Environmental NO2 Level is Associated with 2-Year Mortality in Patients Undergoing Peritoneal Dialysis

An ongoing issue related to global urbanization is the association of air pollution with increased incidences of morbidity and mortality. However, no in-depth study has investigated this issue focusing on peritoneal dialysis (PD) patients. Therefore, this study assessed the effects of traffic-related air pollutants and other important mortality-associated factors on 2-year mortality in PD patients.A total of 160 PD patients were recruited in this 2-year retrospective observational study. Differences in air quality were analyzed with respect to the patients’ living areas. The PD patients were categorized into 2 groups according to high (n = 65) and low (n = 95) nitrogen dioxide (NO₂) exposure. Demographic, hematological, nutritional, inflammatory, biochemical, air pollutants, and dialysis-related data were analyzed. Univariate and multivariate Cox regression analyses were used for 2-year mortality analysis.A total of 160 PD patients (38 men and 122 women) were enrolled. Fourteen patients (8.8%) died within 2 years; among them, the causes of death were infection (n = 10), malignancy (n = 1), and cardiovascular events (n = 3). Among the 10 patients who died from infection, 5, 4, and 1 died from pneumonia, PD-related peritonitis, and sepsis of unknown origin, respectively. All patients who died from pneumonia were living in high environmental NO₂ exposure areas. Multivariate Cox regression analysis showed that age (hazard ratio [HR] 1.073, 95% confidence interval [CI] [1.013–1.137]; P = 0.017), white blood cell count (HR 1.41, 95% CI [1.116–1.781]; P = 0.004), log normalized protein nitrogen appearance (HR 0.0001, 95% CI [0–0.073]; P = 0.005), high cardiothoracic ratio (HR 14.28, 95% CI [1.778–114.706]; P = 0.012), and high environmental NO₂ exposure (HR 3.776, 95% CI [1.143–12.47]; P = 0.029) were significantly associated with 2-year mortality.PD patients with high environmental NO₂ exposure had a higher 2-year mortality rate than those with low exposure. Therefore, air pollution may be associated with 2-year mortality in such patients.     

Air Pollution and the Risk of Cardiac Defects: A Population-Based Case-Control Study

Previous epidemiologic studies have assessed the role of the exposure to ambient air pollution in the development of cardiac birth defects, but they have provided somewhat inconsistent results. To assess the associations between exposure to ambient air pollutants and the risk of cardiac defects, a population-based case-control study was conducted using 1087 cases of cardiac defects and a random sample of 10,870 controls from 1,533,748 Taiwanese newborns in 2001 to 2007.Logistic regression was performed to calculate odds ratios for 10 ppb increases in O₃ and 10 μg/m³ increases in PM₁₀. In addition, we compared the risk of cardiac defects in 4 categories-high exposure (>75th percentile); medium exposure (75th to 50th percentile); low exposure (<50th–25th percentile); reference (<25th percentile) based on the distribution of each pollutant. The risks of ventricular septal defects (VSD), atrial septal defects (ASD), and patent ductus arteriosus (PDA) were associated with 10 ppb increases in O₃ exposure during the first 3 gestational months among term and preterm babies. In comparison between high PM₁₀ exposure and reference category, there were statistically significant elevations in the effect estimates of ASD for all and terms births. In addition, there was a negative or weak association between SO_2, NO₂, CO, and cardiac defects_.The study proved that exposure to outdoor air O₃ and PM₁₀ during the first trimester of gestation may increase the risk of VSD, ASD, and PDA.     

Hemoglobin A1c Levels and the Risk of Cardiovascular Disease in People Without Known Diabetes: A Population-Based Cohort Study in Japan

High hemoglobin A_1c (HbA_1c) levels are strongly associated with an increased risk of cardiovascular disease (CVD) in people with and without diabetes. However, information regarding the relationship between low HbA_1c levels and the risk of CVD among people without known diabetes is limited. The aim of this large-scale, prospective, population-based cohort study was to clarify the association between HbA_1c levels and CVD risk among people without known diabetes.We followed-up 10,980 men and 18,079 women (46–80 years old and free of CVD and cancer at baseline) in the Japan Public Health Center-based Prospective Study. Using Cox models, we estimated the hazard ratios for CVD risk with adjustments for age, sex, geographic areas, body mass index, smoking status, sports and physical exercise, alcohol intake, systolic blood pressure, non-high-density lipoprotein cholesterol, and high-density lipoprotein cholesterol.During the median follow-up of 9.4 years, 935 CVD events (770 strokes and 165 coronary heart diseases) occurred. We observed a nonlinear association between HbA_1c levels and CVD risk in participants without known diabetes. Compared with HbA_1c levels of 5.0 to 5.4% (31–36 mmol/mol), the hazard ratios for CVD in participants without known diabetes were 1.50 (95% confidence interval: 1.15–1.95), 1.01 (0.85–1.20), 1.04 (0.82–1.32), and 1.77 (1.32–2.38) for HbA_1c levels of <5.0% (<31 mmol/mol), 5.5 to 5.9% (37–41 mmol/mol), 6.0 to 6.4% (42–47 mmol/mol), and ≥6.5% (≥48 mmol/mol), respectively (P value for nonlinear trend: <0.001). In addition, the hazard ratio for CVD was 1.81 (1.43–2.29) in patients with known diabetes compared with participants with HbA_1c levels of 5.0 to 5.4% and without known diabetes. This nonlinear relation persisted after excluding people with kidney dysfunction, liver dysfunction, anemia, body mass index <18.5 kg/m², or early events within 3 years of follow-up (P value for nonlinear trend: <0.01 for all tests).In conclusion, both low and high levels of HbA_1c were associated with a higher risk of CVD in a Japanese general population without known diabetes.     

Short-Term Exposure to Ambient Air Pollution and Mortality From Myocardial Infarction

BackgroundShort-term exposure to ambient air pollution has been linked to occurrence of myocardial infarction (MI); however, only a limited number of studies investigated its association with death from MI, and the results remain inconsistent.ObjectivesThis study sought to investigate the association of short-term exposure to air pollution across a wide range of concentrations with MI mortality.MethodsA time-stratified case-crossover study was conducted to investigate 151,608 MI death cases in Hubei province (China) from 2013 to 2018. Based on each case’s home address, exposure to particulate matter with an aerodynamic diameter ≤2.5 μm (PM_2.5), particulate matter with an aerodynamic diameter ≤10 μm (PM₁₀), sulfur dioxide, nitrogen dioxide (NO₂), carbon monoxide, and ozone on each of the case and control days was assessed as the inverse distance–weighted average concentration at neighboring air quality monitoring stations. Conditional logistic regression models were implemented to quantify exposure-response associations.ResultsExposure to PM_2.5, PM₁₀, and NO₂ (mean exposure on the same day of death and 1 day prior) was significantly associated with increased odds of MI mortality. The odds associated with PM_2.5 and PM₁₀ exposures increased steeply before a breakpoint (PM_2.5, 33.3 μg/m³; PM₁₀, 57.3 μg/m³) and flattened out at higher exposure levels, while the association for NO₂ exposure was almost linear. Each 10-μg/m³ increase in exposure to PM_2.5 (<33.3 μg/m³), PM₁₀ (<57.3 μg/m³), and NO₂ was significantly associated with a 4.14% (95% confidence interval [CI]: 1.25% to 7.12%), 2.67% (95% CI: 0.80% to 4.57%), and 1.46% (95% CI: 0.76% to 2.17%) increase in odds of MI mortality, respectively. The association between NO₂ exposure and MI mortality was significantly stronger in older adults.ConclusionsShort-term exposure to PM_2.5, PM₁₀, and NO₂ was associated with increased risk of MI mortality.     

Association between long-term exposure of ambient air pollutants and cardiometabolic diseases: A 2012 Korean Community Health Survey

Background and aim

The associations of long-term exposure to particulate matter <10 μm in size (PM₁₀), nitrogen dioxide (NO₂), carbon monoxide (CO), sulfur dioxide (SO₂), and ozone (O₃) with cardiometabolic diseases (CMD) remain uncertain in the Korean population. Therefore, we sought to examine the associations between PM₁₀, NO₂, CO, SO₂, and O₃ and CMD using data collected from the Korean Community Health Survey.

Relationship of MTHFR Gene 677C→T Polymorphism,Homocysteine, and Estimated Glomerular Filtration Rate Levels With the Risk of New-Onset Diabetes

East Asian patients with diabetes have a higher risk for renal complications and strokes than Europeans. We aimed to evaluate the effect of methylenetetrahydrofolate reductase (MTHFR) gene 677C→T polymorphism, which was associated with a higher stroke risk and was common in the Chinese population, as well as homocysteine and estimated glomerular filtration rate (eGFR) levels on the risk of new-onset diabetes (NOD).A total of 2422 subjects without diabetes were followed-up for 7 years. NOD was defined as fasting plasma glucose ≥7.0 mmol/L or self-reported physician diagnosis of diabetes.Compared with subjects with MTHFR 677CC genotype, those with TT genotype had a higher risk of NOD in females (odds ratio 2.78, 95% confidence interval 1.39–5.56) but not in males (0.80, 0.40–1.61, P for interaction = 0.008). Furthermore, MTHFR 677C→T polymorphism was more strongly associated with the risk of NOD among females with higher body mass index (BMI, ≥23 vs <23 kg/m², P for interaction = 0.009) or lower high-density lipoprotein-cholesterol (HDL-C, <1.3 vs ≥1.3 mmol/L, P for interaction = 0.015) levels. Hyperhomocysteinemia (≥16 vs <10 μmol/L) was not significantly associated with NOD in males (0.88, 0.42–1.85) or females (1.52, 0.65–3.57). However, mildly decreased eGFR (<90 vs 90–120 mL/min/1.73 m²) was associated with NOD mainly in males (1.96, 1.01–3.78; females, 0.74, 0.32–1.72, P for interaction = 0.134).Females with MTHFR 677TT genotype had a significantly higher risk of NOD, particularly those with higher BMI or low HDL-C levels. The higher risk of NOD associated with mildly decreased eGFR also warrants more investigation. Our results provide insights into the ethnic differences of diabetic complications between East Asian patients and Europeans.     

Hepatic,Renal and Inflammatory Biomarkers are Positively Associated with Blood Pressure Changes in Healthy Pregnant Women: A Prospective Cohort

This article evaluates the association of hepatic, renal, and inflammatory biomarkers with changes in systolic (SBP) and diastolic (DBP) blood pressure (BP) during healthy pregnancies.A prospective cohort study with 225 healthy pregnant women was conducted in Rio de Janeiro, Brazil. SBP and DBP were evaluated throughout pregnancy (5th–13th, 20th–26th, and 30th–36th gestational weeks) and were the outcomes. The following biomarkers were measured at the first trimester and analyzed according to tertiles of the sample distribution and were considered the main independent predictors: alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), uric acid (UA), creatinine (Cr), and C-reactive protein (CRP) concentrations. The statistical analysis included 3 stages of modeling with the longitudinal linear mixed-effects procedures: Model 1 was adjusted for gestational age and quadratic gestational age; Model 2 included interactions between the biomarkers and gestational age; and Model 3 was adjusted for self-reported skin color, education, parity, early-pregnancy body mass index (BMI) (under/normal <25; overweight/obese ≥25 kg/m²), smoking habit, and leisure-time physical activity. Additional models were performed for CRP and UA with the inclusion of interaction terms between the biomarkers and BMI.Women classified in the third tertile of the ALP (≥61.1 U/L; β_SBP = 3.474; 95% confidence interval [CI]: 0.955–5.992; β_DBP = 3.291; 95% CI: 1.098–5.485), ALT (≥14.3 U/L; β_SBP = 2.232; 95% CI: 0.221–4.242; β_DBP = 2.355; 95% CI: 0.721–3.989), and Cr values (≥48.6 μmol/L; β_DBP = 1.927; 95% CI: 0.347–3.508) presented higher BP levels during pregnancy compared to those in the first and second tertiles. Women in the highest tertile of the ALP concentration distribution presented a lower rate of change in SBP and DBP during pregnancy (interaction term with gestational age β_SBP = −0.004; 95% CI: −0.007 to −0.001; P = 0.02; β_DBP = −0.003; 95% CI: −0.006 to −0.001; P = 0.01). Higher UA concentrations were associated with higher SBP levels only in overweight/obese women (β = 3.878; 95% CI: 0.687–7.068), whereas higher CRP concentrations (≥2.6 mg/L) were associated with higher DBP in under/normal weight women (β =2.252; 95% CI: 0.267–4.236).ALP, ALT, and Cr concentrations were positively associated with BP levels, whereas ALP was associated with a lower rate of change in BP. The associations of UA and CRP with BP differ according to the early-pregnancy BMI.     

The Association Between Body Mass Index and All-Cause Mortality in Patients With Type 2 Diabetes Mellitus: A 5.5-Year Prospective Analysis

Abundances of study in different population have noted that obese cardiovascular disease (CVD) patients have a better prognosis than leaner patients, which refer to the phenomenon of obesity paradox. However, data on the association between body mass index (BMI) and mortality among Asian patients are limited, especially in patients with type 2 diabetes mellitus (T2DM). We investigate the association between BMI and all-cause mortality in Taiwanese patients with T2DM to define the optimal body weight for health.We conducted a longitudinal cohort study of 2161 T2DM patients with a mean follow-up period of 66.7 ± 7.5 months. Using Cox regression models, BMI was related to the risk of all-cause mortality after adjusting all confounding factors.A U-shaped association between BMI and all-cause mortality was observed among all participants. Those with BMIs <22.5 kg/m² had a significantly elevated all-cause mortality as compared with those with BMIs 22.5 to 25.0 kg/m², (BMIs 17.5–20.0 kg/m²: hazard ratio 1.989, P < 0.001; BMIs 20.0–22.5 kg/m²: hazard ratio 1.286, P = 0.02), as did those with BMIs >30.0 kg/m² (BMIs 30.0–32.5 kg/m²: hazard ratio 1.670, P < 0.001; BMIs 32.5–35.0 kg/m²: hazard ratio, 2.632, P < 0.001). This U-shaped association remained when we examined the data by sex, age, smoking, and kidney function.Our study found a U-shaped relationship between all-cause mortality and BMI in Asian patients with T2DM, irrespective of age, sex, smoking, and kidney function. BMI <30 kg/m² should be regarded as a potentially important target in the weight management of T2DM.     

Effects of regular breakfast habits on metabolic and cardiovascular diseases: A protocol for systematic review and meta-analysis

Background:Breakfast, which is considered as an important meal of the day, is being ignored by an increasing number of people as the pace of modern life accelerates. Although a large number of previous studies have reported the relationship between skipping breakfast and type 2 diabetes mellitus, most of them were cross-sectional studies. It remains unclear how skipping breakfast affects such specific cardio-metabolic diseases as hypertension, strokes and hypercholesterolemia.Methods:The protocols and reports of this meta-analysis are based on a meta-analysis of observational studies in epidemiological guidelines (MOOSE). Relevant studies were systematically retrieved from PubMed, Embase, Web of Science and the Cochrane Library, and were restricted to English from the inception to May 10, 2019. All the results were obtained by RRs, and outcomes of interests should include the occurrence of cardiovascular and metabolic diseases.Results:Fourteen cohort studies in total were eventually included. Compared with people having breakfast frequency_{≦3times/week}, those with a frequency_{>3 times/week} have reduced the risk of type 2 diabetes mellitus, obesity, Metabolic Syndrome, Low high-density lipoprotein cholesterolemia, Cardiovascular Diseases, cardiovascular Mortality, hypertension and strokes, with (RR = 0.8 [95% CI: 0.7–0.91], P = .142, I² = 37.6%), (RR = 0.74 [95% CI: 0.59–0.94], P < .001, I² = 89%), (RR = 0.86 [95% CI:0.75–0.99], P = .512, I² = 0%), (RR = 0.75 [95% CI:0.61–0.93], P = .643, I² = 0%), (RR = 0.87 [95% CI:0.81–0.93], P = .479, I² = 0%), (RR = 0.63 [95% CI:0.51–0.78], P = .396, I² = 0%), (RR = 0.92 [95% CI:0.86–0.98], P = .419, I² = 0.7%), and (RR = 0.89 [95% CI:0.79–0.99], P = .238, I² = 29%), respectively.Conclusions:A regular daily breakfast habit benefits the cardio-metabolism to a great extent, reducing the risk of Cardiovascular Diseases, type 2 diabetes mellitus, obesity, hypertension, strokes, Metabolic Syndrome, cardiovascular Mortality, Low high-density lipoprotein cholesterolemia, and Abdominal obesity, while it is not significantly related to hypercholesterolemia and coronary heart disease regardless of gender. Nevertheless, skipping breakfast once a week may greatly reduce the benefits of cardio-metabolism. Therefore, public institutions should promote and encourage citizens to cultivate regular daily breakfast habits.     

Cardiovascular Risk Factors Increase the Risks of Diabetic Peripheral Neuropathy in Patients With Type 2 Diabetes Mellitus: The Taiwan Diabetes Study

This study aimed to examine whether poor glycemic control, measured by glycated hemoglobin A1C (HbA1c) and other cardiovascular risk factors, can predict diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes mellitus (DM).Patients aged ≥30 years with type 2 DM, enrolled in the National Diabetes Care Management Program, and free of DPN (n = 37,375) in the period 2002 to 2004 were included and followed up until 2011. The related factors were analyzed using Cox proportional hazards regression models.For an average follow-up of 7.00 years, 8379 cases of DPN were identified, with a crude incidence rate of 32.04/1000 person-years. After multivariate adjustment, patients with HbA1c levels 7 to 8%, 8 to 9%, 9 to 10%, and ≥10% exhibited higher risk of DPN (adjusted HR: 1.11 [1.04–1.20], 1.30 [1.21–1.40], 1.32 [1.22–1.43], and 1.62 [1.51–1.74], respectively) compared with patients with HbA1c level 6 to 7%. There was a significant linear trend in DPN incidence with increasing HbA1c (P < 0.001) and significant HRs of DPN for patients with HbA1c level ≥7%, blood pressure ≥130/85 mm Hg, triglycerides (TG) ≥150 mg/dL, high density of lipoprotein-cholesterol (HDL-C) <40 mg/dL in males and <50 mg/dL in females, low density of lipoprotein-cholesterol (LDL-C) ≥100 mg/dL, and estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m².Patients with type 2 DM and HbA1c ≥7.0% exhibit increased risk of DPN, demonstrating a linear relationship. The incidence of DPN is also associated with poor glucose control and cardiovascular risk factors like hypertension, hyper-triglyceridemia, low HDL-C, high LDL-C, and decreased eGFR.     

Impact of Environmental Particulate Matter and Peritoneal Dialysis-related Infection in Patients Undergoing Peritoneal Dialysis

In patients undergoing peritoneal dialysis (PD), PD-related infection is a major cause of PD failure and hospital admission. Good air quality is required when dialysate exchange or exit site wound care is performed. To our knowledge, investigation of air pollution as a factor for PD-related infection in patients undergoing dialysis is limited. This study aimed to assess the effect of environmental particulate matter (PM) and other important risk factors on 1-year PD-related infection in patients undergoing PD.A total of 175 patients undergoing PD were recruited in this 1-year retrospective observational study. Differences in environmental PMs (PM₁₀ and PM_2.5) were analyzed with respect to the patients’ living areas. The patients undergoing PD were categorized into 2 groups according to PM_2.5 exposure: high (n = 61) and low (n = 114). Demographic, hematological, nutritional, inflammatory, biochemical, and dialysis-related data were analyzed. Multivariate binary logistic and multivariate Cox regression analyses were used to analyze 1-year PD-related infection.A total of 175 patients undergoing PD (50 men and 125 women) were enrolled. Thirty-five patients had PD-related infection within 1 year. Multivariate Cox regression analysis showed that high environmental PM_2.5 exposure (hazard ratio (HR): 2.0, 95% confidence interval [CI] [1.03–3.91]; P = .04) and female sex (HR: 2.77, 95% CI [1.07–7.19]; P = .03) were risk factors for 1-year PD-related infection.Patients undergoing PD with high environmental PM_2.5 exposure had a higher 1-year PD-related infection rate than that in those with low exposure. Therefore, air pollution may be associated with PD-related infection in such patients.     

CHA2DS2-VASc score predicts the slow flow/no-reflow phenomenon in ST-segment elevation myocardial infarction patients with multivessel disease undergoing primary percutaneous coronary intervention

ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) have a higher incidence of slow-flow/no-reflow (SF-NR) phenomenon during primary percutaneous coronary intervention (PPCI) than those with single vessel disease. Currently, no effective tools exist to predict the risk of SF-NR in this population. The present study aimed to evaluate whether CHA₂DS₂-VASc score can be used as a simple tool to predict this risk.This study consecutively included STEMI patients hospitalized in Beijing Anzhen Hospital from January 2005 to January 2015. Among these patients, 1032 patients with MVD were finally enrolled. Patients were divided into SF-NR (+) group and SF-NR (–) group according to whether SF-NR occurred during PPCI. SF-NR was defined as the thrombolysis in myocardial infarction (TIMI) grade ≤2.There were 134 patients (13%) in the SF-NR (+) group. Compared with the SF-NR (–) group, patients in the SF-NR (+) group are elder, with lower left ventricular ejection fraction and higher CHA₂DS₂-VASc score. Multiple logistic regression analysis indicated that CHA₂DS₂-VASc score ≥3 (odds ratio [OR], 2.148; 95% confidence interval [CI], 1.389–3.320; P = .001), current smoking (OR, 1.814; 95% CI, 1.19–2.764; P = .006), atrial fibrillation (OR, 2.892; 95% CI, 1.138–7.350; P = .03), complete revascularization (OR, 2.307; 95% CI, 1.202–4.429; P = .01), and total length of stents ≥40 mm (OR, 1.482; 95% CI, 1.011–2.172; P = .04) were independent risk factors of SF-NR. The incidence of SF-NR in patients with CHA₂DS₂-VASc score ≥3 was 1.7 times higher than that in patients with CHA₂DS₂-VASc score <3. Additionally, patients with CHA₂DS₂-VASc score ≥3 plus ≥2 risk factors have 3 times higher incidence of SF-NR than those with CHA₂DS₂-VASc score ≥3 plus 0 to 1 risk factor.CHA₂DS₂-VASc score ≥3 can be used as a simple and sensitive indicator to predict SF-NR phenomenon and guide the PPCI strategy in STEMI patients with MVD.     

The Feasibility of Venovenous Extracorporeal Life Support to Treat Acute Respiratory Failure in Adult Cancer Patients

Venovenous extracorporeal life support (VV-ECLS) is a lifesaving but invasive treatment for acute respiratory failure (ARF) that is not improved with conventional therapy. However, using VV-ECLS to treat ARF in adult cancer patients is controversial.This retrospective study included 14 cancer patients (median age: 58 years [interquartile range: 51–66]; solid malignancies in 13 patients and hematological malignancy in 1 patient) who received VV-ECLS for ARF that developed within 3 months after anticancer therapies. VV-ECLS would be considered in selected patients with a P_aO₂/F_iO₂ ratio ≤70 mmHg under advanced mechanical ventilation.Before ECLS, the medians of intubation day, P_aO₂/F_iO₂ ratio, and Sequential Organ Failure Assessment (SOFA) score were 8 (2–12), 62 mmHg (53–76), and 10 (9–14), respectively. The case numbers of bacteremia, thrombocytopenia (platelet count <50000 cells/μL), and neutropenia (actual neutrophil count <1000 cells/μL) detected before ECLS were 3 (21%), 2 (14%), and 1 (7%), respectively. After 24 hours of ECLS, a significant improvement was seen in P_aO₂/F_iO₂ ratio but not in SOFA score. Six patients experienced major hemorrhages during ECLS. The median ECLS day, ECLS weaning rate, and hospital survival were 11 (7–16), 50% (n = 7), and 29% (n = 4). The development of dialysis-dependent nephropathy predicted death on ECLS (odds ratio: 36; 95% confidence interval: 1.8–718.7; P = 0.01). With a median follow-up of 11 (6–43) months, half of the survivors died of cancer recurrence and the others were in partial remission.The most prominent benefit of VV-ECLS is to improve the arterial oxygenation and rest the lungs. This may increase the chance of recovery from ARF in selected cancer patients.     

PM2.5 Air Pollution and Cardiovascular Disease-Associated Disability among Middle-Aged and Older Adults

Background:Increasing evidence regards the role of ambient particles on morbidity and mortality caused by cardiovascular diseases (CVDs). However, there was no evidence about the association between ambient particles and CVD-associated disability. This study used large national representative data to investigate the relationship between long-term exposure to an aerodynamic diameter less than or equal to 2.5 µm (PM_2.5) and CVD-associated disability among Chinese adults aged 45 years old and above and estimated the burden of CVD-associated disability attributed to PM_2.5.Methods:Using data from the Second National Sample Survey on Disability, this study used a combination of self-reports or family members’ reports and on-site medical diagnosis by experienced specialists to ascertain CVD-associated disability in 852,742 adults aged 45 years old and above. Logistic regression models and spline regression models were used to examine the association between PM_2.5 long-term exposure and CVD-associated disability, and the population attributable risk was calculated to assess the burden of CVD-associated disability contributed to PM_2.5.Results:Every increase of 10 μg/m³ in PM_2.5 was associated with an 8% (OR = 1.08, 95% CI: 1.05, 1.10) increase the odds of CVD-associated disability. Stratified analyses by demographic factors suggested that this association was robust. There were 1.05 (0.74,1.35) million -3.53 (3.29,3.75) million CVD-associated disabilities attributed to high PM_2.5 concentration exposure (≥35 µg/m³) among middle-aged and older adults in 2006. A reduction in PM_2.5 concentrations to 35 µg/m³ corresponded to a decrease of 13.59% (9.55%, 17.46%)–23.98% (17.17%, 30.25%) in CVD-associated disability by age group, respectively, and this magnitude increased in areas with a high prevalence of CVD-related disability.Conclusions:This study suggests that reducing PM_2.5 concentrations may contribute to preventing CVD-associated disability and decreasing air pollution-related medical expenditures and rehabilitation fees.     

Obesity or increased body mass index and the risk of severe outcomes in patients with COVID-19: A protocol for systematic review and meta-analysis

Background:To assess the effect of obesity or a high body mass index (BMI) on the risk of severe outcomes in patients with coronavirus disease 2019 (COVID-19).Methods:Studies on the relationship between BMI or obesity and COVID-19 since December 2019. The odds ratio (OR) and weighted mean difference (WMD) with their 95% confidence intervals (CIs) were used to assess the effect size.Results:BMI was significantly increased in COVID-19 patients with severe illness (WMD: 1.18; 95% CI: 0.42–1.93), who were admitted to an intensive care unit (ICU) (WMD: 1.46; 95% CI: 0.96–1.97), who required invasive mechanical ventilation (IMV) (WMD: 2.70, 95% CI: 1.05–4.35) and who died (WMD: 0.91, 95% CI: 0.02–1.80). In Western countries, obesity (BMI of ≥30 kg/m²) increased the risk of hospitalization (OR: 2.08; 95% CI: 1.22–3.54), admission to an ICU (OR: 1.54; 95% CI: 1.29–1.84), need for IMV (OR: 1.73, 95% CI: 1.38–2.17), and mortality (OR: 1.43; 95% CI: 1.17–1.74) of patients with COVID-19. In the Asian population, obesity (BMI of ≥28 kg/m²) increased the risk of severe illness (OR: 3.14; 95% CI: 1.83–5.38). Compared with patients with COVID-19 and a BMI of <25 kg/m², those with a BMI of 25–30 kg/m² and ≥30 kg/m² had a higher risk of need for IMV (OR: 2.19, 95% CI: 1.30–3.69 and OR: 3.04; 95% CI: 1.76–5.28, respectively). The risk of ICU admission in patients with COVID-19 and a BMI of ≥30 kg/m² was significantly higher than in those with a BMI of 25–30 kg/m² (OR: 1.49; 95% CI: 1.00–2.21).Conclusion:As BMI increased, the risks of hospitalization, ICU admission, and need for IMV increased, especially in COVID-19 patients with obesity.Ethics and dissemination:This systematic review and meta-analysis does not require an ethics approval as it does not collect any primary data from patients.     

A survey of PM2.5 preventive behavioral intention and related factors among community elderly in Northern Taiwan

Population aging and air pollution are global concerns. The purpose of this study is to explore the relationship among particulate matter with a diameter of 2.5 μm or less (PM_2.5) knowledge, PM_2.5 preventive attitude, and PM_2.5 preventive behavioral intention in the elderly.A cross-sectional survey design was applied in this study, including usage intention and snowball sampling. A total of 617 elderly people aged over 65 participated, and the collected data were quantitatively analyzed.The results showed that the mean score of PM_2.5 knowledge of the elderly was 10.34 (79.53%) with the standard deviation (SD) of 3.42, the mean score of PM_2.5 preventive attitude was 4.58 (91.60%) with SD of 0.49, and the mean score of PM_2.5 preventive behavioral intention was 4.72 (94.40%) with SD of 0.40. Elderly people''s characteristics regarding PM_2.5 knowledge and PM_2.5 preventive attitude explained 22% (adjusted R² = 0.22, F = 30.44, P < .001) of the variance in PM_2.5 preventive behavioral intention.It is concluded that we found no difference in PM_2.5 knowledge, PM_2.5 preventive attitude, or PM_2.5 preventive behavioral intention among the elderly with or without chronic diseases. In our opinion, health education regarding the threat of PM_2.5 to the health of the elderly should be strengthened, to enhance their knowledge, preventive attitude, and preventive behavioral intention of PM_2.5.     

Risk factors and nursing countermeasures of postoperative pulmonary infection in patients with breast cancer: A retrospective analysis

It is necessary to elucidate the potential risk factors of pulmonary infection to provide references for the management of breast cancer.Our study was a retrospective design, patients who underwent modified radical mastectomy for breast cancer in our department of breast surgery from January 2019 to November 2020 were included. The personal and clinical data of included patients with and without pulmonary infection were compared.A total of 234 patients with radical mastectomy were included, the incidence of pulmonary infection was 15.38% with 95%confidence interval (CI) 11.42% to 18.98%. There were significant differences in the age, body mass index, diabetes, duration of surgery, combined radiotherapy and chemotherapy, and duration of drainage between patients with and without pulmonary infections (all P < .05). Logistic regression analysis indicated that age ≥55 years (odds ratio [OR] 2.128, 95%CI 1.105–3.426), body mass index ≥ 24 kg/m²(OR 2.344, 95%CI 1.031–3.299), diabetes (OR 2.835, 95%CI 1.132–4.552), duration of surgery ≥120 minutes (OR 1.394, 95%CI 1.012–1.044), combined radiotherapy and chemotherapy (OR 3.122, 95%CI 1.124–5.273), duration of drainage ≥5 days (OR 1.851, 95%CI 1.112–2.045) might be the independent risk factors of pulmonary infection in patients after radical mastectomy(all P < .05). Pseudomonas aeruginosa and Klebsiella pneumoniae are the most commonly seen bacteria.The incidence of postoperative pulmonary infections in breast cancer patients is high, and there are many associated risk factors. The perioperative management of patients should be strengthened targeted on those risk factors in clinical practice.     

The safety and efficacy of low-dose mineralocorticoid receptor antagonists in dialysis patients: A meta-analysis

Introduction:Our aim was to evaluate the safety and efficacy of low-dose mineralocorticoid receptor antagonists (MRAs) in dialysis patients.Methods:We systematically searched PubMed, EMBASE, and Cochrane libraries for clinical trials on the use of MRAs in dialysis patients. Review Manager 5.3 software was used to analyze relevant data and evaluate the quality of evidence.Results:We identified nine randomized controlled trials including 1128 chronic dialysis patients. In terms of safety, when hyperkalemia was defined as serum potassium level ≥5.5 mmol/L, low-dose MRAs were significantly associated with hyperkalemia (relative risk [RR] 1.76, 95% confidence intervals [CI] 1.07–2.89, P = .02); however, when hyperkalemia was defined as serum potassium level ≥6.0 mmol/L or serum potassium level ≥6.5 mmol/L, no significant association was observed between low-dose MRAs and hyperkalemia (RR 1.40, 95% CI 0.83–2.37, P = .20; RR 1.98, 95% CI 0.91–4.30, P = .09, respectively). Use of low-dose MRAs can reduce cardiovascular mortality by 54% compared with the control group (0.46, 95% CI 0.28–0.76, P = .003). Similarly, the RR of all-cause mortality for the low-dose MRAs group was 0.48 (95% CI 0.33–0.72, P = .0003).Conclusion:Low-dose MRAs may benefit dialysis patients without significantly increasing moderate to severe hyperkalemia.     

High Blood Pressure and All-Cause and Cardiovascular Disease Mortalities in Community-Dwelling Older Adults

Although hypertension is common among older adults, the optimal blood pressure (BP) for survival in older adults remains unclear. We attempt to use a large cohort to assess the relationship between BP and mortality and to gain insight into what level of BP is required for optimal survival in older adults.A total of 77,389 community-dwelling adults, aged ≥65 years, were followed between 2006 and 2010. Mortality was determined using matching cohort identifications with national death files. Cox proportional hazards regression models were used to evaluate the relationship of BP with all-cause, cardiovascular disease (CVD), and expanded-CVD mortalities.The mortality risks of the stage 2–3 hypertension group were substantial (all-cause mortality: hazard ratio [HR]: 1.23; 95% confidence interval [CI]: 1.10–1.37; CVDs mortality: HR: 1.31; 95% CI: 1.05–1.64; expanded-CVDs mortality: HR: 1.40; 95% CI: 1.15–1.71). The cardiovascular and expanded-cardiovascular mortality risks were lowest when systolic blood pressures were 120 to 129 mm Hg, and increased significantly when systolic blood pressures (SBPs) were ≥160 mm Hg or diastolic BPs were ≥90 mm Hg. A J-curve phenomenon for SBP on CVD and expanded-CVD mortality was observed. The impacts of stage 2–3 hypertension on mortality risks were significantly increased among women. The mortality risks of hypertension were not attenuated with older age.This study provides insight for identifying the optimal BP for survival in older adults, and extends the knowledge of the impacts of hypertension on mortality risks among women and the older adults.