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BackgroundNo single multimorbidity measure is validated for use in NHS (National Health Service) England’s General Practice Extraction Service Data for Pandemic Planning and Research (GDPPR), the nationwide primary care data set created for COVID-19 pandemic research. The Cambridge Multimorbidity Score (CMMS) is a validated tool for predicting mortality risk, with 37 conditions defined by Read Codes. The GDPPR uses the more internationally used Systematized Nomenclature of Medicine clinical terms (SNOMED CT). We previously developed a modified version of the CMMS using SNOMED CT, but the number of terms for the GDPPR data set is limited making it impossible to use this version. ObjectiveWe aimed to develop and validate a modified version of CMMS using the clinical terms available for the GDPPR. MethodsWe used pseudonymized data from the Oxford-Royal College of General Practitioners Research and Surveillance Centre (RSC), which has an extensive SNOMED CT list. From the 37 conditions in the original CMMS model, we selected conditions either with (1) high prevalence ratio (≥85%), calculated as the prevalence in the RSC data set but using the GDPPR set of SNOMED CT codes, divided by the prevalence included in the RSC SNOMED CT codes or (2) conditions with lower prevalence ratios but with high predictive value. The resulting set of conditions was included in Cox proportional hazard models to determine the 1-year mortality risk in a development data set (n=500,000) and construct a new CMMS model, following the methods for the original CMMS study, with variable reduction and parsimony, achieved by backward elimination and the Akaike information stopping criterion. Model validation involved obtaining 1-year mortality estimates for a synchronous data set (n=250,000) and 1-year and 5-year mortality estimates for an asynchronous data set (n=250,000). We compared the performance with that of the original CMMS and the modified CMMS that we previously developed using RSC data. ResultsThe initial model contained 22 conditions and our final model included 17 conditions. The conditions overlapped with those of the modified CMMS using the more extensive SNOMED CT list. For 1-year mortality, discrimination was high in both the derivation and validation data sets (Harrell C=0.92) and 5-year mortality was slightly lower (Harrell C=0.90). Calibration was reasonable following an adjustment for overfitting. The performance was similar to that of both the original and previous modified CMMS models. ConclusionsThe new modified version of the CMMS can be used on the GDPPR, a nationwide primary care data set of 54 million people, to enable adjustment for multimorbidity in predicting mortality in people in real-world vaccine effectiveness, pandemic planning, and other research studies. It requires 17 variables to produce a comparable performance with our previous modification of CMMS to enable it to be used in routine data using SNOMED CT.

BackgroundInnovation in seasonal influenza vaccine development has resulted in a wider range of formulations becoming available. Understanding vaccine coverage across populations including the timing of administration is important when evaluating vaccine benefits and risks. ObjectiveThis study aims to report the representativeness, uptake of influenza vaccines, different formulations of influenza vaccines, and timing of administration within the English Primary Care Sentinel Cohort (PCSC). MethodsWe used the PCSC of the Oxford-Royal College of General Practitioners Research and Surveillance Centre. We included patients of all ages registered with PCSC member general practices, reporting influenza vaccine coverage between September 1, 2019, and January 29, 2020. We identified influenza vaccination recipients and characterized them by age, clinical risk groups, and vaccine type. We reported the date of influenza vaccination within the PCSC by International Standard Organization (ISO) week. The representativeness of the PCSC population was compared with population data provided by the Office for National Statistics. PCSC influenza vaccine coverage was compared with published UK Health Security Agency’s national data. We used paired t tests to compare populations, reported with 95% CI. ResultsThe PCSC comprised 7,010,627 people from 693 general practices. The study population included a greater proportion of people aged 18-49 years (2,982,390/7,010,627, 42.5%; 95% CI 42.5%-42.6%) compared with the Office for National Statistics 2019 midyear population estimates (23,219,730/56,286,961, 41.3%; 95% CI 4.12%-41.3%; P

Summary: Background: The cardiovascular and kidney benefits of sodium-glucose co-transporter-2 (SGLT2) inhibitors in people with chronic kidney disease (CKD) are well established. The implementation of updated SGLT2 inhibitor guidelines and prescribing in the real-world CKD population remains largely unknown. Methods: A cross-sectional study of adults with CKD registered with UK primary care practices in the Oxford-Royal College of General Practitioners Research and Surveillance Centre network on the 31st December 2022 was undertaken. Pseudonymised data from electronic health records held securely within the Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub (ORCHID) were extracted. An update to a previously described ontological approach was used to identify the study population, using a combination of Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) indicating a diagnosis of CKD and laboratory confirmed CKD based on Kidney Disease: Improving Global Outcomes (KDIGO) diagnostic criteria. We examined the extent to which SGLT2 inhibitor guidelines apply to and are then implemented in adults with CKD. A logistic regression model was used to identify factors associated with SGLT2 inhibitor prescribing, reported as odds ratios (ORs) with 95% confidence intervals (CI). The four guidelines under investigation were the United Kingdom Kidney Association (UKKA) Clinical Practice Guideline SGLT2 Inhibition in Adults with Kidney Disease (October 2021), American Diabetes Association (ADA) and KDIGO Consensus Report on Diabetes Management in CKD (October 2022), National Institute for Health and Care Excellence (NICE) Guideline Type 2 Diabetes in Adults: Management (June 2022), and NICE Technology Appraisal Dapagliflozin for Treating CKD (March 2022). Findings: Of 6,670,829 adults, we identified 516,491 (7.7%) with CKD, including 32.8% (n = 169,443) who had co-existing type 2 diabetes (T2D). 26.8% (n = 138,183) of the overall CKD population had a guideline directed indication for SGLT2 inhibitor treatment. A higher proportion of people with CKD and co-existing T2D were indicated for treatment, compared to those without T2D (62.8% [n = 106,468] vs. 9.1% [n = 31,715]). SGLT2 inhibitors were prescribed to 17.0% (n = 23,466) of those with an indication for treatment, and prescriptions were predominantly in those with co-existing T2D; 22.0% (n = 23,464) in those with T2D, and

BackgroundHepatitis A outbreaks in the United Kingdom are uncommon. Most people develop mild to moderate symptoms that resolve, without sequelae, within months. However, in high-risk groups, including those with underlying chronic liver disease (CLD), hepatitis A infection can be severe, with a higher risk of mortality and morbidity. The Health Security Agency and the National Institute of Health and Care Excellence recommend preexposure hepatitis A vaccination given in 2 doses to people with CLD, regardless of its cause. There are currently no published reports of vaccination coverage for people with CLD in England or internationally. ObjectiveThis study aims to describe hepatitis A vaccination coverage in adults with CLD in a UK primary care setting and compare liver disease etiology, sociodemographic characteristics, and comorbidities in people who are and are not exposed to the hepatitis A vaccine. MethodsWe will conduct a retrospective cohort study with data from the Primary Care Sentinel Cohort of the Oxford-Royal College of General Practitioners Clinical Informatics Digital Hub database, which is nationally representative of the English population. We will include people aged 18 years and older who have been registered in general practices in the Research and Surveillance Centre network and have a record of CLD between January 1, 2012, and December 31, 2022, including those with alcohol-related liver disease, chronic hepatitis B, chronic hepatitis C, nonalcohol fatty liver disease, Wilson disease, hemochromatosis, and autoimmune hepatitis. We will carefully curate variables using the Systematized Nomenclature of Medicine Clinical Terms. We will report the sociodemographic characteristics of those who are vaccinated. These include age, gender, ethnicity, population density, region, socioeconomic status (measured using the index of multiple deprivation), obesity, alcohol consumption, and smoking. Hepatitis A vaccination coverage for 1 and 2 doses will be calculated using an estimate of the CLD population as the denominator. We will analyze the baseline characteristics using descriptive statistics, including measures of dispersion. Pairwise comparisons of case-mix characteristics, comorbidities, and complications will be reported according to vaccination status. A multistate survival model will be fitted to estimate the transition probabilities among four states: (1) diagnosed with CLD, (2) first dose of hepatitis A vaccination, (3) second dose of hepatitis A vaccination, and (4) death. This will identify any potential disparities in how people with CLD get vaccinated. ResultsThe Research and Surveillance Centre population comprises over 8 million people. The reported incidence of CLD is 20.7 cases per 100,000. International estimates of hepatitis A vaccine coverage vary between 10% and 50% in this group. ConclusionsThis study will describe the uptake of the hepatitis A vaccine in people with CLD and report any disparities or differences in the characteristics of the vaccinated population. International Registered Report Identifier (IRRID)PRR1-10.2196/51861

BackgroundThe Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) is one of Europe’s oldest sentinel systems, working with the UK Health Security Agency (UKHSA) and its predecessor bodies for 55 years. Its surveillance report now runs twice weekly, supplemented by online observatories. In addition to conducting sentinel surveillance from a nationally representative group of practices, the RSC is now also providing data for syndromic surveillance. ObjectiveThe aim of this study was to describe the cohort profile at the start of the 2021-2022 surveillance season and recent changes to our surveillance practice. MethodsThe RSC’s pseudonymized primary care data, linked to hospital and other data, are held in the Oxford-RCGP Clinical Informatics Digital Hub, a Trusted Research Environment. We describe the RSC’s cohort profile as of September 2021, divided into a Primary Care Sentinel Cohort (PCSC)—collecting virological and serological specimens—and a larger group of syndromic surveillance general practices (SSGPs). We report changes to our sampling strategy that brings the RSC into alignment with European Centre for Disease Control guidance and then compare our cohort’s sociodemographic characteristics with Office for National Statistics data. We further describe influenza and COVID-19 vaccine coverage for the 2020-2021 season (week 40 of 2020 to week 39 of 2021), with the latter differentiated by vaccine brand. Finally, we report COVID-19–related outcomes in terms of hospitalization, intensive care unit (ICU) admission, and death. ResultsAs a response to COVID-19, the RSC grew from just over 500 PCSC practices in 2019 to 1879 practices in 2021 (PCSC, n=938; SSGP, n=1203). This represents 28.6% of English general practices and 30.59% (17,299,780/56,550,136) of the population. In the reporting period, the PCSC collected >8000 virology and >23,000 serology samples. The RSC population was broadly representative of the national population in terms of age, gender, ethnicity, National Health Service Region, socioeconomic status, obesity, and smoking habit. The RSC captured vaccine coverage data for influenza (n=5.4 million) and COVID-19, reporting dose one (n=11.9 million), two (n=11 million), and three (n=0.4 million) for the latter as well as brand-specific uptake data (AstraZeneca vaccine, n=11.6 million; Pfizer, n=10.8 million; and Moderna, n=0.7 million). The median (IQR) number of COVID-19 hospitalizations and ICU admissions was 1181 (559-1559) and 115 (50-174) per week, respectively. ConclusionsThe RSC is broadly representative of the national population; its PCSC is geographically representative and its SSGPs are newly supporting UKHSA syndromic surveillance efforts. The network captures vaccine coverage and has expanded from reporting primary care attendances to providing data on onward hospital outcomes and deaths. The challenge remains to increase virological and serological sampling to monitor the effectiveness and waning of all vaccines available in a timely manner.

BackgroundSocial distancing and other nonpharmaceutical interventions to reduce the spread of COVID-19 infection in the United Kingdom have led to substantial changes in delivering ongoing care for patients with chronic conditions, including type 2 diabetes mellitus (T2DM). Clinical guidelines for the management and prevention of complications for people with T2DM delivered in primary care services advise routine annual reviews and were developed when face-to-face consultations were the norm. The shift in consultations from face-to-face to remote consultations caused a reduction in direct clinical contact and may impact the process of care for people with T2DM. ObjectiveThe aim of this study is to explore the impact of the COVID-19 pandemic’s first year on the monitoring of people with T2DM using routine annual reviews from a national primary care perspective in England. MethodsA retrospective cohort study of adults with T2DM will be performed using routinely collected primary care data from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC). We will describe the change in the rate of monitoring of hemoglobin A1c (HbA1c) between the first year of the COVID-19 pandemic (2020) and the preceding year (2019). We will also report any change in the eight checks that make up the components of these reviews. The change in HbA1c monitoring rates will be determined using a multilevel logistic regression model, adjusting for patient and practice characteristics, and similarly, the change in a composite measure of the completeness of all eight checks will be modeled using ordinal regression. The models will be adjusted for the following patient-level variables: age, gender, socioeconomic status, ethnicity, COVID-19 shielding status, duration of diabetes, and comorbidities. The model will also be adjusted for the following practice-level variables: urban versus rural, practice size, Quality and Outcomes Framework achievement, the National Health Service region, and the proportion of face-to-face consultations. Ethical approval was provided by the University of Oxford Medical Sciences Interdivisional Research Ethics Committee (September 2, 2021, reference R77306/RE001). ResultsThe analysis of the data extract will include 3.96 million patients with T2DM across 700 practices, which is 6% of the available Oxford-RCGP RSC adult population. The preliminary results will be submitted to a conference under the domain of primary care. The resulting publication will be submitted to a peer-reviewed journal on diabetes and endocrinology. ConclusionsThe COVID-19 pandemic has impacted the delivery of care, but little is known about the process of caring for people with T2DM. This study will report the impact of the COVID-19 pandemic on these processes of care. International Registered Report Identifier (IRRID)DERR1-10.2196/35971

Background Weight loss, hyperglycaemia and diabetes are known features of pancreatic cancer. We quantified the timing and the amount of changes in body mass index (BMI) and glycated haemoglobin (HbA1c), and their association with pancreatic cancer from five years before diagnosis. Methods A matched case-control study was undertaken within 590 primary care practices in England, United Kingdom. 8,777 patients diagnosed with pancreatic cancer (cases) between 1st January 2007 and 31st August 2020 were matched to 34,979 controls by age, gender and diabetes. Longitudinal trends in BMI and HbA1c were visualised. Odds ratios adjusted for demographic and lifestyle factors (aOR) and 95% confidence intervals (CI) were calculated with conditional logistic regression. Subgroup analyses were undertaken according to the diabetes status. Results Changes in BMI and HbA1c observed for cases on longitudinal plots started one and two years (respectively) before diagnosis. In the year before diagnosis, a 1 kg/m2 decrease in BMI between cases and controls was associated with aOR for pancreatic cancer of 1.05 (95% CI 1.05 to 1.06), and a 1 mmol/mol increase in HbA1c was associated with aOR of 1.06 (1.06 to 1.07). ORs remained statistically significant (p < 0.001) for 2 years before pancreatic cancer diagnosis for BMI and 3 years for HbA1c. Subgroup analysis revealed that the decrease in BMI was associated with a higher pancreatic cancer risk for people with diabetes than for people without (aORs 1.08, 1.06 to 1.09 versus 1.04, 1.03 to 1.05), but the increase in HbA1c was associated with a higher risk for people without diabetes than for people with diabetes (aORs 1.09, 1.07 to 1.11 versus 1.04, 1.03 to 1.04). Conclusions The statistically significant changes in weight and glycaemic control started three years before pancreatic cancer diagnosis but varied according to the diabetes status. The information from this study could be used to detect pancreatic cancer earlier than is currently achieved. However, regular BMI and HbA1c measurements are required to facilitate future research and implementation in clinical practice.

BackgroundBreastfeeding confers substantial benefits to child health and has also been associated with lower risk of maternal cardiovascular diseases (CVDs) in later life. However, the evidence on the effects of CVD is still inconsistent, especially in East Asians, in whom the frequency and duration of breastfeeding significantly differ from those in the West. Methods and ResultsIn 2004–2008, the nationwide China Kadoorie Biobank recruited 0.5 million individuals aged 30 to 79 years from 10 diverse regions across China. During 8 years of follow‐up, 16 671 incident cases of coronary heart disease and 23 983 cases of stroke were recorded among 289 573 women without prior CVD at baseline. Cox regression yielded adjusted hazard ratios (HRs) and 95% CIs for incident CVD by breastfeeding. Overall, ≈99% of women had given birth, among whom 97% reported a history of breastfeeding, with a median duration of 12 months per child. Compared with parous women who had never breastfed, ever breastfeeding was associated with a significantly lower risk of CVD, with adjusted HRs of 0.91 (95% CI, 0.84–0.99) for coronary heart disease and 0.92 (95% CI, 0.85–0.99) for stroke. Women who had breastfed for ≥24 months had an 18% (HR, 0.82; 0.77–0.87) lower risk of coronary heart disease and a 17% (HR, 0.83; 0.79–0.87) lower risk of stroke compared with women who had never breastfed. Among women who ever breastfed, each additional 6 months of breastfeeding per child was associated with an adjusted HR of 0.96 (95% CI, 0.94–0.98) for coronary heart disease and 0.97 (95% CI, 0.96–0.98) for stroke. ConclusionsAmong Chinese women, a history of breastfeeding was associated with an ≈10% lower risk of CVD in later life and the magnitude of the inverse association was stronger among those with a longer duration of breastfeeding.

Background: In England, most prescribing of direct-acting oral anticoagulants for atrial fibrillation (AF) is in primary care. However, there remain gaps in our understanding of dosage and disparities in use. We aimed to describe trends in direct oral anticoagulant (DOAC) prescribing, including dose reduction in people with renal impairment and other criteria, and adherence.Methods: Using English primary care sentinel network data from 2014 to 2019, we assessed appropriate DOAC dose adjustment with creatinine clearance (CrCl). Our primary care sentinel cohort was a subset of 722 general practices, with 6.46 million currently registered patients at the time of this study.Results: Of 6 464 129 people in the cohort, 2.3% were aged ≥18 years with a diagnosis of AF, and 30.8% of these were prescribed vitamin K antagonist and 69.1% DOACs. Appropriate DOAC prescribing following CrCl measures improved between 2014 and 2019; dabigatran from 21.3% (95% CI 15.1% to 28.8%) to 48.7% (95% CI 45.0% to 52.4%); rivaroxaban from 22.1% (95% CI 16.7% to 28.4%) to 49.9% (95% CI 48.5% to 53.3%); edoxaban from 10.0% (95% CI 0.3% to 44.5%) in 2016 to 57.6% (95% CI 54.5% to 60.7%) in 2019; apixaban from 30.8% (95% CI 9.1% to 61.4%) in 2015 to 60.5% (95% CI 57.8% to 63.2%) in 2019.Adherence was highest for factor Xa inhibitors, increasing from 50.1% (95% CI 47.7% to 52.4%) in 2014 to 57.8% (95% CI 57.4% to 58.2%) in 2019. Asian and black/mixed ethnicity was associated with non-adherence (OR 1.81, 95% CI 1.56 to 2.09) as was male gender (OR 1.19, 95% CI 1.15 to 1.22), higher socioeconomic status (OR 1.60, 95% CI 1.52 to 1.68), being an ex-smoker (OR 1.12, 95% CI 1.06 to 1.19) and hypertension (OR 1.07, 95% CI 1.03 to 1.17).Conclusions: The volume and quality of DOAC prescribing has increased yearly. Future interventions to augment quality of anticoagulant management should target disparities in adherence. [ABSTRACT FROM AUTHOR]

Background: Social distancing and other nonpharmaceutical interventions to reduce the spread of COVID-19 infection in the United Kingdom have led to substantial changes in delivering ongoing care for patients with chronic conditions, including type 2 diabetes mellitus (T2DM). Clinical guidelines for the management and prevention of complications for people with T2DM delivered in primary care services advise routine annual reviews and were developed when face-to-face consultations were the norm. The shift in consultations from face-to-face to remote consultations caused a reduction in direct clinical contact and may impact the process of care for people with T2DM. Objective: The aim of this study is to explore the impact of the COVID-19 pandemic’s first year on the monitoring of people with T2DM using routine annual reviews from a national primary care perspective in England. Methods: A retrospective cohort study of adults with T2DM will be performed using routinely collected primary care data from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC). We will describe the change in the rate of monitoring of hemoglobin A1c (HbA1c) between the first year of the COVID-19 pandemic (2020) and the preceding year (2019). We will also report any change in the eight checks that make up the components of these reviews. The change in HbA1c monitoring rates will be determined using a multilevel logistic regression model, adjusting for patient and practice characteristics, and similarly, the change in a composite measure of the completeness of all eight checks will be modeled using ordinal regression. The models will be adjusted for the following patient-level variables: age, gender, socioeconomic status, ethnicity, COVID-19 shielding status, duration of diabetes, and comorbidities. The model will also be adjusted for the following practice-level variables: urban versus rural, practice size, Quality and Outcomes Framework achievement, the National Health Service region, and the proportion of face-to-face consultations. Ethical approval was provided by the University of Oxford Medical Sciences Interdivisional Research Ethics Committee (September 2, 2021, reference R77306/RE001). Results: The analysis of the data extract will include 3.96 million patients with T2DM across 700 practices, which is 6% of the available Oxford-RCGP RSC adult population. The preliminary results will be submitted to a conference under the domain of primary care. The resulting publication will be submitted to a peer-reviewed journal on diabetes and endocrinology. Conclusions: The COVID-19 pandemic has impacted the delivery of care, but little is known about the process of caring for people with T2DM. This study will report the impact of the COVID-19 pandemic on these processes of care. [ABSTRACT FROM AUTHOR]

Pancreatic cancer is the 10th most common cancer diagnosed; despite recent advances in many areas of oncology, survival remains poor, in part owing to late diagnosis. Whilst primary care data are used widely for epidemiology and pharmacovigilance, they are less used for observing survival. In this study we extracted a pancreatic cancer cohort from a nationally representative English primary care database of electronic health records (EHRs) and reported on their symptom and mortality data. A total of 11, 649 cases were identified within the Oxford Royal College of General Practitioners (RCGP) Clinical Informatics Digital Hub network. All-cause mortality data was recorded for 4623 (39.69%). Mean age at recording of cancer diagnosis was 71.4 years (SD 12.0 years). 1-year and 5-year survival was 22.06% and 3.27% respectively. Within a multivariate model, age had a significant impact on survival; those diagnosed under the age of 60 had the longest survival, as compared to those age 60 -- 79 (HR: 1.36, 95% CI: 1.20 -- 1.54, p < 0.001) and 80+ (HR: 2.13, 95% CI: 1.86 -- 2.44, p < 0.01). Symptomatology was examined; at any time point abdominal pain was the most commonly reported symptom present in 5271 cases (45.2%), but within the 12 months preceding diagnosis jaundice was the most common feature, present in 2587 patients (22.2%). Future studies clarifying other contributing factors on survival outcomes and patterns of symptomatology are needed; primary care EHRs provide an opportunity to evaluate real-world cancer patient cohort data. [ABSTRACT FROM AUTHOR]

Vegetable production in Subtropical China is distinguished by excessive nitrogen (N) fertilization, frequent irrigation, and multiple crop rotations in a single year. The aforementioned variables are closely related to soil nitrous oxide (N2O) and methane (CH4) emissions. Hence, we conducted a field trial to measure N2O and CH4 emissions using static chamber–gas chromatograph. Four treatments were used: control (CK) with no fertilizer, 100% chemical N fertilization (CN), the conventional 30% chicken manure N plus 70%CN (CMN + CN), and 30% chicken manure biochar N plus 70%CN (CMBN + CN). The annual cumulative N2O emissions reached 12.4, 63.5, 111.8, and 44.1 kg N2O-N ha−1 for the CK, CN, CMN + CN, and CMBN + CN treatments, respectively. Compared to the CN and CMN + CN treatments, the CMBN + CN treatment reduced N2O emissions by 35.9%–65.7%, while it simultaneously increased the total vegetable yield by 16.1% compared to the CN treatment. Seven seasons mean N2O emission factors are 1.3% for CN, 3.8% for CMN + CN, and 0.9% for CMBN + CN. The CH4 emission was negligible, ranging from 0.07 kg CH4-C ha−1 for the CK treatment to 0.8 kg CH4-C ha−1 for the CN treatment. N2O emissions peaked under the conditions of an interior chamber temperature of around 31.9 °C and the water-filled pore space (WFPS) of the soil being approximately 60%. Future climate change will intensify, triggering higher N2O emissions from subtropical vegetable fields. CMB can be one of the best substitutes for direct chicken manure application as a soil supplement because it has a beneficial effect on improving vegetable yield and reducing N2O emissions in Subtropical China.

Climate change and rapid urbanization have exacerbated the occurrence and impact of floods. It is essential to carry out a quantitative flood risk assessment and manage the flood risk before a disaster occurs. This article presents a combined riverine flood risk model to obtain the exceedance probability loss (EPL) curve and expected annual damage (EAD) under the current climate. This model includes a rapid flood model and a flood damage model. It aims to simulate the flood risk and evaluate the flood damage at 10-, 30-, 50-, 100-, and 200-year return period events. The results show that: (1) The total inundation areas will sharply increase when the flood return periods are over 30 years. (2) The EAD is 1,476 million dollars in the Jiulong River Basin (JRB). When the flood return period is over 30 years, the total damage increases sharply. (3) The flood risk in the lower reaches of the JRB is higher than in the upper reaches when the flood event is beyond a 20-year return period. (4) Industrial sector damage is the largest, followed by tertiary industry, transportation, construction, agriculture, and infrastructure. The combined model chain can quickly assess the flood risk in the river basin and judge the flood risk in a watershed compared to the national level. In addition, it can be applied to other river basins, and it will provide actionable information for future flood risk management.

ObjectiveThe objective of this study was to investigate the feasibility and effectiveness of laparoscopic-assisted radical resection of type I choledochal cyst (CC) guided by the principles of enhanced recovery after surgery (ERAS).MethodsA retrospective cohort study of type I CC admitted to our hospital between May 2020 and December 2021 were analyzed, a total of 41 patients with choledochal cyst underwent surgery during this period and 30 cases were selected based on inclusion and exclusion criteria. Patients (n = 15) who received the traditional treatment from May 2020 to March 2021 were included in the traditional group. Patients (n = 15) who received ERAS from April 2021 to December 2021 were included in the ERAS group. Both groups underwent surgery performed by the same surgical team. Preoperative data of the two groups were recorded, and relevant data were statistically analyzed and compared.ResultsThere was a statistically significant difference in the dose of opioids. Significant differences were observed between the ERAS and traditional groups in the results of the FLACC pain assessment scale on the 1st and 2nd day after surgery, time of gastric tube, urinary catheter and abdominal drainage tube removal, time of first defecation after operation, time of first eating after operation, time to reach full food intake, results of CRP, ALB, and ALT on the 3rd and 7th postoperative day, postoperative hospital stay, and total treatment cost. No significant differences were observed between the two groups in terms of gender, age, body weight, cyst size, preoperative CRP, ALB, ALT, intraoperative blood loss, operation time, and the number of cases converted to laparotomy. Neither the FLACC pain assessment scale on the 3rd day after surgery, the incidence of postoperative complications, nor the rate of readmission within 30 days showed significant differences.ConclusionsLaparoscopic-assisted radical resection of type I CC guided by the principles of ERAS is safe and effective for children. The ERAS concept demonstrated advantages over traditional laparoscopic surgery, including reduced opioid use, shorter time to first postoperative defecation, earlier resumption of postoperative feeding, shorter time to reach full feeding, shorter postoperative hospital stay, and lower total treatment cost.

Improving yield in potato production with minimal environmental impact is of great significance for China’s potato staple food policy. Previous research has been limited by the absence of regional-scale parameters to evaluate the environmental costs of regional potato production. To address this gap, we utilized the input–output analysis method to offer a thorough estimation of nitrogen (N), phosphorus (P), and potassium (K) inputs and outputs in the potato production stage at a regional scale, leveraging a meta-analysis dataset from plenty of the literature. On this basis, we calculated the virtual N, P, and K factors (VNFs, VPFs, and VKFs) for different potato production regions, under both conventional and optimal management practices. China’s potato production suffered from excessive N and P inputs, while K inputs remained insufficient. Significant spatial heterogeneities were observed for the VNFs, VPFs, and VKFs across different potato production regions. Northeast China and northwest China emerged as the most suitable potato cultivation regions because they demonstrated high potato yields with relatively low inputs and, consequently, lower VNFs and VPFs. Southwest China was the most vital region where targeted efforts could lead to reducing VNF and VPF, thus significantly mitigating environmental N and P losses. In addition to reducing fertilizer inputs, site-specific and whole optimization measures are proposed to lower the environmental costs and promote the sustainable development of potato production.

Climate change and socioeconomic developments are increasing the frequency and severity of floods. Flood management is widely recognized as an effective way to reduce the adverse consequences, and a more resilient and sustainable flood management approach has been the goal in recent studies. This study used a detailed bibliometric analysis of keywords, terms and timelines in the research field of the flood research. It provides new insight into the flood research trends, by examining the research frontiers from 2000 to 2021. We conclude that the trend of flood research has experienced a transition from flood control to flood resilience. The review shows that flood research has moved from traditional flood management, which provides mitigation strategies, to flood risk management, which provides an adaptation approach—adjusting mitigation measures, to flood resilience management, which provides a more resilient and sustainable plan to cope with flood disasters. We also present a detailed overview of the field of flood research, and review the definition of risk, risk analysis methods, flood management, flood risk management, flood resilience, and corresponding implementation strategies. We conclude that integrating the concept of resilience into the framework of risk management is a better approach in future flood management directions. Consequently, appropriate options and decisions prior to disaster, during disaster, and post-disaster will effectively reduce the adverse consequences using the theory of risk, resilience, and sustainability.

Improving the digital economy and environmental governance efficiency are important methods for current high-quality economic development. Based on the panel data of 11 cities in Zhejiang, on the eastern coast of China, fine particulate matter smaller than a 2.5 μm (PM2.5) environmental efficiency (PMEE) was measured by the undesirable output Slack-Based Measure-Data Envelopment Analysis (SBM-DEA) model. The fixed effect regression model, the divergences in the difference model and other empirical methods were obtained to test the driving mechanism of social-economic factors on the PMEE. The results showed that: (1) the concentration of PM2.5 was continually decreasing, and environmental quality experienced a continuous improvement in Zhejiang province in the observation period, although cities such as Hangzhou, Jiaxing and Shaoxing have relatively severe PM2.5 pollution. (2) The total average value of PMEE in Zhejiang was 0.6430 over the observation period, while there was still a lot of room for improvement when compared to the production frontier. Additionally, PMEE in each city showed a fluctuating growth trend. Cities with a higher PMEE were mainly Zhoushan, Hangzhou and Ningbo. (3) The level of the digital economy had a positive role in promoting the PMEE, which was statistically significant. The level of pollution control and technological innovation also had a significantly positive effect. However, the ratio of the industrial output value to the gross domestic product (GDP) presented a negative effect on the PMEE. In the future, it is suggested that the development of the urban digital economy should be accelerated in an all-around way to improve the efficiency of government pollution control and to improve the technical efficiency of PM2.5 via innovative technological progress.

Based on China’s potato staple food policy, we chose potatoes as a study case to analyze the following indicators—the virtual new nitrogen factor (VNNF), the virtual new phosphorus factor (VNPF), the virtual irrigation-water (IW) factor (VIWF), the virtual total water (IW + precipitation) factor (VTWF), and the virtual greenhouse gas (GHG) emission factor (VCF) of the potatoes consumed by households in the six potato cultivation regions—by reviewing 220 publications from 2000 to 2020. The results showed that the VNNF ranged between 17.8 ± 7.8 and 30.1 ± 17.0 kg N kg−1 N in the consumed potato, the VNPF ranged between 8.4 ± 5.0 and 18.8 ± 11.3 kg P kg−1 P in the consumed potato, the VIWF ranged between 0.3 ± 1.0 and 1.8 ± 1.4 m3 IW kg−1 for the consumed standard yield (except in the three mainly rainfed potato regions), the VTWF ranged between 4.8 ± 2.2 and 9.3 ± 3.7 m3 total water kg−1 for the consumed standard yield, and the VCF ranged between 3.4 ± 1.5 and 5.9 ± 2.4 kg CO2 equivalent kg−1 for the consumed standard yield, under the conventional practice in the six potato cultivation regions. The normalization score results indicate that the northeast, northwest, southwest, and south of China are relatively more suitable regions in which to plant potatoes, based on the VNNF, VNPF, VIWF or VTWF, and VCF indicators.

Exploring the coordinated development of urbanization (U), technology innovation (T), and the atmospheric environment (A) is an important way to realize the sustainable development of new-type urbanization in China. Compared with existing research, we developed an integrated index system that accurately represents the overall effect of the three subsystems of UTA, and a new weight determination method, the structure entropy weight (SEW), was introduced. Then, we constructed a coordinated development index (CDI) of UTA to measure the level of sustainability of new-type urbanization. This study also analyzed trends observed in UTA for 11 cities in Zhejiang Province of China, using statistical panel data collected from 2006 to 2017. The results showed that: (1) urbanization efficiency, the benefits of technological innovation, and air quality weigh the most in the indicator systems, which indicates that they are key factors in the behavior of UTA. The subsystem scores of the 11 cities show regional differences to some extent. (2) Comparing the coordination level of UTA subsystems, we found that the order is: coordination degree of UT > coordination degree of UA > coordination degree of TA. This suggests that the atmospheric environment system improvement is an important strategic decision for sustainable urbanization in Zhejiang. (3) The UTACDI values of the 11 cities are not high enough, as the coordination is mainly low, basic, or good, while none of the cities reached the stage of excellent coordination. (4) Gray Model (1,1) revealed that the time taking to achieve excellent coordination varies for different cities. Hangzhou and Ningbo were predicted to reach the excellent coordination level in 2018. Other cities are predicted to take 2−4 years to adjust their urbanization strategies enough to be considered to have excellent coordination of their UTA system.