Implementation of an Electronic Alert to Improve Timeliness of Second Dose Antibiotics for Patients With Suspected Serious Infections in the Emergency Department: A Quasi-Randomized Controlled Trial.

STUDY OBJECTIVE: Delays in the second dose of antibiotics in the emergency department (ED) are associated with increased morbidity and mortality in patients with serious infections. We analyzed the influence of clinical decision support to prevent delays in second doses of broad-spectrum antibiotics in the ED. METHODS: We allocated adult patients who received cefepime or piperacillin/tazobactam in 9 EDs within an integrated health care system to an electronic alert that reminded ED clinicians to reorder antibiotics at the appropriate interval vs usual care. The primary outcome was a median delay in antibiotic administration. Secondary outcomes were rates of intensive care unit (ICU) admission, hospital mortality, and hospital length of stay. We included a post hoc secondary outcome of frequency of major delay (>25% of expected interval for second antibiotic dose). RESULTS: A total of 1,113 ED patients treated with cefepime or piperacillin/tazobactam were enrolled in the study, of whom 420 remained under ED care when their second dose was due and were included in the final analysis. The clinical decision support tool was associated with reduced antibiotic delays (median difference 35 minutes, 95% confidence interval [CI], 5 to 65). There were no differences in ICU transfers, inpatient mortality, or hospital length of stay. The clinical decision support tool was associated with decreased probability of major delay (absolute risk reduction 13%, 95% CI, 6 to 20). CONCLUSIONS: The implementation of a clinical decision support alert reminding clinicians to reorder second doses of antibiotics was associated with a reduction in the length and frequency of antibiotic delays in the ED. There was no effect on the rates of ICU transfers, inpatient mortality, or hospital length of stay.

CT utilization in evaluation of skin and soft tissue extremity infections in the ED: Retrospective cohort study.

OBJECTIVE: Skin and soft tissue infections (SSTI) are commonly diagnosed in the emergency department (ED). While most SSTI are diagnosed with patient history and physical exam alone, ED clinicians may order CT imaging when they suspect more serious or complicated infections. Patients who inject drugs are thought to be at higher risk for complications from SSTI and may undergo CT imaging more frequently. The objective of this study is to characterize CT utilization when evaluating for SSTI in ED patients particularly in patients with intravenous drug use (IVDU), the frequency of significant and actionable findings from CT imaging, and its impact on subsequent management and ED operations. METHODS: We performed a retrospective analysis of encounters involving a diagnosis of SSTI in seven EDs across an integrated health system between October 2019 and October 2021. Descriptive statistics were used to assess overall trends, compare CT utilization frequencies, actionable imaging findings, and surgical intervention between patients who inject drugs and those who do not. Multivariable logistic regression was used to analyze patient factors associated with higher likelihood of CT imaging. RESULTS: There were 4833 ED encounters with an ICD-10 diagnosis of SSTI during the study period, of which 6% involved a documented history of IVDU and 30% resulted in admission. 7% (315/4833) of patients received CT imaging, and 22% (70/315) of CTs demonstrated evidence of possible deep space or necrotizing infections. Patients with history of IVDU were more likely than patients without IVDU to receive a CT scan (18% vs 6%), have a CT scan with findings suspicious for deep-space or necrotizing infection (4% vs 1%), and undergo surgical drainage in the operating room within 48 h of arrival (5% vs 2%). Male sex, abnormal vital signs, and history of IVDU were each associated with higher likelihood of CT utilization. Encounters involving CT scans had longer median times to ED disposition than those without CT scans, regardless of whether these encounters resulted in admission (9.0 vs 5.5 h), ED observation (5.5 vs 4.1 h), or discharge (6.8 vs 2.9 h). DISCUSSION: ED clinicians ordered CT scans in 7% of encounters when evaluating for SSTI, most frequently in patients with abnormal vital signs or a history of IV drug use. Patients with a history of IVDU had higher rates of CT findings suspicious for deep space infections or necrotizing infections and higher rates of incision and drainage procedures in the OR. While CT scans significantly extended time spent in the ED for patients, this appeared justified by the high rate of actionable findings found on imaging, particularly for patients with a history of IVDU.

Low Prevalence of Folic Acid Supplementation during Pregnancy: A Multicenter Study in Vietnam.

Periconceptional folic acid (FA) supplementation is recommended to prevent neural tube defects (NTDs), but little information is known about its use in Vietnam. It is important that FA supplements start to be taken when planning a pregnancy and continued through the first trimester to prevent NTDs, as the neural tube closes in the first month of pregnancy. However, FA supplementation in Vietnam is usually recommended to commence from the first antenatal visit, which is usually at 16 weeks, and very few women take FA before their first visit. This multicenter study aimed to determine the prevalence of FA supplement use and associated maternal characteristics in Vietnam. FA supplementation was assessed in 2030 singleton pregnant women between 2015 and 2016. In total, 654 (32.2%) women reported taking either supplements containing FA alone or multivitamins containing FA, and 505 (24.9%) reported correctly taking supplements containing FA alone. Women who were aged 30 years or over, had low education levels, had formal employment, and whose current pregnancy was first or unplanned were less likely to supplement with FA. Education programs are needed to encourage FA supplementation when contemplating pregnancy.

Recreational Centres' Facilities and Activities to Support Healthy Ageing in Singapore.

OBJECTIVE: This study examined the physical and social environment (facilities and activities) of Singapore's Recreational Centres (RCs) and female patrons' (>50 years) perception of the RC facilities and activities. MATERIALS AND METHODS: A total of 100 RCs were audited, and 22 face-to-face interviews were undertaken. RESULTS: Physical activity classes were the main activity offered (mean = eight classes per month), with walking (29.8%) and aerobics sessions (17.5%) being the most frequent. Nutrition classes and social activities were offered less often (mean = one class per month). The activities were well received by patrons, offering opportunities to interact while participating in physical activity and nutrition classes. However, the need for staff training, consideration of patron's abilities and the desire to engage in alternative activities were expressed. CONCLUSION: Overall, RCs' facilities and activities were well liked by the patrons but opportunities for improvements were identified. Regular reviews of facilities and activities through consultation with the RC patrons and managers are needed to ensure that the facilities and activities remain relevant and practical to the patrons. This will help to support active lifestyles and healthy eating practices among older adults residing within the community.

Habitual tea drinking associated with a lower risk of type 2 diabetes in Vietnamese adults.

BACKGROUND AND OBJECTIVES: The association between tea consumption and type 2 diabetes risk remains inconsistent in Asian populations. This case-control study investigated the association between habitual tea consumption and the risk of type 2 diabetes among Vietnamese adults. METHODS AND STUDY DESIGN: A hospital-based case-control study was conducted during 2013-2015 in Vietnam. A total of 599 newly diagnosed diabetic cases (aged 40-65 years) and 599 hospital-based controls, frequency matched by age and sex, were recruited. Information about frequency, quantity, and duration of tea drinking, together with demographics, habitual diet and lifestyle characteristics, was obtained from direct interviews using a validated and reliable questionnaire. Unconditional logistic regression analyses were performed to assess the association between different metrics of tea consumption and the type 2 diabetes risk. RESULTS: Control subjects reported higher tea consumption levels than the cases in terms of duration, frequency, and quantity of tea drunk. After accounting for confounding factors, increasing tea consumption was found to be associated with a reduced risk of type 2 diabetes; the adjusted odds ratio (95% confidence interval) was 0.66 (0.49, 0.89) for participants drinking >2 cups/day, relative to those drinking <1 cup/day. Significant inverse dose-response relationships were also observed for average number of cups consumed daily and years of tea drinking (p<0.01). CONCLUSIONS: Habitual tea consumption is associated with a reduced risk of type 2 diabetes among Vietnamese adults.

Risk of bias and methodological issues in randomised controlled trials of acupuncture for knee osteoarthritis: a cross-sectional study.

OBJECTIVE: To assess risk of bias and to investigate methodological issues concerning the design, conduct and analysis of randomised controlled trials (RCTs) testing acupuncture for knee osteoarthritis (KOA). METHODS: PubMed, EMBASE, Cochrane Central Register of Controlled Trials and four major Chinese databases were searched for RCTs that investigated the effect of acupuncture for KOA. The Cochrane tool was used to examine the risk of bias of eligible RCTs. Their methodological details were examined using a standardised and pilot-tested questionnaire of 48 items, together with the association between four predefined factors and important methodological quality indicators. RESULTS: A total of 248 RCTs were eligible, of which 39 (15.7%) used computer-generated randomisation sequence. Of the 31 (12.5%) trials that stated the allocation concealment, only one used central randomisation. Twenty-five (10.1%) trials mentioned that their acupuncture procedures were standardised, but only 18 (7.3%) specified how the standardisation was achieved. The great majority of trials (n=233, 94%) stated that blinding was in place, but 204 (87.6%) did not clarify who was blinded. Only 27 (10.9%) trials specified the primary outcome, for which 7 used intention-to-treat analysis. Only 17 (6.9%) trials included details on sample size calculation; none preplanned an interim analysis and associated stopping rule. In total, 46 (18.5%) trials explicitly stated that loss to follow-up occurred, but only 6 (2.4%) provided some information to deal with the issue. No trials prespecified, conducted or reported any subgroup or adjusted analysis for the primary outcome. CONCLUSION: The overall risk of bias was high among published RCTs testing acupuncture for KOA. Methodological limitations were present in many important aspects of design, conduct and analyses. These findings inform the development of evidence-based methodological guidance for future trials assessing the effect of acupuncture for KOA.

Assessing self-reported green tea and coffee consumption by food frequency questionnaire and food record and their association with polyphenol biomarkers in Japanese women.

BACKGROUND AND OBJECTIVES: Despite the demonstrated protective effects of green tea and coffee intake against several chronic diseases, finding between studies have not been consistent. One potential reason of this discrepancy is the imprecision in the measurement of tea or coffee consumption using food frequency questionnaire (FFQ) and food record (FR) in epidemiological studies. METHODS AND STUDY DESIGN: In a sample of 57 healthy Japanese women, intake of green tea and coffee was estimated by a validated FFQ and a 3-day FR, while their plasma and urine concentrations of polyphenol biomarkers were measured by HPLC. The polyphenols assessed included (-)-epigallocatechin gallate (EGCG), (-)-epicatechin gallate (ECG), (-)-epigallocatechin (EGC) and (-)- epicatechin (EC), caffeic acid (CA) and chlorogenic acid (CGA). RESULTS: Green tea consumption estimated by FFQ and FR showed moderate association, while strong association was detected for coffee consumption. Urinary green tea polyphenol concentrations were moderately-strongly associated with FR-estimated intake, while the associations were weak with FFQ. Similarly, coffee polyphenols in urine were moderately associated with FR-estimated coffee intake, whereas FFQ showed poor correlation. The associations between urinary and plasma polyphenols ranged from moderate to high. CONCLUSIONS: The results indicated that firstly, the FFQ tends to overestimate green tea intake. Secondly, the urinary polyphenols are preferred over plasma polyphenols as a potential surrogate marker of the short-term green tea and coffee intake, while their use as an indicator of long-term consumption is not reliable.

Problems and Prospects: Public Health Regulation of Dietary Supplements.

Dietary supplements are a global business worth more than US$100 billion annually. These supplements are taken by up to 50% of adults and perhaps one-third of children in economically advanced economies. Definitions of dietary supplements differ from country to country, and regulation is generally lax and often seems to be directed more toward promoting commerce than protecting public health. Supplements may directly cause toxic reactions or may interact with other supplements or pharmaceuticals. Some supplements are found to have been contaminated with heavy metals, and others do not contain the expected quantities of active ingredients. In general, supplements are not needed except in cases of established deficiencies, and excess of some nutrients can increase cancer rates. There are important public health reasons for taking some supplements, including folate and iodine in pregnancy. This review discusses the public health concerns associated with dietary supplements and suggests directions for further regulation.

Consumption of dietary supplements by Chinese women during pregnancy and postpartum: A prospective cohort study.

The objectives of this study were to investigate usage patterns and factors associated with maternal dietary supplementation by Chinese women. A prospective cohort study of 695 mothers, who gave birth to a singleton baby, was conducted in Jiangyou, Sichuan Province of China. Information on dietary supplement use was collected from participants by personal interview at hospital discharge and followed up by telephone at 1, 3, and 6 months postpartum. Logistic regression analysis and generalised linear-mixed modelling were performed to determine factors affecting dietary supplementation during pregnancy and the first 6 months postpartum, respectively. A total of 81.8 and 32.1% of women consumed dietary supplements during pregnancy and postpartum, respectively. Calcium was the most popular supplement (pregnancy 63.9%; postpartum 28.1%), whereas folic acid was only taken during pregnancy (62.3%) with an average usage duration of 2.5 (standard deviation 1.3) months among users. High school and above education, adjusted odds ratio (OR) = 2.67, 95% confidence interval (CI) [1.63, 4.38], and attendance at prenatal classes (adjusted OR = 1.99, 95% CI [1.05, 3.76]) were associated with dietary supplementation during pregnancy. Mothers with a higher level of education (adjusted OR = 3.10, 95% CI [1.81, 5.30]) were also more likely to use dietary supplements in the postpartum period. Although dietary supplementation appeared to be common among Chinese mothers, maternal intake of folic acid was well below the guidelines. There is a need for further nutrition education on maternal use of micronutrient supplements, especially targeting mothers who are less educated.

Increased Calcium Supplementation Postpartum Is Associated with Breastfeeding among Chinese Mothers: Finding from Two Prospective Cohort Studies.

The calcium supplementation status during the postpartum period among Chinese lactating women is still unclear. The objective of this study is to utilize data from two population-based prospective cohort studies to examine the calcium supplementation status and to identify whether breastfeeding is associated with increased calcium supplementation among Chinese mothers after child birth. Information from 1540 mothers on breastfeeding and calcium supplementation measured at discharge, 1, 3, and 6 months postpartum were extracted to evaluate the association between breastfeeding and calcium supplementation postpartum. A generalized linear mixed model was applied to each study initially to account for the inherent correlation among repeated measurements, adjusting for socio-demographic, obstetric factors and calcium supplementation during pregnancy. In addition, breastfeeding status measured at different follow-up time points was treated as a time dependent variable in the longitudinal analysis. Furthermore, the effect sizes of the two cohort studies were pooled using fixed effect model. Based on the two cohort studies, the pooled likelihood of taking calcium supplementation postpartum among breastfeeding mothers was 4.02 times (95% confidence interval (2.30, 7.03)) higher than that of their non-breastfeeding counterparts. Dietary supplementation intervention programs targeting different subgroups should be promoted in Chinese women, given currently a wide shortage of dietary calcium intake and calcium supplementation postpartum.

Elevated plasma and urinary concentrations of green tea catechins associated with improved plasma lipid profile in healthy Japanese women.

This study investigated green tea catechins in plasma and urine and chronic disease biomarkers. We hypothesized that plasma and urinary concentration of green tea catechins are associated with cardiovascular disease and diabetes biomarkers. First void urine and fasting plasma samples were collected from 57 generally healthy females aged 38 to 73 years (mean, 52 ± 8 years) recruited in Himeji, Japan. The concentrations of plasma and urinary green tea catechins were determined by liquid chromatography coupled with mass tandem spectrometer. Low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglyceride, glucose, insulin, glycated hemoglobin, and C-reactive protein in plasma/serum samples were analyzed by a commercial diagnostic laboratory. Statistical associations were assessed using Spearman correlation coefficients. The results showed weak associations between plasma total catechin and triglyceride (r = -0.30) and LDL cholesterol (r = -0.28), whereas plasma (-)-epigallocatechin-3-gallate, (-)-epigallocatechin, (-)-epicatechin-3-gallate, and (-)-epicatechin exhibited weak to moderate associations with triglyceride or LDL cholesterol, but little associations with HDL cholesterol, body fat, and body mass index were evident. Urinary total catechin was weakly associated with triglyceride (r = -0.19) and LDL cholesterol (r = -0.15), whereas urinary (-)-epigallocatechin-3-gallate (r = -0.33), (-)-epigallocatechin (r = -0.23), and (-)-epicatechin-3-gallate (r = -0.33) had weak to moderate correlations with triglyceride and similarly with body fat and body mass index. Both plasma (r = -0.24) and urinary (r = -0.24) total catechin, as well as individual catechins, were weakly associated with glycated hemoglobin. Plasma total and individual catechins were weakly to moderately associated with C-reactive protein, but not the case for urinary catechins. In conclusion, we found weak to moderate associations between plasma and urinary green tea catechin concentrations and plasma biomarkers of cardiovascular disease and diabetes.

Consumption of Chinese herbal medicines during pregnancy and postpartum: A prospective cohort study in China.

OBJECTIVE: to investigate usage patterns and factors associated with maternal consumption of Chinese herbal medicines in China. DESIGN: prospective cohort study. Information on the use of Chinese herbal medicines was collected from mothers by personal interview at hospital discharge and followed up by telephone at one, three and six months postpartum. SETTING: seven hospitals in Jiangyou, Sichuan Province of China. PARTICIPANTS: 695 mothers who gave birth to a singleton infant. MEASUREMENTS: prevalence, type, frequency and duration of herbal medicine usage. Logistic mixed regression analyses were performed to determine factors affecting the use. FINDINGS: a total of 43.5% and 45.0% of mothers consumed Chinese herbal medicines during pregnancy and postpartum, respectively. Angelica sinsensis was the most popular herbal medicine among the participants (pregnancy 28.8%, postpartum 26.8%). Although herbal medicines were taken more regularly by postpartum users, the median usage duration varied from two to three months during pregnancy but 1-1.6 months postpartum. The majority of users (pregnancy 42.9%, postpartum 55.1%) were advised by their mother or mother-in-law to take Chinese herbal medicines. Antenatal alcohol drinking (adjusted odds ratio 2.75, 95% confidence interval 1.01-7.53) was associated with a marginally higher prevalence of herbal consumption during pregnancy, whereas mothers with a lower family income (adjusted odds ratio 1.52, 95% confidence interval 1.12-2.04) were more likely to consume Chinese herbal medicines in the postpartum period. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: consumption of Chinese herbal medicines appears to be prevalent among Chinese mothers, especially those drinking alcohol whilst pregnant and women from a lower income household. Maternity health professionals need to be aware of the lack of evidence to support the use of Chinese herbal medicines during pregnancy and postpartum, and to provide their clients with scientifically based advice regarding herbal medicine use.

Soy and isoflavone intake associated with reduced risk of ovarian cancer in southern Chinese women.

Isoflavones, mainly found in soy, have been shown to inhibit ovarian cancer cell proliferation. We hypothesized that soy consumption and isoflavone intake are related to the risk of ovarian cancer. A case-control study was conducted in southern China to ascertain this hypothesis. Five hundred incident patients with histologically confirmed cancer of the ovary and 500 controls (mean age 59 years) were recruited from four public hospitals in Guangzhou. Information on habitual consumption of soy foods, including soybean, soy milk, fresh tofu, dried tofu, and soybean sprout, was obtained face-to-face from participants through a validated and reliable semi-quantitative food frequency questionnaire. Isoflavone intakes were then estimated using the USDA nutrient database. The ovarian cancer patients reported lower consumption levels of individual and total soy foods (75.3 ± 53.6 g/day) compared to the controls (110.7 ± 88.8 g/day). Logistic regression analyses showed that regular intake of soy foods could reduce the ovarian cancer risk, the adjusted odds ratio being 0.29 (95% confidence interval 0.20 to 0.42) for women who consumed at least 120 g/day relative to those less than 61 g/day. Similarly, isoflavone intakes were inversely associated with the ovarian cancer risk, with significant dose-response relationships (P < 0.001). We concluded that consumption of soy foods is associated with a reduced risk of ovarian cancer in southern Chinese women.

Birth preparedness and skilled attendance at birth in Nepal: implications for achieving millennium development goal 5.

OBJECTIVE: to assess birth preparedness in expectant mothers and to evaluate its association with skilled attendance at birth in central Nepal. DESIGN: a community-based prospective cohort study using structured questionnaires. SETTING: Kaski district of Nepal. PARTICIPANTS: a total of 701 pregnant women of more than 5 months gestation were recruited and interviewed, followed by a second interview within 45 days of delivery. MEASUREMENTS: outcome was skilled attendance at birth. Birth preparedness was measured by five indicators: identification of delivery place, identification of transport, identification of blood donor, money saving and antenatal care check-up. FINDINGS: level of birth preparedness was high with 65% of the women reported preparing for at least 4 of the 5 arrangements. It appears that the more arrangements made, the more likely were the women to have skilled attendance at birth (OR=1.51, p<0.001). For those pregnant women who intended to save money, identified a delivery place or identified a potential blood donor, their likelihood of actual delivery at a health facility increased by two to three fold. However, making arrangements for transportation and antenatal care check-up were not significantly associated with skilled attendance at birth. CONCLUSIONS: intention to deliver in a health-care facility as measured by birth preparedness indicators was associated with actual skilled attendance at birth. Birth preparedness packages could increase the proportion of skilled attendance at birth in the pathway of meeting the Millennium Development Goal 5.

Tea consumption reduces ovarian cancer risk.

OBJECTIVE: To ascertain the relationship between tea drinking and the risk of ovarian cancer among southern Chinese women, a case-control study was conducted in southern China during 2006-2008. METHODS: Five hundred incident patients with histologically confirmed epithelial carcinoma of the ovary and 500 controls (mean age 59 years) were recruited from four public hospitals in Guangzhou. Information on frequency, quantity and duration of tea drinking, amount of dried tea leaves brewed, together with habitual diet and lifestyle characteristics, was obtained face-to-face from participants using a validated and reliable questionnaire. Logistic regression analyses were performed to assess the association between tea consumption variables and the ovarian cancer risk. RESULTS: The control subjects reported higher tea consumption levels and prevalence (78.8%) than the ovarian cancer patients (51.4%). Regular drinking of green tea, black tea and/or oolong tea was associated with a lower risk of ovarian cancer, the adjusted odds ratio being 0.29 (95% confidence interval 0.22-0.39) after accounting for confounding factors. When compared with non-drinkers, apparent inverse dose-response relationships were observed for years of drinking, number of cups and quantity of tea consumed, as well as amount of dried tea leaves brewed (p < 0.01). CONCLUSION: Regular tea consumption is associated with a reduced risk of ovarian cancer for southern Chinese women.

Green tea drinking is inversely associated with urinary incontinence in middle-aged and older women.

AIMS: To investigate the association between green tea consumption and urinary incontinence among middle-aged and older women. METHODS: Three hundred community-dwelling women aged 40-75 years were recruited in middle and southern Japan. A validated food frequency questionnaire was administered face-to-face to obtain information on dietary intake and habitual tea and coffee consumption. Urinary incontinence status was ascertained using the International Consultation on Incontinence Questionnaire-Short Form. RESULTS: The prevalence of urinary incontinence was 27.5% among 298 eligible participants. The 82 women who leaked urine tended to drink less green tea (daily mean intake 622, SD 554 ml) than others without the condition (daily mean intake 757, SD 571 ml), P = 0.04. Relative to non-drinkers, the adjusted odds ratios of urinary incontinence were 0.37 (95% CI 0.15-0.91) for drinking more than 700 ml and 0.34 (95% CI 0.13-0.88) for drinking 4 or more cups daily. The corresponding dose-response relationships for these quantity (P = 0.04) and frequency (P = 0.01) of intake were significant. However, association with black tea, oolong tea and coffee consumption was not evident. CONCLUSIONS: The findings suggested an inverse association between urinary incontinence and habitual green tea consumption in middle-aged and older women.

Dietary intake of six minerals in relation to the risk of chronic obstructive pulmonary disease.

To investigate the relationship between dietary intake of minerals and the risk of chronic obstructive pulmonary disease (COPD), a case-control study was conducted in central Japan. A total of 278 referred patients (244 men and 34 women) aged 50-75 years with COPD diagnosed within the past four years and 340 community-based controls undertook spirometric measurements of lung function. A structured questionnaire was administered face-to-face to obtain information on demographics and habitual food consumption. Dietary intakes of six major minerals were derived from the Japanese food composition tables. The COPD patients had lower habitual energy-adjusted intakes of calcium, phosphorus and iron than controls, but not sodium. A significant reduction in prevalence of COPD was observed for calcium, with adjusted odds ratio 0.65 (95% confidence interval: 0.37- 0.98) for the highest level versus lowest level of intake. A high iron intake was also inversely associated with the COPD risk. In conclusion, an inverse association was evident between dietary calcium intake and the risk of COPD for Japanese adults.

Association between green tea consumption and lung cancer risk.

Green tea is a popular beverage and its health benefits are well known. However, inconsistent results have been reported in observational studies concerning the association between green tea consumption and the lung cancer risk. In this commentary, several methodological issues underlying the measurement of tea exposure are highlighted. The recommendations should be useful for designing and planning prospective cohort studies to ascertain the protective effect of green tea against lung cancer.