Global Burden and Trends of Primary Liver Cancer Attributable to Comorbid Type 2 Diabetes Mellitus Among People Living with Hepatitis B: An Observational Trend Study from 1990 to 2019.

BACKGROUND: Type 2 diabetes mellitus (T2DM) increases the risk of liver cancer among people living with hepatitis B virus (HBV). Our study aimed to estimate the global burden and trends of liver cancer attributable to comorbid T2DM among people living with HBV from 1990 to 2019. METHODS: We calculated the population attributable fractions (PAFs) of liver cancer attributable to comorbid T2DM among the burden of HBV-related liver cancer. We applied the PAFs to the burden of HBV-related liver cancer derived from the Global Burden of Disease (GBD) 2019 database to obtain the burden of liver cancer attributable to HBV-T2DM comorbidity. The prevalence, disability-adjusted life year (DALY), and deaths of liver cancer attributable to the comorbidity were assessed at the global, regional, and country levels and then stratified by the sociodemographic index (SDI), sex, and age group. Estimated annual percentage changes (EAPCs) were calculated to quantify the temporal trends. RESULTS: In 2019, the global age-standardized prevalence and DALY rates of liver cancer attributable to HBV-T2DM comorbidity were 9.9 (8.4-11.5) and 182.4 (154.9-212.7) per 10,000,000 individuals, respectively. High-income Asia Pacific and East Asia had the highest age-standardized prevalence and DALY rates of liver cancer attributable to HBV-T2DM comorbidity, respectively. From 1990 to 2019, age-standardized prevalence and DALY rates increased in 16 out of 21 GBD regions. High-income North America had the largest annual increases in both age-standardized prevalence rates (EAPC = 6.07; 95% UI, 5.59 to 6.56) and DALY rates (EAPC = 4.77; 95% UI, 4.35 to 5.20), followed by Australasia and Central Asia. Across all SDI regions, the high SDI region exhibited the most rapid increase in age-standardized prevalence and DALY rates from 1990 to 2019. Additionally, men had consistently higher disease burdens than women across all age groups. The patterns of mortality burden and trends are similar to those of DALYs. CONCLUSIONS: The burden of liver cancer attributable to comorbid T2DM among people living with HBV has exhibited an increasing trend across most regions over the last three decades. Tailored prevention strategies targeting T2DM should be implemented among individuals living with HBV.

Relationships between long-term exposure to major PM2.5 constituents and outpatient visits and hospitalizations in Guangdong, China.

Ambient fine particulate matter (PM2.5) has attracted considerable attention due to its crucial role in the rising global disease burden. Evidence of health risks associated with exposure to PM2.5 and its major constituents is important for advancing hazard assessments and air pollution emission policies. We investigated the relationship between exposure to major constituents of PM2.5 and outpatient visits as well as hospitalizations in Guangdong Province, China, where 127 million residents live in a severe PM2.5 pollution environment. An approach that integrates the generalized weighted quantile sum (gWQS) regression with the difference-in-differences (DID) approach was used to assess the overall mixture effects and relative contributions of each constituent. We observed significant associations between long-term exposure to the mixture of PM2.5 constituents (WQS index) and outpatient visits (IR%, percentage increases in risk per unit WQS index increase:1.73, 95%CI: 1.72, 1.74) as well as hospitalizations (IR%:5.15, 95%CI: 5.11, 5.20). Black carbon (weight: 0.34) and nitrate (weight: 0.60) respectively exhibited the highest contributions to outpatient visits and hospitalizations. The overall mixture effects on outpatient visits and hospitalizations were higher with increased summer air temperatures (IR%: 7.54, 95%CI: 7.33, 7.74 and IR%: 9.55, 95%CI: 8.36, 10.75, respectively) or decreased winter air temperatures (IR%: 1.88, 95%CI: 1.68, 2.08 and IR%: 4.87, 95%CI: 3.73, 6.02, respectively). Furthermore, the overall mixture effects on outpatient visits and hospitalizations were significantly higher in populations with higher socioeconomic status (P < 0.01). It's crucial to address the primary sources of nitrate precursor substances and black carbon (mainly traffic-related and industrial-related air pollutants) and consider the complex interaction effects between air temperature and PM2.5 in the context of climate change. Of particular concern is the need to prioritize healthcare demands in economically disadvantaged regions and to address the health inequalities stemming from the uneven distribution of healthcare resources and PM2.5 pollution.

Unveiling causal connections: Long-term particulate matter exposure and type 2 diabetes mellitus mortality in Southern China.

Evidence of the potential causal links between long-term exposure to particulate matters (PM, i.e., PM1, PM2.5, and PM1-2.5) and T2DM mortality based on large cohorts is limited. In contrast, the existing evidence usually suffers from inherent bias with the traditional association assessment. A prospective cohort of 580,757 participants in the southern region of China were recruited during 2009 and 2015 and followed up through December 2020. PM exposure at each residential address was estimated by linking to the well-established high-resolution simulation dataset. Hazard ratios (HRs) were calculated using time-varying marginal structural Cox models, an established causal inference approach, after adjusting for potential confounders. During follow-up, a total of 717 subjects died from T2DM. For every 1 µg/m3 increase in PM2.5, the adjusted HRs and 95% confidence interval (CI) for T2DM mortality was 1.036 (1.019-1.053). Similarly, for every 1 µg/m3 increase in PM1 and PM1-2.5, the adjusted HRs and 95% CIs were 1.032 (1.003-1.062) and 1.085 (1.054-1.116), respectively. Additionally, we observed a generally more pronounced impact among individuals with lower levels of education or lower residential greenness which as measured by the Normalized Difference Vegetation Index (NDVI). We identified substantial interactions between NDVI and PM1 (P-interaction = 0.003), NDVI and PM2.5 (P-interaction = 0.019), as well as education levels and PM1 (P-interaction = 0.049). The study emphasizes the need to consider environmental and socio-economic factors in strategies to reduce T2DM mortality. We found that PM1, PM2.5, and PM1-2.5 heighten the peril of T2DM mortality, with education and green space exposure roles in modifying it.

Analysis of health service utilization and influencing factors due to COVID-19 in Beijing: a large cross-sectional survey.

BACKGROUND: In the wake of China's relaxed zero-COVID policy, there was a surge in coronavirus disease 2019 (COVID-19) infections. This study aimed to examine the infection status and health service utilization among Beijing residents during a widespread outbreak, and to explore the factors that affected utilization of health services due to COVID-19. METHODS: A cross-sectional survey was conducted among Beijing residents from 13 January to 13 February 2023, collecting information on socio-demographic characteristics, health behaviours, COVID-19 infection status, utilization of health services and depressive symptoms. Multivariate Tobit regression was used for data analysis. RESULTS: Among the 53 924 participants, 14.7% were older than 60 years, 63.7% were female and 84.8% were married. In total, 44 992 of the 53 924 individuals surveyed (83.4%) contracted COVID-19 during 2020-2023, and 25.2% (13 587) sought corresponding health services. The majority of individuals (85.6%) chose in-person healthcare, while 14.4% chose internet-based healthcare. Among those who chose in-person healthcare, 58.6% preferred primary healthcare institutions and 41.5% were very satisfied with the treatment. Factors affecting health service utilization include being female (ß = -0.15, P < 0.001), older than 60 years (ß = 0.23, P < 0.01), non-healthcare workers (ß = -0.60, P < 0.001), rich self-rated income level (ß = 0.59, P < 0.001), having underlying disease (ß = 0.51, P < 0.001), living alone (ß = -0.19, P < 0.05), depressive symptoms (ß = 0.06, P < 0.001) and healthy lifestyle habits, as well as longer infection duration, higher infection numbers and severe symptoms. CONCLUSION: As COVID-19 is becoming more frequent and less severe, providing safe and accessible healthcare remains critical. Vulnerable groups such as the elderly and those with underlying conditions need reliable health service. Prioritizing primary healthcare resources and online medical services have played a vital role in enhancing resource utilization efficiency.

Revisiting the complex time-varying effect of non-pharmaceutical interventions on COVID-19 transmission in the United States.

Introduction: Although the global COVID-19 emergency ended, the real-world effects of multiple non-pharmaceutical interventions (NPIs) and the relative contribution of individual NPIs over time were poorly understood, limiting the mitigation of future potential epidemics. Methods: Based on four large-scale datasets including epidemic parameters, virus variants, vaccines, and meteorological factors across 51 states in the United States from August 2020 to July 2022, we established a Bayesian hierarchical model with a spike-and-slab prior to assessing the time-varying effect of NPIs and vaccination on mitigating COVID-19 transmission and identifying important NPIs in the context of different variants pandemic. Results: We found that (i) the empirical reduction in reproduction number attributable to integrated NPIs was 52.0% (95%CI: 44.4, 58.5%) by August and September 2020, whereas the reduction continuously decreased due to the relaxation of NPIs in following months; (ii) international travel restrictions, stay-at-home requirements, and restrictions on gathering size were important NPIs with the relative contribution higher than 12.5%; (iii) vaccination alone could not mitigate transmission when the fully vaccination coverage was less than 60%, but it could effectively synergize with NPIs; (iv) even with fully vaccination coverage >60%, combined use of NPIs and vaccination failed to reduce the reproduction number below 1 in many states by February 2022 because of elimination of above NPIs, following with a resurgence of COVID-19 after March 2022. Conclusion: Our results suggest that NPIs and vaccination had a high synergy effect and eliminating NPIs should consider their relative effectiveness, vaccination coverage, and emerging variants.

Long-term PM1 exposure and hypertension hospitalization: A causal inference study on a large community-based cohort in South China.

Limited evidence exists on the effect of submicronic particulate matter (PM1) on hypertension hospitalization. Evidence based on causal inference and large cohorts is even more scarce. In 2015, 36,271 participants were enrolled in South China and followed up through 2020. Each participant was assigned single-year, lag0-1, and lag0-2 moving average concentration of PM1 and fine inhalable particulate matter (PM2.5) simulated based on satellite data at a 1-km resolution. We used an inverse probability weighting approach to balance confounders and utilized a marginal structural Cox model to evaluate the underlying causal links between PM1 exposure and hypertension hospitalization, with PM2.5-hypertension association for comparison. Several sensitivity studies and the analyses of effect modification were also conducted. We found that a higher hospitalization risk from both overall (HR: 1.13, 95% CI: 1.05-1.22) and essential hypertension (HR: 1.15, 95% CI: 1.06-1.25) was linked to each 1 µg/m3 increase in the yearly average PM1 concentration. At lag0-1 and lag0-2, we observed a 17%-21% higher risk of hypertension associated with PM1. The effect of PM1 was 6%-11% higher compared with PM2.5. Linear concentration-exposure associations between PM1 exposure and hypertension were identified, without safety thresholds. Women and participants that engaged in physical exercise exhibited higher susceptibility, with 4%-22% greater risk than their counterparts. This large cohort study identified a detrimental relationship between chronic PM1 exposure and hypertension hospitalization, which was more pronounced compared with PM2.5 and among certain groups.

Assessing the effectiveness of the expanded hepatitis A vaccination program in China: an interrupted time series design.

INTRODUCTION: China initialised the expanded hepatitis A vaccination programme (EHAP) in 2008. However, the effectiveness of the programme remains unclear. We aimed to comprehensively evaluate the effectiveness of EHAP in the country. METHODS: Based on the provincial data on the incidence of hepatitis A (HepA), the population and meteorological variables in China, we developed interrupted time series (ITS) models to estimate the effectiveness of EHAP with the autocorrelation, seasonality and the meteorological confounders being controlled. Results were also stratified by economic zones, age groups and provinces. RESULTS: We found a 0.9% reduction (RR=0.991, 95% CI: 0.990 to 0.991) in monthly HepA incidence after EHAP, which was 0.3% greater than the reduction rate before EHAP in China. Across the three economic regions, we found a 1.1% reduction in HepA incidence in both central and western regions after EHAP, which were 0.3% and 1.2% greater than the reduction rates before EHAP, respectively. We found a decreased reduction rate for the eastern region. In addition, we found generally increased reduction rate after EHAP for age groups of 0-4, 5-14 and 15-24 years. However, we found decreased reduction rate among the 25-64 and ≥65 years groups. We found a slight increased rate after EHAP in Shanxi Province but not elsewhere. CONCLUSION: Our finding provides comprehensive evidence on the effectiveness of EHAP in China, particularly in the central and western regions, and among the population aged 0-24 years old. This study has important implications for the adjustment of vaccination strategies for other regions and populations.

Predicting the incidence of infectious diarrhea with symptom surveillance data using a stacking-based ensembled model.

BACKGROUND: Infectious diarrhea remains a major public health problem worldwide. This study used stacking ensemble to developed a predictive model for the incidence of infectious diarrhea, aiming to achieve better prediction performance. METHODS: Based on the surveillance data of infectious diarrhea cases, relevant symptoms and meteorological factors of Guangzhou from 2016 to 2021, we developed four base prediction models using artificial neural networks (ANN), Long Short-Term Memory networks (LSTM), support vector regression (SVR) and extreme gradient boosting regression trees (XGBoost), which were then ensembled using stacking to obtain the final prediction model. All the models were evaluated with three metrics: mean absolute percentage error (MAPE), root mean square error (RMSE), and mean absolute error (MAE). RESULTS: Base models that incorporated symptom surveillance data and weekly number of infectious diarrhea cases were able to achieve lower RMSEs, MAEs, and MAPEs than models that added meteorological data and weekly number of infectious diarrhea cases. The LSTM had the best prediction performance among the four base models, and its RMSE, MAE, and MAPE were: 84.85, 57.50 and 15.92%, respectively. The stacking ensembled model outperformed the four base models, whose RMSE, MAE, and MAPE were 75.82, 55.93, and 15.70%, respectively. CONCLUSIONS: The incorporation of symptom surveillance data could improve the predictive accuracy of infectious diarrhea prediction models, and symptom surveillance data was more effective than meteorological data in enhancing model performance. Using stacking to combine multiple prediction models were able to alleviate the difficulty in selecting the optimal model, and could obtain a model with better performance than base models.

Assessing the impact of comorbid type 2 diabetes mellitus on the disease burden of chronic hepatitis B virus infection and its complications in China from 2006 to 2030: a modeling study.

BACKGROUND: China bears a high burden of both hepatitis B virus (HBV) infection and type 2 diabetes mellitus (T2DM). T2DM accelerates the progression of liver disease among individuals infected with HBV. This study aims to assess the excess disease burden caused by comorbid T2DM among HBV-infected individuals in China. METHODS: We estimated the disease burden of HBV and its complications in China from 2006 to 2030 using individual-based Markov models. The baseline population consisted of 93 million HBV-infected individuals derived from the 2006 National Serological Epidemiological Survey. We developed two models: one incorporated the impact of T2DM on the disease progression of HBV infection, while the other did not consider the impact of T2DM. By comparing the outcomes between these two models, we estimated the excess disease burden attributable to comorbid T2DM among HBV-infected individuals. RESULTS: The incidence of severe HBV complications, including cirrhosis, hepatocellular carcinoma (HCC), and liver-related deaths, exhibited an increasing trend from 2006 to 2030 among the Chinese HBV-infected population. Comorbid T2DM increased the annual incidence and cumulative cases of severe HBV complications. From 2006 to 2022, comorbid T2DM caused 791,000 (11.41%), 244,000 (9.27%), 377,000 (8.78%), and 796,000 (12.19%) excess cases of compensated cirrhosis, decompensated cirrhosis, HCC, and liver-related deaths, respectively. From 2023 to 2030, comorbid T2DM is projected to result in an 8.69% excess in severe HBV complications and an 8.95% increase in liver-related deaths. Among individuals aged 60 and older at baseline, comorbid T2DM led to a 21.68% excess in severe HBV complications and a 28.70% increase in liver-related deaths from 2006 to 2022, with projections indicating a further 20.76% increase in severe HBV complications and an 18.31% rise in liver-related deaths over the next seven years. CONCLUSIONS: Comorbid T2DM imposes a substantial disease burden on individuals with HBV infection in China. Healthcare providers and health policymakers should develop and implement tailored strategies for the effective management and control of T2DM in individuals with HBV infection.

Spatial-temporal distribution of preterm birth in China, 1990-2020: A systematic review and modelling analysis.

BACKGROUND: Little is known about the long-term trends of preterm birth rates in China and their geographic variation by province. OBJECTIVES: To estimate the annual spatial-temporal distribution of preterm birth rates in China by province from 1990 to 2020. DATA SOURCES: We searched PubMed, EMBASE, Web of Science, CNKI, WANFANG and VIP from January 1990 to September 2023. STUDY SELECTION AND DATA EXTRACTION: Studies that provided data on preterm births in China after 1990 were included. Data were extracted following the Guidelines for Accurate and Transparent Health Estimates Reporting. SYNTHESIS: We assessed the quality of each survey using a 9-point checklist. We estimated the annual preterm birth risk by province using Bayesian multilevel logistic regression models considering potential socioeconomic, environmental, and sanitary predictors. RESULTS: Based on 634 survey data from 343 included studies, we found a gradual increase in the preterm birth risk in most provinces in China since 1990, with an average annual increase of 0.7% nationally. However, the preterm birth rates in Inner Mongolia, Hubei, and Fujian Province showed a decline, while those in Sichuan were quite stable since 1990. In 2020, the estimates of preterm birth rates ranged from 2.9% (95% Bayesian credible interval [BCI] 2.1, 3.8) in Inner Mongolia to 8.5% (95% BCI 6.6, 10.9) in Jiangxi, with the national estimate of 5.9% (95% BCI 4.3, 8.1). Specifically, some provinces were identified as high-risk provinces for either consistently high preterm birth rates (e.g. Jiangxi) or relatively large increases (e.g. Shanxi) since 1990. CONCLUSIONS: This study provides annual information on the preterm birth risk in China since 1990 and identifies high-risk provinces to assist in targeted control and intervention for this health issue.

Potential causal links and mediation pathway between urban greenness and lung cancer mortality: Result from a large cohort (2009 to 2020).

Urban greenness, as a vital component of the urban environment, plays a critical role in mitigating the adverse effects of rapid urbanization and supporting urban sustainability. However, the causal links between urban greenness and lung cancer mortality and its potential causal pathway remain poorly understood. Based on a prospective community-based cohort with 581,785 adult participants in southern China, we applied a doubly robust Cox proportional hazard model to estimate the causal associations between urban greenness exposure and lung cancer mortality. A general multiple mediation analysis method was utilized to further assess the potential mediating roles of various factors including particulate matter (PM1, PM2.5-1, and PM10-2.5), temperature, physical activity, and body mass index (BMI). We observed that each interquartile range (IQR: 0.06) increment in greenness exposure was inversely associated with lung cancer mortality, with a hazard ratio (HR) of 0.89 (95 % CI: 0.83, 0.96). The relationship between greenness and lung cancer mortality might be partially mediated by particulate matter, temperature, and physical activity, yielding a total indirect effect of 0.826 (95 % CI: 0.769, 0.887) for each IQR increase in greenness exposure. Notably, the protective effect of greenness against lung cancer mortality could be achieved primarily by reducing the particulate matter concentration.

The impact of long-term PM1 exposure on all-cause mortality and its interaction with BMI: A nationwide prospective cohort study in China.

BACKGROUND: China has a serious air pollution problem and a high prevalence of obesity. The interaction between the two and its impact on all-cause mortality is a public health issue of great concern. OBJECTIVES: This study aimed to investigate the association between long-term exposure to particulate matter with aerodynamic diameter ≤ 1 µm (PM1) and all-cause mortality, as well as the interaction effect of body mass index (BMI) in the association. METHODS: A total of 33,087 participants from 162 counties in 25 provinces in China were included, with annual average PM1 exposure being estimated based on the county address. The PM1-mortality relation was evaluated using the time-varying Cox proportional hazards models, with the dose-response relationship being fitted using the penalized splines. Besides, the potential interaction effect of BMI in the PM1-mortality relation was evaluated. RESULTS: The incidence of all-cause deaths was 76.99 per 10,000 person-years over a median of 8.2 years of follow-up. After controlling for potential confounders, the PM1-mortality relation was approximately J-shaped. The full-adjustment analysis observed the hazard ratio (HR) of all-cause mortality was 1.114 [95 % confidence interval (CI): 1.017-1.220] corresponding to a 10 µg/m3 rise in PM1 concentration. Further stratified analyses suggested the adverse effects of PM1 might be more pronounced among the underweight. DISCUSSION: Higher PM1 concentrations were associated with an increase in all-cause mortality. The BMI might further alter the relation, and the underweight population was the sensitive subgroup of the population that needed to be protected.

The role of illness-related cognition in the relationships between resilience and depression/anxiety in nasopharyngeal cancer patients.

OBJECTIVE: Resilience has been reported as an important predictor of better mental health and prognoses in cancer patients, while its mechanisms were not clearly elucidated. In this study, we surveyed a large sample of nasopharyngeal carcinoma patients to investigate the mediating role of illness-related cognition (illness perception, stigma and meaning in life) on the associations between resilience and symptoms of anxiety and depression. METHODS: This cross-sectional study involved 773 participants diagnosed with nasopharyngeal carcinoma. Participants completed a self-reported structured questionnaire to assess their illness perception, stigma and meaning in life, resilience and symptoms of anxiety and depression. Structural equation models (SEM) were employed to explore the relationship between resilience and symptoms of anxiety and depression in the entire sample, as well as in two subgroups: Subgroup I (0-1 year since diagnosis), and Subgroup II (over 1 year since diagnosis). RESULTS: In the entire sample, after adjusting for potential confounders, illness perception, stigma and meaning in life were found to mediate the protective effect of resilience on symptoms of depression (mediating effect proportion: 65.25%) and anxiety (mediating effect proportion: 67.63%). In Subgroup I, direct effects were dominant in the associations between resilience and symptoms of anxiety (mediating effect proportion: 37.95%) and depression (mediating effect proportion: 29.13%). However, in Subgroup II, the associations between resilience and symptoms of anxiety (mediating effect proportion: 98.92%) and depression (mediating effect proportion: 81.04%) were completely mediated. CONCLUSIONS: Our study suggests that direct and indirect effects of resilience on depression and anxiety dominate in early periods (0-1 year) and long-term periods (over 1 year) following the cancer diagnosis, respectively. The findings indicate that comprehensive intervention considering both the direct effect of resilience in early stages (e.g., health education prescription and social support groups) and the indirect effects of illness cognition in long-term periods (e.g., cognitive behavioral therapies) are likely to yield the most favorable outcomes for cancer patients.

Long-term particulate matter exposure and the risk of neurological hospitalization: Evidence from causal inference of a large longitudinal cohort in South China.

With limited evidence on the neurological impact of particulate matter (PM) exposure in China, particularly for PM1 which is smaller but more toxic, we conducted a large Chinese cohort study using causal inference approaches to comprehensively clarify such impact. A total of 36,271 participants in southern China were recruited in 2015 and followed up through 2020. We obtained the neurological hospitalizations records by linking the cohort data to the electronic reports from 418 medical institutions across the study area. By using high-resolution PM concentrations from satellite-based spatiotemporal models and the cohort data, we performed marginal structural Cox models under causal assumptions to assess the potential causal links between time-varying PM exposure and neurological hospitalizations. Our findings indicated that increasing PM1, PM2.5, and PM10 concentrations by 1 µg/m³ were associated with higher overall neurological hospitalization risks, with hazard ratios (HRs) of 1.10 (95% confidence interval (CI) 1.04-1.16), 1.09 (95% CI 1.04-1.14), and 1.03 (95% CI 1.00-1.06), respectively. PM1 appeared to have a stronger effect on neurological hospitalization, with a 1% and 7% higher impact compared to PM2.5 and PM10, respectively. Additionally, each 1-µg/m3 increase in the annual PM1 concentration was associated with an elevated risk of hospitalizations for ischemic stroke (HR: 1.15; 95% CI, 1.06-1.26), which tended to be larger than the estimates for PM2.5 (HR: 1.13, 95% CI, 1.04-1.23) and PM10 (HR: 1.05, 95% CI, 1.00-1.09). Furthermore, never-married or female individuals tended be at a greater risk compared with their counterparts. Our study provides important insights into the health impact of particles, particularly smaller particles, on neurological hospitalization risk and highlights the need for clean-air policies that specifically target these particles.

The complex role of air pollution on the association between greenness and respiratory mortality: Insight from a large cohort, 2009-2020.

BACKGROUND: Although emerging studies have illuminated the protective association between greenness and respiratory mortality, efforts to quantify the potentially complex role of air pollution in the causal pathway are still limited. We aimed to examine the potential roles of air pollution in the causal pathway between greenness and respiratory mortality in China. METHODS: We used data from a community-based prospective cohort of 654,115 participants in southern China (Jan 2009-Dec 2020). We evaluated the greenness exposure as a three-year moving average Normalized Difference Vegetation Index (NDVI) within the 500 m buffer around the residence. Cox proportional hazards model was applied to estimate the association between greenness and respiratory mortality. Causal mediation analysis combined with a four-way dimensional decomposition method was utilized to simultaneously quantify the interaction and mediation role of air pollution including PM2.5, PM10, or NO2 on the greenness-respiratory mortality relationship. FINDINGS: We observed 6954 respiratory deaths during 12 years of follow-up. Increasing NDVI level from the lowest to the highest quartile is associated with a 19 % (95%CI: 13-25 %) reduction in the respiratory mortality risk. For the total protective effect, the proportion attributable to the overall negative interaction between greenness and air pollution (PM2.5, PM10, or NO2) was 2.2 % (1.7-3.2 %), 3.5 % (0.4-3.7 %), or 25.0 % (22.8-27.1 %), respectively. Simultaneously, we estimated 25.5 % (20.1-32.0 %), 49.5 % (32.5-71.9 %), or 1.0 % (0.8-1.2 %) of the total protective association was mediated through a reduction in PM2.5, PM10, or NO2, respectively. INTERPRETATION: Increased greenness exposure mitigated respiratory mortality through both the antagonistic interaction and mediation pathway of air pollution (PM2.5, PM10, or NO2).

Is COPD mortality in South China causally linked to the long-term PM1 exposure? Evidence from a large community-based cohort.

BACKGROUND: Long-term ambient particulate matter (PM) exposure has been found associated with chronic obstructive pulmonary disease (COPD) mortality in an increasing body of research. However, limited evidence was available on the potential causal links between PM1 and COPD mortality, especially in highly exposed areas. OBJECTIVES: To examine the COPD mortality risk following long-term ambient PM1 exposure in south China. METHODS: The cohort included 580,757 participants recruited during 2009-2015. Satellite-based annual concentrations of PM1 were estimated at a spatial resolution of 1 km × 1 km and assigned to each participant based on their residential addresses. We analyzed the potential causal links between time-varying PM1 exposure and COPD mortality using marginal structural cox models within causal frameworks. Stratified analyses were also performed to identify the potential susceptible groups. RESULTS: The annual average PM1 concentration continuously decreased over time. After adjusting for confounders, each 1 µg/m3 increase in PM1 concentration corresponded to an 8.1 % (95% confidence interval: 6.4-9.9 %) increment in the risk of COPD mortality. The impact of PM1 was more pronounced among the elderly and those with low exercise frequency, with a 1.9-6.9 % higher risk than their counterparts. We further observed a 0.1-9.7 % greater risk among those who lived in lower greenness settings. Additionally, we observed higher effect estimates in participants with long-term low PM1 exposure compared to the general population. CONCLUSIONS: COPD mortality risk significantly increased following long term ambient PM1 exposure, particularly among groups with certain demographics or long-term low exposure.

Prevalence and trends of polypharmacy in U.S. adults, 1999-2018.

BACKGROUND: Polypharmacy is one of the most important health issues for its potential impacts on disease burden and healthcare costs. The aim of this study was to update a comprehensive picture of prevalence and trends in polypharmacy over 20 years in U.S. adults. METHODS: Participants included 55,081 adults aged ≥ 20 from the National Health and Nutrition Examination Survey, January 1, 1999, through December 31, 2018. The simultaneously use of ≥ 5 drugs in one individual was defined as polypharmacy. National prevalence and trends in polypharmacy were evaluated among U.S. adults within different demo-socioeconomic status and pre-existing diseases. RESULTS: From 1999-2000 to 2017-2018, the overall percentages of adults with polypharmacy remained on the rise, increasing from 8.2% (7.2-9.2%) to 17.1% (15.7-18.5%) (average annual percentage change [AAPC] = 2.9%, P = .001). The polypharmacy prevalence was considerably higher in the elderly (from 23.5% to 44.1%), in adults with heart disease (from 40.6% to 61.7%), and in adults with diabetes (from 36.3% to 57.7%). Also, we observed a greater increase rate of polypharmacy in men (AAPC = 4.1%, P < .001), in the Mexican American (AAPC = 6.3%, P < .001), and in the non-Hispanic Black (AAPC = 4.4%, P < .001). CONCLUSIONS: From 1999-2000 to 2017-2018, the prevalence of polypharmacy is continually increasing in U.S. adults. The polypharmacy was especially higher in the older, in patients with heart disease, or diabetes. The high prevalence urges the healthcare providers and health policymakers to manage polypharmacy among specific population groups.

Impact and Cost-Effectiveness of Biomedical Interventions on Adult Hepatitis B Elimination in China: A Mathematical Modelling Study.

BACKGROUND: China has one of the highest hepatitis B virus (HBV) disease burdens worldwide and tracking progress toward the 2030 HBV elimination targets is essential. This study aimed to assess the impact of biomedical interventions (i.e., adult vaccination, screening and treatment) on the adult HBV epidemic, estimate the time for HBV elimination, and evaluate the cost-effectiveness of the interventions in China. METHODS: A deterministic compartmental model was developed to project the HBV epidemic from 2022 to 2050 and estimate the time to meet elimination targets under four intervention scenarios. Cost-effectiveness was calculated using incremental cost per quality-adjusted life year (QALY) gained, i.e., average cost-effectiveness ratio (CER). RESULTS: Under the status quo, there will be 42.09-45.42 million adults living with HBV in 2050 and 11.04-14.36 million HBV-related deaths cumulatively from 2022 to 2050. Universal vaccination would cumulatively avert 3.44-3.95 million new cases at a cost of US$1027-1261/QALY gained. The comprehensive strategy would cumulatively avert 4.67-5.24 million new chronic cases and 1.39-1.85 million deaths, expediting the realization of the elimination targets forward to 2049. This strategy was also cost-effective with an average CER of US$20,796-26,685/QALY and a saved healthcare cost of US$16.10-26.84 per person. CONCLUSION: China is not on track to meet the elimination targets but comprehensive biomedical interventions can accelerate the realization of the targets. A comprehensive strategy is cost-effective and cost-saving, which should be promoted in primary care infrastructures. Universal adult vaccination may be appropriate in the near future considering practical feasibility.

Uptake of an App-Based Case Management Service for HIV-Positive Men Who Have Sex With Men in China: Process Evaluation Study.

BACKGROUND: Men who have sex with men (MSM) in China are disproportionately affected by the HIV epidemic, and medication adherence to antiretroviral treatment in this vulnerable population is suboptimal. To address this issue, we developed an app-based case management service with multiple components, informed by the Information Motivation Behavioral skills model. OBJECTIVE: We aimed to conduct a process evaluation for the implementation of an innovative app-based intervention guided by the Linnan and Steckler framework. METHODS: Process evaluation was performed alongside a randomized controlled trial in the largest HIV clinic in Guangzhou, China. Eligible participants were HIV-positive MSM aged ≥18 years planning to initiate treatment on the day of recruitment. The app-based intervention had 4 components: web-based communication with case managers, educational articles, supportive service information (eg, information on mental health care and rehabilitation service), and hospital visit reminders. Process evaluation indicators of the intervention include dose delivered, dose received, fidelity, and satisfaction. The behavioral outcome was adherence to antiretroviral treatment at month 1, and Information Motivation Behavioral skills model scores were the intermediate outcome. Logistic and linear regression was used to investigate the association between intervention uptake and outcomes, controlling for potential confounders. RESULTS: A total of 344 MSM were recruited from March 19, 2019, to January 13, 2020, and 172 were randomized to the intervention group. At month 1 follow-up, there was no significant difference in the proportion of adherent participants between the intervention and control groups (66/144, 45.8% vs 57/134, 42.5%; P=.28). In the intervention group, 120 participants engaged in web-based communication with case managers and 158 accessed at least 1 of the delivered articles. The primary concern captured in the web-based conversation was the side effects of the medication (114/374, 30.5%), which was also one of the most popular educational articles topics. The majority (124/144, 86.1%) of participants that completed the month 1 survey rated the intervention as "very helpful" or "helpful." The number of educational articles accessed was associated with adequate adherence in the intervention group (odds ratio 1.08, 95% CI 1.02-1.15; P=.009). The intervention also improved the motivation score after adjusting for baseline values (ß=2.34, 95% CI 0.77-3.91; P=.004). However, the number of web-based conversations, regardless of conversation features, was associated with lower motivation scores in the intervention group. CONCLUSIONS: The intervention was well-received. Delivering educational resources of interest may enhance medication adherence. The uptake of the web-based communication component could serve as an indicator of real-life difficulties and could be used by case managers to identify potential inadequate adherence. TRIAL REGISTRATION: Clinicaltrial.gov NCT03860116; https://clinicaltrials.gov/ct2/show/NCT03860116. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-020-8171-5.

Interactions between long-term ambient particle exposures and lifestyle on the prevalence of hypertension and diabetes: insight from a large community-based survey.

INTRODUCTION: Evidence on the interaction of lifestyle and long-term ambient particle (PM) exposure on the prevalence of hypertension, diabetes, particularly their combined condition is limited. We investigate the associations between PM and these outcomes and whether the associations were modified by various lifestyles. METHODS: This was a large population-based survey during 2019-2021 in Southern China. The concentrations of PM were interpolated and assigned to participants by the residential address. Hypertension and diabetes status were from questionnaires and confirmed with the community health centres. Logistic regression was applied to examine the associations, followed by a comprehensive set of stratified analyses by the lifestyles including diet, smoking, drinking, sleeping and exercise. RESULTS: A total of 82 345 residents were included in the final analyses. For each 1 µg/m3 increase in PM2.5, the adjusted OR for the prevalence of hypertension, diabetes and their combined condition were 1.05 (95% CI 1.05 to 1.06), 1.07 (95% CI 1.06 to 1.08) and 1.05 (95% CI 1.04 to 1.06), respectively. We observed that the association between PM2.5 and the combined condition was greatest in the group with 4-8 unhealthy lifestyles (OR=1.09, 95% CI 1.06 to 1.13) followed by the group with 2-3 and those with 0-1 unhealthy lifestyle (P interaction=0.026). Similar results and trends were observed in PM10 and/or in those with hypertension or diabetes. Individuals who consumed alcohol, had inadequate sleep duration or had poor quality sleep were more vulnerable. CONCLUSION: Long-term PM exposure was associated with increased prevalence of hypertension, diabetes and their combined condition, and those with unhealthy lifestyles suffered greater risks of these conditions.