2017年成都市PM2.5质量浓度与呼吸系统急救人次的关系

  目的  分析2017年成都市大气细颗粒物（particulate matter 2.5,PM_2.5）对呼吸系统急救人次的近期影响。  方法  收集成都市2017年1月1日～12月31日的PM_2.5每日24 h质量浓度均值、每日呼吸系统疾病急救人次数、日均气温和相对湿度,采用广义相加时间序列模型,在每日总急救人次数无明显长期趋势的基础上,控制气象因素（气温和气湿）、“星期效应”混杂因素后,分析PM_2.5与呼吸系统急救人次的关系。  结果  成都市2017年因呼吸系统疾病急救呼救共9 309人次,平均每天26人次。日均温度16.6 ℃,日均相对湿度81.2%,全年PM_2.5质量浓度均值为53.6 μg/m3。单污染物模型滞后时间效应分析发现,最强效应期为暴露当日,在最强效应期空气中PM_2.5质量浓度每升高10 μg/m3,居民因呼吸系统疾病急救风险增加1.26%（95%可信区间:0.56%～1.97%）,且PM_2.5质量浓度与居民因呼吸系统疾病急救风险几乎呈正向直线关系。双污染物模型分析发现,每日臭氧质量浓度8 h滑动平均值（O_3-8h）能够增强PM_2.5质量浓度对人群急救风险的效应。  结论  空气PM_2.5污染,可能增加居民因呼吸系统疾病急救的风险。     

流行病学分布研究进展

肺气肿、心脏病和高血压死亡归因危险比依次为9.3%、5.8%和 5.1%. Katzman等根据上海研究资料认为痴呆是老年人的一种"恶性"疾病.瑞典一个社区人群(≥75岁)AD死亡率为1.9/100 人年痴呆患者5年病死率为70%(非痴呆者为35%),AD导致死亡的RR为2.0 (95%CI 1.5～2.7),人群死亡归因危险比为14%.法国一项历时8年的人群队列研究显示AD患者死亡的RR为1.7 (95% CI 1.3～2.2),导致痴呆患者死亡的主要疾病为呼吸系统疾病(RR=2.8,95% CI 1.3～6.2)和脑血管病(RR＝1.7,95% CI0.8～3. 7).痴呆明显缩短患者寿命,不同研究报告痴呆患者的平均存活时间从3～10年不等.     

吸烟、酒精、胆石病和糖尿病作为胰腺癌的危险因素的研究

对170例胰腺癌和170例对照组非肿瘤疾病进行对比，计算其相对危险度（RR），评价糖尿病、胆石病、吸烟和饮酒作为胰腺癌危险因素的意义。结果显示吸烟者胰腺癌危险度明显增加（RR1.9，95％CI1.2～3.9），并随吸烟年限和吸烟量增加而增加；饮酒无相关性；胆石病（RR3．4，95％CI1．6～9．7）和糖尿病（RR3．27，95％CI2.61～4．05）胰腺癌的危险度均有增加。但糖尿病仅出现在胰腺癌发病前的2年内才有意义，它可能是胰腺癌的结果而不是危险因素。     

兰州市气温和相对湿度对慢性阻塞性肺疾病患者门诊就诊人次的影响及其交互效应

目的 解日均气温,日均相对湿度与慢性阻塞性肺疾病患者门诊就诊人次的关系,以及日均气温,日均相对湿度的影响是否存在滞后效应.方法: 采用泊松广义线性回归模型结合分布滞后非线性模型分析 2013年1月至2017年12月兰州市日均气温,日均相对湿度及其交互作用对慢性阻塞性肺疾病患者门诊就诊人次的影响.结果: 日均气温与慢性阻塞性肺疾病的门诊就诊人次呈非线性关系,-12 ℃~-8 ℃时门诊就诊人次随着日均气温的下降而逐渐增加,气温每下降1℃,慢性阻塞性肺疾病门诊就诊人次增加11.60%.日均相对湿度对慢性阻塞性肺疾病的门诊就诊人次也呈非线性影响,日均相对湿度在15%~28%范围时,门诊就诊人次随着相对湿度的降低而逐渐增加,相对湿度每下降1%,慢性阻塞性肺疾病门诊就诊人次增加37.05%.气温与相对湿度对慢性阻塞性肺疾病的影响存在交互作用,即不同相对湿度条件下,气温作用有所差异,当日均相对湿度≤50%,日均气温≤11 ℃时,气温的效应最明显,气温每下降1 ℃,慢性阻塞性肺疾病日门诊就诊人次全人群增加12.68%,男性5.62%,女性7.56%,<65岁人群5.24%,≥65岁人群14.74%.当日均相对湿度>50%,日均气温≤11 ℃时,气温每下降1 ℃,慢性阻塞性肺疾病日门诊就诊人次全人群增加9.00%,<65岁人群7.11%,≥65岁人群10.93%.当日均相对湿度>50%,日均气温>11 ℃时和日均相对湿度≤50%,日均气温>11 ℃时,气温对慢性阻塞性肺疾病日门诊就诊人次无影响.结论: 日均气温与日均相对湿度有一定的交互作用,低温干燥(相对湿度≤50%,气温≤11 ℃时)环境和低温高湿(相对湿度>50%,气温≤11 ℃时)环境均可增加慢性阻塞性肺疾病患者门诊就诊风险.     

兰州市气温和相对湿度对慢性阻塞性肺疾病患者门诊就诊人次的影响及其交互效应

目的 解日均气温,日均相对湿度与慢性阻塞性肺疾病患者门诊就诊人次的关系,以及日均气温,日均相对湿度的影响是否存在滞后效应.方法: 采用泊松广义线性回归模型结合分布滞后非线性模型分析 2013年1月至2017年12月兰州市日均气温,日均相对湿度及其交互作用对慢性阻塞性肺疾病患者门诊就诊人次的影响.结果: 日均气温与慢性阻塞性肺疾病的门诊就诊人次呈非线性关系,-12 ℃~-8 ℃时门诊就诊人次随着日均气温的下降而逐渐增加,气温每下降1℃,慢性阻塞性肺疾病门诊就诊人次增加11.60%.日均相对湿度对慢性阻塞性肺疾病的门诊就诊人次也呈非线性影响,日均相对湿度在15%~28%范围时,门诊就诊人次随着相对湿度的降低而逐渐增加,相对湿度每下降1%,慢性阻塞性肺疾病门诊就诊人次增加37.05%.气温与相对湿度对慢性阻塞性肺疾病的影响存在交互作用,即不同相对湿度条件下,气温作用有所差异,当日均相对湿度≤50%,日均气温≤11 ℃时,气温的效应最明显,气温每下降1 ℃,慢性阻塞性肺疾病日门诊就诊人次全人群增加12.68%,男性5.62%,女性7.56%,<65岁人群5.24%,≥65岁人群14.74%.当日均相对湿度>50%,日均气温≤11 ℃时,气温每下降1 ℃,慢性阻塞性肺疾病日门诊就诊人次全人群增加9.00%,<65岁人群7.11%,≥65岁人群10.93%.当日均相对湿度>50%,日均气温>11 ℃时和日均相对湿度≤50%,日均气温>11 ℃时,气温对慢性阻塞性肺疾病日门诊就诊人次无影响.结论: 日均气温与日均相对湿度有一定的交互作用,低温干燥(相对湿度≤50%,气温≤11 ℃时)环境和低温高湿(相对湿度>50%,气温≤11 ℃时)环境均可增加慢性阻塞性肺疾病患者门诊就诊风险.     

大气颗粒物质量浓度与四川大学华西医院非意外创伤急诊人次的时间序列研究

目的 分析大气颗粒物（PM_2.5和PM₁₀）质量浓度对医院非意外创伤急诊人次的短期效应,探讨大气颗粒物对人群健康的急性危害。方法 采用广义相加模型分析2014～2016年成都市区大气污染物质量浓度对四川大学华西医院非意外创伤急诊人次的短期效应,并在不同年龄组（<65岁组和≥65岁组）中进行分层分析。结果 2014年1月1日至2016年11月30日期间成都市区大气颗粒物PM_2.5和PM₁₀的年平均质量浓度分别为66.47 μg/m3和109.35 μg/m3。在非意外创伤急诊全人群中,大气颗粒物的健康效应在滞后1 d时最大,PM_2.5和PM₁₀的日均质量浓度每增加10 μg/m3,急诊人次数分别增加0.634%（95%CI: 0.273%~0.997%）和0.413%（95%CI: 0.166%~0.660%）。在≥65岁组中,调整全部气态污染物（SO₂+NO₂+CO+O3）的影响后, PM_2.5和PM₁₀的日均质量浓度每增加10 μg/m3,滞后1 d的急诊人次数分别增加1.439%（95%CI:0.599%~2.287%）和 1.150%（95%CI:0.566%~1.738%）。结论 大气颗粒物质量浓度升高与非意外创伤急诊人次数呈正相关,且存在滞后效应,对65岁以上老年人群健康的急性损害较大。     

日均气温对社区居民脑卒中死亡影响的时间序列研究

背景 全球气候变化导致极端天气事件频发，气温对居民脑卒中死亡的影响正愈发受到关注。 目的 分析日均气温对浦东新区居民脑卒中死亡的影响。 方法 收集2005—2019年浦东新区居民脑卒中死亡资料（包括出血性脑卒中和缺血性脑卒中死亡资料）、气象资料（包括气温、相对湿度、大气压）及大气污染物资料〔包括大气颗粒物（PM10）、二氧化硫（SO2）与二氧化氮（NO2）〕。利用分布滞后非线性模型分析日均气温对浦东新区居民脑卒中的影响以及效应的累积性与滞后性。根据年龄及受教育水平开展分层分析，探究敏感人群。 结果 2005—2019年，浦东新区累计报告居民脑卒中死亡30 337人，其中出血性脑卒中与缺血性脑卒中死亡分别为11 221、15 308人，分别占脑卒中死亡总数的36.99%、50.46%。研究期间浦东新区居民每日脑卒中死亡5.54人，出血性脑卒中与缺血性脑卒中死亡分别为2.05、2.79人；气温、相对湿度、大气压的日均值分别为17.25 ℃、73.75%、1 015.83 hPa，PM10、SO2、NO2浓度日均值分别为68.87、28.82、44.68 μg/m3。浦东新区以日均温度的中位数（P50=18.2 ℃）为参照，低温（P5=3.0 ℃）对脑卒中与出血性脑卒中的效应在滞后0~14 d（Lag 0~14 d）达到最大〔脑卒中：相对危险度（RR）=1.34，95%CI（1.15，1.56）；出血性脑卒中：RR=1.61，95%CI（1.25，2.08）〕，低温的影响表现出明显的累积性与滞后性，缺血性脑卒中对低温的影响不敏感；高温（P95=30.1 ℃）对脑卒中与缺血性脑卒中的效应在Lag 0~1 d达到最大〔脑卒中：RR=1.26，95%CI（1.12，1.41）；缺血性脑卒中：RR=1.64，95%CI（1.39，1.93）〕，高温作用较为短促，出血性脑卒中对高温的影响不敏感。分层分析结果显示，低温对<75岁人群脑卒中死亡效应不具有统计学意义，对≥75岁人群脑卒中死亡效应在Lag 0~14 d达到最大；低温对小学及以下、中学及以上文化水平人群脑卒中死亡效应分别在Lag 0~21 d、Lag 0~14 d达到最大。高温对<75岁、中学及以上人群脑卒中死亡效应不具有统计学意义，对≥75岁、小学及以下人群脑卒中死亡效应均在Lag 0~1 d达到最大。在Lag 0~3 d，高温对小学及以下文化水平人群脑卒中死亡效应高于中学及以上文化水平人群（P<0.05）。 结论 低温与高温均导致浦东新区居民脑卒中死亡风险上升，低温与高温分别增加居民出血性脑卒中与缺血性脑卒中死亡风险，而小学及以下文化水平人群在高温环境下更易发生脑卒中死亡。     

北京市大气污染与呼吸系统疾病死亡的相关性——基于卫星遥感数据的时空分析

目的：利用垂直湿度校正法校正气溶胶光学厚度（aerosol optical depth,AOD）,并探索校正AOD作为衡量大气污染程度的指标与人群健康结局建立暴露反应关系的可行性。方法：先采用空间插值方法对AOD、地面PM2.5、相对湿度和边界层高度进行插值以获得不同地理位置的各项数据,按照地理位置与北京市呼吸系统疾病死亡数据进行匹配。利用大气边界层高度及由相对湿度计算得到的气溶胶吸湿增长因子分别对AOD进行垂直校正与湿度校正。为进行对比,将校正AOD和PM2.5采用标准化法进行无量纲化处理,使用广义相加混合模型,控制时间趋势、温湿度效应、星期几效应和节假日效应等,得到无量纲化后的校正AOD与PM2.5对北京市居民每日呼吸系统疾病总死亡和慢性阻塞性肺病（chronic obstructive pulmonary disease,COPD）死亡的急性效应。结果：经过垂直湿度校正后的AOD与PM2.5相关系数达到0.72。累积滞后0~3 d(lag 0~3)的标准化校正AOD对呼吸系统疾病总死亡数及COPD死亡数的累积滞后效应最强,每升高1个单位,超额危险度分别为3.64%（95%CI为0.58%~6.78%）和 4.92%（95%CI为1.81%~8.14%）。累积滞后0~1 d(lag 0~1)的标准化PM2.5对呼吸系统疾病死亡及COPD死亡的累积滞后效应最强,每升高1个单位（约155 μg/m3）,超额危险度分别为3.96%（95%CI为0.82%~7.19%）及6.12%（95%CI为1.44%~11.02%）。与地面PM2.5的效应相比,校正AOD引起呼吸系统疾病死亡及COPD死亡效应的置信区间较窄,对于捕捉颗粒物对居民每日死亡的滞后效应更为敏感;且不同累积滞后天数的校正AOD对呼吸系统疾病死亡及COPD死亡的效应均具有统计学意义,对于捕捉颗粒物对于居民死亡的累积滞后效应更为敏感。结论：校正AOD可以反映地面颗粒物对北京市居民每日呼吸系统疾病死亡的影响,在缺乏地面监测的情况下,可以使用校正AOD作为衡量大气污染物的指标与人群健康结局建立暴露反应关系。     

东北某部驻地空气可入肺颗粒浓度与营区呼吸道疾病就诊病例的相关性研究

[目的]应用病例交叉设计的分析方法,定量评价东北某部驻地附近日均可入肺污染微粒的浓度（PM25）对驻地营区呼吸道疾病发病就诊人次的影响.[方法]从2011年11月-2013年1月期间,搜集营区呼吸道疾病就诊人次数据和营区附近PM2.5、二氧化硫（SO2）、二氧化氮（NO2）监测水平,应用病例交叉设计法评估营区呼吸道疾病的发病人次和空气可入肺微粒监测的相关性.[结果]研究期间,呼吸道疾病门急诊就诊官兵共为3 086人次,空气污染监测日均PM25、SO2、NO2分别是（147.7士73.53）、（121.4±46.79）、（92.4±37.73） μg/m3,通过统计学计算,呼吸道疾病的发病人次与空气中可入肺污染微粒存在明显的统计学相关性,比值比（odds ratio,ORs）分别为：1.016 [95％可信区间（confidence interval,CI）为1.007～1.029]、1.021 （95％CI：1.008～1.033）、1.024（95％CI：1.009～1.037）.[结论]研究表明呼吸道疾病就诊人次随PM2.5的浓度增加而增多.     

基于分布滞后非线性模型评估气温对缺血性脑卒中发病的影响

目的：探讨气温对居民缺血性脑卒中发病的影响。方法：收集2013-2020年山东生态队列平邑县子队列缺血性脑卒中发病数据及气象数据。采用分布滞后非线性模型(DLNM)分析气温对全人群缺血性脑卒中发病的影响,并探讨不同性别、年龄人群间的差异。结果：2013-2020年共观察缺血性脑卒中病人50 427例,纳入缺血性脑卒中发病病人42 014例,日均发病数为14例。日均气温与缺血性脑卒中发病人数呈非线性关系。高温与缺血性脑卒中发病人数的增加有关,且高温对其发病存在即刻效应和滞后效应,高温在0～10 d滞后的累积相对危险度(RR)为1.433(95%CI:1.079～1.902)。低温和较低温对于全人群在特定累积时段存在一定保护作用,且随着时间的推移保护作用减弱,低温和较低温在0～10 d滞后的合并RR分别为0.618(95%CI:0.455～0.840)和0.712(95%CI:0.608～0.834)。分层分析结果显示,高温对男性、≥65岁人群缺血性脑卒中发病危害较大,高温累积滞后10 d时,男性组人群缺血性脑卒中发病风险达到最大,RR值为1.678(95%CI:1.193～2.361);...     

宫颈癌相关危险因素致病风险的Meta分析

目的综合评价我国女性宫颈癌相关危险因素的关联强度。方法系统收集1990年1月～2011年6月宫颈癌相关危险因素的研究文献,纳入合格研究文献16篇,共计研究对象11 126例。按照NOS标准对纳入文献进行质量评价;采用Stata10.0软件进行Meta分析,得到各相关危险因素与宫颈癌发病风险关联强度合并的OR值及其95%可信区间。结果文献质量评价A级文献6篇、B级文献10篇。在分析的16个因素中有12个因素差异具有统计学意义,与妊娠相关的危险因素及其OR值(95%可信区间)分别为:怀孕≥3次2.384(95%CI:1.659～3.425)、分娩≥3次2.265(95%CI:1.669～3.074)、流产≥3次3.713(95%CI:2.470～5.581)和初次怀孕年龄≤21岁2.390(95%CI:1.731～3.225);与性行为相关的危险因素分别为:结婚≥2次2.522(95%CI:1.714～3.713)、初次性生活年龄≤20岁3.467(95%CI:2.456～4.893)、性伴侣≥3个2.539(95%CI:1.613～3.996);与妇科疾病相关的因素分别为:性传播疾病史5.861(95%CI:1.048～13.67)、妇科病史4.807(95%CI:2.899～7.971);另外,受教育程度≤9年3.536(95%CI:2.204～5.672)、主动或被动吸烟3.055(95%CI:2.435～3.833)和农村或郊区居住地2.134(95%CI:1.010～4.509)等环境因素也与发病风险相关。结论妊娠等相关因素与我国女性宫颈癌发病风险密切相关。     

Prevalence of gestational diabetes mellitus among Swampy Cree women in Moose Factory, James Bay

BACKGROUND: Although high rates of gestational diabetes mellitus have been documented in native populations, few studies have examined rates of the disease among native Indians in Canada. The authors conducted a study to estimate the prevalence of gestational diabetes among Swampy Cree women, to identify factors predictive of the occurrence of gestational diabetes, and to identify delivery and infant outcomes related to the presence of the disease. METHODS: Information on Swampy Cree women who gave birth at Weeneebayko Hospital, Moose Factory, James Bay, Ont., between 1987 and 1995 was obtained from medical charts. Patients with and without gestational diabetes were compared. Logistic regression analysis was used to identify independent predictors of gestational diabetes. Delivery and infant outcomes that occurred secondary to gestational diabetes were also identified by means of logistic regression. RESULTS: A total of 1401 deliveries occurred at Weeneebayko Hospital over the study period, of which 1298 were included in the study. Gestational diabetes was diagnosed in 110 (8.5% [95% confidence interval (CI) 6.9%-9.9%]) of the 1298 pregnancies. Factors predictive of gestational diabetes were age 35 years or more (relative risk [RR] 4.1, 95% CI 1.5-11.7), a history of gestational diabetes in a previous pregnancy (RR 6.4, 95% CI 3.5-11.7), diastolic blood pressure of 80 mm Hg or higher at the first prenatal visit (RR 1.7, 95% CI 1.1-2.8), weight greater than 80 kg at the first prenatal visit (RR 4.9, 95% CI 1.8-12.9) and having a first-degree relative with diabetes (RR 3.0, 95% CI 1.4-6.1). The only delivery outcome independently associated with the presence of gestational diabetes was an increased likelihood of needing assisted delivery (forceps or vacuum extraction) (RR 2.8, 95% CI 1.1-7.0). Shoulder dystocia was indirectly associated with gestational diabetes owing to increased infant birth weight. Infant outcomes associated with the presence of gestational diabetes were birth weight greater than 4500 g (RR 2.4, 95% CI 1.4-3.8), hyperbilirubinemia (RR 2.9, 95% CI 1.4-6.1), hypoglycemia (RR 7.3, 95% CI 3.7-14.4) and hypocalcemia (RR 8.9, 95% CI 2.3-33.7). INTERPRETATION: Gestational diabetes occurred in a significant minority of Swampy Cree women and was associated with a number of adverse outcomes.     

Incidence of cervical squamous intraepithelial lesions in HIV-infected women

CONTEXT: Women infected with human immunodeficiency virus (HIV) are at increased risk for cervical squamous intraepithelial lesions (SILs), the precursors to invasive cervical cancer. However, little is known about the causes of this association. OBJECTIVES: To compare the incidence of SILs in HIV-infected vs uninfected women and to determine the role of risk factors in the pathogenesis of such lesions. DESIGN: Prospective cohort study conducted from October 1,1991, to June 30, 1996. SETTING: Urban clinics for sexually transmitted diseases, HIV infection, and methadone maintenance. PARTICIPANTS: A total of 328 HIV-infected and 325 uninfected women with no evidence of SILs by Papanicolaou test or colposcopy at study entry. MAIN OUTCOME MEASURE: Incident SILs confirmed by biopsy, compared by HIV status and risk factors. RESULTS: During about 30 months of follow-up, 67 (20%) HIV-infected and 16 (5%) uninfected women developed a SIL (incidence of 8.3 and 1.8 cases per 100 person-years in sociodemographically similar infected and uninfected women, respectively [P<.001]). Of incident SILs, 91% were low grade in HIV-infected women vs 75% in uninfected women. No invasive cervical cancers were identified. By multivariate analysis, significant risk factors for incident SILs were HIV infection (relative risk [RR], 3.2; 95% confidence interval [CI], 1.7-6.1), transient human papillomavirus (HPV) DNA detection (RR, 5.5; 95% CI, 1.4-21.9), persistent HPV DNA types other than 16 or 18 (RR, 7.6; 95% CI, 1.9-30.3), persistent HPV DNA types 16 and 18 (RR, 11.6; 95% CI, 2.7-50.7), and younger age (<37.5 years; RR, 2.1; 95% CI, 1.3-3.4). CONCLUSIONS: In our study, 1 in 5 HIV-infected women with no evidence of cervical disease developed biopsy-confirmed SILs within 3 years, highlighting the importance of cervical cancer screening programs in this population.     

The Value of Patient Self-report for Disease Surveillance

Objective

To determine the accuracy of self-reported information from patients and families for use in a disease surveillance system.

Design

Patients and their parents presenting to the emergency department (ED) waiting room of an urban, tertiary care children’s hospital were asked to use a Self-Report Tool, which consisted of a questionnaire asking questions related to the subjects’ current illness.

Measurements

The sensitivity and specificity of three data sources for assigning patients to disease categories was measured: the ED chief complaint, physician diagnostic coding, and the completed Self-Report Tool. The gold standard metric for comparison was a medical record abstraction.

Results

A total of 936 subjects were enrolled. Compared to ED chief complaints, the Self-Report Tool was more than twice as sensitive in identifying respiratory illnesses (Rate ratio [RR]: 2.10, 95% confidence interval [CI] 1.81–2.44), and dermatological problems (RR: 2.23, 95% CI 1.56–3.17), as well as significantly more sensitive in detecting fever (RR: 1.90, 95% CI 1.67–2.17), gastrointestinal problems (RR: 1.10, 95% CI 1.00–1.20), and injuries (RR: 1.16, 95% CI 1.08–1.24). Sensitivities were also significantly higher when the Self-Report Tool performance was compared to diagnostic codes, with a sensitivity rate ratio of 4.42 (95% CI 3.45–5.68) for fever, 1.70 (95% CI 1.49–1.93) for respiratory problems, 1.15 (95% CI 1.04–1.27) for gastrointestinal problems, 2.02 (95% CI 1.42–2.87) for dermatologic problems, and 1.06 (95% CI 1.01–1.11) for injuries.

Conclusions

Disease category assignment based on patient-reported information was significantly more sensitive in correctly identifying a disease category than data currently used by national and regional disease surveillance systems.     

Association of cancer with AIDS-related immunosuppression in adults

CONTEXT: Large-scale studies are needed to determine if cancers other than Kaposi sarcoma, non-Hodgkin lymphoma, and cervical cancer occur in excess in persons with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS). OBJECTIVES: To examine the general cancer pattern among adults with HIV/AIDS and to distinguish immunosuppression-associated cancers from other cancers that may occur in excess among persons with HIV/AIDS. DESIGN, SETTING, AND SUBJECTS: Analysis of linked population-based AIDS and cancer registry data from 11 geographically diverse areas in the United States, including 302 834 adults aged 15 to 69 years with HIV/AIDS. The period of study varied by registry between 1978 and 1996. MAIN OUTCOME MEASURE: Relative risks (RRs) of cancers, calculated by dividing the number of observed cancer cases by the number expected based on contemporaneous population-based incidence rates. We defined cancers potentially influenced by immunosuppression by 3 criteria: (1) elevated overall RR in the period from 60 months before to 27 months after AIDS; (2) elevated RR in the 4- to 27-month post-AIDS period; and (3) increasing trend in RR from before to after AIDS onset. RESULTS: Expected excesses were observed for the AIDS-defining cancers, but non-AIDS-defining cancers also occurred in statistically significant excess (n = 4422; overall RR, 2.7; 95% confidence interval [CI], 2.7-2.8). Of individual cancers, only Hodgkin disease (n = 612; RR, 11.5; 95% CI, 10.6-12.5), particularly of the mixed cellularity (n = 217; RR, 18.3; 95% CI, 15.9-20.9) and lymphocytic depletion (n = 36; RR, 35.3; 95% CI, 24.7-48.8) subtypes; lung cancer (n = 808; RR, 4.5; 95% CI, 4.2-4.8); penile cancer (n = 14; RR, 3.9; 95% CI, 2.1-6.5); soft tissue malignancies (n = 78; RR, 3.3; 95% CI, 2.6-4.1); lip cancer (n = 20; RR, 3.1; 95% CI, 1.9-4.8); and testicular seminoma (n = 115; RR, 2.0; 95% CI, 1.7-2.4) met all 3 criteria for potential association with immunosuppression. CONCLUSION: Although occurring in overall excess, most non-AIDS-defining cancers do not appear to be influenced by the advancing immunosuppression associated with HIV disease progression. Some cancers that met our criteria for potential association with immunosuppression may have occurred in excess in persons with HIV/AIDS because of heavy smoking (lung cancer), frequent exposure to human papillomavirus (penile cancer), or inaccurately recorded cases of Kaposi sarcoma (soft tissue malignancies) in these persons. However, Hodgkin disease, notably of the mixed cellularity and lymphocytic depletion subtypes, and possibly lip cancer and testicular seminoma may be genuinely influenced by immunosuppression.     

Predictors of acute complications in children with type 1 diabetes

CONTEXT: Diabetic ketoacidosis and severe hypoglycemia are acute complications of type 1 diabetes that are related, respectively, to insufficient or excessive insulin treatment. However, little is known about additional modifiable risk factors. OBJECTIVE: To examine the incidence of ketoacidosis and severe hypoglycemia in children with diabetes and to determine the factors that predict these complications. DESIGN, SETTING, AND PARTICIPANTS: A cohort of 1243 children from infancy to age 19 years with type 1 diabetes who resided in the Denver, Colo, metropolitan area were followed up prospectively for 3994 person-years from January 1, 1996, through December 31, 2000. MAIN OUTCOME MEASURES: Incidence of ketoacidosis leading to hospital admission or emergency department visit and severe hypoglycemia (loss of consciousness, seizure, or hospital admission or emergency department visit). RESULTS: The incidence of ketoacidosis was 8 per 100 person-years and increased with age in girls (4 per 100 person-years in < 7; 8 in 7-12; and 12 in > or =13 years; P<.001 for trend). In multivariate analyses, sex-adjusted and stratified by age (<13 vs > or =13 years), the risk of ketoacidosis in younger children increased with higher hemoglobin A(1c) (HbA(1c)) (relative risk [RR], 1.68 per 1% increase; 95% confidence interval [CI], 1.45-1.94) and higher reported insulin dose (RR, 1.40 per 0.2 U/kg per day; 95% CI, 1.20-1.64). In older children, the risk of ketoacidosis increased with higher HbA(1c) (RR, 1.43; 95% CI, 1.30-1.58), higher reported insulin dose (RR, 1.13; 95% CI, 1.02-1.25), underinsurance (RR, 2.18; 95% CI, 1.65-2.95), and presence of psychiatric disorders (for boys, RR, 1.59; 95% CI, 0.96-2.65; for girls, RR, 3.22; 95% CI, 2.25-4.61). The incidence of severe hypoglycemia was 19 per 100 person-years (P<.001 for trend) and decreased with age in girls (24 per 100 patient-years in < 7, 19 in 7-12, and 14 in > or =13 years). In younger children, the risk of severe hypoglycemia increased with diabetes duration (RR, 1.39 per 5 years; 95% CI, 1.16-1.69) and underinsurance (RR, 1.33; 95% CI, 1.08-1.65). In older children, the risk of severe hypoglycemia increased with duration (RR, 1.34; 95% CI, 1.25-1.51), underinsurance (RR, 1.42; 95% CI, 1.11-1.81), lower HbA(1c) (RR, 1.22; 95% CI, 1.12-1.32), and presence of psychiatric disorders (RR, 1.56; 95% CI, 1.23-1.98). Eighty percent of episodes occurred among the 20% of children who had recurrent events. CONCLUSIONS: Some children with diabetes remain at high risk for ketoacidosis and severe hypoglycemia. Age- and sex-specific incidence patterns suggest that ketoacidosis is a challenge in adolescent girls while severe hypoglycemia continues to affect disproportionally the youngest patients and boys of all ages. The pattern of modifiable risk factors indicates that underinsured children and those with psychiatric disorders or at the extremes of the HbA(1c) distribution should be targeted for specific interventions.     

地塞米松治疗或预防早产儿慢性肺疾病远期预后的Meta分析

目的系统评价早产儿生后应用地塞米松预防或治疗慢性肺疾病（CLD）的远期预后。方法制定文献的纳入排除标准及检索策略,检索Medline、Embase数据库、Cochrane图书馆及中国生物医学期刊引文数据库、中国期刊全文数据库、中国维普数据库、万方数据库;手工检索近年国际国内儿科会议文集,获得有关早产儿应用地塞米松预防或治疗CLD的远期预后（随访时间≥2年）的随机对照实验（RCT）文献。应用RevMan5．0软件对早产儿应用地塞米松预防和治疗CLD的远期预后如神经系统预后、呼吸系统预后及死亡率等进行Meta分析。结果共纳入8个RCT（共13篇文献）进入Meta分析。数据合并分析结果显示,应用地塞米松组儿童期反复呼吸系统疾病发生率从49．7％降至38．9％,RR=0．57（95％CI：0．37～0．88,P〈0．05）。神经系统发育的远期预后方面,地塞米松组患儿脑瘫的发生率明显升高,RR=1．95（95％CI：1．41～2．71,P〈0．01）;依据地塞米松的应用时间进行分层分析发现,早期（生后1周内）应用地塞米松组脑瘫发生率较对照组明显升高,RR=2．59（95％CI：1．59—4．21,P〈0．叭）,而晚期（出生1周以后）应用地塞米松组脑瘫发生率与对照组差异无统计学意义,RR=1．5（95％CI：0．95～2．36,P=0．08）;智力落后（RR=0．77,95％CI：0．28～0．14,P〉0．05）、耳聋（RR=0．52,95％c,：0．17～1．56,P：0．24）及严重视力障碍（RR=1．56,95％CI：0．77～3．18,P=0．22）的发生率在地塞米松组及对照组间差异无统计学意义。两组的死亡率差异无统计学意义,RR=0．91（95％CI：0．71～1．16,P〉0．05）。结论生后静脉应用地塞米松预防或治疗CLD的早产儿儿童期反复呼吸系统疾病的发生率降低;脑瘫的发生率明显增高,但多发生于早期应用地塞米松的早产儿,出生后晚期应用者脑瘫发生率无显著增加;地塞米松并不能降低CLD患儿的死亡率。     

Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis

CONTEXT: Establishing relative benefit or harm from specific antihypertensive agents is limited by the complex array of studies that compare treatments. Network meta-analysis combines direct and indirect evidence to better define risk or benefit. OBJECTIVE: To summarize the available clinical trial evidence concerning the safety and efficacy of various antihypertensive therapies used as first-line agents and evaluated in terms of major cardiovascular disease end points and all-cause mortality. DATA SOURCES AND STUDY SELECTION: We used previous meta-analyses, MEDLINE searches, and journal reviews from January 1995 through December 2002. We identified long-term randomized controlled trials that assessed major cardiovascular disease end points as an outcome. Eligible studies included both those with placebo-treated or untreated controls and those with actively treated controls. DATA EXTRACTION: Network meta-analysis was used to combine direct within-trial between-drug comparisons with indirect evidence from the other trials. The indirect comparisons, which preserve the within-trial randomized findings, were constructed from trials that had one treatment in common. DATA SYNTHESIS: Data were combined from 42 clinical trials that included 192 478 patients randomized to 7 major treatment strategies, including placebo. For all outcomes, low-dose diuretics were superior to placebo: coronary heart disease (CHD; RR, 0.79; 95% confidence interval [CI], 0.69-0.92); congestive heart failure (CHF; RR, 0.51; 95% CI, 0.42-0.62); stroke (RR, 0.71; 0.63-0.81); cardiovascular disease events (RR, 0.76; 95% CI, 0.69-0.83); cardiovascular disease mortality (RR, 0.81; 95% CI, 0.73-0.92); and total mortality (RR, 0.90; 95% CI, 0.84-0.96). None of the first-line treatment strategies-beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers (CCBs), alpha-blockers, and angiotensin receptor blockers-was significantly better than low-dose diuretics for any outcome. Compared with CCBs, low-dose diuretics were associated with reduced risks of cardiovascular disease events (RR, 0.94; 95% CI, 0.89-1.00) and CHF (RR, 0.74; 95% CI, 0.67-0.81). Compared with ACE inhibitors, low-dose diuretics were associated with reduced risks of CHF (RR, 0.88; 95% CI, 0.80-0.96), cardiovascular disease events (RR, 0.94; 95% CI, 0.89-1.00), and stroke (RR, 0.86; 0.77-0.97). Compared with beta-blockers, low-dose diuretics were associated with a reduced risk of cardiovascular disease events (RR, 0.89; 95% CI, 0.80-0.98). Compared with alpha-blockers, low-dose diuretics were associated with reduced risks of CHF (RR, 0.51; 95% CI, 0.43-0.60) and cardiovascular disease events (RR, 0.84; 95% CI, 0.75-0.93). Blood pressure changes were similar between comparison treatments. CONCLUSIONS: Low-dose diuretics are the most effective first-line treatment for preventing the occurrence of cardiovascular disease morbidity and mortality. Clinical practice and treatment guidelines should reflect this evidence, and future trials should use low-dose diuretics as the standard for clinically useful comparisons.     

剖宫产瘢痕妊娠患者侧支动脉的形成及其危险因素分析

目的：探讨剖宫产瘢痕妊娠行子宫动脉栓塞术时发现侧支动脉形成的概率及其危险因素。方法：分析2009年1月至2014年6月在中南大学湘雅三医院进行子宫动脉栓塞术的剖宫产瘢痕妊娠患者资料,并根据有无侧支动脉的形成将患者分成有侧支动脉组(34例)及无侧支动脉组(对照组,110例)。记录可能引起侧支动脉形成的各项参数,分别用t检验、χ2检验及Fisher精确检验法进行单因素分析,对P<0.20的参数进行logistic多因素分析,计算其相对危险度(RR)及95%可信区间(95%CI)。结果：有侧支动脉形成的剖宫产瘢痕妊娠患者的发病率为23.4%。单因素及logistic多因素回归分析表明：胎盘前置(RR=78.556,95%CI：2.869~2 150.651,P=0.010)、盆腔炎症(RR=6.633,95% CI：1.595~27.592,P=0.009)、人流手术史(RR=18.381,95%CI：1.683~200.752,P=0.017)及子宫肌瘤或腺肌症(RR=12.580,95%CI：1.004~157.550, P=0.050)与剖宫产瘢痕妊娠侧支动脉的形成密切相关。结论：前置胎盘、盆腔炎症、人流手术史以及子宫肌瘤或腺肌症是剖宫产瘢痕妊娠患者侧支动脉形成的危险因素。