Investigating the causal association of generalized and abdominal obesity with microvascular complications in patients with type 2 diabetes: A community-based prospective study.

AIM: The paradoxical protective association between overweight/obesity and diabetic microvascular complications (DMC), a phenomenon well-known as the obesity paradox, has been considered a non-causal association based on methodological influences. We aimed to investigate the association of generalized and abdominal obesity, as measured by body mass index (BMI) and waist circumference (WC), respectively, with DMC in patients with type 2 diabetes (T2D), using a causal inference approach. MATERIALS AND METHODS: We enrolled 1436 patients with clinically diagnosed T2D but not DMC at baseline in a community-based prospective cohort in China between 2017 and 2019 and followed them annually until 2022 with new-onset DMC recorded. Marginal structural Cox models with inverse probability weighting were constructed to determine the causal association. Subgroup analyses were performed to identify potential effect modifiers. RESULTS: We observed 360 incident DMC cases, including 109 cases of diabetic nephropathy (DN) and 277 cases of diabetic retinopathy (DR) during four follow-up visits. Multivariable-adjusted hazard ratios (95% confidence intervals) for overall DMC, DN and DR were 1.037 (1.005-1.071), 1.117 (1.062-1.175) and 1.018 (0.980-1.059) for 1 kg/m2 increase in BMI, and 1.005 (0.994-1.017), 1.034 (1.018-1.051) and 1.000 (0.987-1.014) for 1 cm increase in WC, respectively. Similar patterns were observed across the BMI and WC categories, while the positive association appeared to be more pronounced in women. CONCLUSIONS: Generalized but not abdominal obesity was associated with an increased risk for the overall DMC, whereas both obesities were causally related to DN, albeit not DR, in T2D. Routine weight management should not be neglected in diabetes care, particularly in women.

Metabolic score for insulin resistance (METS-IR) and new-onset type 2 diabetes in a middle-aged and elderly population: a nationwide prospective cohort study and implications for primary care.

BACKGROUND: The metabolic score for insulin resistance (METS-IR) has emerged as a noninsulin-based index for the approximation of IR, yet longitudinal evidence supporting the utility of METS-IR in primary prevention of type 2 diabetes mellitus (T2DM) remains limited. OBJECTIVE: We aimed to investigate the longitudinal association between METS-IR, which combines fasting plasma glucose (FPG), lipid profiles and anthropometrics that can be routinely obtained in resource-limited primary care settings, and incidence of new-onset T2DM. METHODS: We conducted a closed-cohort analysis of a nationwide, prospective cohort of 7,583 Chinese middle-aged and older adults who were free of T2DM at baseline, sampled from 28 out of 31 provinces in China. We examined the characteristics of subjects stratified by elevated blood pressure (BP) at baseline and new-onset T2DM at follow-up. We performed Cox proportional hazard regression analysis to explore associations of baseline METS-IR with incident T2DM in subjects overall, and in subjects stratified by baseline BP. We also applied net reclassification improvement (NRI) and integrated discrimination improvement (IDI) to examine the incremental value of METS-IR. RESULTS: During a mean follow-up period of 6.3 years, T2DM occurred in 527 subjects, among which, two-thirds (63.0%, 95% confidence interval [CI]: 58.7% to 67.1%) had baseline FPG <110 mg/dL. A standard deviation unit increase in baseline METS-IR was associated with the first incidence of T2DM (adjusted hazard ratio [aHR]=1.33, 1.22 to 1.45, P<.001) in all participants. Similar results were obtained in subjects with normal baseline BP (aHR=1.41, 1.22 to 1.62, P<.001) and elevated baseline BP (aHR=1.29, 1.16 to 1.44, P<.001). The predictive capability for incident T2DM improved by adding METS-IR to FPG. In study subjects with new-onset T2DM whose baseline FPG <126 mg/dL and <110 mg/dL, 63.0% (95%CI, 60.0% to 65.9%) and 58.1% (95%CI, 54.3% to 61.9%) of subjects had baseline METS-IR above the cut-off values, respectively. CONCLUSIONS: METS-IR was significantly associated with new-onset T2DM regardless of baseline BP level. Regular monitoring of METS-IR on top of routine blood glucose in clinical practice may add to the ability to enhance the early identification of primary care population at risk for T2DM.

The association between organised colorectal cancer screening strategies and reduction of its related mortality: a systematic review and meta-analysis.

BACKGROUND: To assess the long-term association between organised colorectal cancer (CRC) screening strategies and CRC-relate mortality. METHODS: We systematically reviewed studies on organised CRC screening through PubMed, Ovid Medline, Embase and Cochrane from the inception. We retrieved characteristics of organised CRC screening from included literature and matched mortality (over 50 years) of those areas from the International Agency for Research on Cancer in May 2023. The variations of mortality were reported via the age-standardised mortality ratio. A random-effects model was used to synthesis results. RESULTS: We summarised 58 organised CRC screening programmes and recorded > 2.7 million CRC-related deaths from 22 countries where rollout screening programmes were performed. The CRC screening strategy with faecal tests (guaiac faecal occult blood test (gFOBT) or faecal immunochemical tests (FIT)) or colonoscopy as the primary screening offer was associated with a 41.8% reduction in mortality, which was higher than those offered gFOBT (4.4%), FIT (16.7%), gFOBT or FIT (16.2%), and faecal tests (gFOBT or FIT) or flexible sigmoidoscopy (16.7%) as primary screening test. The longer duration of screening was associated with a higher reduction in the pooled age-standardised mortality ratio. In particular, the pooled age-standardised mortality ratio became non-significant when the screening of FIT was implemented for less than 5 years. CONCLUSIONS: A CRC screening programme running for > 5 years was associated with a reduction of CRC-related mortality. Countries with a heavy burden of CRC should implement sustainable, organised screening providing a choice between faecal tests and colonoscopy as a preferred primary test.

Association of Visceral Obesity Indices With Incident Diabetic Retinopathy in Patients With Diabetes: Prospective Cohort Study.

BACKGROUND: Visceral adipose tissue plays an active role in the pathogenesis of type 2 diabetes and vascular dysfunction. The lipid accumulation product (LAP), visceral adiposity index (VAI), and Chinese VAI (CVAI) have been proposed as simple and validated surrogate indices for measuring visceral adipose tissue. However, the evidence from prospective studies on the associations between these novel indices of visceral obesity and diabetic retinopathy (DR) remains scant. OBJECTIVE: This study aimed to investigate the longitudinal associations of LAP, VAI, and CVAI with incident DR in Chinese patients with diabetes. METHODS: This was a prospective cohort study conducted in Guangzhou in southern China. We collected baseline data between November 2017 and July 2020, while on-site follow-up visits were conducted annually until January 2022. The study participants consisted of 1403 patients with a clinical diagnosis of diabetes, referred from primary care, who were free of DR at baseline. The LAP, VAI, and CVAI levels were calculated by sex-specific equations based on anthropometric and biochemical parameters. DR was assessed using 7-field color stereoscopic fundus photographs and graded according to the modified Airlie House Classification scheme. Time-dependent Cox proportional hazard models were constructed to estimate the hazard ratios with 95% CIs. Restricted cubic spline curves were fitted to examine the dose-response relationship between the 3 indices of visceral obesity and new-onset DR. Subgroup analyses were performed to investigate the potential effect modifiers. RESULTS: The mean age of study participants was 64.5 (SD 7.6) years, and over half (816/1403, 58.2%) were female. During a median follow-up of 2.13 years, 406 DR events were observed. A 1-SD increment in LAP, VAI, or CVAI was consistently associated with increased risk for new-onset DR, with a multivariable­adjusted hazard ratio of 1.24 (95% CI 1.09-1.41; P=.001), 1.22 (95% CI 1.09-1.36; P<.001), and 1.48 (95% CI 1.19-1.85; P=.001), respectively. Similar patterns were observed across tertiles in LAP (P for trend=.001), VAI (P for trend<.001), and CVAI (P for trend=.009). Patients in the highest tertile of LAP, VAI, and CVAI had an 84%, 86%, and 82% higher hazard of DR, respectively, compared to those in the lowest tertile. A nonlinear dose-response relationship with incident DR was noted for LAP and VAI (both P for nonlinearity<.05), but not for CVAI (P for nonlinearity=.51). We did not detect the presence of effect modification by age, sex, duration of diabetes, BMI, or comorbidity (all P for interaction>.10). CONCLUSIONS: Visceral obesity, as measured by LAP, VAI, or CVAI, is independently associated with increased risk for new-onset DR in Chinese patients with diabetes. Our findings may suggest the necessity of incorporating regular monitoring of visceral obesity indices into routine clinical practice to enhance population-based prevention for DR.

Risk prediction of bladder cancer among person with diabetes: A derivation and validation study.

AIMS: This study aimed to devise and validate a clinical scoring system for risk prediction of bladder cancer to guide urgent cystoscopy evaluation among people with diabetes. METHODS: People with diabetes who received cystoscopy from a large database in the Chinese population (2009-2018). We recruited a derivation cohort based on random sampling from 70% of all individuals. We used the adjusted odds ratios (aORs) for independent risk factors to devise a risk score, ranging from 0 to 5: 0-2 'average risk' (AR) and 3-5 'high risk' (HR). RESULTS: A total of 5905 people with diabetes, among whom 123 people with BCa were included. The prevalence rate in the derivation (n = 4174) and validation cohorts (n = 1731) was 2.2% and 1.8% respectively. Using the scoring system constructed, 79.6% and 20.4% in the derivation cohort were classified as AR and HR respectively. The prevalence rate in the AR and HR groups was 1.57% and 4.58% respectively. The risk score consisted of age (18-70: 0; >70: 2), male sex (1), ever/ex-smoker (1) and duration of diabetes (≥10 years: 1). Individuals in the HR group had 3.26-fold (95% CI = 1.65-6.44, p = 0.025) increased prevalence of bladder than the AR group. The concordance (c-) statistics was 0.72, implying a good discriminatory capability of the risk score to stratify high-risk individuals who should consider earlier cystoscopy. CONCLUSIONS: The risk prediction algorithm may inform urgency of cystoscopy appointments, thus allowing a more efficient use of resources and contributing to early detection of BCa among people planned to be referred.

Changes in body weight and cardiovascular risk factors in a Chinese population with type 2 diabetes mellitus: a longitudinal study.

Introduction: The primary care management of blood glucose, blood pressure, lipid profiles, and body weight is important among patients with type 2 diabetes mellitus (T2DM) to prevent disease progression. Information on how weight changes would improve or deteriorate cardiovascular (CV) risk factors is warranted for making primary care recommendations. We aimed to investigate the changes in body weight and CV risk factors and to analyse their association in a Chinese population with T2DM. Methods: We retrieved longitudinal data between 2020 and 2021 from 1,758 adult primary care patients enrolled in a diabetic retinopathy (DR) screening programme. Linear associations of changes in body weight with CV risk factors were explored. Multivariable logistic regression analysis was performed to examine associations between different weight change categories and the worsening of CV risk factors. Results: The mean age of all the participants was 63.71 years, and over half of participants were females. During a one-year follow-up period, 24.7% of patients had a weight loss of ≥3%, while 22.2% of patients had a weight gain of ≥3%. Patients who had a weight loss of ≥3% were more likely to prevent the worsening of haemoglobin A1c (HbA1c) and triglycerides, while those who had a weight gain of ≥3% tended to have worsened HbA1c, lipid profiles, and blood pressure. Conclusion: Results from this real-world investigation suggested the concurrent need for weight loss intervention among patients who are overweight or obese and weight gain prevention among patients whose body weight falls within the normal range in the context of community-based diabetes management.

Associations between maternal complications during pregnancy and childhood asthma: a retrospective cohort study.

Background: Studies on the associations between maternal complications during pregnancy and childhood asthma are exclusively conducted in Western countries. The findings are mixed and may not be translated to other populations. We aimed to investigate the associations among the Chinese population and to determine whether the associations were mediated through pre-term birth, caesarean delivery, low birthweight and not breastfeeding in the first 6 months. Methods: We conducted a retrospective cohort study of 166 772 children in Guangzhou, China. Information on maternal gestational hypertension, gestational diabetes and gestational anaemia during pregnancy was extracted from medical records. Ever-diagnosis of asthma in children aged 6-12 years was obtained by questionnaire. Logistic regression models and mediation analyses were used to estimate the adjusted odds ratios (aORs) and 95% confidence intervals for childhood asthma. Results: Gestational hypertension, gestational diabetes and gestational anaemia during pregnancy were associated with an increased risk of ever-diagnosed childhood asthma: aOR 1.48 (95% CI 1.37-1.60), 1.71 (95% CI 1.65-1.78) and 1.34 (95% CI 1.26-1.45), respectively. A stronger association was observed for two or three gestational complications (aOR 2.02 (95% CI 1.93-2.16)) than one gestational complication (aOR 1.64 (95% CI 1.52-1.77)). The aOR for the three gestational complications was 1.35 (95% CI 1.26-1.45), 1.63 (95% CI 1.58-1.70) and 1.32 (95% CI 1.24-1.43), respectively, after controlling for the mediators, including pre-term birth, caesarean delivery, low birthweight and not breastfeeding in the first 6 months. Conclusions: Gestational hypertension, gestational diabetes and gestational anaemia were associated with childhood asthma, and the associations were partially explained by the mediation effects.

Longitudinal changes in blood pressure and fasting plasma glucose among 5,398 primary care patients with concomitant hypertension and diabetes: An observational study and implications for community-based cardiovascular prevention.

Aims: To assess longitudinal changes in blood pressure (BP) and fasting plasma glucose (FPG) in primary care patients with concomitant hypertension and type 2 diabetes mellitus (T2DM), and to explore factors associated with patients' inability to improve BP and FPG at follow-up. Methods: We constructed a closed cohort in the context of the national basic public health (BPH) service provision in an urbanised township in southern China. Primary care patients who had concomitant hypertension and T2DM were retrospectively followed up from 2016 to 2019. Data were retrieved electronically from the computerised BPH platform. Patient-level risk factors were explored using multivariable logistic regression analysis. Results: We included 5,398 patients (mean age 66 years; range 28.9 to 96.1 years). At baseline, almost half [48.3% (2,608/5,398)] of patients had uncontrolled BP or FPG. During follow-up, more than one-fourth [27.2% (1,467/5,398)] of patients had no improvement in both BP and FPG. Among all patients, we observed significant increases in systolic BP [2.31 mmHg, 95% confidence interval (CI): 2.04 to 2.59, p < 0.001], diastolic BP (0.73 mmHg, 0.54 to 0.92, p < 0.001), and FPG (0.12 mmol/l, 0.09 to 0.15, p < 0.001) at follow-up compared to baseline. In addition to changes in body mass index [adjusted odds ratio (aOR)=1.045, 1.003 to 1.089, p = 0.037], poor adherence to lifestyle advice (aOR = 1.548, 1.356 to 1.766, p < 0.001), and unwillingness to actively enrol in health-care plans managed by the family doctor team (aOR = 1.379, 1.128 to 1.685, p = 0.001) were factors associated with no improvement in BP and FPG at follow-up. Conclusion: A suboptimal control of BP and FPG remains an ongoing challenge to primary care patients with concomitant hypertension and T2DM in real-world community settings. Tailored actions aiming to improve patients' adherence to healthy lifestyles, expand the delivery of team-based care, and encourage weight control should be incorporated into routine healthcare planning for community-based cardiovascular prevention.

Factors associated with weight gain during COVID-19 pandemic: A global study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has resulted in changes in lifestyle habits and experiences of mental health outcomes, some of which were possibly related to weight gain, leading to an increase in the prevalence of obesity, which is associated with the development of several severe diseases. Concerns regarding weight gain and its impact on health outcomes are prevalent worldwide, with obesity being one of the highest causes of mortality in current society. METHODS: A self-reported questionnaire collected data from participants aged 18 years of age and above from 26 countries and regions worldwide. Post-hoc multiple logistic regression analyses have been done to evaluate the association between demographic and socioeconomic factors, and the perspectives that were identified to be associated with weight gain. RESULTS: Participants belonging to a younger age group; with a higher level of education; living in an urban area; living with family members; employed full-time; and had obesity were found to be more vulnerable to weight gain. After adjusting for socio-demographic factors, participants who were quarantined; exercised less prior to the pandemic; consumed unhealthy foods; and reported negative thoughts such as helplessness and the perceived risk of COVID-19, were more likely to experience weight gain; while negative thoughts such as having no means of control over the COVID-19 pandemic and the consequences of the COVID-19 pandemic will have great personal effect were associated with females, students, and people living in the rural area. CONCLUSIONS: Weight gain risk during the pandemic was significantly associated with certain socio-demographic and COVID-19 related factors. To improve public health outcomes, future research should conduct a longitudinal evaluation on the effects of COVID-19 experiences upon health choices. Streamlined mental support should also be provided to the vulnerable groups which were prone to negative thoughts that were associated with weight gain.

Association between METS-IR and Prediabetes or Type 2 Diabetes Mellitus among Elderly Subjects in China: A Large-Scale Population-Based Study.

The metabolic score for insulin resistance (METS-IR) was recently proposed as a non-insulin-based, novel index for assessing insulin resistance (IR) in the Western population. However, evidence for the link between METS-IR and prediabetes or type 2 diabetes mellitus (T2DM) among the elderly Chinese population was still limited. We aimed to investigate the associations between METS-IR and prediabetes or T2DM based on large-scale, cross-sectional, routine physical examination data. In a total of 18,112 primary care service users, an increased METS-IR was independently associated with a higher prevalence of prediabetes (adjusted odds ratio [aOR] = 1.457, 95% confidence interval [CI]: 1.343 to 1.581, p < 0.001) and T2DM (aOR = 1.804, 95%CI: 1.720 to 1.891, p < 0.001), respectively. The aOR for prediabetes in subjects with the highest quartile of METS-IR was 3.060-fold higher than that in those with the lowest quartile of METS-IR. The aOR for T2DM in subjects with the highest quartile of METS-IR was 6.226-fold higher than that in those with the lowest quartile of METS-IR. Consistent results were obtained in subgroup analyses. Our results suggested that METS-IR was significantly associated with both prediabetes and T2DM. The monitoring of METS-IR may add value to early identification of individuals at risk for glucose metabolism disorders in primary care.

Resilience level and its association with maladaptive coping behaviours in the COVID-19 pandemic: a global survey of the general populations.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has induced a significant global concern on mental health. However few studies have measured the ability of individuals to "withstand setbacks, adapt positively, and bounce back from adversity" on a global scale. We aimed to examine the level of resilience, its determinants, and its association with maladaptive coping behaviours during the pandemic. METHODS: The Association of Pacific Rim Universities (APRU) conducted a global survey involving 26 countries by online, self-administered questionnaire (October 2020-December 2021). It was piloted-tested and validated by an expert panel of epidemiologists and primary care professionals. We collected data on socio-demographics, socioeconomic status, clinical information, lifestyle habits, and resilience levels measured by the Brief Resilience Scale (BRS) among adults aged ≥ 18 years. We examined factors associated with low resilience level, and evaluated whether low resilience was correlated with engagement of maladaptive coping behaviours. RESULTS: From 1,762 surveys, the prevalence of low resilience level (BRS score 1.00-2.99) was 36.4% (America/Europe) and 24.1% (Asia Pacific). Young age (18-29 years; adjusted odds ratio [aOR] = 0.31-0.58 in older age groups), female gender (aOR = 1.72, 95% C.I. = 1.34-2.20), poorer financial situation in the past 6 months (aOR = 2.32, 95% C.I. = 1.62-3.34), the presence of one (aOR = 1.56, 95% C.I. = 1.19-2.04) and more than two (aOR = 2.32, 95% C.I. = 1.59-3.39) medical conditions were associated with low resilience level. Individuals with low resilience were significantly more likely to consume substantially more alcohol than usual (aOR = 3.84, 95% C.I. = 1.62-9.08), take considerably more drugs (aOR = 12.1, 95% C.I. = 2.72-54.3), buy supplements believed to be good for treating COVID-19 (aOR = 3.34, 95% C.I. = 1.56-7.16), exercise less than before the pandemic (aOR = 1.76, 95% C.I. = 1.09-2.85), consume more unhealthy food than before the pandemic (aOR = 2.84, 95% C.I. = 1.72-4.67), self-isolate to stay away from others to avoid infection (aOR = 1.83, 95% C.I. = 1.09-3.08), have an excessive urge to disinfect hands for avoidance of disease (aOR = 3.08, 95% C.I. = 1.90-4.99) and transmission (aOR = 2.54, 95% C.I. = 1.57-4.10). CONCLUSIONS: We found an association between low resilience and maladaptive coping behaviours in the COVID-19 pandemic. The risk factors identified for low resilience in this study were also conditions known to be related to globalization-related economic and social inequalities. Our findings could inform design of population-based, resilience-enhancing intervention programmes.

In-Hospital Emergency Treatment Delay Among Chinese Patients with Acute Ischaemic Stroke: Relation to Hospital Arrivals and Implications for Triage Pathways.

Introduction: Timely access to emergency treatment during in-hospital care phase is critical for managing the onset of acute ischaemic stroke (AIS), particularly in developing countries. We aimed to explore in-hospital emergency treatment delay and the relation of door-to-needle (DTN) time to ambulance arrivals vs walk-in arrivals. Methods: Data were collected from 1276 Chinese AIS patients admitted to a general, tertiary-level hospital for intravenous thrombolysis. Information on patients' characteristics and time taken during in-hospital emergency treatment was retrieved from the hospital registry data and medical records. Ambulance arrival was defined as being transported by emergency ambulance services, while walk-in arrival was defined as arriving at hospital by regular vehicle. In-hospital emergency treatment delay occurred when the DTN time exceeded 60 minutes. We performed multivariable logistic regression analysis to explore the association between hospital arrivals (by ambulance vs by walk-in) and treatment delay after adjustment for age, sex, education, marital status, residence, medical insurance, number of symptoms, clinical severity and survival outcome. Results: Over half (53.76%) of patients aged over 60 years. Around one-fifth (20.61%) of patients admitted to hospital through emergency ambulance services, while their counterparts arrived by regular vehicle. Overall, the median time taken from the hospital door to treatment initiation was 86.0 minutes. Patients arrived by ambulance (adjusted odds ratio [aOR] = 1.744, 95% confidence interval [CI] = 1.185-2.566, p = 0.005), had higher socio-economic status (aOR = 1.821, 95% CI = 1.251-2.650; p = 0.002), or paid out-of-pocket (aOR = 2.323, 95% CI = 1.764-3.060; p < 0.001) had an increased likelihood of in-hospital emergency treatment delays. Conclusion: In-hospital emergency treatment delay is common in China, and occurs throughout the entire emergency treatment journey. Having a triage pathway involving hospital arrival by ambulance seems to be more likely to experience in-hospital emergency treatment delay. Further efforts to improve triage pathways may require qualitative evidence on provider- and institutional-level factors associated with in-hospital emergency treatment delay.

Frequency of Follow-Up Attendance and Blood Glucose Monitoring in Type 2 Diabetic Patients at Moderate to High Cardiovascular Risk: A Cross-Sectional Study in Primary Care.

Regular follow-up attendance in primary care and routine blood glucose monitoring are essential in diabetes management, particularly for patients at higher cardiovascular (CV) risk. We sought to examine the regularity of follow-up attendance and blood glucose monitoring in a primary care sample of type 2 diabetic patients at moderate-to-high CV risk, and to explore factors associated with poor engagement. Cross-sectional data were collected from 2130 patients enrolled in a diabetic retinopathy screening programme in Guangdong province, China. Approximately one-third of patients (35.9%) attended clinical follow-up <4 times in the past year. Over half of patients (56.9%) failed to have blood glucose monitored at least once per month. Multivariable logistic regression analysis showed that rural residents (adjusted odds ratio [aOR] = 0.420, 95% confidence interval [CI] = 0.338-0.522, p < 0.001, for follow-up attendance; aOR = 0.580, 95%CI: 0.472-0.712, p < 0.001, for blood glucose monitoring) and subjects with poor awareness of adverse consequences of diabetes complications (aOR = 0.648, 95%CI = 0.527-0.796, p < 0.001, for follow-up attendance; aOR = 0.770, 95%CI = 0.633-0.937, p = 0.009, for blood glucose monitoring) were both less likely to achieve active engagement. Our results revealed an urban-rural divide in patients' engagement in follow-up attendance and blood glucose monitoring, which suggested the need for different educational approaches tailored to the local context to enhance diabetes care.

Maternal and neonatal characteristics associated with clinical outcomes of TOLAC from 2012-20 in the USA: Evidence from a retrospective cohort study.

Background: The risks of a few maternal and/or neonatal morbidities are higher with the trial of labour after caesarean (TOLAC) owing to unplanned caesarean delivery. Thus, it is imperative to consider the trade-off between the risk of side effects and the potential benefits before TOLAC utilisation and whether TOLAC should be provided to women with specific characteristics related to previous caesarean delivery. We aimed to investigate maternal and neonatal characteristics associated with TOLAC utilisation, compare maternal and/or neonatal morbidities in TOLAC women with women who chose planned caesarean deliveries, and assess specific characteristics related to maternal and/or neonatal morbidities in women with TOLAC utilisation. Methods: In this retrospective cohort study, we used nationwide, linked birth and infant death data in the United States between 2012 and 2020, which covers all 50 states in the US. Poisson regression models using generalised estimating equations yielded adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) of TOLAC utilisation and unsuccessful TOLAC by maternal and neonatal characteristics. Logistic regression models using generalised estimating equations yielded adjusted odds ratios (aORs) with 95% CIs of maternal and neonatal morbidities. Statistical analysis was performed from February 2022 to July 2022. Findings: The sample included 4,898,441 women with mean (SD) maternal age years (5.4 years; range 13-50). Several specific maternal and neonatal characteristics were significantly associated with unsuccessful TOLAC, although women with TOLAC utilisation were associated with significantly lower risks of maternal unplanned hysterectomy (aOR, 0.60; 95% CI, 0.60-0.61), admission to intensive care (aOR, 0.84; 95% CI, 0.84-0.85), and neonatal seizures (aOR, 0.80; 95% CI, 0.74-0.84). In women who attempted TOLAC, advanced maternal age, higher maternal body mass index, more than 2 previous caesarean deliveries, having maternal co-morbidities and fetal malpresentation increased the likelihood of maternal and neonatal morbidities. Interpretation: When utilising TOLAC, specific maternal and neonatal characteristics in pregnant women should be considered in conjunction with the potential benefits of TOLAC in preventing maternal and neonatal morbidities. Funding: This study is funded by the Clinical Medicine Plus X - Young Scholars Project, Peking University, the Fundamental Research Funds for the Central Universities (No: PKU2022LCXQ008).

Using self-determination theory in research and evaluation in primary care.

BACKGROUND: Multimorbidity (the co-existence of two or more long-term conditions within an individual) is a complex management challenge, with a very limited evidence base. Theories can help in the design and operationalization of complex interventions. OBJECTIVE: This article proposes self-determination theory (SDT) as a candidate theory for the development and evaluation of interventions in multimorbidity. METHODS: We provide an overview of SDT, its use in research to date, and its potential utility in complex interventions for patients with multimorbidity based on the new MRC framework. RESULTS: SDT-based interventions have mainly focused on health behaviour change in the primary prevention of disease, with limited use in primary care and chronic conditions management. However, SDT may be a useful candidate theory in informing complex intervention development and evaluation, both in randomized controlled trials and in evaluations of 'natural experiments'. We illustrate how it could be used multimorbidity interventions in primary care by drawing on the example of CARE Plus (a primary care-based complex intervention for patients with multimorbidity in deprived areas of Scotland). CONCLUSIONS: SDT may have utility in both the design and evaluation of complex interventions for multimorbidity. Further research is required to establish its usefulness, and limitations, compared with other candidate theories. PATIENT OR PUBLIC CONTRIBUTION: Our funded research programme, of which this paper is an early output, has a newly embedded patient and public involvement group of four members with lived experience of long-term conditions and/or of being informal carers. They read and commented on the draft manuscript and made useful suggestions on the text. They will be fully involved at all stages in the rest of the programme of research.

Effect of healthy lifestyle index and lifestyle patterns on the risk of mortality: A community-based cohort study.

Background: Limited evidence was available on the association of the integrated effect of multidimensional lifestyle factors with mortality among Chinese populations. This cohort study was to examine the effect of combined lifestyle factors on the risk of mortality by highlighting the number of healthy lifestyles and their overall effects. Methods: A total of 11,395 participants from the Guangzhou Heart Study (GZHS) were followed up until 1 January 2020. Individual causes of death were obtained from the platform of the National Death Registry of China. The healthy lifestyle index (HLI) was established from seven dimensions of lifestyle, and lifestyle patterns were extracted from eight dimensions of lifestyle using principal component analysis (PCA). Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were estimated using the Cox proportional hazard regression model. Results: During 35,837 person-years of follow-up, 184 deaths (1.61%) were observed, including 64 from cardiovascular disease. After adjustment for confounders, HLI was associated with a 50% (HR: 0.50, 95% CI: 0.25-0.99) reduced risk of all-cause mortality when comparing the high (6-7 lifestyle factors) with low (0-2 lifestyle factors) categories. Three lifestyle patterns were defined and labeled as pattern I, II, and III. Lifestyle pattern II with higher factor loadings of non-smoking and low-level alcohol drinking was associated with a decreased risk of all-cause mortality (HR: 0.63, 95% CI: 0.43-0.92, P -trend = 0.023) when comparing the high with low tertiles of pattern score, after adjustment for confounders. Every 1-unit increment of pattern II score was associated with a decreased risk (HR: 0.97, 95% CI: 0.95-0.99) of all-cause mortality. The other two patterns were not associated with all-cause mortality, and the association of cardiovascular mortality risk was observed with neither HLI nor any lifestyle pattern. Conclusion: The results suggest that the more dimensions of the healthy lifestyle the lower the risk of death, and adherence to the lifestyle pattern characterized with heavier loading of non-smoking and low-level alcohol drinking reduces the risk of all-cause mortality. The findings highlight the need to consider multi-dimensional lifestyles rather than one when developing health promotion strategies.

A cost-effectiveness analysis of capecitabine maintenance therapy versus routine follow-up for early-stage triple-negative breast cancer patients after standard treatment from a perspective of Chinese society.

BACKGROUND: Capecitabine maintenance therapy is safe and efficacious for early-stage triple-negative breast cancer (TNBC) patients, but the cost-effectiveness of its long-term use has not been investigated. Here, we evaluated the cost-effectiveness of capecitabine maintenance therapy, compared with routine follow-up, in early-stage TNBC patients after standard treatment from a perspective of Chinese society. METHODS: A three-state Markov model based on the data from the SYSUCC-001 trial was constructed to estimate the cost-effectiveness of capecitabine maintenance therapy in a month cycle over a period of 30-year time horizon. A 5% annual discount rate was set for all costs and benefits. One-way and probabilistic sensitivity analyses were performed to explore the model uncertainties. The main outcomes include quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICER), and the number needed to treat (NNT) to prevent one additional event. RESULTS: Compared with routine follow-up, 1-year capecitabine maintenance therapy yielded an additional 1.29 quality-adjusted life years (QALYs) at an additional cost of $3391.70, with an ICER of $2630.53 (95% CI: $1159.81-$5090.12) per QALY gained. The ICER was considerably lower than the recommended willingness-to-pay (WTP) threshold (i.e., $28,130.00 per QALY). The results were sensitive to the discount rate, drug cost, and treatment cost after relapse. Further, the NNT to prevent one additional relapse case was 29.2 (95% CI: 13.2-196.6), 16.7 (95% CI: 8.4-111.6), and 12.0 (95% CI: 5.7-82.6) at 1, 2, and 5 years, respectively. CONCLUSIONS: One-year capecitabine maintenance therapy for early-stage TNBC after standard treatment, compared with routine follow-up, was found to be highly cost-effective with promising clinical benefits and acceptable increased costs. Real-world studies are warranted to validate our findings in the future.

Factors Associated with Vaccination Intention against the COVID-19 Pandemic: A Global Population-Based Study.

Several vaccines have been developed for COVID-19 since the pandemic began. This study aimed to evaluate the factors associated with COVID-19 vaccination intention. A global survey was conducted across 26 countries from October, 2020 to December, 2021 using an online self-administered questionnaire. Demographic information, socio-economic status, and clinical information were collected. A logistic regression examined the associations between vaccine intention and factors such as perceptions and the presence of chronic physical and mental conditions. The sample included 2459 participants, with 384 participants (15.7%) expressing lower COVID-19 vaccination intent. Individuals who identified as female; belonged to an older age group; had a higher level of education; were students; had full health insurance coverage; or had a previous history of influenza vaccination were more willing to receive vaccination. Conversely, those who were working part-time, were self-employed, or were receiving social welfare were less likely to report an intention to get vaccinated. Participants with mental or physical health conditions were more unwilling to receive vaccination, especially those with sickle cell disease, cancer history within the past five years, or mental illness. Stronger vaccination intent was associated with recommendations from the government or family doctors. The presence of chronic conditions was associated with lower vaccine intention. Individuals with health conditions are especially vulnerable to health complications and may experience an increased severity of COVID-19 symptoms. Future research should evaluate the effectiveness of interventions targeting the vaccine perceptions and behaviours of at-risk groups. As such, public awareness campaigns conducted by the government and proactive endorsement from health physicians may help improve COVID-19 vaccination intention.

Association of Habitual Physical Activity With the Risk of All-Cause Mortality Among Chinese Adults: A Prospective Cohort Study.

Objective: This study was conducted to evaluate the association of the risk of all-cause mortality with habitual physical activity (HPA) and its different domains among Chinese adults. Methods: A total of 11,994 participants from the Guangzhou Heart Study were followed up until 1 January 2020. Information on HPA, including leisure-time physical activity (LTPA) and commute activity, was collected using a modified Global Physical Activity Questionnaire. Individual cause of death was obtained from the National Death Registry of China. Cox proportional hazards regression model was used to estimate hazard ratio (HR) and 95% confidence interval (CI) after adjustment for covariates. Results: During 37,715 person-years of follow-up, 208 deaths (1.73%) were observed. When compared with the highest with the lowest exposure tertiles, HPA and LTPA were associated with 34% (HR: 0.66, 95% CI: 0.46-0.95) and 30% (HR: 0.70, 95% CI: 0.49-0.99) reduced risk of all-cause mortality after adjustment for covariates. Commute activity was not associated with mortality risk. For the specific component of LTPA, we found that every 1 MET-h/week increment of the housework was associated with a 1% (HR: 0.99, 95% CI: 0.98-0.99) decreased mortality risk, and performing brisk walking/health exercises/Yangko was associated with a 46% reduced mortality risk (HR: 0.54, 95% CI: 0.29-0.99). Conclusion: This study suggests that a higher level of HPA and LTPA was associated with a lower risk of all-cause mortality. Our findings suggest people to perform HPA, especially LTPA, as a strategy for mortality reduction and health promotion.