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Unexplained mortality during the US COVID-19 pandemic: retrospective analysis of death certificate data and critical assessment of excess death calculations

Por: Fairman · K. A. · Goodlet · K. J. · Rucker · J. D. · Zawadzki · R. S.
Objectives

Cause-of-death discrepancies are common in respiratory illness-related mortality. A standard epidemiological metric, excess all-cause death, is unaffected by these discrepancies but provides no actionable policy information when increased all-cause mortality is unexplained by reported specific causes. To assess the contribution of unexplained mortality to the excess death metric, we parsed excess deaths in the COVID-19 pandemic into changes in explained versus unexplained (unreported or unspecified) causes.

Design

Retrospective repeated cross-sectional analysis, US death certificate data for six influenza seasons beginning October 2014, comparing population-adjusted historical benchmarks from the previous two, three and five seasons with 2019–2020.

Setting

48 of 50 states with complete data.

Participants

16.3 million deaths in 312 weeks, reported in categories—all causes, top eight natural causes and respiratory causes including COVID-19.

Outcome measures

Change in population-adjusted counts of deaths from seasonal benchmarks to 2019–2020, from all causes (ie, total excess deaths) and from explained versus unexplained causes, reported for the season overall and for time periods defined a priori: pandemic awareness (19 January through 28 March); initial pandemic peak (29 March through 30 May) and pandemic post-peak (31 May through 26 September).

Results

Depending on seasonal benchmark, 287 957–306 267 excess deaths occurred through September 2020: 179 903 (58.7%–62.5%) attributed to COVID-19; 44 022–49 311 (15.2%–16.1%) to other reported causes; 64 032–77 054 (22.2%–25.2%) unexplained (unspecified or unreported cause). Unexplained deaths constituted 65.2%–72.5% of excess deaths from 19 January to 28 March and 14.1%–16.1% from 29 March through 30 May.

Conclusions

Unexplained mortality contributed substantially to US pandemic period excess deaths. Onset of unexplained mortality in February 2020 coincided with previously reported increases in psychotropic use, suggesting possible psychiatric or injurious causes. Because underlying causes of unexplained deaths may vary by group or region, results suggest excess death calculations provide limited actionable information, supporting previous calls for improved cause-of-death data to support evidence-based policy.

Characteristics of low-tier female sex workers who engage in commercial sex with old male clients in Zhejiang province, China: a cross-sectional study

Por: Jiang · T. · Pan · X. · Ma · Q. · Jiang · J. · Chen · L. · Wang · H. · Zhou · X. · Chen · W.
Objectives

To characterise low-tier female sex workers (FSWs) who engage in commercial sex with old male clients (OMCs).

Design

Cross-sectional study.

Setting

Twenty-one counties in Zhejiang province, China.

Participants

A total of 2647 low-tier FSWs who participated in our survey from September to November 2013, and responded to the question regarding whether they engaged in commercial sex with OMCs during the previous month.

Main outcome measures

Data on sociodemographic characteristics, sexual behaviours, risk perception of HIV/sexually transmitted infection (STI), ever exposure to an HIV prevention service and degree of self-efficacy regarding condom use were collected via a face-to-face questionnaire administered by trained interviewers.

Results

Of the 2647 participants, 1165 (44.0%) had engaged in commercial sex with OMCs in the previous month. Low-tier FSWs working out of roadside shops, those who had engaged in sex work for longer, those with a larger number of clients, those who had engaged in anal or oral sex during the previous month, those currently using contraception measures, those who had STI symptoms and those who had been exposed to HIV prevention services during the previous 6 months were more likely to engage in commercial sex with OMCs. FSWs with a high level of education; those working out of small venues other than streets, hair salons and roadside shops; those who charged more for commercial sex; those who had sex with young clients during the previous month and those who had seen a doctor during the previous 6 months were less likely to engage in commercial sex with OMCs.

Conclusions

Low-tier FSWs who engaged in commercial sex with OMCs reported more risky behaviours than those who did not engage in this behaviour. Attention should be paid to these behaviours in future interventions targeting low-tier FSWs.

Hospital management of major stroke types in Chinese adults: a population-based study of 20 000 hospitalised stroke cases

Por: Qin · H. · Turnbull · I. · Chen · Y. · Wright · N. · Liu · L. · Pei · P. · Tang · W. · Xiang · S. · Guo · Y. · Zhao · X. · Clarke · R. · Li · L. · Wang · Y. · Chen · Z. · On behalf of The China Kadoorie Biobank Collaborative Group
Objectives

To compare hospital treatments for major stroke types in Chinese adults by stroke pathological types, sex, age, calendar year, hospital tier, region and other factors.

Design

Cross-sectional analysis of medical records retrieved from 20 229 stroke cases in the China Kadoorie Biobank.

Setting

Ten diverse areas (five urban, five rural) in China.

Participants

First-incident stroke cases who were recruited during an 11-year follow-up of 0.5M participants in the China Kadoorie Biobank.

Methods

Electronic copies of medical records of stroke cases were retrieved for clinical adjudication by local neurologists. Stroke cases were classified as ischaemic stroke (IS) (including lacunar infarction (LACI) and non-LACI (non-LACI)), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH) and unspecified stroke types.

Results

Among 20 299 first-ever stroke cases, 17 306 (85%) had IS, 7123 had non-LACI, 6690 had LACI, 3493 had silent LACI, 2623 (13%) had ICH and 370 (2%) had SAH. Among IS cases, antiplatelet treatment was used by 64% (65% non-LACI, 66% LACI, 56% silent LACI), lipid-lowering by 50% (52% non-LACI, 53% LACI, 43% silent LACI) and blood pressure-lowering by ~42% of all IS types, with positive trends in the use of these treatments by calendar year and hospital tier. Among ICH cases, 53% used blood pressure-lowering and 10% used lipid-lowering treatments, respectively. In contrast, traditional Chinese medicines (TCMs) were used by 59% of IS (50% non-LACI, 62% LACI, 74% silent LACI), 38% of ICH and 30% of SAH cases, with positive trends by calendar year and by hospital tier.

Conclusions

Among IS cases, use of antiplatelet and lipid-lowering medications increased in recent years, but use of TCM still exceeded use of blood pressure-lowering treatment. In contrast, blood pressure-lowering treatment was widely used for ICH, but only half of all ICH cases used blood pressure-lowering treatment.

Social and life skills in adolescents who have self-harmed: analysis of survey responses from a national sample of adolescents in Norway

Por: Fadum · E. A. · Carlsen · E. O. · Ramberg · M. · Strand · L. A. · Haberg · S. E. · Borud · E. · Martinussen · M.
Objective

Social and life skills (SLS) may be important in the prevention and treatment of self-harm, but few studies have described this relationship. We examined three components of SLS in adolescents who reported self-harm that was, according to themselves, diagnosed by a clinician.

Design

Cross-sectional.

Setting

National screening prior to military service.

Participants

176 284 residents of Norway born in 1999–2001 received a declaration of health. We included 171 486 individuals (84 153 (49%) women and 87 333 (51%) men) who were 17 (n=1 67 855) or 18 years of age (n=3631) when they completed the declaration.

Outcome measure

The main outcome was clinically diagnosed self-harm, defined as self-harm that the adolescents themselves stated had been diagnosed by a clinician. Components of SLS were social interactions; coping strategies; and emotional regulation/aggression. The association between SLS and self-reported clinically diagnosed self-harm was assessed in hierarchical multiple regression models controlling for sex; school absence; and feelings of emotional pain.

Results

Three percent (n=5507) of the adolescents reported clinically diagnosed self-harm. The three components of SLS together added little to the prediction of clinically diagnosed self-harm (R2=0.02). After controlling for school absence and emotional pain, emotional regulation/aggression was the only SLS-component that was independently associated with clinically diagnosed self-harm (OR 1.33, 95% CI 1.31 to 1.36). The young men who said they had been clinically diagnosed for self-harm scored slightly worse on social interactions (Hedge’s g (g) = –0.13, pg = –0.18, p

Conclusion

Young women and young men who reported clinically diagnosed self-harm had more problems with emotional regulation/aggression than other adolescents, but did not have worse social interactions or coping strategies.

Pregnancy anaemia, child health and development: a cohort study in rural India

Por: Heesemann · E. · Mähler · C. · Subramanyam · M. A. · Vollmer · S.
Objective

To assess how pregnancy anaemia affects the offspring’s early childhood development, child haemoglobin (Hb) levels child growth and diseases incidence 2 years after birth in a low-income setting. Furthermore, we investigate the mediating role of childhood Hb levels with disease incidences and skills.

Design

Prospective cohort study.

Setting and participants

The study participants are 941-999 mother–child dyads from rural Madhepura in Bihar, India. In 2015, the women were recruited during pregnancy from registers in mother–child centres of 140 villages for the first wave of data collection. At the time of the second wave in 2017, the children were 22–32 months old.

Primary and secondary outcome measures

The recruited women were visited at home for a household survey and the measurement of the women’s and child’s Hb level, child weight and height. Data on the incidence of diarrhoea and respiratory diseases or fever were collected from interviews with the mothers. To test motor, cognitive, language and socioemotional skills of the children, we used an adapted version of the child development assessment FREDI.

Results

The average Hb during pregnancy was 10.2 g/dL and 69% of the women had pregnancy anaemia. At the age of 22–32 months, a 1 g/dL increase in Hb during pregnancy was associated with a 0.17 g/dL (95% CI: 0.11 to 0.23) increase in Hb levels of the child. Children of moderately or severely anaemic women during pregnancy showed 0.57 g/dL (95% CI: –0.78 to –0.36) lower Hb than children of non-anaemic women. We find no association between the maternal Hb during pregnancy and early skills, stunting, wasting, underweight or disease incidence. While childhood anaemia does not correlate with childhood diseases, we find an association of a 1 g/dl increase in the child's Hb with 0.04 SDs higher test scores.

Conclusions

While pregnancy anaemia is a risk factor for anaemia during childhood, we do not find evidence for an increased risk of infectious diseases or early childhood development delays.

Prevalence and factors contributing to dental caries in 12-15-year-old school adolescents in northeast China

Por: Li · J. · Zhang · K. · Lu · Z.
Objectives

The present study investigated the prevalence and factors contributing to dental caries in 12–15-year-old adolescents in northeast China to provide information for dental caries promotion programmes.

Design, setting and participants

A cross-sectional survey including caries examination and questionnaire was performed in Liaoning province, China. 3731 12–15-year-old school adolescents participated in the survey. School adolescents were randomly selected and received a clinical oral examination and completed questionnaires that assessed their oral health-related behaviours and attitudes.

Results

Overall, 3731 12–15-year-old school adolescents participated in the survey. The prevalence of dental caries in these adolescents was 53.65%, and the mean number of decayed–missing–filled teeth (DMFT) in the adolescents was 1.64±2.38 in northeast China, which was higher than the mean in China as a whole. A remarkable difference in DMFTwas exhibited between age groups, region and gender (p

Conclusion

The 12–15-year-old school adolescents assessed exhibited a high prevalence of dental caries and low awareness of oral health. It is critical to protect permanent teeth, and oral and dental health education and promotion should be more comprehensively integrated into school courses for these adolescents.

Social inequalities and dynamics of the early COVID-19 epidemic: a prospective cohort study in France

Por: Bajos · N. · Counil · E. · Franck · J.-e. · Jusot · F. · Pailhe · A. · Spire · A. · Martin · C. · Lydie · N. · Slama · R. · Meyer · L. · Warszawski · J. · for the EpiCoV study group · Bajos · Warszawski · Bagein · Barlet · Beck · Counil · FlorenceJusot · Lydie · Martin · Meyer · Pailhe
Objective

Although social inequalities in COVID-19 mortality by race, gender and socioeconomic status are well documented, less is known about social disparities in infection rates and their shift over time. We aim to study the evolution of social disparities in infection at the early stage of the epidemic in France with regard to the policies implemented.

Design

Random population-based prospective cohort.

Setting

From May to June 2020 in France.

Participants

Adults included in the Epidémiologie et Conditions de Vie cohort (n=77 588).

Main outcome measures

Self-reported anosmia and/or ageusia in three categories: no symptom, during the first epidemic peak (in March 2020) or thereafter (during lockdown).

Results

In all, 2052 participants (1.53%) reported anosmia/ageusia. The social distribution of exposure factors (density of place of residence, overcrowded housing and working outside the home) was described. Multinomial regressions were used to identify changes in social variables (gender, class and race) associated with symptoms of anosmia/ageusia. Women were more likely to report symptoms during the peak and after. Racialised minorities accumulated more exposure risk factors than the mainstream population and were at higher risk of anosmia/ageusia during the peak and after. By contrast, senior executive professionals were the least exposed to the virus with the lower rate of working outside the home during lockdown. They were more affected than lower social classes at the peak of the epidemic, but this effect disappeared after the peak.

Conclusion

The shift in the social profile of the epidemic was related to a shift in exposure factors under the implementation of a stringent stay-at-home order. Our study shows the importance to consider in a dynamic way the gender, socioeconomic and race direct and indirect effects of the COVID-19 pandemic, notably to implement policies that do not widen health inequalities.

Is sarcopenia associated with anxiety symptoms and disorders? A systematic review and meta-analysis protocol

Por: West · E. C. · Williams · L. J. · Corney · K. B. · Pasco · J. A.
Introduction

Sarcopenia is a skeletal muscle disorder characterised by a progressive decline in muscle mass and function (strength and performance). Sarcopenia is associated with numerous adverse health outcomes and has recently been linked to neurological and psychiatric disorders, including dementia and depression. Whether sarcopenia is related to other common psychiatric illnesses, such as anxiety, is unclear. We aim to systematically identify and review the extant literature regarding the association between sarcopenia and anxiety symptomatology and/or disorders (anxiety) in adults.

Methods and analysis

We will conduct a systematic search across four online databases (CINAHL, Embase, MEDLINE Complete and PsycINFO) from inception to September 2021. Two reviewers will independently confirm study selection and assess methodological quality of included studies. If possible, a meta-analysis will be performed to determine pooled OR for the relationship between sarcopenia and anxiety. If meta-analysis is not possible due to methodological heterogeneity a ‘best evidence synthesis’ will be performed.

Ethics and dissemination

This review will use published data only, thus, ethical approval will not be required. Findings will be published in a peer-reviewed journal and presented at conferences.

PROSPERO registration number

CRD42020209420.

Using hierarchical clustering analysis to evaluate COVID-19 pandemic preparedness and performance in 180 countries in 2020

Por: Sadeghi · B. · Cheung · R. C. Y. · Hanbury · M.
Objective

To rank and score 180 countries according to COVID-19 cases and fatality in 2020 and compare the results to existing pandemic vulnerability prediction models and results generated by standard epidemiological scoring techniques.

Setting

One hundred and eighty countries’ patients with COVID-19 and fatality data representing the healthcare system preparedness and performance in combating the pandemic in 2020.

Design

Using the retrospective daily COVID-19 data in 2020 broken into 24 half-month periods, we applied unsupervised machine learning techniques, in particular, hierarchical clustering analysis to cluster countries into five groups within each period according to their cumulative COVID-19 fatality per day over the year and cumulative COVID-19 cases per million population per day over the half-month period. We used the average of the period scores to assign countries’ final scores for each measure.

Primary outcome

The primary outcomes are the COVID-19 cases and fatality grades in 2020.

Results

The United Arab Emirates and the USA with F in COVID-19 cases, achieved A or B in the fatality scores. Belgium and Sweden ranked F in both scores. Although no African country ranked F for COVID-19 cases, several African countries such as Gambia and Liberia had F for fatality scores. More developing countries ranked D and F in fatality than in COVID-19 case rankings. The classic epidemiological measures such as averages and rates have a relatively good correlation with our methodology, but past predictions failed to forecast the COVID-19 countries’ preparedness.

Conclusion

COVID-19 fatality can be a good proxy for countries’ resources and system’s resilience in managing the pandemic. These findings suggest that countries’ economic and sociopolitical factors may behave in a more complex way as were believed. To explore these complex epidemiological associations, models can benefit enormously by taking advantage of methods developed in computer science and machine learning.

Malnutrition and contributing factors among newborns delivered at the University of Gondar Hospital, Northwest Ethiopia: a cross-sectional study

Por: Gonete · A. T. · Alemu · T. G. · Mekonnen · E. G. · Takele · W. W.
Objectives

To estimate the prevalence of various indicators of malnutrition (stunting, wasting, low birth weight, concurrent stunting and wasting, overweight/obesity and double burden malnutrition) among newborns and to investigate factors associated with these nutritional disorders.

Methods

A hospital-based cross-sectional study was conducted from 10 March through to May 2020. A total of 419 newborns were recruited into the study to estimate the prevalence of low birth weight and stunting. After excluding 28 newborns whose length was less than 45 cm, 394 newborn–mother dyads were approached to estimate wasting and overweight/obesity. A systematic random sampling technique was used to select participants. All independent variables were entered into the multivariable logistic regression model and variables that had significant associations were identified based on a p value.

Results

A very small proportion of the newborns 2.5% (0.9% to 4.1%) were concurrently wasted and stunted. The prevalence rates of low birth weight and wasting were 20.8% (16.8% to 24.6%) and 10.9% (7.82% to 14.01%), respectively. The magnitude of overweight/obesity was 12.7% (9.3% to 15.9%) where 2.8% (1.1% to 4.4%) of newborns have the double burden of malnutrition. Having a father with a primary level of education 2.82 (1.19 to 6.65) and being stunted at birth 3.17 (1.6 to 6.0) were variables that were associated with increased odds of low birth weight. The odds of being overweight/obese are significantly higher among newborns born to mothers who are urban dwellers 0.35 (0.12 to 0.99).

Conclusions

The study underscores that malnutrition is a pressing public health concern that demands due emphasis. Fathers’ educational status (low level) and being stunted are associated with a high burden of low birth weight. Mothers’ residency (being urban) is associated with an elevated risk of overweight/obesity among newborns. Thus, improving the health literacy of fathers and preventing stunting at birth are recommended to mitigate low birth weight.

Secondary attack rate of COVID-19 among contacts and risk factors, Tamil Nadu, March-May 2020: a retrospective cohort study

Por: Karumanagoundar · K. · Raju · M. · Ponnaiah · M. · Kaur · P. · viswanathan · V. · Rubeshkumar · P. · Sakthivel · M. · Shanmugiah · P. · Ganeshkumar · P. · Muthusamy · S. K. · Sendhilkumar · M. · Venkatasamy · V. · Sambath · I. · Ilangovan · K. · Murugesan · J. · Govindarajan · R. · Sha
Objective

To describe the characteristics of contacts of patients with COVID-19 case in terms of time, place and person, to calculate the secondary attack rate (SAR) and factors associated with COVID-19 infection among contacts.

Design

A retrospective cohort study

Setting and participants

Contacts of cases identified by the health department from 14 March 2020to 30 May 2020, in 9 of 38 administrative districts of Tamil Nadu. Significant proportion of cases attended a religious congregation.

Outcome measure

Attack rate among the contacts and factors associated with COVID-19 positivity.

Results

We listed 15 702 contacts of 931 primary cases. Of the contacts, 89% (n: 14 002) were tested for COVID-19. The overall SAR was 4% (599/14 002), with higher among the household contacts (13%) than the community contacts (1%). SAR among the contacts of primary cases with congregation exposure were 5 times higher than the contacts of non-congregation primary cases (10% vs 2%). Being a household contact of a primary case with congregation exposure had a fourfold increased risk of getting COVID-19 (relative risk (RR): 16.4; 95% CI: 13 to 20) than contact of primary case without congregation exposure. Among the symptomatic primary cases, household contacts of congregation primaries had higher RR than household contacts of other cases ((RR: 25.3; 95% CI: 10.2 to 63) vs (RR: 14.6; 95% CI: 5.7 to 37.7)). Among asymptomatic primary case, RR was increased among household contacts (RR: 16.5; 95% CI: 13.2 to 20.7) of congregation primaries compared with others.

Conclusion

Our study showed an increase in disease transmission among household contacts than community contacts. Also, symptomatic primary cases and primary cases with exposure to the congregation had more secondary cases than others.

Prevalence, incidence, and risk factors for myopia among urban and rural children in southern China: protocol for a school-based cohort study

Por: Chen · X. · Ye · G. · Zhong · Y. · Jin · L. · Liang · X. · Zeng · Y. · Zheng · Y. · lan · M. · Liu · Y.
Introduction

Myopia is the common cause of reduced uncorrected visual acuity among school-age children. It is more prevalent in urban than in rural areas. Although many myopia studies have focused on the effect of urbanisation, it remains unclear how visual experience in urban regions could affect childhood myopia. This study aims to investigate the incidence and prevalence of myopia among school-age children in urban and rural settings, thereby identifying the environmental factors that affect the onset and progression of myopia.

Methods and analysis

A school-based cohort study will be conducted. We will enroll all first-grade students from an urban (10 primary schools) and a rural (10 primary schools) regions of Zhaoqing city, China. Over 3-year follow-up period, students will receive detailed eye examinations annually and complete questionnaires about living habits and environment. In a 5% random subsample of the cohort, physical activity, light intensity and eye-tracking data will be obtained using wearable devices, and high-resolution macular images will be obtained by optical coherence tomography (OCT). The primary outcome is incident myopia, defined as myopia (spherical equivalent refractive of at least –0.5D) detected during follow-up among those without myopia at baseline.

Ethics and dissemination

Ethics approval was obtained from the ethics committee of the Zhongshan Ophthalmic Center (number: 2019KYPJ171). Study findings will be published in a peer-reviewed journal.

Trial registration number

NCT04219228.

Risk of infection and contribution to transmission of SARS-CoV-2 in school staff: a systematic review

Por: Karki · S. J. · Joachim · A. · Heinsohn · T. · Lange · B.
Objective

To summarise the comparative risk of infection in school staff and their contribution to SARS-CoV-2 transmission.

Design

Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

Data sources

MEDLINE, WHO COVID-19 database and preView were searched on 29 January 2021.

Eligibility criteria

We included studies that reported risk of SARS-CoV-2 infection in school staff or transmission of SARS-CoV-2 in school settings.

Data extraction and synthesis

Data extraction was done in duplicates. Data synthesis was qualitative. We report attack rates and infection risk in school settings for staff and students stratified by control measures taken and infection dynamics at the point of data collection.

Results

Eighteen studies were included. Three studies in low incidence settings showed low attack rates similar for teachers and students. Five studies in medium incidence settings and two studies in high incidence settings showed secondary attack rates up to 16% in school staff.

Seroprevalence studies, two in each low and high incidence settings showed an infection risk of 0%–0.2% and 1.7%–28% for teachers.

The risk of infection for teachers compared with students were similar in one study in low incidence setting, higher in three studies (RR 1.2–4.4) and lower in three studies in medium to high incidence settings. The risk of infection for teachers in a high infection environment is higher in face-to-face than in distance classes when compared with general population groups. The risk of infections as well as risk of hospitalisation both increased for teachers during school openings compared with school closure.

Conclusion

While in low incidence settings there is little evidence for school staff to be at high risk of SARS-CoV-2 infection, in high incidence settings there is an increased risk of SARS-CoV-2 infection in school staff teaching face-to-face compared to staff teaching digitally and general population.

PROSPERO registration number

CRD42021239225.

Associations between maternal characteristics and pharmaceutical treatment of gestational diabetes: an analysis of the UK Born in Bradford (BiB) cohort study

Por: Martine-Edith · G. · Johnson · W. · Hunsicker · E. · Hamer · M. · Petherick · E. S.
Objectives

To identify the maternal characteristics associated with pharmaceutical treatment of gestational diabetes mellitus (GDM).

Design

Prospective birth cohort study.

Setting

Bradford, UK.

Participants

762 women from the Born in Bradford (BiB) cohort who were treated for GDM in a singleton pregnancy. BiB cohort participants were recruited from 2007 to 2010. All women booked for delivery were screened for GDM between 26 and 28 weeks of gestation using a 75 g 2-hour oral glucose tolerance test (OGTT).

Outcome measure

GDM treatment type: lifestyle changes advice (lifestyle changes), lifestyle changes advice with supplementary insulin (insulin) and lifestyle changes advice with supplementary metformin (metformin).

Results

244 (32%) women were prescribed lifestyle changes advice alone while 518 (68%) were offered supplemental pharmaceutical treatment. The odds of receiving pharmaceutical treatment relative to lifestyle changes advice alone were increased for mothers who were obese (OR 4.6, 95% CI 2.8 to 7.5), those who smoked (OR 2.6, 95% CI 1.2 to 5.5) and had higher fasting glucose levels at OGTT (OR 2.1, 95% CI 1.6 to 2.7). The odds of being prescribed pharmaceutical treatment rather than lifestyle changes advice were lower for Pakistani women (OR 0.7, 95% CI 0.4 to 1.0)) than White British women. Relative to insulin treatment, metformin was more likely to be offered to obese women than normal weight women (relative risk ratio, RRR 3.2, 95% CI 1.3 to 7.8) and less likely to be prescribed to women with higher fasting glucose concentrations at OGTT (RRR 0.3, 95% CI 0.2 to 0.6).

Conclusions

In the BiB cohort, GDM pharmaceutical treatment tended to be prescribed to women who were obese, White British, who smoked and had more severe hyperglycaemia. The characteristics of metformin-treated mothers differed from those of insulin-treated mothers as they were more likely to be obese but had lower glucose concentrations at diagnosis.

Weight change, cardio-metabolic risk factors and cardiovascular incidence in people with serious mental illness: protocol of a population-based cohort study in the UK from 1998 to 2020

Por: Lee · C. · Waite · F. · Smith · M. C. · Gao · M. · Bankhead · C. · Aveyard · P. · Piernas · C.
Introduction

People with serious mental illness (SMI), which includes people with diagnoses of schizophrenia spectrum and bipolar disorders, face significant health inequality. This includes a life expectancy reduced by 15–20 years mostly due to premature cardiovascular disease (CVD) compared with the general population. Excess weight gain and related comorbidities are preventable risk factors for CVD. To improve the understanding and management of CVD in people with SMI, we will examine the association between SMI and: (1) weight change; (2) cardio-metabolic risk factors for CVD; and (3) incidence of and mortality from CVD. We will also (4) examine the incidence of referral to weight management services for people with SMI compared with people without SMI.

Methods and analysis

In this retrospective cohort study, we will link general practice records from the UK Clinical Practice Research Datalink Aurum database. We will establish a cohort of patients diagnosed with SMI between 1998 and 2020 who are matched with up to four controls on age, sex, general practice and calendar year. We will use multivariable mixed-effects linear regression models and Cox proportional hazard models with sequential adjustment for potential confounders identified by separate directed acyclic graphs.

Ethics and dissemination

This study has been reviewed and approved by the Independent Scientific Advisory Committee for Medicines and Healthcare products Regulatory Agency database research. The results will be published in a peer-reviewed journal.

Cross-sectional study evaluating the seroprevalence of SARS-CoV-2 antibodies among healthcare workers and factors associated with exposure during the first wave of the COVID-19 pandemic in New York

Por: Bryan · A. · Tatem · K. · Diuguid-Gerber · J. · Cooke · C. · Romanoff · A. · Choudhury · N. · Scanlon · M. · Kishore · P. · Sydney · E. · Masci · J. · Bakshi · P. · Pemmasani · S. · Davis · N. J. · Maru · D.
Objective

Estimate the seroprevalence of SARS-CoV-2 antibodies among New York City Health and Hospitals (NYC H+H) healthcare workers during the first wave of the COVID-19 pandemic, and describe demographic and occupational factors associated with SARS-CoV-2 antibodies among healthcare workers.

Design

Descriptive, observational, cross-sectional study using a convenience sample of data from SARS-CoV-2 serological tests accompanied by a demographic and occupational survey administered to healthcare workers.

Setting

A large, urban public healthcare system in NYC.

Participants

Participants were employed by NYC H+H and either completed serological testing at NYC H+H between 30 April 2020 and 30 June 2020, or completed SARS-CoV-2 antibody testing outside of NYC H+H and were able to self-report results from the same time period.

Primary outcome measure

SARS-CoV-2 serostatus, stratified by key demographic and occupational characteristics reported through the demographic and occupational survey.

Results

Seven hundred and twenty-seven survey respondents were included in analysis. Participants had a mean age of 46 years (SD=12.19) and 543 (75%) were women. Two hundred and fourteen (29%) participants tested positive or reported testing positive for the presence of SARS-CoV-2 antibodies (IgG+). Characteristics associated with positive SARS-CoV-2 serostatus were Black race (25% IgG +vs 15% IgG–, p=0.001), having someone in the household with COVID-19 symptoms (49% IgG +vs 21% IgG–, p

Conclusions

Results underscore the significance that community factors and inequities might have on SARS-CoV-2 exposure for healthcare workers.

Associations of obesity, physical activity level, inflammation and cardiometabolic health with COVID-19 mortality: a prospective analysis of the UK Biobank cohort

Por: Hamrouni · M. · Roberts · M. J. · Thackray · A. · Stensel · D. J. · Bishop · N.
Objectives

To investigate the associations of physical activity level with COVID-19 mortality risk across body mass index (BMI) categories, and to determine whether any protective association of a higher physical activity level in individuals with obesity may be explained by favourable levels of cardiometabolic and inflammatory biomarkers.

Design

Prospective cohort study (baseline data collected between 2006 and 2010). Physical activity level was assessed using the International Physical Activity Questionnaire (high: ≥3000 Metabolic Equivalent of Task (MET)-min/week, moderate: ≥600 MET-min/week, low: not meeting either criteria), and biochemical assays were conducted on blood samples to provide biomarker data.

Setting

UK Biobank.

Main outcome measures

Logistic regressions adjusted for potential confounders were performed to determine the associations of exposure variables with COVID-19 mortality risk. Mortality from COVID-19 was ascertained by death certificates through linkage with National Health Service (NHS) Digital.

Results

Within the 259 397 included participants, 397 COVID-19 deaths occurred between 16 March 2020 and 27 February 2021. Compared with highly active individuals with a normal BMI (reference group), the ORs (95% CIs) for COVID-19 mortality were 1.61 (0.98 to 2.64) for highly active individuals with obesity, 2.85 (1.78 to 4.57) for lowly active individuals with obesity and 1.94 (1.04 to 3.61) for lowly active individuals with a normal BMI. Of the included biomarkers, neutrophil count and monocyte count were significantly positively associated with COVID-19 mortality risk. In a subanalysis restricted to individuals with obesity, adjusting for these biomarkers attenuated the higher COVID-19 mortality risk in lowly versus highly active individuals with obesity by 10%.

Conclusions

This study provides novel evidence suggesting that a high physical activity level may attenuate the COVID-19 mortality risk associated with obesity. Although the protective association may be partly explained by lower neutrophil and monocyte counts, it still remains largely unexplained by the biomarkers included in this analysis.

Importance of accounting for loss to follow-up when comparing mortality between immigrants and long-term residents: a population-based retrospective cohort

Por: Vyas · M. V. · Fang · J. · Austin · P. C. · Laupacis · A. · Cheung · M. C. · Silver · F. L. · Kapral · M. K.
Objectives

To evaluate the association between immigration status and all-cause mortality in different disease cohorts, and the impact of loss to follow-up on the observed associations.

Design

Population-based retrospective cohort study using linked administrative health data in Ontario, Canada.

Setting

We followed adults with a first-ever diagnosis of ischaemic stroke, cancer or schizophrenia between 2002 and 2013 from index event to death, loss to follow-up, or end of follow-up in 2018.

Primary and secondary outcome measures

Our outcomes of interest were all-cause mortality and loss to follow-up. For each disease cohort, we calculated adjusted HRs of death in immigrants compared with long-term residents, adjusting for demographic characteristics and comorbidities, with and without censoring for those who were lost to follow-up. We calculated the ratio of two the HRs and the respective CL using bootstrapping methods.

Results

Immigrants were more likely to be lost to follow-up than long-term residents in all disease cohorts. Not accounting for this loss to follow-up overestimated the magnitude of the association between immigration status and mortality in those with ischaemic stroke (HR of death before vs after accounting for censoring: 0.78 vs 0.83, ratio=0.95; 95% CL 0.93 to 0.97), cancer (0.74 vs 0.78, ratio=0.96; 0.95 to 0.96), and schizophrenia (0.54 vs 0.56, ratio=0.97; 0.96 to 0.98).

Conclusions

Immigrants to Canada have a survival advantage that varies by the disease studied. The magnitude of this advantage is modestly overestimated by not accounting for the higher loss to follow-up in immigrants.

Systematic review and meta-analyses on associations of endogenous testosterone concentration with health outcomes in community-dwelling men

Por: Marriott · R. J. · Harse · J. · Murray · K. · Yeap · B. B.
Objectives

The overall study aim is to clarify the relation of endogenous sex hormones with major health outcomes in men. This paper reports a systematic review focusing on published estimates for testosterone associations.

Setting

Community-dwelling men.

Participants

20 180 adult men participated in the final set of studies identified and selected from a systematic review. Eligible studies included prospective cohort studies with plasma or serum testosterone concentrations measured for adult men using mass spectrometry with at least 5 years of follow-up data and one of the specified outcome measures recorded. Only published or grey literature items written in English were considered.

Primary and secondary outcome measures

Planned prospective outcome measures: cardiovascular disease (CVD) events, CVD deaths, all-cause mortality, cancer deaths, cancer diagnoses, cognitive decline, dementia. Meta-analyses were of the most frequently reported outcomes in selected studies: CVD deaths and all-cause mortality. Succinct characterisations of testosterone associations with other outcomes are also presented.

Results

Screening of 1994 deduplicated items identified 9 suitable studies, with an additional 2 identified by colleagues (11 in total). Summary estimates of mean testosterone concentration and age at recruitment for 20 180 adult men were 15.4±0.7 nmol/L and 64.9±3.3 year. Despite considerable variation in mean testosterone, a metaregression estimated no significant dependence on mean age at recruitment among studies (slope=–0.03, 95% CI –0.11 to 0.06). Meta-analyses demonstrated negligible heterogeneity and no significant effect of a 5 nmol/L increase in testosterone on the risk of all-cause mortality (HR=0.96, 95% CI 0.89 to 1.03) or death from CVD (HR=0.95, 95% CI 0.83 to 1.08).

Conclusions

Analyses of published estimates did not demonstrate associations of endogenous testosterone with CVD deaths or with all-cause mortality. Suggested further research includes the planned individual participant data meta-analyses for selected studies, enabling the investigation of non-linear summary effects.

PROSPERO registration number

PROSPERO: CRD42019139668.

Oxford Understanding Relationships, Sex, Power, Abuse and Consent Experiences (OUR SPACE) cross-sectional survey: a study protocol

Por: Steele · B. · Degli Esposti · M. · Mandeville · P. · Hamnett · G. · Nye · E. · Humphreys · D. K.
Introduction

Sexual violence among higher education students is a public health concern, threatening the general safety of students, often with significant physical and mental health implications for victims. Establishing the prevalence estimates of sexual violence at higher education institutions (HEIs) is essential for designing and resourcing responses to sexual violence, including monitoring the effectiveness of prevention initiatives and institutional programmes. Yet, to date, there have been no rigorous studies assessing prevalence of sexual violence at HEIs in the UK.

Methods and analysis

Informed by guidance from Universities UK, the University of Oxford administration and the related student advocacy groups working within the University, Oxford Understanding Relationships, Sex, Power, Abuse and Consent Experiences is a cross-sectional survey of all undergraduate and graduate students over the age of 18 enrolled at the University of Oxford, UK. The survey design uses a complete sampling approach and measures adapted from previous campus climate surveys in the USA as well as the Sexual Experiences Survey (USA). The analysis will estimate the prevalence of sexual harassment and sexual violence perpetration and victimisation, and will examine whether ethnicity, gender identity, and sexual orientation are associated with these primary outcomes.

Ethics and dissemination

Ethical approval was obtained by the Social Sciences and Humanities Interdivisional Research Ethics Committee at the University of Oxford which is a subcommittee of the Central University Research Ethics Committee (ref no.: R73805/RE001). The research team will disseminate findings through peer-reviewed journal articles and conference presentations. A report cowritten by authors and stakeholders will be shared with Oxford University students.

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