Temporal change in multimorbidity prevalence, clustering patterns, and the association with mortality: findings from the China Kadoorie Biobank study in Jiangsu Province.

Objectives: The characteristics of multimorbidity in the Chinese population are currently unclear. We aimed to determine the temporal change in multimorbidity prevalence, clustering patterns, and the association of multimorbidity with mortality from all causes and four major chronic diseases. Methods: This study analyzed data from the China Kadoorie Biobank study performed in Wuzhong District, Jiangsu Province. A total of 53,269 participants aged 30-79 years were recruited between 2004 and 2008. New diagnoses of 15 chronic diseases and death events were collected during the mean follow-up of 10.9 years. Yule's Q cluster analysis method was used to determine the clustering patterns of multimorbidity. A Cox proportional hazards model was used to estimate the associations of multimorbidity with mortalities. Results: The overall multimorbidity prevalence rate was 21.1% at baseline and 27.7% at the end of follow-up. Multimorbidity increased more rapidly during the follow-up in individuals who had a higher risk at baseline. Three main multimorbidity patterns were identified: (i) cardiometabolic multimorbidity (diabetes, coronary heart disease, stroke, and hypertension), (ii) respiratory multimorbidity (tuberculosis, asthma, and chronic obstructive pulmonary disease), and (iii) mental, kidney and arthritis multimorbidity (neurasthenia, psychiatric disorders, chronic kidney disease, and rheumatoid arthritis). There were 3,433 deaths during the follow-up. The mortality risk increased by 24% with each additional disease [hazard ratio (HR) = 1.24, 95% confidence interval (CI) = 1.20-1.29]. Compared with those without multimorbidity at baseline, both cardiometabolic multimorbidity and respiratory multimorbidity were associated with increased mortality from all causes and four major chronic diseases. Cardiometabolic multimorbidity was additionally associated with mortality from cardiovascular diseases and diabetes, with HRs of 2.64 (95% CI = 2.19-3.19) and 28.19 (95% CI = 14.85-53.51), respectively. Respiratory multimorbidity was associated with respiratory disease mortality, with an HR of 9.76 (95% CI = 6.22-15.31). Conclusion: The prevalence of multimorbidity has increased substantially over the past decade. This study has revealed that cardiometabolic multimorbidity and respiratory multimorbidity have significantly increased mortality rates. These findings indicate the need to consider high-risk populations and to provide local evidence for intervention strategies and health management in economically developed regions.

Influences of resolvin D1 and D2 on the risk of type 2 diabetes mellitus: a Chinese community-based cohort study.

Background: Although cellular and animal studies have reported that resolvin D1 (RvD1) and resolvin D2 (RvD2) are mechanisms involved in the development of type 2 diabetes mellitus (T2DM), the impact of RvD1 and RvD2 on the risk of T2DM at a population level remains unclear. Methods: We included 2755 non-diabetic adults from a community-based cohort in China and followed them for seven years. Cox proportional hazards model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association of RvD1 and RvD2 with T2DM probability. Time-dependent receiver operator characteristics (ROC) curve was used to evaluate the predictive performance of RvD1 and RvD2 for the risk of T2DM based on the Chinese CDC T2DM prediction model (CDRS). Results: A total of 172 incident T2DM cases were identified. Multivariate-adjusted HRs (95% CI) for T2DM across quartiles of RvD1 levels (Q1, Q2, Q3 and Q4) were 1.00, 1.64 (1.03-2.63), 1.80 (1.13-2.86) and 1.61 (1.01-2.57), respectively. Additionally, body mass index (BMI) showed a significant effect modification in the association of RvD1 with incident T2DM (P interaction = 0.026). After multivariate adjustment, the HR (95% CI) for T2DM in the fourth compared with the first quartile of RvD2 was 1.94 (95% CI: 1.24-3.03). Time-dependent ROC analysis showed that the area under time-dependent ROC curves of the "CDRS+RvD1+RvD2" model for the 3-, 5- and 7-year risk of T2DM were 0.842, 0.835 and 0.828, respectively. Conclusions: Higher RvD1 and RvD2 levels are associated with a higher risk of T2DM at the population level.

Association of healthy lifestyle with incident cardiovascular diseases among hypertensive and normotensive Chinese adults.

Background: Whether lifestyle improvement benefits in reducing cardiovascular diseases (CVD) events extend to hypertensive patients and whether these benefits differ between hypertensive and normotensive individuals is unclear. This study aimed to investigate the associations of an overall healthy lifestyle with the subsequent development of CVD among participants with hypertension and normotension. Methods: Using data from the Suzhou subcohort of the China Kadoorie Biobank study of 51,929 participants, this study defined five healthy lifestyle factors as nonsmoking or quitting for reasons other than illness; nonexcessive alcohol intake; relatively higher physical activity level; a relatively healthy diet; and having a standard waist circumference and body mass index. We estimated the associations of these lifestyle factors with CVD, ischemic heart disease (IHD) and ischemic stroke (IS). Results: During a follow-up of 10.1 years, this study documented 6,151 CVD incidence events, 1,304 IHD incidence events, and 2,243 IS incidence events. Compared to those with 0-1 healthy lifestyle factors, HRs for those with 4-5 healthy factors were 0.71 (95% CI: 0.62, 0.81) for CVD, 0.56 (95% CI: 0.42, 0.75) for IHD, and 0.63 (95% CI: 0.51, 0.79) for IS among hypertensive participants. However, we did not observe this association among normotensive participants. Stratified analyses showed that the association between a healthy lifestyle and IHD risk was stronger among younger participants, and the association with IS risk was stronger among hypertensive individuals with lower household incomes. Conclusion: Adherence to a healthy lifestyle pattern is associated with a lower risk of cardiovascular diseases among hypertensive patients, but this benefit is not as pronounced among normotensive patients.

Association between physical activity and cancer risk among Chinese adults: a 10-year prospective study.

BACKGROUND: In China, the quantity of physical activity differs from that in Western countries. Substantial uncertainty remains about the relevance of physical activity for cancer subtypes among Chinese adults. OBJECTIVE: This study aimed to investigate the association between total daily physical activity and the incidence of common types of cancer. METHODS: A total of 53,269 participants aged 30-79 years were derived from the Wuzhong subcohort of the China Kadoorie Biobank study during 2004-2008. We included 52,938 cancer-free participants in the final analysis. Incident cancers were identified through linkage with the health insurance system and death registries. Cox proportional hazard models were introduced to assess the associations of total daily physical activity with the incidence of 6 common types of cancer. RESULTS: During a follow-up of 10.1 years, 3,674 cases of cancer were identified, including 794 (21.6%) from stomach cancer, 722 (19.7%) from lung cancer, 458 (12.5%) from colorectal cancer, 338 (9.2%) from liver cancer, 250 (6.8%) from breast cancer, and 231 (6.3%) from oesophageal cancer. Compared to the participants in the lowest quartile of physical activity levels, those in the highest quartile had an 11% lower risk for total cancer incidence (hazard ratio [HR]: 0.89, 95% confidence interval [CI]: 0.81-0.99), 25% lower risk for lung cancer incidence (HR: 0.75, 95% CI: 0.60-0.94), and 26% lower risk for colorectal cancer incidence (HR: 0.74, 95% CI: 0.55-1.00). There were significant interactions of physical activity with sex and smoking on total cancer (both P for interaction < 0.005), showing a lower risk for females and never smokers (HR: 0.92, 95% CI: 0.87-0.98 and HR: 0.93, 95% CI: 0.87-0.98, respectively). CONCLUSIONS: Higher physical activity levels are associated with a reduced risk of total, lung, and colorectal cancer.

Low-risk Lifestyle and Health Factors and Risk of Mortality and Vascular Complications in Chinese Patients With Diabetes.

BACKGROUND: There is an evidence gap about whether a low-risk lifestyle is as important as achieving blood pressure (BP) and random blood glucose (RBG) control. OBJECTIVES: To explore the long-term impacts and relative importance of low-risk lifestyle and health factors on the risk of all-cause and cancer mortality and macrovascular and microvascular complications among patients with diabetes. METHODS: This study included 26,004 diabetes patients in the China Kadoorie Biobank. We defined 5 lifestyle factors (smoking, alcohol drinking, physical activity, fruit and vegetable intake, and waist-to-hip ratio) and 2 health factors (BP and RBG). Cox regression was used to yield adjusted hazard ratios (HRs) and CIs for individual and combined lifestyle and health factors with the risks of diabetes-related outcomes. RESULTS: There were 5063 deaths, 6848 macrovascular complications, and 2055 microvascular complications that occurred during a median follow-up of 10.2 years. Combined low-risk lifestyle factors were associated with lower risk of all main outcomes, with HRs (95% CIs) for participants having 4 to 5 low-risk factors vs 0 to 1 of 0.50 (0.44-0.57) for all-cause mortality, 0.55 (0.43-0.71) for cancer mortality, 0.60 (0.54-0.67) for macrovascular complications, and 0.75 (0.62-0.91) for microvascular complications. The combined 4 to 5 low-risk lifestyle factors showed relative importance in predicting all-cause and cancer mortality and macrovascular complications. CONCLUSIONS: Assuming causality exists, our findings suggest that adopting a low-risk lifestyle should be regarded as important as achieving ideal BP and glycemic goals in the prevention and management of diabetes-related adverse outcomes.

Associations of visit-to-visit variabilities and trajectories of serum lipids with the future probability of type 2 diabetes mellitus.

BACKGROUND: Serum lipid abnormalities are generally considered as a major risk factor for type 2 diabetes mellitus (T2DM). However, evidence for the effect of long-term serum lipid fluctuations on future T2DM probability remains limited. METHODS: A total of 4475 nondiabetic participants who underwent annual health examinations between 2010 and 2013 were followed for the subsequent 5-year risk of T2DM. The Cox proportional hazards model was performed to evaluate the associations of visit-to-visit variabilities and trajectories of triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c) and low-density lipoprotein cholesterol (LDL-c) with T2DM probability. RESULTS: During the five-year follow-up, 223 newly developed T2DM cases were identified. Compared with the "Low" TG trajectory, "Moderate" and "Moderate-High" TG trajectories were significantly associated with T2DM incidence, with adjusted hazard ratios (HRs) and 95 % confidence intervals (CIs) of 1.51 (1.12-2.03) and 2.55 (1.62-4.03), respectively. Additionally, participants in the third and fourth quartiles of TG/standard deviation (SD) were associated with increased T2DM probability when compared with those in the lowest quartile. After excluding individuals with prediabetes, participants with "Moderate-High" TG trajectory still had a 2.43-fold greater risk of T2DM compared with those with "Low" TG trajectory (95 % CI: 1.28-4.63). In addition, compared with participants in "Low" HDL-c trajectory, the future T2DM probability was significantly reduced in those with "Moderate" and "High" HDL-c trajectories, with HR (95 % CI) of 0.52 (0.37-0.72) and 0.38 (0.18-0.80), respectively. After excluding individuals with prediabetes, the "Moderate" HDL-c trajectory remained associated with decreased T2DM probability when compared with "Low" HDL-c trajectory (HR: 0.55, 95 % CI: 0.35-0.88). However, the incidence of T2DM was not associated with the long-term fluctuations of TC and LDL-c. CONCLUSIONS: Long-term visit-to-visit variability of TG, and the change trajectories of TG and HDL-c were significantly associated with future T2DM probability. Moreover, these associations were not affected after excluding individuals with prediabetes.

Pneumonia hospitalizations and the subsequent risk of incident ischaemic cardiovascular disease in Chinese adults.

BACKGROUND: Acute respiratory infections have been associated with a transient increase in cardiovascular risk. However, whether such an association persists beyond 1 month and the potential modifying effect of cardiovascular risk factors on such an association are less well established. METHODS: The China Kadoorie Biobank enrolled 512 726 participants aged 30-79 years from 10 areas across China during 2004-2008. By the end of 2017, a total of 5444 participants with new-onset ischaemic heart disease (IHD) and 4846 with ischaemic stroke (IS) who also had at least a record of hospitalization for pneumonia during follow-up were included. We used a self-controlled case-series method and calculated the age- and season-adjusted relative incidences (RIs) and 95% confidence intervals (CIs) for ischaemic cardiovascular disease (CVD) after pneumonia. RESULTS: The risk of ischaemic CVD increased during days 1-3 after pneumonia hospitalization, with an RI (95% CI) of 4.24 (2.92-6.15) for IHD and 1.85 (1.02-3.35) for IS. The risk gradually reduced with longer duration since pneumonia hospitalization but remained elevated until days 92-365 for IHD (1.23, 1.12-1.35) and days 29-91 for IS (1.25, 1.05-1.48). Pre-existing cardiovascular risk factors amplified the associations between pneumonia and ischaemic CVD risks, such as chronic obstructive pulmonary disease for both IHD and IS, and diabetes and smoking for IHD (all Pinteraction < 0.05). Besides, the risk of ischaemic CVD was also higher among the participants aged ≥70 years (Pinteraction < 0.001 for IHD and 0.033 for IS). CONCLUSION: Among middle-aged and older Chinese adults, pneumonia hospitalization was associated with both short- and long-term increases in ischaemic CVD risk for ≤1 year.

The association between daily total physical activity and risk of cardiovascular disease among hypertensive patients: a 10-year prospective cohort study in China.

BACKGROUND: The effect of high levels of physical activity and relationship between daily total physical activity and the risk of cardiovascular disease (CVD) among hypertensive people were not clear. This study aimed to explore the optimum level of physical activity for CVD prevention. METHODS: Data used in the present study was derived from the sub-study of China Kadoorie Biobank study (CKB) in Jiangsu province of China. The CKB was a prospective cohort study established during 2004-2008. At baseline, 53,259 participants aged 35-74 years were recruited for the CKB Jiangsu sub-study conducted in Wuzhong district of Suzhou City. Among those 53,259 participants, the 20,179 hypertensive individuals were our study population. The outcome events were cardiovascular diseases (CVDs), while the independent variable was total daily physical activity. The Cox proportional hazard models were introduced to investigate the association between total physical activity and CVDs, reporting as hazard ratios (HR) and 95% confidence intervals (CIs). RESULTS: During a 10.1-year follow-up, 2419 CVD cases were identified. After adjustment for potential confounding factors, compared with participants at the lowest level of daily total physical activity, the hazard ratios for CVDs were 0.87 (95%CI: 0.79-0.97), 0.73 (95%CI: 0.65-0.83) and 0.75 (95%CI: 0.65-0.85) for participants within 2, 3 and 4 quartiles of physical activity. Such a negative association between total physical activity and CVDs were also observed among participants by gender and age-group, but within patients with stage 1 hypertension only. Moreover, the association of physical activity with CVDs was U-shape and the lowest HR (0.63, 95%CI: 0.54-0.74) was observed at 35.4 MET-h/d of total physical activity. CONCLUSIONS: Total daily physical activity was negatively associated with CVDs among hypertensive adults in China, and this association was U-shape. It has some public health implications that community-based total physical activity intervention campaigns can be of help for CVDs prevention among hypertensive people in China.

[Performance Assessment of Permeable Interlocking Concrete Pavement Facility Structure].

Two permeable parking lots and one impervious concrete pavement were constructed in Shanghai to study the hydrological and water quality performance of permeable interlocking concrete pavements (PICP) with different base course materials. The hydrological performance and water quality of the influent and effluent under actual precipitation conditions in 2018 were monitored, and the two PICPs used cement-stabilized crushed stones (PICP1) and crushed stones (PICP2) as the base course, respectively. Results show that the annual total volume reduction rates of PICP1 and PICP2 are 37.0% and 38.7%, respectively. The peak flow reduction rate and the time to the peak flow of PICP1 are slightly better than PICP2. PICP1 has better transformation efficiency on NH4+-N in comparison to PICP2, and the release of NO3--N occurs in both PICPs. Moreover, PICP1 has lower effluent concentrations than PICP2 on pollutants like TSS, TP, PP, and DP. The PICP with cement-stabilized crushed stones as base course is helpful to improve the hydrological performance and water quality of the effluent.

Association between environmental tobacco smoke exposure and risk of type 2 diabetes mellitus in Chinese female never smokers: A population-based cohort study.

BACKGROUND: Evidence for the association between environmental tobacco smoke (ETS) exposure and the risk of type 2 diabetes mellitus (T2DM) is limited. The aim of this study was to investigate this association in female never smokers. METHODS: We analyzed 28 177 female participants of the China Kadoorie Biobank (CKB) in the Suzhou area, who were never smokers and had no diabetes. ETS exposure was defined as being exposed to other people's tobacco smoke either at home, workplace, or in public places at least 1 d/wk. Cox proportional hazard regression models were used to assess the association between ETS exposure and incident T2DM according to the frequency and duration of ETS exposure. RESULTS: A total of 774 incident cases of T2DM were identified during a median 7.3-year follow-up. Compared with no ETS exposure, hazard ratios (95% CIs) for all ETS exposure, daily, and ≥14 h/wk ETS exposure were 1.17 (1.00-1.37), 1.23 (1.04-1.46), and 1.25 (1.03-1.53), respectively. Moreover, a positive dose-response relationship was observed between ETS exposure level and T2DM (all P <.05 for trend). CONCLUSIONS: This prospective study suggests that ETS exposure increases the risk of T2DM incidence with dose-response relationship in female never smokers. Thus, reducing ETS exposure may help decrease the burden of T2DM in Chinese females.

Chronic hepatitis B virus infection and total and cause-specific mortality: a prospective cohort study of 0.5 million people.

OBJECTIVES: Chronic hepatitis B virus (HBV) infection is associated with a higher risk of liver diseases. Substantial uncertainty remains, however, about the associations of HBV infection with mortality from extrahepatic causes, especially from subtypes of cardiovascular diseases. We prospectively examined the association of chronic HBV infection with total and cause-specific mortality. DESIGN: Population-based prospective cohort study. SETTING: China Kadoorie Biobank in which participants from 10 geographically diverse areas across China were enrolled between 2004 and 2008. PARTICIPANTS: 475 801 participants 30-79 years of age without reporting major chronic diseases at baseline were enrolled. Hepatitis B surface antigen (HBsAg) was tested using an on-site rapid test strip at baseline. PRIMARY AND SECONDARY OUTCOME MEASURES: Total and cause-specific mortality. RESULTS: A total of 35 822 deaths were recorded during ~10 years of follow-up. In multivariable-adjusted analyses, compared with HBsAg-negative participants, HBsAg-positive participants had an increased risk of total mortality (HR=2.01, 95% CI: 1.91 to 2.12), which was higher in men (HR=2.16, 95% CI: 2.01 to 2.31) than in women (HR=1.74, 95% CI: 1.60 to 1.90). Presence of HBsAg was associated with increased mortality from liver cancer (1339 deaths, HR=13.95, 95% CI: 12.46 to 15.62), infections (410 deaths, HR=10.30, 95% CI: 8.21 to 12.94), digestive diseases (688 deaths, HR=6.83, 95% CI: 5.49 to 8.50), intracerebral haemorrhage (4077 deaths, HR=1.38, 95% CI: 1.14 to 1.68) and ischaemic heart diseases (4624 deaths, HR=1.31, 95% CI: 1.09 to 1.58). The positive association between HBsAg status and risk of death was stronger in participants younger than 50 years, smokers, physically active or non-hypertensive participants. CONCLUSIONS: Among Chinese adults, chronic HBV infection was associated with increased mortality from a range of hepatic and extrahepatic diseases.

[Hydrological Performance Assessment of Permeable Parking Lots in High Water Areas].

In order to evaluate the hydrological performance of permeable pavements in mitigating the surface runoff, four pilot-scale permeable pavement units were constructed in Shanghai and compared with impervious pavements. Three of the permeable facilities with waterproof liners included a pervious concrete pavement (facility Ⅰ), permeable interlocking concrete pavement using cement stabilized macadam as the base course (facility Ⅱ) and permeable interlocking concrete pavement using macadam as the base course (facility Ⅲ). The other two facilities were a conventional permeable interlocking concrete pavement without a liner (facility Ⅳ) and an impervious concrete pavement control (facility 0). V-notch flow meters, data loggers, and a rainfall meter were mounted to monitor the hydrological data. A double-ring infiltrometer was applied to evaluate the infiltration rate of the pavements. During the one-year experiment, the surface runoff and the underdrain discharge flow rate of the four pilot-scale facilities were continuously monitored in actual rainfall and the total volume reduction, peak flow reduction, and peak concentrating time of different facilities were investigated. The results showed that the surface steady infiltration rates of permeable interlocking concrete pavements were less than those of the pervious concrete, and the surface steady infiltration rates of the two types of surface layers decreased after one year of usage. The surface runoff reduction of the four facilities showed no significant differences. The water volume reduction rate of the three types of facilities was weak. The annual total volume reduction rates were 24.2%, 28.5%, and 28.4%, and the controlled rainfall amounts were 5.2 mm, 7.8 mm, and 7.8 mm. The peak flow reduction rate and the time to the peak flow of facility Ⅰ were smaller than those of facility Ⅱ and facility Ⅲ. The peak flow reduction rate and the time to the peak flow of the three facilities showed significant negative correlation with rainfall intensity.

[Performance of Applying Scale Permeable Pavements for Control of Runoff Pollution in an Area with High Groundwater Level].

The purpose of this article was to study the effect of permeable pavements on runoff pollution control and its possible influence on groundwater quality in the area with high groundwater level. Three experimental permeable parking lots and one impermeable parking lot were built in urban Shanghai in order to monitor their quality of influent and effluent water under actual precipitation conditions, in order to investigate the performance of pollutant control effects and to evaluate the possibility of the pollution of groundwater. The results showed that all the three facilities could effectively remove TP, TSS, COD, Cr, Mn, Cu, Zn, Pb and O&G, but imposed poor removal efficiency on TN. Obvious release of NO3--N occurred in all three pavements. The permeable interlocking concrete pavement using cement stabilized crushed stones as base course and the one using crushed stones as base course had a better removal efficiency on NH4+-N than the previous concrete one. The quality of effluent water from different permeable pavements had no significant difference except NH4+-N. The in-situ groundwater quality was generally worse than background values of groundwater in Shanghai. Effluent water quality of three permeable pavements was generally worse than that of the in-situ groundwater, and a number of indicators belonged to or were close to groundwater class V standard. In the area with high groundwater level, there was risk of groundwater pollution caused by permeable pavements without liners.

Interoperative radiotherapy of seventy-two cases of early breast cancer patients during breast-conserving surgery.

OBJECTIVE: To evaluate interoperative radiotherapy after breast conservative surgery in early breast cancer patients in terms of postoperative complications, cosmetic outcome and recurrence events. METHODS: From June 2007 to Dec 2011, 143 early breast cancer patients received breast conservative surgery. Seventy-two (study group) received interoperative radiotherapy, compared with 71 patients (control group) given routine radiotherapy. Postoperative complications were evaluated 1 month after surgery; cosmetic outcome was evaluated 1 year postoperatively; recurrence and death events were followed up. RESULTS: The average wound healing time was 13~22 d in the study group and 9~14 d in the control group. In the study group, 2 patients developed lyponecrosis, 16 patients showed wound edema while no such side effects were found in the control group. No infection or hematomas were found in either group. In the study group (59 cases), overall cosmetic outcome in 53 patients was graded as excellent or good, and in 6 as fair or poor. Meanwhile in the control group (56 cases), 42 patients were graded as excellent or good, and 14 as fair or poor (P=0.032). After a follow-up from 3 to 54 months (median: 32 months), two patients (2.78%) in study group developed local relapses, one of them (1.39%) died, 2 patients (2.78%) developed bone metastases. In control group, one patient (1.41%) developed local relapse, 2 patients (2.82%) developed bone metastases, and no one died. CONCLUSION: Intraoperative radiotherapy is safe and reliable with good cosmetic outcome.

Radiation field feature of 188Re esophageal stent.

OBJECTIVE: To evaluate the radiation field feature of Re esophageal stent and provide scientific basis for clinical application. METHODS: We measure the beta-ray, gamma-ray and bremssfrahlung dose of every selected point on the bionics esophageal stent and then draw out computer software by mathematical formula. RESULTS: The radiation field of Re esophageal stent has its own feature: the max range of beta-ray is 11 mm, 90% dose construction field is within 1.5 mm, 95% dose range is within 2.5 mm, and only 4.21% of total energy of gamma-ray and bremssfrahlung is out of 6.5 mm range. The absorption dose of every direction in same point of the esophageal model was similar (P>0.05). CONCLUSION: Beta ray is the major radiation of Re esophageal stent while gamma-ray and bremssfrahlung are 4.21% among the radiation field. The max dose construction field is within 0.5-1.5 mm, just short at the depth of esophagus mucosa within 0.5-1.5 mm range. So Re stent is a good choice of palliative intracavitary radiotherapy of esophageal carcinoma.