Development and validation of 10-year risk prediction models of cardiovascular disease in Chinese type 2 diabetes mellitus patients in primary care using interpretable machine learning-based methods.

AIM: To develop 10-year cardiovascular disease (CVD) risk prediction models in Chinese patients with type 2 diabetes mellitus (T2DM) managed in primary care using machine learning (ML) methods. METHODS: In this 10-year population-based retrospective cohort study, 141 516 Chinese T2DM patients aged 18 years or above, without history of CVD or end-stage renal disease and managed in public primary care clinics in 2008, were included and followed up until December 2017. Two-thirds of the patients were randomly selected to develop sex-specific CVD risk prediction models. The remaining one-third of patients were used as the validation sample to evaluate the discrimination and calibration of the models. ML-based methods were applied to missing data imputation, predictor selection, risk prediction modelling, model interpretation, and model evaluation. Cox regression was used to develop the statistical models in parallel for comparison. RESULTS: During a median follow-up of 9.75 years, 32 445 patients (22.9%) developed CVD. Age, T2DM duration, urine albumin-to-creatinine ratio (ACR), estimated glomerular filtration rate (eGFR), systolic blood pressure variability and glycated haemoglobin (HbA1c) variability were the most important predictors. ML models also identified nonlinear effects of several predictors, particularly the U-shaped effects of eGFR and body mass index. The ML models showed a Harrell's C statistic of >0.80 and good calibration. The ML models performed significantly better than the Cox regression models in CVD risk prediction and achieved better risk stratification for individual patients. CONCLUSION: Using routinely available predictors and ML-based algorithms, this study established 10-year CVD risk prediction models for Chinese T2DM patients in primary care. The findings highlight the importance of renal function indicators, and variability in both blood pressure and HbA1c as CVD predictors, which deserve more clinical attention. The derived risk prediction tools have the potential to support clinical decision making and encourage patients towards self-care, subject to further research confirming the models' feasibility, acceptability and applicability at the point of care.

Assessment of psychometric performance for the Chinese version of the Brief Inventory of Perceived Stress integrating exploratory graph analysis and confirmatory factor analysis.

OBJECTIVE: This study was to evaluate measurement properties of the Chinese version of the Brief Inventory of Perceived Stress (BIPS-C) and confirm possible solutions for measuring the constructs underlying perceived stress. METHODS: A total of 1356 community residents enrolled and were randomly split into two halves. The first half was used to explore the underlying constructs of the BIPS-C by exploratory graph analysis (EGA) and the second half was used to compare and confirm the constructs by confirmatory factor analysis (CFA). RESULTS: The EGA identified a one-factor model of the BIPS-C with an accuracy of 99.3%. One-factor, three-factor, second-order, and bifactor models were compared by CFAs. The bifactor model with one general and three specific factors was found to be the most adequate [comparative fit index (CFI) = 0.990; Tucker-Lewis index (TLI) = 0.979; root mean square error of approximation (RMSEA) = 0.058] and was superior to the other models. The related bifactor indices showed a stronger existence of the general factor. The bifactor model of the BIPS-C also showed adequate internal consistency with McDonald's omega and omega subscales ranging from moderate to strong (0.677-0.869). CONCLUSION: The BIPS-C demonstrates sufficient measurement properties for assessing general perceived stress.

Nonrestorative sleep and its associated factors in Chinese adolescents and the moderation effects of coffee or tea consumption.

BACKGROUND: Nonrestorative sleep (NRS) is related to numerous adverse outcomes. There is rare evidence of its associated factors, especially in Chinese adolescents. This study aimed to explore the factors associated with NRS in Chinese adolescents and the potential moderation effects of coffee or tea consumption. METHODS: This cross-sectional study invited adolescents attending Grades 7-11 in Nanjing, China, to complete a self-administered questionnaire, including their NRS, stress, anxiety, physical symptoms, depression, sociodemographics, and lifestyles. Linear regressions were applied to investigate the associated factors of their NRS, with the moderation effects of coffee or tea consumption and other characteristics being tested by additionally including their interactions. RESULTS: Totally 481 adolescents (49% male, age 15.5 ± 1.5 years) were enrolled, with the average global NRS score of 42.16 ± 7.57. Higher family income (ß = 2.01, P = 0.007), longer sleep duration (ß = 2.33, P = 0.011), and moderate after-class activity (ß = 1.50, P = 0.044) contributed less NRS, while higher educational level (ß = -2.60, P = 0.033), more coffee or tea consumption (ß = -1.68, P = 0.013), physical symptoms (ß = -3.85, P < 0.001), stress (ß = -0.23, P = 0.005), anxiety (ß = -1.54, P = 0.045), and depression (ß = -0.13, P = 0.014) contributed more NRS. Females (ß = 0.82, P = 0.005), older age (ß = -0.46, P = 0.029), and higher education level (ß = -1.68, P < 0.001) contributed less refreshment from sleep, more physical/medical symptoms of NRS, and less daytime function, respectively. Coffee or tea consumption moderated the associations of somatic symptoms (ß = 0.25, P = 0.021), stress (ß = 0.29, P = 0.022), anxiety (ß = 0.27, P = 0.005), and depression (ß = 0.17, P = 0.021) with NRS. CONCLUSIONS: Longer sleep duration, moderate after-class activity, reduced coffee or tea consumption, and promotion of physical and mental health may help reduce adolescents' NRS. Coffee or tea consumption may help buffer the negative associations of somatic symptoms, stress, anxiety, and depression with NRS.

Prediction of adolescent weight status by machine learning: a population-based study.

BACKGROUND: Adolescent weight problems have become a growing public health concern, making early prediction of non-normal weight status crucial for effective prevention. However, few temporal prediction tools for adolescent four weight status have been developed. This study aimed to predict the short- and long-term weight status of Hong Kong adolescents and assess the importance of predictors. METHODS: A population-based retrospective cohort study of adolescents was conducted using data from a territory-wide voluntary annual health assessment service provided by the Department of Health in Hong Kong. Using diet habits, physical activity, psychological well-being, and demographics, we generated six prediction models for successive weight status (normal, overweight, obese and underweight) using multiclass Decision Tree, Random Forest, k-Nearest Neighbor, eXtreme gradient boosting, support vector machine, logistic regression. Model performance was evaluated by multiple standard classifier metrics and the overall accuracy. Predictors' importance was assessed using Shapley values. RESULTS: 442,898 Primary 4 (P4, Grade 4 in the US) and 344,186 in Primary 6 (P6, Grade 6 in the US) students, with followed up until their Secondary 6 (Grade 12 in the US) during the academic years 1995/96 to 2014/15 were included. The XG Boosts model consistently outperformed all other model in predicting the long-term weight status at S6 from P4 or P6. It achieved an overall accuracy of 0.72 or 0.74, a micro-averaging AUC of 0.92 or 0.93, and a macro-averaging AUC of 0.83 or 0.86, respectively. XG Boost also demonstrated accurate predictions for each predicted weight status, surpassing the AUC values obtained by other models. Weight, height, sex, age, frequency and hours of aerobic exercise were consistently the most important predictors for both cohorts. CONCLUSIONS: The machine learning approaches accurately predict adolescent weight status in both short- and long-term. The developed multiclass model that utilizing easy-assessed variables enables accurate long-term prediction on weight status, which can be used by adolescents and parents for self-prediction when applied in health care system. The interpretable models may help to provide the early and individualized interventions suggestions for adolescents with weight problems particularly.

Prevalence and Factors Associated With Willingness to Sustain Pandemic-Induced Digital Work in the General Population and Moderating Effects of Screen Hours: Cross-Sectional Study.

BACKGROUND: The pandemic has accelerated digital work transformation, yet little is known about individuals' willingness to sustain such digital modes and its associated factors. A better understanding of this willingness and its drivers is crucial for guiding the development of future digital work infrastructure, training programs, and strategies to monitor and prevent related health issues. OBJECTIVE: This study aims to quantify the general population's willingness to sustain pandemic-induced digital work, identify its associated factors, and examine how screen time moderates these relationships. METHODS: A cross-sectional study was conducted targeting Hong Kong residents aged ≥18 years who have increased engagement in digital work since the pandemic. Data were collected through self-reported, web-based surveys. Descriptive statistics determined prevalence rates, while structured multiphase logistic regression identified associated factors and explored the moderating effects of screen hour levels. RESULTS: This unfunded study enrolled 1014 participants from May 2 to June 24, 2022, and completed data analysis within 3 months after data collection. A total of 391 (38.6%; 95% CI 35.6%-41.6%) participants expressed willingness to sustain digital work. Positive factors associated with this willingness included being an employee (odds ratio [OR] 3.12, 95% CI 1.59-6.45; P=.001), being health professionals (OR 3.32, 95% CI 1.49-7.82; P=.004), longer screen hours (OR 1.09, 95% CI 1.03-1.15; P=.002), and higher depression levels (OR 1.20, 95% CI 1.01-1.44; P=.04). Conversely, negatively associated factors included older age (OR 0.87, 95% CI 0.81-0.94; P=.001), extroversion (OR 0.66, 95% CI 0.51-0.86; P=.002), higher eHealth literacy (OR 0.96, 95% CI 0.93-0.98; P<.001), perceived greater susceptibility to COVID-19 (OR 0.84, 95% CI 0.74-0.96; P=.009), residence in a high-severity COVID-19 community (OR 0.73, 95% CI 0.63-0.84; P<.001), having infected individuals in the immediate social circle (OR 0.64, 95% CI 0.46-0.88; P=.006), higher BMI (OR 0.94, 95% CI 0.90-0.99; P=.02), feelings of being out of control (OR 0.96, 95% CI 0.93-0.98; P=.002), and higher fear of COVID-19 (OR 0.96, 95% CI 0.94-0.98; P=.001). In addition, a moderating effect of screen hour level (high: >8 h/d; low: ≤8 h/d) influenced the association among 10 factors related to willingness to sustain pandemic-induced digital work, including age, education level, household size, needs for regular medical care, BMI, frequency of both vigorous and moderate physical activities, perceived COVID-19 severity, immediate social circle COVID-19 presence, and fear of COVID-19 (all P values for interaction <.05). CONCLUSIONS: The substantial willingness of the general population to sustain digital work after the pandemic highlights the need for robust telework infrastructure, thorough monitoring of adverse health outcomes, and the potential to expand telehealth services among this group. The identification of factors influencing this willingness and the moderating role of screen hours inform the development of personalized strategies to enhance digital work acceptance where needed.

Effectiveness of group cognitive behavioral therapy for depression in adults: a systematic review and meta-analysis of delivery by different healthcare professionals.

This study addresses the gap in understanding the varied effectiveness of group cognitive behavioral therapy (gCBT) delivered by different professionals. This study aims to address this gap by conducting a systematic review of randomized controlled trials (RCTs) that evaluate gCBT and compare it to inactive controls in adults with a clinical diagnosis of depression. A total of 33 RCTs were included for analysis. In the overall analysis, 'profession of gCBT deliverer' was not a significant moderator in the meta-regression model (p = 0.57). For people without comorbidity, the overall effect size estimate was -0.69 (95% CI, -1.01. to -0.37, p = 0.03). Among gCBT deliverers, psychologists and nurses/psychiatric nurses demonstrated significant effectiveness, with psychologists showing a large effect size of -0.78 (95% CI, -1.25 to -0.30, p < 0.01) and nurses/psychiatric nurses showing a medium effect size of -0.45 (95% CI, -0.85 to -0.05, p = 0.03). The certainty of evidence for both professionals was moderate. These results have significant implications for the delivery of mental healthcare, as nurses/psychiatric nurses may be more accessible and cost-effective than psychologists in some settings. However, further research is necessary to determine the effectiveness of gCBT delivered by a broader range of healthcare professionals for patients with depression and other comorbidities.

Trajectories of fasting glucose and glycated haemoglobin in obese and non-obese incident diabetes: Results from two large cohort studies.

AIMS: Diabetes development mechanisms vary by weight status. We aimed to compare cardiometabolic risk and characterize fasting plasma glucose (FPG) and glycated haemoglobin (HbA1c) trajectories before diagnosing type 2 diabetes in individuals with/without obesity. METHODS: Data from the China Health and Retirement Longitudinal Study (CHARLS) and English Longitudinal Study of Ageing (ELSA) were analysed. Participants without diabetes and with a body mass index of 18.5-40 kg/m2 at baseline were included. Incident diabetes was ascertained by self-reported physician diagnosis and/or antidiabetic drug use, FPG ≥126 mg/dl and/or HbA1c ≥6.5%. The difference in the FPG/HbA1c trajectory before the diabetes diagnosis in participants with/without obesity was examined using mixed-effects models. RESULTS: Among 11 925 eligible participants, 1361 incident diabetes cases (mean age: 61.4 years; male: 46.2%) were identified within 15 years of follow-up. Obese diabetes showed higher levels of diastolic blood pressure and C-reactive protein at diagnosis than non-obese diabetes. Mixed-effects models indicated the difference in the FPG trajectory before diagnosis by weight status was non-significant with a slope difference of 0.149 mg/dl (SE = 0.642, p = .816, CHARLS) and 0.013 mg/dl (SE = 0.013, p = .337, ELSA). However, obese diabetes showed a steep increase in HbA1c before diagnosis with a slope difference of 0.036% (SE = 0.016, p = .021) in the CHARLS and 0.032% (SE = 0.014, p = .027) in the ELSA, respectively. Sex-stratified analyses showed that the difference in HbA1c trajectory before the diabetes diagnosis by weight status was only significant in males. CONCLUSIONS: Obese and non-obese diabetes developments may share a similar FPG but distinct HbA1c trajectory. Obese diabetes interventions require more attention to cardiometabolic risks. Moreover, studies addressing weight/sex-related differences in diabetes aetiologies and treatments are warranted.

Adaptation and validation of the Chinese version of the Sleep Quality Questionnaire.

STUDY OBJECTIVES: Sleep quality is essential to health. The current study aimed to adapt and validate the Sleep Quality Questionnaire (SQQ) into Chinese language. METHODS: The Chinese version of the SQQ (SQQ-C) was created following the guidelines for cross-cultural adaptation. Compliant with the COSMIN methodology, baseline data (N = 13,325) examined three validity domains and internal consistency, including content validity using the content validity index (CVI) and the cognitive debriefing and focus group (relevance, comprehensiveness and comprehensibility), construct validity using structural validity and cross­sectional measurement invariance, and criterion validity using concurrent/convergent validity. Follow-up data (N = 3410) gathered within a mean of 168 (167-207) h interval were used to additionally assess longitudinal measurement invariance and test-retest reliability using intraclass correlation coefficient (ICC). RESULTS: Scale-level CVI/Average was equal to 0.922; Item-level CVIs ranged from 0.889 to 1.000 (excellent), except for item 2 (0.556-fair). A panel of local experts and local participants during cognitive debriefing and focus group stated that it had sufficient relevance and comprehensibility but a slight deficiency in comprehensiveness. Confirmatory factor analysis indicated a stable two-factor structure encompassing Daytime Sleepiness Subscale and Sleep Difficulty Subscale from baseline to follow-up data. The SQQ-C-9 (without item 2) outperformed the SQQ-C-10 (full form). The SQQ-C-9 provided evidence of measurement invariance (strict) across subgroups (cohorts, gender, and age) and across time. The SQQ-C was negatively correlated with the Chinese Nonrestorative Sleep Scale and the Chinese Sleep Condition Indicator. Cronbach's alpha (α), McDonald's Omega (ω), and ICC, respectively, ranged from 0.712 to 0.838, 0.723 to 0.840, and 0.738 to 0.764 for total scale and each subscale. CONCLUSION: The SQQ-C exhibits adequate psychometric properties and a stable two-factor structure, and should enable valuable assessments of sleep quality in clinical and research settings.

Short form development of the Chinese work readiness scale for graduate nurse: An optimal test assembly approach.

AIM: To develop and psychometrically test shortened 37-item Chinese Work Readiness Scale for Graduate Nurse without compromising its reliability and validity. DESIGN: Two cross-sectional studies. METHODS: Data were obtained from two cross-sectional online surveys on the same target group of newly graduated nurses in China. The two periods of data collection were from June to August 2018 and from June and July 2021, with 1348 respondents completing the 37-item Chinese Work Readiness Scale for Graduate Nurse. The optimal test assembly procedure based on a generalized partial credit model was adopted to shorten the scale. RESULTS: The mean age of the 1348 nurses was 22.3 years (standard deviation = 1.5), with 1257 (93.2%) being female. The category characteristic curve showed that a 5-point Likert scale was adequate in lieu of the original 10-point Likert scale. The optimal test assembly procedure identified a 17-item version that maintained at least 0.9 correlation with the full scale, a Cronbach's alpha of at least 0.9, and at least 70% of the test information retained. Its discrimination parameters ranged from 1.68 to 2.84, whereas the difficulty parameters were monotonic and ranged from -4.50 to 1.56. When retaining only 50% of test information, a 9-item version was obtained. Its discrimination parameters ranged from 1.84 to 4.55, and difficulty parameters ranged from -3.37 to 1.15. The Cronbach's alphas for the 17-item and 9-item versions were 0.97 and 0.95 respectively. CONCLUSIONS: Both the 17-item and 9-item versions are appropriate for assessing registered nurses' work readiness, with the 9-item version demanding more subjects to compensate for the reduced information. Optimal test assembly approach is appropriate in shortening self-reported scales in the nursing field, while retaining satisfactory levels of reliability, validity, test information and conceptual adequacy. PATIENT OR PUBLIC CONTRIBUTION: This study involved graduate nurses who provided responses to the test scale and experts who contributed to the content validation.

Perceptions and experiences of sexual violence among Chinese men who have sex with men in Hong Kong.

AIM: This study aimed to understand the perceptions and experiences of sexual violence among Chinese men who have sex with men (MSM) in Hong Kong. DESIGN: The study adopted a qualitative descriptive design with thematic analysis. METHODS: Thirty-one Chinese MSM were recruited in Hong Kong from May to June 2019 using purposive sampling. Individual semi-structured interviews were conducted with the participants. The interview data were transcribed verbatim from the recordings and analysed using Braun and Clarke's thematic analysis approach. RESULTS: Four themes were identified: (1) different forms of sexual violence, from physical to virtual; (2) inner struggles with fears and worry; (3) low awareness and perceived risk of sexual violence - 'it has nothing to do with me' and (4) dilemma towards sexual violence prevention. CONCLUSION: The study provided qualitative evidence regarding the experiences and perceptions of sexual violence among Chinese MSM in Hong Kong. Physical and image-based forms of sexual violence were identified, which led the participants to experience psychological distress, fear of contracting human immunodeficiency virus/other sexually transmitted infections, notoriety within the gay community, and discrimination and stigmatization within their family and workplace. To reduce the risk of sexual violence, some participants were cautious about the venue in which they engaged in sex and the habit of sharing sexually explicit photos with others. However, some participants had low awareness and perceived risk of sexual violence. IMPACTS: This study was the first to fill the research gap on sexual violence issues among Chinese MSM using dating apps in Hong Kong. The qualitative findings enhanced the scholarly understanding of Chinese MSM's perceptions and experiences of sexual violence. The study findings can help nursing staff and other healthcare professionals to develop tailored primary, secondary and tertiary sexual violence prevention programmes for MSM or beyond.

Impact of adherence to exercise interventions on effectiveness in a randomized controlled trial in improving sleep in advanced lung cancer patients: A comparison between aerobic exercise and Tai Chi.

OBJECTIVES: Adherence plays a vital role in the effectiveness of non-pharmacological interventions. The disappearance of interventions' effects at follow-up was caused by inadequate self-practice beyond intervention period. The purpose of this study is to examine the factors associated with adherence to aerobic exercise and Tai Chi and the impact of adherence on the short- and long-term effectiveness in improving sleep in patients with advanced lung cancer. METHODS: This study analyzed data collected in a clinical trial that evaluated the effects of aerobic exercise and Tai Chi in patients with advanced lung cancer. Two types of exercises were maintained at the same intensity but with different dosage. A total of 99 patients with advanced lung cancer who were recruited between 2018 and 2020 were included. Data were collected using self-report questionnaires. RESULTS: Fifty participants were randomly assigned to aerobic exercise and 49 to Tai Chi intervention. Higher levels of satisfaction and lower levels of depression were significantly associated with higher attendance and compliance in both groups. Low fatigue levels contributed to higher attendance in Tai Chi. Both attendance and compliance were significantly associated with long-term sleep improvement. SIGNIFICANCE OF RESULTS: Higher levels of satisfaction and lower levels of depression were important characteristics of attendance and compliance with home-based practice in both groups, whereas lower levels of fatigue uniquely contributed to higher attendance in Tai Chi. Better exercise adherence improves long-term effectiveness of sleep in patients with advanced lung cancer. Adopting strategies is imperative to promote exercise adherence in patients with greater levels of depression and fatigue.

Association of weight status and the risks of diabetes in adults: a systematic review and meta-analysis of prospective cohort studies.

Obesity is a known risk factor for type 2 diabetes mellitus (T2DM); however, the associations between underweight and T2DM and between weight status and prediabetes have not been systematically reviewed. We aimed to estimate the relative risks (RRs) of prediabetes/T2DM in underweight/overweight/obesity relative to normal weight. PubMed, Embase, Web of Science, and Cochrane Library were searched from inception to December 8, 2021. Prospective cohort studies with a minimum 12-month follow-up period reporting the association between baseline body mass index (BMI) categories and risk of prediabetes/T2DM in adults were included. Study quality was assessed using the Newcastle-Ottawa Scale. The main analyses of T2DM risk were performed using the ethnic-specific (Asian/non-Asian) BMI classification and additional analyses of prediabetes/T2DM risk by including all eligible studies. Random-effects models with inverse variance weighting were used. Subgroup analyses and meta-regression were conducted to explore the potential effects of pre-specified modifiers. The study protocol was registered with PROSPERO (CRD42020215957). Eighty-four articles involving over 2.69 million participants from 20 countries were included. The pooled RR of prediabetes risk was 1.24 (95% CI: 1.19-1.28, I2 = 9.7%, n = 5 studies) for overweight/obesity vs. normal weight. The pooled RRs of T2DM based on the ethnic-specific BMI categories were 0.93 (95% CI: 0.75-1.15, I2 = 55.5%, n = 12) for underweight, 2.24 (95% CI: 1.95-2.56, I2 = 92.0%, n = 47) for overweight, 4.56 (95% CI: 3.69-5.64, I2 = 96%, n = 43) for obesity, and 22.97 (95% CI: 13.58-38.86, I2 = 92.1%, n = 6) for severe obesity vs. normal weight. Subgroup analyses indicated that underweight is a protective factor against T2DM in non-Asians (RR = 0.68, 95% CI: 0.40-0.99, I2 = 56.1%, n = 6). The magnitude of the RR of T2DM in overweight/obesity decreased with age and varied by region and the assessment methods for weight and T2DM. Overweight/obesity was associated with an increased prediabetes/T2DM risk. Further studies are required to confirm the association between underweight and prediabetes/T2DM, particularly in Asian populations.

Short-form development of the specific module of the QLICD-CRF(V2.0) for assessing the quality of life of patients with chronic renal failure.

BACKGROUND: A short instrument would enhance the viability of a study. Therefore, we aimed to shorten the specific module (SPD-10) of the Quality of Life Instrument for Chronic Diseases - Chronic Renal Failure (QLICD-CRF) for assessing the quality of life of patients with chronic renal failure. METHODS: The 10-item SPD-10 was self-administered to 164 patients with chronic renal failure. A shortened form was first obtained by a tandem use of the classical test theory (CTT), the generalizability theory (GT), and the item response theory (IRT). In addition, we also shortened the SPD-10 by the Optimal Test Assembly (OTA). RESULTS: Both the tandem use of GT, CTT and IRT, and the OTA derived the same 7-item shortened version (SPD-7). It included items CRF1, CRF2, CRF3, CRF4, CRF6, CRF8, and CRF9 of the SPD-10. The SPD-7 had a Cronbach alpha of 0.78. The correlation coefficients of its total and factor scores with those of the SPD-10 were 0.96 and 0.98, respectively. Confirmatory factor analysis confirmed the unidimensional structure of the SPD-7, with the comparative fit index=0.96, the Tucker-Lewis index=0.94, and the root mean square error of approximation=0.09. CONCLUSION: The short-form SPD-7 is reliable and valid for assessing the impact of clinical symptoms and side effects on the quality of life of patients with chronic renal failure. It is an efficient option without compromising the measurement performance of the SPD-10.

Promoting moderate-to-vigorous physical activities in patients with advanced lung cancer: preferences and social cognitive factors, and the mediating roles.

PURPOSE: The purpose of this study is to assess the prevalence and preferences of moderate-to-vigorous physical activities (MVPA) in patients with advanced lung cancer, explore the social cognitive factors that were associated with MVPA and interest in PA counseling and program, and examine the mediating role of social cognitive factors. METHODS: This was a cross-sectional study. Questionnaires on PA levels, PA counseling and programming preferences, and social cognitive variables (social support and self-efficacy) were administered to 105 patients with advanced lung cancer. Linear regression model was used to explore the social cognitive factors associated with MVPA, and logistic regression model was used to explore the factors associated with interest in PA counseling and program. Mediation analysis was used to examine the mediating role of self-efficacy on social support and MVPA. RESULTS: Merely 30.5% of patients met the recommended level of MVPA; however, the majority of patients (89.5%) were interested in PA program. Social support (ß = 0.60; p = 0.007) and self-efficacy (ß = 1.06; p = 0.027) were positively associated with MVPA. Specifically, self-efficacy mediated the relationship between social support and MVPA (ß = 0.63, p = 0.004). CONCLUSION: The majority of the patients with advanced lung cancer did not meet the recommended level of MVPA; however, they are interested in receiving PA counseling and joining PA programs. Social support was key to promoting higher levels of MVPA, and the association was mediated by self-efficacy. The established mediating model provides insights into designing PA programs and targeting the mediating variable, self-efficacy, to enhance the level of MVPA.

Skipping Breakfast and Eating Breakfast Away From Home Were Prospectively Associated With Emotional and Behavioral Problems in 115,217 Chinese Adolescents.

BACKGROUND: Breakfast is deemed the most important meal of the day. We examined the prospective associations of breakfast habits with emotional/behavioral problems in adolescents and potential effect modification. METHODS: 115,217 Primary 6 students (United States Grade 6; mean age, 11.9; standard deviation [SD], 0.59 years) who attended the Student Health Service of Department of Health in Hong Kong in 2004/05, 2006/07, 2008/09 were followed till Secondary 6 (United States Grade 12). Emotional/behavioral problems were biennially examined using Youth Self-Report since Secondary 2 (United States Grade 8). Lifestyles were biennially examined using standardized questionnaires since Primary 6. Prospective associations of breakfast habit with emotional/behavioral problems and potential effect modification were examined using generalized estimating equations. RESULTS: Compared with eating breakfast at home, eating breakfast away from home was significantly associated with total emotional/behavioral problems and seven syndromes, including withdrawal, somatic complaints, anxiety/depression, thought problems, attention problems, delinquent behaviors, and aggressive behaviors (adjusted odds ratios [AORs] 1.22-2.04), while skipping breakfast showed stronger associations with the above problems and social problems (AORs 1.34-2.29). Stronger associations were observed in younger students for total and attention problems (P < 0.03) and in those with lower weight status for delinquent behaviors (P = 0.005). CONCLUSION: Eating breakfast away from home and especially skipping breakfast were prospectively associated with adolescent emotional/behavioral problems. The associations weakened with increasing age for total emotional/behavioral and attention problems, and weakened with higher weight status for delinquent behaviors, highlighting the vulnerability of younger and underweight children. If the associations are causal, increasing home breakfast may reduce adolescent emotional/behavioral problems and benefit psychosocial health.

Late-onset or chronic overweight/obesity predicts low self-esteem in early adolescence: a longitudinal cohort study.

BACKGROUND: How weight status changes with time may affect self-esteem was seldom studied. We identified the distinct trajectories of overweight/obesity over age and assessed their associations with different domains of self-esteem in Hong Kong Chinese children. METHODS: Territory-wide longitudinal data of 48,558 children (girls: 50.0%; 6.3 ± 0.51 years) studying Primary 1 in the academic cohorts of 1995/96 and 1996/97 followed till Primary 6 were obtained from the Student Health Service of Hong Kong. Weight was annually measured and categorized as underweight/normal and overweight/obese and self-esteem was measured in Primary 6. Distinct trajectories of weight status were first identified using growth mixture modeling and their associations with low self-esteem were assessed by logistic regression. RESULTS: Four distinct overweight/obesity trajectories were identified: never (76.8%), late-onset (8.1%), early-onset (4.2%) and chronic (10.9%) overweight/obesity. Compared with children who were never overweight/obese, more of those in the late-onset or chronic overweight/obesity group showed low self-esteem and specific domains including general, social and academic/school-related (adjusted odds ratios: 1.20 - 1.43, all P < 0.001) except parent/home-related self-esteem (P = 0.36), whereas children being in the early-onset overweight/obesity group showed no significant difference (P ≥ 0.53) except a lower risk of low social self-esteem (adjusted odds ratio = 0.82, P = 0.03). CONCLUSIONS: Late-onset or chronic overweight/obesity predicted low general, social and academic/school-related self-esteem. Children who successfully reduced weight may have equal levels of self-esteem or even better social self-esteem than those being always underweight/normal weight. Overweight/obese children had a vulnerability to self-esteem in non-domestic environments.

COVID-19 related fear and depression of pregnant women and new mothers.

OBJECTIVE: To explore factors associated with depression and COVID-19 related fear among pregnant women and new mothers. DESIGN: A cross-sectional survey was conducted in China from July 2020 to July 2021. SAMPLE: A total of 3027 pregnant and new mothers were recruited. MEASUREMENT: Sociodemographic characteristics and the perceptions of the COVID-19 pandemic were collected. The Patient Health Questionnaire-9 (PHQ-9) and the Fear Scale was used to assess the depressive and fear level towards the COVID-19 pandemic, respectively. RESULTS: Approximately 17.2% of the participants had depression (PHQ-9 ≥10). In Hong Kong, participants who perceived that they have increased knowledge to prevent infection were less likely to have depression (adjusted odds ratio [aOR] = 0.83; 95% confidence interval [CI] = 0.74-0.94). There was no association between perceived severity if infected and severity of spread and the depression level in our sample. An inverse relationship was found between the COVID-19 related fear level and perceived knowledge to prevent infection (Beta-coefficient [ß] = -0.20; 95% CI = -0.38 to -0.02). CONCLUSION: Public health nurses need to promote accurate and up to date COVID-19 related information at clinical and community settings and implement effective screening for depression and fear symptoms to identify these high-risk groups to improve women's psychological well-being.

Work readiness: Its determinants and association with work-related outcomes among new graduate nurses.

AIMS: This study aimed to identify determinants of work readiness and to assess the influences of work readiness on work-related outcomes in graduate nurses. BACKGROUND: Higher work readiness facilitates smoother role transitions of new graduate nurses. However, determinants of work readiness had not been fully examined. In addition, the relationships between work readiness and work-related outcomes, such as coping self-efficacy and occupational commitment, are also crucial but had not been assessed. METHODS: We recruited 794 graduate nurses and assessed their work readiness before working as nurses. After they commenced their work, we assessed their occupational commitment, coping self-efficacy and intention to remain. All assessments were conducted online. RESULTS: There were 728 (92%) female respondents. The mean scores and standard deviation (SD) of work readiness, coping self-efficacy, occupational commitment and intention to remain were 261.51 (SD: 45.40), 30.30 (SD: 6.13), 81.65 (SD: 11.56) and 11.01 (SD: 2.36), respectively. Based on a regression analysis, determinants of work readiness were positive school climate, student leadership experience, nursing as the primary choice of discipline and perceived influences of COVID-19 on the honorability of being a nurse and the willingness to be a nurse (p < .001). Moreover, after adjusted by all demographics and characteristics variables, higher work readiness would result in higher coping self-efficacy (estimated coefficient = 0.06, p < .001), occupational commitment (estimated coefficient = 0.06, p < .001) and intention to remain (estimated coefficient = 0.01, p = .002). CONCLUSION: Work readiness is a composite concept affected by psychosocial and environmental factors, which can predict new graduate nurses' future self-efficacy, occupational commitment and intention to remain. IMPLICATIONS FOR NURSING MANAGEMENT: The management of new graduate nurses when they begin to work could target their work readiness. Transition programmes that consider our identified determinants can be provided to those who show lower work readiness.

Prediction models and nomograms for 10-year risk of end-stage renal disease in Chinese type 2 diabetes mellitus patients in primary care.

AIMS: To develop and validate 10-year risk prediction models, nomograms and charts for end-stage renal disease (ESRD) in Chinese patients with type 2 diabetes mellitus (T2DM) in primary care, in order to guide individualized treatment. MATERIALS AND METHODS: This was a 10-year population-based observational cohort study. A total of 141 516 Chinese T2DM patients without history of cardiovascular disease or ESRD who were managed in public primary care clinics in 2008 were included and followed up until December 2017. Two-thirds of these patients were randomly selected to develop sex-specific ESRD risk prediction models using Cox regressions. The validity and accuracy of the models were tested on the remaining third of patients using Harrell's C-index. We selected variables based on their clinical and statistical importance to construct the nomograms and charts. RESULTS: The median follow-up period was 9.75 years. The cumulative incidence of ESRD was 6.0% (men: 6.1%, women: 5.9%). Age, diabetes duration, systolic blood pressure (SBP), SBP variability, diastolic blood pressure, triglycerides, glycated haemoglobin (HbA1c), HbA1c variability, urine albumin to creatinine ratio (UACR), and estimated glomerular filtration rate (eGFR) were significant predictors for both sexes. Smoking and total cholesterol to HDL cholesterol ratio were additional significant predictors for men and women, respectively. The models showed Harrell's C-statistics of 0.889/0.889 (women/men). Age, eGFR, UACR, SBP and HbA1c were selected for both sexes to develop nomograms and charts. CONCLUSIONS: Using routinely available variables, the 10-year ESRD risk of Chinese T2DM patients in primary care can be predicted with approximately 90% accuracy. We have developed different tools to facilitate routine ESRD risk prediction in primary care, so that individualized care can be provided to prevent or delay ESRD in T2DM patients.

Generative adversarial networks for imputing missing data for big data clinical research.

BACKGROUND: Missing data is a pervasive problem in clinical research. Generative adversarial imputation nets (GAIN), a novel machine learning data imputation approach, has the potential to substitute missing data accurately and efficiently but has not yet been evaluated in empirical big clinical datasets. OBJECTIVES: This study aimed to evaluate the accuracy of GAIN in imputing missing values in large real-world clinical datasets with mixed-type variables. The computation efficiency of GAIN was also evaluated. The performance of GAIN was compared with other commonly used methods, MICE and missForest. METHODS: Two real world clinical datasets were used. The first was that of a cohort study on the long-term outcomes of patients with diabetes (50,000 complete cases), and the second was of a cohort study on the effectiveness of a risk assessment and management programme for patients with hypertension (10,000 complete cases). Missing data (missing at random) to independent variables were simulated at different missingness rates (20, 50%). The normalized root mean square error (NRMSE) between imputed values and real values for continuous variables and the proportion of falsely classified (PFC) for categorical variables were used to measure imputation accuracy. Computation time per imputation for each method was recorded. The differences in accuracy of different imputation methods were compared using ANOVA or non-parametric test. RESULTS: Both missForest and GAIN were more accurate than MICE. GAIN showed similar accuracy as missForest when the simulated missingness rate was 20%, but was more accurate when the simulated missingness rate was 50%. GAIN was the most accurate for the imputation of skewed continuous and imbalanced categorical variables at both missingness rates. GAIN had a much higher computation speed (32 min on PC) comparing to that of missForest (1300 min) when the sample size is 50,000. CONCLUSION: GAIN showed better accuracy as an imputation method for missing data in large real-world clinical datasets compared to MICE and missForest, and was more resistant to high missingness rate (50%). The high computation speed is an added advantage of GAIN in big clinical data research. It holds potential as an accurate and efficient method for missing data imputation in future big data clinical research. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03299010 ; Unique Protocol ID: HKUCTR-2232.