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Introduction The physical and mental health of nurses may significantly impact the entire medical care group and directly affect the quality of medical services. Due to the intense emotional involvement and often problematic working conditions that characterise their profession, nurses appear to be especially susceptible to a complex set of stressors with repercussions to their health. Several landmark studies of nurses have provided an abundance of evidence on risk factors that influence the health status of nurses. However, few studies have investigated the health status of nurses who work in high-intensity work environments in China. The National Nurse Health Study (NNHS) objective is to build an ambispective cohort to gather web-based information on early-life events, daily habits, occupational and environmental risk factors, and health outcomes of a specific subset of healthcare professionals of Chinese nurses.Methods and analysis NNHS, which was developed at a tertiary hospital in Beijing, China, is a research initiative that enrolls registered nurses working at Peking University Third Hospital. A web-based self-administered system was designed to collect health-related data and link them with previous physical examination data. During the study period, participants with signed informed consent will be invited to annually repeat a similar procedure.Ethics and dissemination The NNHS research protocol was approved by the Institutional Ethics Committee and provides promising data that contribute to the understanding of pathophysiological links between early-life events, body composition, gut microbiota, and inflammatory and metabolic risk profiles. Moreover, the combination of a user-friendly tool with the innovative purposes of the NNHS offers a remarkable resource to test hypotheses about mechanisms of diseases, including work stress, and further plan preventive programmes in public health.Trial registration number The study was registered on Clinicaltrials.gov (https://clinicaltrials.gov/ct2/show/NCT04572347) and the China Cohort Consortium (http://chinacohort.bjmu.edu.cn/project/102/).

Objectives To evaluate the risk of psychiatric disorders and all-cause mortality associated with belimumab therapy in patients with SLE.Methods A literature search of four electronic bibliographic databases, including PubMed, EMBASE, Scopus and Cochrane databases, was conducted for randomised controlled trials (RCTs) reporting adverse reactions between belimumab and placebo. OR and 95% CI were calculated using the Mantel-Haenszel method with fixed-effects or random-effects model, depending on the heterogeneity test.Results In total, 11 eligible RCTs including 8824 patients with SLE were randomised into belimumab (5160 patients with 5552 patient-years) and placebo (3664 patients with 3985 patient-years) groups, respectively. Overall, no increased risk was identified with belimumab therapy at all dosages compared with placebo in patients with SLE regarding all psychiatric disorders (OR 0.89, 95% CI 0.64 to 1.23, I2=58%) and all-cause mortality (OR 1.10, 95% CI 0.64 to 1.89, I2=0%). The subgroup analysis of psychiatric disorders also revealed no statistically elevated risks in serious psychiatric disorders (OR 1.15, 95% CI 0.77 to 1.70, I2=47%), non-serious psychiatric disorders (OR 0.83, 95% CI 0.60 to 1.16, I2=52%), suicidal ideation or behaviour (OR 0.87, 95% CI 0.57 to 1.33, I2=0%), and depression (OR 1.29, 95% CI 0.90 to 1.85, I2=15%). Secondary analysis restricting belimumab at approved dose of 10 mg/kg only yielded similar results.Conclusion Belimumab therapy overall does not increase psychiatric events and all-cause mortality risks, whereas the results from Belimumab Assessment of Safety in SLE Study are suggestive of increased risk of psychiatric adverse events with belimumab exposure. Consequently, post-marketing data are needed to ascertain its psychiatric safety, especially serious mental disorders.

Objective We aimed to evaluate the validity of an algorithm to classify diagnoses according to the appropriateness of outpatient antibiotic use in the context of Chinese free text.Setting and participants A random sample of 10 000 outpatient visits was selected between January and April 2018 from a national database for monitoring rational use of drugs, which included data from 194 secondary and tertiary hospitals in China.Research design Diagnoses for outpatient visits were classified as tier 1 if associated with at least one condition that ‘always’ justified antibiotic use; as tier 2 if associated with at least one condition that only ‘sometimes’ justified antibiotic use but no conditions that ‘always’ justified antibiotic use; or as tier 3 if associated with only conditions that never justified antibiotic use, using a tier-fashion method and regular expression (RE)-based algorithm.Measures Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the classification algorithm, using classification made by chart review as the standard reference, were calculated.Results The sensitivities of the algorithm for classifying tier 1, tier 2 and tier 3 diagnoses were 98.2% (95% CI 96.4% to 99.3%), 98.4% (95% CI 97.6% to 99.1%) and 100.0% (95% CI 100.0% to 100.0%), respectively. The specificities were 100.0% (95% CI 100.0% to 100.0%), 100.0% (95% CI 99.9% to 100.0%) and 98.6% (95% CI 97.9% to 99.1%), respectively. The PPVs for classifying tier 1, tier 2 and tier 3 diagnoses were 100.0% (95% CI 99.1% to 100.0%), 99.7% (95% CI 99.2% to 99.9%) and 99.7% (95% CI 99.6% to 99.8%), respectively. The NPVs were 99.9% (95% CI 99.8% to 100.0%), 99.8% (95% CI 99.7% to 99.9%) and 100.0% (95% CI 99.8% to 100.0%), respectively.Conclusions The RE-based classification algorithm in the context of Chinese free text had sufficiently high validity for further evaluating the appropriateness of outpatient antibiotic prescribing.

Introduction The best approach for choledocholithiasis remains a matter of debate. Choledocholithiasis is usually treated with endoscopic sphincterotomy (EST), laparoscopic common bile duct exploration (LCBDE) or laparoscopic transcystic common bile duct exploration (LTCBDE). Data pertaining to the clinical outcomes of these approaches in the management of patients with cholecysto-choledocholithiasis in China are limited. An analysis of the economic burden associated with these treatments is lacking. The Chinese REgistry Study on the Treatment of Cholecysto-Choledocholithiasis (CREST Choles) was designed to address these issues in a real-world setting.Methods and analysis CREST Choles was an ambispective, multicenter, observational, open-cohort study. A total of 2700 patients undergoing one of the three treatments (EST+laparoscopic cholecystectomy (LC), LCBDE+LC and LTCBDE+LC) during the period from 1 January 2013 to 1 December 2018 at participating centres were enrolled in the study. Patients with gallstones and confirmed common bile duct stones were included. Data pertaining to demographics, disease history, procedural details, imaging features and follow-up were collected. Follow-up was conducted at least 6 months after enrolment in the study and annual follow-up will be conducted until December 2020. The primary outcome is the rate of adverse outcomes within 3 years postoperatively. Economic analysis (eg, incremental cost-effectiveness ratio) would be performed to compare expense across treatments.Ethics and dissemination Ethical approval was obtained at all participating centres. The registry presented is the first attempt to comprehensively evaluate the cost of treatment for cholecysto-choledocholithiasis in China. Findings are expected to be available in 2020 and will facilitate clinical decision making in such cases.Trial registration number NCT02554097.

Objectives To evaluate the risk of cancers of digestive system with incretin-based therapies among patients with type 2 diabetes mellitus.Research design and methods Medline, Embase, Cochrane Library and ClinicalTrials.gov databases were searched for randomized controlled clinical trials that compared incretin-based drugs with placebo or other antidiabetic drugs. Paired reviewers independently screened citations, extracted data and assessed risk of bias of included studies. Network meta-analysis was performed, followed by subgroup analysis. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the quality of evidence.Results A total of 84 studies (n=101 595) involving cancers of digestive system were identified (a median follow-up of 30 weeks). The risk of cancers of digestive system with incretin-based therapies was comparable with insulin (OR: 0.86, 95% CI 0.27 to 2.69), metformin (OR: 0.32, 95% CI 0.07 to 1.38), sodium-glucose co-transporter 2 (OR: 5.26, 95% CI 0.58 to 47.41), sulfonylureas (OR: 1.27, 95% CI 0.68 to 2.39), thiazolidinediones (OR: 0.42, 95% CI 0.13 to 1.42), alpha-glucosidase inhibitors (OR: 2.98, 95% CI 0.12 to 73.80), and placebo (OR: 0.87, 95% CI 0.71 to 1.05). The results of subgroup analysis based on the type of digestive system cancers indicated that incretin-based therapies did not increase the risk of gastrointestinal cancers, respectively. The results of subgroup analysis based on age, duration, mean HbA1c, trial duration, and sample size did not indicate the risk of digestive system cancers.Conclusions Moderate to high Grading of Recommendations Assessment, Development and Evaluation evidence suggests that incretin-based therapies were not associated with an increased risk of cancer of digestive system in patients with type 2 diabetes mellitus.

Background and objective Moyamoya disease (MMD) is an increasingly recognised cause of stroke, mainly described in East Asia. China is the largest nation in Asia, but few studies reported the epidemiology of MMD, especially at a national level. We aimed to estimate the incidence and prevalence of MMD in China.Methods We performed a population-based study using data from the national databases of Urban Basic Medical Insurance between 2013 and 2016, covering approximately 0.50 billion individuals. MMD cases were identified by diagnostic code (International Classification of Diseases, 10th Revision I67.5) or related diagnostic text.Results A total of 1987 MMD patients (mean age 44.45±14.30 years, female-to-male ratio 1.12) were identified, representing a national crude incidence of 0.59 (95% CI: 0.49 to 0.68) and a prevalence of 1.01 (95% CI: 0.81 to 1.21) per 100 000 person-years in 2016. Rates were higher in females than in males for the incidence (0.66 vs 0.52) and prevalence (1.05 vs 0.90). And the age-specific rates showed a bimodal distribution, with the highest peak in middle-aged group and the second peak in child group.Conclusions Our results confirm that MMD is relatively common in East Asians, but the rates in China were lower than those in other East Asian countries such as Japan and Korea. The unique epidemiological features, including a relatively weak female predominance and a shift in the highest peak of incidence from children to adults, revealed new sight into MMD. Further research is expected to explore the potential pathogenesis of MMD.

Objective: Amyotrophic lateral sclerosis (ALS) is a severe neurodegenerative disease and information on disease burden of ALS in mainland China was limited. We aimed to estimate the prevalence and incidence of ALS in China.Methods: We used 2012-2016 data from China's Urban Employee Basic Medical Insurance and Urban Residence Basic Medical Insurance, covering approximately 0.43 billion individuals. ALS cases were identified by the primary diagnosis (International Classification of Diseases code or text of diagnosis) in the insurance database.Results: The crude prevalence and incidence in 2016 were 2.91 per 100 000 person-years (95% CI 2.31 to 3.58) and 1.65 (95% CI 1.33 to 2.01), respectively. The standardised prevalence and incidence based on 2010 Chinese census data were 2.97 (95% CI 2.91 to 3.03) and 1.62 (95% CI 1.58 to 1.67), respectively. The annual prevalence between 2013 and 2016 remained relatively constant, ranging from 2.91 (95% CI 2.31 to 3.58) in 2016 to 3.29 (95% CI 2.51 to 4.17) in 2014 (linear regression: β=-0.129, p=0.104). Both rates peaked in the group aged 75-79 years.Conclusions: The prevalence and incidence of ALS in mainland China were lower than those in developed countries, and maintained a relatively stable trend. The age at onset and age at diagnosis for ALS patients were younger than those in developed countries. Further research is expected to clarify the potential pathophysiological mechanism of ALS. [ABSTRACT FROM AUTHOR]

Objective We aimed to evaluate the validity of an algorithm to classify diagnoses according to the appropriateness of outpatient antibiotic use in the context of Chinese free text. Setting and participants A random sample of 10 000 outpatient visits was selected between January and April 2018 from a national database for monitoring rational use of drugs, which included data from 194 secondary and tertiary hospitals in China. Research design Diagnoses for outpatient visits were classified as tier 1 if associated with at least one condition that ‘always’ justified antibiotic use; as tier 2 if associated with at least one condition that only ‘sometimes’ justified antibiotic use but no conditions that ‘always’ justified antibiotic use; or as tier 3 if associated with only conditions that never justified antibiotic use, using a tier-fashion method and regular expression (RE)-based algorithm. Measures Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the classification algorithm, using classification made by chart review as the standard reference, were calculated. Results The sensitivities of the algorithm for classifying tier 1, tier 2 and tier 3 diagnoses were 98.2% (95% CI 96.4% to 99.3%), 98.4% (95% CI 97.6% to 99.1%) and 100.0% (95% CI 100.0% to 100.0%), respectively. The specificities were 100.0% (95% CI 100.0% to 100.0%), 100.0% (95% CI 99.9% to 100.0%) and 98.6% (95% CI 97.9% to 99.1%), respectively. The PPVs for classifying tier 1, tier 2 and tier 3 diagnoses were 100.0% (95% CI 99.1% to 100.0%), 99.7% (95% CI 99.2% to 99.9%) and 99.7% (95% CI 99.6% to 99.8%), respectively. The NPVs were 99.9% (95% CI 99.8% to 100.0%), 99.8% (95% CI 99.7% to 99.9%) and 100.0% (95% CI 99.8% to 100.0%), respectively. Conclusions The RE-based classification algorithm in the context of Chinese free text had sufficiently high validity for further evaluating the appropriateness of outpatient antibiotic prescribing. [ABSTRACT FROM AUTHOR]

Objectives The 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline recommended 130/80 mm Hg as blood pressure (BP) target goals. However, the generalisability of this recommendation to populations at large with hypertension remains controversial. We assessed the association between BP and cardiovascular diseases (CVDs) mortality using a 20-year follow-up study among Chinese populations. Design Prospective cohort study. Participants 7314 participants were followed up for a median of 20 years in Fangshan District, Beijing, China. Methods The primary outcome variable was death from cardiovascular causes. The adjusted HR for CVDs mortality associated with baseline BP was calculated using Cox regression analysis. Results We identified 350 deaths from CVDs (148 stroke, 113 coronary heart disease and 89 other CVDs) during follow-up. Hypertension (defined by systolic BP (SBP)/diastolic BP (DBP) ≥140/90 mm Hg) was significantly associated with mortality due to CVDs (HR=2.49, 95% CI=1.77 to 3.50) among people aged 35–59 years rather than people aged ≥60 years. In addition, there was no significant association between stage 1 hypertension defined by the 2017 ACC/AHA (SBP/DBP of 130–139/80-89 mm Hg) and CVDs mortality when compared with SBP/DBP of <120/80 in neither the participants aged <60 years (HR=0.90, 95% CI=0.54 to 1.50) nor participants aged ≥60 years (HR=1.47, 95% CI=0.94 to 2.29). Conclusion The study revealed hypertension of SBP/DBP≥140/90 mm Hg was an important risk factor of CVDs mortality, especially among people aged 35–59 years. However, stage 1 hypertension under the definition of 2017 ACC/AHA was not associated with an increased risk of CVDs mortality. This study indicated that whether adopting the new hypertension definition needs further consideration in rural Chinese populations. [ABSTRACT FROM AUTHOR]

Introduction The best approach for choledocholithiasis remains a matter of debate. Choledocholithiasis is usually treated with endoscopic sphincterotomy (EST), laparoscopic common bile duct exploration (LCBDE) or laparoscopic transcystic common bile duct exploration (LTCBDE). Data pertaining to the clinical outcomes of these approaches in the management of patients with cholecysto-choledocholithiasis in China are limited. An analysis of the economic burden associated with these treatments is lacking. The Chinese REgistry Study on the Treatment of Cholecysto-Choledocholithiasis (CREST Choles) was designed to address these issues in a real-world setting. Methods and analysis CREST Choles was an ambispective, multicenter, observational, open-cohort study. A total of 2700 patients undergoing one of the three treatments (EST+laparoscopic cholecystectomy (LC), LCBDE+LC and LTCBDE+LC) during the period from 1 January 2013 to 1 December 2018 at participating centres were enrolled in the study. Patients with gallstones and confirmed common bile duct stones were included. Data pertaining to demographics, disease history, procedural details, imaging features and follow-up were collected. Follow-up was conducted at least 6 months after enrolment in the study and annual follow-up will be conducted until December 2020. The primary outcome is the rate of adverse outcomes within 3 years postoperatively. Economic analysis (eg, incremental cost-effectiveness ratio) would be performed to compare expense across treatments. Ethics and dissemination Ethical approval was obtained at all participating centres. The registry presented is the first attempt to comprehensively evaluate the cost of treatment for cholecysto-choledocholithiasis in China. Findings are expected to be available in 2020 and will facilitate clinical decision making in such cases. [ABSTRACT FROM AUTHOR]

Objectives To estimate the prevalence of prostate cancer with bone metastasis in Beijing, and to estimate hospital visits and direct treatment costs among male urban employees with the disease in Beijing. Design Cross-sectional observational study. Setting and participants Patients with prostate cancer and bone metastasis from the Urban Employee Basic Medical Insurance database covering the employed population of Beijing, China, from 2011 to 2014. Primary and secondary outcome measures Prevalence, treatment costs and healthcare visits of patients with prostate cancer and bone metastasis. Results A total of 1672 individuals were identified as having prostate cancer. Of these, 737 (44.1%) had bone metastasis, and among these, this was already present at the time of initial prostate cancer diagnosis in 27.0% (199/737). Mean age was 74.6 years (SD ±9.1). Prevalence of prostate cancer with bone metastasis increased from 5.3 per 100 000 males in 2011 to 8.3 per 100 000 males in 2014. The total annual health expenditure per patient (in 2014 American dollars) during the study period was $15 772.1 (SD=$16 942.6) ~$18 206.3 (SD=$18 700.2); 88% of these costs were reimbursed by insurance. Medication accounted for around 50% of total healthcare costs. Western drugs accounted for over 80% of medical costs with endocrine therapy being the most commonly prescribed treatment. There was an average 6.7% increase in expenditure related to diagnostical and therapeutical procedures over study years. Conclusions The increase in the prevalence of prostate cancer with bone metastasis and associated healthcare costs in China reveals the growing clinical and economical burden of this disease. The high prevalence of bone metastasis among patients with prostate cancer seen in our study suggests that efforts may be needed to improve symptoms awareness and promote early help-seeking behaviour among the Chinese population. [ABSTRACT FROM AUTHOR]

Objectives: To describe the natural history and clinical features of sporadic amyotrophic lateral sclerosis (ALS) in Chinese patients, and to report data on the prognostic factors for survival.Methods: All patients referred to our ALS centre between 2003 and 2012 were followed up every 3 months. Survival and tracheotomy were predefined as primary outcome measures. Group differences were analysed using parametric and non-parametric tests as appropriate. Survival was analysed using the Kaplan-Meier method and Cox regression analysis.Results: Of the 1624 patients with ALS, 75.1% had limb-onset, 14.0% had bulbar-onset, 7.8% had flail-arm syndrome (FAS), 2.6% had progressive muscular atrophy and 0.5% had primary lateral sclerosis. The male:female ratio was 1.7:1, and the mean age at onset was 49.8 years. The median diagnostic delay was 14 months, and the median survival time after symptom onset was 71 months. Male gender, older age at symptom onset, lower body mass index, shorter diagnostic delay, bulbar-onset ALS phenotype, higher Airlie House category at presentation, rural place of residence, use of traditional Chinese medicine and a history of contact with pesticides were associated with poorer survival, whereas female gender or an FAS phenotype may have a better prognosis.Conclusions: The clinical characteristics and outcomes of Chinese patients with sporadic ALS were different compared with patients from other countries. Compared with other studies, the age at onset of Chinese patients was earlier, the percentage of bulbar-onset ALS was lower and the prognosis was better. This study substantially advances the understanding of the clinical features and epidemiology of this rare disease. [ABSTRACT FROM AUTHOR]