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Background: Children with asthma may have a reduced ventilatory capacity, which could lead to symptoms and early termination of a cardiopulmonary exercise test (CPET). The purpose of this study was to examine the effects of short-acting beta agonist (albuterol) administration on estimated ventilatory capacity in children with asthma. Methods: Fifteen children (eleven boys, 10.6 ± 0.9 years) completed spirometry at baseline, after 180 µg of albuterol, and after the CPET in this cross-sectional study. Ventilatory capacity was calculated from forced vital capacity (FVC) and isovolume forced expiratory time from 25 to 75% of FVC (isoFET25–75) as follows: FVC/2 × [60/(2 × isoFET25–75)]. Differences in outcome variables between baseline, after albuterol administration, and after the CPET were detected with repeated measures mixed models with Bonferroni post hoc corrections. Results: Estimated ventilatory capacity was higher after albuterol (68.7 ± 21.2 L/min) and after the CPET (75.8 ± 25.6 L/min) when compared with baseline (60.9 ± 22.0 L/min; P = 0.003). Because forced vital capacity did not change, the increased ventilatory capacity was primarily due to a decrease in isoFET25–75 (i.e., an increase in mid-flows or isoFEF25–75). Conclusion: Albuterol administration could be considered prior to CPET for children with asthma with relatively well-preserved FEV1 values to increase ventilatory capacity pre-exercise and potentially avoid symptom-limited early termination of testing.

High-sensitivity C-reactive protein (hs-CRP) is a widely used clinical biomarker of systemic inflammation, implicated in many chronic conditions, including type 1 diabetes (T1D). Despite the increasing emphasis on dietary intake as a modifiable risk factor for systemic inflammation, the association of hs-CRP with fruit and vegetable consumption is relatively underexplored in T1D. To address this gap, we investigated the longitudinal associations of dietary pattern-derived fruit and vegetable scores with hs-CRP in adults with and without T1D. Additionally, we examined the impact of berry consumption as a distinct food group. Data were collected in the Coronary Artery Calcification in Type 1 Diabetes study over two visits that were three years apart. At each visit, participants completed a food frequency questionnaire, and hs-CRP was measured using a particle-enhanced immunonephelometric assay. Mixed effect models were used to examine the three-year association of fruit and vegetable scores with hs-CRP. Adjusted models found a significant inverse association between blueberry intake and hs-CRP in the nondiabetic (non-DM) group. Dietary Approaches to Stop Hypertension- and Alternative Healthy Eating Index-derived vegetable scores were also inversely associated with hs-CRP in the non-DM group (all p-values ≤ 0.05). Conversely, no significant associations were observed in the T1D group. In conclusion, dietary pattern-derived vegetable scores are inversely associated with hs-CRP in non-DM adults. Nonetheless, in T1D, chronic hyperglycemia and related metabolic abnormalities may override the cardioprotective features of these food groups at habitually consumed servings.

Esophageal squamous cell carcinoma (ESCC) is a deadly consequence of radiation exposure to the esophagus. ESCC arises from esophageal epithelial cells that undergo malignant transformation and features a perturbed squamous cell differentiation program. Understanding the dose- and radiation quality-dependence of the esophageal epithelium response to radiation may provide insights into the ability of radiation to promote ESCC. We have explored factors that may play a role in esophageal epithelial radiosensitivity and their potential relationship to ESCC risk. We have utilized a murine three-dimensional (3D) organoid model that recapitulates the morphology and functions of the stratified squamous epithelium of the esophagus to study persistent dose- and radiation quality-dependent changes. Interestingly, although high-linear energy transfer (LET) Fe ion exposure induced a more intense and persistent alteration of squamous differentiation and 53BP1 DNA damage foci levels as compared to Cs, the MAPK/SAPK stress pathway signaling showed similar altered levels for most phospho-proteins with both radiation qualities. In addition, the lower dose of high-LET exposure also revealed nearly the same degree of morphological changes, even though only ~36% of the cells were predicted to be hit at the lower 0.1 Gy dose, suggesting that a bystander effect may be induced. Although p38 and ERK/MAPK revealed the highest levels following high-LET exposure, the findings reveal that even a low dose (0.1 Gy) of both radiation qualities can elicit a persistent stress signaling response that may critically impact the differentiation gradient of the esophageal epithelium, providing novel insights into the pathogenesis of radiation-induced esophageal injury and early stage esophageal carcinogenesis.

Plain Language Summary In sub-Saharan Africa (SSA), studies have shown that the proportion of married women who want to stop having children has been increasing as well as the proportion using modern contraceptive methods among them. These studies also indicated that this proportion of women are higher in certain regions of Africa than the others. To extend these previous findings, we performed geographical analysis to assess how the proportion of married/in-union women who want to stop having children and the ones using modern methods among them differ geographically. Our findings indicated that neighboring countries where the proportion of married/in-union women who want to stop having children was higher than the overall average were concentrated in eastern and southern Africa (ESA), while neighboring countries in which the proportion of married/in-union women who want to stop having children was lower than the overall average were concentrated in western and central Africa (WCA). Similarly, the results also showed that neighboring countries where the proportion of married/in-union women using modern contraceptive methods among those who want to stop having children was lower than the overall average were concentrated in WCA. Our findings suggest that increasing joint decision making on family planning and uptake of antenatal care in SSA may improve the use of modern contraceptive methods among married/in-union women who want to stop childbearing.

During space travel, astronauts will experience a unique environment that includes continuous exposure to microgravity and stressful living conditions. Physiological adaptation to this is a challenge and the effect of microgravity on organ development, architecture, and function is not well understood. How microgravity may impact the growth and development of an organ is an important issue, especially as space flight becomes more commonplace. In this work, we sought to address fundamental questions regarding microgravity using mouse mammary epithelial cells in 2D and 3D tissue cultures exposed to simulated microgravity. Mouse mammary HC11 cells contain a higher proportion of stem cells and were also used to investigate how simulated microgravity may impact mammary stem cell populations. In these studies, we exposed mouse mammary epithelial cells to simulated microgravity in 2D and then assayed for changes in cellular characteristics and damage levels. The microgravity treated cells were also cultured in 3D to form acini structures to define if simulated microgravity affects the cells’ ability to organize correctly, a quality that is of key importance for mammary organ development. These studies identify changes occurring during exposure to microgravity that impact cellular characteristics such as cell size, cell cycle profiles, and levels of DNA damage. In addition, changes in the percentage of cells revealing various stem cell profiles were observed following simulated microgravity exposure. In summary, this work suggests microgravity may cause aberrant changes in mammary epithelial cells that lead to an increase in cancer risk.

ObjectiveAdopting an external focus of attention has been shown to benefit motor performance and learning. However, the potential of optimizing attentional focus for improving prosthetic motor skills in lower limb prosthesis (LLP) users has not been examined. In this study, we investigated the frequency and direction of attentional focus embedded in the verbal instructions in a clinical prosthetic training setting.MethodsTwenty-one adult LLP users (8 female, 13 male; 85% at K3 level; mean age = 50.5) were recruited from prosthetic clinics in the Southern Nevada region. Verbal interactions between LLP users and their prosthetists (mean experience = 10 years, range = 4-21 years) during prosthetic training were recorded. Recordings were analyzed to categorize the direction of attentional focus embedded in the instructional and feedback statements as internal, external, mixed, or unfocused. We also explored whether LLP users' age, time since amputation, and perceived mobility were associated with the proportion of attentional focus statements they received.ResultsWe recorded a total of 20 training sessions, yielding 904 statements of instruction from 338 minutes of training. Overall, one verbal interaction occurred every 22.1 seconds. Among the statements, 64% were internal, 9% external, 3% mixed, and 25% unfocused. Regression analysis revealed that female, older, and higher functioning LLP users were significantly more likely to receive internally-focused instructions (p = 0.006, 0.035, and 0.024, respectively).ConclusionsOur results demonstrated that verbal instructions and feedback are frequently provided to LLP users during prosthetic training. Most verbal interactions are focused internally on the LLP users' body movements and not externally on the movement effects.Impact statementWhile more research is needed to explore how motor learning principles may be applied to improve LLP user outcomes, clinicians should consider adopting the best available scientific evidence during treatment. Overreliance on internally-focused instructions as observed in the current study may hinder prosthetic skill learning.

Abstract Background We aimed to evaluate the variation in gun violence-related research in the US over time to determine if there are meaningful changes in frequency of research at certain time points. Related publications were searched from the Web of Science. Methods We searched articles from Web of Science to collect publication data of gun violence research in three disciplines (clinical sciences, life sciences, and social behavior sciences) from 1981 to 2018. The joinpoint regression approach was applied to evaluate the trend of publication ratio. We also adopted the generalized additive mixed model to compare the publication ratio among the three research disciplines. Results During the study period, each research discipline had a significant decrease in publication ratios, especially social behavioral sciences from 2001 to 2011, with an annual percentage change = − 9.77% (95% CI = − 13.45, − 5.93; p-value < .0001). After combining the three research disciplines, the average change of the publication ratio was significantly increased 9.18% (95% CI = 6.42, 12.01; p-value < .0001) per year from 1981 to 2018. Compared to social behavioral sciences, both clinical sciences and life sciences had a significantly smaller publication ratio. Conclusions Gun violence research exhibited a significant downward trend in publications in the early 2000s, which may be attributed at least in part to limited federal funding, but the publication ratio increased since the 2010s. To enhance the amount of peer-reviewed gun violence research so that research-informed gun violence interventions are more likely to succeed, decision-makers should keep supporting quality research.

Abstract Background There is a global commitment to eliminating tuberculosis (TB). It is critical to detect and treat cases of latent TB infection (LTBI), the reservoir of new TB cases. Our study assesses trends in publication of LTBI-related research. Methods We used the keywords (“latent tuberculosis” OR “LTBI” OR “latent TB”) to search the Web of Science for LTBI-related articles published 1995–2018, then classified the results into three research areas: laboratory sciences, clinical research, and public health. We calculated the proportions of LTBI-related articles in each area to three areas combined, the average rates of LTBI-related to all scientific and TB-related articles, and the average annual percent changes (AAPC) in rates for all countries and for the top 13 countries individually and combined publishing LTBI research. Results The proportion of LTBI-related articles increased over time in all research areas, with the highest AAPC in laboratory (38.2%/yr), followed by public health (22.9%/yr) and clinical (15.1%/yr). South Africa (rate ratio [RR] = 8.28, 95% CI 5.68 to 12.08) and India (RR = 2.53, 95% CI 1.74 to 3.69) had higher RRs of overall TB-related articles to all articles, but did not outperform the average of the top 13 countries in the RRs of LTBI-related articles to TB-related articles. Italy (RR = 1.95, 95% CI 1.45 to 2.63), Canada (RR = 1.73, 95% CI 1.28 to 2.34), and Spain (RR = 1.53, 95% CI 1.13 to 2.07) had higher RRs of LTBI-related articles to TB-related articles. Conclusions High TB burden countries (TB incidence > 100 per 100,000 population) published more overall TB-related research, whereas low TB burden countries showed greater focus on LTBI. Given the potential benefits, high TB burden countries should consider increasing their emphasis on LTBI-related research.

Abstract Background Several Zika virus (ZIKV) outbreaks have occurred since October 2015. Because there is no effective treatment for ZIKV infection, developing an effective surveillance and warning system is currently a high priority to prevent ZIKV infection. Despite Aedes mosquitos having been known to spread ZIKV, the calculation approach is diverse, and only applied to local areas. This study used meteorological measurements to monitor ZIKV infection due to the high correlation between climate change and Aedes mosquitos and the convenience to obtain meteorological data from weather monitoring stations. Methods This study applied the Bayesian structured additive regression modeling approach to include spatial interactive terms with meteorological factors and a geospatial function in a zero-inflated Poisson model. The study area contained 32 administrative departments in Colombia from October 2015 to December 2017. Weekly ZIKV infection cases and daily meteorological measurements were collected. Mapping techniques were adopted to visualize spatial findings. A series of model selections determined the best combinations of meteorological factors in the same model. Results When multiple meteorological factors are considered in the same model, both total rainfall and average temperature can best assess the geographic disparities of ZIKV infection. Meanwhile, a 1-in. increase in rainfall is associated with an increase in the logarithm of relative risk (logRR) of ZIKV infection of at most 1.66 (95% credible interval [CI] = 1.09, 2.15) as well as a 1 °F increase in average temperature is significantly associated with at most 0.79 (95% CI = 0.12, 1.22) increase in the logRR of ZIKV. Moreover, after controlling rainfall and average temperature, an independent geospatial function in the model results in two departments with an excessive ZIKV risk which may be explained by unobserved factors other than total rainfall and average temperature. Conclusion Our study found that meteorological factors are significantly associated with ZIKV infection across departments. The study determined both total rainfall and average temperature as the best meteorological factors to identify high risk departments of ZIKV infection. These findings can help governmental agencies monitor at risk areas according to meteorological measurements, and develop preventions in those at risk areas in priority.

Several studies have identified improvements in the risks of cardiovascular disease in adults following a Mediterranean dietary pattern. However, data are scarce on its association with coronary artery calcification (CAC) and pericardial adiposity (PAT) in US adults with and without diabetes. To address this gap, we conducted a case-control study using baseline data from the Coronary Artery Calcification in Type 1 Diabetes (CACTI) study [n = 1255; Type 1 Diabetes (T1D): n = 563; non-Diabetes Mellitus (non-DM): n = 692]. Participants completed a validated food frequency questionnaire, fasting (12 h overnight fast) biochemical analyses, and a physical examination including anthropometric measures. CAC and PAT were measured using electron beam-computed tomography. Logistic regression models were used to examine the associations of the Mediterranean-Style Dietary Pattern Score (MSDPS) with CAC (presence or absence), and linear regression models were applied to PAT analyses. In all of the adjusted models, no significant associations with CAC were found. For PAT, an increasing MSDPS was consistently associated with its lower volume in models adjusted for age, sex, diabetes status, total calories, and body mass index (all p < 0.05). The association between MSDPS and PAT was attenuated after adjusting for serum lipids and physical activity. In conclusion, the baseline data from the CACTI study show that a greater adherence to MSDPS is associated with a lower PAT volume and provide evidence that the Mediterranean dietary pattern is associated with lower cardiovascular risk markers.

Purpose: The number of Filipino Americans in Las Vegas, Nevada, is growing considerably, but no research to date has assessed the specific health needs of this burgeoning population. Thus, this study aims to assess health behaviors, perceived community health problems, and self-reported diseases/conditions among Filipino Americans in the Greater Las Vegas area and evaluate any difference by gender. Methods: A cross-sectional survey was conducted among 200 Filipino American adults residing in the Greater Las Vegas area using a prevalidated instrument. Results: The self-reported prevalence of hypertension, high cholesterol, and diabetes was 48%, 46%, and 25%, respectively. Adverse health behaviors, in terms of insufficient exercise and diets lacking in fruits and vegetables, were noted among our participants. Approximately 67% of participants reported exercising less than the recommended 150?min of physical activity per week and

Failure to thrive (FTT) impairs the expected normal physical growth of children. This study aimed to evaluate the effects of cyproheptadine hydrochloride on growth parameters in prepubertal children with FTT. The medical records of prepubertal children who were newly diagnosed with FTT at China Medical University Hospital between 2007 and 2016 were retrospectively examined. The patients were divided into two groups depending on whether they had (T-group) or had not (NT-group) received cyproheptadine hydrochloride (0.3 mg/kg daily) for at least 14 days. The mean length of the treatment period was 97.22 days (range: 14-532 days). Weight, height, and body mass index were adjusted for age using the median values in the growth charts for Taiwanese boys and girls as the reference. A total of 788 patients aged 3-11 years were enrolled, 50 in the T-group and 738 in the NT-group. No statistically significant difference in the median age-adjusted weight value was noted between the T-group and NT-group during the follow up period. In the T-group, age-adjusted weight and body mass index were inversely associated with age (P

Background: Disease control involves multiple actions overtime to halt the spread of COVID-19. The role of a country’s governance in slowing the spread of COVID-19 has not yet been well investigated. Objective: This study aims to investigate the association between governance and the trend of COVID-19 incidence in countries with the highest prevalence. We hypothesized that countries with better governance are more likely to mitigate the spread of COVID-19 than countries with worse governance. Methods: We analyzed 62 most prevalent countries with at least 10,000 accumulative confirmed cases from January 22 to June 15, 2020. Countries were further grouped into three different levels of governance (25 better governance, 24 fair governance, and 13 worse governance), identified outbreak and mitigation periods using the joinpoint regression model, and compared the number of days and average daily percent change in incidence in two periods by governance level using the one-way analysis of variance. Findings: The average outbreak period in the 62 countries lasted 84.0 days. Sixty percent of countries (N = 37) had experienced outbreak periods, followed by a mitigation period. In contrast, the rest forty percent of countries (N = 25) still had a rising trend. In the outbreak period, better governance countries had a more rapid increase but a shorter outbreak period (71.2 days) than countries with fair (93.5 days) and worse (90.8 days) governance. Most countries with better governance (84.0%) revealed a declining trend in COVID-19 incidence, while such a trend was less than half of fair and worse governance countries (38.5%–41.7%). Conclusions: Countries with better governance are more resilient during the COVID-19 crisis. While the mitigation of COVID-19 is observed in most better governance countries, the incidence of COVID-19 is still surging in most fair and worse governance countries, and the possibility of a recurring epidemic of COVID-19 in countries cannot be ignored.

BackgroundFemale permanent contraception is a cost-effective contraceptive method that can help clients with the desire to limit childbearing achieve their reproductive intention. However, despite its benefits, the use of FPC remains low in sub-Saharan Africa (SSA), and limited studies have examined the correlates of its uptake. In this study, we assessed the individual- and country-level factors associated with the use of FPC among married or in-union women using modern contraceptive methods to limit childbearing in SSA.MethodsThis study was a secondary data analysis of individual- and country-level data obtained from the Demographic and Health Surveys (DHS) Program and three open data repositories. The study included 29,777 married or in-union women aged 15-49 years using modern contraceptive methods to limit childbearing from DHS conducted in 33 sub-Sahara African countries between 2010 and 2018. We performed descriptive statistics and fitted multilevel logistic regression models to determine the predisposing, enabling, and need factors associated with the use of FPC.ResultsApproximately 13% of the women used FPC. About 20% of the variance in the odds of using FPC was attributable to between-country differences. In the full model, the significant individual-level factors associated with the use of FPC compared with other modern contraceptive methods were: age (odds ratio [OR] = 1.10; 95%CI = 1.08-1.12), living children (OR = 1.11, 95%CI = 1.04-1.16), high household wealth (OR = 1.39, 95%CI = 1.18-1.64), rural residence (OR = 0.83, 95% CI = 0.71-0.97), joint contraceptive decision with partner (OR = 1.68, 95% = 1.43-1.99), contraceptive decision by partner and others (OR = 2.46, 95% = 1.97-3.07), and the number of living children less than the ideal number of children (OR = 1.40, 95%CI = 1.21-1.62). The significantly associated country-level factors were births attended by skilled health providers (OR = 1.03, 95%CI = 1.00-1.05) and density of medical doctors (OR = 1.37, 95%CI = 1.01-1.85).ConclusionsOur results suggest that both individual- and country-level factors affect uptake of FPC in SSA. Increasing geographic, economic, and psychosocial access to FPC may improve its uptake in SSA.

Abstract Background Zika virus (ZIKV) infection is a pandemic and a public health emergency. It is transmitted by mosquitoes, primarily the Aedes genus. In light of no treatment currently, it is crucial to develop effective vector control programs to prevent the spread of ZIKV infection earlier when observing possible risk factors, such as weather conditions enhancing mosquito breeding and surviving. Methods This study collected daily meteorological measurements and weekly ZIKV infectious cases among 32 departments of Colombia from January 2015–December 2016. This study applied the distributed lag nonlinear model to estimate the association between the number of ZIKA virus infection and meteorological measurements, controlling for spatial and temporal variations. We examined at most three meteorological factors with 20 lags in weeks in the model. Results Average humidity, total rainfall, and maximum temperature were more predictable of ZIKV infection outbreaks than other meteorological factors. Our models can detect significantly lagged effects of average humidity, total rainfall, and maximum temperature on outbreaks up to 15, 14, and 20 weeks, respectively. The spatial analysis identified 12 departments with a significant threat of ZIKV, and eight of those high-risk departments were located between the Equator and 6°N. The outbreak prediction also performed well in identified high-risk departments. Conclusion Our results demonstrate that meteorological factors could be used for predicting ZIKV epidemics. Building an early warning surveillance system is important for preventing ZIKV infection, particularly in endemic areas.

An amendment to this paper has been published and can be accessed via the original article.

Summary: Background: Two international Conventions from the International Labor Organization (ILO; C162 Asbestos Convention) and the UN (Basel Convention) offer governments guidelines for achieving a total asbestos ban policy, but the long-term effect of these Conventions on policy implementation, and the role of government effectiveness, remains unknown. We aimed to investigate associations between government ratification of the ILO and UN international Conventions, government effectiveness, and implementation of a national total asbestos ban. Methods: We obtained data for year of a national asbestos ban, year of ratification of one or both international Conventions, and World Bank government effectiveness scores for 108 countries that ever used asbestos. We did a survival analysis for countries with data in the follow-up period (March 22, 1989, to Feb 2, 2018) to assess whether ratification of the international Conventions and greater government effectiveness were associated with time of implementation of a national total asbestos ban. Findings: Of 108 countries with data for asbestos consumption, nine were excluded because they implemented an asbestos ban before 1989. Therefore, 99 countries were included in the survival analysis. 26 countries ratified both international Conventions and 73 ratified either one or no Convention. Countries that ratified both Conventions had a shorter time to adoption of a total asbestos ban (mean 8·9 [SD 6·4] years) than did countries that ratified one or no Conventions (16·9 [6·1] years). After controlling for government effectiveness, countries that ratified both Conventions had a significantly higher conditional probability of banning asbestos than did those ratifying one or no Convention (hazard ratio [HR] 41·8, 95% CI 4·5–383·3; p=0·0010). For every 1 point increment in government effectiveness, the percentage change in HR for persistent asbestos consumption significantly increased by 127% (95% CI 13–354; p=0·021). Interpretation: This study confirms that adoption of both the C162 Asbestos Convention and the Basel Convention facilitates countries in moving towards a total asbestos ban. The effect was reinforced by government effectiveness. Both international programmes and new agreements towards total asbestos bans and government commitments are needed. Funding: China Medical University, and the Ministry of Science and Technology (Taiwan).

The purpose of this study was to determine and explore factors (age, sex, anthropometry, running and injury/pain history, tendon gross morphology, neovascularization, ankle range of motion, and ankle plantarflexor muscle endurance) related to intra-tendinous morphological alterations of the Achilles tendon in runners. An intra-tendinous morphological change was defined as collagen fiber disorganization detected by a low peak spatial frequency radius (PSFR) obtained from spatial frequency analysis (SFA) techniques in sonography. Ninety-one runners (53 males and 38 females; 37.9 ± 11.6 years) with 8.8 ± 7.3 years of running experience participated. Height, weight, and waist and hip circumferences were recorded. Participants completed a survey about running and injury/pain history and the Victorian Institute of Sport Assessment-Achilles (VISA-A) survey. Heel raise endurance and knee-to-wall composite dorsiflexion were assessed. Brightness-mode (B-mode) sonographic images were captured longitudinally and transversely on the Achilles tendon bilaterally. Sonographic images were analyzed for gross morphology (i.e., cross-sectional area [CSA]), neovascularization, and intra-tendinous morphology (i.e., PSFR) for each participant. The factors associated with altered intra-tendinous morphology of the Achilles tendon were analyzed using a generalized linear mixed model. Multivariate analyses revealed that male sex was significantly associated with a decreased PSFR. Additionally, male sex and the presence of current Achilles tendon pain were found to be significantly related to decreased PSFR using a univariate analysis. Our findings suggested that male sex and presence of current Achilles tendon pain were related to intra-tendinous morphological alterations in the Achilles tendon of runners.

Background: Low cardiorespiratory fitness is associated with increased risk of hypertension and atherosclerosis in adults with prehypertension. The purpose of this study was to quantify cardiorespiratory fitness and to examine the utility of supramaximal constant-load verification testing for validating maximal oxygen uptake (VO2max) attainment in adults with prehypertension. Methods: Eleven adults (four women) with prehypertension (22.5 ± 2.9 y; body mass index (BMI): 24.6 ± 3.2 kg·m2) underwent an incremental exercise test followed 15 min later by a verification test at 105% of maximal work rate on a cycle ergometer. Results: There was no statistical difference in VO2 between the incremental (2.23 ± 0.54 L·min−1) and verification tests (2.28 ± 0.54 L·min−1; p = 0.180). Only three out of eleven participants had a higher VO2 during the verification when compared with the incremental test. If the verification test had not been conducted, one participant would have been incorrectly classified as having low cardiorespiratory fitness based on incremental test results alone. Conclusions: Verification testing validates the attainment of VO2max and can potentially reduce the over-diagnosis of functional impairment (i.e., deconditioning) in adults with prehypertension.

This paper assesses concordance and inconsistency among three small area estimation methods that are currently providing county-level health indicators in the United States. The three methods are multi-level logistic regression, spatial logistic regression, and spatial Poison regression, all proposed since 2010. Diabetes prevalence is estimated for each county in the continental United States from the 2012 sample of Behavioral Risk Factor Surveillance System. The mapping results show that all three methods displayed elevated diabetes prevalence in the South. While the Pearson correlation coefficients among three model-based estimates were all above 0.60, the highest one was 0.80 between the multilevel and spatial logistic methods. While point estimates are apparently different among the three small area estimate methods, their top and bottom of quintile distributions are fairly consistent based on Bangdiwala’s B-statistic, suggesting that outputs from each method would support consistent policy making in terms of identifying top and bottom percent counties.

Physical inactivity is one of the risk factors of diabetes. In addition, physical inactivity is attributed to urbanization-related factors, such as poverty, which is also one of the risk factors of diabetes. We hypothesized that physical inactivity is a mediator in the association between diabetes and poverty, and that spatial heterogeneity exists in these relationships. This study adopted a spatiotemporal modelling approach to conduct this mediator analysis. From 2004-2011, data were collected at the county level in 48 contiguous states (with a total of 3,109 counties) from the Behavioral Risk Factor Surveillance System (BRFSS) and American Community Survey. Poverty percentage significantly affected physical inactivity prevalence and diabetes prevalence in two separate models. Using a model with both physical inactivity and poverty percentages as independent variables, we verified that physical inactivity prevalence is a significant mediator. In this model, physical inactivity prevalence resulted in a significant positive association with diabetes prevalence, and the influence of poverty percentage on diabetes prevalence was significantly reduced (P=0.0009). An advanced spatiotemporal analysis revealed that 32.65% of counties having a significant positive association between diabetes prevalence and physical inactivity prevalence also had a significant positive association between physical inactivity prevalence and poverty percentage. Those counties were also likely located in the South and Southeast of USA. In summary, the findings of this study demonstrate the mediating effect of physical inactivity between diabetes and poverty. When implementing diabetes prevention in communities with higher poverty, appropriate strategies to reduce the cost burden of physical activity programmes should be considered.

Dengue fever is one of the most widespread vector-borne diseases and has caused more than 50 million infections annually over the world. For the purposes of disease prevention and climate change health impact assessment, it is crucial to understand the weather-disease associations for dengue fever. This study investigated the nonlinear delayed impact of meteorological conditions on the spatiotemporal variations of dengue fever in southern Taiwan during 1998–2011. We present a novel integration of a distributed lag nonlinear model and Markov random fields to assess the nonlinear lagged effects of weather variables on temporal dynamics of dengue fever and to account for the geographical heterogeneity. This study identified the most significant meteorological measures to dengue fever variations, i.e., weekly minimum temperature, and the weekly maximum 24-hour rainfall, by obtaining the relative risk (RR) with respect to disease counts and a continuous 20-week lagged time. Results show that RR increased as minimum temperature increased, especially for the lagged period 5–18 weeks, and also suggest that the time to high disease risks can be decreased. Once the occurrence of maximum 24-hour rainfall is >50 mm, an associated increased RR lasted for up to 15 weeks. A temporary one-month decrease in the RR of dengue fever is noted following the extreme rain. In addition, the elevated incidence risk is identified in highly populated areas. Our results highlight the high nonlinearity of temporal lagged effects and magnitudes of temperature and rainfall on dengue fever epidemics. The results can be a practical reference for the early warning of dengue fever. Keywords: Dengue fever, Temporal delayed effect, Spatiotemporal modeling, Distributed lag nonlinear effects, Climatic effect

Asthma is one of the most prevalent chronic diseases in the United States of America (USA), and many of its risk factors have so far been investigated and identified; however, evidence is limited on how spatial disparities impact the disease. The purpose of this study was to provide scientific evidence on the location influence on asthma in the four states of south- western USA (California, Arizona, New Mexico and Texas) which, together, include 360 counties. The Behavioral Risk Factor Surveillance System database for these four states covering the period of 2000 to 2011 was used in this analysis, and a Bayesian structured additive regression model was applied to analyse by a geographical information system. After adjusting for individual characteristics, socioeconomic status and health behaviour, this study found higher odds associated with asth- ma and a likely cluster around the Bay Area in California, while lower odds appeared in several counties around the larger cities of Texas, such as Dallas, Houston and San Antonio. The significance map shows 43 of 360 counties (11.9%) to be high-risk areas for asthma. The level of geographical disparities demonstrates that the county risk of asthma prevalence varies significantly and can be about 19.9% (95% confidence interval: 15.3-25.8) higher or lower than the overall asthma prevalence. We provide an efficient method to utilise and interpret the existing surveillance data on asthma. Visualisation by maps may help deliver future interventions on targeted areas and vulnerable populations to reduce geographical disparities in the burden of asthma.

Clinical and epidemiological research has reported a strong association between diabetes and obesity. However, whether increased diabetes prevalence is more likely to appear in areas with increased obesity prevalence has not been thoroughly investigated in the United States (US). The Bayesian structured additive regression model was applied to identify whether counties with higher obesity prevalence are more likely clustered in specific regions in 48 contiguous US states. Prevalence data adopted the small area estimate from the Behavioral Risk Factor Surveillance System. Confounding variables like socioeconomic status adopted data were from the American Community Survey. This study reveals that an increased percentage of relative risk of diabetes was more likely to appear in Southeast, Northeast, Central and South regions. Of counties vulnerable to diabetes, 36.8% had low obesity prevalence, and most of them were located in the Southeast, Central, and South regions. The geographic distribution of counties vulnerable to diabetes expanded to the Southwest, West and Northern regions when obesity prevalence increased. This study also discloses that 7.4% of counties had the largest average in predicted diabetes prevalence compared to the other counties. Their average diabetes prevalence escalated from 8.7% in 2004 to 11.2% in 2011. This study not only identifies counties vulnerable to diabetes due to obesity, but also distinguishes counties in terms of different levels of vulnerability to diabetes. The findings can provide the possibility of establishing targeted surveillance systems to raise awareness of diabetes in those counties.

Understanding the spatial characteristics of dengue fever (DF) incidences is crucial for governmental agencies to implement effective disease control strategies. We investigated the associations between environmental and socioeconomic factors and DF geographic distribution, are proposed a probabilistic risk assessment approach that uses threshold-based quantile regression to identify the significant risk factors for DF transmission and estimate the spatial distribution of DF risk regarding full probability distributions. To interpret risk, return period was also included to characterize the frequency pattern of DF geographic occurrences. The study area included old Kaohsiung City and Fongshan District, two areas in Taiwan that have been affected by severe DF infections in recent decades. Results indicated that water-related facilities, including canals and ditches, and various types of residential area, as well as the interactions between them, were significant factors that elevated DF risk. By contrast, the increase of per capita income and its associated interactions with residential areas mitigated the DF risk in the study area. Nonlinear associations between these factors and DF risk were present in various quantiles, implying that water-related factors characterized the underlying spatial patterns of DF, and high-density residential areas indicated the potential for high DF incidence (e.g., clustered infections). The spatial distributions of DF risks were assessed in terms of three distinct map presentations: expected incidence rates, incidence rates in various return periods, and return periods at distinct incidence rates. These probability-based spatial risk maps exhibited distinct DF risks associated with environmental factors, expressed as various DF magnitudes and occurrence probabilities across Kaohsiung, and can serve as a reference for local governmental agencies.

Adverse health impacts of Asian dust storms (ADS) have been widely investigated and discussed in respiratory disease, but no study has examined the association between ADS events and their impact on eye diseases, especially in children. The impact of ADS events on the incidence of children's conjunctivitis is examined by analyzing the data from children's clinic visits registered in the 41 districts of Taipei area in Taiwan during the period 2002-2007. The structural additive regression modeling approach was used to assess the association between ADS events and clinic visits for conjunctivitis in children with consideration of day-of-the-week effects, temperature, and air quality levels. This study identifies an acute increase in the relative rate for children's conjunctivitis clinic visits during ADS periods with 1.48% (95% CI = 0.79, 2.17) for preschool children (aged

Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States. It is unclear how county-level primary care physician (PCP) availability and socioeconomic deprivation affect the spatial and temporal variation of breast cancer incidence and mortality.We used the 1988-2008 public-use county-based data from nine Surveillance, Epidemiology, and End Results (SEER) programs to analyze the temporal and spatial disparity of PCP availability and socioeconomic deprivation on early-stage incidence, advanced-stage incidence and breast cancer mortality. The spatio-temporal analysis was implemented by a novel structural additive modeling approach.Greater PCP availability was significantly associated with higher early-stage incidence, advanced-stage incidence and mortality during the entire study period while socioeconomic deprivation was significantly negatively associated with early-stage incidence, advanced-stage incidence, and mortality up to 1992. However, the observed influence of PCP availability and socioeconomic deprivation varied by county.We showed important associations of PCP availability and socioeconomic deprivation with the three breast cancer indicators. However, the effect of these associations varied over time and across counties. The association of PCP availability and socioeconomic deprivation was stronger in selected counties.

Concerns have been raised about the adverse impact of Asian dust storms (ADS) on human health; however, few studies have examined the effect of these events on children's health. Using databases from the Taiwan National Health Insurance and Taiwan Environmental Protection Agency, this study investigates the documented daily visits of children to respiratory clinics during and after ADS that occurred from 1997 to 2007 among 12 districts across Taipei City by applying a Bayesian structural additive regressive model controlled for spatial and temporal patterns. This study finds that the significantly impact of elevated children's respiratory clinic visits happened after ADS. Five of the seven lagged days had increasing percentages of relative rate, which was consecutively elevated from a 2-day to a 5-day lag by 0.63%∼2.19% for preschool children (i.e., 0∼6 years of age) and 0.72%∼3.17% for school children (i.e., 7∼14 years of age). The spatial pattern of clinic visits indicated that geographical heterogeneity was possibly associated with the clinic's location and accessibility. Moreover, day-of-week effects were elevated on Monday, Friday, and Saturday. We concluded that ADS may significantly increase the risks of respiratory diseases consecutively in the week after exposure, especially in school children.

High-sensitivity C-reactive protein (hs-CRP) is a widely used clinical biomarker of systemic inflammation, implicated in many chronic conditions, including type 1 diabetes (T1D). Despite the increasing emphasis on dietary intake as a modifiable risk factor for systemic inflammation, the association of hs-CRP with fruit and vegetable consumption is relatively underexplored in T1D. To address this gap, we investigated the longitudinal associations of dietary pattern-derived fruit and vegetable scores with hs-CRP in adults with and without T1D. Additionally, we examined the impact of berry consumption as a distinct food group. Data were collected in the Coronary Artery Calcification in Type 1 Diabetes study over two visits that were three years apart. At each visit, participants completed a food frequency questionnaire, and hs-CRP was measured using a particle-enhanced immunonephelometric assay. Mixed effect models were used to examine the three-year association of fruit and vegetable scores with hs-CRP. Adjusted models found a significant inverse association between blueberry intake and hs-CRP in the nondiabetic (non-DM) group. Dietary Approaches to Stop Hypertension- and Alternative Healthy Eating Index-derived vegetable scores were also inversely associated with hs-CRP in the non-DM group (all p-values ≤ 0.05). Conversely, no significant associations were observed in the T1D group. In conclusion, dietary pattern-derived vegetable scores are inversely associated with hs-CRP in non-DM adults. Nonetheless, in T1D, chronic hyperglycemia and related metabolic abnormalities may override the cardioprotective features of these food groups at habitually consumed servings. [ABSTRACT FROM AUTHOR]

Rotating shift work is associated with an increased risk of cardiovascular disease (CVD). This study compared the CVD risk score in 129 male line workers aged 22–49 years on different shifts in a medium-sized metal production factory from 2017 to 2020. We classified workers into four groups: permanent day shift, weekly rotation involving five consecutive nights, weekly rotation involving 3–4 consecutive nights, and monthly rotation involving two consecutive nights. We used the Framingham Risk Score to estimate the 30-yr risks of general and hard CVD (CVD risk estimates). We investigated the differences in CVD risk estimates between different groups using linear mixed models. The average 30-yr Framingham CVD risk estimates of each group ranged from 17.5% to 31.2% for general CVD and from 10.5% to 20.5% for hard CVD. Workers on weekly rotations involving 3–5 consecutive nights had 5%–10% significantly higher CVD risk estimates than workers on the permanent day shift. Workers on weekly rotations also had 6%–8% higher BMI-based CVD risk estimates than those on the monthly rotation involving two consecutive nights. While 24-h shift rotations are unavoidable, our findings underscored the potential CVD risk among workers on weekly rotations involving more consecutive nights. [ABSTRACT FROM AUTHOR]