Associations of Ambient Particulate Matter with Maternal Thyroid Autoimmunity and Thyroid Function in Early Pregnancy.

This prospective birth cohort study evaluated the association of exposure to PM2.5 (diameter ≤2.5 µm), PM1-2.5 (1-2.5 µm), and PM1 (≤1 µm) with maternal thyroid autoimmunity and function during early pregnancy. A total of 15,664 pregnant women were included at 6 to 13+6 gestation weeks in China from 2018 to 2020. Single-pollutant models using generalized linear models (GLMs) showed that each 10 µg/m3 increase in PM2.5 and PM1-2.5 was related with 6% (odds ratio [OR] = 1.06, 95% confidence interval [CI]: 1.01, 1.12) and 15% (OR = 1.15, 95% CI: 1.08, 1.22) increases in the risk of thyroid autoimmunity, respectively. The odds of thyroid autoimmunity significantly increased with each interquartile range increase in PM2.5 and PM1-2.5 exposure (P for trend <0.001). PM1 exposure was not significantly associated with thyroid autoimmunity. GLM with natural cubic splines demonstrated that increases in PM2.5 and PM1-2.5 exposure were associated with lower maternal FT4 levels, while a negative association between PM1 and FT4 levels was found when exposure exceeded 32.13 µg/m3. Only PM2.5 exposure was positively associated with thyrotropin (TSH) levels. Our findings suggest that high PM exposure is associated with maternal thyroid disruption during the early pregnancy.

Elevated serum uric acid to creatinine ratio is associated with adverse pregnancy outcomes: a prospective birth cohort study.

Purpose: This study evaluated the association between maternal serum uric acid-to-creatinine ratio (SUA/SCr) in the first trimester and adverse maternal and neonatal outcomes. Methods: A prospective birth cohort study was conducted between 2018 and 2021. Logistic regression models and restricted cubic splines were utilized to estimate the associations between the SUA/SCr ratio and feto-maternal pregnancy outcomes. Women were stratified according to maternal age and pre-pregnancy body mass index. Results: This study included 33,030 pregnant women with live singleton pregnancies. The overall prevalence of gestational diabetes mellitus (GDM), pregnancy-induced hypertension (PIH), cesarean delivery, preterm birth, large-for-gestational age (LGA), small-for-gestational age, and low Apgar scores were 15.18%, 7.96%, 37.62%, 4.93%, 9.39%, 4.79% and 0.28%, respectively. The highest quartile of SUA/SCr was associated with the highest risk of GDM (odds ratio [OR] 2.14, 95% CI 1.93-2.36), PIH (OR 1.79, 95% CI 1.58-2.04), cesarean delivery (OR 1.24, 95% CI 1.16-1.33), and preterm birth (OR 1.30, 95% CI 1.12-1.51). The associations between SUA/SCr with adverse pregnancy outcomes showed linear relationships except for GDM (P < 0.001 for all, P < 0.001 for non-linearity). Subgroup analyses revealed that the associations between the SUA/SCr ratio and the risks of PIH and LGA were significantly stronger in younger pregnant women (P = 0.033 and 0.035, respectively). Conclusion: Maternal SUA/SCr levels were associated positively with the risk of adverse pregnancy outcomes. Timely monitoring of SUA and SCr levels during early pregnancy may help reduce the risk of adverse pregnancy outcomes and provide a basis for interventions.

The association between dyslipidaemia in the first trimester and adverse pregnancy outcomes in pregnant women with subclinical hypothyroidism: a cohort study.

BACKGROUND: Subclinical hypothyroidism (SCH) is linked to dyslipidaemia and adverse pregnancy outcomes. However, the impact of dyslipidaemia on the outcome of pregnancy in SCH is unclear. METHODS: We enrolled 36,256 pregnant women and evaluated their pregnancy outcomes. The following data was gathered during the first trimester (≤ 13+ 6 weeks of gestation): total cholesterol (TC), low-density lipoprotein (LDL-C), triglyceride (TG), high-density lipoprotein (HDL-C), free thyroxine (FT4) and thyroid-stimulating hormone (TSH) concentrations. The reference ranges for lipids were estimated to range from the 5th to the 95th percentile. Logistic regression assessed the relationships between dyslipidaemia and adverse pregnancy outcomes, including abortion, preeclampsia/eclampsia, low birth weight, foetal growth restriction, premature rupture of foetal membranes, gestational hypertension, preterm birth, macrosomia and gestational diabetes mellitus (GDM). Additionally, the best thresholds for predicting adverse pregnancy outcomes based on TSH, FT4, and lipid levels were determined using receiver operating characteristic curves. RESULTS: In the first trimester, LDL-C > 3.24 mmol/L, TG > 1.92 mmol/L, HDL-C < 1.06 mmol/L, and TC > 5.39 mmol/L were used to define dyslipidaemia. In this cohort, 952 (3.56%) patients were diagnosed with SCH, and those who had dyslipidaemia in the first trimester had higher incidences of gestational hypertension (6.59% vs. 3.25%), preeclampsia/eclampsia (7.14% vs. 3.12%), GDM (22.53% vs. 13.77%), and low birth weight (4.95% vs. 2.08%) than did those without dyslipidaemia. However, after adjusting for prepregnancy body mass index (pre-BMI), dyslipidaemia was no longer related to these risks. Furthermore, elevated TG dyslipidaemia in SCH patients was connected to an enhanced potential of gestational hypertension (odds ratio [OR]: 2.687, 95% confidence interval [CI]: 1.074 ~ 6.722), and elevated LDL-C dyslipidaemia correlated with increased preeclampsia/eclampsia risk (OR: 3.172, 95% CI: 1.204 ~ 8.355) after accounting for age, smoking status, alcohol use, pre-BMI, and levothyroxine use. Additionally, the combination of TC, TG, LDL-C, pre-BMI, and TSH exhibited enhanced predictive capabilities for gestational hypertension, preeclampsia/eclampsia, and GDM. Values of 0.767, 0.704, and 0.706 were obtained from the area under the curve. CONCLUSIONS: Among pregnant women with SCH, dyslipidaemia in early pregnancy was related to elevated risks of adverse pregnancy consequences. The combined consideration of age, pre-BMI, TSH, and lipid levels in the first trimester could be beneficial for monitoring patients and implementing interventions to reduce adverse pregnancy outcomes.

Elevated levels of renal function tests conferred increased risks of developing various pregnancy complications and adverse perinatal outcomes: insights from a population-based cohort study.

OBJECTIVES: Physiological changes during pregnancy can affect the results of renal function tests (RFTs). In this population-based cohort study, we aimed to establish trimester-specific reference intervals (RIs) of RFTs in singleton and twin pregnancies and systematically investigate the relationship between RFTs and adverse pregnancy outcomes. METHODS: The laboratory results of the first- and third-trimester RFTs, including blood urea nitrogen (BUN), serum uric acid (UA), creatinine (Crea) and cystatin C (Cys C), and the relevant medical records, were retrieved from 29,328 singleton and 840 twin pregnant women who underwent antenatal examinations from November 20, 2017 to January 31, 2021. The trimester-specific RIs of RFTs were estimated with both of the direct observational and the indirect Hoffmann methods. The associations between RTFs and pregnancy complications as well as perinatal outcomes were assessed by logistic regression analysis. RESULTS: Maternal RFTs showed no significant difference between the direct RIs established with healthy pregnant women and the calculated RIs derived from the Hoffmann method. In addition, elevated levels of RFTs were associated with increased risks of developing various pregnancy complications and adverse perinatal outcomes. Notably, elevated third-trimester RFTs posed strong risks of preterm birth (PTB) and fetal growth restriction (FGR). CONCLUSIONS: We established the trimester-specific RIs of RFTs in both singleton and twin pregnancies. Our risk analysis findings underscored the importance of RFTs in identifying women at high risks of developing adverse complications or outcomes during pregnancy.

Potential impact of ambient temperature on maternal blood pressure and hypertensive disorders of pregnancy: A nationwide multicenter study based on the China birth cohort.

Limited evidence exists regarding the association between ambient temperature and blood pressure (BP) level of pregnant women. To investigate the associations of ambient temperature with maternal BP and hypertensive disorders of pregnancy (HDP), we studied 105,063 participants in 38 centers of 17 provinces from November 2017 to December 2021. BP was measured with standardized automated digital sphygmomanometers. Ambient temperature was classified into five classes as very hot, moderate hot, mild, moderate cold, and very cold. Generalized linear mixed models were used to investigate the ambient temperature-BP/HDP associations, controlling for multiple covariates. No significant associations of first-trimester ambient temperature with maternal BP and HDP prevalence were observed. Compared with mild temperature, second-trimester very cold and second-trimester moderate cold were statistically associated with the increase of 1.239 mmHg (95% CI: 0.908, 1.569) and 0.428 mmHg (95% CI: 0.099, 0.757) for second-trimester systolic blood pressure (SBP), respectively. Similar trends were also observed in the association between second-trimester cold exposure and second-trimester diastolic blood pressure (DBP), in the association between second-trimester cold exposure and third-trimester SBP/DBP as well as in the association between third-trimester cold exposure and third-trimester SBP/DBP although some estimates were not statistically significant. Furthermore, in the second and third trimester, very cold [second trimester: adjusted odds ratio (aOR) = 1.298; third trimester: aOR = 1.236) and moderate cold (second trimester: aOR = 1.208; third trimester: aOR = 1.146) exposures also increased the odds of HDP, and these associations were stronger among participants aged ≥35 years or from North China. The second and third trimesters are the critical exposure windows for ambient temperature exposure-BP/HDP associations. During this period, exposure to cold ambient temperature was associated with elevated BP as well as increased HDP prevalence among most Chinese pregnant women, those aged ≥35 years or from North China being more vulnerable.

Serum uric acid and the risk of gestational diabetes mellitus: a systematic review and meta-analysis.

AIMS: Serum uric acid (SUA) is considered as a risk factor for gestational diabetes mellitus (GDM). However, current studies showed inconsistent results. This study aimed to explore the relationship between SUA levels and GDM risk. METHODS: Eligible studies were retrieved from PubMed, Web of Science, Embase, China National Knowledge Infrastructure, and Wanfang databases up to November 1, 2022. The pooled standardized mean difference (SMD) and 95% confidence interval (CI) were used to represent the difference in SUA levels between GDM women and controls. The combined odds ratios (OR) and 95% CI were applied to assess association between SUA levels and GDM risk. Subgroup analyses were conducted on study continents, design, and quality, detection time of SUA, and GDM diagnostic criteria. RESULTS: Totally 11 studies including five case-control and six cohort studies, in which 80,387 pregnant women with 9815 GDM were included. The overall meta-analysis showed that the mean SUA level in GDM group was significantly higher than in controls (SMD = 0.423, 95%CI = 0.019-0.826, p = .040, I2 = 93%). Notably, pregnant women with elevated levels of SUA had a significantly increased risk of GDM (OR = 1.670, 95%CI = 1.184-2.356, p = .0035, I2 = 95%). Furthermore, subgroup analysis performed on the detection time of SUA showed a significant difference in the association between SUA and GDM risk within different trimesters (1st trimester: OR = 3.978, 95%CI = 2.177-7.268; 1st to 2nd trimester: OR = 1.340, 95%CI = 1.078-1.667; p between subgroups <.01). CONCLUSIONS: Elevated SUA was positively associated with GDM risk, particularly in the 1st trimester of pregnancy. Further studies with high quality are required to validate the findings of this study.

Coronavirus Disease 2019 Pandemic-Related Long-Term Chronic Impacts on Psychological Health of Perinatal Women in China.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has caused far-reaching changes in all areas of society. However, limited data have focused on the long-term impacts on perinatal psychological health. This study aims to evaluate long-term impacts of COVID-19 pandemic crisis on psychological health among perinatal women and investigate associated factors. STUDY DESIGN: A multicenter, cross-sectional study, the psychological subproject of China Birth Cohort Study (CBCS), was conducted in 2021. Demographic and obstetric characteristics, pregnancy outcomes, psychological status, and COVID-19-pandemic-related factors were obtained. The symptoms of depression, anxiety, and insomnia of participants were assessed by Patient Health Questionnaire, Edinburgh Postpartum Depression Scale, Generalized Anxiety Disorder Scale, and Insomnia Severity Index, respectively. Multivariate logistic regression was used to identify associated factors of adverse psychological symptoms. RESULTS: Totally, 1,246 perinatal women were enrolled, with the overall prevalence of depression, anxiety, and insomnia symptoms being 63.16, 41.89, and 44.38%, respectively. Perinatal women who needed psychological counseling and were very worried about the COVID-19 pandemic were 1.8 to 7.2 times more likely to report symptoms of depression, anxiety, and insomnia. Unemployment, flu-like symptoms, younger maternal age, and previous diseases before pregnancy were risk factors for depression, anxiety, or insomnia. CONCLUSION: Our study revealed that the prevalence of perinatal depression, anxiety, and insomnia symptoms was at a high level even 1 year after the pandemic outbreak, implying pandemic-associated long-term psychological impacts on perinatal women existed. Government should not only pay attention to the acute effects of psychological health but also to long-term psychological impacts on perinatal women after major social events. KEY POINTS: · The prevalence of perinatal psychological symptoms was at a high level after the COVID-19 outbreak.. · Perinatal women who were very worried about COVID-19 were more often to have psychological symptoms.. · Perinatal women with demands of mental counseling were more likely to report psychological symptoms..

The China birth cohort study (CBCS).

The China birth cohort study (CBCS) is a prospective longitudinal, mega-cohort study and the first national-based birth cohort study, aiming to establish a birth cohort covering representative geographical areas of the whole of China to investigate risk factors for birth defects and develop strategies for their reduction. Pregnant women who are of Chinese nationality, are 6-13+6 weeks of gestation, plan to attend the routine antenatal examination and deliver in the study site, and give their informed, written consent are eligible to participate in this study. All participants are followed-up through an in-person interview at 20-23+6 weeks and again at 28-33+6 weeks of gestation, and at delivery, respectively. CBCS has been divided into three phases from 20th November 2017 to 31st December 2021, and the first two phases have now been completed on 29th February 2020, enrolling 120 377 eligible pregnant women during this period. During the same period a total of 40 837 participants had been followed up to the end of pregnancy. Study recruitment will continue until December 2021 to achieve the target of 500 000 participants. Meanwhile, biological samples including peripheral blood, amniocytes, cord blood, placenta, or umbilical cord tissue have been collected from participants according to various conditions. The incidence of birth defects in this group is 2.5% and congenital heart disease is the most common type of birth defect seen so far. A website is in the advanced stages of planning, to allow seamless data transfer and facilitate collaboration with groups around the world.

Identifying Performance Outliers for Stroke Care Based on Composite Score of Process Indicators: an Observational Study in China.

BACKGROUND: Variability in the quality of stroke care is widespread. Identifying performance-based outlier hospitals based on quality indicators (QIs) has become a common practice. OBJECTIVES: To develop a tool for identifying performance-based outlier hospitals based on risk-adjusted adherence rates of process indicators. DESIGN: Hospitals were classified into five-level outliers based on the observed-to-expected ratio and P value. The composite quality score was derived by summation of the points for each indicator for each hospital, and associations between outlier status and outcomes were determined. PARTICIPANTS: Patients diagnosed with acute ischemic stroke, January 1, 2011-May 31, 2017. INTERVENTION: N/A MAIN OUTCOME MEASURES: Independence at discharge (the modified Rankin Scale = 0-2). KEY RESULTS: A total of 501,132 patients from 519 hospitals were identified. From 0.39 to 19.65% of hospitals were identified as high outliers according to various QIs. Composite quality scores ranged from - 20 to 16. Providers that were high outliers based on QI2, QI8, QI9, and QI11 had higher independent rates. For composite quality score, each point increase corresponded to an 8% increase in the odds of independent rate. CONCLUSION: Nationwide variation in the quality of acute stroke care exists at the hospital level. Variability in the quality of stroke care can be captured by our proposed quality score. Applying this quality score as a benchmarking tool could provide audit-level feedback to policymakers and hospitals to aid quality improvement.

Factors analysis on the use of key quality indicators for narrowing the gap of quality of care of breast cancer.

BACKGROUND: There are differences in the quality of care among breast cancer patients. Narrowing the quality differences could be achieved by increasing the utilization rate of indicators. Here we explored key indicators that can improve the quality of care and factors that may affect the use of these indicators. METHODS: A total of 3669 breast cancer patients were included in our retrospective study. We calculated patient quality-of-care composite score based on patient average method. Patients were divided into high- and low-quality groups according to the mean score. We obtained the indicators with large difference in utilization between the two groups. Multilevel logistic regression model was used to analyze the factors influencing quality of care and use of indicators. RESULTS: The mean composite score was 0.802, and the number of patients in the high- and low-quality groups were 1898 and 1771, respectively. Four indicators showed a difference in utilization between the two groups of over 40%. Histological grade, pathological stage, tumor size and insurance type were the factors affecting the quality of care. In single indicator evaluation, besides the above factors, age, patient income and number of comorbidities may also affect the use of these four indicators. Number of comorbidities may have opposite effects on the use of different indicators, as does pathological stage. CONCLUSIONS: Identifying key indicators for enhancing the quality-of-care of breast cancer patients and factors that affect the indicator adherence may provide guides for enhancing the utilization rate of these indicators in clinical practice.

Long-term effects of neoadjuvant radiotherapy, adjuvant radiotherapy, and chemotherapy-only on survival of locally advanced non-small cell lung Cancer undergoing surgery: a propensity-matched analysis.

BACKGROUND: The optimal timing of radiotherapy (RT) with respect to surgery remains controversial for locally advanced non-small cell lung cancer (LA NSCLC) undergoing surgery and the long-term effect of neoadjuvant RT, adjuvant RT, and chemotherapy-only on survival is unknown. METHODS: A retrospective study with Greedy 5 → 1 Digit propensity score matching technique was performed for locally advanced NSCLC patients identified from the Surveillance, Epidemiology, and End Results (SEER) database during 2004 to 2012. Kaplan-Meier and the log-rank test were conducted to compare NSCLC-specific survival. Cox proportional hazards multivariable regression was performed to assess the impact of different treatment regimens on cancer-specific mortality after adjustment for demographic factors, histology type, tumor grade, tumor size, nodal stage, and extent of resection. RESULTS: One thousand, two hundred and seventy-eight locally advanced NSCLC patients undergoing surgery were identified after propensity matching. Cox regression analyses showed the risk of cancer-specific mortality is not significantly different among neoadjuvant RT, adjuvant RT, and chemotherapy-only. Subgroup analyses showed that for patients with T1/2 & N2/3, the surgery plus chemotherapy-only group showed markedly higher mortality risk (HR = 1.42, 95%CI:1.10-1.83) than the neoadjuvant RT group. Other risk factors include older age, higher tumor grade, larger tumor size, and greater lymph node involvement. CONCLUSIONS: The findings of this study suggest that the benefit of additional neoadjuvant or adjuvant RT to chemotherapy may be linked to a proper selection of LA NSCLC patients who undergo surgery. The timing of radiotherapy should be decided on the premise of fully considering patients' condition and the quality of life after treatment.

The effect of low insurance reimbursement on quality of care for non-small cell lung cancer in China: a comprehensive study covering diagnosis, treatment, and outcomes.

BACKGROUND: The insurance reimbursement rate of medical cost affects the quality and quantity of health services provided in China. The nature of this relationship, however, has not been reliably described in the field of non-small cell lung cancer (NSCLC). The objective of the current study was to examine the impact of low reimbursement rates of medical costs on diagnosis, treatment and outcomes among patients with NSCLC. METHODS: We examined care of 2643 NSCLC patients and we divided the study cohort into a high reimbursement rate group and a low reimbursement rate group. The impact of reimbursement rates of medical costs on quality of care of NSCLC patients were examined using logistic regression and generalized linear models. RESULTS: Compared with patients insured with high reimbursement rate, patients insured through lower reimbursement rate programs were less likely to benefit from early detection and treatment services. Delayed detection was more common in low reimbursement group and they were less likely to be recommended for adjuvant chemotherapy, or to receive adjuvant chemotherapy and postoperative radiation therapy and they had lower odds to receipt chemotherapy response assessment. However, low reimbursement rate group had lower rate of in-hospital mortality and metastases. CONCLUSIONS: Low reimbursement rate mainly negatively influenced the diagnosis and treatment of NSCLC. Reducing the gap in reimbursement rate between the three health insurance schemes should be a focus of equalizing access to care and improving the level of medical compliance and finally improving quality of care of NSCLC.

Short- and long-term effects of clinical pathway on the quality of surgical non-small cell lung cancer care in China: an interrupted time series study.

OBJECTIVE: To examine the short- and long-term effect of clinical pathway for non-small cell lung cancer surgery on the length of stay, the compliance of quality indicators and risk-adjusted post-operative complication rate. DESIGN: A retrospective quasi-experimental study from June 2011 to October 2015. SETTING: A tertiary cancer hospital in China. PARTICIPANTS: Patients diagnosed as non-small cell lung cancer who underwent curative resection. INTERVENTION(S): Clinical pathway was implemented at January 2013. Hence, the study period was divided into three periods: pre-pathway, from June 2011 to December 2012; short-term period, from January 2013 to December 2013; long-term period, from January 2014 to October 2015. MAIN OUTCOME MEASURE(S): Three length of hospital stay indicators, four process performance indicators and one outcome indicator. RESULTS: ITS showed there was a significant decline of 2 days (P = 0.0421) for total length of stay and 2.23 days (P = 0.0199) for post-operative length of stay right after the implementation of clinical pathway. Short-term level changes were found in the compliance rate of required number of lymph node sampling (-8.08%, P = 0.0392), and risk-adjusted complication rate (9.02%, P = 0.0001). There were no statistically significant changes in other quality of care indicators. CONCLUSIONS: The clinical pathway had a positive impact on the length of stay but showed a transient negative effect on complication rate and the quality of lymph node sampling.

Development of quality indicators for non-small cell lung cancer care: a first step toward assessing and improving quality of cancer care in China.

BACKGROUND: Large gap exists between clinical practice and recommended care and large room exists for the improvement of care quality for non-small cell lung cancer (NSCLC) in China. Results of some studies have shown that assessment of care quality can help to make improvement and the development of quality indicators is deemed as the initial and most essential part. Yet there is no such an indicators system specifically suitable for Chinese health care system. The goal of the study is to set up a group of Chinese quality indicators for NSCLC care and make it the first step towards the improvement of NSCLC care quality in China. METHODS: We constructed a new indicator framework based on the characteristics of NSCLC care and the nature of Chinese health care system. Under the new framework, potential indicators were collected and a 3-round modified Delphi process was conducted by a national multi-disciplinary Expert Panel to develop a set of indicators until they reached the final consensus. RESULTS: A new indicator framework (structure, process, communication, management of symptoms or treatment toxicity and outcome) was developed. Seventy four indicators were extracted from guidelines and relevant literatures as potential indicators; 43 indicators plus 1 suggested indicator were remained after the discussion of Round 1; questionnaires of Round 2 were rated by Expert Panel and 19 indicators met the inclusion criteria and entered Round 3; 2 of the eliminated indicators in Round 2 were retrieved by the Expert Panel at the in-person meeting (Round 3). Therefore, 21 indicators got the final consensus of the Expert Panel. CONCLUSIONS: Guided by the new indicator structure, a set of indicators suitable for Chinese healthcare system was developed and can be utilized to measure and improve the care quality of non-small cell lung cancer.

Effect of the medical insurance on the quality of care for Chinese patients with chronic heart failure.

OBJECTIVE: To assess the effect of medical insurance on the quality of care for patients with chronic heart failure (CHF). DESIGN: Seven quality indicators were used to assess the association between medical insurance and quality of care. Statistical analyses were conducted using multilevel logistic models for the total population and the subpopulation stratified by sex and age. PARTICIPANTS: In total, 1862 CHF patients who were admitted in 20 tertiary hospitals between 1 January 2009 and 31 October 2010. RESULTS: Of 1862 patients, 53.8% patients had basic medical insurance and 26.9% patients paid the hospital costs by themselves. After adjusting for confounding factors, patients with New Rural Cooperative Medical Scheme (NRCMS) were more likely to receive warfarin (odds ratios [OR], 3.89; 95% confidence interval [CI], 1.08-13.99; P = 0.038), but less likely to receive aldosterone receptor antagonist (OR, 0.21; 95% CI, 0.08-0.56; P = 0.002) than patients without any medical insurance. Urban Employee Basic Medical Insurance (UEBMI) and NRCMS were associated with more use of discharge instructions ([OR, 3.54; 95% CI, 2.44-5.13; P < 0.001] and [OR, 2.09; 95% CI, 1.21-3.62; P = 0.009], respectively). After stratified by sex, male patients with UEBMI were more likely to receive the evaluation of left ventricular function than male patients without any medical insurance (OR, 1.78; 95% CI, 1.06-2.98; P = 0.029). CONCLUSIONS: UEBMI and NRCMS could increase the adherence to quality indicators of CHF to some extent. Improving the medical insurance system is expected to achieve equality in medical security and improve the quality of care for CHF patients.

Developing a set of quality indicators for breast cancer care in China.

OBJECTIVE: Large gaps exist between clinical practice and recommended care of breast cancer. Evidence demonstrates that assessment of breast cancer care can help bridge these gaps. However, no valid indicators are currently available for measurement of breast cancer care in China. This study aimed to develop a set of quality indicators to measure and improve the quality of breast cancer care. DESIGN: A modified Delphi process was implemented, and each of the six selection criteria (scientific evidence, utility, interpretability, validity, preventability and data availability) for potential indicators was evaluated on a 5-point scale. PARTICIPANTS: A 16-member expert panel was assembled, including 10 medical oncologists, 5 surgical oncologists and 1 radiation oncologist. MAIN OUTCOME MEASURE: Quality indicators with mean ratings ≥4, coefficient of variation equal to or <25% and selectivity ≥81.25% in each of the six selection criteria were retained for the face-to-face round. RESULTS: Twenty-six indicators were retained from the rating round and five indicators were retrieved in the face-to-face round. A total of 31 indicators constituted the final set of quality indicators, and the number of indicators pertaining to structure, process, communication and cooperation, management of symptoms or treatment toxicity and outcome was 1, 24, 2, 2 and 2, respectively. CONCLUSIONS: Quality indicators for breast cancer care can be systematically developed and will be utilized as a quality measurement tool for breast cancer care.

Thoracic paravertebral block for perioperative lung preservation during VATS pulmonary surgery: study protocol of a randomized clinical trial.

BACKGROUND: Postoperative pulmonary complications (PPCs) extend the length of stay of patients and increase the perioperative mortality rate after video-assisted thoracoscopic (VATS) pulmonary surgery. Thoracic paravertebral block (TPVB) provides effective analgesia after VATS surgery; however, little is known about the effect of TPVB on the incidence of PPCs. The aim of this study is to determine whether TPVB combined with GA causes fewer PPCs and provides better perioperative lung protection in patients undergoing VATS pulmonary surgery than simple general anaesthesia. METHODS: A total of 302 patients undergoing VATS pulmonary surgery will be randomly divided into two groups: the paravertebral block group (PV group) and the control group (C group). Patients in the PV group will receive TPVB: 15 ml of 0.5% ropivacaine will be administered to the T4 and T7 thoracic paravertebral spaces before general anaesthesia induction. Patients in the C group will not undergo the intervention. Both groups of patients will be subjected to a protective ventilation strategy during the operation. Perioperative protective mechanical ventilation and standard fluid management will be applied in both groups. Patient-controlled intravenous analgesia is used for postoperative analgesia. The primary endpoint is a composite outcome of PPCs within 7 days after surgery. Secondary endpoints include blood gas analysis, postoperative lung ultrasound score, NRS score, QoR-15 score, hospitalization-related indicators and long-term prognosis indicators. DISCUSSION: This study will better evaluate the impact of TPVB on the incidence of PPCs and the long-term prognosis in patients undergoing VATS lobectomy/segmentectomy. The results may provide clinical evidence for optimizing perioperative lung protection strategies. TRIAL REGISTRATION: ClinicalTrials.gov NCT05922449 . Registered on June 25, 2023.

Association Between Maternal Thyroid Function in Early Pregnancy and Gestational Diabetes: A Prospective Cohort Study.

CONTEXT: Previous studies on the relationship between thyroid gland function and the development of gestational diabetes mellitus (GDM) have reported different results, leading to the need for a cohort study design with a large sample size. OBJECTIVE: We aimed to investigate the relationship between thyroid function in early pregnancy and GDM. METHODS: This was a prospective cohort study based on the China Birth Cohort Study (CBCS), from February 2018 to December 2020. The study took place at a tertiary maternal and child health hospital. A total of 36 256 pregnant women were successfully recruited based on the CBCS. The main outcome measure was GDM. RESULTS: This study consisted of 26 742 pregnant women who met the inclusion criteria, of whom 3985 (14.90%) were diagnosed with GDM, and the women with GDM were older than their healthy counterparts (33.26 ± 4.01 vs 31.51 ± 3.76 years, P < .001). After removing potential influencing variables, we found that increased thyroid-stimulating hormone (TSH) (adjusted odds ratio [aOR] 1.030, 95% CI 1.007, 1.054, P = .012) and subclinical hypothyroidism (aOR 1.211, 95% CI 1.010, 1.451, P = .039), but not free thyroxine or thyroid peroxidase antibody, were associated with the occurrence of GDM. Further analysis indicated a nonlinear relationship between TSH and GDM (P < .05): when TSH ≤ 1.24 mIU/L, the occurrence of GDM was elevated with increasing TSH, but when TSH > 1.24 mIU/L, this trend was not obvious. CONCLUSION: High TSH might be associated with increased risk of GDM.

Levothyroxine Treatment in Pregnant Women with Thyrotropin Levels Ranging Between 2.5 and 10 mIU/L: A Propensity Score Matched Analysis.

Objective: To clarify the association between levothyroxine (LT4) treatment and various adverse pregnancy outcomes in pregnant women with thyrotropin (TSH) levels ranging between 2.5 and 10.0 mIU/L in the first trimester, stratified according to thyroid peroxidase antibody (TPOAb) positivity and TSH level. Methods: This retrospective analysis of retrospectively and prospectively collected cohort data included Chinese pregnant women with TSH levels of 2.5-10 mIU/L and normal free thyroxine levels (11.8-18.4 pmol/L) in the first trimester. All participants were followed up until the completion of pregnancy, and information on LT4 treatment, pregnancy complications, and pregnancy outcomes was recorded. A 1:1 nearest-neighbor propensity score matching (PSM) between the LT4-treated and - untreated groups with a caliper distance of 0.02 was performed using a multivariable logistic regression model. Multivariable-adjusted modified Poisson regression was used to estimate the relative risk (RR) and 95% confidence interval (CI) of LT4 treatment for adverse pregnancy outcomes. Subgroup analyses were also performed in four subgroups simultaneously stratified by TPOAb status (negative or positive) and TSH levels (2.5-4.0 mIU/L as high-normal group and 4.0-10.0 mIU/L as SCH group). The study was registered in the Chinese Clinical Trial Registry (ChiCTR2100047394). Results: Among the 4,370 pregnant women in the study, 1,342 received LT4 treatment and 3,028 did not. The 1:1 PSM yielded 668 pairs of individuals and revealed that LT4 treatment was significantly associated with a decreased risk of pregnancy loss (RR = 0.528, 95% CI: 0.344-0.812) and an increased risk of small-for-gestational-age infants (RR = 1.595, 95% CI: 1.023-2.485). Subgroup analyses suggested that the above effects of LT4 treatment were mainly from TPOAb-negative participants. LT4 treatment was associated with an increased risk of preterm birth (RR = 2.214, 95% CI: 1.016-4.825) in TPOAb-positive pregnant women with high-normal TSH levels. Conclusion: LT4 treatment was significantly associated with a lower risk of pregnancy loss and a higher risk of small-for-gestational-age infants in pregnant women with TSH levels of 2.5-10 mIU/L. An increased risk of preterm birth was observed in the LT4-treated group among TPOAb-positive participants with TSH levels of 2.5-4.0 mIU/L.