Positive Association Research Articles

Deubiquitinase USP10 promotes osteosarcoma autophagy and progression through regulating GSK3β-ULK1 axis.

Deubiquitinating enzymes (DUBs) are pivotal in maintaining cell homeostasis by regulating substrate protein ubiquitination in both healthy and cancer cells. Ubiquitin-specific protease 10 (USP10)belongs to the DUB family. In this study, we investigated the clinical and pathological significance of USP10 and Unc-51-like autophagy activating kinase 1 (ULK1) in osteosarcoma (OS), as well as the mechanism of USP10 action in ULK1-mediated autophagy and disease progression. The analysis of OS and adjacent normal tissues demonstrated that USP10 and ULK1 were significantly overexpressed in OS, and a positive association between their expression and malignant properties was observed. USP10 knockdown in OS cells reduced ULK1 mRNA and protein expression, whereas USP10 overexpression increased ULK1 mRNA and protein expression. In vitro experiments showed that USP10 induced autophagy, cell proliferation, and invasion by enhancing ULK1 expression in OS cell lines. Furthermore, we found that the regulation of ULK1-mediated autophagy, cell proliferation, and invasion in OS by USP10 was dependent on glycogen synthase kinase 3β (GSK3β) activity. Mechanistically, USP10 promoted ULK1 transcription by interacting with and stabilising GSK3β through deubiquitination, which, in turn, increased the activity of the ULK1 promoter, thereby accelerating OS progression. Using a xenograft mouse model, we showed that Spautin-1, a small-molecule inhibitor targeting USP10, significantly reduced OS development,with its anti-tumour activity significantly enhanced when combined with the chemotherapeutic agent cisplatin. Collectively, we demonstrated that the USP10-GSK3β-ULK1 axis promoted autophagy, cell proliferation, and invasion in OS. The findings imply that targeting USP10 may offer a promising therapeutic avenue for treating OS.

Fine Particulate Matter and Osteoporosis: Evidence, Mechanisms, and Emerging Perspectives.

Air pollution, particularly fine particulate matter with an aerodynamic diameter of ≤ 2.5 μm (PM2.5), has been recognized for its adverse effects on multiple organs beyond the lungs. Among these, the bone began to garner significant attention. This review covers epidemiological, animal and cell studies on PM2.5 exposure and bone health as well as studies on PM2.5-induced diseases with skeletal complications. Emerging evidence from epidemiological studies indicates a positive association between PM2.5 exposure and the incidence of osteoporosis and fractures, along with a negative association with bone mineral density. Experimental studies have demonstrated that PM2.5 can disrupt the metabolic balance between osteoclasts and osteoblasts through inflammatory responses, oxidative stress, and endocrine disruption, thereby triggering bone loss and osteoporosis. Additionally, this review proposes a secondary mechanism by which PM2.5 may impair bone homeostasis via pathological alterations in other organs, offering new perspectives on the complex interactions between environmental pollutants and bone health. In conclusion, this contemporary review underscores the often-overlooked risk factors of PM2.5 in terms of its adverse effects on bone and elucidates the mechanisms of both primary and secondary toxicity. Further attention should be given to exploring the molecular mechanisms of PM2.5-induced bone impairment and developing effective intervention strategies. With global climate change, increasing ozone pollution, emerging pollutants, and multifactorial exposure to environmental factors, these issues are likely to become of greater concern in the near future.

Occupational exposure to benzene and risk of non-Hodgkin lymphoma in an extended follow-up of two population-based prospective cohorts of Chinese men and women.

The carcinogenicity of benzene was reevaluated by the International Agency for Research on Cancer in 2017, with the Working Group reaffirming positive yet inconclusive associations with non-Hodgkin lymphoma (NHL). To extend our previous observation of a significant exposure-response for cumulative occupational benzene exposure and NHL risk among Chinese women in a population-based cohort in Shanghai, we extended follow-up of this cohort and pooled the data with a similarly designed population-based cohort of men in Shanghai. Cumulative exposure estimates were derived for 134,449 participants in the pooled analysis by combining ordinal job-exposure matrix intensity ratings with quantitative benzene measurements from an inspection database of Shanghai factories. Associations between benzene exposure metrics and NHL (n = 363 cases including multiple myeloma [MM]) were assessed using Cox proportional hazard models. Ever occupational exposure to benzene in the pooled population was associated with NHL risk (HR = 1.5, 95% CI = 1.2-2.0), and exposure-response relationships were observed for increasing duration (ptrend = .003) and cumulative exposure (ptrend = .003). Associations with ever exposure, duration, and cumulative exposure were similar for NHL with and without MM in the case definition, including lifetime cumulative exposures in the highest quartile (HR = 1.6, 95% CI = 1.1-2.4 with MM included; HR = 1.7, 95% CI = 1.1-2.7 with MM excluded). An elevated risk of the chronic lymphocytic leukemia subtype was suggested in the pooled analyses (HR for ever vs. never exposure = 2.3, 95% CI = 0.9-5.6). These observations provide additional support for a plausible association between occupational benzene exposure and risk of NHL.

A Comparison of Throwing Arm Kinetics and Ball Velocity in High School Pitchers With Overall Fast and Overall Slow Cumulative Joint and Segment Velocities.

Individual maximum joint and segment angular velocities have shown positive associations with throwing arm kinetics and ball velocity in baseball pitchers. To observe how cumulative maximum joint and segment angular velocities, irrespective of sequence, affect ball velocity and throwing arm kinetics in high school pitchers. Descriptive laboratory study. High school (n = 55) pitchers threw 8 to 12 fastball pitches while being evaluated with 3-dimensional motion capture (480 Hz). Maximum joint and segment angular velocities (lead knee extension, pelvis rotation, trunk rotation, shoulder internal rotation, and forearm pronation) were calculated for each pitcher. Pitchers were classified as overall fast, overall slow, or high velocity for each joint or segment velocity subcategory, or as population, with any pitcher eligible to be included in multiple subcategories. Kinematic and kinetic parameters were compared among the various subgroups using t tests with post hoc regressions and multivariable regression models created to predict throwing arm kinetics and ball velocity, respectively. The lead knee extension and pelvis rotation velocity subgroups achieved significantly higher normalized elbow varus torque (P = .016) and elbow flexion torque (P = .018) compared with population, with equivalent ball velocity (P = .118). For every 1-SD increase in maximum pelvis rotation velocity (87 deg/s), the normalized elbow distractive force increased by 4.7% body weight (BW) (B = 0.054; β = 0.290; P = .013). The overall fast group was older (mean ± standard deviation, 16.9 ± 1.4 vs 15.4 ± 0.9 years; P = .007), had 8.9-mph faster ball velocity (32.7 ± 3.1 vs 28.7 ± 2.3 m/s; P = .002), and had significantly higher shoulder internal rotation torque (63.1 ± 17.4 vs 43.6 ± 12.0 Nm; P = .005), elbow varus torque (61.8 ± 16.4 vs 41.6 ± 11.4 Nm; P = .002), and elbow flexion torque (46.4 ± 12.0 vs 29.5 ± 6.8 Nm; P < .001) compared with the overall slow group. A multiregression model for ball velocity based on maximum joint and segment angular velocities and anthropometrics predicted 53.0% of variance. High school pitchers with higher maximum joint and segment velocities, irrespective of sequence, demonstrated older age and faster ball velocity at the cost of increased throwing shoulder and elbow kinetics. Pitchers and coaching staff should consider this trade-off between faster ball velocity and increasing throwing arm kinetics, an established risk factor for elbow injury.

The association between Internet use and intrinsic capacity among older adults in China: The mediating role of social participation.

This study aims to explore the relationship between Internet use and intrinsic capability among Chinese older adults, and the potential mediating role of social participation. We verified the correlation between Internet use and intrinsic capacity using multiple linear regression and verified the mediating role of social participation using the Sobel and Bootstrap tests. The results of multiple linear regression show that there is a significant positive association between Internet use and intrinsic capacity (B=0.717, p<.001); and social participation plays a mediating role, explaining a total of 20.5% of the association (indirect effect=0.147, 95% CI: 0.067-0.227). Our findings suggest that Internet use significantly improves intrinsic capacity among Chinese older adults, with social participation playing a mediating role. Increasing Internet adoption rates and promoting social participation may help improve intrinsic capacity among older adults.

Isomer of per- and polyfluoroalkyl substances and red blood cell indices in adults: The Isomers of C8 Health Project in China.

This study aimed to explore the isomer-specific, sex-specific, and joint associations of PFAS and red blood cell indices. We used data of 1,238 adults from the Isomers of C8 Health Project in China. Associations of PFAS isomers and red blood cell indices were explored using multiple linear regression models, Bayesian Kernel Machine Regression models and subgroup analysis across sex. We found that serum concentration of linear (n-) and branched (Br-) isomers of perfluorooctane sulfonate (PFOS) and perfluorohexanesulfonic acid (PFHxS) were significantly associated with red blood cell indices in single-pollutant models, with stronger associations observed for n-PFHxS than Br-PFHxS, in women than in men. For instance, the estimated percentage change in hemoglobin concentration for n-PFHxS (3.65%; 95% CI: 2.95%, 4.34%) was larger than that for Br-PFHxS (0.96%; 95% CI: 0.52%, 1.40%). The estimated percentage change in red blood cell count for n-PFHxS in women (2.55%; 95% CI: 1.81%, 3.28%) was significantly higher than that in men (0.12%; 95% CI: -1.04%, 1.29%) (Pinter < 0.001). Similarly, sex-specific positive association of PFAS mixture and outcomes was observed. Therefore, the structure, susceptive population, and joint effect of PFAS isomers should be taken into consideration when evaluating the health risk of chemicals.

Brooding duration does not depend on cat predation risk but is related to weather and phenology in the wandering albatross (Diomedea exulans).

Parental investment increases offspring fitness at the expense of the parent's ability to invest in other offspring. In many animal species, parents guard their offspring after birth. The parental decision over the duration of this period is expected to be triggered by the associated fitness costs and benefits for both offspring and parents. Here, we evaluated the relevance of several intrinsic and environmental variables in determining brooding period duration in the wandering albatross (Diomedea exulans) and questioned whether brooding duration was related to chick subsequent survival and biometry prior to fledging. We used a semi-experimental design to increase the variance in cat abundance, a recent predator of albatross chicks, and predicted that an increased predation risk at the nest scale would trigger longer chick brooding and thus, protection. In addition, we questioned the influence of weather conditions, hatching date, and characteristics of chicks (sex and biometry) and parents (sex and age) on brooding duration. We report no effect of predation risk or parental characteristics on brooding duration. However, the probability for a parent to end brooding decreased with forthcoming unfavorable weather. Our data also revealed reduced brooding duration for late-hatched chicks and a positive association between brooding duration and chick structural size, and between the frequency of shifts between parents and chick structural size. Finally, brooding duration was not associated with chick survival or with chick biometry prior to fledging. We discuss these results in light of pre-existing hypotheses on fitness costs and benefits associated with brooding duration for chicks and parents.

Cancer incidence in a cohort of Danish firefighters: An extended long-term follow-up 1968-2021.

To update and extend the examination of cancer incidence in a cohort of Danish firefighters, now adding 7 years of follow-up and 2766 additional firefighters. The primary focus was directed toward cancer sites that recently contributed to the hazard evaluation conducted by the International Agency for Research on Cancer (IARC). The updated cohort consisted of 11,827 male Danish firefighters who were followed up for cancer from 1968 to 2021. Cohort cancer morbidity was compared with a working population reference group, and standardized incidence ratios (SIR) were used for estimation of relative risks, along with 95% confidence intervals (95% CI). Among full-time firefighters, SIR of skin melanoma was 1.30 (95% CI: 1.02-1.66), and SIR = 1.37 (95% CI: 1.02-1.85) for over 5 years of employment. Slightly positive associations were also observed for cancer of the urinary bladder (SIR = 1.16; 95% CI: 0.93-1.45), prostate (SIR = 1.11; 95% CI: 0.97-1.28), and testis (SIR = 1.11; 95% CI: 0.75-1.63). This updated study provides evidence indicating an elevated risk of skin melanoma in firefighters. Consistent with IARC's evaluation, we also identified positive associations for urinary bladder, prostate, and testis cancer. In contrast, our findings did not suggest an increased risk of colon cancer, non-Hodgkin lymphoma, and mesothelioma. The latter may be due to small numbers in our still relatively young cohort. Continuous follow-up for cancer in firefighters is warranted, including assessment of influence from surveillance bias.

Inner strength, coping self-efficacy and coping strategy of patients with peritoneal dialysis: A exploratory cross-sectional study.

The purpose of the study was to investigate and analyse inner strength of patients with peritoneal dialysis, explore the associations among inner strength, coping self-efficacy (CSE) and medial coping modes. This was a cross-sectional study which was conducted in nephrology departments of two affiliated hospitals of a comprehensive university in China. Convenience sampling was chosen to collect data. A total of 191 patients undergoing peritoneal dialysis were recruited by convenience sampling in two hospitals. Data involved of sociodemographic and clinical materials, inner strength, CSE and medical coping modes were collected from the patients. IBM SPSS Statistics 21.0 was used to process and analyse the data. The averaged score of inner strength was 95.74 (SD = 13.52). The inner strength, CSE and confrontation coping had positive associations with each other. Besides, inner strength and CSE was negatively associated with acceptance-resignation coping strategy, respectively.

Biochemical and haematological effects of serum PFOA, ADV and cC6O4 in workers of a chemical company producing fluoropolymers, Italy, 2013-2022

Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are widely used in the manufacture of fluoropolymers. We evaluated biochemical and haematological effects of three PFAS, serum perfluorooctanoic acid (PFOA), ADV, and cC6O4 in workers of a fluoropolymer company. Using data (2013-2022), we fitted random intercept regression models adjusted for several covariates and reciprocal adjustment between the three PFAS. We analysed data of 814 workers (698 men, 116 women), 607 from the chemical plant, 207 from the research centre, for a total of 4912 blood samples (2065 with all three PFAS measured). Median levels of PFOA and ADV were 21.3 and 120μg/L. Most (65.5%) cC6O4 measurements were below the limits of quantification (which varied over time from 5 to 0.1μg/L). For PFOA, we observed positive associations with total cholesterol (+1.1% increase per ln(PFOA) increase) and apolipoprotein B (+1.4%) and negative associations with alkaline phosphatase (-1.5%); suggestive associations were also found with RBC (-0.4%), IgA (-1.5%), IgM (-1.4%). ADV was positively associated with total and LDL cholesterol (+1.0% and +1.6% per ln(ADV) increase), apolipoprotein B (+1.0%), GGT (+2.1%), IgM (+1.4%), and WBC (+1.5%) and negatively associated with direct bilirubin (-2.3%) and alpha-2-globulins (-0.7%); suggestive associations were found for indirect bilirubin (-2.0%), oestradiol (-2.1%), ad CRP (+6.0%). For samples with detectable cC6O4 levels we observed higher values of ALP (+2.3%), proteins (+0.5%), IgG (+0.7%) and platelets (+1.6%) and suggestively increased total bilirubin (+3.9%), RBC (+0.6%), and oestradiol (+5.8%). Some associations (total cholesterol, apolipoprotein B, WBC, total bilirubin, and alkaline phosphatase showed reverse time trends in parallel with the strong decrease of serum PFOA and ADV over the study period. We found associations of serum PFOA and ADV with lipid metabolism, liver function, and immunoglobulins. The reverse time trends of some endpoints in parallel with decrease of serum PFOA and ADV reinforce causal interpretation of results. cC6O4 showed a different pattern of associations.

Active Travel, Public Transport and the Built Environment in Youth: Interactions with Perceived Safety, Distance to School, Age and Gender

IntroductionThis study examined interactive effects of the built environment, perceived safety, age and gender on active travel and public transport use among adolescents for school journeys. MethodThis study used cross-sectional data from 440 adolescents (mean age 15.4 ± 1.5 years, 58% girls) in Melbourne, Australia. Adolescents self-reported their school travel modes, perceptions of traffic and personal safety. Exclusive active travel and public transport use to/from school were determined. Objective built environment features around home and school (1 km buffer) were generated. Multilevel logistic regression was used to estimate main and interactive associations. ResultsOverall, 18% travelled exclusively by active travel and 32% by public transport. Distance to school was negatively associated with exclusive active school travel (OR=0.44, 95%CI: 0.34, 0.56). Distance to school moderated the association between some built environment attributes (land use mix, residential density around home, distance to public transport stops) and odds of active school travel. There was a positive association between residential density around school and active school travel among those who perceived their traffic environment to be safer. Boys were more likely than girls to use public transport if they lived further from school. A negative association between distance to a public transport stop from home and the odds of public transport use was observed among those who perceived their environment to be less safe. ConclusionThe findings highlight the complexity of influences on mode choice for the school journey. Distance to school remains one of the most important predictors of active travel/public transport use. Supportive built environment attributes, such as a diverse mix of land use around home had facilitating effects on active travel among adolescents who lived closer to school. Multilevel interventions that target both the environment and perceived safety are needed to promote active travel and public transport use among adolescents.

Skin microbiome and causal relationships in three dermatological diseases: Evidence from Mendelian randomization and Bayesian weighting.

Atopic dermatitis (AD), psoriasis (PSO), rosacea, and other related immune skin diseases are affected by multiple complex factors such as genetic and microbial components. This research investigates the causal relationships between specific skin microbiota and these diseases by using Mendelian randomization (MR), and Bayesian weighted Mendelian randomization (BWMR). We utilized genome-wide association study (GWAS) data to analyze the associations between various skin bacteria and three dermatological diseases. Single nucleotide polymorphisms (SNPs) served as instrumental variables (IVs) in MR methods, including inverse variance weighted (IVW), and MR Egger. BWMR was employed to validate results and address pleiotropy. The IVW analysis identified significant associations between specific skin microbiota and dermatological diseases. ASV006_Dry, ASV076_Dry, and Haemophilus_Dry were significantly positively associated with AD, whereas Kocuria_Dry was negatively associated. In PSO, ASV005_Dry was negatively associated, whereas ASV004_Dry, Rothia_Dry, and Streptococcus_Moist showed positive associations. For rosacea, ASV023_Dry was significantly positively associated, while ASV016_Moist, Finegoldia_Dry, and Rhodobacteraceae_Moist were significantly negatively associated. These results were corroborated by BWMR analysis. Bacterial species such as Finegoldia, Rothia, and Streptococcus play crucial roles in the pathogenesis of AD, PSO, and rosacea. Understanding these microbial interactions can aid in developing targeted treatments and preventive strategies, enhancing patient outcomes and quality of life.

Does product market competition affect corporate waste management? International evidence

We investigate the impact of product market competition (PMC) on corporate waste generation and Recycling. Analysing a global sample of 42 countries from 2002-2020, we find a positive (negative) association between the PMC and corporate waste generation (Recycling). Our channel analysis reveals that PMC diminishes both a company's profitability and cash flow, leading to lower waste management (Recycling). In further analysis, we demonstrate that the positive effect of PMC on waste generation is more prominent in financially constrained firms. Our study provides novel evidence of the consequential impact of competition on sustainability initiatives and presents important policy implications for regulators.

Did COVID-19 risk perceptions influence the handwashing behavior of the Filipino population?

The COVID-19 pandemic reminded people of the importance of proper handwashing. The degree of health risk perceptions and handwashing behavior during the COVID-19 pandemic opens essential lessons for delivering water, sanitation, and hygiene (WASH) programs across the globe. We measured the relationship between COVID-19 risk perception and the handwashing behavior of 386 Filipinos in a highly urbanized city in the Philippines. Self-made COVID-19 risk perception scale (CRPS) (Cronbach's α 0.93) and handwashing behavior scale (HBS) (Cronbach's α 0.84) were administered face-to-face. The results show that the overall handwashing behavior has a median of 4.1 (frequently), while the interquartile range (IQR) is 0.5. Regression analysis revealed that COVID-19 risk perception has a significant positive association with overall handwashing behavior (B=0.369, p-value &amp;lt;0.05). The COVID-19 risk perception accounts for 36.9% of the variance in handwashing behavior, F (1, 384) =11.6360, p-value=0.0007. This study proposes that public health authorities target people's experiential learning style in designing and delivering intervention programs against non-compliance with proper handwashing.

Validation of supervisor support scale and work-life balance checklist in Malay Language among Malaysian working mothers

Working mothers burdened with work and household responsibilities face challenges with work-life balance, which could be empowered through supervisor support in the workplace. Therefore, it is vital to identify the impact of supervisor support on working mothers’ work-life balance. However, available instruments to measure both constructs for the Malay-speaking Malaysian population are dearth. This study assessed the psychometric properties of the Malay version of the supervisor support scale (SS-Malay) and work-life balance checklist (WLB-Malay) and investigated the relationship between these variables among Malaysian working mothers. Using purposive sampling, 200 working mothers (M=38.80, SD=8.43) for the pilot study and 275 working mothers (M=38.33, SD=7.86) for the actual study completed either an online or printed survey consisting of demographic information, the supervisor support scale, and the work-life balance checklist. Exploratory factor analysis conducted on the pilot study data reported a two-factor structure for WLB-Malay and one factor for SS-Malay. Similarly, confirmatory factor analysis confirmed the unidimensional factor of SS-Malay, and two factors of WLB-Malay: concerned about work, and self. Reliability was established with alpha, omega, and composite reliability values of more than .70. Discriminant validity was established with correlation values of less than .90, and concurrent validity was established with significant moderation positive association between constructs. Structural equation modelling reported a satisfactory model fit for both scales and identified a positive impact of supervisor support on work-life balance among Malaysian working mothers. Accordingly, both WLB-Malay and SS-Malay are culturally fit for Malaysian working mothers.

Elevated remnant cholesterol was associated with the increased metabolically unhealthy obesity risk in Chinese youth.

Metabolically unhealthy obesity is characterized by the presence of cardiovascular metabolic risks such as hypertension, dyslipidemia, and hyperglycemia. Research has shown a correlation between remnant cholesterol (RC) concentrations and abdominal obesity in children. However, the effect of RC concentration on metabolically unhealthy obesity remains unclear. This study included 3114 Chinese adolescents who received health check-ups. We used logistic regression models and receiver operating characteristic analysis to evaluate the correlation between RC concentration and metabolically unhealthy obesity in a cross-sectional design. After controlling for possible confounding variables, we found that individuals in the top and fourth quintiles of RC concentrations had a significantly higher likelihood of developing metabolically unhealthy obesity compared to those in the bottom quintile (ORs, 4.810 and 1.836; 95% CIs, 3.209-7.212 and 1.167-2.890, respectively). The risk of metabolically unhealthy obesity tended to increase with RC concentration (ptrend<0.001). In addition, boys showed positive associations between RC concentration and both BMI (r = 0.305, p<0.001) and waist circumference (r = 0.306, p<0.001). According to the analysis, the predictive accuracy of metabolically unhealthy obesity was 0.736 (95% CI, 0.690-0.781) for boys and 0.630 (95% CI, 0.573-0.687) for girls. The ideal prediction threshold was 0.66 for boys and 0.59 for girls. Our findings indicate that elevated RC concen-tration is linked to a higher likelihood of developing metabolically unhealthy obesity in young individuals, regardless of other known risk factors.

Effect of antibiotics and antibiotic by-products on the chlorine resistance of biofilms in drinking water distribution systems

This study investigated the effects of tetracycline (TC) and sulfadiazine (SD), along with their degradation products, on biofilm chlorine resistance. The results showed that low concentrations of antibiotics and their degradation products promoted biofilm formation on tube surfaces and increased resistance to chlorine. There was a positive correlation between antibiotic levels, degradation products, and biofilm chlorine resistance within a specific concentration range. SD had a more significant impact on biofilm chlorine resistance compared to TC. The presence of both antibiotics and their degradation products in water led to an increase in biofilm chlorine resistance, especially when combined with 0.3 mg/L sodium hypochlorite. The study shows a positive association between antibiotic and degradation product concentrations and the biofilms' improved chlorine resistance, a phenomenon that could have major consequences for water treatment efforts. Additionally, higher concentrations of antibiotics and their degradation products were associated with reduced biodiversity within the biofilm. Overall, the findings suggest that the presence of antibiotics and their degradation products can influence biofilm formation, alter bacterial species composition, and enhance biofilm resistance to chlorine in drinking water distribution systems. This fresh perspective on the relationship between pharmaceutical residues and microbial communities in water systems could transform our approach to assuring water safety and combatting antimicrobial resistance.

Primary care quality and provider disparities in China: a standardized-patient-based study

BackgroundPrimary health care is the foundation of high-performing health systems. Achieving an improved primary care system requires a thorough understanding of the current quality of care among various providers within the system. As the world’s largest developing country, China has made significant investments in primary care over the past decade. This study evaluates the quality of primary care across different provider types in China, offering in- sights for enhancing China’s primary care system. MethodsWe merged data from four standardized patient (SP) research projects to compare the quality of five major primary care providers in China: rural clinics, county hospitals, migrant clinics, urban community health cen- ters (CHCs), and online platforms. We evaluated quality of care across process quality (e.g., checklist completion), diagnosis quality (e.g., diagnostic accuracy), and case management (e.g., correct medication), employing multiple regression analyses to explore quality differences by provider type, and their associations with physician characteristics. FindingsWe document a poor quality of primary care in China, with no- table disparities across different providers. CHCs emerge as relatively reliable primary care providers in terms of process quality, diagnostic accuracy, and cor- rect medication prescriptions. Online platforms outpace rural clinics, county hospitals, and migrant clinics in many areas, showcasing their potential to en- hance access to quality healthcare resources in under-resourced rural regions. We observe a positive association between the qualifications of physicians and the quality of primary care, underscoring the necessity for a greater presence of more highly qualified practitioners. InterpretationPrimary care quality in China varies greatly among providers, reflecting inequalities in healthcare access. While online platforms indicate po- tential for improving care in under-resourced areas, their high referral rates suggest they cannot completely substitute traditional care. The findings em- phasize the need for more qualified practitioners and stringent regulation to enhance care quality and reduce unnecessary treatments. FundingNo founders had a role in the study design, data collection, data analysis, data interpretation, or writing of the report. We have acknowledged this in the revised manuscript.

A cross-cultural investigation of active transportation and community participation: Results from the WHO survey of Global Ageing and Adult Health

Little is known about how the associations between active transportation and community participation may vary across national contexts. Using representative datasets from China, Ghana, India, Mexico, Russia, and South Africa collected in the Study on Global Ageing and Adult Health (N = 33,535), we estimated multi-group confirmatory factor analyses, tests of measurement invariance, and predictive models. Standardized coefficients were equivalent across countries and showed a modest positive association between active transportation and community participation (the variance explained by active transportation ranged from 1.3% to 7.5% across countries). These results suggest that supporting active transportation can help mitigate negative environmental and health changes associated with increased vehicular travel and support social capital via community participation.

Associations between 24-hour activity behaviours and emotional and behavioural problems of left-behind children: a component analysis of data from a cross-sectional study

ObjectivesThis study employed compositional data analysis to examine the association between 24-hour activity behaviours and emotional and behavioural problems among left-behind children (LBC).DesignCross-sectional analysis.SettingThe research used a cross-sectional approach to...