A pilot study of Kangaroo mother care in early essential newborn care in resource-limited areas of China: the facilitators and barriers to implementation.

BACKGROUND: Implementation of Kangaroo Mother Care (KMC) in resource-limited areas of China may face unique barriers, such as a lack of resources, geographic location and more traditional culture among others. This qualitative study analyses the facilitators and barriers to implementing KMC in county-level health facilities in resource-limited areas of China for the promotion of KMC on a larger scale. METHODS: Participants from 4 of the 18 pilot counties where early essential newborn care was implemented through the Safe Neonatal Project and 4 control counties not enrolled in Safe Neonatal Project were selected using purposive sampling. A total of 155 participants were interviewed, including stakeholders of the Safe Neonatal Project such as national maternal health experts, relevant government officials and medical staff. Thematic analysis was used to process and analyse the interview content in order to summarise the facilitators and barriers to implementing KMC. RESULTS: KMC was accepted in the pilot areas but still faced certain challenges due to institutional regulation, resource provision and the perceptions of health staff, postpartum mothers and their families as well as COVID-19 prevention and control regulations. The facilitators identified were government officials and medical staff acceptance and the incorporation of KMC into routine clinical care. The barriers identified were a lack of dedicated funding and other resources, the present scope of health insurance and KMC cost-sharing mechanism, providers' knowledge and practical abilities, parental awareness, postpartum discomfort, fathers' inadequate involvement, and the impact from COVID-19. CONCLUSION: The Safe Neonatal Project pilot experience indicated the feasibility of implementing KMC in more areas of China. Optimising institutional regulations, providing necessary supporting resources and enhancing education and training may help to refine the implementation and scale-up of KMC practice in China.

Pro-thrombotic changes associated with exposure to ambient ultrafine particles in patients with chronic obstructive pulmonary disease: roles of lipid peroxidation and systemic inflammation.

BACKGROUND: Exposure to particulate matter air pollution is associated with an increased risk of cardiovascular mortality in patients with chronic obstructive pulmonary disease (COPD), but the underlying mechanisms are not yet understood. Enhanced platelet and pro-thrombotic activity in COPD patients may explain their increased cardiovascular risk. We aim to explore whether short-term exposure to ambient particulate matter is associated with pro-thrombotic changes in adults with and without COPD, and investigate the underlying biological mechanisms in a longitudinal panel study. Serum concentration of thromboxane (Tx)B2 was measured to reflect platelet and pro-thrombotic activity. Lipoxygenase-mediated lipid peroxidation products (hydroxyeicosatetraenoic acids [HETEs]) and inflammatory biomarkers (interleukins [ILs], monocyte chemoattractant protein-1 [MCP-1], tumour necrosis factor alpha [TNF-α], and macrophage inflammatory proteins [MIPs]) were measured as potential mediating determinants of particle-associated pro-thrombotic changes. RESULTS: 53 COPD and 82 non-COPD individuals were followed-up on a maximum of four visits conducted from August 2016 to September 2017 in Beijing, China. Compared to non-COPD individuals, the association between exposure to ambient ultrafine particles (UFPs) during the 3-8 days preceding clinical visits and the TxB2 serum concentration was significantly stronger in COPD patients. For example, a 103/cm3 increase in the 6-day average UFP level was associated with a 25.4% increase in the TxB2 level in the COPD group but only an 11.2% increase in the non-COPD group. The association in the COPD group remained robust after adjustment for the levels of fine particulate matter and gaseous pollutants. Compared to the non-COPD group, the COPD group also showed greater increases in the serum concentrations of 12-HETE (16.6% vs. 6.5%) and 15-HETE (9.3% vs. 4.5%) per 103/cm3 increase in the 6-day UFP average. The two lipid peroxidation products mediated 35% and 33% of the UFP-associated increase in the TxB2 level of COPD patients. UFP exposure was also associated with the increased levels of IL-8, MCP-1, MIP-1α, MIP-1ß, TNF-α, and IL-1ß in COPD patients, but these inflammatory biomarkers did not mediate the TxB2 increase. CONCLUSIONS: Short-term exposure to ambient UFPs was associated with a greater pro-thrombotic change among patients with COPD, at least partially driven by lipoxygenase-mediated pathways following exposure. Trial registration ChiCTR1900023692 . Date of registration June 7, 2019, i.e. retrospectively registered.

Effectiveness of early essential newborn care implementation in four counties of western China.

BACKGROUND: Neonatal survival is a public health concern globally. However, the regional disparity in neonatal mortality between rural counties of western China and urban areas of eastern provinces remains high. Early essential newborn care (EENC), recommended by World Health Organization, refers to a set of cost-effective interventions to improve neonatal health and development outcomes. In this study, we aimed to explore the effectiveness of EENC implementation in four counties of western China. METHODS: Pre- and post-intervention investigations were conducted in four selected EENC intervention counties and four control counties of four western provinces of China, from June to August 2017 and from December 2020 to April 2021 respectively. A mixed quantitative and qualitative approach was used for data collection and analysis. Data on the coverage of EENC practices were collected via a post-intervention face-to-face questionnaire survey with postpartum mothers before hospital discharge. Hospital-reported data on neonatal health indicators were obtained through mail surveys in both investigations. We also performed semi-structured interviews with policymakers, health staff and postpartum mothers to understand their perceptions about the usefulness of EENC implementation. RESULTS: Overall, 599 mother-newborn pairs in the intervention group and 699 pairs in the control group participated in the post-intervention survey. Controlling for the confounding factor of province, the proportion of newborns receiving EENC interventions was higher in the intervention group than in the control group (P < 0.05). Intervention groups in four provinces had higher coverage of: any skin-to-skin contact (99.50% vs. 49.07%); early breastfeeding initiation (within 60 min of birth) (90.84% vs. 80.35%); no medicine applied to the umbilical cord (98.50% vs. 9.73%); routine eye care (93.16% vs. 8.73%); and vitamin K1 administration (98.33% vs. 88.98%). EENC implementation was associated with decreased risk of neonatal diarrhea (OR: 0.326, 95% CI: 0.123, 0.865) and eye infection (OR: 0.147, 95% CI: 0.045, 0.483). Policymakers, health staff and postpartum mothers expressed satisfaction with the EENC interventions, noting a willingness among staff and policymakers to implement and sustain these interventions; the promotion of these interventions within hospital policy; the positive emotions experienced by postpartum mothers; perceived improvements in health; and improvements in support for health workers. CONCLUSION: EENC-recommended core practices (except kangaroo mother care) have been successfully introduced in pilot hospitals. The efficacy of EENC implementation should be highly recognized to accelerate the progress towards its national roll out.

Organic Components of Personal PM2.5 Exposure Associated with Inflammation: Evidence from an Untargeted Exposomic Approach.

Fine particulate matter (PM2.5) can promote chronic diseases through the fundamental mechanism of inflammation; however, systemic information is lacking on the inflammatory PM2.5 components. To decipher organic components from personal PM2.5 exposure that were associated with respiratory and circulatory inflammatory responses in older adults, we developed an exposomic approach using trace amounts of particles and applied it on 424 personal PM2.5 samples collected in a panel study in Beijing. Applying an integrated multivariate and univariate untargeted strategy, a total of 267 organic compounds were filtered and then chemically identified according to their association with exhaled nitric oxide (eNO)/interleukin (IL)-6 or serum IL-1ß/IL-6, with monocyclic and polycyclic aromatic compounds (i.e., MACs and PACs) as the representatives. Indoor-derived species with medium volatility including MACs were mainly associated with systemic inflammation, while low-volatile ambient components that originate from combustion sources, such as PACs, were mostly associated with airway inflammation. Following ambient component exposure, we found an inverted U-shaped relationship on change of eNO with insulin resistance, suggesting a higher risk of cardiopulmonary dysfunction for individuals with homeostatic model assessment for insulin resistance (HOMA-IR) levels > 2.3. Overall, this study provided a practical untargeted strategy for the systemic investigation of PM2.5 components and proposed source-specific inflammatory effects.

Effects of an Animation-Based Comprehensive Sexuality Education Package: A 2-Year Repeated Intervention Study.

BACKGROUND: Preadolescents, who are in a transitional phase of development, may experience higher exposure to heterosexual interactions while facing higher risks regarding misinformation in sexual knowledge and unsafe engagement in sexual activities. There is a deficiency in the availability of qualified educators and age-appropriate teaching materials for sexuality education in China. METHODS: We implemented an animation-based comprehensive sexuality education package among preadolescents aged 9 to 12 years from eight schools in Anhui, China. The first round of intervention included 1,835 participants, lasting 2 months from September to November 2020. A total of 374 participants, accounting for 52% of the intervention group, received a second round of intervention in September 2021. Participants completed immediate follow-up assessment and 1-year follow-up assessment to assess changes in their sexual knowledge, attitudes, and other outcomes. Propensity score matching and difference-in-difference analysis were performed to determine the short- and long-term impacts. RESULTS: Significant improvements were observed for both sexual knowledge and sexual attitudes in the immediate follow-up. There was no significant effect on pornography-seeking behavior or awareness of experiencing sexual abuse. After 1 year, the effect was sustained for sexual knowledge, but slightly declined for sexual attitudes. The second intervention significantly improved sexual knowledge; however, no significant change in sexual attitudes, pornography-seeking behavior, or awareness of experiencing sexual abuse was observed. CONCLUSIONS: Our comprehensive sexuality education package was effective in improving sexual knowledge both immediately and 1 year after the intervention. Repeated intervention can be an effective strategy for promoting preadolescent health development regarding comprehensive sexuality education.

Co-occurrence of and factors associated with health risk behaviors among adolescents: a multi-center study in sub-Saharan Africa, China, and India.

Background: Despite lifelong and detrimental effects, the co-occurrence of health risk behaviors (HRBs) during adolescence remains understudied in low- and middle-income countries. This study examines the co-occurrence of HRBs and its correlates among adolescents in sub-Saharan Africa, China, and India. Methods: A multi-country cross-sectional study was conducted in 2021-2022, involving 9697 adolescents (aged 10-19 years) from eight countries, namely Burkina Faso, China, Ethiopia, India, Ghana, Nigeria, Tanzania, and Uganda. A standardized questionnaire was administered to examine five types of HRBs - physical inactivity, poor dietary habits, smoking, alcohol consumption, and risky sexual behavior. Latent class analysis was employed to identify clustering patterns among the behaviors, and logistic regression was used to identify the correlates of these patterns. Findings: Three clusters of HRBs were identified, with Cluster 1 (27.73%) characterized by the absence of any specific risky behavior, Cluster 2 (68.16%) characterized by co-occurrence of physical inactivity and poor dietary habits, and Cluster 3 (4.11%) characterized by engagement in smoking, alcohol consumption, and risky sexual behavior. Relative to Cluster 1, being in Cluster 2 was associated with being female (aOR 1.20, 95% CI 1.09-1.32), not enrolled in education (aOR 0.84, 95% CI 0.71-0.99), and not engaged in paid work (aOR 1.23, 95% CI 1.08-1.41). Compared with those Cluster 1, adolescents in Cluster 3 were less likely to be female (aOR 0.41, 95% CI 0.32-0.54), be engaged in paid work (aOR 0.54, 95% CI 0.41-0.71), more likely to be older (aOR 7.56, 95% CI 5.18-11.03), not be enrolled in educational institution (aOR 1.74, 95% CI 1.27-2.38), and more likely to live with guardians other than parents (aOR 1.56, 95% CI 1.19-2.05). Interpretation: The significant clustering patterns of HRBs among adolescents in sub-Saharan Africa, China, and India highlights the urgent need for convergent approaches to improve adolescent health behaviors. Early life and school-based programs aimed at promoting healthy behaviors and preventing risky and unhealthy behaviors should be prioritized to equip adolescents with the tools and skills for lifelong well-being. Funding: Fondation Botnar (Grant #INV-037672) and Harvard T.H. Chan School of Public Health, partially funded this study.

Predicting Risky Sexual Behavior Among College Students Through Machine Learning Approaches: Cross-sectional Analysis of Individual Data From 1264 Universities in 31 Provinces in China.

BACKGROUND: Risky sexual behavior (RSB), the most direct risk factor for sexually transmitted infections (STIs), is common among college students. Thus, identifying relevant risk factors and predicting RSB are important to intervene and prevent RSB among college students. OBJECTIVE: We aim to establish a predictive model for RSB among college students to facilitate timely intervention and the prevention of RSB to help limit STI contraction. METHODS: We included a total of 8794 heterosexual Chinese students who self-reported engaging in sexual intercourse from November 2019 to February 2020. We identified RSB among those students and attributed it to 4 dimensions: whether contraception was used, whether the contraceptive method was safe, whether students engaged in casual sex or sex with multiple partners, and integrated RSB (which combined the first 3 dimensions). Overall, 126 predictors were included in this study, including demographic characteristics, daily habits, physical and mental health, relationship status, sexual knowledge, sexual education, sexual attitude, and previous sexual experience. For each type of RSB, we compared 8 machine learning (ML) models: multiple logistic regression (MLR), naive Bayes (BYS), linear discriminant analysis (LDA), random forest (RF), gradient boosting machine (GBM), extreme gradient boosting (XGBoost), deep learning (DL), and the ensemble model. The optimal model for both RSB prediction and risk factor identification was selected based on a set of validation indicators. An MLR model was applied to investigate the association between RSB and identified risk factors through ML methods. RESULTS: In total, 5328 (60.59%) students were found to have previously engaged in RSB. Among them, 3682 (41.87%) did not use contraception every time they had sexual intercourse, 3602 (40.96%) had previously used an ineffective or unsafe contraceptive method, and 1157 (13.16%) had engaged in casual sex or sex with multiple partners. XGBoost achieved the optimal predictive performance on all 4 types of RSB, with the area under the receiver operator characteristic curve (AUROC) reaching 0.78, 0.72, 0.94, and 0.80 for contraceptive use, safe contraceptive method use, engagement in casual sex or with multiple partners, and integrated RSB, respectively. By ensuring the stability of various validation indicators, the 12 most predictive variables were then selected using XGBoost, including the participants' relationship status, sexual knowledge, sexual attitude, and previous sexual experience. Through MLR, RSB was found to be significantly associated with less sexual knowledge, more liberal sexual attitudes, single relationship status, and increased sexual experience. CONCLUSIONS: RSB is prevalent among college students. The XGBoost model is an effective approach to predict RSB and identify corresponding risk factors. This study presented an opportunity to promote sexual and reproductive health through ML models, which can help targeted interventions aimed at different subgroups and the precise surveillance and prevention of RSB among college students through risk probability prediction.

Effects of Sexuality Education on Sexual Knowledge, Sexual Attitudes, and Sexual Behaviors of Youths in China: A Cluster-Randomized Controlled Trial.

PURPOSE: There is a lack of trained educators and age-appropriate teaching materials for sex education in China. This study aims to assess the effects of an internet-based sexuality education programme on sexual knowledge, attitudes, and behaviors among adolescents in China. METHODS: We undertook a multicentre, cluster-randomized controlled trial in 29 vocational high schools in Guangdong and Yunnan, China. Students in the intervention group received weekly sexuality education delivered over two months based on a sexuality education package named "You and Me". A questionnaire was completed at baseline by all students, after receiving a sexuality education by the intervention group, and once a year after receiving sexuality education by the intervention group or at a similar time point by the control group. RESULTS: Between October 2018 and December 2019, 3,151 participants from 29 schools/clusters were recruited, from which 1,760 students were randomly assigned to receive an eight-session internet-based sexuality education package. Significant improvements were observed for both sexual knowledge and sexual attitudes immediately after the intervention and one year after the intervention. However, no significant effects were observed for sexual behaviors. DISCUSSION: The internet-based sexuality education package was found to positively affect the sexual knowledge and sexual attitudes among adolescents, providing a potential solution to the lack of trained educators and teaching resources for implementing country-wide sexuality education in China. However, further research is still needed to determine the effects of sexuality education packages on sexual behaviors.

Transcriptional pathways of elevated fasting blood glucose associated with short-term exposure to ultrafine particles: A panel study in Beijing, China.

There is growing concern about the strong health effects of ultrafine particles (UFPs). However, less is known about the biological mechanisms. The objective of this study is to examine the association between short-term exposure to UFPs and fasting blood glucose (FBG) levels, and explore the potential physiological mechanisms at transcriptional levels. In a panel study of 135 participants, we measured FBG and the whole blood transcriptome repeatedly. The concentrations of ambient air pollutants were monitored continuously at a station. Linear mixed-effects models coupled with a mediating effect model were used to discriminate transcripts associated with air pollutant exposure and ln-transformed FBG levels. We found that FBG was significantly associated with interquartile range increase in the average UFPs concentrations 1-13 d prior to the clinical visits (ranging from 5.1% [95% CI 2.0-8.1%] in the 1-d time-window to 12.1% [95% CI 6.5-17.8%] in the 13-d time-window). Top 1000 transcripts associated with FBG increase following UFPs exposure were enriched into some biological pathways, such as pro-opiomelanocortin processing, negative regulation of hypoxia-inducible factor 1 A function, ubiquinone metabolism, and antigen presentation by major histocompatibility complex class I, classical pathway. These results suggest that elevated FBG associated with UFPs exposure may be related to regulation of metabolism, immune response, DNA damage, and apoptosis and survival.

Neuroendocrine stress hormones associated with short-term exposure to nitrogen dioxide and fine particulate matter in individuals with and without chronic obstructive pulmonary disease: A panel study in Beijing, China.

Air pollution is a major trigger of chronic obstructive pulmonary disease (COPD). Dysregulation of the neuroendocrine hypothalamic-pituitary-adrenal (HPA) and sympathetic-adrenal medullary (SAM) axes is essential in progression of COPD. However, it is not clear whether air pollution exposure is associated with neuroendocrine responses in individuals with and without COPD. Based on a panel study of 51 stable COPD patients and 78 non-COPD participants with 384 clinical visits, we measured the morning serum levels of corticotropin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH), cortisol, norepinephrine, and epinephrine as indicators of stress hormones released from the HPA and SAM axes. Ambient nitrogen dioxide (NO2), fine particulate matter (PM2.5), and meteorological conditions were continuously monitored at the station from 2 weeks before the start of clinical visits. Linear mixed-effects models were used to estimate associations between differences in stress hormones following an average of 1-14-day exposures to NO2 and PM2.5. The average 1 day air pollutant levels prior to the clinical visits were 24.4 ± 14.0 ppb for NO2 and 55.6 ± 41.5 µg/m3 for PM2.5. We observed significant increases in CRH, ACTH, and norepinephrine, and decreases in cortisol and epinephrine with interquartile range increase in the average NO2 and PM2.5 concentrations in all participants. In the stratified analyses, we identified significant between-group difference in epinephrine following NO2 exposure in individuals with and without COPD. These results may suggest the susceptibility of COPD patients to the neuroendocrine responses associated with short-term air pollution exposure.

Ceramide metabolism mediates the impaired glucose homeostasis following short-term black carbon exposure: A targeted lipidomic analysis.

BACKGROUND: Ambient particulate matter (PM), especially its carbonaceous composition black carbon (BC) increases cardiometabolic risks, yet the underlying mechanisms are incompletely understood. Ceramides (Cer; a class of sphingolipids) are biological intermediates in glucose metabolism. OBJECTIVES: To explore whether Cer metabolism mediates impaired glucose homeostasis following short-term PM exposure. METHODS: In a panel study in Beijing, China, 112 participants were followed-up between 2016 and 2017. Targeted lipidomic analyses quantified 26 sphingolipids in 387 plasma samples. Ambient BC and PM with aerodynamic diameter ≤ 2.5 µm (PM2.5) were continuously monitored in a station. We examined the associations of sphingolipid levels with average BC and PM2.5 concentrations 1-14 days before clinical visits using linear mixed-effects models, and explored the mediation effects of sphingolipids on PM-associated fasting blood glucose (FBG) difference using mediation analyses. RESULTS: Increased levels of FBG and multiple sphingolipids in Cer metabolic pathways were associated with BC exposure in 1-14-day time window, but not with PM2.5 exposure. For each 10 µg/m3 increase in the average BC concentration 1-14 days before the clinical visits, species in the Cer C24:1 pathway (Cer, dihydroceramide, hexosylceramide, lactosylceramide, and sphingomyelin C24:1) increased in levels ranging from 11.8% (95% confidence interval [CI]: -6.2-33.2) to 48.7% (95% CI: 8.8-103.4), as did the Cer C16:0, C18:0, and C20:0 metabolic pathway species, ranging from 3.2% (95% CI: -5.6-12.9) to 32.4% (95% CI: 7.0-63.8), respectively. The Cer C24:1 metabolic pathway species mediated 6.5-25.5% of the FBG increase associated with BC exposure in 9-day time window. The Cer C16:0, C18:0, and C20:0 metabolic pathway species mediated 5.4-26.2% of the BC-associated FBG difference. CONCLUSIONS: In conclusion, Cer metabolism may mediate impaired glucose homeostasis following short-term BC exposure. The current findings are preliminary, which need to be corroborated by further studies.

Personal exposure to electrophilic compounds of fine particulate matter and the inflammatory response: The role of atmospheric transformation.

Atmospheric oxidation can produce electrophilic compounds, altering the health effects induced by fine particulate matter (PM2.5); however, little is known about these electrophilic compounds or their health effects. Using electron capture negative ionization, we systematically detected 301 electrophilic compounds from personal PM2.5 samples in a panel study in urban Beijing. Most were oxygen-containing compounds with 3-17 double bond equivalents (DBE), suggesting the dominance of oxidized aromatic structures. Over 64% of the species, mostly outdoor-originated, were associated with inflammatory cytokines in both exhaled breath condensate and serum. Primary components of polycyclic aromatic hydrocarbons (PAHs) and high-DBE oxygenated PAHs, mainly from fossil fuel combustion, were positively associated with interleukin (IL)- 6, a cytokine related to oxidative homeostasis. Oxidized secondary species, particularly maleic and phthalic anhydrides, were negatively associated with IL-2/IL-8, which changed by - 3.8% to - 16.4% per one-fold increase in the abundance of the secondary source, indicating the immune disorders in response to the oxidized aerosols. Mediation analysis demonstrated the necessity of transformation products between atmospheric oxidation capacity and IL-2/IL-8 inhibition. This study provides new information on particulate electrophilic compounds and highlights the role of atmospheric chemistry in specific immune disorders.

Susceptibility of patients with chronic obstructive pulmonary disease to heart rate difference associated with the short-term exposure to metals in ambient fine particles: A panel study in Beijing, China.

Susceptibility of patients with chronic obstructive pulmonary disease (COPD) to cardiovascular autonomic dysfunction associated with exposure to metals in ambient fine particles (PM2.5, particulate matter with aerodynamic diameter ≤2.5 µm) remains poorly evidenced. Based on the COPDB (COPD in Beijing) panel study, we aimed to compare the associations of heart rate (HR, an indicator of cardiovascular autonomic function) and exposure to metals in PM2.5 between 53 patients with COPD and 82 healthy controls by using linear mixed-effects models. In all participants, the HR levels were significantly associated with interquartile range increases in the average concentrations of Cr, Zn, and Pb, but the strength of the associations differed by exposure time (from 1.4% for an average 9 days (d) Cr exposure to 3.5% for an average 9 d Zn exposure). HR was positively associated with the average concentrations of PM2.5 and certain metals only in patients with COPD. Associations between HR and exposure to PM2.5, K, Cr, Mn, Ni, Cu, Zn, As, and Se in patients with COPD significantly differed from those in health controls. Furthermore, association between HR and Cr exposure was robust in COPD patients. In conclusion, our findings indicate that COPD could exacerbate difference in HR following exposure to metals in PM2.5.

Associations between differences in anemia-related blood cell parameters and short-term exposure to ambient particle pollutants in middle-aged and elderly residents in Beijing, China.

Anemia is a highly prevalent disease among older populations, with multiple adverse health outcomes, and particles exposure is a potential risk factor for anemia. However, evidence on associations of exposure to particles with small size with anemia-related blood cell parameters levels in the elderly is limited, and the underlying mechanisms are unclear. Based on a panel study in Beijing, we found that in 135 elderly participants, mass concentrations of particle with an aerodynamic diameter ≤ 2.5 µm (PM2.5), black/elemental carbon (BC/EC, particle size range: 0-2.5 µm), and number concentrations of ultrafine particles (UFPs, particle size range: 5.6-93.1 nm) and accumulated mode particles (Acc, size range: 93.1-560 nm) were significantly associated with levels of red blood cell count (RBC), hemoglobin (HGB), hematocrit (HCT), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC). The mean ± SD for PM2.5, UFPs, Acc, BC, OC, and EC were 69.7 ± 61.1 µg/m3, 12.5 ± 4.3 × 103/cm3, 1.6 ± 1.2 × 103/cm3, 3.0 ± 2.0 µg/m3, 8.7 ± 6.7 µg/m3, and 2.1 ± 1.6 µg/m3, respectively. Cotinine (higher than 50 ng/mL) is used as an indicator of smoking exposure. The association between MCHC difference and per interquartile range (IQR) increase in average UFPs concentration 14 d before clinical visits was -0.7% (95% CI: -1.1% to -0.3%). Significant associations of UFPs and Acc exposure with MCHC and MCH levels remain robust after adjustment for other pollutants. Furthermore, 25.2% (95% CI: 7.4% to 64.8%) and 29.8% (95% CI: 5.3% to 214.4%) of the difference in MCHC associated with average UFPs and Acc concentrations 14 d before clinical visits were mediated by the level of tumor necrosis factor α (TNF α), a biomarker of systemic inflammation. Our findings for the first time provide the evidence that short-term UFPs and Acc exposure contributed to the damage of anemia-related blood cell in the elderly, and systemic inflammation was a potential internal mediator.

Risk factors in air pollution exposome contributing to higher levels of TNFα in COPD patients.

BACKGROUND: Air pollutants are found associated with various health effects in chronic obstructive pulmonary patients. Given the complicate chemical components of air pollutants, it is not clear which components are the main risk factors for these health effects. OBJECTIVES: Based on the COPD in Beijing (COPDB) study and exposome concept, we examined comprehensively the air pollution components to screen out high-risk factors for systemic inflammation of COPD patients. METHODS: Concentrations of PM with aerodynamic diameter ≤ 2.5 µm (PM2.5), ultrafine and accumulated-mode particles (UFPs and Acc), PM2.5-contained carbonaceous components/elements/water soluble ions, gaseous pollutants, temperature, and relative humidity (RH) were continuously monitored around participants. Urinary polycyclic aromatic hydrocarbons (PAHs) and cotinine, and serum tumor necrosis factor α (TNFα) were measured from 53 COPD and 82 non-COPD participants. Lifestyle variables were recorded using follow-up questionnaire. Linear mixed effects (LME) models were used to assess the associations of TNFα differences with exposure to air pollutants, meteorological variations, and lifestyle. RESULTS: In COPD patients, the associations of TNFα differences with exposure to ozone, Cd, UFPs, Acc, 2-hydroxydibenzofuran, temperature and RH parameters, and several elements in PM2.5 were significant in certain time-windows. For example, per interquartile range (IQR) increase in average ozone concentration 14 d before visits was associated with 17.3% (95% confidence interval: 6.8%, 27.7%) TNFα difference. Associations between ozone, Cd, UFPs, Acc, the maximum value of RH, and 2-hydroxydibenzofuran exposure and TNFα differences remained robust in two-pollutant models, and contributed to 19.0%, 10.5%, 2.2%, 1.6%, 2.1%, and 1.5% TNFα differences, respectively. Among the high-risk factors for COPD patients, the responses to UFPs, Acc, and 2-hydroxydibenzofuran were not robust in non-COPD participants. DISCUSSION: Ozone, Cd, UFPs, Acc, PAHs exposure and RH variation were high-risk factors of systemic inflammation for COPD patients, and the profile of high-risk factors were different from those in general population.

Effects of an Internet-Based and Teacher-Facilitated Sexuality Education Package: A Cluster-Randomized Trial.

BACKGROUND: This study aimed to evaluate the effects of an internet-based and teacher-facilitated sexuality education package on the sexual knowledge and attitudes of Chinese adolescents. METHODS: Six middle schools where no sexuality education had been performed with a total of 501 adolescent students (245 males and 256 females) were included in the trial. In total, 14 classes were randomly assigned to the intervention (internet-based sexuality education package) or the control group (classes were conducted as per normal). Students' sexual knowledge and attitudes were assessed at the baseline, at the end of the intervention, and 12 months after the intervention. Generalized linear models were employed to assess the effects of the intervention. RESULTS: Positive effects of the intervention were observed on sexual knowledge (ß = 4.65, 95% CI: 4.12-5.17) and attitudes (ß = 1.25, 95% CI: 1.00-1.50) at the end of the intervention. After 12 months, the effects sustained but the magnitude declined for sexual knowledge (ß = 2.39, 95% CI: 1.85-2.93) and attitudes (ß = 0.49, 95% CI: 0.23-0.75). There were no significant differences between male and female students. CONCLUSIONS: Although further modifications are required, the sexuality education package can increase the accessibility of comprehensive sexuality education to adolescents in rural areas in China.

Association between exposure to polycyclic aromatic hydrocarbons and lipid peroxidation in patients with chronic obstructive pulmonary disease.

Polycyclic aromatic hydrocarbons (PAHs) are toxic airborne pollutants and may cause adverse effects at high level of oxidative stress. Here we hypothesized that individuals with impaired lung function are susceptible to PAHs associated oxidative damage. Hence, we carried out a panel study and conducted four follow-up visits on 40 chronic obstructive pulmonary disease (COPD) patients and 75 healthy controls. Hydroxylated PAHs (OH-PAHs) and malonaldehyde (MDA) were measured in urine as exposure and oxidative stress markers, respectively, which showed significant association in all participants. Quantitatively, a 1-fold increase in OH-PAHs was associated with a 4.1-15.1% elevation of MDA. The association between OH-PAHs and MDA levels became stronger in participants with impaired lung function. For 1% decrease of FEV1/FVC, the increase of MDA associated with a 1-fold increase in OH-PAHs was up to 0.49%, suggesting an increased susceptibility to PAH-induced oxidative damage in individuals with worse lung function. This study observed that impaired lung function modified the association between PAH exposure and oxidative damage, which might accelerate the aggravation of COPD, and therefore highlighted the necessity of protection measures to decrease the additional adverse effects of air pollution exposure. CAPSULE: Individuals with worse lung function may be more susceptible to PAH-induced lipid peroxidation.

Susceptibility of individuals with lung dysfunction to systemic inflammation associated with ambient fine particle exposure: A panel study in Beijing.

BACKGROUND: The underlying mechanism on the susceptibility of chronic obstructive pulmonary disease (COPD) patients to air pollution has yet to be clarified. OBJECTIVES: Based on the COPD in Beijing (COPDB) study, we examined whether lung dysfunction contributed to pollutant-associated systemic inflammation in COPD patients. METHODS: Proinflammatory biomarkers including interleukin-8 (IL-8) and tumor necrosis factor α (TNFα) were measured in serum samples collected from 53 COPD and 82 healthy participants. Concentrations of particulate matter with aerodynamic diameter ≤ 2.5 µm (PM2.5), carbonaceous components in PM2.5, and PM size distribution were continuously monitored. Linear mixed effects models were used to examine the associations of biomarker differences with particle exposure, between COPD and healthy participants, and across subgroups with different levels of lung dysfunction. RESULTS: COPD patients showed higher differences in IL-8 and TNFα levels associated with exposure to measured pollutants, comparing to healthy controls. In advanced analysis, particle-associated differences in IL-8 and TNFα levels were higher in participants with poorer lung ventilation and diffusion capacity, and higher ratio of residual volume. For example, an interquartile range increase in average PM2.5 concentration 2 weeks before visits was associated with a 15.7% difference in IL-8 level in participants with the lowest ratio of measured value to predicted value of forced expiratory volume in 1 s (FEV1%pred) (65.2%), and the association decreased monotonically with increasing FEV1%pred. Associations between differences in TNFα level and average ultrafine particle concentration 1 week before visits increased gradually with increasing ratio of measured value to predicted value of residual volume/total lung capacity. CONCLUSIONS: COPD patients, especially those with poorer lung function, are more susceptible to systemic inflammation associated with fine particle exposure.

Susceptibility of individuals with chronic obstructive pulmonary disease to air pollution exposure in Beijing, China: A case-control panel study (COPDB).

Exposure to air pollution is one of the major risk factors contributing to the occurrence and development of chronic obstructive pulmonary disease (COPD). However, few studies have investigated the susceptibility of patients with COPD to air pollution. Here, we provided a study protocol. A panel study of a total of 480 samples to compare the response to air pollution exposure between 60 patients with COPD and 60 healthy control subjects has been performed in Beijing (the COPDB study) since May 2016. The health assessment and exposure evaluation methods used in this COPDB study are summarized here. Throat, exhaled breath and condensate, urine, serum, plasma, and blood samples, as well as cardiopulmonary function indexes were repeatedly collected over four visits. Indicators of inflammation, oxidative stress, infection, metabolic changes, and genetic differences were then analyzed. Personal and ambient levels of fine particles and their components, as well as gaseous pollutants were monitored during the follow-up period. Linear mixed-effects models were used to evaluate the associations between changes in biomarkers and exposure to air pollution in both patients with COPD and healthy control subjects. Based on the COPDB study, the susceptibility of COPD patients and underlying mechanisms, involving difference in inflammatory, infection, metabolic, and genetic response to different air pollutants, were investigated. Our preliminary result shows that air pollution-associated changes in heart rate were higher in COPD patients than the healthy controls. More investigations of the underlying mechanisms of the susceptibility are ongoing. This study has been registered in ChiCTR with the number of ChiCTR1900023692.

Association of internal exposure to polycyclic aromatic hydrocarbons with inflammation and oxidative stress in prediabetic and healthy individuals.

Polycyclic aromatic hydrocarbons (PAHs) are key air pollutants that may contribute to the risk of numerous diseases by inducing inflammation and oxidative stress. Individuals with metabolic disorders may be more susceptible to PAH-induced inflammation and oxidative stress. To test this hypothesis, we designed a panel study involving 60 patients with pre-type 2 diabetes (pre-T2D) and 60 reference participants, and conducted up to seven repeated clinical examinations. Urinary metabolites of PAHs (i.e., OH-PAHs), measured as indicators of total PAH exposure, showed significant associations with markers of respiratory and systemic inflammation, including exhaled nitric oxide, interleukin (IL)-6 in exhaled breath condensate, and blood IL-2 and IL-8 levels and leucocyte count. The most significant effect was on urinary malondiadehyde (MDA), a marker of lipid peroxidation; a onefold increase of OH-PAHs was associated with 9.2-46.0% elevation in MDA in pre-T2D participants and 9.8-31.2% increase in healthy references. Pre-T2D participants showed greater increase in MDA, suggesting that metabolic disorder enhanced the oxidative damage induced by PAH exposure. This study revealed the association between PAH exposure and markers of inflammation and oxidative stress, and the enhanced responses of pre-T2D patients suggested that individuals with metabolic disorders were more susceptible to the adverse health effects of PAH exposure.