Use of Palliative Care Among Adults With Newly Diagnosed Heart Failure: Insights From a US National Insured Patient Sample.

BACKGROUND: Despite the known benefits for individuals with heart failure (HF), incomplete data suggest a low use of palliative care (PC) for HF in the United States. We aimed to investigate the national PC use for adults with HF by determining when they received their first PC consultation (PCC) and the associations with clinical factors following diagnosis of HF. METHODS AND RESULTS: We conducted a retrospective cohort study in a national all-payer electronic health record database to identify adults (aged ≥18 years) with newly diagnosed HF between 2011 and 2018. The proportion of those who received PCC within 5 years following a diagnosis of HF, and associations of time to first PCC with patient characteristics and HF-specific clinical markers were determined. We followed 127 712 patients for a median of 792 days, of whom 18.3% received PCC in 5 years. Shorter time to receive PCC was associated with diagnoses of HF in 2016 to 2018 (compared with 2010-2015: adjusted hazard ratio [aHR], 1.421 [95% CI, 1.370-1.475]), advanced HF (aHR, 2.065 [95% CI, 1.940-2.198]), cardiogenic shock (aHR, 2.587 [95% CI, 2.414-2.773]), implantable cardioverter-defibrillator (aHR, 5.718 [95% CI, 5.327-6.138]), and visits at academic medical centers (aHR, 1.439 [95% CI, 1.381-1.500]). CONCLUSIONS: Despite an expanded definition of PC and recommendations by professional societies, PC for HF remains low in the United States. Racial and geographic variations in access and use of PC exist for patients with HF. Future studies should interrogate the mechanisms of PC underusage, especially before advanced stages, and address barriers to PC services across the health care system.

Building alternative payment models in health care.

Introduction: Global interest is growing in new value-based models of financing, delivering, and paying for health care services that could produce higher-quality and lower cost outcomes for patients and for society. However, research indicates evidence gaps in knowledge related to alternative payment models (APMs) in early experimentation phases or those contracted between private insurers and their health care provider-partners. The aim of this research was to understand and update the literature related to learning how industry experts design and implement APMs, including specific elements of their models and their choice of stakeholders to be involved in the design and contractual details. Methods: A literature review was conducted to guide the research focus and to select themes. The sample was selected using snowball sampling to identify subject matter experts (SMEs). Researchers conducted 16 semi-structured interviews with SMEs in the US, the Netherlands, and Germany in September and October 2021. Interviews were transcribed and using Braun and Clarke's six-phase approach to thematic analysis, researchers independently read, reviewed, and coded participants' responses related to APM design and implementation and subsequently reviewed each other's codes and themes for consistency. Results: Participants represented diverse perspectives of the payer, provider, consulting, and government areas of the health care sector. We found design considerations had five overarching themes: (1) population and scope of care and services, (2) benchmarking, metrics, data, and technology; (3) finance, APM type, risk adjustment, incentives, and influencing provider behavior, (4) provider partnerships and the role of physicians, and (5) leadership and regulatory issues. Discussion: This study confirmed several of the core components of APM model designs and implementations found in the literature and brought insights on additional aspects not previously emphasized, particularly the role of physicians (especially in leadership) and practice transformation/care processes necessary for providers to thrive under APM models. Importantly, researchers found significant concerns relevant for policymakers about regulations relating to health data sharing, rigid price-setting, and inter-organizational data communication that greatly inhibit the ability to experiment with APMs and those models' abilities to succeed long-term.

Air Pollution Metabolomic Signatures and Chronic Respiratory Diseases Risk: A Longitudinal Study.

BACKGROUND: Although evidence has documented the associations of ambient air pollution with chronic respiratory diseases (CRDs) and lung function, the underlying metabolic mechanisms remain largely unclear. RESEARCH QUESTION: How does the metabolomic signature for air pollution relate to CRD risk, respiratory symptoms, and lung function? STUDY DESIGN AND METHODS: We retrieved 171,132 participants free of COPD and asthma at baseline from the UK Biobank, who had data on air pollution and metabolomics. Exposures to air pollutants (particulate matter with diameter ≤ 2.5 µm [PM2.5], particulate matter with a diameter ≤ 10 µm, nitrogen oxide [NOX], and NO2) were assessed for 4 years before baseline considering residential address histories. We used 10-fold cross-validation elastic net regression to identify air pollution-associated metabolites. Multivariable Cox models were used to assess the associations between metabolomic signatures and CRD risk. Mediation and pathway analysis were conducted to explore the metabolic mechanism underlying the associations. RESULTS: During a median follow-up of 12.51 years, 8,951 and 5,980 incident COPD and asthma cases were recorded. In multivariable Cox regressions, air pollution was positively associated with CRD risk (eg, hazard ratio per interquartile range increment in PM2.5, 1.09; 95% CI, 1.06-1.13). We identified 103, 86, 85, and 90 metabolites in response to PM2.5, particulate matter with a diameter ≤ 10 µm, NOX, and NO2 exposure, respectively. The metabolomic signatures showed significant associations with CRD risk (hazard ratio per SD increment in PM2.5 metabolomic signature, 1.11; 95% CI, 1.09-1.14). Mediation analysis showed that peripheral inflammatory and erythrocyte-related markers mediated the effects of metabolomic signatures on CRD risk. We identified 14 and 12 perturbed metabolic pathways (energy metabolism and amino acid metabolism pathways, etc) for PM2.5 and NOX metabolomic signatures. INTERPRETATION: Our study identifies metabolomic signatures for air pollution exposure. The metabolomic signatures showed significant associations with CRD risk, and inflammatory- and erythrocyte-related markers partly mediated the metabolomic signatures-CRD links.

Reflections on Managing the Performance of Value-Based Healthcare: A Scoping Review.

BACKGROUND: Value-based healthcare (VBHC), which can be viewed as a strategy to organize and improve healthcare services, has far-reaching organizational and managerial consequences. It is common managerial practice to support the execution of a strategy by monitoring the ensuing activities. Such monitoring provides feedback and guidance on the execution of these activities to the management of an organization and helps to realize organizational strategies. Monitoring of activities is commonly done by performance management systems. Given the rising attention in the literature and in practice for VBHC, we ask to what extent VBHC is supported by performance management systems in practice, and how we can explain what we find to support further successful implementation of VBHC. METHODS: In our scoping review of financial and performance management at the organization or unit-level of healthcare organizations that apply value-based approaches, we identified 1267 unique papers in Embase, Medline, OVID, and Web of Science. After the (double-blinded) title and abstract screening, 398 full-text articles were assessed for further analysis. RESULTS: Our review reveals only eleven original papers discussing specifically the integration of VBHC and performance management systems. Almost all the featured applications in these papers focus on a specific project or medical specialty. Only one paper exemplifies how VBHC has been integrated with the performance management systems of a medical institution, and no paper provides a clear link with strategy execution. We ask why this is the case and propose several explanations by studying the extant performance management literature. We see these explanations as issues for further reflection for VBHC practitioners and researchers. CONCLUSION: We conclude that one of the reasons for the absence of papers integrating VBHC and performance management systems is formed by the tensions that exist between striving for "the best care" or even for providing "all care that is viably possible" and pursuing greater (financial) efficiency. Implementing VBHC as an important organizational strategy and explicating this strategy in the performance management systems requires that these tensions need to be brought into the fore. When this is not done, we believe that VBHC adoptions that are fully integrated with performance management systems will remain limited in practice.

Dietary Diversity and Inflammatory Diet Associated with All-Cause Mortality and Incidence and Mortality of Type 2 Diabetes: Two Prospective Cohort Studies.

A higher dietary diversity score (DDS) and a lower energy-adjusted dietary inflammatory index (E-DII) may be associated with lower risks of type 2 diabetes (T2D) and mortality. This cohort study aimed to investigate the associations of DDS and E-DII with all-cause mortality, incidence of T2D, and mortality of T2D, as well as the joint effects of these two dietary factors. A total of 181,360 participants without all types of diabetes at baseline from the UK Biobank and 42,139 participants from the US NHANES were included. Cox proportional hazards models were used to assess the associations of DDS and E-DII with outcomes. In the UK Biobank data, 8338 deaths, 3416 incident T2D cases, and 353 T2D deaths occurred during a median follow-up of 12.5 years. In the US NHANES data, 6803 all-cause deaths and 248 T2D-specific deaths were recorded during a median follow-up of 9.6 years. We observed that higher DDS and lower E-DII were significantly associated with lower risks of total mortality and incident T2D. Compared with low DDS, the hazard ratios (HRs) and 95% confidence intervals (CIs) of high DDS were 0.69 (0.64, 0.74) for all-cause mortality, 0.79 (0.70, 0.88) for incident T2D in the UK Biobank, and 0.69 (0.61, 0.78) for all-cause mortality in the US NHANES. Compared with participants in tertile 3 of E-DII, those in tertile 1 had a lower risk of overall death [HR 0.86 (95% CI: 0.81, 0.91) in UK Biobank; 0.83 (0.77, 0.88) in US NHANES] and incident T2D [0.86 (0.79, 0.94)] in UK Biobank. No evidence was observed of the interactive effects of DDS and E-DII on either all-cause mortality or the incidence and mortality of T2D. There was no significant association found between any exposure and T2D mortality in this study. In conclusion, our results revealed that higher DDS and lower E-DII were associated with both total mortality and incident T2D in UK and US adults.

Air pollution associated with incidence and progression trajectory of chronic lung diseases: a population-based cohort study.

BACKGROUND: No prior study has examined the effects of air pollution on the progression from healthy to chronic lung disease, subsequent chronic lung multimorbidity and further to death. METHODS: We used data from the UK Biobank of 265 506 adults free of chronic lung disease at recruitment. Chronic lung multimorbidity was defined as the coexistence of at least two chronic lung diseases, including asthma, chronic obstructive pulmonary disease and lung cancer. The concentrations of air pollutants were estimated using land-use regression models. Multistate models were applied to assess the effect of air pollution on the progression of chronic lung multimorbidity. RESULTS: During a median follow-up of 11.9 years, 13 863 participants developed at least one chronic lung disease, 1055 developed chronic lung multimorbidity and 12 772 died. We observed differential associations of air pollution with different trajectories of chronic lung multimorbidity. Fine particulate matter showed the strongest association with all five transitions, with HRs (95% CI) per 5 µg/m3 increase of 1.31 (1.22 to 1.42) and 1.27 (1.01 to 1.57) for transitions from healthy to incident chronic lung disease and from incident chronic lung disease to chronic lung multimorbidity, and 1.32 (1.21 to 1.45), 1.24 (1.01 to 1.53) and 1.91 (1.14 to 3.20) for mortality risk from healthy, incident chronic lung disease and chronic lung multimorbidity, respectively. CONCLUSION: Our study provides the first evidence that ambient air pollution could affect the progression from free of chronic lung disease to incident chronic lung disease, chronic lung multimorbidity and death.

Ambient air pollution associated with incidence and progression trajectory of cardiometabolic diseases: A multi-state analysis of a prospective cohort.

BACKGROUND: Previous studies on the association between ambient air pollution and cardiometabolic diseases (CMDs) focused on a single disease, without considering cardiometabolic multimorbidity (CMM) and the progression trajectory of CMDs. METHODS: Based on the UK Biobank cohort, we included 372,530 participants aged 37-73 years at baseline (2006-2010) with follow-up until September 2021. Incident CMDs cases were identified based on self-reported information and multiple health-related records in the UK Biobank. CMM was defined as the occurrence of at least two CMDs, including ischemic heart disease (IHD), stroke and type 2 diabetes (T2D). Exposure to ambient air pollutants, including particulate matter (PM) with aerodynamic diameter ≤2.5 µm (PM2.5), ≤10 µm (PM10), nitrogen dioxide (NO2), and nitrogen oxides (NOx) were estimated at participants' geocoded residential addresses based on the high-resolution (1 × 1 km) pollution data from 2001 to 2021 provided by UK Department for Environment, Food and Rural Affairs. Multi-state models with adjustment for potential confounders were used to examine the impact of long-term exposure to ambient air pollution on transitions from healthy to first CMD (FCMD), subsequently to CMM, and further to death. RESULTS: During a median follow-up of 12.6 years, 40,112 participants developed at least one CMD, 3896 developed CMM, and 21,739 died. Among the four pollutants, PM2.5 showed the strongest associations with all transitions from healthy to FCMD, to CMM, and then to death [hazard ratios (95 % confidence intervals) per interquartile range (IQR) increment: 1.62 (1.60, 1.64) and 1.68 (1.61, 1.76) for transitions from healthy to FCMD and from FCMD to CMM, and 1.62 (1.59, 1.66), 1.67 (1.61, 1.73), and 1.52 (1.38, 1.67) for death risk from healthy, FCMD, and CMM, respectively]. After dividing FCMDs into three specific CMDs, we found that ambient air pollution had differential impacts on disease-specific transitions within the same transition phase. CONCLUSIONS: Our findings indicate that there is potential for air pollution mitigation in contributing to the prevention of the development and progression of CMDs.

Association between maternal family history of hypertension and preterm birth: modification by noise exposure and multivitamin intake.

OBJECTIVE: To measure the effect of maternal family history of hypertension on preterm birth (PTB) and to identify factors that modified this association. METHODS: A case-control study was nested in a prospective cohort of the entire pregnant population in Wuhan, China, from 2011 to 2013. Home-visit interviews were scheduled for all PTBs and their controls, to collect extensive information on maternal exposures to behavioral, environmental, and intergenerational risk factors of PTB. The effects of maternal family history of hypertension on PTB were measured by logistic regression analyses, controlling for potential confounders. Potential effect modifiers were examined using stratified analyses. RESULTS: There were 2393 PTBs and 4263 full-term births out of all eligible births. A positive association was observed between maternal family history of hypertension and PTB, after adjusted for potential confounders (adjusted odds ratio: 1.17 [1.03, 1.33]). A higher effect was observed when mothers were exposed to certain noise during pregnancy (adjusted odds ratio: 1.37 [1.14, 1.65]) and/or when they did not take multivitamins during pregnancy (adjusted odds ratio: 1.46 [1.20, 1.78]), whereas, this association was weaker and no longer significant when mothers took multivitamins during pregnancy (adjusted odds ratio: 1.00 [0.84, 1.19]) and/or when they were not exposed to certain noise during pregnancy (adjusted odds ratio: 1.01 [0.85, 1.12]). The modification effect from maternal multivitamin intake was significant on both spontaneous and medically indicated PTBs, and the modification effect from maternal exposure to certain noise was only significant on spontaneous PTB. CONCLUSIONS: Increased PTB risk was observed for pregnant women with a family history of hypertension in Wuhan, China. This effect was stronger when pregnant women did not take multivitamin and/or exposed to certain noise during pregnancy, than those who took multivitamin and/or unexposed to certain noise.

Ambient air pollution, lifestyle, and genetic predisposition associated with type 2 diabetes: findings from a national prospective cohort study.

BACKGROUND: The combined effects of ambient air pollution, lifestyle, and genetic predisposition on incident Type 2 Diabetes (T2D) have not been well documented. METHODS: A total of 263,733 participants without T2D at baseline were identified from the UK Biobank. Annual concentrations of five air pollutants were estimated using Land Use Regression, while a healthy lifestyle score (HLS) was constructed using 7 major lifestyle factors, and polygenic risk score (PRS) was generated using 73 genetic variants. Cox regression was used to determine the association between air pollution and incident T2D for different HLS/PRS categories. Potential HLS/PRS interactions and population attributable fraction (PAF) were also examined. RESULTS: During a median follow-up of 11.94 years, 7827 (2.97 %) incident T2D cases were identified. Association between air pollution and incident T2D was stronger among those with higher HLS/PRS in a dose-response fashion. In addition, synergistic interactions between lifestyles and air pollution were observed. Lifestyle was the leading risk factor of T2D with a weighted PAF of 25.54 % (95 % CI: 19.22 %, 27.77 %) for intermediate HLS and 24.24 % (18.24 %, 26.36 %) due to unhealthy HLS. Overall, we estimated that about 25 % of T2D cases could be attributable to air pollution and associated interactions. CONCLUSIONS: Associations between air pollution and T2D were stronger among individuals with unhealthier lifestyle on an additive interaction scale. Public health interventions that address both reduction of exposure to high levels of air pollution in addition to lifestyle changes may have more benefit on reducing T2D risk than focusing on lifestyle changes alone.

Associations between conjunctivitis and ambient PM2.5 and physical activity: A nationwide prospective cohort study.

BACKGROUND: Currently, there is no evidence of fine particulate matter pollution (PM2.5) altering the relationship between physical activity (PA) and the risk of conjunctivitis. METHODS: Based on the UK Biobank study, we included 308,507 participants aged 40-69 years at baseline (2006 to 2010) and prospectively followed up for conjunctivitis diagnosis till 2020. Annual concentrations of PM2.5 in 2010 were estimated for each participant using Land Use Regression models. PA levels during work and leisure time were reported via the International Physical Activity Questionnaire at baseline. We used Cox proportional hazards models to examine the associations of PM2.5 and PA with incident conjunctivitis, as well as their interaction at both multiplicative and additive scales. RESULTS: During the 11.6 years of follow up, we identified 4002 incident conjunctivitis cases. High-PA (≥3000 metabolic equivalent of task [MET]-mins/week) was associated with lower risk of conjunctivitis (hazard ratio [HR]: 0.79, 95% confidence interval [CI]: 0.73-0.86) compared to low-PA (0 to <600 MET-mins/week), while every 1 µg/m3 increment in PM2.5 was associated with a 16% higher risk of conjunctivitis (HR = 1.16, 95% CI: 1.09-1.23). We did not observe statistically significant interactions between PM2.5 and PA on their associations with conjunctivitis. CONCLUSION: Habitual PA and PM2.5 exposure were oppositely related to incident conjunctivitis. The benefits of PA remain in people irrespective of exposure to air pollution.

Association of types of diabetes and insulin dependency on birth outcomes.

BACKGROUND: Diabetes rates among pregnant women in the United States have been increasing and are associated with adverse pregnancy outcomes. AIM: To investigate differences in birth outcomes (preterm birth, macrosomia, and neonatal death) by diabetes status. METHODS: Cross-sectional design, using linked Missouri birth and death certificates (singleton births only), 2010 to 2012 (n = 204057). Exposure was diabetes (non-diabetic, pre-pregnancy diabetes-insulin dependent (PD-I), pre-pregnancy diabetes-non-insulin dependent (PD-NI), gestational diabetes- insulin dependent (GD-I), and gestational diabetes-non-insulin dependent (GD-NI)]. Outcomes included preterm birth, macrosomia, and infant mortality. Confounders included demographic characteristics, adequacy of prenatal care, body mass index, smoking, hypertension, and previous preterm birth. Bivariate and multivariate logistic regression assessed differences in outcomes by diabetes status. RESULTS: Women with PD-I, PD-NI, and GD-I remained at a significantly increased odds for preterm birth (aOR 2.87, aOR 1.77, and aOR 1.73, respectively) and having a very large baby [macrosomia] (aOR 3.01, aOR 2.12, and aOR 1.96, respectively); in reference to non-diabetic women. Women with GD-NI were at a significantly increased risk for macrosomia (aOR1.53), decreased risk for their baby to die before their first birthday (aOR 0.41) and no difference in risk for preterm birth in reference to non-diabetic women. CONCLUSION: Diabetes is associated with the poor birth outcomes. Clinical management of diabetes during pregnancy and healthy lifestyle behaviors before pregnancy can reduce the risk for diabetes and poor birth outcomes.

Ambient gaseous pollutants and emergency ambulance calls for all-cause and cause-specific diseases in China: a multicity time-series study.

Much attention has been paid to the health effects of ambient particulate matter pollution; the effects of gaseous air pollutants have not been well studied. Emergency ambulance calls (EACs) may provide a better indicator of the acute health effects than the widely used health indicators, such as mortality and hospital admission. We estimated the short-term associations between gaseous air pollutants [nitrogen dioxide (NO2), sulfur dioxide (SO2), and ozone (O3)] and EACs for all-cause, cardiovascular, and respiratory diseases in seven Chinese cities from 2014 to 2019. We used generalized additive models and random-effects meta-analysis to examine the city-specific and pooled associations. Stratified analyses were conducted by age, sex, and season. A total of 1,626,017 EACs were observed for all-cause EACs, including 230,537 from cardiovascular diseases, and 96,483 from respiratory diseases. Statistically significant associations were observed between NO2 and EACs for all-cause diseases, while the effects of SO2 were positive, but not statistically significant in most models. No significant relationship was found between O3 and EACs. Specifically, each 10 µg/m3 increase in the 2-day moving average concentration of NO2 was associated with a 1.07% [95% confidence interval (CI): 0.40%, 1.76%], 0.76% (95% CI: 0.19%, 1.34%) and 0.06% (95% CI: -1.57%, 1.73%) increase in EACs due to all-cause, cardiovascular and respiratory diseases, respectively. Stratified analysis showed a larger effect of NO2 on all-cause EACs in the cold season [excess relative risk (ERR): 0.33% (95% CI: 0.05%, 0.60%) for warm season, ERR: 0.77% (95% CI: 0.31%, 1.23%) for cold season]. Our study indicates that acute exposures to NO2 might be an important trigger of the emergent occurrence of all-cause, cardiovascular and respiratory diseases, and this effect should be of particular concern in the cold season. Further policy development for controlling gaseous air pollution is warranted to reduce the emergent occurrence of cardiopulmonary diseases.

Efficacy Evaluation Study for Microburst Insulin Infusion: A Novel Model of Care.

Objectives: This study aims to evaluate the impact of Microburst Insulin Infusion (MII) treatment on Type 1 and 2 diabetic patients' HbA1c, lipids, peripheral neuropathy, and patient-reported health status. Methods: We reviewed clinical charts, including lab results, for more than 80 diabetic and pre-diabetic patients treated at one U.S. outpatient clinic in St. Louis, Missouri between February 2017 and December 2019. Data included patient demographics, treatment data, lab and neuropathy tests, and self-reported patient health status questions. The explanatory variable was number of months of MII treatment. Treatments are 3-4 h in length, with two intensive infusions the first week and one treatment each week thereafter, usually for 12 weeks total. Lab tests were at 12-week intervals. Generalized linear modeling and t-tests assessed the significance of differences between patients' baseline lab values, neuropathy measures, and health status before treatment vs. after final treatment. Results: Number of MII treatments per patient ranged from 1 to 262, over 1-24 months. Time in MII treatment was significantly associated with reductions in HbA1c by nearly 0.04 points per month, and triglycerides declined 3 points per month. Neuropathy measures of large toe vibratory sensation (clanging tuning fork) improved significantly, as did patient-reported health and feelings of improvement since beginning treatment. Discussion: The MII therapy appears to be efficacious in treating diabetic patients, particularly those with complications like neuropathy. Our findings affirmed several other studies. We uniquely incorporated patient health questionnaires, and empirically studied MII treatment efficacy for diabetes in a population large enough to permit statistically valid inferences. With multiple waves of data for over 80 patients, this is one of the most extensive quantitative studies of microburst insulin infusion therapy conducted to date, with protocols more uniformly implemented and survey instruments more consistently administered by the same clinical team. Given the advances in insulin infusion therapy brought by MII, and early indications of its efficacy, the time is right for more in-depth studies of the outcomes patients can achieve, the physiological mechanisms by which they occur, MII's comparative effectiveness vis-à-vis traditional treatments, and cost-effectiveness.

Associations between trees and grass presence with childhood asthma prevalence using deep learning image segmentation and a novel green view index.

Limitations of Normalized Difference Vegetation Index (NDVI) potentially contributed to the inconsistent findings of greenspace exposure and childhood asthma. The aim of this study was to use a novel greenness exposure assessment method, capable of overcoming the limitation of NDVI to determine the extent to which it was associated with asthma prevalence in Chinese children. During 2009-2013, a cross-sectional study of 59,754 children aged 2-17 years was conducted in northeast China. Tencent street view images surrounding participants' schools were segmented by a deep learning model, and streetscape greenness was extracted. The green view index (GVI) was used to assign exposure and higher value indicates more green coverage. Mixed-effects logistic regression models were used to calculate the adjusted odds of asthma per interquartile range (IQR) increase of GVI for trees and grass. Participants were further stratified to investigate whether particulate matter with an aerodynamic diameter <2.5 µm (PM2.5) was a modifier. An IQR increase in GVI800m for trees was associated with lower adjusted odds of doctor-diagnosed asthma (OR: 0.76; 95%CI: 0.72-0.80) and current asthma (OR: 0.82; 95%CI: 0.75-0.89). An IQR increase in GVI800m for grass was associated with higher adjusted odds of doctor-diagnosed asthma (OR: 1.04; 95%CI: 1.00-1.08) and current asthma (OR: 1.08; 95%CI: 1.02-1.14). After stratification by PM2.5 exposure level, the negative association between trees and asthma, and the positive association between grass and asthma were observed only in low PM2.5 exposure levels (≤median: 56.23 µg/m3). Our results suggest that types of vegetation may play a role in the association between greenness exposure and childhood asthma. Exposure to trees may reduce the odds of childhood asthma, whereas exposure to grass may increase the odds. Additionally, PM2.5 may modify the associations of trees and grass with childhood asthma.

Different sized particles associated with all-cause and cause-specific emergency ambulance calls: A multicity time-series analysis in China.

BACKGROUND: Compared with mortality and hospital admission, emergency ambulance calls (EACs) could be a more accurate outcome indicator to reflect the health effects of short-term air pollution exposure. However, such studies have been scarce, especially on a multicity scale in China. METHODS: We estimated the associations of different diameter particles [i.e., inhalable particulate matter (PM10), coarse particulate matter (PMc), and fine particulate matter (PM2.5)] with EACs for all-cause, cardiovascular, and respiratory diseases in seven Chinese cities. We collected data on EACs and air pollution from 2014 to 2019. We used generalized additive models and random-effects meta-analysis to examine the city-specific and overall associations. Stratified analyses were conducted to examine the effect modifications of gender, age, and season. RESULTS: Significant associations of PM10 and PM2.5 with EACs were observed, while the PMc associations were positive but not statistically significant in most analyses. Specifically, each 10 µg/m3 increase in 2-day moving average concentration of PM10 was associated with a 0.25% [95% confidence interval (CI): 0.04%, 0.47%] increase in all-cause EACs, 0.13% (95% CI: -0.01%, 0.26%) in cardiovascular EACs, and 0.35% (95% CI: 0.04%, 0.66%) in respiratory EACs. The corresponding increases in daily EACs for PM2.5 were 0.30% (95% CI, 0.03%, 0.57%), 0.13% (95% CI, -0.07%, 0.33%), and 0.46% (95% CI, 0.01%, 0.92%). Season of the year also modifies the association between particulate matter pollution and EACs. CONCLUSIONS: Short-term exposure to PM10 and PM2.5 were positively associated with daily all-cause and respiratory-related EACs. The associations were stronger during warm season than cold season. Our findings suggest that the most harmful fraction of particulate matter pollution is PM2.5, which has important implications for current air quality guidelines and regulations in China.

Prolonged Life Expectancy for Those Dying of Stroke by Achieving the Daily PM2.5 Targets.

This time-series study collects data on stroke-related mortality, years of life lost (YLL), air pollution, and meteorological conditions in 96 Chinese cities from 2013 to 2016 and proposes a three-stage strategy to generate the national and regional estimations of avoidable YLL, gains in life expectancy and stroke-related population attributable fraction by postulating that the daily fine particulate matter (PM2.5) has been kept under certain standards. A total of 1 318 911 stroke deaths are analyzed. Each 10 µg m-3 increment in PM2.5 at lag03 is associated with a city-mean increase of 0.31 (95% CI: 0.19, 0.44) years of life lost from stroke. A number of 914.11 (95% CI: 538.28, 1288.94) years of city-mean life lost from stoke could be avoided by attaining the WHO's Air Quality Guidelines (AQG) (25 µg m-3). Moreover, by applying the AQG standard, 0.11 (0.08, 0.15) years of life lost might be prevented for each death, and about 0.91% (95% CI: 0.62%, 1.19%) of the total years of life lost from stroke might be explained by the daily excess PM2.5 exposure. This study indicates that stroke patients can have a longer life expectancy if stricter PM2.5 standards are put in place, especially ischemic stroke patients.

Investigation of simple, objective, and effective indicators for predicting acute paraquat poisoning outcomes.

Initial symptoms of paraquat (PQ) toxicity are often not obvious, and the lack of advanced testing equipment and medical conditions in the primary hospital make it difficult to provide early diagnosis and timely treatment. To explore simple, objective, and effective indicators of prognosis for primary clinicians, we retrospectively analyzed acute PQ poisoning in 190 patients admitted to our hospital from 2008 to 2017. Based on their condition at the time of discharge, patients were categorized into either the survival group (n = 71) or the mortality group (n = 119). Age, PQ ingested amount, urinary PQ, urinary protein, white blood cell (WBC), and serum creatinine (Cr) were the key factors associated with the prognosis for PQ poisoning. We identified specific diagnostic thresholds for these key indicators of PQ poisoning: PQ ingested amount (36.50 mL), urinary PQ (semiquantitative result "++"), urinary protein (semiquantitative result "±"), WBC (16.50 × 109/L), and serum Cr (102.10 µmol/L). Combining these five indicators to identify poisoning outcomes was considered objective, accurate, and convenient. When the combined score was <1, the predicted probability of patient death was 6%. When the combined score was ≥3, the predicted probability of patient death was 96%. These findings provide metrics to assist primary clinicians in predicting outcomes of acute PQ poisoning at earlier stages, a basis for administering treatment.

The mediation effect of maternal glucose on the association between ambient air pollution and birth weight in Foshan, China.

Maternal blood glucose level is associated with fetal growth, therefore, its role in the associations between air pollution and birth weight deserves investigation. We examined the mediation effect of maternal blood glucose on the associations between maternal air pollution exposure and birth weight. A total of 10,904 pregnant women in Foshan, China during 2015-2019 were recruited. Oral glucose tolerance test (OGTT) was administered to each participant after late trimester 2. Air pollution data at the monitoring stations in residential districts was used to estimate exposures of each participant during trimester 1 and trimester 2. Mixed-effects linear models were used to estimate the associations between air pollution and birth weight. After controlling for ten covariates, the direct effect of PM2.5 and SO2 (each 10 µg/m3 increment) on birth weight was -15.7 g (95% CI: -29.4, -4.8 g) and -83.6 g (95% CI: -134.8, -33.0 g) during trimester 1. The indirect effect of PM2.5 and SO2 (each 10 µg/m3 increment) on birth weight by increasing maternal fasting glucose level was 6.6 g (95% CI: 4.6, 9.1 g) and 22.0 g (95% CI: 4.1, 44.0 g) during trimester 1. Our findings suggest that air pollution might affect the birth weight through direct and indirect pathway, and the indirect effect might be mediated by maternal blood glucose.