the statistically significant differences between the two phases. Results: Totally 10,385 COPD cases were identified in phase 1, the majority were male (87.7%) and the mean age was 75.3 [+ or -] 9.9 years. Among the 3102 active smokers, 1788 (57.6%) were referred to receive the smoking cessation counselling and 1578 (50.9%) actually attended it. A total of 4866 cases (46.9%) received seasonal influenza vaccine (SIV) and 4227 cases (40.7%) received pneumococcal vaccine (PCV). A total of 1983 patients (19.1%) had spirometry test done before and 1327 patients (12.8%) had history of hospital admission due to acute exacerbation of COPD (AECOPD). After the proactive implementation phase, performance on all criteria was significantly improved in phase 2, with a marked increase in the SIV and PCV uptake rate and spirometry performance rate. Most importantly, a significant reduction in AECOPD rate leading to hospital admission had been achieved (9.6%, P<0.00001). Conclusion: COPD care at all public primary care clinics of HAHK had been significantly improved for all audit criteria via the systematic team approach, which, in turn, reduced the hospital admission rate and helped relieve the burden of the health care system. Keywords: clinical audit, COPD, quality improvement, primary care

Objective: To enhance the quality of COPD management in primary care via a two-phase clinical audit in Hong Kong. Methods: COPD patients aged 40 or above and had attended any of the 73 public primary care clinics under the Hospital Authority of Hong Kong (HAHK) for follow up (FU) during the audit period were included. Performance of six evidence-based audit criteria on COPD care was reviewed in phase 1 from 1st April 2017 to 31st March 2018. Service gaps were identified and a series of quality improvement strategies were executed in the one-year implementation phase. The outcome of the service enhancement was assessed in phase 2 from 1st April 2019 to 31st March 2020. Student's t-test and the chi-square test were used to examine the statistically significant differences between the two phases. Results: Totally 10,385 COPD cases were identified in phase 1, the majority were male (87.7%) and the mean age was 75.3 [+ or -] 9.9 years. Among the 3102 active smokers, 1788 (57.6%) were referred to receive the smoking cessation counselling and 1578 (50.9%) actually attended it. A total of 4866 cases (46.9%) received seasonal influenza vaccine (SIV) and 4227 cases (40.7%) received pneumococcal vaccine (PCV). A total of 1983 patients (19.1%) had spirometry test done before and 1327 patients (12.8%) had history of hospital admission due to acute exacerbation of COPD (AECOPD). After the proactive implementation phase, performance on all criteria was significantly improved in phase 2, with a marked increase in the SIV and PCV uptake rate and spirometry performance rate. Most importantly, a significant reduction in AECOPD rate leading to hospital admission had been achieved (9.6%, P<0.00001). Conclusion: COPD care at all public primary care clinics of HAHK had been significantly improved for all audit criteria via the systematic team approach, which, in turn, reduced the hospital admission rate and helped relieve the burden of the health care system. Keywords: clinical audit, COPD, quality improvement, primary care

The result of published studies on the clinical outcome of peritoneal dialysis (PD) after kidney allograft failure is conflicting. There are also few published data on the outcome of patients who had PD before kidney transplant and then return to PD after allograft failure. We reviewed 100 patients who were started on PD after kidney allograft failure between 2001 and 2020 (failed transplant group); 50 of them received PD before transplant. We compared the clinical outcome to 200 new PD patients matched for age, sex, and diabetic status (control group). The patients were followed for 45.8 ± 40.5 months. the 2-year patient survival rate was 83.3% and 87.8% for the failed transplant and control groups, respectively (log rank test, p = 0.2). The corresponding 2-year technique survival rate 66.5% and 71.7% (p = 0.5). The failed transplant and control groups also had similar hospitalization rate and peritonitis rate. In the failed transplant group, there was also no difference in patient survival, technique survival, hospitalization, or peritonitis rate between those with and without PD before transplant. In the failed transplant group, patients who had PD before transplant and then returned to PD after allograft failure had substantial increase in D/P4 (0.585 ± 0.130 to 0.659 ± 0.111, paired t-test, p = 0.032) and MTAC creatinine (7.74 ± 3.68 to 9.73 ± 3.00 ml/min/1.73m2, p = 0.047) from the time before the transplant to the time after PD was resumed after failed allograft. The clinical outcome of PD patients with a failed kidney allograft is similar to other PD patients. However, patients who have a history of PD before kidney transplant and then return to PD after allograft failure have increased peritoneal transport parameters.

Frailty and obesity contribute to the adverse clinical outcome of peritoneal dialysis (PD) patients, but the interaction between frailty and obesity remains uncertain. To examine the interaction between frailty and obesity on the clinical outcome of PD patients. Single centre prospective observational cohort study. 267 prevalent Chinese PD patients were recruited. Frailty was identified by a standard score. General and central obesity were determined by body mass index (BMI) and waist-hip ratio (WHR), respectively. Body composition was assessed by bioimpedance spectroscopy. All patients were followed for two years. Outcome measures included all-cause as well as cardiovascular mortality and hospitalization. Of the 267 patients, 120 (44.9%) were frail. Frail individuals were more likely to have central obesity (p < 0.001) but not general obesity. Although WHR did not predict patient survival, there was a significant interaction between WHR and frailty on patient survival and cardiovascular survival (p = 0.002 and p = 0.038, respectively). For patients without frailty, the two-year cardiovascular survival was 91.3% and 74.4% for those with and without central obesity, respectively (p = 0.002). For patients with frailty, however, the two-year cardiovascular survival was 64.6% and 66.7% for those with and without central obesity, respectively (p = 0.6). For patients without frailty, the number of hospital admission for cardiovascular disease over 2 years were 0.12 ± 0.37 and 0.34 ± 0.72 for those with and without central obesity, respectively (p = 0.03). For frail patients, however, the number of hospital admission was similar between those with and without central obesity. There is a significant interaction between frailty and central obesity on the outcome of PD patients. The protective role of central obesity is only apparent in PD patients without frailty but not the frail ones, and there is a little prognostic value of general (non-central) obesity.

Background: Physical frailty contributes to adverse clinical outcomes in peritoneal dialysis (PD) patients. Little has been reported about frailty transitions in this population. We aimed to describe the transitions of frailty in PD patients and identify factors that predicted changes in frailty state. Methods: In a prospective observational study, we recruited 267 PD patients. Frailty was assessed by a validated frailty score. Depression was graded by PHQ-9 score, and nutritional status was evaluated by serum albumin, Subjective Global Assessment (SGA), and comprehensive Malnutrition Inflammation Score (MIS). The primary outcome was the change in frailty score at follow-up compared to baseline. Results: At baseline, 194 (72.7%) patients were classified as frail. With time, their frailty scores significantly increased (p < 0.001), and 93 of the surviving subjects (78.2%) were classified as frail. There was a modest significant correlation between change in MIS (p < 0.001), change in SGA score (p < 0.001), and change in PHQ-9 score (p < 0.001) with change in frailty score. An increase in PHQ-9 score (p < 0.001) and MIS (p = 0.001), as well as longer duration of hospitalization (p = 0.001), was independently associated with a greater change in frailty score after adjustment for confounding factors. Frailty score was also improved in patients who were converted to hemodialysis (p = 0.048) and received renal transplantation (p = 0.005). Conclusion: Our findings suggested that frailty transitions were common in PD patients. Worsening in nutrition and depression, together with a longer duration of hospitalization, were associated with worsening in frailty.

Background Sarcopenia is common in peritoneal dialysis (PD) patients. Modified creatinine index (MCrI) by the Canaud's formula and single-pool Kt/V value is an accurate surrogate marker for muscle mass in hemodialysis patients. However, the method of calculation and validity of MCrI has not been tested in PD. Methods In the exploratory cohort, we studied 138 consecutive patients converted from PD to hemodialysis. Their MCrI during PD, calculated by the Canaud's formula with total weekly Kt/V, and the conventional MCrI after conversion to HD, were compared by the Bland–Altman method. Their correlation with muscle mass as determined by bioimpedance spectroscopy and creatinine kinetic methods was explored. The result was then validated in a second cohort of 605 incident PD patients. Results In the exploratory cohort, the average bias of computing MCrI during PD and hemodialysis was 0.758 mg/kg/day (95%CI −4.356 to 5.873 mg/kg/day). The MCrI during PD significantly correlated with the muscle mass by creatinine kinetics (r = .684, P < .0001) and by bioimpedance spectroscopy (r = .641, P < .0001), but not with protein nitrogen appearance, overhydration, or adipose tissue mass, and the result was similar in the validation cohort. For incident PD patients, MCrI quartile was significantly associated with the risk of death from all cause in 12 months (Gray's test, P = .013) but not conversion to chronic hemodialysis (P = .14). Conclusion In PD patients, MCrI computed by the Canaud's formula and total weekly Kt/V is a simple and reliable marker of skeletal muscle mass and may serve as a short-term prognostic indicator.