Behavioral counseling for cardiovascular disease prevention in 36 low-income and middle-income countries.

BACKGROUND: Given the substantial prevalence of cardiovascular disease (CVD) in low-income and middle-income countries (LMICs), evaluation of behavioral counseling for prevention of CVD is important. METHODS: We pooled nationally representative cross-sectional surveys from 36 LMICs between 2013 and 2020. The population was divided into three groups according to CVD risk: the potential risk group, the risk group and the CVD group. We estimated the prevalence of six types of behavioral counseling among the three groups separately: smoking, salt reduction, fruit and vegetable intake, dietary fat reduction, physical activity and body weight. RESULTS: There were 16,057 (25.4%) in the potential risk group, 43,113 (49.9%) in the risk group, and 7796 (8.6%) in the CVD group. The prevalence of receiving at least four types of counseling in the three groups was 15.6% (95% CI 13.9 to 17.5), 14.9% (95% CI 14.0 to 15.9), and 19.8% (95% CI 17.7 to 22.2), respectively. The lowest prevalence was for tobacco use counseling: 24.5% (95% CI 22.5 to 26.4), 23.2% (95% CI 22.1 to 24.3), and 32.1% (95% CI 29.5 to 34.8), respectively. The prevalence of counseling was higher in upper-middle-income countries than in lower-middle-income countries. Women, older people, those with more education, and those living in urban areas were more likely to receive counseling. CONCLUSION: The prevalence of behavioral counseling for CVD is low in LMICs, especially among potentially at-risk populations and in low-income countries. These findings highlight the current urgent need to improve CVD prevention and management systems to enhance behavioral counseling and intervention.

Regional differences in the contribution of smoking, dietary and cooking behaviours to airflow obstruction in China: A population-based case-control study.

BACKGROUND AND OBJECTIVE: The major contributing risk factors to airflow obstruction (AO) in China remain largely unknown. We examined the environmental and lifestyle risk factors of unrecognized AO in the baseline of a population-based cohort drawn from 115 urban and rural communities across 12 provinces in China. METHODS: Amongst 46,285 adults recruited from 2005 to 2009, 3686 were identified with AO on spirometry (defined by the ratio of forced expiratory volume in the first second to forced vital capacity <0.7) and without known chronic lung disease. These cases were age- and sex-matched to 11,129 controls with normal spirometry and no chronic lung disease from the same community. Conditional multivariable adjusted OR and population attributable fraction (PAF) were calculated for each identified risk factor and their combined effect. RESULTS: Compared to controls, smoking initiation age <20 years (OR 1.22 [95% CI 1.01-1.48]), smoking duration ≥40 years (OR 1.82 [1.50-2.22]), low vegetables (OR 1.86 [1.67-2.07]) and fruits (OR 1.14 [1.02-1.29]) intake, cooking with biomass fuels (OR 2.54 [2.32-2.78]) and poor kitchen ventilation (OR 1.37 [1.19-1.58]) were significantly associated with elevated risks of unrecognized AO. The combined effect of these lifestyle factors significantly elevated the odds by 25 fold (18.6-34.3). The addition of prior tuberculosis and low socioeconomic status further increased the odds to 40.1 (28.2-57.0) and the PAF to 66.7% (51.1-78.1). CONCLUSION: Smoking, unhealthy diet, biomass cooking fuels and low socioeconomic status are strongly associated with AO. Addressing these risk factors could substantially reduce the burden of AO in China.

Association of spirometric restriction with mortality in the silicotics: a cohort study.

BACKGROUND: Restrictive spirometry pattern (RSP), defined as reduced forced vital capacity (FVC) in absence of airflow obstruction (AFO), is associated with increased risk of mortality in general population. However, evidence in the patients with silicosis is limited. This study was aimed to investigate the relationship between RSP and the risk of death in a silicotic cohort. METHOD: This retrospective cohort study used data from the Pneumoconiosis Clinic, Hong Kong Department of Health that containing 4315 patients aged 18-80 years and diagnosed with silicosis during 1981-2019, with a follow-up till 31 December 2019. Spirometry was carried out at the diagnostic examination of silicosis. Lung function categories were classified as normal spirometry (FEV1/FVC ≥ 0.7, FVC ≥ 80% predicted), RSP only (FEV1/FVC ≥ 0.7, FVC < 80% predicted), AFO only (FEV1/FVC < 0.7, FVC ≥ 80% predicted), and RSP&AFO mixed (FEV1/FVC < 0.7, FVC < 80% predicted). The hazard ratio (HR) and 95% confidence intervals (95% CI) were computed using a Cox proportional hazards model adjusting for age, body mass index, history of tuberculosis, smoking status, pack-years, and radiographic characteristics of silicotic nodules. RESULTS: Among the 4315 patients enrolled in the study, the prevalence of RSP was 24.1% (n = 1038), including 11.0% (n = 473) with RSP only and 13.1% (n = 565) with mixed RSP and AFO. During the follow-up period, a total of 2399 (55.6%) deaths were observed. Compared with the silicotics with normal spirometry, those with RSP only had significantly increased risk of all-cause mortality (HR = 1.63, 95% CI 1.44-1.85) and respiratory-related mortality (HR = 1.56, 95% CI 1.31-1.85). Notably, a higher risk of mortality was observed in silicotics with mixed ventilatory defects of both RSP and AFO (all-cause mortality: HR = 2.22, 95% CI 1.95-2.52; respiratory-related mortality: HR = 2.59, 95% CI 2.18-3.07) than in those with RSP only. CONCLUSION: RSP is significantly associated with increased risk of all-cause and respiratory-related mortality in the silicotics, and patients with mixed restrictive and obstructive ventilatory defect have higher risk of mortality than those with single RSP or AFO. These findings emphasize the importance of recognizing RSP in the occupational settings, especially for the silicotic patients with mixed ventilatory defect.

Associations of dietary copper intake with cardiovascular disease and mortality: findings from the Chinese Perspective Urban and Rural Epidemiology (PURE-China) Study.

BACKGROUND: Previous in vitro and animal experiments have shown that copper plays an important role in cardiovascular health. Dietary copper is the main source of copper in the human body and the association between dietary copper and cardiovascular disease remains unclear. Our study aimed to investigate the associations of dietary copper intake with the risk of major cardiovascular disease incidence, cardiovascular disease mortality, and all-cause mortality in Chinese adults. METHODS: Our study is based on Prospective Urban Rural Epidemiology China (PURE-China), a large prospective cohort study of 47 931 individuals aged 35-70 years from 12 provinces in China. Dietary intake was recorded using a validated semi-quantitative food frequency questionnaire designed specifically for the Chinese population. The daily intake of copper was obtained by multiplying the daily food intake with the nutrient content provided in the Chinese Food Composition Table (2002). Cox frailty proportional hazards models were developed to evaluate the association between dietary copper intake with mortality, major cardiovascular disease events, and their composite. RESULTS: A total of 45 101 participants (mean age: 51.1 ± 9.7 years old) with complete information were included in the current study. The mean dietary copper intake was 2.6 ± 1.1 mg/d. During the 482 833 person-years of follow-up, 2 644(5.9%) participants died, 4 012(8.9%) developed new cardiovascular diseases, and 5 608(12.4%) participants experienced the composite endpoint. Compared with those in the first and second quartile of dietary copper intake, individuals in the third and fourth quantile had higher risk of composite outcomes, all-cause death, cardiovascular disease death, major cardiovascular disease and stroke occurrences. The associations remained similar in the subgroup and sensitivity analyses. CONCLUSIONS: Our findings demonstrated that excessive dietary copper intake was associated with higher risks of death and cardiovascular diseases in Chinese adults. Further studies in populations with different dietary characteristics are needed to obtain dose-response relationships and to refine global dietary recommendations.

Modifiable risk factors associated with cardiovascular disease and mortality in China: a PURE substudy.

AIMS: To examine the incidence of cardiovascular disease (CVD) and mortality in China and in key subpopulations, and to estimate the population-level risks attributable to 12 common modifiable risk factors for each outcome. METHODS AND RESULTS: In this prospective cohort of 47 262 middle-aged participants from 115 urban and rural communities in 12 provinces of China, it was examined how CVD incidence and mortality rates varied by sex, by urban-rural area, and by region. In participants without prior CVD, population-attributable fractions (PAFs) for CVD and for death related to 12 common modifiable risk factors were assessed: four metabolic risk factors (hypertension, diabetes, abdominal obesity, and lipids), four behavioural risk factors (tobacco, alcohol, diet quality, and physical activity), education, depression, grip strength, and household air pollution. The mean age of the cohort was 51.1 years. 58.2% were female, 49.2% were from urban areas, and 59.6% were from the eastern region of China. The median follow-up duration was 11.9 years. The CVD was the leading cause of death in China (36%). The rates of CVD and death were 8.35 and 5.33 per 1000 person-years, respectively, with higher rates in men compared with women and in rural compared with urban areas. Death rates were higher in the central and western regions of China compared with the eastern region. The modifiable risk factors studied collectively contributed to 59% of the PAF for CVD and 56% of the PAF for death in China. Metabolic risk factors accounted for the largest proportion of CVD (PAF of 41.7%), and hypertension was the most important risk factor (25.0%), followed by low education (10.2%), high non-high-density lipoprotein cholesterol (7.8%), and abdominal obesity (6.9%). The largest risk factors for death were hypertension (10.8%), low education (10.5%), poor diet (8.3%), tobacco use (7.5%), and household air pollution (6.1%). CONCLUSION: Both CVD and mortality are higher in men compared with women, and in rural compared with urban areas. Large reductions in CVD could potentially be achieved by controlling metabolic risk factors and improving education. Lowering mortality rates will require strategies addressing a broader range of risk factors.

Risk assessment and prediction for lung cancer among Hong Kong Chinese men.

OBJECTIVE: Most of the previous risk prediction models for lung cancer were developed from smokers, with discriminatory power ranging from 0.57 to 0.72. We constructed an individual risk prediction model for lung cancer among the male general population of Hong Kong. METHODS: Epidemiological data of 1,069 histology confirmed male lung cancer cases and 1,208 community controls were included in this analysis. Residential radon exposure was retrospectively reconstructed based on individual lifetime residential information. Multivariable logistic regression with repeated cross-validation method was used to select optimal risk predictors for each prediction model for different smoking strata. Individual absolute risk for lung cancer was estimated by Gail model. Receiver-operator characteristic curves, area under the curve (AUC) and confusion matrix were evaluated to demonstrate the model performance and ability to differentiate cases from non-cases. RESULTS: Smoking and smoking cessation, education, lung disease history, family history of cancer, residential radon exposure, dietary habits, carcinogens exposure, mask use and dust control in workplace were selected as the risk predictors for lung cancer. The AUC of estimated absolute risk for all lung cancers was 0.735 (95% CI: 0.714-0.756). Using 2.83% as the cutoff point of absolute risk, the predictive accuracy, positive predictive value and negative predictive value were 0.715, 0.818 and 0.674, respectively. CONCLUSION: We developed a risk prediction model with moderate discrimination for lung cancer among Hong Kong males. External validation in other populations is warranted for this model in future studies.

Association of Dietary Phytosterols Intake and Survival of Esophageal Squamous Cell Carcinoma: A Prospective Cohort Study.

BACKGROUND: The association of dietary phytosterols intake with survival of esophageal squamous cell carcinoma (ESCC) remains unclear. This study was to examine the effect of dietary phytosterols intake on ESCC survival in a Chinese rural population. METHODS: A total of 942 incident ESCC patients diagnosed between 2011 and 2013 in Yanting area were followed up until March 1st, 2020. Dietary intake five years before ESCC diagnosis was collected using a food frequency questionnaire. The outcome of interest was all-cause mortality. Cox proportional hazards regression model was used to estimate hazard ratio (HR) and 95% confidence intervals (CI). RESULTS: When comparing the highest with lowest intake quartiles, intake of five specific and total phytosterols was not significantly associated with risk of death after adjustment for covariates, the adjusted HR (95% CI) for ß-sitosterol, campesterol, stigmasterol, ß-sitostanol, campestanol and total phytosterols was 0.90 (95% CI: 0.70-1.16), 0.92 (95% CI: 0.71-1.19), 0.86 (95% CI: 0.66-1.12), 0.93 (95% CI: 0.73-1.20), 0.94 (95% CI: 0.72-1.21), 0.89 (95% CI: 0.69-1.15), respectively. CONCLUSION: This study does not find any association between pre-diagnostic phytosterols intake and risk of all-cause mortality among ESCC patients. Further research is required to determine the effect of post-diagnostic phytosterols intake on ESCC survival.

Dietary intake of monounsaturated and polyunsaturated fatty acids is related to the reduced risk of esophageal squamous cell carcinoma.

BACKGROUND: The relationship of consumption of dietary fat and fatty acids with esophageal squamous cell carcinoma (ESCC) risk remains unclear. This study aimed to explore the relationship of dietary fat and fatty acids intake with ESCC risk. METHODS: This case-control study included 879 incident cases and 892 community-based controls recruited from Southwest China. A food frequency questionnaire was adopted to collect information about dietary information, and intake of fat, saturated fatty acid (SFA), monounsaturated fatty acid (MUFA), polyunsaturated fatty acid (PUFA), and total fatty acid (TFA) was calculated. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were estimated using the logistic regression model. RESULTS: When comparing the highest with lowest intake quintiles, MUFA (OR: 0.33, 95% CI: 0.21-0.51), PUFA (OR: 0.32, 95% CI: 0.20-0.51), and TFA (OR: 0.44, 95% CI: 0.28-0.70) were related to a reduced risk of ESCC after adjusting for confounders; for non-drinkers rather than drinkers, the intake of SFA was significantly related to a 61% (OR: 0.39, 95% CI: 0.19-0.81) reduced risk of ESCC when comparing the highest with the lowest intake quintiles. Dietary fat was not related to the risk of ESCC. CONCLUSIONS: This study suggested that the more intake of MUFA and PUFA, the lower risk of ESCC, whereas the protective effect of TFA was only observed among non-drinkers. Strategic nutritional programs should consider food rich in unsaturated fatty acids to mitigate the occurrence of ESCC.

The role of dietary carotenoids in preventing the development of esophageal squamous cell carcinoma.

Background and aims: Experimental studies showed that carotenoids had anti-carcinogenesis properties, but epidemiological studies on the association between dietary carotenoids and esophageal squamous cell carcinoma (ESCC) risk were limited, and the findings were inconsistent. This study aimed to investigate the roles of intake of dietary carotenoids in the development of ESCC among a rural Chinese population. Methods: A population-based case-control study was conducted in Southwest China. A total of 915 incident ESCC cases and 925 community-based controls were included. A validated food frequency questionnaire with 76-item was adopted to collect information about dietary consumption. Intake of dietary calories and each carotenoid was calculated according to the China food composition tables. Odds ratios (OR) with 95% confidence intervals (CI) were calculated by using logistic regression model, with adjustments for age, gender, body mass index, family cancer history, cigarette smoking, alcohol drinking, education, marital status, prudent pattern score, and total calories. Results: In comparison of the highest with lowest intake quartiles, intake of total carotene (OR: 0.70, 95% CI: 0.52-0.96, Ptrend: 0.024), α-carotene (OR: 0.62, 95% CI: 0.46-0.83, Ptrend: 0.014), ß-carotene (OR: 0.63, 95% CI: 0.46-0.86, P-trend: 0.005), and the sum of lutein and zeaxanthin (OR: 0.41, 95% CI: 0.29-0.56, Ptrend<0.001) was significantly associated with a decreased risk of ESCC after adjustment for confounders. Conclusions: The results indicated that a higher intake of total carotene, α-carotene, ß-carotene, and the sum of lutein and zeaxanthin was associated with a lower risk of ESCC.

Association of current income and reduction in income during the COVID-19 pandemic with anxiety and depression among non-healthcare workers.

BACKGROUND: Many workers experienced income reduction during the coronavirus disease 2019 (COVID-19) pandemic, which may link to adverse mental health. AIMS: This study aimed to examine the association of current income and reduction in income during COVID-19 with anxiety and depression levels among non-healthcare workers. METHODS: This is a multi-city cross-sectional study. We used standardized questionnaires to collect information. We regrouped the current income and income reduction during COVID-19 according to the tertile and median value of each specific city. Depression, Anxiety and Stress Scales-21 item short version (DASS-21) was used to assess anxiety and depression levels. We performed multinomial logistic regression to examine the association of current and reduced income with anxiety and depression. Path models were developed to outline the potential modification/indirect effect of subsidies from government. RESULTS: Large income reduction and low current income were significantly associated with more anxiety/depression symptoms. Path analysis showed that government subsidies could not significantly alleviate the impact of reduced income on anxiety/depression. CONCLUSION: Our findings showed that large income reduction and low current income were independently associated with anxiety/depression, while these symptoms may not be ameliorated by one-off government funds. This study suggests the need for long-term policies (e.g. developing sustained economic growth policies) to mitigate negative impacts of the COVID-19.

Past Shift Work and Incident Coronary Heart Disease in Retired Workers: A Prospective Cohort Study.

Present shift work has been associated with coronary heart disease (CHD) among employed workers, but it remains unclear whether shift work performed in the past is still associated with CHD in retired workers. We recruited 21,802 retired workers in Shiyan, China, in 2008-2010 and 2013 and followed them for CHD events occurring up to December 31, 2018. Retired workers with longer durations of past shift work (rounded to 0.25 years) had higher CHD risks (for those with ≤5.00, 5.25-10.00, 10.50-20.00, and >20.00 years of past shift work, hazard ratios were 1.05 (95% confidence interval (CI): 0.94, 1.16), 1.08 (95% CI: 0.94, 1.25), 1.23 (95% CI: 1.07, 1.42), and 1.28 (95% CI: 1.08, 1.51), respectively). The association was substantially higher among service or sales workers than among manufacturing or manual-labor workers (for every 5-year increase in past shift work, hazard ratio = 1.11 (95% CI: 1.05, 1.16) vs. hazard ratio = 1.02 (95% CI: 0.98, 1.06)). Moreover, the risk was lower among those who were physically active than among their inactive counterparts (P for interaction = 0.019). Longer duration of past shift work was associated with higher risk of incident CHD among these retired workers, especially those from the service or sales sectors. Physical exercise might be beneficial in reducing the excess risk.

Joint effect between bisphenol A and alcohol consumption on benign prostatic hyperplasia: A case-control study in Hong Kong Chinese males.

BACKGROUND: Whether bisphenol A (BPA) exposure is a contributing factor to benign prostatic hyperplasia (BPH) remains unclear. This study evaluated the association between chronic BPA exposure and BPH risk, and explored whether this association was modified by alcohol drinking. METHODS: This study included a total of 650 BPH cases and 650 controls recruited from the same hospital in Hong Kong during 2011-2016. Chronic BPA exposure level was estimated by a validated cumulative BPA exposure index (CBPAI). We performed unconditional logistic regression model to examine the association of BPH risk with potential sources of BPA exposure via oral intake and CBPAI. We further tested the interactions between CBPAI and alcohol consumption habits on BPH risk. RESULTS: A positive exposure-response relationship was observed between CBPAI and BPH risk. Frequent BPA exposure via oral intake of foods heated in a plastic box/bag (odds ratio [OR] = 3.52, 95% confidence interval [CI]: 1.51-8.22), cooling water in a plastic bottle (OR = 2.65, 95% CI: 1.33-5.27), or using a plastic cup to contain hot water (OR = 4.14, 95% CI: 1.02-16.89), was significantly associated with increased BPH risk. Compared with nonalcohol drinkers, alcohol drinkers was insignificantly associated with BPH risk (OR = 1.10, 95% CI: 0.77-1.57), but it demonstrated a more remarkable positive gradient between CBPAI exposure and BPH risk among alcohol drinkers, indicating an additive interaction between CBPAI and alcohol on BPH risk (synergy index = 4.24, 95% CI: 1.21-14.94). CONCLUSIONS: Chronic oral BPA exposure increased BPH risk with a positive exposure-response relationship among Hong Kong Chinese, and alcohol drinking amplified the effect of BPA on BPH. Hence, minimizations of containing food or water/beverage in plastic containers and drinking alcohol are recommended in the community to mitigate BPH risk. Future larger and designated studies are warranted.

Lung cancer risk in painters: results from the SYNERGY pooled case-control study consortium.

OBJECTIVES: We evaluated the risk of lung cancer associated with ever working as a painter, duration of employment and type of painter by histological subtype as well as joint effects with smoking, within the SYNERGY project. METHODS: Data were pooled from 16 participating case-control studies conducted internationally. Detailed individual occupational and smoking histories were available for 19 369 lung cancer cases (684 ever employed as painters) and 23 674 age-matched and sex-matched controls (532 painters). Multivariable unconditional logistic regression models were adjusted for age, sex, centre, cigarette pack-years, time-since-smoking cessation and lifetime work in other jobs that entailed exposure to lung carcinogens. RESULTS: Ever having worked as a painter was associated with an increased risk of lung cancer in men (OR 1.30; 95% CI 1.13 to 1.50). The association was strongest for construction and repair painters and the risk was elevated for all histological subtypes, although more evident for small cell and squamous cell lung cancer than for adenocarcinoma and large cell carcinoma. There was evidence of interaction on the additive scale between smoking and employment as a painter (relative excess risk due to interaction >0). CONCLUSIONS: Our results by type/industry of painter may aid future identification of causative agents or exposure scenarios to develop evidence-based practices for reducing harmful exposures in painters.

Changes in physical activity and rest-activity circadian rhythm among Hong Kong community aged population before and during COVID-19.

BACKGROUND: This study aims to determine the changes in physical activity and actigraphy-measured rest-activity circadian rhythm among Hong Kong community aged population before and during the outbreak of COVID-19. METHODS: This is a three repeated measure population-based cross-sectional study. We recruited community older men aged > 60 years in three periods of the COVID-19 outbreak in Hong Kong, i.e., before the COVID-19 outbreak (2 July 2019-8 January 2020), between the 2nd and 3rd waves of COVID-19 (23 June 2020-9 July 2020), and during the 3rd wave of COVID-19 (15 September 2020-29 September 2020). Participants reported detailed information on their physical activity habits using the International Physical Activity Questionnaire and wore actigraphs continuously for 7 days (168 h). The actigraph data were then transferred to four rest-activity circadian rhythm parameters: midline statistic of rhythm (MESOR), amplitude, acrophase and percent rhythm. Multivariate logistic regression was performed to estimate the association of period effect of COVID-19 on physical activity and rest-activity circadian rhythm parameters. RESULTS: Among the 242 community older men, 106 (43.8%) of them were recruited before the COVID-19 outbreak, 66 (27.3%) were recruited between the 2nd and 3rd waves of COVID-19, and 70 (28.9%) were recruited during the late phase of the 3rd wave of COVID-19. Compared with those recruited before COVID-19, participants recruited between the 2nd and 3rd waves of COVID-19 had lower physical activity (adjusted odds ratio (AOR) = 2.03, 95% confidence interval (95%CI) =1.05-3.93), MESOR (AOR = 2.05, 95%CI = 1.01-4.18), and amplitude (AOR = 1.91, 95%CI = 0.95-3.83). There was no difference in physical activity or circadian rhythm parameters between subjects recruited before and during the late phase of the 3rd wave. CONCLUSIONS: This study found that the effect of COVID-19 on physical activity and rest-activity circadian rhythm for the community people may be short-term, indicating strong resilience of the community population. Although maintaining physical activity are encouraged for the older adults to sustain good health, a rebound in their physical activity may be a sign for the next wave of outbreak if insufficient social distancing and population protection are facilitated.

Exposure to Organophosphate Pesticides and Menstrual Cycle Characteristics in Chinese Preconceptional Women.

Organophosphates (OPs) are the most heavily used pesticides in China. The Chinese population, including preconceptional women, is highly exposed, yet little is known regarding the associations between OP exposure and menstruation in humans. We conducted a cross-sectional analysis in women preparing for pregnancy to investigate the relationship between biomarkers of OP exposure and menstrual cycle characteristics. From 2013 to 2015, 627 women visiting free preconception-care clinics at 2 maternity hospitals in Shanghai, China, were included. Information on menstrual cycle characteristics was obtained through questionnaires. OP exposure was assessed by measuring urine concentrations of 6 dialkylphosphate metabolites (dimethylphosphate, dimethylthiophosphate, dimethyldithiophosphate, diethylphosphate, diethylthiophosphate, and diethyldithiophosphate). The relationship between concentrations of dialkylphosphate metabolites and menstrual cycle characteristics was analyzed using multiple linear regression models and logistic regression models. Log-transformed levels of diethyl phosphate metabolites (the sum of diethylphosphate and diethylthiophosphate levels) were related to a higher risk of irregularity of menstrual cycles (adjusted odds ratio = 2.36, 95% confidence interval: 1.28, 4.34). Subjects with a higher concentration of diethyl phosphate metabolites (log-transformed) had a shorter duration of menstrual bleeding (adjusted ß = -0.33, 95% confidence interval: -0.64, -0.02). The findings suggest that OP exposure may be associated with alterations in menstrual function in preconceptional women.

Association of academic performance, general health with health-related quality of life in primary and high school students in China.

PURPOSE: To explore the association of academic performance and general health status with health-related quality of life (HRQoL) in school-aged children and adolescents in China. METHODS: In this cross-sectional study conducted in 2018, students (grade 4-12) were randomly chosen from primary and high schools in Nanjing, China. HRQoL, the outcome measure, was recorded using the Child Health Utility 9D, while self-rated academic performance and general health were the independent variables. Mixed-effects regression models were applied to compute mean difference (MD) and 95% confidence interval (CI) of HRQoL utility score between students with different levels of academic performance and general health. RESULTS: Totally, 4388 participants completed the study, with a response rate of 97.6%. The mean HRQoL utility score was 0.78 (SD: 0.17). After adjustment for socio-demographic attributes, physical activity, sedentary behavior, dietary patterns, body weight status and class-level clustering effects, students with fair (MD = 0.048, 95% CI 0.019, 0.078) and good (MD = 0.082, 95% CI 0.053, 0.112) self-rated academic performance reported higher HRQoL utility scores than those with poor academic performance, respectively. Meanwhile, students with fair (MD = 0.119, 95% CI 0.083, 0.154) and good (MD = 0.183, 95% CI 0.148, 0.218) self-assessed general health also recorded higher HRQoL utility scores than those with poor health, separately. Consistent findings were observed for participants by gender, school type and residential location. CONCLUSIONS: Both self-rated academic performance and general health status were positively associated with HRQoL among Chinese students, and such relationships were independent of lifestyle-related behaviors and body weight status.

Association of sleep duration with risk of all-cause mortality and poor quality of dying in oldest-old people: a community-based longitudinal study.

BACKGROUND: While sleep duration has been shown to be associated with health outcomes, few studies have been conducted among the oldest old. In addition, the impact of sleep duration on quality of dying is unknown. We aimed to evaluate how sleep duration affects all-cause mortality and quality of dying in people aged 80 + . METHODS: This community-based longitudinal study was performed by using data from 15,048 individuals aged ≥80 with information on sleep duration in the Chinese Longitudinal Healthy Longevity Survey. Cox and logistic regression models with penalized splines were applied to explore the shape of the association between sleep duration and all-cause mortality and poor quality of dying respectively and identify the interval of sleep duration resulting in the lowest risk of both. RESULTS: During a median follow-up of 3.1 years, 11,582 deaths including 4116 individuals who experienced poor quality of dying were recorded. Sleep duration showed a U-shaped association with all-cause mortality and sleeping about 8 h had the minimum risk of death; a J-shaped association was found between sleep duration and poor quality of dying. Compared with sleep duration of 7-9 h, the adjusted hazard ratio of total deaths was 1.08 (95% CI 1.03-1.13) for short duration (< 7 h) and 1.12 (95% CI 1.07-1.17) for long duration (> 9 h); the adjusted odds ratio of poor QOD was 1.10 (95% CI 1.01-1.21) for long duration, but this association was restricted to those with baseline unhealthy status (P-interaction = 0.04). CONCLUSIONS: Sleeping a little longer may be better for individuals over 80 years old, and sleep duration of 7-9 h per day is optimal for both survival and good quality of life near death.

Association of estimated sleep duration and naps with mortality and cardiovascular events: a study of 116 632 people from 21 countries.

AIMS: To investigate the association of estimated total daily sleep duration and daytime nap duration with deaths and major cardiovascular events. METHODS AND RESULTS: We estimated the durations of total daily sleep and daytime naps based on the amount of time in bed and self-reported napping time and examined the associations between them and the composite outcome of deaths and major cardiovascular events in 116 632 participants from seven regions. After a median follow-up of 7.8 years, we recorded 4381 deaths and 4365 major cardiovascular events. It showed both shorter (≤6 h/day) and longer (>8 h/day) estimated total sleep durations were associated with an increased risk of the composite outcome when adjusted for age and sex. After adjustment for demographic characteristics, lifestyle behaviours and health status, a J-shaped association was observed. Compared with sleeping 6-8 h/day, those who slept ≤6 h/day had a non-significant trend for increased risk of the composite outcome [hazard ratio (HR), 1.09; 95% confidence interval, 0.99-1.20]. As estimated sleep duration increased, we also noticed a significant trend for a greater risk of the composite outcome [HR of 1.05 (0.99-1.12), 1.17 (1.09-1.25), and 1.41 (1.30-1.53) for 8-9 h/day, 9-10 h/day, and >10 h/day, Ptrend < 0.0001, respectively]. The results were similar for each of all-cause mortality and major cardiovascular events. Daytime nap duration was associated with an increased risk of the composite events in those with over 6 h of nocturnal sleep duration, but not in shorter nocturnal sleepers (≤6 h). CONCLUSION: Estimated total sleep duration of 6-8 h per day is associated with the lowest risk of deaths and major cardiovascular events. Daytime napping is associated with increased risks of major cardiovascular events and deaths in those with >6 h of nighttime sleep but not in those sleeping ≤6 h/night.

Immune gene expression profiling reveals heterogeneity in luminal breast tumors.

BACKGROUND: Heterogeneity of immune gene expression patterns of luminal breast cancer (BC), which is clinically heterogeneous and overall considered as low immunogenic, has not been well studied especially in non-European populations. Here, we aimed at characterizing the immune gene expression profile of luminal BC in an Asian population and associating it with patient characteristics and tumor genomic features. METHODS: We performed immune gene expression profiling of tumor and adjacent normal tissue in 92 luminal BC patients from Hong Kong using RNA-sequencing data and used unsupervised consensus clustering to stratify tumors. We then used luminal patients from The Cancer Genome Atlas (TCGA, N = 564) and a Korean breast cancer study (KBC, N = 112) as replication datasets. RESULTS: Based on the expression of 130 immune-related genes, luminal tumors were stratified into three distinct immune subtypes. Tumors in one subtype showed higher level of tumor-infiltrating lymphocytes (TILs), characterized by T cell gene activation, higher expression of immune checkpoint genes, higher nonsynonymous mutation burden, and higher APOBEC-signature mutations, compared with other luminal tumors. The high-TIL subtype was also associated with lower ESR1/ESR2 expression ratio and increasing body mass index. The comparison of the immune profile in tumor and matched normal tissue suggested a tumor-derived activation of specific immune responses, which was only seen in high-TIL patients. Tumors in a second subtype were characterized by increased expression of interferon-stimulated genes and enrichment for TP53 somatic mutations. The presence of three immune subtypes within luminal BC was replicated in TCGA and KBC, although the pattern was more similar in Asian populations. The germline APOBEC3B deletion polymorphism, which is prevalent in East Asian populations and was previously linked to immune activation, was not associated with immune subtypes in our study. This result does not support the hypothesis that the germline APOBEC3B deletion polymorphism is the driving force for immune activation in breast tumors in Asian populations. CONCLUSION: Our findings suggest that immune gene expression and associated genomic features could be useful to further stratify luminal BC beyond the current luminal A/B classification and a subset of luminal BC patients may benefit from checkpoint immunotherapy, at least in Asian populations.

Urinary bisphenol A and incidence of metabolic syndrome among Chinese men: a prospective cohort study from 2013 to 2017.

OBJECTIVES: Experimental studies suggested that bisphenol A (BPA) exposure increased the risk of metabolic syndrome (MetS) through the mechanism of insulin resistance. All previous epidemiological studies of BPA and MetS were cross-sectional studies, and their findings were mixed. This study aims to provide further evidence on the association between urinary BPA and risk of MetS using a prospective cohort study in China. METHODS: The study population was from the Shenzhen Night shift workers' cohort. A total of 1227 male workers were recruited from the baseline survey in 2013 and then followed until 2017. Modified Adult Treatment Panel III criteria were used to identify the cases of MetS. Urinary BPA concentration was assessed using high-performance liquid chromatography-tandem mass spectrometry, and it was categorised into three subgroups by tertiles to obtain the adjusted HR (aHR) and 95% CI using Cox proportional hazard model. RESULTS: During 4 years of follow-up, 200 subjects developed MetS. Compared with the lowest urinary BPA subgroup, a weakly increased risk of MetS was suggested among those with the middle (aHR=1.19, 95% CI 0.87 to 1.63) and high level of urinary BPA (aHR=1.16, 95% CI 0.84 to 1.59); however, the significant association with MetS was restricted primarily to the smokers, showing a positive gradient with urinary BPA (middle level: aHR=2.40, 95% CI 1.13 to 5.08; high level: aHR=2.87, 95% CI 1.38 to 5.98; p trend=0.010). CONCLUSION: This prospective cohort study provided further evidence that exposure to BPA may increase the risk of MetS, and this association was further positively modified by cigarette smoking.