[Proactively embracing the challenges of multimorbidity].

With rapid socio-economic development and the acceleration of population aging, the average life span of human beings has increased significantly. Individuals suffering from the co-existence of multiple diseases (multimorbidity) have become a new normal in public health and posed severe challenge to human health. Multimorbidity significantly reduces the quality of life, increases disability and mortality risks, complicates disease treatment and care and increases burden of the healthcare system with higher costs. This commentary discusses the definition of multimorbidity and common public misconceptions, then assesses its profound impact on overall public health, socio-economic development and healthcare system. We also proposes the potential strategies to meet the challenges posed by multimorbidity. The main aim is to raise awareness of multimorbidity, advocate proactive responses to improve public health and build a healthy society through the development of prevention and treatment systems and promote precision prevention and treatment for multimorbidity.

[Evaluation effect of COMPERA 2.0 risk assessment model on prognosis of Chinese patients with pulmonary arterial hypertension].

Objectives: To clarify the evaluation effect of COMPERA 2.0 risk assessment model on prognosis of pulmonary arterial hypertension (PAH) in China. Methods: Patients with newly diagnosed PAH admitted in Fuwai hospital between April 2019 and March 2022 were enrolled retrospectively and divided in low, intermediate-low, intermediate-high and high strata by scores of COMPERA 2.0 risk assessment model. All the patients were followed up by clinic or telephone. The primary endpoint was defined as a composite of all-cause mortality, exacerbated heart failure and aggravated symptoms. Kaplan-Meier analysis and log-rank trend test were used to determine the risk of endpoints among the 4 groups. Multivariate Cox proportional hazards regression were used to analyze the association between COMPERA 2.0 scores and prognosis in patients with PAH. Results: A total of 951 patients with PAH were enrolled in this study. The age [M (Q1, Q3)] of the patients was 35 (28, 47) years, of which 706 cases (74.2%) were females. A total of 328 cases (34.5%) were assigned in low strata, 264 cases (27.8%) in intermediate-low strata, 193 cases (20.3%) in intermediate-high strata, and 166 cases (17.5%) in high strata. During the duration [M (Q1, Q3)] of follow-up after discharge of 1.8 (1.0, 2.8) years, the primary endpoint was occurred in 12.8% (42/328), 21.2% (56/264), 28.5% (55/193) and 42.8% (71/166) of low, intermediate-low, intermediate-high and high strata, respectively. The rates of primary endpoint were significantly increased with strata rising (P<0.001). Multivariate Cox proportional hazards regression showed that COMPERA 2.0 risk scores were associated with the primary endpoints in PAH patients (HR=1.801, 95%CI: 1.254-2.588, P=0.001) after adjusting confounders. Conclusion: COMPERA 2.0 risk assessment model is a simple and effective tool for evaluating the prognosis of newly diagnosed PAH patients in China.

[Comparison of three different measurement methods to determine resting energy expenditure in patients with decompensated hepatitis B cirrhosis].

Objective: To compare the differences to determine resting energy expenditure (REE) measured with indirect calorimetry and REE predicted by formula method and body composition analyzer in patients with decompensated hepatitis B cirrhosis, so as to provide theoretical guidance for the implementation of precision nutrition intervention. Methods: Patients with decompensated hepatitis B cirrhosis who were admitted to Henan Provincial People's Hospital from April 2020 to December 2020 were collected. REE was determined by the body composition analyzer and the H-B formula method. Results: were analyzed and compared to REE measured by the metabolic cart. Results A total of 57 cases with liver cirrhosis were included in this study. Among them, 42 were male, aged (47.93 ± 8.62) years, and 15 were female aged (57.20 ± 11.34) years. REE measured value in males was (1 808.14 ± 201.47) kcal/d, compared with the results calculated by the H-B formula method and the measured result of body composition, and the difference was statistically significant (P = 0.002 and 0.003, respectively). REE measured value in females was (1 496.60 ± 131.28) kcal/d, compared with the results calculated by the H-B formula method and the measured result of body composition, and the difference was statistically significant (P = 0.016 and 0.004, respectively). REE measured with the metabolic cart had correlation with age and area of visceral fat in men (P = 0.021) and women (P = 0.037). Conclusion: Metabolic cart use will be more accurate to obtain resting energy expenditure in patients with decompensated hepatitis B cirrhosis. Body composition analyzer and formula method may underestimate REE predictions. Simultaneously, it is suggested that the effect of age on REE in H-B formula should be fully considered for male patients, while the area of visceral fat may have a certain impact on the interpretation of REE in female patients.

[Anemia status and related factors among left-behind children in poverty-stricken rural areas, in China, 2016].

Objective: To explore the prevalence of anemia and related factors among left-behind children in poverty-stricken rural areas in China, to provide basic information for anemia prevention and treatment for children. Methods: Data from the National Nutrition Improvement Program for Rural Compulsory Education Students in 2016 were used to express the prevalence of anemia among left-behind children. By using the multistage stratified random cluster sampling method, left-behind children of the 6-17-years-old in poverty-stricken rural areas were recruited in this study. Blood hemoglobin concentration of these students was determined by cyanmethemoglobin method. Anemia was judged by the WHO recommended standard and combined with the sea level elevation correction standard. Frequencies of food intake were collected through questionnaires. Data was then available for analysis including the level of hemoglobin and anemia rates. Relationship between anemia and food intakes as well as other influential factors was also analyzed. Results: The overall anemia prevalence (AP) was 11.6% among the participants. Rates of AP among the 6-, 7-, 15- and 16-17-years-old were 21.1%, 18.0%, 20.6% and 17.3%, respectively. Rates of AP among left-behind girls of 10-11-years-old and the 13-15-years-old were significantly higher than those in boys at the same age (P<0.01) group. Factors including: being girls (OR=1.34, 95%CI: 1.23-1.45), at grade 7 to 9 (OR=1.47, 95%CI:1.30-1.67) and mother being migrant worker (OR=1.32, 95%CI:1.16- 1.50) had higher proportions of getting anemia. Factors as living in the western area (OR=0.85, 95%CI: 0.78-0.93), taking breakfast every day (OR=0.70, 95%CI: 0.64-0.76), having meat more than twice per week (OR=0.84, 95%CI: 0.75-0.93) and having two kinds of vegetables per day (OR=0.85, 95%CI: 0.75-0.96) appeared protective. Conclusions: Prevalence of anemia in left-behind children from the poverty-stricken rural areas was high, including junior middle school students from grade 7 to 9 at the early stage of youth development, girls and children with mothers as migrant workers. Anemia should be reduced by promoting the protective factors as having breakfast, increasing intakes of meat and fresh vegetables.

Assessment of tobacco control advocacy behavioural capacity among public health faculty and students: a cluster intervention study.

OBJECTIVES: This study assessed the outcomes of a tobacco control advocacy behavioural capacity (ABC)-building programme among public health faculty and students in China. STUDY DESIGN: This is a cluster intervention study with subjects matching in the different stages of the intervention and observation. METHODS: Public health students (n = 1046) and faculty (n = 199) were recruited in the intervention group. The intervention included a series of tobacco control advocacy curriculum and activities that were developed and implemented at schools or departments of public health in 22 universities across China. The control group participants (n = 540) were public health undergraduate students from another 11 universities selected from the different geographic regions. A comprehensive assessment tool was used to measure the tobacco control ABC and perceived stress level to compare changes at baseline, midterm and 12-month follow-up. Repeated measures analysis of variance, paired t tests and chi-squared tests, general linear model and generalized estimating equation were used to determine the time effect for targeted students and faculty. Multivariate analysis of variance and logistic regression model were conducted to evaluate the treatment effects for students between intervention and control sites. RESULTS: Nine hundred and thirty-seven students and 170 faculty members in the intervention group and 469 students in the control group were valid for the final evaluation. Findings from treatment effect analyses show that the capacity-building programme significantly improved public health students' ABC, including awareness of tobacco control messages (F = 107.65, P < 0.01), general and public heath tobacco control attitudes (F = 7.52, P < 0.01; F = 8.53, P < 0.01), advocacy interest and motivation (F = 10.11, P < 0.01) and public advocacy behaviour for both family members and relatives or friends. The perceived stress in the intervention group students was also reduced significantly in comparison with the control group students (F = 4.99, P < 0.01). For faculty members, their ABC except advocacy for family members was all increased by time effect analyses. The training programme did not impact faculty and students' smoking behaviour. CONCLUSIONS: This study provided evidence to support the implementation of tobacco control advocacy capacity training among public health professionals and students to curb the tobacco epidemic in China.

Implementation of B'More Healthy Communities for Kids: process evaluation of a multi-level, multi-component obesity prevention intervention.

B'More Healthy Communities for Kids was a multi-level, multi-component obesity prevention intervention to improve access, demand and consumption of healthier foods and beverages in 28 low-income neighborhoods in Baltimore City, MD. Process evaluation assesses the implementation of an intervention and monitor progress. To the best of our knowledge, little detailed process data from multi-level obesity prevention trials have been published. Implementation of each intervention component (wholesaler, recreation center, carryout restaurant, corner store, policy and social media/text messaging) was classified as high, medium or low according to set standards. The wholesaler component achieved high implementation for reach, dose delivered and fidelity. Recreation center and carryout restaurant components achieved medium reach, dose delivered and fidelity. Corner stores achieved medium reach and dose delivered and high fidelity. The policy component achieved high reach and medium dose delivered and fidelity. Social media/text messaging achieved medium reach and high dose delivered and fidelity. Overall, study reach and dose delivered achieved a high implementation level, whereas fidelity achieved a medium level. Varying levels of implementation may have balanced the performance of an intervention component for each process evaluation construct. This detailed process evaluation of the B'More Healthy Communities for Kids allowed the assessment of implementation successes, failures and challenges of each intervention component.

Factors associated with hospitalisation costs in patients with chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of hospital admissions, which can result in a significant financial burden. OBJECTIVE: To determine hospitalisation costs and factors associated with higher costs in patients with acute exacerbations of COPD (AE-COPD). DESIGN: Patients hospitalised for a whole year formed the study cohort. Demographic features, clinical data and hospitalisation bills were evaluated retrospectively. Student's t-test or the Mann-Whitney U-test were used to compare the mean values of variables between high-cost and low-cost groups. Logistic regression analysis was used to study the relationship between hospitalisation costs with clinical factors. RESULTS: A total of 188 patients were evaluated. The mean length of stay in hospital (LOSH) was 8.5 days. The mean cost of AE-COPD was US$1722.0. Costs were significantly associated with LOSH and the per cent predicted value of forced expiratory volume in one second. Age, sex, smoking index, partial oxygen pressure, partial carbon dioxide pressure, haemoglobin concentration and white blood cell counts were not associated with hospitalisation costs. CONCLUSION: Medications and laboratory services are the main drivers of hospitalisation costs in AE-COPD. Longer LOSH and reduced pulmonary function determine the high costs in hospitalised patients with AE-COPD admitted to a general ward. To reduce hospitalisation costs, more emphasis should be placed on shortening LOSH and preventing the worsening of pulmonary function.

Effect of peer support on diabetes distress: a cluster randomized controlled trial.

AIM: To investigate whether peer support would reduce diabetes distress and improve glycaemic control when added to usual diabetes education among adults with Type 2 diabetes in China. METHODS: We conducted a cluster randomized trial involving 400 adults with Type 2 diabetes from eight communities in Nanjing. All participants received usual education for an average of 2 h each month from physicians, certified diabetes educators, dieticians, psychologists and podiatric nurses. Peer support was led by trained peer leaders and included diabetes knowledge- and skills-sharing at least once a month, as well as peer-to-peer communication. The primary outcome was diabetes distress measured using the Diabetes Distress Scale at 12 months. Secondary outcomes included fasting plasma glucose, 2-h postprandial glucose and HbA1c concentration. Outcome data were collected from all participants at baseline, 6 months and 12 months. RESULTS: From 2012 to 2013, there were 200 participants in each study arm at baseline. Compared with the usual education arm, the peer support with usual education arm had greater reductions in regimen-related distress (1.4 ± 0.6 vs 1.2 ± 0.4; P=0.004) and total distress (1.3 ± 0.4 vs 1.2 ± 0.3; P=0.038) at 6 months. At 12 months, the scores for emotional burden (1.2 ± 0.3 vs 1.4 ± 0.6; P=0.002), physician-related distress (1.1 ± 0.3 vs 1.3 ± 0.4; P=0.001) and total scores (1.2 ± 0.3 vs 1.3 ± 0.4; P=0.002) were significantly lower in the peer support with usual education arm than in the usual education arm. Fasting plasma glucose levels were lower in the peer support with usual education arm than in the usual education arm at 6 months (7.5 ± 1.95 vs 8.0 ± 2.2; P=0.044) and 12 months (7.0 ± 2.3 vs 7.6 ± 1.5; P=0.008). CONCLUSIONS: Beyond the benefits of usual education, peer support was effective in reducing diabetes distress for Type 2 diabetes mellitus. (Clinical Trials Registry no: NCT02119572).

Gastrointestinal Symptoms in Diabetes: Prevalence, Assessment, Pathogenesis, and Management.

If you haven't measured something, you really don't know much about it.-Karl Pearson (attributed)Gastrointestinal (GI) symptoms represent an important and often unappreciated cause of morbidity in diabetes, although the significance of this burden across the spectrum of patients and the underlying pathophysiology, including the relationship of symptoms with glycemic control, remain poorly defined. The relevance of GI symptoms and the necessity for their accurate assessment have increased with the greater focus on the gut as a therapeutic target for glucose lowering. This review addresses the prevalence, assessment, pathogenesis, and management of GI symptoms in diabetes, beginning with broad principles and then focusing on specific segments of the GI tract. We initially performed a literature search of PubMed by using synonyms and combinations of the following search terms: "gastrointestinal symptoms", "diabetes", "prevalence", "pathogenesis", "diagnosis", and "management". We restricted the search results to English only. Review papers and meta-analyses are presented as the highest level of evidence where possible followed by randomized controlled trials, uncontrolled trials, retrospective and observational data, and expert opinion.

Estimating Survival in Patients With Lung Cancer and Brain Metastases: An Update of the Graded Prognostic Assessment for Lung Cancer Using Molecular Markers (Lung-molGPA).

IMPORTANCE: Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. As systemic therapies improve, patients with lung cancer live longer and thus are at increased risk for brain metastases. Understanding how prognosis varies across this heterogeneous patient population is essential to individualize care and design future clinical trials. OBJECTIVE: To update the current Diagnosis-Specific Graded Prognostic Assessment (DS-GPA) for patients with non-small-cell lung cancer (NSCLC) and brain metastases. The DS-GPA is based on data from patients diagnosed between 1985 and 2005, and we set out to update it by incorporating more recently reported gene and molecular alteration data for patients with NSCLC and brain metastases. This new index is called the Lung-molGPA. DESIGN, SETTING, AND PARTICIPANTS: This is a multi-institutional retrospective database analysis of 2186 patients diagnosed between 2006 and 2014 with NSCLC and newly diagnosed brain metastases. The multivariable analyses took place between December 2015 and May 2016, and all prognostic factors were weighted for significance by hazard ratios. Significant factors were included in the updated Lung-molGPA prognostic index. MAIN OUTCOMES AND MEASURES: The main outcome was survival. Multiple Cox regression was used to select and weight prognostic factors in proportion to their hazard ratios. Log rank tests were used to compare adjacent classes and to compare overall survival for adenocarcinoma vs nonadenocarcinoma groups. RESULTS: The original DS-GPA was based on 4 factors found in 1833 patients with NSCLC and brain metastases diagnosed between 1985 and 2005: patient age, Karnofsky Performance Status, extracranial metastases, and number of brain metastases. The patients studied for the creation of the DS-GPA had a median survival of 7 months from the time of initial treatment of brain metastases. To design the updated Lung-molGPA, we analyzed data from 2186 patients from 2006 through 2014 with NSCLC and newly diagnosed brain metastases (1521 adenocarcinoma and 665 nonadenocarcinoma). Significant prognostic factors included the original 4 factors used in the DS-GPA index plus 2 new factors: EGFR and ALK alterations in patients with adenocarcinoma (mutation status was not routinely tested for nonadenocarcinoma). The overall median survival for the cohort in the present study was 12 months, and those with NSCLC-adenocarcinoma and Lung-molGPA scores of 3.5 to 4.0 had a median survival of nearly 4 years. CONCLUSIONS AND RELEVANCE: In recent years, patient survival and physicians' ability to predict survival in NSCLC with brain metastases has improved significantly. The updated Lung-molGPA incorporating gene alteration data into the DS-GPA is a user-friendly tool that may facilitate clinical decision making and appropriate stratification of future clinical trials.

A medical cost estimation with fuzzy neural network of acute hepatitis patients in emergency room.

Taiwan is an area where chronic hepatitis is endemic. Liver cancer is so common that it has been ranked first among cancer mortality rates since the early 1980s in Taiwan. Besides, liver cirrhosis and chronic liver diseases are the sixth or seventh in the causes of death. Therefore, as shown by the active research on hepatitis, it is not only a health threat, but also a huge medical cost for the government. The estimated total number of hepatitis B carriers in the general population aged more than 20 years old is 3,067,307. Thus, a case record review was conducted from all patients with diagnosis of acute hepatitis admitted to the Emergency Department (ED) of a well-known teaching-oriented hospital in Taipei. The cost of medical resource utilization is defined as the total medical fee. In this study, a fuzzy neural network is employed to develop the cost forecasting model. A total of 110 patients met the inclusion criteria. The computational results indicate that the FNN model can provide more accurate forecasts than the support vector regression (SVR) or artificial neural network (ANN). In addition, unlike SVR and ANN, FNN can also provide fuzzy IF-THEN rules for interpretation.

Clinical Assessment of 2D/3D Registration Accuracy in 4 Major Anatomic Sites Using On-Board 2D Kilovoltage Images for 6D Patient Setup.

To provide a comprehensive assessment of patient setup accuracy in 6 degrees of freedom (DOFs) using 2-dimensional/3-dimensional (2D/3D) image registration with on-board 2-dimensional kilovoltage (OB-2 DkV) radiographic images, we evaluated cranial, head and neck (HN), and thoracic and abdominal sites under clinical conditions. A fast 2D/3D image registration method using graphics processing unit GPU was modified for registration between OB-2 DkV and 3D simulation computed tomography (simCT) images, with 3D/3D registration as the gold standard for 6 DOF alignment. In 2D/3D registration, body roll rotation was obtained solely by matching orthogonal OB-2 DkV images with a series of digitally reconstructed radiographs (DRRs) from simCT with a small rotational increment along the gantry rotation axis. The window/level adjustments for optimal visualization of the bone in OB-2 DkV and DRRs were performed prior to registration. Ideal patient alignment at the isocenter was calculated and used as an initial registration position. In 3D/3D registration, cone-beam CT (CBCT) was aligned to simCT on bony structures using a bone density filter in 6DOF. Included in this retrospective study were 37 patients treated in 55 fractions with frameless stereotactic radiosurgery or stereotactic body radiotherapy for cranial and paraspinal cancer. A cranial phantom was used to serve as a control. In all cases, CBCT images were acquired for patient setup with subsequent OB-2 DkV verification. It was found that the accuracy of the 2D/3D registration was 0.0 ± 0.5 mm and 0.1° ± 0.4° in phantom. In patient, it is site dependent due to deformation of the anatomy: 0.2 ± 1.6 mm and -0.4° ± 1.2° on average for each dimension for the cranial site, 0.7 ± 1.6 mm and 0.3° ± 1.3° for HN, 0.7 ± 2.0 mm and -0.7° ± 1.1° for the thorax, and 1.1 ± 2.6 mm and -0.5° ± 1.9° for the abdomen. Anatomical deformation and presence of soft tissue in 2D/3D registration affect the consistency with 3D/3D registration in 6 DOF: the discrepancy increases in superior to inferior direction.

Associations of depression with impaired glucose regulation, newly diagnosed diabetes and previously diagnosed diabetes in Chinese adults.

AIM: To examine the association between depression and impaired glucose regulation, newly diagnosed diabetes and previously diagnosed diabetes in middle-aged and elderly Chinese people, and whether depression was associated with different treatment regimens or durations of diabetes. METHODS: A cross-sectional study was performed among 229,047 adults living in the community aged ≥ 40 years from 25 centres in China. The self-reported depression rating scale Patient Health Questionnaire 9 (PHQ-9) was used to diagnose probable and sub-threshold depression. Glucose metabolism status was determined according to World Health Organization 1999 diagnostic criteria. RESULTS: The numbers of participants with normal glucose regulation, impaired glucose regulation, newly diagnosed diabetes and previously diagnosed diabetes were 120,458, 59,512, 24,826 and 24,251, respectively. The prevalence of sub-threshold depression in the total sample of participants was 4.8% (4.8%, 4.8%, 4.4% and 5.6% from normal glucose regulation to previously diagnosed diabetes, respectively), and the prevalence of probable depression was 1.1% (1.1%, 1.0%, 0.9% and 1.8% from normal glucose regulation to previously diagnosed diabetes, respectively). Compared with participants with normal glucose regulation, those with previously diagnosed diabetes had increased odds of probable depression [odds ratio (OR) = 1.61, 95% confidence interval (CI) 1.39-1.87] and sub-threshold depression (OR = 1.14, 95% CI 1.06-1.24), after adjustment for multiple confounding factors. Newly diagnosed diabetes or impaired glucose regulation was not associated with depression. Among those with previously diagnosed diabetes, insulin treatment was associated with greater odds of depression compared with no treatment or oral anti-diabetic medicine. CONCLUSION: Previously diagnosed diabetes, but not newly diagnosed diabetes or impaired glucose regulation, was associated with a higher prevalence of depression. Patients receiving insulin were more likely to have depression than those not receiving treatment or being treated with oral anti-diabetic medicine.

Seasonal variation and health risk assessment of polycyclic aromatic hydrocarbons in Miaoli city, Taiwan.

The ambient PAHs levels in the downtown area of a traditional small city were analyzed for winter and summer seasons. A total of 16 PAHs in gaseous and particulate phase were quantified. The average gaseous PAHs were 2,189 ± 1,194 and 623.8 ± 545.1 ng/m(3) in winter and summer seasons, respectively. For the PAHs in particulate phase, they were 40.32 ± 12.15 and 11.99 ± 5.63 ng/m(3) in winter and summer seasons, respectively. These values were comparable to those reported for large cities or even higher. The estimated BaPeq was 12.32 ± 6.34 ng/m(3). As low-molecular-weight PAHs primarily existed in gaseous phase, high-molecular-weight PAHs in particulate phase became a significant fraction of total particulate phase PAHs. Particulate phase PAHs was significantly inversely associated with the ambient temperature for each individual PAHs species. However, this relationship did not exist for high-molecular-weight PAHs in gaseous phase. The results indicated the photo-degradation of high-molecular-weight PAHs should warrant a further thoughtfully investigation.

A modified mini nutritional assessment without BMI predicts nutritional status of community-living elderly in Taiwan.

OBJECTIVE: The study was to determine whether a modified MNA (Mini Nutritional Assessment) which adopted population-specific anthropometric cut-points but without BMI could maintain its predicting ability in community-living elderly in Taiwan. DESIGN: Purposive sampling. SETTING: Community-living elderly. PARTICIPANTS: Three hundred and one (138 male and 163 female) > 65-year-old outpatients seeking free annual health examination at an area hospital in central Taiwan. MEASUREMENTS: A structured questionnaire elicited personal data, lifestyle information and answers to the MNA. Laboratory results from health checkup provided the needed biochemical data. Each subject's nutritional status was assessed with the MNA in three versions: the original, the MNA-TI (with population-specific cut-points), and the MNA-TII (further eliminated the BMI question and redistributed its score to the MAC and CC questions). RESULTS: All three versions identified the same 0.7% elderly malnourished. The proportions predicted at risk of malnutrition were 16.6, 12.0 and 10% according to the original, MNA-TI and MNA-TII, respectively. Friedman Test and post hoc analysis indicated that the pattern predicted by the original MNA was different from that predicted by the two modified versions whereas the patterns predicted by the two modified versions were not different from each other. CONCLUSION: Adoption of population-specific anthropometric cut-points improves the predicting ability of the MNA in Taiwanese elderly, and the improved functionality is maintained in a version without BMI (but with adjusted MAC and CC scores). A MNA without BMI has greater applicability and can enhance professional efficiency of healthcare workers.

Smoking patterns among Chinese rural-urban migrant workers.

OBJECTIVES: To estimate smoking prevalence and identify correlates of smoking initiation among rural-urban migrant workers. STUDY DESIGN: Subjects were 4198 rural-urban migrant workers, aged 18 years and older, residing in three Chinese cities. METHODS: Participants were identified through multistage quota sampling. They were asked about their migration history, pre-migration and post-migration smoking status, employment and home life. Analyses were conducted using Chi-squared test and multiple logistic regression. RESULTS: Overall, smoking prevalence was higher subsequent to migration (28.4%) compared with before migration (20.8%) (P<0.01). Initiation of daily smoking was associated with gender [odds ratio (OR) 0.02]; high school or greater education (OR 0.48; vs elementary school or lower); having a monthly personal income of 1000-1999 Yuan (OR 2.60), 2000-2999 Yuan (OR 3.08) or > or =3000 Yuan (OR 4.04) (vs <500 Yuan US$ 1=7.5 Yuan); and history of migration to three cities (OR:1.65) or four or more cities (OR 2.80) (vs one city). Initiation of occasional smoking was only associated with gender (OR 0.11). Solitude was the primary situational trigger for smoking initiation. CONCLUSIONS: A migratory lifestyle is associated with smoking initiation. Findings could inform the design of tobacco control programmes that would target Chinese rural-urban migrant workers as a special population.

Patterns and correlates of stress among rural Chinese males: a four-region study.

OBJECTIVES: Prior research has revealed a high prevalence of stress among general urban populations in China. However, little is known about stress in rural Chinese counterparts. This research estimates the prevalence of severe stress among rural Chinese males and identifies sociodemographic and psychological correlates. STUDY DESIGN: The study design was a cross-sectional survey with multistage sampling. METHODS: Subjects were male residents aged > or =15 years from four geographic regions of China (N=4414), namely Jinbei, Jinnan, Guidongbei and Subei. Information was collected on perceived stress and potential sociodemographic and behavioural correlates as well as on perceived health status. Data were assessed by means of chi(2) tests and unconditional logistic regression analysis. RESULTS: The mean score for the rural male resident sample on the Chinese Perceived Stress Scale (CPSS) was 24.8 (standard deviation=7.7), and 44% of subjects reported severe stress. With Subei residents as the referent, respondents from Guidongbei region [adjusted odds ratio (OR)=0.66; 95% confidence interval (CI)=0.52-0.84] had a lower likelihood of reporting severe stress and those from Jinbei region (OR=3.54; 95% CI=2.85-4.39) and Jinnan region (OR=2.73; 95% CI=2.21-2.39) had higher likelihoods. Respondents aged 35-44 years (OR=0.69; 95% CI=0.55-0.85) and > or =45 years (OR=0.67; 95% CI=0.54-0.83) had a lower likelihood of reporting severe stress than those aged <25 years, and respondents in non-farming jobs (OR=1.33; 95% CI=1.09-1.62) had an excess likelihood relative to those in farming. An excess likelihood of reporting severe stress was manifest among the divorced and widowed relative to the unmarried, and a lower likelihood was observed among respondents with a higher education relative to the least educated. Hedonism seeking was positively associated with severe stress among rural Chinese males (OR=2.43; 95% CI=2.09-2.84) and social participation was negatively associated (OR=0.62, 95% CI=0.54-0.73). CONCLUSIONS: This study found a high stress level among rural Chinese males. To ameliorate this problem, we recommend policy and prevention initiatives at national and local levels.

Assessment of specificity of eight chemical inhibitors using cDNA-expressed cytochromes P450.

1. The selectivity of eight chemical inhibitors has been extensively evaluated with 10 cDNA-expressed human cytochrome P450 isoforms (CYP). The results indicate that sulphaphenazole, quinidine and alpha-naphthoflavone are selective inhibitors of CYP2C9 (IC50 = 0.5-0.7 microM), CYP2D6 (0.3-0.4 microM) and CYP1A (0.05-5 microM) respectively on the basis of the IC50, which are much lower than those of other P450 isoforms (> 10-fold). 2. Ketoconazole exhibited potent inhibition of both CYP3A4-catalysed metabolism of phenanthrene, testosterone, diazepam (IC50 = 0.03-0.5 microM) and CYP1A1-catalysed deethylation of 7-ethoxycoumarin (0.33 microM). The selectivity of ketoconazole for other P450s was highly related to the concentration used. 3. Diethyldithiocarbamate, orphenadrine and furafylline were shown separately to be less selective inhibitors of CYP2E1, CYP2B6 and CYP1A isoforms by a broad range of IC50 that overlap those observed with other P450 isoforms. 4. Furafylline, quinidine and alpha-naphthoflavone activated CYP3A4-catalysed phenanthrene metabolism by 1.7-, 2- and 15-fold respectively. 5. The selectivity of orphenadrine and ketoconazole was further examined by using inhibitory monoclonal antibodies (MAb). Inhibitory MAb specific for the individual P450 isoforms may be of greater value than chemical inhibitors.

Cost analysis of second-line therapies for platinum-refractory ovarian cancer: reimbursement dilemmas for Medicare patients.

Currently used options for salvage therapy for epithelial ovarian cancer include intravenously administered paclitaxel or topotecan and orally administered altretamine or etoposide. The response rates for these agents are similar (14-26%), whereas the type and incidence of adverse events differ. Under current legislation, Medicare will reimburse intravenous outpatient chemotherapy regimens only or oral regimens with a marketed intravenous formulation, despite that 89% of cancer patients prefer oral therapies. To compare the out-of-pocket costs and costs to the Medicare system, a cost minimization analysis of treatment with these agents was conducted using published phase II and phase III data. The total cost of treatment was $15,767 for paclitaxel, $18,635 for topotecan, $4477 for altretamine, and $5016 for etoposide. The out-of-pocket costs to the patient were $83, $37, $4477, and $6, respectively. Although a physician's first consideration in choosing a therapy is efficacy and toxicity, current Medicare reimbursement policies restrict patient options for cancer care. Because Medicare adopts managed care and health maintenance organizations into the management of patient care, cost effectiveness will likely become an important consideration in the treatment of cancer.

The effect of reimbursement policies on the management of Medicare patients with refractory ovarian cancer.

Ovarian cancer patients who are covered by Medicare are faced with therapeutic decisions that require consideration of out-of-pocket costs for oral anticancer agents and complete reimbursement for more expensive intravenous and often more toxic medications. The response rates for oral agents such as altretamine or etoposide are similar to those for intravenous paclitaxel or topotecan (14% to 26%), but the economic considerations differ markedly. Under current legislation, Medicare will completely cover the costs for the two intravenous outpatient chemotherapy regimens, but does not provide any financial support for oral regimens that do not have associated injectable formulations. This is a matter of concern for patients, as 89% prefer oral therapies. We compared the out-of-pocket costs and costs to the Medicare system of oral and intravenous agents used for refractory ovarian cancer, using published phase II and phase III data. The total cost of treatment was $18,635 for topotecan, $15,767 for paclitaxel, $7,721 for etoposide, and $4,477 for altretamine. Conversely, out-of-pocket costs for Medicare patients without Medigap coverage were highest for altretamine, at the full cost of $4,477, whereas Medicare covered all but $83 for topotecan, $37 for paclitaxel, and $66 for etoposide. Current Medicare reimbursement policies may affect patient options for cancer care. These policies are changing and should continue to change as Medicare adopts more managed care strategies.