Assessing long-term effects of gaseous air pollution exposure on mortality in the United States using a variant of difference-in-differences analysis

Long-term mortality effects of particulate air pollution have been investigated in a causal analytic frame, while causal evidence for associations with gaseous air pollutants remains extensively lacking, especially for carbon monoxide (CO) and sulfur dioxide (SO2). In this study, we estimated the causal relationship of long-term exposure to nitrogen dioxide (NO2), CO, SO2, and ozone (O3) with mortality. Utilizing the data from National Morbidity, Mortality, and Air Pollution Study, we applied a variant of difference-in-differences (DID) method with conditional Poisson regression and generalized weighted quantile sum regression (gWQS) to investigate the independent and joint effects. Independent exposures to NO2, CO, and SO2 were causally associated with increased risks of total, nonaccidental, and cardiovascular mortality, while no evident associations with O3 were identified in the entire population. In gWQS analyses, an interquartile range-equivalent increase in mixture exposure was associated with a relative risk of 1.067 (95% confidence interval: 1.010-1.126) for total mortality, 1.067 (1.009-1.128) for nonaccidental mortality, and 1.125 (1.060-1.193) for cardiovascular mortality, where NO2 was identified as the most significant contributor to the overall effect. This nationwide DID analysis provided causal evidence for independent and combined effects of NO2, CO, SO2, and O3 on increased mortality risks among the US general population.

New insights into the involvement of serotonin and BDNF-TrkB signalling in cannabidiol's antidepressant effect

Cannabidiol (CBD) is a phytocannabinoid devoid of psychostimulant properties and is currently under investigation as a potential antidepressant drug. However, the mechanisms underlying CBD's antidepressant effects are not yet well understood. CBD targets include a variety of receptors, enzymes, and transporters, with different binding-affinities. Neurochemical and pharmacological evidence indicates that both serotonin and BDNF-TrkB signalling in the prefrontal cortex are necessary for the antidepressant effects induced by CBD in animal models. Herein, we reviewed the current literature to dissect if these are independent mechanisms or if CBD-induced modulation of the serotonergic neurotransmission could mediate its neuroplastic effects through subsequent regulation of BDNF-TrkB signalling, thus culminating in rapid neuroplastic changes. It is hypothesized that: a) CBD interaction with serotonin receptors on neurons of the dorsal raphe nuclei and the resulting disinhibition of serotonergic neurons would promote rapid serotonin release in the PFC and hence its neuroplastic and antidepressant effects; b) CBD facilitates BDNF-TRKB signalling, especially in the PFC, which rapidly triggers neurochemical and neuroplastic effects. These hypotheses are discussed with perspectives for new drug development and clinical applications.

A compartmental model for smoking dynamics in Italy: a pipeline for inference, validation, and forecasting under hypothetical scenarios

We propose a compartmental model for investigating smoking dynamics in an Italian region (Tuscany). Calibrating the model on local data from 1993 to 2019, we estimate the probabilities of starting and quitting smoking and the probability of smoking relapse. Then, we forecast the evolution of smoking prevalence until 2043 and assess the impact on mortality in terms of attributable deaths. We introduce elements of novelty with respect to previous studies in this field, including a formal definition of the equations governing the model dynamics and a flexible modelling of smoking probabilities based on cubic regression splines. We estimate model parameters by defining a two-step procedure and quantify the sampling variability via a parametric bootstrap. We propose the implementation of cross-validation on a rolling basis and variance-based Global Sensitivity Analysis to check the robustness of the results and support our findings. Our results suggest a decrease in smoking prevalence among males and stability among females, over the next two decades. We estimate that, in 2023, 18% of deaths among males and 8% among females are due to smoking. We test the use of the model in assessing the impact on smoking prevalence and mortality of different tobacco control policies, including the tobacco-free generation ban recently introduced in New Zealand.

Trends of falls mortality among older adults in urban and rural China, 1987-2021

BACKGROUND

Falls in older age pose a major public health concern, with unclear urban-rural patterns of falls mortality in China. This study examines the trends of late-life falls mortality in urban and rural China over a 35-year period.

METHODS

Falls mortality data were sourced from China's National Health Commission. Joinpoint regression analysis was used to examine changes in trends and age-period-cohort modelling to estimate age, period and cohort effects on fall-related mortality from 1987 to 2021. Net drift, local drift, longitudinal age curves and period relative risks were also calculated.

RESULTS

The age-standardised falls mortality in older age showed a long-term trend of initial decline prior to 2003, followed by a steep increase thereafter, with notable distinctions between urban and rural patterns. The rise in rural populations, particularly among older males, was more conspicuous. In rural areas, the decline in falls mortality diminished with age, contrary to the urban trend. Falls mortality increased with age in both urban and rural older populations, peaking in the group aged 85-89. The period effect curves of falls mortality in urban and rural areas both approximated a U-shaped pattern while there were minor variations in early cohorts.

CONCLUSIONS

China has experienced a consistent rise in late-life falls mortality in recent years. Notably, there are significant urban-rural disparities in age, period and cohort effects of fall-related mortality among older adults. Rural residents, males and older age groups have potential higher fatal-falls risk. Targeted strategies should be implemented to prevent late-life falls.

Recent progress of endoplasmic reticulum stress in the mechanism of atherosclerosis

The research progress of endoplasmic reticulum (ER) stress in atherosclerosis (AS) is of great concern. The ER, a critical cellular organelle, plays a role in important biological processes including protein synthesis, folding, and modification. Various pathological factors may cause ER stress, and sustained or excessive ER stress triggers the unfolded protein response, ultimately resulting in apoptosis and disease. Recently, researchers have discovered the importance of ER stress in the onset and advancement of AS. ER stress contributes to the occurrence of AS through different pathways such as apoptosis, inflammatory response, oxidative stress, and autophagy. Therefore, this review focuses on the mechanisms of ER stress in the development of AS and related therapeutic targets, which will contribute to a deeper understanding of the disease's pathogenesis and provide novel strategies for preventing and treating AS.

Understanding Reductions of PM2.5 Concentration and Its Chemical Composition in the United States: Implications for Mitigation Strategies

Motivated by the recent tightening of the US annual standard of fine particulate matter (PM2.5) concentrations from 12 to 9 μg/m3, there is a need to understand the spatial variation and drivers of historical PM2.5 reductions. We evaluate and interpret the variability of PM2.5 reductions across the contiguous US using high-resolution estimates of PM2.5 and its chemical composition over 1998-2019, inferred from satellite observations, air quality modeling, and ground-based measurements. We separated the 3092 counties into four characteristic regions sorted by PM2.5 trends. Region 1 (primarily Central Atlantic states, 25.9% population) exhibits the strongest population-weighted annual PM2.5 reduction (-3.6 ± 0.4%/yr) versus Region 2 (primarily rest of the eastern US, -3.0 ± 0.3%/yr, 39.7% population), Region 3 (primarily western Midwest, -1.9 ± 0.3%/yr, 25.6% population), and Region 4 (primarily the Mountain West, -0.4 ± 0.5%/yr, 8.9% population). Decomposition of these changes by chemical composition elucidates that sulfate exhibits the fastest reductions among all components in 2720 counties (76% of population), mostly over Regions 1-3, with the 1998-2019 mean sulfate mass fraction in PM2.5 decreasing from Region 1 (29.5%) to Region 4 (11.8%). Complete elimination of the remaining sulfate may be insufficient to meet the new standard for many regions in exceedance. Additional measures are needed to reduce other PM2.5 sources and components for further progress.

The global burden of disease attributable to preterm birth and low birth weight in 204 countries and territories from 1990 to 2019: An analysis of the Global Burden of Disease Study

Background

Preterm birth and low birth weight (PBLBW), recognised globally as primary contributors to infant mortality in children under five, have not been sufficiently investigated in terms of their worldwide impact. In this study we aimed to thoroughly evaluate the contemporary trends in disease burden attributable to PBLBW.

Methods

We analysed data from 204 countries and territories between 1990-2019, as sourced from the 2019 Global Burden of Disease Study. We analysed the global incidence of mortality and disability-adjusted life years (DALYs) associated with PBLBW, stratified by age, gender, year, and geographic location, alongside the socio-demographic index (SDI). We calculated the annual percentage changes to evaluate the dynamic trends over time. We employed a generalised linear model and scrutinised the relationship between the SDI and the disease burden attributed to PBLBW.

Results

In 2019, the global age-standardised rate of deaths and DALYs related to PBLBW showed significant declines. Over the period 1990-2019, both death and DALY rates displayed substantial downward trends, with similar change trends observed for both females and males. Age-specific ratios revealed a decrease in PBLBW-related deaths and DALYs with increasing age, primarily during the neonatal stages (zero to 27 days). The leading three causes of PBLBW-related DALYs in 2019 were neonatal disorders, lower respiratory infections, and sudden infant death syndrome. Furthermore, the association between SDI and PBLBW-related DALYs indicated that the age-standardised DALY rates in 204 countries and territories worldwide were negatively correlated with SDI in 2019. From 1990 to 2019, the age-standardised DALY rates decreased linearly in most regions, except sub-Saharan Africa.

Conclusions

The persistent global burden of disease associated with PBLBW is particularly pronounced in neonates aged less than 28 days and in regions with low SDI. In this study, we highlighted the critical need for tailored interventions aimed at mitigating the detrimental effects of PBLBW to attain specific sustainable development goals, particularly those centred on enhancing child survival and overall well-being.

Assessing the predictive value of the suppressed 1 mg overnight dexamethasone suppression test in success of bariatric surgery

Bariatric surgery has been proven to be a successful intervention for managing obesity. There are numerous studies in the literature aiming to predict the factors influencing the success of bariatric surgery. Our study aims to determine whether preoperative 1 mg overnight dexamethasone suppression test (1 mg-DST) serum cortisol levels can serve as predictors of the effectiveness of bariatric surgery in severe obese patients without Cushing syndrome. A total of 98 patients who underwent bariatric surgery were included in the study. The preoperative 1 mg-DST levels, insulin levels, thyroid function tests, and lipid profiles of the patients were recorded. The patients' preoperative, postoperative 3rd, and 6th month weights were recorded and the percent total weight loss (%TWL) is calculated. Patients were categorized into 2 groups based on their TWL at 6 months. The 1 mg-DST results were significantly lower in the high-TWL-6 group (0.93 ± 0.37 μg/dL) compared to the low-TWL-6 group (1.09 ± 0.36 μg/dL, P = .040). Similarly, Homeostatic Model Assessment for Insulin Resistance values were lower in the high-TWL-6 group (5.63 ± 2.21) compared to the low-TWL-6 group (6.63 ± 2.55, P = .047). The optimal cutoff value found for 1 mg-DST level was 0.97 µg/dL, providing 50% sensitivity and 70% specificity. This study is the first to examine the predictive role of suppressed 1 mg-DST levels on postoperative weight loss in nondiabetic patients. The most prominent result of this study was that we observed a negative correlation between 1 mg-DST levels and %TWL.

Epigenetic link between Agent Orange exposure and type 2 diabetes in Korean veterans

Conflicting findings have been reported regarding the association between Agent Orange (AO) exposure and type 2 diabetes. This study aimed to examine whether AO exposure is associated with the development of type 2 diabetes and to verify the causal relationship between AO exposure and type 2 diabetes by combining DNA methylation with DNA genotype analyses. An epigenome-wide association study and DNA genotype analyses of the blood of AO-exposed and AO-unexposed individuals with type 2 diabetes and that of healthy controls were performed. Methylation quantitative trait locus and Mendelian randomisation analyses were performed to evaluate the causal effect of AO-exposure-identified CpGs on type 2 diabetes. AO-exposed individuals with type 2 diabetes were associated with six hypermethylated CpG sites (cg20075319, cg21757266, cg05203217, cg20102280, cg26081717, and cg21878650) and one hypo-methylated CpG site (cg07553761). Methylation quantitative trait locus analysis showed the methylation levels of some CpG sites (cg20075319, cg20102280, and cg26081717) to be significantly different. Mendelian randomisation analysis showed that CpG sites that were differentially methylated in AO-exposed individuals were causally associated with type 2 diabetes; the reverse causal effect was not significant. These findings reflect the need for further epigenetic studies on the causal relationship between AO exposure and type 2 diabetes.

Global burden of type 2 diabetes in adolescents from 1990 to 2019

Purpose

To evaluate the burden of type 2 diabetes (T2D) among adolescents (15-24 years old) from 1990 to 2019.

Methods

The age-standardized incidence rate (ASIR) and disability-adjusted life years (DALYs) rate of adolescents were analyzed according to age, sex, geographical location, and sociodemographic index (SDI). The estimated annual percentage change (EAPC) was estimated to quantify the trends.

Results

From 1990 to 2019, the ASIR (EAPC = 1.07) and age-standardized DALY rate (EAPC = 2.01) of T2D in adolescents showed an increasing trend. The ASIR was higher in males than in females. The burden was greater in the 20-24-year age group. Of the five SDI regions, the highest ASIR and age-standardized DALY rate were found in low-middle-SDI regions, while the greatest increase in these rates was observed in high-SDI regions (EAPC = 3.28 and 3.55, respectively). Of the 21 regions analyzed, the highest ASIR and age-standardized DALY rate were found in Oceania. Of the 204 countries analyzed, the Marshall Islands (651.16) and Kiribati (277.42) had the highest ASIR and DALYs, respectively. The regions with the greatest increase in the ASIR from 1990 to 2019 were Western Europe (EAPC = 4.15), high-income North America (EAPC = 4.72).

Conclusions

The global burden of T2D in adolescents showed an overall upward trend from 1990 to 2019. It is necessary to strengthen prevention measures related to risk factors for T2D among young people, especially in areas with a low-to-medium SDI.

Epidemiological trends of subarachnoid hemorrhage at global, regional, and national level: a trend analysis study from 1990 to 2021

BACKGROUND

Subarachnoid hemorrhage (SAH) is a subtype of hemorrhagic stroke characterized by high mortality and low rates of full recovery. This study aimed to investigate the epidemiological characteristics of SAH between 1990 and 2021.

METHODS

Data on SAH incidence, mortality, and disability-adjusted life-years (DALYs) from 1990 to 2021 were obtained from the Global Burden of Disease Study (GBD) 2021. Estimated annual percentage changes (EAPCs) were calculated to evaluate changes in the age-standardized rate (ASR) of incidence and mortality, as well as trends in SAH burden. The relationship between disease burden and sociodemographic index (SDI) was also analyzed.

RESULTS

In 2021, the incidence of SAH was found to be 37.09% higher than that in 1990; however, the age-standardized incidence rates (ASIRs) showed a decreased [EAPC: -1.52; 95% uncertainty interval (UI) -1.66 to -1.37]. Furthermore, both the number and rates of deaths and DALYs decreased over time. It was observed that females had lower rates compared to males. Among all regions, the high-income Asia Pacific region exhibited the highest ASIR (14.09/100,000; 95% UI 12.30/100,000 - 16.39/100,000) in 2021, with an EPAC for ASIR < 0 indicating decreasing trend over time for SAH ASIR. Oceania recorded the highest age-standardized mortality rates (ASMRs) and age-standardized DALYs rates among all regions in 2021 at values of respectively 8.61 (95% UI 6.03 - 11.95) and 285.62 (95% UI 209.42 - 379.65). The burden associated with SAH primarily affected individuals aged between 50 - 69 years old. Metabolic risks particularly elevated systolic blood pressure were identified as the main risk factors contributing towards increased disease burden associated with SAH when compared against environmental or occupational behavioral risks evaluated within the GBD framework.

CONCLUSIONS

The burden of SAH varies by gender, age group, and geographical region. Although the ASRs have shown a decline over time, the burden of SAH remains significant, especially in regions with middle and low-middle SDI levels. High systolic blood pressure stands out as a key risk factor for SAH. More specific supportive measures are necessary to alleviate the global burden of SAH.

A Review of the Increasing Global Impact of Climate Change on Human Health and Approaches to Medical Preparedness

At the end of 2023, the World Health Organization (WHO) identified climate change as the greatest threat to human health. Global climate change is due to rising atmospheric concentrations of greenhouse gasses, primarily due to the burning of fossil fuels, mainly by populations in developed and developing countries. In 2022, the world experienced the highest temperatures for over 100,000 years. However, in 2022, global investment in fossil fuels increased by 10% and reached more than USD 1 trillion. The 2023 Lancet Commission report concluded that there has been little progress in protecting individuals from the adverse health effects of climate change. It is clear that global action against climate change needs to move more quickly, and the inequalities in the effects of climate change, including the impact on health, are increasing. This article aims to review the ongoing global impact of climate change on human health at individual and population levels, including recent initiatives and medical approaches to prepare for this increasing challenge.

Patterns of inpatient acute care and emergency department utilization within one year post-initial amputation among individuals with dysvascular major lower extremity amputation in Ontario, Canada: A population-based retrospective cohort study

INTRODUCTION

Lower extremity amputation (LEA) is a life altering procedure, with significant negative impacts to patients, care partners, and the overall health system. There are gaps in knowledge with respect to patterns of healthcare utilization following LEA due to dysvascular etiology.

OBJECTIVE

To examine inpatient acute and emergency department (ED) healthcare utilization among an incident cohort of individuals with major dysvascular LEA 1 year post-initial amputation; and to identify factors associated with acute care readmissions and ED visits.

DESIGN

Retrospective cohort study using population-level administrative data.

SETTING

Ontario, Canada.

POPULATION

Adults individuals (18 years or older) with a major dysvascular LEA between April 1, 2004 and March 31, 2018.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Acute care hospitalizations and ED visits within one year post-initial discharge.

RESULTS

A total of 10,905 individuals with major dysvascular LEA were identified (67.7% male). There were 14,363 acute hospitalizations and 19,660 ED visits within one year post-discharge from initial amputation acute stay. The highest common risk factors across all the models included age of 65 years or older (versus less than 65 years), high comorbidity (versus low), and low and moderate continuity of care (versus high). Sex differences were identified for risk factors for hospitalizations, with differences in the types of comorbidities increasing risk and geographical setting.

CONCLUSION

Persons with LEA were generally more at risk for acute hospitalizations and ED visits if higher comorbidity and lower continuity of care. Clinical care efforts might focus on improving transitions from the acute setting such as coordinated and integrated care for sub-populations with LEA who are more at risk.

Hypertension in frail older adults: current perspectives

Hypertension is one of the most common chronic diseases in older people, and the prevalence is on the rise as the global population ages. Hypertension is closely associated with many adverse health outcomes, including cardiovascular disease, chronic kidney disease and mortality, which poses a substantial threat to global public health. Reasonable blood pressure (BP) management is very important for reducing the occurrence of adverse events. Frailty is an age-related geriatric syndrome, characterized by decreased physiological reserves of multiple organs and systems and increased sensitivity to stressors, which increases the risk of falls, hospitalization, fractures, and mortality in older people. With the aging of the global population and the important impact of frailty on clinical practice, frailty has attracted increasing attention in recent years. In older people, frailty and hypertension often coexist. Frailty has a negative impact on BP management and the prognosis of older hypertensive patients, while hypertension may increase the risk of frailty in older people. However, the causal relationship between frailty and hypertension remains unclear, and there is a paucity of research regarding the efficacious management of hypertension in frail elderly patients. The management of hypertension in frail elderly patients still faces significant challenges. The benefits of treatment, the optimal BP target, and the choice of antihypertensive drugs for older hypertensive patients with frailty remain subjects of ongoing debate. This review provides a brief overview of hypertension in frail older adults, especially for the management of BP in this population, which may help in offering valuable ideas for future research in this field.

Health system description and assessment: a scoping review of templates for systematic analyses

BACKGROUND

Understanding and comparing health systems is key for cross-country learning and health system strengthening. Templates help to develop standardised and coherent descriptions and assessments of health systems, which then allow meaningful analyses and comparisons. Our scoping review aims to provide an overview of existing templates, their content and the way data is presented.

MAIN BODY

Based on the WHO building blocks framework, we defined templates as having (1) an overall framework, (2) a list of indicators or topics, and (3) instructions for authors, while covering (4) the design of the health system, (5) an assessment of health system performance, and (6) should cover the entire health system. We conducted a scoping review of grey literature published between 2000 and 2023 to identify templates. The content of the identified templates was screened, analyzed and compared. We found 12 documents that met our inclusion criteria. The building block `health financing´ is covered in all 12 templates; and many templates cover ´service delivery´ and ´health workforce'. Health system performance is frequently assessed with regard to 'access and coverage', 'quality and safety', and 'financial protection'. Most templates do not cover 'responsiveness' and 'efficiency'. Seven templates combine quantitative and qualitative data, three are mostly quantitative, and two are primarily qualitative. Templates cover data and information that is mostly relevant for specific groups of countries, e.g. a particular geographical region, or for high or for low and middle-income countries (LMICs). Templates for LMICs rely more on survey-based indicators than administrative data.

CONCLUSIONS

This is the first scoping review of templates for standardized descriptions of health systems and assessments of their performance. The implications are that (1) templates can help analyze health systems across countries while accounting for context; (2) template-guided analyses of health systems could underpin national health policies, strategies, and plans; (3) organizations developing templates could learn from approaches of other templates; and (4) more research is needed on how to improve templates to better achieve their goals. Our findings provide an overview and help identify the most important aspects and topics to look at when comparing and analyzing health systems, and how data are commonly presented. The templates were created by organizations with different agendas and target audiences, and with different end products in mind. Comprehensive health systems analyses and comparisons require production of quantitative indicators and complementing them with qualitative information to build a holistic picture.

CLINICAL TRIAL REGISTRATION

  Not applicable.

Traditional Chinese medicine lowering lipid levels and cardiovascular events across baseline lipid levels among coronary heart disease: a meta-analysis of randomized controlled trials

Background

Dyslipidemia is a critical driver in the development of coronary heart disease (CHD), which further exacerbates the risk of major adverse cardiovascular events (MACEs). Chinese herbal medicine (CHM) plays an important role in the regulation of lipid levels and improvement of prognosis. However, few systematic reviews report whether the efficacy of CHM therapy for regulating lipid levels and lowering cardiovascular events is associated with baseline lipid levels.

Methods

Randomized controlled trials assessing efficacy of CHM for lipid profiles and MACEs among patients with CHD were searched in six databases. Two authors independently extracted studies according to a predesigned form. Cochrane risk of bias tool and Grading of Recommendations Assessment, Development, and Evaluation system were used to assess the methodological quality of the included studies. The primary outcomes were blood lipid levels and MACEs including cardiovascular mortality, non-fatal myocardial infarction, revascularization, angina pectoris, heart failure, and non-fatal stroke across baseline lipid levels. The secondary outcomes were individual components of the primary outcomes.

Results

A total of 23 trials with 7,316 participants were included in this study. Altogether 377 cardiovascular events occurred in 3,670 patients in the CHM group, while 717 events occurred in 3,646 patients in the Western medicine-alone group. Compared with the Western medicine alone, additional CHM significantly lowered low-density lipoprotein cholesterol (LDL-C) [MD = -0.46, 95% CI (-0.60 to -0.32), P < 0.00001, I 2 = 96%]. The risk reduction in MACEs associated with CHM vs. Western medicine therapy was 0.52 [95% CI (0.47-0.58), P < 0.00001, I 2  = 0%], but varied by baseline LDL-C level (P = 0.03 for interaction). Triglycerides (TG) level was also significantly lowered by additional CHM vs. Western medicine alone [MD = -0.27, 95% CI (-0.34 to -0.20), P < 0.00001, I 2 = 81%], and risk reduction for MACEs also varied with baseline TG, with greater risk reduction in higher baseline TG subgroups (P = 0.03 for interaction). Similar results were observed with total cholesterol and high-density lipoprotein cholesterol.

Conclusion

Compared with Western medicine alone, additional CHM was associated with lower risk of cardiovascular events and improvement of lipid profiles. Risk reduction for cardiovascular events was associated with baseline LDL-C and TG levels.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023425791.

Association between sleep duration and possible sarcopenia in middle-aged and elderly Chinese individuals: evidence from the China health and retirement longitudinal study

BACKGROUND

Sarcopenia is a common cause of disability in the aging population, and managing sarcopenia is an important step in building intrinsic capacity and promoting healthy aging. A growing body of evidence suggests that sleep deprivation may be a mediator of the development of sarcopenia. The purpose of this study was to explore the longitudinal association between sleep duration and possible sarcopenia using data from a national sample.

METHODS

Two waves of data from the CHARLS database for 2011 and 2015 were used in this study. All possible sarcopenia participants met the Asia Working Group for Sarcopenia 2019 (AWGS 2019) diagnostic criteria. Sleep duration was assessed using a self-report questionnaire, and sleep duration was categorized as short (≤ 6 h), medium (6-8 h), or long (> 8 h) based on previous studies. Longitudinal associations between sleep duration and possible sarcopenia will be calculated by univariate and multifactorial logistic regression analyses and expressed as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 5654 individuals participated in the follow-up study, with a prevalence of possible sarcopenia of 53.72% (578) in the short sleep duration group, 38.29% (412) in the medium sleep duration group, and 7.99% (86) in the long sleep duration group. According to the crude model of the second-wave follow-up study, short sleep durations were significantly more strongly associated with possible sarcopenia than were medium and long sleep durations (OR: 1.35, 95% CI: 1.17-1.55, P = 0.000). The association between short sleep duration and possible sarcopenia was maintained even after adjustment for covariates such as age, gender, residence, education level, BMI, smoking status, alcohol consumption and comorbidities (OR: 1.18, 95% CI: 1.02-1.36, P = 0.029). In the subgroup analysis, short sleep duration was associated with low grip strength (OR: 1.20, 95% CI: 1.02-1.41, P = 0.031).

CONCLUSIONS

Sleep deprivation may be closely associated with the development of possible sarcopenia in middle-aged and elderly people, which provides new insights and ideas for sarcopenia intervention, and further studies are needed to reveal the underlying mechanisms involved.

Technology-based suicide prevention: An umbrella review

Background

The objective is to summarize evidence from systematic reviews, scoping reviews, and meta-analyses evaluating the effects of any format of Internet-based, mobile-, or telephone-based intervention as a technology-based intervention in suicide prevention.

Materials and Methods

This is an umbrella review, that followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement guidelines. An electronic search was done on September 29, 2022. Data were extracted by reviewers and then methodological quality and risk of bias were assessed by A Measurement Tool to Assess Systematic Reviews-2. Statistical analysis was done by STATA version 17. Standard mean difference was extracted from these studies and by random effect model, the overall pooled effect size (ES) was calculated. I2 statistic was used to assess the heterogeneity between studies. For publication bias, the Egger test was used.

Results

Six reviews were included in our study, all with moderate quality. The overall sample size was 24631. The ES for standard mean differences of the studies is calculated as - 0.20 with a confidence interval of (-0.26, -0.14). The heterogeneity is found as 58.14%, indicating a moderate-to-substantial one. The Egger test shows publication bias.

Conclusion

Our results show that technology-based interventions are effective. We propose more rigorous randomized controlled trials with different control groups to assess the effectiveness of these interventions.

The spectrum of health conditions in community-based cross-sectional surveys in Southeast Asia 2010-21: a scoping review

BACKGROUND

Southeast Asia is undergoing an epidemiological transition with non-communicable illnesses becoming increasingly important, yet infectious diseases (tuberculosis, HIV, hepatitis B, malaria) remain widely prevalent in some populations, while emerging and zoonotic diseases threaten. There are also limited population-level estimates of many important heath conditions. This restricts evidence-based decision-making for disease control and prevention priorities. Cross-sectional surveys can be efficient epidemiological tools to measure the prevalence of a wide range of diseases, but no systematic assessment of their coverage of different health conditions has been produced for the region.

METHODS

We conducted a systematic search in Medline, Embase, Global Health, CINAHL, Scopus, Web of Science Core Collection, and Global Index Medicus, and additionally Google Scholar. Our inclusion criteria were cross-sectional surveys conducted with community-based recruitment, in Bangladesh, Cambodia, Laos, Myanmar, and Thailand, published between January 1, 2010 and January 27, 2021, and reporting the prevalence of any health condition.

RESULTS

542 publications from 337 surveys were included. Non-communicable conditions (n = 205) were reported by more surveys than infectious conditions (n = 124). Disability (n = 49), self-report history of any disease or symptoms (n = 35), and self-perceived health status (n = 34), which reflect a holistic picture of health, were studied by many fewer surveys. In addition, 45 surveys studied symptomatic conditions which overlap between non-communicable and infectious conditions. The most surveyed conditions were undernutrition, obesity, hypertension, diabetes, intestinal parasites, malaria, anemia, diarrhea, fever, and acute respiratory infections. These conditions overlap with the most important causes of death and disability in the Global Burden of Disease study. However, other high-burden conditions (e.g. hearing loss, headache disorder, low back pain, chronic liver and kidney diseases, and cancers) were rarely studied.

CONCLUSION

There were relatively few recent surveys from which to estimate representative prevalences and trends of health conditions beyond those known to be high burden. Expanding the spectrum of health conditions in cross-sectional surveys could improve understanding of evolving disease patterns in the region.

Nocturnal systolic blood pressure dipping among people living with HIV and people without HIV: a cross-sectional study in Rural Uganda

Background

In this study, we investigated sleep quality, depression and stress symptoms as hypothesized factors affecting the association between HIV status and nocturnal blood pressure dipping status in rural Uganda.

Methods

Individuals living with HIV (PLHIV) and people without HIV (PwoHIV) underwent 24-hour ambulatory blood pressure monitoring (ABPM) and classified as extreme dippers, dippers and non-dippers based on a percentage nocturnal drop in mean systolic and diastolic blood pressure. Ordinal logistic regression models were used to assess the effect of different exposure variables (HIV status, sleep quality and other covariates) on the outcome (dipping status).

Results

The median age was 45 years (IQR: 35-54) and 80% of the participants were female. 24% of PwoHIV and 16% of PLHIV were overweight, 10% of HIV negative and 3% of the HIV positive individuals were obese. Depression was prevalent in both PLHIV and PwoHIV. Additionally, poor sleep quality was more prevalent in PLHIV compared to PwoHIV (70% versus 58%, P= 0.046). The study found that 53% of participants had normal dipping, while 35.1% were non-dippers, with non-dipping being more prevalent in PwoHIV individuals (34.9% vs 29.7%, P<0.001). PLHIV had 3.6 times the odds of being extreme dippers compared to PwoHIV (OR 3.64, 95% CI: 1.40 - 9.44).

Conclusion

This study identified high proportions of non-dipping BP profiles among both PLHIV and PwoHIV. However, the odds of being extreme dippers were higher among PLHIV compared to PwoHIV. Further research is needed to understand the underlying mechanisms contributing to extreme dipping patterns in PLHIV.

Changes in the Structure of Tax Revenues of Russian Regions

The purpose of the study is to justify the use of the invariance property of the index method to study the change in the structure of tax revenues of Russian regions in the period from 2017 to 2021. The object of the study is eighty-five regions of the Russian Federation, and the subject is their financial and economic activities. Data from Rosstat and the Russian Federation’s FTS were used for the analysis. To date, the index method is actively used in the conduct of economic analysis at the macro- and meso-levels. The novelty of the study is that only the authors of the article on the basis of indices monitor the state of activity of the regions of the country, based on their tax revenues. The quantitative analysis is implemented using the statistical processing and data visualization functions of the R programming language. The intersubjective comparison was done to identify areas that require financial and economic transformation to improve the activities of the country’s regions. The comparison is made not only for one time, but also in dynamics. The results of the statistical analysis showed that the proposed tax income effectiveness index is an invariant indicator, independent of time and changes in the amount of tax income. It follows from the stationarity of the considered feature that the index values for 2017–2021 can be combined into a single homogeneous statistical aggregate. It was concluded that the index of effectiveness could be used as a grouping feature for the classification of Federation entities. The methodology developed can allow to intensify the socio-economic growth of the regions, indicating points requiring changes. In this regard, the results of the analysis can be useful to: the Ministry of Finance of the Russian Federation and the Federal Tax Service of the Russian Federation for the development of financial and tax policy; the Ministry of Economic Development and administrations of the subjects of the Russian Federation, indicating the economic zones of regions that need to be improved; to representatives of the business community when conducting economic analysis of regions.

Space-time distribution of intestinal infectious diseases and their association with socioeconomic variables in Ecuador

Background

Intestinal infectious diseases are a global concern in terms of morbidity, and they are closely linked to socioeconomic variables such as quality of life, weather and access to healthcare services. Despite progress in spatial analysis tools and geographic information systems in epidemiology, studies in Ecuador that evaluate temporal trends, specific geographic groups, and their correlation with socioeconomic variables are lacking. The absence of such information makes it challenging to formulate public health policies. This study sought to identify the spatial and temporal patterns of these diseases in Ecuador, along with their correlation with socioeconomic variables.

Methods

In Ecuador, the study was carried out in a continental territory, focusing on data related to intestinal infectious diseases collected from the National Institute of Statistics and Census (Instituto Nacional de Estadística y Censos) during the period from 2014 to 2019. This study involved spatial and temporal analyses using tools such as the global Moran's index and Local Indicators of Spatial Association to identify spatial clustering patterns and autocorrelation. Additionally, correlations between morbidity rates and socioeconomic variables were examined.

Results

During the investigated period, Ecuador registered 209,668 cases of these diseases. Notable variations in case numbers were identified, with a 9.2% increase in 2019 compared to the previous year. The most impacted group was children under 5 years old, and the highest rates were centered in the southern and southwestern regions of the country, with Limón Indanza and Chunchi being the cantons with the highest rates, notably showing a significant increase in Limón Indanza. Additionally, there were significant correlations between morbidity rates and socioeconomic variables, school dropout rates, low birth weight, and access to water services.

Conclusion

This study emphasizes the importance of considering socioeconomic variables when addressing these diseases in Ecuador. Understanding these correlations and geospatial trends can guide the development of health policies and specific intervention programs to reduce the incidence in identified high-risk areas. More specific research is needed to understand the underlying causes of variability in morbidity and develop effective prevention strategies.

Saltwater intrusion and human health risks for coastal populations under 2050 climate scenarios

Populations consuming saline drinking water are at greater risk of high blood pressure and potentially other adverse health outcomes. We modelled data and used available datasets to identify countries of higher vulnerability to future saltwater intrusion associated with climate change in 2050 under Representative Concentration Pathways (RCP)4.5 and RCP8.5. We developed three vulnerability criteria to capture geographies with: (1) any coastal areas with projected inland saltwater intrusion of ≥ 1 km inland, (2) > 50% of the population in coastal secondary administrative areas with reliance on groundwater for drinking water, and 3) high national average sodium urinary excretion (i.e., > 3 g/day). We identified 41 nations across all continents (except Antarctica) with ≥ 1 km of inland saltwater intrusion by 2050. Seven low- and middle-income countries of higher vulnerability were all concentrated in South/Southeast Asia. Based on these initial findings, future research should study geological nuances at the local level in higher-risk areas and co-produce with local communities contextually appropriate solutions to secure equitable access to clean drinking water.

Association between dietary (poly)phenol intake and the ATHLOS Healthy Ageing Scale in the Polish arm of the HAPIEE study

Inverse association between (poly)phenol intake and age-related disorders has been demonstrated; however, little is known whether they affect comprehensively assessed healthy aging. The aim of this study was to evaluate the associations between the intake of (poly)phenol (including selected classes and subclasses) and healthy aging scores related to biopsychosocial aspects of health and functioning. A cross-sectional study was performed using data on 9774 randomly selected citizens of Krakow (Poland) who were 45-69 years of age. Dietary (poly)phenol intake was evaluated using a food frequency questionnaire and matching food consumption data with the Phenol-Explorer database. The healthy aging scores were estimated from the ATHLOS Healthy Ageing Scale (HAS) developed by the Ageing Trajectories of Health-Longitudinal Opportunities and Synergies (ATHLOS) consortium. Beta coefficients were calculated using multivariable linear regression models. In multivariable adjusted models, there were significant positive associations between the ATHLOS HAS score and intake of total (poly)phenols (b per increase of 100 mg/day = 0.081; 95% CI, 0.050; 0.112) and among main classes of (poly)phenols with phenolic acids (b = 0.139; 95% CI, 0.098; 0.180). Intake of remaining classes of (poly)phenols (flavonoids, lignans, stilbenes, and others) was not related to the ATHLOS HAS score. Among individual classes studied, hydroxycinnamic acids, flavonols, flavones, and dihydrochalcones were associated with better healthy aging. The findings suggest the beneficial effect of total dietary (poly)phenol and some classes and subclasses of (poly)phenol intake in terms of healthy aging in Poland. These findings should be confirmed in other settings and with prospective data.

Examining geographical inequalities for malaria outcomes and spending on malaria in 40 malaria-endemic countries, 2010-2020

BACKGROUND

While substantial gains have been made in the fight against malaria over the past 20 years, malaria morbidity and mortality are marked by inequality. The equitable elimination of malaria within countries will be determined in part by greater spending on malaria interventions, and how those investments are allocated. This study aims to identify potential drivers of malaria outcome inequality and to demonstrate how spending through different mechanisms might lead to greater health equity.

METHODS

Using the Gini index, subnational estimates of malaria incidence and mortality rates from 2010 to 2020 were used to quantify the degree of inequality in malaria burden within countries with incidence rates above 5000 cases per 100,000 people in 2020. Estimates of Gini indices represent within-country distributions of disease burden, with high values corresponding to inequitable distributions of malaria burden within a country. Time series analyses were used to quantify associations of malaria inequality with malaria spending, controlling for country socioeconomic and population characteristics.

RESULTS

Between 2010 and 2020, varying levels of inequality in malaria burden within malaria-endemic countries was found. In 2020, values of the Gini index ranged from 0.06 to 0.73 for incidence, 0.07 to 0.73 for mortality, and 0.00 to 0.36 for case fatality. Greater total malaria spending, spending on health systems strengthening for malaria, healthcare access and quality, and national malaria incidence were associated with reductions in malaria outcomes inequality within countries. In addition, government expenditure on malaria, aggregated government and donor spending on treatment, and maternal educational attainment were also associated with changes in malaria outcome inequality among countries with the greatest malaria burden.

CONCLUSIONS

The findings from this study suggest that prioritizing health systems strengthening in malaria spending and malaria spending in general especially from governments will help to reduce inequality of the malaria burden within countries. Given heterogeneity in outcomes in countries currently fighting to control malaria, and the challenges in increasing both domestic and international funding allocated to control and eliminate malaria, the efficient targeting of limited resources is critical to attain global malaria eradication goals.

Effectiveness of the Hypertension Screening Corner in Enhancing the Cascade of Care at Primary Healthcare Center Level: Evidence from Zambezia, Mozambique

Background

Hypertension is the leading cause of cardiovascular disease, whose death burden is dramatically increasing in sub-Saharan Africa. To curb its effects, early diagnosis and effective follow-up are essential. Therefore, this study aims to evaluate the impact of a hypertension screening corner on the hypertension care cascade at the primary healthcare level.

Methods

A prospective cohort study was conducted between October 2022 and March 2023 in two PHCCs in Zambezia (Mozambique). The study involved a demographic and socioeconomic status (SES) questionnaire for those screened. Patients with blood pressure (BP) > 140/90 mmHg were given a follow-up questionnaire regarding the care cascade. The four cascade steps were: medical visit, diagnosis confirmation, follow-up visit, and recalling the follow-up appointment. The odds ratio (OR) of reaching each step of the cascade was assessed by binomial logistic regression.

Results

Patients with BP > 140/90 mmHg were 454, and 370 (86.0%) completed both study phases. Individuals attending the medical visit were 225 (60.8%). Those with low SES had a higher probability of visit attendance than those with middle (OR = 0.46, 0.95CI[0.23-0.88] p = 0.020) and high (OR = 0.21 0.95CI[0.10-0.42], p < 0.001). Hypertension diagnosis was confirmed in 181 (80.4%), with higher probability in the low SES group compared to the middle (OR = 0.24 IC95[0.08-0.66], p = 0.007) and high (OR = 0.23, IC95[0.07-0.74], p = 0.016) groups. The OR to complete step 1 and step 2 were higher for older age groups. A follow-up appointment was received and recalled by 166 (91.7%) and 162 (97.6%) patients, respectively.

Conclusions

The hypertension corner proved to be a useful tool for effective screening of hypertension with satisfactory retention in care, especially for people with lower socio-economic status.

Investigating the association between tobacco use and oral health among security guards at a tertiary healthcare centre in New Delhi: a cross-sectional study

Background

Tobacco usage is a major global public health concern, contributing to millions of deaths annually. This study focuses on security guards, an occupational group facing unique challenges, to investigate tobacco prevalence, usage patterns, and associated oral health risks.

Methods

A cross-sectional study was conducted among security guards at a Tertiary Health Care Centre, from October 2022 to February 2023. Data on demographics, tobacco habits, and comorbidities were collected via a structured questionnaire. Clinical oral examinations provisionally diagnosed Oral Potentially Malignant Disorders (OPMDs) based on clinical findings. Appropriate Statistical analyses were employed.

Results

Among 696 security guards, 40.1% used tobacco, including 15.0% smokers and 74.5% engaging in smokeless tobacco. Additionally, 10.3% reported using both smoking and smokeless forms. Non-tobacco users accounted for 59.9%. Tobacco users showed a higher prevalence of OPMDs (11.4%) compared to non-tobacco users (1.4%).

Discussion

Security guards demonstrated a higher tobacco prevalence, with smokeless tobacco being predominant. Gender disparities in tobacco use emphasize the need for gender-specific interventions. The study highlights the significant impact of tobacco on oral health, especially the risk of OPMDs.

Conclusion

A high prevalence of tobacco usage (40.1%), particularly smokeless tobacco, among security guards, emphasizes the importance of targeted interventions within this occupational group. Oral Potentially Malignant Disorders (OPMDs) were significantly more prevalent (11.4%) in tobacco users. The association between tobacco usage and OPMDs reaffirms the well-established association between tobacco and adverse oral health outcomes.

Global, regional, and national burdens of atopic dermatitis under 14: a trend analysis and future prediction based on the global burden of disease study 2019

OBJECTIVE

The aim is to evaluate the global, regional, and national trends in the burden of children and adolescents under 14 from 1990 to 2019, as well as future trend predictions.

METHODS

In Global Burden of Disease (GBD), we reported the incidence, prevalence rate and the years lived with disability (YLDs), the incidence per 100,000 people, and the average annual percentage change (AAPC). We further analyzed these global trends by age, gender, and social development index (SDI). We use joinpoint regression analysis to determine the year with the largest global trend change. Bayesian age-period-cohort (BAPC) was used for predictions.

RESULTS

From 1990 to 2019, the incidence rate, prevalence and YLDs of AD under 14 years old showed a downward trend. The incidence rate of AD among people under 5 years old has the largest decline [AAPC: -0.13 (95% CI: -0.15 to -0.11), P < 0.001]. The incidence rate, prevalence and YLDs of AD in women were higher than those in men regardless of age group. Regional, Asia has the highest AD incidence rate in 2019. National, Mongolia has the highest AD incidence rate in 2019. The largest drop in AD incidence rate, prevalence and YLDs between 1990 and 2019 was in the United States.

CONCLUSION

From 1990 to 2019, the global incidence rate of children and adolescents under 14 declined. With the emergence of therapeutic drugs, the prevalence and YLDs rate declined significantly. From 2020 to 2030, there is still a downward trend.

Dose-response risks of all-cause, cancer, and cardiovascular disease mortality according to sex-specific cigarette smoking pack-year quantiles

INTRODUCTION

This study investigated the risks for all-cause death and death from cancer or cardiovascular diseases due to smoking status and behavior, focusing on differences in smoking duration and amount stratified by sex.

METHODS

The integrated Korean Genome and Epidemiology Study provided data for 209770 individuals who were classified as never, former, or current smokers, based on their current smoking status. Pack-years were computed using daily average smoking amount and total smoking duration, and were categorized into quantiles separately for men and women. Based on the number of deaths in 2018, hazard ratios (HRs) were estimated for all-cause mortality, as well as for death caused by all cancers, lung cancer, and cardiovascular diseases according to pack-years adjusted for age, household income, marital status, body mass index, physical activity, and alcohol consumption.

RESULTS

A significant increase in the risk of all-cause mortality was observed for current smokers (men HR=1.90; 95% CI: 1.69-2.14; women HR=2.25; 95% CI: 1.68-2.99) and former smokers (men HR=1.31; 95% CI: 1.17-1.47; women HR=2.35; 95% CI: 1.63-3.39) compared with that for those who had never smoked. Among men, HR for death from lung cancer was 3.13 (95% CI: 2.06-4.75) in former smokers and tended to increase with each pack-year quantile (range HR: 5.72-17.11). Among women, the HR was estimated to be 17.20 (95% CI: 6.22-47.57) only for >3rd quantile.

CONCLUSIONS

Smoking increases the risks of all-cause death. Considering the persistent risks post-smoking cessation, it is vital to focus on preventing smoking initiation and providing proactive support for successful smoking cessation and maintenance of a smoke-free lifestyle.

A scoping review of the links between early childhood caries and clean water and sanitation: the Sustainable Development Goal 6

INTRODUCTION

The United Nation's Sustainable Development Goal (SDG) 6 calls for universal access to clean water, sanitation and hygiene (WASH), which are crucial elements of health and well-being and fundamental for a life in dignity. Early childhood caries (ECC) is a preventable disease affecting health and quality of life of millions of young children worldwide. This scoping review aims to explore the connection between ECC and access to clean water and sanitation.

METHODS

This scoping review, registered on the Open Science Framework and following PRISMA-ScR guidelines, conducted a thorough search in databases (PubMed, Web of Science, Embase, Google Scholar, SciELO) and websites (via Google) in November 2023. The search, without date limitations, targeted studies in English and Spanish linking ECC to SDG6. Exclusions were made for studies solely focusing on ECC without a direct connection to clean water and sanitation. Descriptive statistics summarized the retrieved papers.

RESULTS

The initial search yielded 303 articles. After removing duplicates, 264 articles remained for title and abstract screening after which 244 were excluded and one report was added through citation searching. The 21 remaining articles underwent full text review. There were no studies on a direct association between access to clean water and sanitation and the prevalence of ECC. There were nine studies that showed indirect associations between ECC and access to clean water and sanitation through the links of: water and sanitation access as a marker for poverty (n = 1), water consumption as a feeding practice (n = 4), and the effectiveness of water fluoridation (n = 4). These were used to develop a conceptual model.

CONCLUSIONS

While it is conceivable that a direct link exists between ECC and access to clean water and sanitation, the available body of research only offers evidence of indirect associations. The exploration of potential pathways connecting water access to ECC warrants further investigation in future research.

Knowledge, Attitudes, and Behaviors around Dietary Fats among People with Type 2 Diabetes: A Systematic Review

This systematic review assesses the knowledge, attitudes, and behaviors (KAB) surrounding dietary fat intake among people with type 2 diabetes mellitus (T2DM) and healthcare professionals. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four databases were searched to identify studies published between 1995 and 2023 reporting people with T2DM or healthcare professionals that measured KAB towards dietary fat. This work was registered at PROSPERO (CRD42020140247). Twenty-four studies were included. Studies assessed knowledge of people with T2DM and reported poor nutrition knowledge regarding the health effect of fat consumption. Two opposing attitudes towards dietary fat was reported: (1) dietary fat should be limited, (2) promoted dietary fat intake through a low-carbohydrate diet. Participants reported behaviors of limiting fat intake, including trimming visible fat or choosing lower-fat alternatives. Total fat intake ranged between 10 and 66% of participants' total energy intake, while saturated fat intake ranged between 10 and 17%. People with T2DM reported poor knowledge of dietary fats in particular, and they were frequently unable to identify high-fat food. Attitudes towards dietary fat were heterogenous, and regarding behaviors, saturated fat intake was higher than recommended. Future studies should assess the KAB of people with T2DM based on dietary fat subtypes.

Integrating mixed reality preparation into acute coronary syndrome simulation for nursing students: a single-group pretest-posttest study

BACKGROUND

Timely and effective intervention within the 'golden hour'-the critical first 90 min after the symptom onset-is crucial for initiating life-saving treatment and reducing mortality in acute coronary syndrome (ACS). This highlights the need for nursing students to be proficient in ACS care, emphasizing the importance of preparatory training. This study enhanced traditional simulation methods by integrating a mixed reality (MR) preparation step, offering a more immersive learning experience. We aimed to evaluate the effectiveness of integrating MR preparation into ACS simulation education, focusing on enhancements in knowledge, self-confidence in learning, and self-efficacy in learning. Additionally, we examined performance, practice immersion, and satisfaction to comprehensively evaluate the MR application.

METHODS

One-group pretest-posttest design was implemented in a convenience sample of thirty-nine senior nursing students from a university in South Korea in August 2022. We developed a simulation program integrating MR preparation into ACS simulation (IMRP-ACSS), which was validated through expert review for content validity. The students participated in the simulation program over six hours across two days, including a 40-minute individual session of MR-based simulation preparation using head-mounted displays (the HoloLens 2). Individual changes in knowledge, self-confidence in learning, and self-efficacy in learning evaluated by the survey were analyzed using paired t-tests. Additionally, group performance assessed using the checklist was analyzed. Immersion and satisfaction were measured with a tool and a 10-point Likert scale, respectively.

RESULTS

Individually, participants demonstrated significantly increased knowledge (t = 11.87, p < .001), self-confidence in learning (t = 7.17, p < .001), and self-efficacy in learning (t = 4.70, p < .001) post-education. Group performance yielded a mean score of 56.43/70 ± 7.45. Groups scored higher in electrocardiogram interpretation, patient safety, and heparin administration. Participants reported a practice immersion level of 37.82/50 ± 9.13 and expressed satisfaction with the program, achieving an average score of 8.85/10 ± 1.35.

CONCLUSION

Integrating MR preparation into ACS simulation enhanced nursing students' knowledge, self-confidence in learning, and self-efficacy in ACS care, providing a replicable and immersive learning experience. This method is an effective addition to nursing education, preparing students through comprehensive, technology-enhanced training.

Assessing the Impact of Non-Exhaust Emissions on the Asthmatic Airway (IONA) Protocol for a Randomised Three-Exposure Crossover Study

BACKGROUND

People living with asthma are disproportionately affected by air pollution, with increased symptoms, medication usage, hospital admissions, and the risk of death. To date, there has been a focus on exhaust emissions, but traffic-related air pollution (TRAP) can also arise from the mechanical abrasion of tyres, brakes, and road surfaces. We therefore created a study with the aim of investigating the acute impacts of non-exhaust emissions (NEEs) on the lung function and airway immune status of asthmatic adults.

METHODS

A randomised three-condition crossover panel design will expose adults with asthma using a 2.5 h intermittent cycling protocol in a random order at three locations in London, selected to provide the greatest contrast in the NEE components within TRAP. Lung function will be monitored using oscillometry, fractional exhaled nitric oxide, and spirometry (the primary outcome is the forced expiratory volume in one second). Biomarkers of inflammation and airborne metal exposure will be measured in the upper airway using nasal lavage. Symptom responses will be monitored using questionnaires. Sources of exhaust and non-exhaust concentrations will be established using source apportionment via the positive matrix factorisation of high-time resolution chemical measures conducted at the exposure sites.

DISCUSSION

Collectively, this study will provide us with valuable information on the health effects of NEE components within ambient PM2.5 and PM10, whilst establishing a biological mechanism to help contextualise current epidemiological observations.

Integrating bioinformatics and multiple machine learning to identify mitophagy-related targets for the diagnosis and treatment of diabetic foot ulcers: evidence from transcriptome analysis and drug docking

Background

Diabetic foot ulcers are the most common and serious complication of diabetes mellitus, the high morbidity, mortality, and disability of which greatly diminish the quality of life of patients and impose a heavy socioeconomic burden. Thus, it is urgent to identify potential biomarkers and targeted drugs for diabetic foot ulcers.

Methods

In this study, we downloaded datasets related to diabetic foot ulcers from gene expression omnibus. Dysregulation of mitophagy-related genes was identified by differential analysis and weighted gene co-expression network analysis. Multiple machine algorithms were utilized to identify hub mitophagy-related genes, and a novel artificial neural network model for assisting in the diagnosis of diabetic foot ulcers was constructed based on their transcriptome expression patterns. Finally, potential drugs that can target hub mitophagy-related genes were identified using the Enrichr platform and molecular docking methods.

Results

In this study, we identified 702 differentially expressed genes related to diabetic foot ulcers, and enrichment analysis showed that these genes were associated with mitochondria and energy metabolism. Subsequently, we identified hexokinase-2, small ribosomal subunit protein us3, and l-lactate dehydrogenase A chain as hub mitophagy-related genes of diabetic foot ulcers using multiple machine learning algorithms and validated their diagnostic performance in a validation cohort independent of the present study (The areas under roc curve of hexokinase-2, small ribosomal subunit protein us3, and l-lactate dehydrogenase A chain are 0.671, 0.870, and 0.739, respectively). Next, we constructed a novel artificial neural network model for the molecular diagnosis of diabetic foot ulcers, and the diagnostic performance of the training cohort and validation cohort was good, with areas under roc curve of 0.924 and 0.840, respectively. Finally, we identified retinoic acid and estradiol as promising anti-diabetic foot ulcers by targeting hexokinase-2 (-6.6 and -7.2 kcal/mol), small ribosomal subunit protein us3 (-7.5 and -8.3 kcal/mol), and l-lactate dehydrogenase A chain (-7.6 and -8.5 kcal/mol).

Conclusion

The present study identified hexokinase-2, small ribosomal subunit protein us3 and l-lactate dehydrogenase A chain, and emphasized their critical roles in the diagnosis and treatment of diabetic foot ulcers through multiple dimensions, providing promising diagnostic biomarkers and targeted drugs for diabetic foot ulcers.

Disease burden of stroke and its subtypes attributable to low dietary fiber in China, 1990-2019

This study aimed to assess the current status and changing trends of the disease burden of stroke and its subtypes due to low dietary fiber intake in China from 1990 to 2019. In cases of stroke and its subtypes attributable to low dietary fiber, deaths, disability-adjusted life-years (DALYs), age-standardized mortality rates (ASMR), age-standardized DALYs rates (ASDR), and percentage change were used to assess disease burden. Data were obtained from the 2019 global burden of disease study. Trends were assessed using Joinpoint regression and age-period-cohort analysis. Between 1990 and 2019, there was a declining trend in stroke and its subtypes, ASDR and ASMR, as well as the corresponding number of deaths and DALYs, due to low dietary fiber intake in China. Subarachnoid hemorrhage (SH) showed the greatest decrease, followed by intracerebral hemorrhage (IH) and ischemic stroke (IS). Local drift curves showed a U-shaped distribution of stroke, IS, and IH DALYs across the whole group and sex-based groups. For mortality, the overall and male trends were similar to those for DALYs, whereas female stroke, IH, and IS showed an upward trend. The DALYs for stroke and IH showed a clear bimodal distribution, IS showed an increasing risk with age. For mortality, the SH subtype showed a decreasing trend, whereas other subtypes showed an increasing risk with age. Both the period and cohort rates of stroke DALYs and motality due to low dietary fiber have declined. Males had a higher risk of DALYs and mortality associated with low fiber levels. The burden of stroke and its subtypes associated with a low-fiber diet in China has been declining over the past 30 years, with different patterns of change for different stroke subtypes and a higher burden for males, highlighting the differential impact of fiber intake on stroke and its subtypes.

How health seeking behavior develops in patients with type 2 diabetes: a qualitative study based on health belief model in China

Background

Type 2 diabetes(T2DM) is a global health problem which is accompanied with multi-systemic complications, and associated with long-term health burden and economic burden. Effective health seeking behavior (HSB) refers to reasonably utilize health resources, effectively prevent and treat diseases, and maintain health. Effective health seeking behavior (HSB) is vital to mitigate the risk of T2DM complications. However, health seeking behavior for T2DM patients remains sub-optimal worldwide.

Objective

The study aimed to explore the internal logic of how health seeking behavior of T2DM patients develops and the influencing factors of health seeking behavior. With a view to provide a reference basis for improving the health seeking behavior situation of T2DM patients.

Methods

This study was conducted at an integrated tertiary hospital in China. People who were diagnosed with T2DM, capable of expressing clearly and had no mental illness, were approached based on a purposive sampling. The experience of T2DM and health seeking behavior were collected via in-depth interviews. A theory-driven thematic analysis based on Health Belief Model (HBM) was applied for data analysis. Inductive reasoning was used to identify emerging themes which were not included in HBM.

Results

26 patients with T2DM were included in the current study. Seven themes were identified, including: (1) T2DM diagnosis and severity; (2) T2DM treatment and management; (3) Perceived susceptibility of diabetes progression; (4) Perceived severity of diabetes progression; (5) Perceived benefits of health seeking behavior; (6) Perceived barriers of health seeking behavior; (7) Perception of behavioral cues. Generally, patients with T2DM lacked reliable sources of information, considered T2DM to be slow-progressing and without posing an immediate threat to life. Consequently, they did not fully grasp the long-term risks associated with T2DM or the protective effects of health seeking behavior.

Conclusion

This study highlighted the challenges in health seeking behavior for patients with T2DM. It suggested that future interventions and strategies should involve multi-faceted approaches, targeting healthcare providers (HCPs), patients with T2DM, and their support networks. This comprehensive strategy can help patients better understand their condition and the importance of effective health seeking behavior. Ultimately, enhancing their capacity for adopting appropriate health-seeking practices.

Liquid Biopsies Based on Cell-Free DNA Integrity as a Biomarker for Cancer Diagnosis: A Meta-Analysis

Liquid biopsies have been identified as a viable source of cancer biomarkers. We aim to evaluate the diagnostic accuracy of cell-free DNA integrity (cfDI) in liquid biopsies for cancer. A comprehensive literature search was conducted through PubMed, Embase, Web of Science, and Cochrane Library up to June 2024. Seventy-two study units from forty-six studies, comprising 4286 cancer patients, were identified and evaluated. The Quality Assessment for Studies of Diagnostic Accuracy-2 (QUADAS-2) was used to assess study quality. Meta-regression analysis was employed to investigate the underlying factors contributing to heterogeneity, alongside an evaluation of publication bias. The bivariate random-effect model was utilized to compute the primary diagnostic outcomes and their corresponding 95% confidence intervals (CIs). The pooled sensitivity, specificity, and positive and negative likelihood ratios of cfDI in cancer diagnosis were 0.70 and 0.77, 3.26 and 0.34, respectively. The overall area under the curve was 0.84, with a diagnostic odds ratio of 10.63. This meta-analysis suggested that the cfDI index has a promising potential as a non-invasive and accurate diagnostic tool for cancer. Study registration: The study was registered at PROSPERO (reference No. CRD42021276290).

Health outcomes and healthcare utilization associated with four undiagnosed chronic conditions: evidence from nationally representative survey data in Sri Lanka

Background

Low awareness of chronic conditions raises the risk of poorer health outcomes and may result in healthcare utilization and spending in response to symptoms of undiagnosed conditions. Little evidence exists, particularly from lower-middle-income countries, on the health and healthcare use of undiagnosed people with an indication of a condition. This study aimed to compare health (physical, mental, and health-related quality of life (HRQoL)) and healthcare (inpatient and outpatient visits and out-of-pocket (OOP) medical spending) outcomes of undiagnosed Sri Lankans with an indication of coronary heart disease (CHD), hypertension, diabetes, and depression with the outcomes of their compatriots who were diagnosed or had no indication of these conditions.

Methods

This study used a nationally representative survey of Sri Lankan adults to identify people with an indication of CHD, hypertension, diabetes, or depression, and ascertain if they were diagnosed. Outcomes were self-reported measures of physical and mental functioning (12-Item Short Form Survey (SF-12)), HRQoL (EQ-5D-5L), inpatient and outpatient visits, and OOP spending. For each condition, we estimated the mean of each outcome for respondents with (a) no indication, (b) an indication without diagnosis, and (c) a diagnosis. We adjusted the group differences in these means for socio-demographic covariates using ordinary least squares (OLS) regression for physical and mental function, Tobit regression for HRQoL, and a generalized linear model (GLM) for healthcare visits and OOP spending.

Results

An indication of each of CHD and depression, which are typically symptomatic, was associated with a lower adjusted mean of physical (CHD -2.65, 95% CI -3.66, -1.63; depression -5.78, 95% CI -6.91, -4.64) and mental functioning (CHD -2.25, 95% CI -3.38, -1.12; depression -6.70, 95% CI -7.97, -5.43) and, for CHD, more annual outpatient visits (2.13, 95% CI 0.81, 3.44) compared with no indication of the respective condition. There were no such differences for indications of hypertension and diabetes, which are often asymptomatic.

Conclusions

Living with undiagnosed CHD and depression was associated with worse health and, for CHD, greater utilization of healthcare. Diagnosis and management of these symptomatic conditions can potentially improve health partly through substitution of effective healthcare for that which primarily responds to symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44263-024-00075-0.

Will urban scale affect health services inequity? The empirical evidence from cities in China

Background

The equity of public resources triggered by city shrinkage is a global challenge. Significantly, the impact of city shrinkage on the allocation of health service resources needs to be better understood. This study explores the impact of population change on government investment and health service delivery in shrinking cities.

Data and method

Using data from China's Urban Statistical Yearbook (2010-2020), we employ regression discontinuity (RD) and fixed-effect models to examine the causal relationship between city shrinkage and health service provision.

Result

Shrinking cities show significant disparities in health resources, particularly in bed numbers (-1,167.58, p < 0.05) and doctor availability (-538.54, p < 0.05). Economic development (p < 0.01) and financial autonomy (p < 0.01) influence hospital bed distribution. Investments in public services (primary schools and teachers, p < 0.01) affect health resource delivery. Robustness tests support our results.

Conclusion

This study reveals how city shrinkage disrupts health service provision and equity, establishing a causal relationship between city shrinkage/expansion and health resource allocation, emphasizing the imbalance caused by urban population changes. City expansion intensifies competition for health resources, while shrinking cities struggle to provide adequate resources due to government reluctance. Policymakers should adapt health resource allocation strategies to meet patient demands in changing urban landscapes.

Global burden and cross-country inequalities in stroke and subtypes attributable to diet from 1990 to 2019

DATA SOURCES

The Global Burden of Diseases, Injuries, and Risk Factors study (GBD) 2019.

BACKGROUND

To describe burden, and to explore cross-country inequalities according to socio-demographic index (SDI) for stroke and subtypes attributable to diet.

METHODS

Death and years lived with disability (YLDs) data and corresponding estimated annual percentage changes (EAPCs) were estimated by year, age, gender, location and SDI. Pearson correlation analysis was performed to evaluate the connections between age-standardized rates (ASRs) of death, YLDs, their EAPCs and SDI. We used ARIMA model to predict the trend. Slope index of inequality (SII) and relative concentration index (RCI) were utilized to quantify the distributive inequalities in the burden of stroke.

RESULTS

A total of 1.74 million deaths (56.17% male) and 5.52 million YLDs (55.27% female) attributable to diet were included in the analysis in 2019.Between 1990 and 2019, the number of global stroke deaths and YLDs related to poor diet increased by 25.96% and 74.76% while ASRs for death and YLDs decreased by 42.29% and 11.34% respectively. The disease burden generally increased with age. The trends varied among stroke subtypes, with ischemic stroke (IS) being the primary cause of YLDs and intracerebral hemorrhage (ICH) being the leading cause of death. Mortality is inversely proportional to SDI (R = -0.45, p < 0.001). In terms of YLDs, countries with different SDIs exhibited no significant difference (p = 0.15), but the SII changed from 38.35 in 1990 to 45.18 in 2019 and the RCI showed 18.27 in 1990 and 24.98 in 2019 for stroke. The highest ASRs for death and YLDs appeared in Mongolia and Vanuatu while the lowest of them appeared in Israel and Belize, respectively. High sodium diets, high red meat consumption, and low fruit diets were the top three contributors to stroke YLDs in 2019.

DISCUSSION

The burden of diet-related stroke and subtypes varied significantly concerning year, age, gender, location and SDI. Countries with higher SDIs exhibited a disproportionately greater burden of stroke and its subtypes in terms of YLDs, and these disparities were found to intensify over time. To reduce disease burden, it is critical to enforce improved dietary practices, with a special emphasis on mortality drop in lower SDI countries and incidence decline in higher SDI countries.

Age-period-cohort analysis of epidemiological trends in pelvic fracture in China from 1992 to 2021 and forecasts for 2046

Background

This study explored the epidemiological trends in pelvic fracture (PF) in China from 1992 to 2021, analyze their relationships with age-period-cohort (APC) factors, and predict the trends of PF from 2022 to 2046.

Methods

Incidence and years lived with disabilities (YLDs) of PF among sexes in China from 1992 to 2021 were obtained through the 2021 Global Burden of Disease (GBD) database. Trends in the incidence and YLDs were described, and a joinpoint regression model was used. The APC model was used to explore the effects of age, period, and cohort on the incidence and YLDs. Nordpred forecasted the incidence and YLDs in China from 2022 to 2046.

Results

In 2021, there were an estimated 0.63 million incidence cases and 0.33 million of YLDs, respectively. The number and age-standardized rate (ASR) of incidence and YLDs were both gradually increased. The average annual percent change (AAPC) in incidence and YLDs for men were 0.26% and -0.17%, respectively. For women, the AAPC values for incidence and YLDs were -0.03% and -0.57% (p < 0. 001), respectively. The relative risk (RR) of PF increases with age, with the lowest risk in those aged 10-14 years for incidence and aged 1-4 for YLDs and the highest risk in those aged >95 years for incidence and aged 90-94 years for YLDs. The period effect showed a totally increase in the risk across the general, male, and female populations. Cohort effects indicated a totally significant decline for both incidence and YLDs. The predicted incidence and YLDs of PF in China from 2022 to 2046 showed an initial rise, followed by a decline, with 2029 and 2034 being the turning point for incidence and YLDs, respectively.

Conclusion

The characteristics of pelvic fracture incidence and YLDs in China are complex. Thus, primary prevention measures must be strengthened. Raising awareness about osteoporosis prevention, enhancing public health education, and promoting good dietary and hygiene habits are appropriate preventive measures for PF in China.

Comparing priority received by global health issues: a measurement framework applied to tuberculosis, malaria, diarrhoeal diseases and dengue fever

INTRODUCTION

The relative priority received by issues in global health agendas is subjected to impressionistic claims in the absence of objective methods of assessment of priority. To build an approach for conducting structured assessments of comparative priority health issues receive, we expand the public arenas model (2021) and offer a framework for future assessments of health issue priority in global and national health agendas.

METHODS

We aimed to develop a more comprehensive set of measures for conducting multiyear priority comparisons of health issues in six agenda-setting arenas by identifying possible measures and data sources, selecting indicators based on feasibility and comparability of measures and gathering the data on selected indicators. We applied these measures to four communicable diseases-tuberculosis (TB), malaria, diarrhoeal diseases and dengue fever-given their differing impressionistic claims of priority. Where possible, we analysed the annual and/or 5-year trends from 2000 through 2022.

RESULTS

We observed that TB and malaria received the highest priority for most periods in the past two decades in most arenas. However, a stagnation in development funding for these two conditions over the last 8-10 years may have fuelled the neglect claims. Despite having a higher disease burden, diarrhoea has been slipping in global priority with reduced spending, fewer clinical trials and stagnating publications. Dengue remains a low-priority condition but has witnessed a sharp rise in attention from the pharmaceutical industry.

DISCUSSIONS

We expanded the arenas model by including a transnational arena (international representation) and additional measurements for various arenas. This analysis presents an approach to enable comparative trend analysis of the markers of agenda status over a multiyear period. More such analyses can bring much-desired objectivity in understanding how attention to global or national health issues changes over time in different arenas, potentiating a more equitable allocation of resources.

Intervention strategies for management of comorbid depression among individuals with hypertension: a scoping review protocol

INTRODUCTION

Hypertension and depression often coexisted, leading to poor health outcome and significant challenges in healthcare management. Since no guidelines or consensus are available for health professionals to manage this comorbidity, identifying interventions in current literature is crucial for gaining a clear picture of evidence and informing future research directions and clinical practice. This scoping review is designed to address this gap by systematically mapping the range of potential interventions for managing comorbid hypertension and depression.

METHODS AND ANALYSIS

Following the Joanna Briggs Institute guidelines for scoping review, this review will comprehensively search databases including PUBMED, Embase, PsycINFO, CINAHL, Cochrane Library Databases, Chinese Biomedical Literature Database and Chinese National Knowledge Infrastructure. Grey literature will be sourced from Google Scholar. A year limit of January 2004-December 2023 will be applied to retrieve the most current peer-reviewed articles in English and Chinese language only. Two reviewers will individually screen and the process will be documented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses for scoping reviews. This review will explore a range of non-pharmacological and multicomponent interventions including psychosocial support, educational programmes, telemedicine and integrated healthcare models. Data extraction will follow the Template for Intervention Description and Replication checklist to ensure detailed and standardised reporting of intervention components. The synthesis of findings will employ both quantitative and qualitative methods to provide a comprehensive overview of the intervention landscape.

ETHICS AND DISSEMINATION

This scoping review, which involves secondary data analysis of publicly available sources, does not require ethical approval. Findings will be disseminated through peer-reviewed publications and presentations at relevant conferences.

STUDY REGISTRATION

Open Science Framework registry (osf.io/j7gt8) in Centre for Open Science on 29 January 2024.

Association between exposure to smoke from cooking fuels and anaemia among women of reproductive age in Ghana

In low- and middle-income countries, indoor air pollution (IAP) is a serious public health concern, especially for women and children who cook with solid fuels. IAP exposure has been linked to a number of medical conditions, including pneumonia, ischemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lung cancer, and anaemia. Around 500 million women of reproductive age (WRA) suffer from anaemia globally, with an estimated 190 million cases in sub-Saharan Africa (SSA). This study, which is based on prior research, investigates the relationship between IAP exposure and anaemia among WRA in Ghana. A diverse sample of 2,406 WRA living in Ghana were interviewed, of which 58.06% were anaemic and used high-pollutant fuels for cooking. Age, place of residence, region, education level, religion, ethnicity, wealth index, type of drinking water, type of toilet facility, and type of cooking fuels were all found to be significantly linked with anaemic state by bivariate analysis. Type of cooking fuels utilized, age, region of residence, and the type of residence were shown to be significant predictors of anaemia status using sequential binary logit regression models. The results emphasise the critical need for efforts to promote the usage of clean cooking fuel in an attempt to lower anaemia prevalence in Ghana. To reduce dependency on solid fuels for cooking, initiatives should promote the use of cleaner cooking fuels and enhance the socioeconomic status of households. These interventions could have significant public health effects by reducing the burden of anaemia and improving maternal and child health outcomes due to the prevalence of anaemia among WRA. Overall, this study sheds light on the relationship between IAP exposure and anaemia in Ghana and highlights the demand for focused public health initiatives to address this serious health problem.

Plasma metabolomics reveals the shared and distinct metabolic disturbances associated with cardiovascular events in coronary artery disease

Risk prediction for subsequent cardiovascular events remains an unmet clinical issue in patients with coronary artery disease. We aimed to investigate prognostic metabolic biomarkers by considering both shared and distinct metabolic disturbance associated with the composite and individual cardiovascular events. Here, we conducted an untargeted metabolomics analysis for 333 incident cardiovascular events and 333 matched controls. The cardiovascular events were designated as cardiovascular death, myocardial infarction/stroke and heart failure. A total of 23 shared differential metabolites were associated with the composite of cardiovascular events. The majority were middle and long chain acylcarnitines. Distinct metabolic patterns for individual events were revealed, and glycerophospholipids alteration was specific to heart failure. Notably, the addition of metabolites to clinical markers significantly improved heart failure risk prediction. This study highlights the potential significance of plasma metabolites on tailed risk assessment of cardiovascular events, and strengthens the understanding of the heterogenic mechanisms across different events.

Age and sex differences in the effects of short- and long-term exposure to air pollution on endothelial dysfunction

BACKGROUND

The effects of air pollution on endothelial function remain unclear across populations. We aimed to use brachial artery flow-mediated dilatation (FMD) to identify demographic differences in the effects of air pollution exposure on endothelial dysfunction.

METHODS

We measured FMD in 850 participants from October 2016 to January 2020. Location-specific concentrations of fine particulate matter < 2.5 μm aerodynamic diameter (PM2.5), inhalable particulate matter < 10 μm aerodynamic diameter (PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), and ozone (O3) measured by fixed ambient air monitoring stations were collected for short- and long-term exposure assessment. Multiple linear regression models and restricted cubic splines were used to assess the associations before and after stratification by age and sex.

RESULTS

This study eventually included 828 participants [551 (66.5%) younger than 65 years and 553 (66.8%) men]. Each 10 µg/m3 increase in 7-day exposure to PM2.5 and PM10 was significantly linearly associated with a 0.07% (β = -0.07, 95% CI: -0.13 to -0.004) and 0.05% (β = -0.05, 95% CI: -0.10 to -0.004) decrease in FMD in the fully adjusted model. After full adjustment, long-term exposure to all air pollutants was significantly associated with impaired FMD. Each 10 µg/m3 increase in long-term exposure to PM2.5 and PM10 was significantly associated with a -0.18% (95% CI: -0.34 to -0.03) and - 0.23% (95% CI: -0.40 to -0.06) change in FMD, respectively. After stratification, the associations of lower FMD with long-term exposure to PM2.5, PM10, SO2, NO2, and CO significantly persisted in men and participants younger than 65 years instead of women or older participants. For short-term exposure, we observed differences consistent with long-term exposure and a stronger effect of 7-day exposure to SO2 in men due to a significant interaction effect.

CONCLUSION

Short- and long-term exposure to different air pollutants are strongly associated with decreased endothelial function, and susceptibility to air pollution varies significantly with age and sex.