The Relationship between Low-Sodium Salt Intake and Both Blood Pressure Level and Hypertension in Chinese Residents.

Compared to common salt, low-sodium salt can reduce blood pressure to varying degrees. However, the exact dosage relationship remains unclear. We aimed to investigate the dose-response relationships between low-sodium salt intake and systolic blood pressure (SBP) and diastolic blood pressure (DBP), as well as the risk of hypertension, and to determine the optimal range for low-sodium salt intake. We investigated the basic characteristics and dietary profile of 350 individuals who consumed low-sodium salt. The samples were divided into three groups according to the 33.3rd and 66.6th percentiles of low-sodium salt intake in condiments (Q1: <4.72 g/d, Q2: ≥4.72 g/d, and <6.88 g/d, and Q3: ≥6.88 g/d). The restricted cubic spline results indicated that low-sodium salt intake decreased linearly with SBP and DBP, while low-sodium intake demonstrated a non-linear, L-shaped relationship with the risk of hypertension, with a safe range of 5.81 g to 7.66 g. The multiple linear regression analysis revealed that compared with group Q1, the DBP in group Q2 decreased by 2.843 mmHg (95%CI: -5.552, -0.133), and the SBP in group Q3 decreased by 4.997 mmHg (95%CI: -9.136, -0.858). Exploratory subgroup analyses indicated that low-sodium salt intake had a significant impact on reducing SBP in males, DBP in females, SBP in rural populations, and DBP in urban populations. The intake of low-sodium salt adheres to the principle of moderation, with 5.81-7.66 g potentially serving as a pivotal threshold.

Association between spot urinary sodium-to-potassium ratio and blood pressure among Chinese adults aged 18-69 years: the SMASH study.

Background: Excessive sodium and low potassium intake are involved in the development of hypertension. Growing evidence showed that the sodium-to-potassium ratio (Na/K) was significantly associated with blood pressure (BP). However, studies on the dose-response relationship of spot urinary Na/K ratio with hypertension and BP in the general population are scarce, especially in the Chinese population. Materials and methods: Data from the post-intervention survey of the Shandong Ministry of Health Action on Salt and Hypertension (SMASH) project was analyzed. Associations between Na/K molar ratio and hypertension prevalence and between Na/K molar ratio and BP indices were analyzed using multivariable logistic and linear regression, respectively, followed by subgroup analysis and interaction analysis. The restricted cubic spline model was used to explore the dose-response relationship. Informed by existing literature, we adjusted for potential confounding factors, including temperature and renal function, to assess the association and dose-response relationship. Results: There was a non-linear positive association between Na/K and hypertension (OR:1.09, 95%CI: 1.08-1.11) and a linear positive association between Na/K and systolic BP, diastolic BP, and mean arterial pressure (ß 0.53, 95%CI: 0.45-0.60; ß 0.36, 95%CI: 0.31-0.41; and ß 0.42, 95%CI: 0.36-0.47, respectively). The association was stronger in individuals with hypertension, female patients, those in the 50-59-year age group, and those who were obese. Environmental temperatures had little impact on associations. Conclusion: Our findings provide further evidence that the spot urinary Na/K ratio is a simple, useful, and convenient indicator for monitoring salt reduction and potassium increase, which could be used in clinical and public health practices.

Association of ambient ozone exposure and greenness exposure with hemorrhagic stroke mortality at different times: A cohort study in Shandong Province, China.

Evidence on the association between long-term ozone exposure and greenness exposure and hemorrhagic stroke (HS) is limited, with mixed results. One potential source of this inconsistency is the difference in exposure time metrics. This study aimed to investigate the association between long-term exposure to ambient ozone, greenness, and mortality from HS using exposure metrics at different times. We also examined whether greenness exposure modified the relationship between ozone exposure and mortality due to HS. The study population consisted of 45771 participants aged ≥40 y residing in 20 counties in Shandong Province who were followed up from 2013 to 2019. Ozone exposure metrics (annual mean and warm season) and the normalized difference a measure of greenness exposure, were calculated. The relationship between environmental exposures (ozone and greenness exposures) and mortality from HS was assessed using time-dependent Cox proportional hazards models, and the modification of greenness exposure was examined using stratified analysis with interaction terms. The person-years at the end of follow-up were 90,663. With full adjustments, the risk of death from hemorrhagic stroke increased by 5% per interquartile range increase in warm season ozone [hazard ratio =1.05; 95 % confidence interval: 1.01-1.08]. No clear association was observed between annual ozone and mortality HS. Both the annual and summer NDVI were found to reduce the risk of HS mortality. The relationships were influenced by age, sex, and residence (urban or rural). Furthermore, greenness exposure was shown to have a modifying effect on the relationship between ozone exposure and the occurrence of HS mortality (P for interaction = 0.001). Long-term exposure to warm season O3 was positively associated with HS mortality, while greenness exposure was inversely associated with HS mortality. Greenness exposure may mitigate the negative effects of warm season ozone exposure on HS mortality.

Greenness mitigate cause-specific mortality associated with air pollutants in ischemic and hemorrhagic stroke patients: An ecological health cohort study.

BACKGROUND: Air pollution is one of the most serious environmental risks to mortality of stroke. However, there exists a noteworthy knowledge gap concerning the different stroke subtypes, causes of death, the susceptibility of stroke patient, and the role of greenness in this context. METHODS: We analyzed data from an ecological health cohort, which included 334,261 patients aged ≥40 years with stroke (comprising 288,490 ischemic stroke and 45,771 hemorrhagic stroke) during the period 2013-2019. We used Cox proportional hazards models with time-varying exposure to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) to assess the associations of annual average fine particulate matter (PM2.5), nitrogen dioxide (NO2), and ozone (O3) with both all-cause and cause-specific mortality. Additionally, we conducted analyses to examine the effect modification by greenness and identify potential susceptibility factors through subgroup analyses. RESULT: In multivariable-adjusted models, long-term exposure to PM2.5 and NO2 was associated with increased risk of all-cause mortality (HR: 1.038, 95% CI: 1.029-1.047 for PM2.5; HR: 1.055, 95% CI: 1.026-1.085 for NO2, per 10 µg/m3, for ischemic stroke patients; similar for hemorrhagic stroke patients). Gradually increasing effect sizes were shown for CVD mortality and stroke mortality. The HRs of mortality were slightly weaker with high versus low vegetation exposure. Cumulative exposures increased the HRs of pollutant-related mortality, and greater greenness decreased this risk. Two subtypes of stroke patients exhibited diverse patterns of benefit. CONCLUSION: Increasing residential greenness attenuates the increased risk of mortality with different patterns due to chronic air pollutants for ischemic and hemorrhagic stroke, offering valuable insights for precise tertiary stroke prevention strategies.

Effect of neighbourhood greenness on the association between air pollution and risk of stroke first onset: A case-crossover study in shandong province, China.

BACKGROUND: Higher neighbourhood greenness is associated with beneficial health outcomes, and short-term exposure to air pollution is associated with an elevated risk of stroke onset. However, little is known about their interactions. METHODS: Daily data on stroke first onset were collected from 20 counties in Shangdong Province, China, from 2013 to 2019. The enhanced vegetation index (EVI) and concentrations of fine particulate matter (PM2.5), nitrogen dioxide (NO2), ozone (O3), carbon monoxide (CO), and sulfur dioxide (SO2) were calculated for each individual at the village or community level based on their home address to measure their neighbourhood exposure to greenness and air pollution. EVI was categorised as low or high, and a time-stratified case-crossover design was used to estimate the percent excess risk (ER%) of stroke associated with short-term exposure to air pollution. We further stratified greenness on the basis of EVI values into quartiles and introduced interaction terms between air pollutant concentrations and the median EVI values of the quartiles to assess the effect of greenness on the associations between short-term exposure and stroke. RESULTS: Individuals living in the high-greenness areas had weaker associations between total stroke risk and exposure to NO2 (low greenness: ER% = 1.765% [95% CI 1.205%-2.328%]; high greenness: ER% = 0.368% [95% CI -0.252% to 0.991%]; P = 0.001), O3 (low greenness: 0.476% [95% CI 0.246%-0.706%]; high greenness: ER% = 0.085% [95% CI -0.156% to 0.327%]; P = 0.011), and SO2 (low greenness: 0.632% [95% CI 0.138%-1.129%]; high greenness: ER% = -0.177% [95% CI -0.782% to 0.431%]; P = 0.035). CONCLUSION: Residence in areas with higher greenness was related to weaker associations between air pollution and stroke risk, suggesting that effectively planning green spaces can improve public health.

Estimating future PM2.5-attributed acute myocardial infarction incident cases under climate mitigation and population change scenarios in Shandong Province, China.

BACKGROUND: The effects of fine particulate matter (PM2.5) on acute myocardial infarction (AMI) have been widely recognized. However, no studies have comprehensively evaluated future PM2.5-attributed AMI burdens under different climate mitigation and population change scenarios. We aimed to quantify the PM2.5-AMI association and estimate the future change in PM2.5-attributed AMI incident cases under six integrated scenarios in 2030 and 2060 in Shandong Province, China. METHODS: Daily AMI incident cases and air pollutant data were collected from 136 districts/counties in Shandong Province from 2017 - 2019. A two-stage analysis with a distributed lag nonlinear model was conducted to quantify the baseline PM2.5-AMI association. The future change in PM2.5-attributed AMI incident cases was estimated by combining the fitted PM2.5-AMI association with the projected daily PM2.5 concentrations under six integrated scenarios. We further analyzed the factors driving changes in PM2.5-related AMI incidence using a decomposition method. RESULTS: Each 10 µg/m3 increase in PM2.5 exposure at lag05 was related to an excess risk of 1.3 % (95 % confidence intervals: 0.9 %, 1.7 %) for AMI incidence from 2017 - 2019 in Shandong Province. The estimated total PM2.5-attributed AMI incident cases would increase by 10.9-125.9 % and 6.4-244.6 % under Scenarios 1 - 3 in 2030 and 2060, whereas they would decrease by 0.9-5.2 % and 33.0-46.2 % under Scenarios 5 - 6 in 2030 and 2060, respectively. Furthermore, the percentage increases in PM2.5-attributed female cases (2030: -0.3 % to 135.1 %; 2060: -33.2 % to 321.5 %) and aging cases (2030: 15.2-171.8 %; 2060: -21.5 % to 394.2 %) would wholly exceed those in male cases (2030: -1.8 % to 133.2 %; 2060: -41.1 % to 264.3 %) and non-aging cases (2030: -41.0 % to 45.7 %; 2060: -89.5 % to -17.0 %) under six scenarios in 2030 and 2060. Population aging is the main driver of increased PM2.5-related AMI incidence under Scenarios 1 - 3 in 2030 and 2060, while improved air quality can offset these negative effects of population aging under the implementation of the carbon neutrality and 1.5 °C targets. CONCLUSION: The combination of ambitious climate policies (i.e., 1.5 °C warming limits and carbon neutrality targets) with stringent clean air policies is necessary to reduce the health impacts of air pollution in Shandong Province, China, regardless of population aging.

Associations of ambient temperature with mortality for ischemic and hemorrhagic stroke and the modification effects of greenness in Shandong Province, China.

BACKGROUND: Evidence is scant on the relative and attributable contributions of ambient temperature on stroke subtypes mortality. Few studies have examined modification effects of multiple greenness indicators on such contributions, especially in China. We quantified the associations between ambient temperature and overall, ischemic, and hemorrhagic stroke mortality; further examined whether the associations were modified by greenness. METHODS: We conducted a multicenter time-series analysis from January 1, 2013 to December 31, 2019. we adopted a distributed lag non-linear model to evaluate county-specific temperature-stroke mortality associations. We then applied a random-effects meta-analysis to pool county-specific effects. Attributable mortality was calculated for cold and heat, defined as temperatures below and above the minimum mortality temperature (MMT). Finally, We conducted a multivariate meta-regression to determine associations between greenness and stroke mortality risks for cold and heat, using normalized difference vegetation index (NDVI), soil adjusted vegetation index (SAVI), and enhanced vegetation index (EVI) as quantitative indicators of greenness exposure. RESULTS: In the study period, 138,749 deaths from total stroke were reported: 86,873 ischemic and 51,876 hemorrhagic stroke. We observed significant W-shaped relationships between temperature and stroke mortality, with substantial differences among counties and regions. With MMT as the temperature threshold, 17.16 % (95 % empirical CI, 13.38 %-19.75 %) of overall, 20.05 % (95 % eCI, 16.46 %-22.70 %) of ischemic, and 12.55 % (95 % eCI, 5.59 %-16.24 %) of hemorrhagic stroke mortality were attributable to non-optimum temperature (combining cold and heat), more mortality was caused by cold (14.94 %; 95 % eCI, 11.57 %-17.34 %) than by heat (2.22 %; 95 % eCI, 1.54 %-2.72 %). Higher levels of NDVI, SAVI and EVI were related to mitigated effects of non-optimum temperatures-especially heat. CONCLUSIONS: Exposure to non-optimum temperatures aggravated stroke mortality risks; increasing greenness could alleviate that risks. This evidence has important implications for local communities in developing adaptive strategies to minimize the health consequences of adverse temperatures.

Effects of the COVID-19 Lockdown on Air Pollutant Levels and Associated Reductions in Ischemic Stroke Incidence in Shandong Province, China.

Background: Local governments in China took restrictive measures after the outbreak of COVID-19 to control its spread, which unintentionally resulted in reduced anthropogenic emission sources of air pollutants. In this study, we intended to examine the effects of the COVID-19 lockdown policy on the concentration levels of particulate matter with aerodynamic diameters of ≤1 µm (PM1), ≤2.5 µm (PM2.5), and ≤10 µm (PM10), nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), and carbon monoxide (CO) and the potential subsequent reductions in the incidence of ischemic and hemorrhagic stroke in Shandong Province, China. Methods: A difference-in-difference model combining the daily incidence data for ischemic and hemorrhagic stroke and air pollutant data in 126 counties was used to estimate the effect of the COVID-19 lockdown on the air pollutant levels and ischemic and hemorrhagic stroke incident counts. The avoided ischemic stroke cases related to the changes in air pollutant exposure levels were further estimated using concentration-response functions from previous studies. Results: The PM1, PM2.5, PM10, NO2, and CO levels significantly decreased by -30.2, -20.9, -13.5, -46.3, and -13.1%, respectively. The O3 level increased by 11.5% during the lockdown compared with that in the counterfactual lockdown phase of the past 2 years. There was a significant reduction in population-weighted ischemic stroke cases (-15,315, 95% confidence interval [CI]: -27,689, -2,942), representing a reduction of 27.6% (95% CI: -49.9%, -5.3%). The change in the number of hemorrhagic stroke cases was not statistically significant. The total avoided PM1-, PM2.5-, PM10-, NO2-, and CO-related ischemic stroke cases were 739 (95% CI: 641, 833), 509 (95% CI: 440, 575), 355 (95% CI: 304, 405), 1,132 (95% CI: 1,024, 1,240), and 289 (95% CI: 236, 340), respectively. Conclusion: The COVID-19 lockdown indirectly reduced the concentration levels of PM1, PM2.5, PM10, NO2, and CO and subsequently reduced the associated ischemic stroke incidence. The health benefits due to the lockdown are temporary, and long-term measures should be implemented to increase air quality and related health benefits in the post-COVID-19 period.

Short-term effects of exposure to ambient PM1, PM2.5, and PM10 on ischemic and hemorrhagic stroke incidence in Shandong Province, China.

BACKGROUND: Short-term exposure to ambient PM2.5 and PM10 is associated with increased risk of mortality and hospital admissions for stroke. However, there is less evidence regarding the effect of exposure to PM1 on stroke incidence. We estimated the incidence risk of stroke and the attributable fractions related to short-term exposure to ambient PM1, PM2.5 and PM10 in China. METHODS: County-specific incidence of stroke was obtained from health statistics in years 2014-2019. We linked county-level mean daily concentrations of PM1, PM2.5 and PM10 with stroke incidence. We used the time stratified case-crossover design to estimate the associations between stroke incidence and exposure to PM1, PM2.5 and PM10. We also estimated the disease burden fractions attributable to PM1, PM2.5, and PM10. RESULTS: The study included a total of 2,193,954 stroke, from which 1,861,331 were ischemic and 332,623 were hemorrhagic stroke. PM1, PM2.5, and PM10 levels were associated with increased risks of total stroke and ischemic stroke at when assessing the associations in exposure at lag0-4 days. The increase of 10 µg/m3 in PM1, PM2.5, and PM10 was associated with total stroke, and the relative risks were 1.012 (95% confidence interval: 1.008, 1.015), 1.006 (1.004, 1.007) and 1.003 (1.002, 1.004), while the associations with ischemic stroke were 1.013 (1.010, 1.017), 1.006 (1.005, 1.008) and 1.003 (1.002, 1.004), respectively. There was no significant association between PM and risk of hemorrhagic stroke. The attributable fractions of total stroke were 6.9% (5.1%, 8.5%), 5.6% (4.2%, 6.8%) and 5.6% (3.9%, 7.1%) for PM1, PM2.5, and PM10, respectively. CONCLUSIONS: PM1 showed a stronger association with stroke, with a larger attributable fraction of outcomes, than PM2.5 and PM10. Clean air policies should target the whole scope of PM, including PM1.

[Deaths and life expectancy losses attributed to high-salt diet in Shandong province].

Objective: To estimate the deaths and life expectancy losses attributed to diet with high salt in Shandong province. Methods: Based on 24 h urinary sodium and blood pressure levels from the final evaluation survey of Shandong-Ministry of Health Action on Salt and Hypertension Project (SMASH) in 2016 and death cause data from Shandong Mortality Surveillance System, the population attributable fractions (PAF) and the deaths due to high-salt diet were calculated based on the framework of comparative risk assessment and the life expectancy loss was calculated by life table method. Results: A total of 32 987 deaths caused by high-salt diets were reported in 2016, accounting for 11.74% of related disease deaths and 4.95% of all deaths. The proportion of deaths due to high-salt diet in men (13.51%) was higher than that in women (9.17%). Cardiovascular diseases were the major causes of deaths due to high salt diet, accounting for 90.82% of all disease deaths caused by high-salt diets. The other causes were gastric cancer (8.10%) and chronic kidney disease (1.08%). The PAF in urban residents (13.87%) was higher than that in rural residents (10.87%). A loss of 0.58 years of the life expectancy were attributed to the high-salt diet. The different diseases caused by high-salt diet had different effects on life expectancy loss, ischemic heart disease ranked first, followed by cerebral hemorrhage and cerebral infarction. Conclusions: The proportion of deaths attributed to high-salt diets was high in Shandong. Cardiovascular diseases were the most important causes of deaths caused by high-salt diets. High-salt diet is still seriously affecting the health of residents in Shandong, indicating that salt reduction interventions need to be strengthened.

Association between dietary essential amino acids intake and metabolic biomarkers: influence of obesity among Chinese children and adolescents.

Essential amino acids (EAAs) are involved in growth and development in children and adolescents. This study was aimed at exploring the relationship between dietary EAA intakes and metabolic biomarker, and the influence of obesity in children and adolescents. A total of 3566 subjects were analysed. Participators were classified according to weight status. Metabolic biomarkers were determined using standardized methods and conditions. Normal, overweight, and obesity statuses were defined according to the Working Group on Obesity in China (WGOC) BMI cutoff points based on age- and sex-specific screening criteria. In normal-weight group, blood uric acid was negatively correlated with dietary Ile, Leu, Lys, Phe, Thr, Val, and His, and zinc was negatively correlated with Ile, Leu, Lys, Phe, Thr, Val, His, Met, and Trp. In overweight group, TC was negatively correlated with Ile, Leu, Phe, Val, and His, and LDL-C was negatively correlated with Ile, Leu, Lys, Phe, Thr, Val, His, and Met, while TG was positively correlated with Leu, Lys, Phe, Thr, Val, and Met. In obesity group, hemoglobin was positively related to Ile, Leu, Lys, Phe, Thr, Val, His, and Trp, while vitamin D was positively correlated with His and Trp. The serum creatinine was negatively correlated with Ile, Leu, Phe, Val, His, and Met in normal-weight group, and positively correlated with Ile, Leu, Lys, Phe, Thr, Val, His, Met, Trp, His, and Trp in obesity group. Dietary amino acid score (AAS) and Leu intake were protective factors for obesity. The association between fasting blood glucose and EAAs intake was weak and labile. Metabolic biomarkers and EAA intakes were only related under certain weight status. The dietary AAS is positively correlated with HDL-C, LDL-C, serum creatinine, albumin, serum vitamin D, and zinc. The subtle relationship of EAAs and kidney function should be explored further. There is a complex relationship between EAAs and metabolic biomarkers, and overweight and obesity have a certain influence on this relationship.

The bridge stenting-based internal drainage in pancreatic trauma patients with main pancreatic duct injury.

Pancreatic trauma is associated with high mortality and morbidity, especially in main pancreatic duct (MPD) injuries. Here, we introduce a novel technique via the placement of bridge stenting-based internal drainage (BSID) along the injured MPD to restore pancreatic tissue integrity. Twelve patients with MPD injury underwent unobstructed BSID as physical support for healing. Six patients with peripheral organ injuries underwent operative end-to-end anastomosis of the MPD by using a polyurethane central venous catheter for the BSID, and the other six patients with isolated proximal MPD rupture received BSID via endoscopic pancreatic stent placement. The BSID technique was successfully performed in all pancreatic trauma patients without the need for a second open surgery. With this simplified BSID-based operation, a short procedure duration (242.7 ± 38.71 min in the surgical group and 100.2 ± 16.24 min in the endoscopic group) and a short hospital stay (13.0 ± 7.05 days) were achieved. However, a few complications (41.67%) still occurred, including pancreatitis, fistula, abscess, pseudocyst, cholangitis, and haemorrhage. Except for the deceased case, all postoperative courses were marked by decreases in the peripancreatic fluid collection, blood amylase recovery, and normal endocrine function. The BSID approach is a feasible surgical approach for the treatment of MPD injury and can be used endoscopically in isolated MPD injuries for its safety and convenience.

Association of a Province-Wide Intervention With Salt Intake and Hypertension in Shandong Province, China, 2011-2016.

Importance: High salt intake is associated with hypertension, which is a leading modifiable risk factor for cardiovascular disease. Objective: To assess the association of a government-led, multisectoral, and population-based intervention with reduced salt intake and blood pressure in Shandong Province, China. Design, Setting, and Participants: This cross-sectional study used data from the Shandong-Ministry of Health Action on Salt and Hypertension (SMASH) program, a 5-year intervention to reduce sodium consumption in Shandong Province, China. Two representative samples of adults (aged 18-69 years) were surveyed in 2011 (15 350 preintervention participants) and 2016 (16 490 postintervention participants) to examine changes in blood pressure, and knowledge, attitudes, and behaviors related to sodium intake. Urine samples were collected from random subsamples (2024 preintervention participants and 1675 postintervention participants) for measuring sodium and potassium excretion. Data were analyzed from January 20, 2017, to April 9, 2019. Interventions: Media campaigns, distribution of scaled salt spoons, promotion of low-sodium products in markets and restaurants, and activities to support household sodium reduction and school-based sodium reduction education. Main Outcomes and Measures: The primary outcome was change in urinary sodium excretion. Secondary outcomes were changes in potassium excretion, blood pressure, and knowledge, attitudes, and behaviors. Outcomes were adjusted for likely confounders. Means (95% CIs) and percentages were weighted. Results: Among 15 350 participants in 2011, 7683 (50.4%) were men and the mean age was 40.7 years (95% CI, 40.2-41.2 years); among 16 490 participants in 2016, 8077 (50.7%) were men and the mean age was 42.8 years (95% CI, 42.5-43.1 years). Among participants with 24-hour urine samples, 1060 (51.8%) were men and the mean age was 40.9 years (95% CI, 40.5-41.3 years) in 2011 and 836 (50.7%) were men and the mean age was 40.7 years (95% CI, 40.1-41.4 years) in 2016. The 24-hour urinary sodium excretion decreased 25% from 5338 mg per day (95% CI, 5065-5612 mg per day) in 2011 to 4013 mg per day (95% CI, 3837-4190 mg per day) in 2016 (P < .001), and potassium excretion increased 15% from 1607 mg per day (95% CI, 1511-1704 mg per day) to 1850 mg per day (95% CI, 1771-1929 mg per day) (P < .001). Adjusted mean systolic blood pressure among all participants decreased from 131.8 mm Hg (95% CI, 129.8-133.8 mm Hg) to 130.0 mm Hg (95% CI, 127.7-132.4 mm Hg) (P = .04), and diastolic blood pressure decreased from 83.9 mm Hg (95% CI, 82.6-85.1 mm Hg) to 80.8 mm Hg (95% CI, 79.4-82.1 mm Hg) (P < .001). Knowledge, attitudes, and behaviors associated with dietary sodium reduction and hypertension improved significantly. Conclusions and Relevance: The findings suggest that a government-led and population-based intervention in Shandong, China, was associated with significant decreases in dietary sodium intake and a modest reduction in blood pressure. The results of SMASH may have implications for sodium reduction and blood pressure control in other regions of China and worldwide.

Endoscopic dissection of refractory pancreatic duct stricture via accessory pancreatic duct approach for concurrent treatment of anomalous pancreaticobiliary junction in aging patients.

BACKGROUND: Although endoscopic management of pancreatic strictures by dilation and stenting is well established, some high-grade strictures are refractory to conventional methods. Here, we report a novel technique via accessory pancreatic duct (APD) approach to simultaneously release chronic pancreatitis-associated pancreatic stricture and correct anomalous pancreaticobiliary junction (APBJ). Due to APBJ and stricture of proximal main pancreatic duct, the APD turned out to be compensatory expansion. The stiff stenosis was dissected along the axial of APD using needle-knife electrocautery or holmium laser ablation, and then the supporting stent was placed into the pancreatic body duct. By doing so, the outflow channels of pancreatic and biliary ducts were exquisitely separated. PATIENTS AND METHODS: Two patients aged 69 and 71 years underwent stricture dissection and stent insertion for fluent drainage of pancreatic juice. The postoperative course was marked by complete abdominal pain relief and normal blood amylase recovery. In the first patient, wire-guided needle-knife electrocautery under fluoroscopic control was applied to release refractory stricture. The second patient was treated by SpyGlass pancreatoscopy-guided holmium laser ablation to lift pancreatic stricture. RESULTS: Plastic stents in APD were removed at 3 months after surgery, and magnetic resonance imaging at 6 months showed strictly normal aspect of the pancreatic duct. CONCLUSION: Although both cases were successful without severe complications, we recommend this approach only for selected patients with short refractory pancreatic strictures due to chronic pancreatitis. In order to prevent severe complications (bleeding, perforation or pancreatitis), direct-view endoscopy-guided electrotomy needs to be developed.

Single-operator cholangioscopy for the treatment of concomitant gallbladder stones and secondary common bile duct stones.

BACKGROUND AND AIM: This study aims to assess the clinical validity and safety of single-operator cholangioscopy system (SOCS) for the treatment of concomitant gallbladder stones and secondary common bile duct (CBD) stones. METHODS: This retrospective study included 10 consecutive patients who had small-sized stones (< 1 cm) in both the gallbladder and CBD; the patients underwent SOCS treatment from June 2016 to December 2016. The clinical validity of this minimally invasive surgery was determined by the operation success rate, stone removal rate, postoperative hospital stay, hospitalization cost, and contrast images before and after the operation. The clinical safety was evaluated by perioperative complications and outcomes, gallbladder stone recurrence, and gallbladder contractility function. RESULTS: Both the technique success rate and the stone removal rate when using SOCS was 100%. There were no serious complications that occurred during the operation; three patients developed acute cholecystitis, and four patients underwent hyperamylasemia after the surgery. The average postoperative hospital stay was 5.8 ± 1.32 days, and the average hospitalization cost was 7466 ± 566.1 dollars. In the follow-up period, which ranged from 3 to 8 months, there was no stone residuals or recurrences in the gallbladder and CBD, and no patient showed a recurrence of biliary colic. In addition, the gallbladder contractility function was proven to be normal within 3 to 6 months after the operation. CONCLUSIONS: SOCS could successfully manage concomitant gallbladder stones and secondary CBD stones and precisely protect normal biliary function.

Step-by-step strategy in the management of residual hepatolithiasis using post-operative cholangioscopy.

Hepatolithiasis is the presence of calculi within the intrahepatic bile duct specifically located proximal to the confluence of the left and right hepatic ducts. The ultimate goal of hepatolithiasis treatment is the complete removal of the stone, the correction of the associated strictures and the prevention of recurrent cholangitis. Although hepatectomy could effectively achieve the above goals, it can be restricted by the risk of insufficient residual liver volume, and has a 15.6% rate of residual hepatolithiasis. With improvements in minimally invasive surgery, post-operative cholangioscopy (POC), provides an additional option for hepatolithiasis treatment with higher clearance rate and fewer severe complications. POC is very safe, and can be performed repeatedly until full patient benefit is achieved. During POC three main steps are accomplished: first, the analysis of the residual hepatolithiasis distribution indirectly by imaging methods or directly endoscopic observation; second, the establishment of the surgical pathway to relieve the strictures; and third, the removal of the stone by a combination of different techniques such as simple basket extraction, mechanical fragmentation, electrohydraulic lithotripsy or laser lithotripsy, among others. In summary, a step-by-step strategy of POC should be put forward to standardize the procedures, especially when dealing with complicated residual hepatolithiasis. This review briefly summarizes the classification, management and complications of hepatolithiasis during the POC process.

Offspring caregivers' depression affected by intergenerational disagreements on preferred living arrangement for the elderly: A phenomena with Chinese characteristic.

OBJECTIVE: This study aimed to explore whether the depression of offspring caregivers can be affected by the intergenerational disagreements on preferred living arrangements for the elderly, and the extent of this influence. METHODS: A total of 875 participants from five urban neighborhoods were investigated in a cross-sectional survey in Jinan, China. Depressive symptoms were assessed by the Self-rating Depression Scale (SDS). Multiple stratification was performed based on participants' characteristics, then generalized linear models (GLM) were used to adjust confounding factor and analyze the effect of the intergenerational disagreements on depressive symptoms among participants with different characteristics. RESULTS: The intergenerational disagreements on preferred living arrangements for the elderly greatly impact on offspring caregivers' depressive symptoms. Especially in the following two situations: (1) in the case of older adults were relatively independent and offspring caregivers had to co-reside with older adults against their own will, the max mean difference on the depression measures was up to 10.603 (p<0.001), in comparison with both parties were willing to co-reside. (2) In the case of older adults were fully dependent and offspring caregivers had not to hire a maid to care older adults against their own will, the max mean difference on the depression measures was up to 8.937 (p<0.001), in comparison with both parties were willing not to hire a maid. CONCLUSION: Intergenerational disagreements on preferred living arrangement for the elderly have negative effect on offspring caregivers' depressive symptoms.

Displacement-based back-analysis of the model parameters of the Nuozhadu high earth-rockfill dam.

The parameters of the constitutive model, the creep model, and the wetting model of materials of the Nuozhadu high earth-rockfill dam were back-analyzed together based on field monitoring displacement data by employing an intelligent back-analysis method. In this method, an artificial neural network is used as a substitute for time-consuming finite element analysis, and an evolutionary algorithm is applied for both network training and parameter optimization. To avoid simultaneous back-analysis of many parameters, the model parameters of the three main dam materials are decoupled and back-analyzed separately in a particular order. Displacement back-analyses were performed at different stages of the construction period, with and without considering the creep and wetting deformations. Good agreement between the numerical results and the monitoring data was obtained for most observation points, which implies that the back-analysis method and decoupling method are effective for solving complex problems with multiple models and parameters. The comparison of calculation results based on different sets of back-analyzed model parameters indicates the necessity of taking the effects of creep and wetting into consideration in the numerical analyses of high earth-rockfill dams. With the resulting model parameters, the stress and deformation distributions at completion are predicted and analyzed.