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AbstractObjectiveTo study the effect of long term exposure to ambient fine particulate matter of diameter ≤2.5 μm (PM2.5) on the incidence of total, ischemic, and hemorrhagic stroke among Chinese adults.DesignPopulation based prospective cohort study.SettingPrediction for Atherosclerotic Cardiovascular Disease Risk in China (China-PAR) project carried out in 15 provinces across China.Participants117 575 Chinese men and women without stroke at baseline in the China-PAR project.Main outcome measuresIncidence of total, ischemic, and hemorrhagic stroke.ResultsThe long term average PM2.5 level from 2000 to 2015 at participants’ residential addresses was 64.9 μg/m3, ranging from 31.2 μg/m3 to 97.0 μg/m3. During 900 214 person years of follow-up, 3540 cases of incident stroke were identified, of which 63.0% (n=2230) were ischemic and 27.5% (n=973) were hemorrhagic. Compared with the first quarter of exposure to PM2.5 (<54.5 μg/m3), participants in the highest quarter (>78.2 μg/m3) had an increased risk of incident stroke (hazard ratio 1.53, 95% confidence interval 1.34 to 1.74), ischemic stroke (1.82, 1.55 to 2.14), and hemorrhagic stroke (1.50, 1.16 to 1.93). For each increase of 10 μg/m3 in PM2.5 concentration, the increased risks of incident stroke, ischemic stroke, and hemorrhagic stroke were 13% (1.13, 1.09 to 1.17), 20% (1.20, 1.15 to 1.25), and 12% (1.12, 1.05 to 1.20), respectively. Almost linear exposure-response relations between long term exposure to PM2.5 and incident stroke, overall and by its subtypes, were observed.ConclusionsThis study provides evidence from China that long term exposure to ambient PM2.5 at relatively high concentrations is positively associated with incident stroke and its major subtypes. These findings are meaningful for both environmental and health policy development related to air pollution and stroke prevention, not only in China, but also in other low and middle income countries.

Hand, foot and mouth disease (HFMD) was listed as a notifiable communicable disease in 2008 and is an emerging public health problem in China, especially for children. However, few data are available on the risk assessment of the potential reasons for HFMD in Beijing. This study examined the association of temperature with the incidence of children's HFMD in Beijing at the daily scale for the first time. A newly developed case-crossover design with a distributed lag nonlinear model (DLNM) was used to assess the delayed and cumulative associations of daily temperature with gender- and age-specific HFMD in Beijing, China, during 2010-2012. Relative humidity, day of the week, public holiday, season and long-term trends were controlled in the model. Among the total of 113,475 cases, the ratio between males and females was 1.52:1. HFMD was more prevalent in May-July. The temperature-HFMD relationships were non-linear in most age groups except for children aged 6-15 years, with a peak at 25.0~27.5°C. The high-temperature risks were greater, appeared earlier and lasted longer than the low-temperature risks. The relative risks for female children and those aged 6-15 years were higher than those among other groups. Rising temperatures increased the incidence of children's HFMD, with the largest association at 25.0~27.5°C. Females and children aged 6-15 years were more vulnerable to changes in temperature with regard to the transmission of HFMD than males and other age groups, respectively. Further studies are warranted to confirm these findings in other populations.

Background Hand-foot-mouth disease (HFMD) is a common infectious disease in China and occurs mostly in infants and children. Beijing is a densely populated megacity, in which HFMD has been increasing in the last decade. The aim of this study was to quantify spatio-temporal characteristics of HFMD and the relationship between meteorological factors and HFMD incidence in Beijing, China. Methods Daily counts of HFMD cases from January 2010 to December 2012 were obtained from the Beijing Center for Disease Prevention and Control (CDC). Seasonal trend decomposition with Loess smoothing was used to explore seasonal patterns and temporal trends of HFMD. Bayesian spatiotemporal Poisson regression models were used to quantify spatiotemporal patterns of HFMD incidence and associations with meteorological factors. Results There were 114,777 HFMD cases reported to Beijing CDC from 1 January 2010 to 31 December 2012 and the raw incidence was 568.6 per 100,000 people. May to July was the peak period of HFMD incidence each year. Low-incidence townships were clustered in central, northeast and southwest regions of Beijing. Mean temperature, relative humidity, wind velocity and sunshine hours were all positively associated with HFMD. The effect of wind velocity was significant with a RR of 3.30 (95%CI: 2.37, 4.60) per meter per second increase, as was sunshine hours with a RR of 1.20 (95%CI: 1.02, 1.40) per 1 hour increase. Conclusions The distribution of HFMD in Beijing was spatiotemporally heterogeneous, and was associated with meteorological factors. Meteorological monitoring could be incorporated into prediction and surveillance of HFMD in Beijing.

Background Few studies have used spatially resolved ambient particulate matter with an aerodynamic diameter of <10 μm (PM 10 ) to examine the impact of PM 10 on ischemic heart disease (IHD) mortality in China. The aim of our study is to evaluate the short-term effects of PM 10 concentrations on IHD mortality by means of spatiotemporal analysis approach. Methods We collected daily data on air pollution, weather conditions and IHD mortality in Beijing, China during 2008 and 2009. Ordinary kriging (OK) was used to interpolate daily PM 10 concentrations at the centroid of 287 township-level areas based on 27 monitoring sites covering the whole city. A generalized additive mixed model was used to estimate quantitatively the impact of spatially resolved PM 10 on the IHD mortality. The co-effects of the seasons, gender and age were studied in a stratified analysis. Generalized additive model was used to evaluate the effects of averaged PM 10 concentration as well. Results The averaged spatially resolved PM 10 concentration at 287 township-level areas was 120.3 ± 78.1 μg/m 3 . Ambient PM 10 concentration was associated with IHD mortality in spatiotemporal analysis and the strongest effects were identified for the 2-day average. A 10 μg/m 3 increase in PM 10 was associated with an increase of 0.33% (95% confidence intervals: 0.13%, 0.52%) in daily IHD mortality. The effect estimates using spatially resolved PM 10 were larger than that using averaged PM 10 . The seasonal stratification analysis showed that PM 10 had the statistically stronger effects on IHD mortality in summer than that in the other seasons. Males and older people demonstrated the larger response to PM 10 exposure. Conclusions Our results suggest that short-term exposure to particulate air pollution is associated with increased IHD mortality. Spatial variation should be considered for assessing the impacts of particulate air pollution on mortality.

Previous studies have reported that atmospheric elemental carbon (EC) may pose potentially elevated toxicity when compared to total ambient fine particulate matter (PM 2.5 ). However, most research on EC has been conducted in the US and Europe, whereas China experiences significantly higher EC pollution levels. Investigating the health impact of EC exposure in China presents considerable challenges due to the absence of a monitoring network to document long-term EC levels. Despite extensive studies on total PM 2.5 in China over the past decade and a significant decrease in its concentration, changes in EC levels and the associated mortality burden remain largely unknown. In our study, we employed a combination of satellite remote sensing, available ground observations, machine learning techniques, and atmospheric big data to predict ground EC concentrations across China for the period 2005–2018, achieving a spatial resolution of 10 km. Our findings reveal that the national average annual mean EC concentration has remained relatively stable since 2005, even as total PM 2.5 levels have substantially decreased. Furthermore, we calculated the all-cause non-accidental deaths attributed to long-term EC exposure in China using baseline mortality data and pooled mortality risk from a cohort study. This analysis unveiled significant regional disparities in the mortality burden resulting from long-term EC exposure in China. These variations can be attributed to varying levels of effectiveness in EC regulations across different regions. Specifically, our study highlights that these regulations have been effective in mitigating EC-related health risks in first-tier cities. However, in regions characterized by a highconcentration of coal-power plants and industrial facilities, additional efforts are necessary to control emissions. This observation underscores the importance of tailoring environmental policies and interventions to address the specific challenges posed by varying emission sources and regional contexts.

China is the most populous country globally and has made significant achievements in the control of infectious diseases over the last decades. The 2003 SARS epidemic triggered the initiation of the China Information System for Disease Control and Prevention (CISDCP). Since then, numerous studies have investigated the epidemiological features and trends of individual infectious diseases in China; however, few considered the changing spatiotemporal trends and seasonality of these infectious diseases over time. This study aims to systematically review the spatiotemporal trends and seasonal characteristics of class A and class B notifiable infectious diseases in China during 2005-2020. We extracted the incidence and mortality data of 8 types (27 diseases) of notifiable infectious diseases from the CISDCP. We used the Mann-Kendall and Sen's methods to investigate the diseases' temporal trends, Moran I statistic for their geographical distribution, and circular distribution analysis for their seasonality. Between January 2005 and December 2020, 51,028,733 incident cases and 261,851 attributable deaths were recorded. Pertussis (P=.03), dengue fever (P=.01), brucellosis (P=.001), scarlet fever (P=.02), AIDS (P<.001), syphilis (P<.001), hepatitis C (P<.001) and hepatitis E (P=.04) exhibited significant upward trends. Furthermore, measles (P<.001), bacillary and amebic dysentery (P<.001), malaria (P=.04), dengue fever (P=.006), brucellosis (P=.03), and tuberculosis (P=.003) exhibited significant seasonal patterns. We observed marked disease burden-related geographic disparities and heterogeneities. Notably, high-risk areas for various infectious diseases have remained relatively unchanged since 2005. In particular, hemorrhagic fever and brucellosis were largely concentrated in Northeast China; neonatal tetanus, typhoid and paratyphoid, Japanese encephalitis, leptospirosis, and AIDS in Southwest China; BAD in North China; schistosomiasis in Central China; anthrax, tuberculosis, and hepatitis A in Northwest China; rabies in South China; and gonorrhea in East China. However, the geographical distribution of syphilis, scarlet fever, and hepatitis E drifted from coastal to inland provinces during 2005-2020. The overall infectious disease burden in China is declining; however, hepatitis C and E, bacterial infections, and sexually transmitted infections continue to multiply, many of which have spread from coastal to inland provinces.

The unbalanced allocation of healthcare resources is a major challenge that hinders access to healthcare. Taking Shenzhen as an example, this study aimed to enhance equity in obtaining healthcare services, through measuring and visualizing the spatial accessibility of community healthcare centers (CHC), and optimizing CHC geospatial allocation. We used the number of health technicians per 10,000 to represent the CHC's service capacity, combined with resident points and census data to calculate the population the CHC needs to carry, and then analyzed the accessibility based on the Gaussian two‐step floating catchment area method. In 2020, five regions in Shenzhen had better spatial accessibility scores: Nanshan (0.250), Luohu (0.246), Futian (0.244), Dapeng (0.226), and Yantian (0.196). The spatial accessibility of CHCs shows a gradual decrease from the city center to the edge, which is affected by economic and topographic factors. With the support of the maximal covering location problem model, we selected up to 567 candidate locations for the new CHC, which could improve Shenzhen's accessibility score from 0.189 to 0.361 and increase the coverage population by 63.46% within a 15‐min impedance. By introducing spatial techniques and maps, this study provides (a) new evidence for promoting equitable access to primary healthcare services in Shenzhen and (b) a foundation for improving the accessibility of public service facilities in other areas. Plain Language Summary This study aimed to enhance equity in obtaining primary healthcare services for residents. Taking Shenzhen, China as an example, measuring and visualizing the spatial accessibility of community healthcare centers, and optimizing its geospatial allocation to reduce the barriers for residents to healthcare institutions. Key Points The problem of unbalanced allocation of primary healthcare resources is gradually emerging Shenzhen residents have unequal access to primary healthcare within 15‐min Economic and topographic factors affect the inequity of access to primary healthcare in Shenzhen

Evidence on the association between osteoporosis and dementia is not fully clear. This study aimed to investigate the potential association between osteoporosis and the subsequent risk of dementia among older adults. We performed a cohort study of 176 150 community-dwelling older adults aged ≥65 years and free of cognitive impairment between 2018 and 2022 using integrated healthcare data from Shenzhen, China. Diagnoses of osteoporosis, osteoporotic fractures, and dementia were identified through linked outpatient and inpatient medical records and death registration records. Multivariate Cox proportional hazards models were used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of incident dementia associated with osteoporosis and osteoporotic fractures. The mean (SD) age of the total study population was 70.7 (5.4) years, and 9 605 had a previous diagnosis of osteoporosis. Over a median follow-up of 2.2 (IQR: 1.8-4.3, maximum: 5.5) years, corresponding to 505 423 person-years at risk, 1 367 incident all-cause dementia cases, including 617 Alzheimer's disease and 298 vascular dementia cases, occurred. Physician-diagnosed osteoporosis was associated with a higher risk of all-cause dementia (HR: 1.80, 95% CI: 1.53-2.12). The increased dementia risk tended to be more prominent among patients with osteoporotic fractures (HR: 2.43, 95% CI: 1.83-3.23) than those without (HR: 1.63, 95% CI: 1.35-1.97). Results were similar for Alzheimer's disease and vascular dementia. This study provides evidence that older adults with osteoporosis, especially those with osteoporotic fractures, have an elevated risk of incident dementia. Effective prevention and management of osteoporosis among the older population may be promising to mitigate the dual burden of osteoporosis and dementia.

Prehypertension and hypertension often coexist with non-alcoholic fatty liver disease (NAFLD) during the progression of cardiovascular disease (CVD). International academic liver societies have recently reached a consensus to replace NAFLD with the new term 'steatotic liver disease' (SLD). In this study, we aimed to evaluate the impact of different SLD subtypes on all-cause and CVD mortality in individuals with prehypertension or hypertension. We included 6074 adults from the National Health and Nutrition Examination Survey (2003-18). The US fatty liver index was used as the diagnostic criterion for SLD, and participants were classified into no SLD, metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction-associated and alcohol-related liver disease (MetALD), and alcohol-related liver disease (ALD). For cases of MASLD, MetALD, and ALD, we further assessed advanced fibrosis using the fibrosis-4 (FIB-4) index. Additionally, we calculated hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression models to assess the associations of SLD subtypes and advanced fibrosis with all-cause and CVD mortality. There were 3505 (57.7%) participants with no SLD, 1284 (21.1%) with MASLD, 777 (12.8%) with MetALD, and 508 (8.4%) with ALD. During a median follow-up period of 8.2 years, the risk of all-cause and CVD mortality progressively increased in participants with MASLD (HR = 1.28; 95% CI = 1.01-1.63 and HR = 1.55; 95% CI = 1.04-2.33, respectively), MetALD (HR = 1.41; 95% CI = 1.05-1.88 and HR = 1.78; 95% CI = 1.10-2.87, respectively), and ALD (HR = 1.83; 95% CI = 1.32-2.53 and HR = 1.80; 95% CI = 1.01-3.19, respectively). Among the individuals with MASLD, MetALD, and ALD, advanced fibrosis was also associated with an increased risk of all-cause and CVD mortality. Individuals with MASLD, MetALD, and ALD had a higher risk of all-cause and CVD mortality than those without SLD. Therefore, early intervention strategies targeting SLD prevention and management may help individuals with prehypertension and hypertension to improve their long-term health.

Background Glucagon‐like peptide‐1 receptor agonists (GLP‐1 RAs), a class of injectable antidiabetic drugs, have shown significant efficacies in improving glycemic and weight control in patients with type 2 diabetes (T2D). However, the long‐term safety of GLP‐1 RAs remains insufficiently studied. This study aimed to provide real‐world evidence on potential adverse outcomes associated with GLP‐1 RAs use in T2D patients without major chronic diseases including impaired cardiac or renal function. Methods We conducted a retrospective cohort study involving 7746 T2D patients on GLP‐1 RAs in Shenzhen, China. They were compared with 124 371 metformin‐only users and 36 146 insulin‐only users, forming two therapy control groups. GLP‐1 RAs users were also further 1:2 paired with the control groups. Competing risk survival analyses were conducted to assess the incidence risks, presenting subdistributional hazard ratios (sHRs) with 95% confidence intervals (CIs) for various adverse outcomes associated with GLP‐1 RAs use. Results Compared with metformin‐only users, GLP‐1 RAs use was associated with increased risks of various adverse outcomes (sHRs with 95% CIs), including pancreatitis (2.01, 1.24–3.24), acute nephritis (3.20, 2.17–4.70), kidney failure (3.73, 2.74–5.08), thyroid cancer (2.25, 1.23–4.10), and thyroid dysfunction (1.27, 1.00–1.63), respectively; Similar results were also found when compared with insulin‐only users. Importantly, long‐term (≥12 months) GLP‐1 RAs use may further elevate the incidence risks of pancreatitis, acute nephritis, thyroid cancer, and thyroid dysfunction. Conclusion Compared with traditional T2D treatments, GLP‐1 RAs use may be associated with increased risks of various adverse outcomes in a Chinese population. Cautions were strongly warranted in the use of GLP‐1 RAs. Further validation is crucial across diverse populations. Highlights GLP‐1 RAs may increase the incidence risks of various adverse outcomes. Prolonged use (over 12 months) of GLP‐1 RAs may further elevate these risks. Cautions were strongly recommended in clinical practice with risk–benefit balance, particularly for risks of pancreatitis, acute nephritis, kidney failure, thyroid cancer/dysfunction.