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Existing PM2.5-morbidity studies using daily mean concentration as exposure metric may fail to capture intra-day variations of PM2.5 concentrations, resulting in underestimated health impacts to some extent. This study introduced a novel indicator, daily excessive concentration hours (DECH), defined as sums of per-hourly excessive concentrations of PM2.5 against a specific threshold within a day. PM2.5 DECHs were separately calculated as daily concentration-hours >8, 10, 15, 20, and 25 μg/m3 (abbreviations: DECH-8, DECH-10, DECH-15, DECH-20, and DECH-25). We adopted a time-stratified case-crossover design with conditional logistic regression models to compare risks of hospitalizations for chronic obstructive pulmonary disease (COPD) associated with PM2.5 mean and DECHs in Shenzhen, China. We observed highly comparable PM2.5-COPD associations using exposure metrics of daily mean and DECHs with above-defined thresholds. For instance, PM2.5 mean and DECHs showed similar increases in risks of COPD hospitalization for an interquartile range rise in exposure, with odds ratio estimates of 1.26 (95% confidence interval: 1.06–1.50) for PM2.5 mean, 1.24 (1.05–1.46) for DECH-10 and 1.21 (1.06–1.39) for DECH-25, respectively. Findings remained robust after further adjusting for gaseous pollutants (e.g., SO2, NO2, CO, and O3) and meteorologic factors (e.g., wind speed and air pressure). Our study strengthened the evidence that DECHs could come be as a novel exposure metric in health risk assessments associated with short-term exposure to ambient PM2.5.

Statement of problem The comparative efficacy of antifungal drugs on oral candidiasis remains unclear. Purpose The purpose of this Bayesian network meta-analysis was to investigate the efficacy of antifungal drugs on oral candidiasis. Material and methods Databases, including PubMed, The Cochrane Library, and Web of Science, were accessed from the dates of their establishment to October, 2018, to collect randomized controlled trials (RCTs) of different antifungal drugs for oral candidiasis. A network meta-analysis was then conducted by using R and Stata 12.0 software programs. Results A total of 31 RCTs involving 4042 participants were included. The meta-analysis showed that, in the treatment of oral candidiasis in reducing the mycological cure rate, itraconazole capsules, itraconazole oral solution, miconazole buccal tablets, miconazole oral gel, clotrimazole, fluconazole, ketoconazole, nystatin, and amphotericin B were better than a placebo. Miconazole oral gel, fluconazole, and ketoconazole were better than nystatin. The network meta-analysis also showed that the effects of antifungal drugs in reducing the mycological cure rate in oral candidiasis were better than those of a placebo: itraconazole capsule (OR=1.20, 95% CrI: 1.07-1.34), itraconazole oral solution (OR=1.50, 95% CrI: 1.14-1.86), miconazole buccal tablet (OR=2.80, 95% CrI: 1.20-4.50), miconazole oral gel (OR=2.90, 95% CrI: 1.70-4.30), clotrimazole (OR=3.80, 95% CrI: 1.65-5.95), fluconazole (OR=2.40, 95% CrI: 1.10-3.80), ketoconazole (OR=3.40, 95% CrI: 1.76-7.04), nystatin (OR=2.50, 95% CrI: 1.43-3.57), and amphotericin B (OR=2.60, 95% CrI: 1.91-3.29). The SUCRA values for each antifungal drug were as follows: placebo (6.80%), itraconazole capsule (51.2%), itraconazole oral solution (75.2%), miconazole buccal tablet (34.4%), miconazole oral gel (76.9%), clotrimazole (64.8%), fluconazole (79.3%), ketoconazole (50.7%), nystatin (15.7%), and amphotericin B (44.4%). Conclusions Antifungal drugs have efficacy in the treatment of oral candidiasis. The effect of fluconazole in reducing the risk of the mycological cure rate in oral candidiasis was better than that of other drugs.

Epithelial-mesenchymal transition (EMT)-related genes play an important role in immunosuppression. However, the correlations of EMT-related genes to prognosis and tumor-infiltrating lymphocytes in different cancers remain unclear. TCGA, GEO databases were used to analyze the expression, prognosis, and immune infiltration of EMT markers in cancer. RT-qPCR, immunohistochemistry, and western blot were used to analysis the expression and prognosis of SNAI1 in gastrointestinal cancers. High SNAI1 expression was closely related with poorer overall survival in gastrointestinal cancers in TCGA cohort. High SNAI1 expression was closely related with poorer overall survival in gastrointestinal cancers, and was validated in GEO database. Simultaneously, high expression of SNAI1 correlates with clinical relevance of gastric cancer. Moreover, SNAI1 expression was associated with tumor-infiltrating immune cells in gastrointestinal cancers. In addition, RT-qPCR, immunohistochemistry, and western blot showed SNAI1 expression was higher in gastrointestinal cancers compared to the normal tissues. Finally, high SNAI1 expression was closely related with poorer overall survival and correlates with clinical relevance of gastrointestinal cancers in an independent validation cohort. In summary, the results approaches to suggest that SNAI1 can be used as a prognostic biomarker for determining prognosis and immune infiltration in gastrointestinal cancers.

Background Numerous studies have consistently demonstrated that high body mass index (BMI) is related to elevated serum alanine aminotransferase (ALT) among adults, but little is known about the association regarding adolescents, especially in China. In this study, we aimed to investigate the association between BMI and ALT activity among Chinese adolescents. Methods A school-based cross-sectional study was performed among nine high schools in Shenzhen, China between February 2017 and June 2018. A generalized linear-regression model adjusting for age and gender was conducted, and bivariate correlation analysis between ALT and BMI was also performed. Results A total of 7,271 adolescents aged from 9 years to 17 years were enrolled. Height, weight, BMI, and ALT were higher among boys than among girls (all P Conclusions We found a significant BMI−ALT relationship. BMI at 20.5 kg/m2 may be a cut-off for evaluating serum ALT. BMIs ≥27.1 kg/m2 for boys and ≥24.9 kg/m2 for girls were linked to an elevated ALT activity for Shenzhen adolescents.

Background Ambient particulate matter (PM) has been linked to adverse health outcomes, but evidence is still relatively limited for emergency department visits (EDVs). Most prior studies used daily mean PM as exposure assessment regardless of within-day variations, which might underestimate the potential acute health effects. In this study, we evaluated the hourly associations between PM and EDVs, so as to further understand the very short-term impacts of PM on EDVs. Methods Hourly data for all-cause EDVs, air pollutants and meteorological factors were collected from Shenzhen, China, between March 1, 2015 and February 28, 2018. A time-stratified case-crossover design with conditional logistic regression analysis was performed to assess the hourly associations between PM and EDVs, adjusting for hourly mean temperature and relative humidity. Subgroup analyses stratified by gender, age and clinic department were conducted to identify vulnerable populations. We further classified the whole year into warm (April to September) and cold (October to March of the next year) months to evaluate seasonal effect modification. Results Hourly mean all-cause EDVs peaked at 9 a.m. and 7 p.m., while PM2.5 and PM10 peaked at 8 a.m. and 8 p.m. The hourly associations between PM and EDVs appeared immediately and persisted for about 10 hours. All-cause EDVs increased 0.72% (95% confidence interval (CI): 0.33, 1.12) and 0.72% (95% CI: 0.45, 0.99) associated with per 10 μg/m3 rise in PM2.5 and PM10 at lag 0–10 h, respectively. Stronger effects of PM2.5 and PM10 on EDVs were observed among younger groups (age Conclusions Our study provided hourly perspective for the short-term associations between PM exposure and increased EDVs. The adverse impacts of PM on EDVs were only identified in cold season, and young people suffered more from both PM2.5 and PM10 exposures. These findings may have valuable implications for public policy promotion on air cleaning, as well as hospital management in optimizing allocation of resources on PM-sensitive conditions.

BACKGROUND Prediabetes is associated with an increased risk of cardiovascular diseases and all-cause mortality. No research in China has evaluated the prevalence of prediabetes among children and adolescents using the HbA1c criterion or the combined FPG-or-HbA1c diagnostic criterion, and researchers paid no attention to the distributions of blood glucose in Shenzhen, especially for juveniles. METHODS We conducted a school-based cross-sectional study based on the first-year students from 17 primary, middle, and high schools. Prediabetes was defined as FPG of 5.6-6.9 mmol/L or HbA1c of 5.7%-6.4%. The crude and standardized prevalence of prediabetes with 95% confidence interval (95% CI) was estimated. RESULTS A total of 7519 participants, aged 6 to 17 years, were included. For all subjects, the crude prevalence (95% CI) of prediabetes was 1.49% (1.21-1.77), 8.72% (8.08-9.36), and 9.80% (9.13-10.47) by the FPG-only, HbA1c-only, and FPG-or-HbA1c criteria, respectively. Based on the 2010 Shenzhen census population, the standardized prevalence was 1.56% (males 1.85%, females 1.19%), 11.05% (males 11.47%, females 10.53%), and 12.19% (males 13.01%, females 11.15%) by the corresponding criteria. The proportion of prediabetes was higher for males than females, and the prevalence decreased with grade for males but increased for females. The association of BMI and prediabetes was U-shaped curve, indicating higher rates of prediabetes for underweight and obesity people. CONCLUSIONS The blood glucose status of children and adolescents in Shenzhen is worrisome, and the early detection and management of prediabetes are imperative. This article is protected by copyright. All rights reserved.

Background Ambient PM1 (particulate matter with aerodynamic diameter ≤1 μm) is an important contribution of PM2.5 mass. However, little is known worldwide regarding the PM1-associated health effects due to a wide lack of ground-based PM1 measurements from air monitoring stations. Methods We collected daily records of hospital admission for respiratory diseases and station-based measurements of air pollution and weather conditions in Shenzhen, China, 2015–2016. Time-stratified case-crossover design and conditional logistic regression models were adopted to estimate hospitalization risks associated with short-term exposures to PM1 and PM2.5. Results PM1 and PM2.5 showed significant adverse effects on respiratory disease hospitalizations, while no evident associations with PM1–2.5 were identified. Admission risks for total respiratory diseases were 1.09 (95% confidence interval: 1.04 to 1.14) and 1.06 (1.02 to 1.10), corresponding to per 10 μg/m3 rise in exposure to PM1 and PM2.5 at lag 0–2 days, respectively. Both PM1 and PM2.5 were strongly associated with increased admission for pneumonia and chronic obstructive pulmonary diseases, but exhibited no effects on asthma and upper respiratory tract infection. Largely comparable risk estimates were observed between male and female patients. Groups aged 0–14 years and 45–74 years were significantly affected by PM1- and PM2.5-associated risks. PM-hospitalization associations exhibited a clear seasonal pattern, with significantly larger risks in cold season than those in warm season among some subgroups. Conclusions Our study suggested that PM1 rather than PM1–2.5 contributed to PM2.5-induced risks of hospitalization for respiratory diseases and effects of PM1 and PM2.5 mainly occurred in cold season.

Background Screening for elevated serum alanine aminotransferase (ALAT) can help identifying individuals at the risks of chronic and metabolic diseases, but blood collection is invasive and cannot be widely used for investigations. Considered as simple and inexpensive screening indices, individual characteristics and anthropometric measurements can be measured in a large crowd and may be important surrogate markers for ALAT levels. This study aimed to examine the diagnostic performance of individual characteristics and anthropometric parameters as predictive factors for discerning an elevated ALAT activity among Shenzhen children and adolescents. Methods A school-based screening study was performed from 9 high schools in Shenzhen during February 2017 and June 2018. Receiver operating characteristic curve was used to examine the diagnostic performance of each variable for detecting elevated ALAT. Results Altogether 7271 students aged 9–17 years were involved. The proportion of elevated ALAT greatly increased with increasing classification of BMI-z. By the sex-specific cut-offs for elevated ALAT (30 U/L boys; 19 U/L girls), BMI showed the highest area under the curve of 0.789 (95% CI 0.765–0.812) and followed by weight (0.779 [0.755–0.802]), BMI-z (0.747 [0.722–0.772]), height (0.622 [0.597–0.647]), and age (0.608 [0.584–0.632]), while height-z was not capable. With the cut-off of 67.8 kg for weight and 22.6 kg/m2 for BMI, the accuracy to identify elevated ALAT was 87.1% for weight and 82.9% for BMI. Conclusions The presence of elevated ALAT was more common in overweight or obese children and adolescents. BMI and weight had the superiority of detecting elevated ALAT, followed by BMI-z, height, and age.

Background Screening for elevated serum alanine aminotransferase (ALT) can help identifying individuals at the risks of chronic and metabolic diseases, but blood collection is invasive and cannot be widely used for investigations. Considered as simple and inexpensive screening indices, anthropometric measurements can be measured in a large crowd and may be important surrogate markers for ALT levels. Among adolescents, few studies focused on the diagnostic performance of anthropometric parameters such as body mass index (BMI) and BMI z-score as predictive factors for discerning an elevated ALT activity. We sought to fill this knowledge gap among Shenzhen adolescents.Methods A school-based study was performed from 9 high schools in Shenzhen during February 2017 and June 2018. Receiver operating characteristic curve was used to examine the diagnostic performance of each measurement.Results Altogether 7271 adolescents aged 9−17 years were involved. The proportion of elevated ALT greatly increased with increasing classification of BMI-z. By the sex-specific cut-offs for elevated ALT (30 U/L boys; 19 U/L girls), BMI showed the highest area under the curve of 0.789 (95% CI 0.765-0.812) and followed by weight (0.779 [0.755-0.802]), BMI-z (0.747 [0.722-0.772]), height (0.622 [0.597-0.647]), and age (0.608 [0.584-0.632]), while height-z was not capable. With the cut-off of 67.8 kg for weight and 22.6 kg/m2 for BMI, the accuracy was 87.1% for weight and 82.9% for BMI.Conclusions The presence of elevated ALT was more common in overweight or obese adolescents. BMI and weight had the superiority of detecting elevated ALT, followed by BMI-z, height, and age.

Background. Serum alanine aminotransferase (ALT) activity was measured not only to detect liver disease, but also to monitor overall health. The purpose of this study was to obtain the prevalence of elevated ALT levels among adolescents. Methods. In a school-based cross-sectional study, a representative sample was analyzed from 9 middle and high schools in Shenzhen, China, during 2017 to 2018. Elevated ALT was defined as diagnostic criterion I (>30 U/L for boys and >19 U/L for girls) and diagnostic criterion II (>40 U/L). Results. From the adolescent population, a total of 7281 students (boys, 4014, and girls, 3267) aged from 10 to 17 years were collected. The prevalence of elevated ALT was 7.11% (6.88% for boys and 7.41% for girls) by criterion I and 2.72% (3.96% for boys and 1.19% for girls) by criterion II. Based on the Shenzhen census and Chinese national census population, the adjusted prevalence of elevated ALT was 7.65% (boys 7.19% and girls 8.21%) and 6.79% (boys 6.07% and girls 7.56%) by criterion I and 2.85% (boys 4.20% and girls 1.16%) and 2.43% (boys 3.49% and girls 1.29%) by criterion II. For age, the overall trends were increasing progressively, regardless of the use of diagnostic criteria for an elevated ALT activity. Conclusions. This study supplements the gap that the prevalence of elevated ALT levels differed in gender, age, and criteria among adolescents of Shenzhen. We should take the prevalence as a predictor and continue to play a warning and preventive role in preparation for further intervention.

Background Temperature change between neighboring days (TCN), an indicator to reflect sudden temperature variation, has been identified as an independent risk factor for human health by small-scale studies. However, the adverse impact of TCN on mortality and effect modification are insufficiently studied, and a larger multi-cities analysis at national level is needed to provide an insightful knowledge. Methods Using daily mortality and meteorological data from 106 communities of United States during 1987 to 2000, we employed a quasi-Poisson regression with distributed lag non-linear model to quantitatively estimate the effect of TCN on mortality for each community and a multivariate meta-analysis to pool the community-specific estimates. Results At national level, a monotonic increasing curve of TCN–mortality association was observed, which indicated that negative TCN (temperature decrease from the previous day) was associated with reduced mortality and positive TCN (temperature increase) elevated the risk of mortality. The relative risk for lag 0–21 days was 0.63 (95% confidence interval: 0.59–0.68) for extremely negative TCN (1st percentile) and 1.46 (1.39–1.54) for extremely positive TCN (99th percentile) on non-accidental mortality. We also found prominent effects of extreme TCNs on mortality for cardiovascular, respiratory, pneumonia, and COPD diseases. People ≥ 75 years and those with respiratory disease, especially pneumonia-deaths, were identified as a particularly vulnerable population to TCN. The TCN–mortality association was modified by season and region. Conclusions A positive TCN was associated with an elevated risk of mortality in United States, with different effect patterns by region and season. Identification of the effect modifiers presented a significantly stronger influence on older adults and those with respiratory disease.

We aimed to explore whether there were cold and heat temperature adverse effects on years of life lost (YLL) for non-accidental mortality in Yuxi, a southwest plateau region of China. From data for 89,467 non-accidental deaths over an 8-year study period, we used a general linear regression model combined with a distributed lag non-linear model to assess the burden of disease non-accidental mortality due to ambient temperature with the YLL indicator. We estimated the mean YLL change per 1 °C decrease from the 25th to 1st percentile mean temperature as the cold effect and per 1 °C increase from the 75th to 99th percentile as the heat effect. The 95% empirical confidence intervals (eCIs) were calculated by using a bootstrap simulation method. The exposure–response curve between average temperature and YLL was U-shaped. The cold effect peaked at the first day after exposure and disappeared at 2 weeks, and the heat effect only lasted for the first 3 days. A per 1 °C decrease from the 25th to 1st mean temperature percentile was associated with an increase of 15.6 (95% eCI: 2.4, 22.9) in YLL for non-accidental diseases, and the cumulative effects due to cold were stronger in contrast to that attributed by heat. Cold temperature had a significant impact on YLL among the subgroups, with higher YLL in cardiovascular disease, stroke, males, Han nationality, married, and those engaged in agriculture than their corresponding categories. An increasing death burden of non-accidental in Yuxi of China due to cold temperature was demonstrated, and the association was also modified by specific disease causes and individual features.

ObjectiveTo examine the total non-accidental mortality burden attributable to ambient temperatures and assess the effect modification of the burden by specific causes of death and individual characteristics in a high plateau area in southwest China.MethodsUsing daily mortality and meteorological data from 2009 to 2016, we applied a quasi-Poisson model combined with a distributed lag non-linear model to estimate the temperature–mortality association with the assessment of attributable fraction and number. We calculated attributable fractions and deaths with 95% empirical CIs (eCIs), that were due to cold and heat, defined as temperatures below and above the median temperature, and for mild and extreme temperatures, defined by cut-offs at the 2.5th and 97.5th temperature percentiles.ResultsWe analysed 89 467 non-accidental deaths; 4131 were attributable to overall temperatures, with an attributable fraction of 4.75% (95% eCI 2.33% to 6.79%). Most of the mortality burden was caused by cold (4.08%; 0.86% to 7.12%), whereas the burden due to heat was low and non-significant (0.67%; −2.44% to 3.64%). Extreme cold (1.17%; 0.58% to 1.69%) was responsible for 24.6% (ie, 1.17% divided by 4.75%) of the total death burden. In the stratification analyses, attributable risk due to cold was higher for cardiovascular than respiratory disease (6.18% vs 3.50%). We found a trend of risk of increased death due to ambient temperatures with increasing age, with attributable fractions of 1.83%, 2.27% and 6.87% for age ≤64, 65–74 and ≥75 years old, respectively. The cold-related burden was slightly greater for females, farmers, ethnic minorities and non-married individuals than their corresponding categories.ConclusionsMost of the burden of death was attributable to cold, and specific causes and individual characteristics might modify the mortality burden attributable to ambient temperatures. The results may help make preventive measures to confront climate change for susceptible population in this region.

Background Despite contributing to the majority of ambient fine particles (PM2.5), PM1 (particulate matter [PM] with aerodynamic diameter ≤1 μm) remains poorly studied in terms of its acute effects on cardiovascular diseases (CVDs) in China. This study aims to evaluate the short-term associations of size-specific PMs (i.e., PM1, PM2.5, and PM10) exposures with hospital admissions for CVDs in a southern Chinese metropolis. Methods We collected 5,969 records of hospital admissions for CVDs and daily average concentrations of air pollutants and weather conditions in Shenzhen from January 1st 2015 to December 31st 2017. We adopted a time-stratified case-crossover design and conditional logistic regression models to assess short-term associations between size-specific PMs and CVD hospitalizations along different exposure days. Results During the study period, annual average concentrations of PM1, PM2.5, and PM10 were 18.7, 27.8, and 45.4 μg/m3, respectively. Compared to PM2.5 and PM10, PM1 exhibited a generally stronger association with CVD hospitalizations. Hospital admissions for CVDs increased by 6.7% (95% confidence interval: 1.2–12.5%), 4.5% (0.4–8.7%), and 3.4% (0.5–6.3%), corresponding to per 10-μg/m3 rise in exposure to PM1, PM2.5, and PM10 at lag 03 days. In our stratified analyses by CVD sub-causes, size-specific PMs showed consistent effects on hypertension but no evident association with ischemic heart disease (IHD) and stroke. Seasonal analysis revealed significantly larger PM-associated risks among IHD patients in cold months (October–March). Nevertheless, in warm months (April–September), the older group (aged 65+ years) was more prone to adverse effects of PM1 exposure at lag 0 day. Conclusion Short-term exposure to size-specific PMs, PM1 in particular, may trigger incidences of CVD hospitalization. To effectively mitigate adverse effects of particulate pollution, evidence-based PM1 standards should be developed as well in Chinese less-polluted megacities.

Background Breakfast is commonly described as the most important meal of the day; however, we have little information regarding its relevance for childhood overweight and obesity in southern mainland China. This study aimed to assess the association between breakfast preferences, consumption location and overweight and obesity for children in Shenzhen. Methods Among 6126 children (median age 7.2 years) at primary schools, 3504 were finally included after a questionnaire survey and physical examination. Ten commonly consumed foods/beverages for breakfast in southern China were exposure variables, and consumption location, total energy demographic and other dietary characteristics were covariates in logistic regression to determine the effect of breakfast preferences on overweight and obesity, estimating odds ratios (ORs) and 95% confidence intervals (CIs). Results Probability of overweight/general obesity was inversely associated with children eating plain congee for breakfast (adjusted OR 0.689, 95% CI 0.566–0.838), restricted to boys after stratification. Probability of overweight/general obesity and central obesity was positively associated with usually eating steamed rice roll for breakfast (OR 1.309, 95% CI 1.090–1.571 and OR 1.351, 95% CI 1.064–1.717, respectively), but the effect on overweight/obesity remained statistically significant for only boys after stratification. Eating steamed rice roll for breakfast and eating out for breakfast had an additive interaction on overweight/obesity. Additionally, eating bread for breakfast had a mild favorable effect on overweight/obesity but only for girls. Conclusions Keeping a healthy weight might benefit children who eat plain congee or bread for breakfast in China. However, frequent consumption of steamed rice roll for breakfast and especially eating out could contribute to overweight and obesity. Thus, we need to promote a healthier breakfast pattern among children in southern China to reduce the odds of obesity.

Background Ambient PM2.5 has been identified as the top leading cause of risk-attributable deaths worldwide, particularly in China. Evidence suggested that PM1 contributed the most majority of PM2.5 concentrations in Chinese cities. However, epidemiologic knowledge to date is of wide lack regarding PM1-associated health effects. Methods We collected daily records of all-cause emergency department visits (EDVs) and ground measurements of ambient air pollutants and meteorological factors in Guangzhou and Shenzhen, China, 2015–2016. Case-crossover design and conditional logistic regression models were used to comparatively assess the short-term effects of ambient PM1, PM2.5, and PM10 on EDVs. Stratified analyses by gender, age and season were performed to identify vulnerable groups and periods. Results PM1, PM2.5 and PM10 were all significantly associated with increased EDVs in both cities. Population risks for EDVs increased by 2.2% [95% confidence interval, 1.8 to 2.6] in Guangzhou and 1.7% [1.0 to 2.4] in Shenzhen, for a 10 μg/m3 rise in PM1 at lag 0–1 days and lag 0–4 days, respectively. Relatively lower risks were found to be associated with PM2.5 and PM10. PM-EDVs associations exhibited no gender differences, but varied across age groups. Compared with adults and the elderly, children under 14 years-of-age suffered higher PM-induced risks. Results from both cities suggested greatly significant effect modification by season, with consistently stronger PM-EDVs associations during cold months. Conclusions Our study added comparative evidence for increased EDVs risks associated with short-term exposures to ambient PM1, PM2.5 and PM10. Besides, PM-associated effects were significantly stronger among children and during cold months.

Background Research argued that daily excessive concentration hours (DECH) could be more informative through accounting for within-day variations, when assessing population-level exposure to ambient fine particle (PM2.5). However, few studies have comparatively investigated PM2.5-associated risks using DECH and two common metrics of daily mean and hourly peak concentration. Methods We collected daily records of all-cause emergency department visits (EDVs) and hourly data on air pollutants and meteorological factors from Shenzhen, China, 2015–2018. According to guidelines proposed by the World Health Organization, DECH was calculated by summing up daily concentrations exceeding 25 μg/m3. Based on time-stratified case-crossover design, we adopted conditional logistic regression models to assess short-term attributable risks of EDVs associated with PM2.5 using three exposure metrics. Results DECH and daily average of PM2.5 strongly elevated risks of EDVs, while less evident associations were observed using hourly peak metric. Estimated excess relative risks at lag 0 day were 0.56% (95% confidence interval [CI]: 0.21 to 0.91), 0.69% (95% CI: 0.25 to 1.13) and 0.37% (95% CI: 0.02 to 0.76), respectively, associated with an interquartile range increase in DECH (420.2 μg/m3), 24-h average (24.9 μg/m3) and hourly peak concentration (38 μg/m3). More emergency visits could be attributed to DECH than daily mean PM2.5, with attributable fractions of 2.02% (95% CI: 1.42 to 2.61) and 1.09% (95% CI: 0.69 to 1.49), respectively. Conclusions This study added evidence for increased risk of EDVs associated with exposure to ambient PM2.5. DECH was a potential alternative exposure metric for PM2.5 assessment, which may have implications for future revision of air quality standards.

OBJECTIVEIntracerebral hemorrhage (ICH) is associated with a poor prognosis and high mortality, but no study has elucidated the association between glycemic variability (GV) and functional outcome in ICH. The authors of this study aimed to determine whether GV is a predictor of 30-day functional outcome in ICH patients.METHODSThe study recruited 366 patients with first-ever acute-onset ICH in the period during 2014 and 2015. Fasting blood glucose was assessed on admission and with 7-day continuous monitoring. Glycemic variability was calculated and expressed by the standard deviation (GluSD) and coefficient of variation (GluCV). Patients were divided into groups of those with diabetes mellitus (DM), stress hyperglycemia (SHG), and normal glucose (NG). Functional outcome was measured using the modified Rankin Scale.RESULTSThe numbers of patients with DM, SHG, and NG were 108 (29.5%), 127 (34.7%), and 131 (35.8%), respectively. As compared with the DM patients, those with SHG had higher mortality (29.9% vs 15.7%, p < 0.05) and a poorer prognosis (64.6% vs 52.8%, p < 0.05). Poor prognosis was associated with both high GluSD (OR 1.54, 95% CI 1.19–1.99) and high GluCV (1.05, 1.02–1.09), especially in the DM group. The area under the receiver operating characteristic curve was greater for the GluSD (OR 0.929, 95% CI 0.902–0.956) and the GluCV (0.932, 0.906–0.958) model than the original model (0.860, 0.823–0.898) in predicting a poor outcome.CONCLUSIONSStress hyperglycemia may be associated with increased mortality and a poor outcome in ICH, and increased GV may be independently associated with a poor outcome, particularly in ICH patients with DM.

The existing definitions of metabolic syndrome (MetS) may not be fully appropriate for the Shantou population because of ethnic and regional differences. We sought to establish a 95% multivariate medical reference range (MMRR) model for diagnosing MetS in Shantou adults and to evaluate the prevalence of MetS by the MMRR, JCDCG (the Chinese Guidelines) and International Diabetes Federation (IDF) criteria. A total of 4,580 participants were recruited in Shantou, southern China. We developed a MMRR model based on the combinatorial indicatrixes method for three categorized indicatrixes. According to the developed MMRR criteria, men (women) in Shantou have MetS by meeting 3 or more of the following: waist circumference ≥89 (81) cm; triglycerides level ≥1.73 (1.64) mmol/L; high-density lipoprotein cholesterol level ≤1.07 (1.05) mmol/L; blood pressure ≥138/89 (136/85) mmHg; and fasting plasma glucose ≥5.8 (5.7) mmol/L. The agreement of the MMRR with JCDCG and IDF criteria was “substantial” (both κ > 0.68), but the recommended reference values and proportion of individual components of MetS defined by the 3 criteria differed. The population-based MMRR criteria may be appropriate for diagnosing MetS in Shantou population and the model might be useful for generalization to other geographic regions.

Background Supplementation with B vitamins for stroke prevention has been evaluated over the years, but which combination of B vitamins is optimal for stroke prevention is unclear. We performed a network meta-analysis to assess the impact of different combinations of B vitamins on risk of stroke. Methods A total of 17 trials (86 393 patients) comparing 7 treatment strategies and placebo were included. A network meta-analysis combined all available direct and indirect treatment comparisons to evaluate the efficacy of B vitamin supplementation for all interventions. Results B vitamin supplementation was associated with reduced risk of stroke and cerebral hemorrhage. The risk of stroke was lower with folic acid plus vitamin B6 as compared with folic acid plus vitamin B12 and was lower with folic acid plus vitamin B6 plus vitamin B12 as compared with placebo or folic acid plus vitamin B12. The treatments ranked in order of efficacy for stroke, from higher to lower, were folic acid plus vitamin B6 > folic acid > folic acid plus vitamin B6 plus vitamin B12 > vitamin B6 plus vitamin B12 > niacin > vitamin B6 > placebo > folic acid plus vitamin B12. Conclusions B vitamin supplementation was associated with reduced risk of stroke; different B vitamins and their combined treatments had different efficacy on stroke prevention. Folic acid plus vitamin B6 might be the optimal therapy for stroke prevention. Folic acid and vitamin B6 were both valuable for stroke prevention. The efficacy of vitamin B12 remains to be studied.

Background Consistent evidence has shown that high diurnal temperature range (DTR) is associated with excess mortality, but little is known about the subgroups in the association. We aimed to identify the effect modifiers, including individual characteristics and specific mortality causes, of the association in a high plateau region with large DTR and extensive ethnic minorities in China. Methods We conducted a case-only analysis in 77,319 non-accidental deaths in Yuxi during 2007–2014, and evaluated the effect modifiers of the association of high DTR exposure and mortality. All non-accidental deaths were divided into cardiovascular, respiratory, and “other” causes. High DTR days were defined as ≥ 90th percentile of DTR. Results Risk of mortality on high DTR days was associated with age 75–84 years (odds ratio 1.07; 95% confidence interval 1.01–1.14) and ≥ 85 years (1.16; 1.08–1.24) as compared with age ≤ 64 years. The risk of the association was less for the Dai ethnic minority than Chinese Han (0.85; 0.75–0.96). Farmers (1.08; 1.03–1.14) and people with hypertension (1.09; 1.02–1.16) showed greater risk of dying on high DTR days than non-farmers and people without hypertension, respectively. Compared with “other” mortality causes, the risk was greater with cardiovascular causes (1.09; 1.04–1.15), notably ischemic heart disease (1.16; 1.08–1.25) and myocardial infarction (1.18; 1.08–1.29) in heart disease (1.11; 1.04–1.17), and ischemic stroke (1.17; 1.06–1.28) in stroke deaths (1.09; 1.03–1.15), as well as chronic bronchitis (1.22; 1.11–1.33) and chronic obstructive pulmonary disease (1.12; 1.05–1.20) in respiratory deaths (1.11; 1.04–1.18). Conclusions Individual characteristics and specific mortality causes can modify the association of high DTR and mortality. This knowledge may help in better targeting the vulnerable populations and developing more effective intervention strategies.