Pyogenic liver abscess is usually a complication of biliary tract disease. Taiwan features among the countries with the highest incidence of colorectal cancer (CRC) and hepatocellular carcinoma (HCC). Few studies have investigated whether patients with pyogenic liver abscess (PLA) have higher incidence rates of CRC and HCC. However, these findings have been inconclusive. The risks of CRC and HCC in patients with PLA and the factors contributing to cancer development were assessed in these patients. The clinical tests significantly associated with cancers in these patients with PLA were determined to assist in the early diagnosis of these cancers. Odds ratios (ORs) and 95% confidence intervals (CIs) were determined using binary logistic regression Cancer classification models were constructed using the decision tree algorithm C5.0 to compare the accuracy among different models with those risk factors of cancers and then determine the optimal model. Thereafter, the rules were summarized using the decisi8on tree model to assist in the diagnosis. The results indicated that CRC and HCC  and CRC  risks were higher in patients with PLA than those without PLA. The decision tree analysis demonstrated that the model with the PLA variable had the highest accuracy, and that classification could be conducted using fewer factors, indicating that PLA is critical in HCC and CRC. Two rules were determined for assisting in the diagnosis of CRC and HCC using the decision tree model. Biliary tract disease is the most common cause of liver abscess. There has been an increasing incidence of PLA arising from malignancies and their treatment, including liver metastasis, and complications of transarterial chemoembolization or radiofrequency ablation . The annAccording to the data published by the Statistics Department of Taiwan Health and Welfare Ministry, the top 10 causes of death in Taiwan in the year of 2017 were chronic diseases. Of these, malignant tumors represented the main cause of death in Taiwan, followed by heart disease, cerebrovascular diseases, diabetes, and pneumonia. Malignant tumors accounted for 28% of the total mortality .Only few population-based studies have reported increased incidence of GI tract caner in patients with PLA ,8. WhethTherefore, the primary purpose of this study was to analyze the risks of CRC and HCC in patients with PLA, the factors contributing to cancer development in these patients, and the clinical tests for the diagnosis of these cancers. The medical records and clinical data were retrieved from the database. Statistics and data mining technology were used to identify potential risk factors associated with these cancers. The optimal models of decision tree analysis were determined to help the clinicians identify the appropriate clinical tests for the early diagnosis of these cancers and increase the healthy lifespan of patients.Liver cancer is reported to be the sixth most common cancer and the fourth leading cause of cancer death worldwide in 2018, with about 841,000 new cases and 782,000 deaths annually . The higPrimary liver cancer includes hepatocellular carcinoma (HCC) (comprising 75–85% of cases), intrahepatic cholangiocarcinoma (comprising 10–15% of cases), and metastatic cancers from other organs. The main risk factors for HCC are chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV), heavy alcohol intake, obesity, type 2 diabetes, and aflatoxin-contaminated foodstuffs .Patients with HCC have cirrhosis resulting from the following one or more etiologic risk factors, such as HCV infection, HBV infection, and heavy alcohol drinking. HCC develops at an annual incidence of 2–7% in patients with active viral (HCV or HBV) hepatitis with liver cirrhosis in the United Sates. Because of the advent of highly effective and well-tolerated direct-acting antiviral agents for the treatment of HCV infection, the number of patients cured of HCV has increased rapidly. With the increasing trend of obesity and metabolic syndrome, NAFLD is now the fastest growing cause of chronic liver disease, cirrhosis, and HCC . Based on a recent systematic review of the available data, the authors analyzed 47 studies with 15,158 patients, of whom 6284 (41.4%) had HCC detected by surveillance . HCC surThe liver enzymes tests, AFP, hepatitis markers, and images studies  were analyzed in this study.Colorectal cancer usually originates from a noncancerous growth called a polyp that occurs on the inner lining of the colon or rectum and grows slowly over a period of 10 to 20 years. An adenomatous polyp  is the most common type. Although all adenomas have the potential to become cancerous, only fewer than 10% are estimated to turn into cancer. Cancer arising from the inner lining of the colorectum is called adenocarcinoma and accounts for approximately 96% of all CRCs .The incidence rates of CRC are three-to-four-times more common in developed than in developing countries and more common among men than women. The age-standardized incidence rate per 100,000 of CRC in both sexes is 19.7 in the world . The age-standardized incidence rate among men is about 30.1/100,000 in high-HDI (human development index) nations, while it is 8.4 in low-HDI nations; and the same statistics for women are 20.9 and 5.9, respectively . DevelopIn the United States, CRC is the third most commonly diagnosed cancer and the second leading cause of death from cancer . About 3Screening for colorectal cancer is recommended by American Society of Clinical Oncology. For people who are asymptomatic, aged 50 to 75 years, without family history of colorectal cancer, at average risk, and in settings with high incidences of colorectal cancer, the following screening options are recommended: Guaiac fecal occult blood test and fecal immunochemical testing (basic), flexible sigmoidoscopy (add option in limited setting), and colonoscopy (add option in enhanced setting) . The datHui and Jha (2000) proposed that new technologies can aid in understanding the relationship between data and in clustering large amounts of stored data . This tyHan, Pei, and Kamber (2011) proposed a seven-step data mining process: (1) Cleaning data to remove noise; (2) integrating data from different sources; (3) selecting data related to the target from databases; (4) transforming data by simplifying, converting, or encoding them; (5) applying data mining techniques to extract useful knowledge; (6) evaluating patterns using metrics to identify useful information; and (7) presenting the results visually to aid decision-making .Luk et al. (2007) investigated data on liver tissue proteomes and proposed an artificial neural network and decision tree model analysis of liver cancer proteomes. They concluded that classification-like neural networks were superior to decision trees, but decision trees were more appropriate for the discovery of markers than neural networks .Kurosaki et al. 2012) proposed a data mining model that used simple and readily available factors that could aid in identifying patients at a high risk of HCC among patients with chronic hepatitis C using a decision tree and logistic regression [12 proposA considerable proportion of domestic and foreign research has focused on neural networks, decision trees, and logistic regression. These three methods have advantages and limitations. However, the majority of scholars agree that decision tree extraction rules are more suitable for identifying rules to assist in diagnosis. Therefore, decision trees were used for data mining in the present study. The conclusions obtained by the decision tree can be explained, which facilitates identifying the causal association rules between the input and cancer, and the decision tree is thus more suitable for this study than the other methods.Patient data provided by the Clinical Informatics Research and Development Center, Taichung Veterans General Hospital, Taiwan, were analyzed. The data acquisition period was from January 1, 2006, to December 31, 2013. Research participants were divided into two groups: Experimental and control groups. The experimental group was comprised inpatients with a PLA with a primary diagnosis ICD-9-CM code 572.0. Patient data, including age and gender, were tracked from the date of first hospitalization or first diagnosis of liver abscess and were followed up for 10 years. The control group was selected based on pairing with the experimental group according to age and genders. The ratio of experimental to control participants was 1:10. All patients hospitalized from 2006 to 2013 were sampled by random sampling. Their clinical data were tracked from one year before the date of the first hospitalization and were followed up thereafter until 2013. Patients with AIDS (ICD-9-CM code 043) or a history of cancer before the first hospitalization were excluded from both groups. The flowchart of patient selection and exclusion in this study is illustrated in Research on the collected data items was divided into two parts. The first part was general basic information (patient age and gender). The second part was the diagnosis data obtained in the hospital using the ICD-9-CM codes: Diabetes (ICD-9-CM code 250.0), hepatitis B (ICD-9-CM codes 070.2 and 070.3), hepatitis C , alcoholic cirrhosis (ICD-9-CM codes 571–571.3), hepatic cirrhosis (ICD-9-CM codes 571.5 and 571.6), fatty liver (ICD-9-CM code 571.8), abnormal liver function (ICD-9-CM code 794.8), obesity (ICD-9-CM code 278.0), gastric cancer (ICD-9-CM code 151), CRC (ICD-9-CM codes 153 and 154), liver cancer (ICD-9-CM codes 155.0 and 155.1), biliary tract cancer (ICD-9-CM code 156), pancreatic cancer (ICD-9-CM code 157), breast cancer (ICD-9-CM codes 174 and 175), nasopharyngeal carcinoma (ICD-9-CM code 147), lung cancer (ICD-9-CM code 162), cervical cancer (ICD-9-CM code 180), and kidney cancer (ICD-9-CM code 189). The following laboratory test data were obtained: the tumor indexes CEA, CA-199, and AFP; blood characteristics, comprising blood glucose, AST, ALT, bilirubin, albumin, total cholesterol, platelet, hemoglobin, and triglyceride levels; anti-HCV antibody, HBs Ag, HBe Ag, anti-HBs antibody, and anti-HBc antibody levels; and fecal occult blood examination results. Colonoscopy results were also documented. Imaging examinations, including computed tomography, abdominal ultrasound, and magnetic resonance imaging reports, were also collected. The pathology report included pathological test results.After data preprocessing and research variable conversion, the data revealed that the inspection items created by each patient were not the same, resulting in the lack of some information. Originally, this problem was to be addressed by treating the differences as missing values or by taking the average value of the data for treatment. After a discussion with the hospital’s physicians, it was considered that if a patient had not undergone a test, it indicated that the patient did not need the test. The patient was in the healthy group and was categorized as 0.The descriptions of patients’ situations in colonoscopy and imaging examination reports also differed based on physicians’ habits of writing. Reports displayed different writing methods but similar diagnoses. For instance, similar statements appeared on liver ultrasound reports, such as a 3.5-cm abscess in the left liver lobe, 3.7-cm abscess in the right liver lobe, or 4.2-cm the left liver abscess. Each diagnosis was categorized as “hepatic abscess” to reduce excessive variables. Therefore, the data were converted into scores according to the standard value of each test item: not checked → 0, check result was normal → 1, or check result was abnormal → 2.K kinds of results in one event and the corresponding probability is iP, then the amount of information obtained after the event occurs is given asThe decision tree is the original classification algorithm of Iterative Dichotomiser 3 (ID3), the predecessor of C4.5 and C5.0, proposed by Quinlan and other scholars in 1986 . The algX is the predictive variable (category k), where n is the total number of samples . According to the variable X, the information gains of n samples divided into 1m, 2m, …, km are as follows:Second, information gain is classified into two categories (with and without cancer), and When building a decision tree, the goal of each node is to segment the training data to identify the optimal segmentation and segmentation points. Therefore, for each node generated, the training subset is removed to calculate the quantity of information gain, and the value with the largest information gain is regarded as the branch node. The next branch node is then selected according to the recursive action until each training material belongs to a category. The decision tree algorithm C5.0 used here was improved by Quinlan’s C4.5 algorithm proposed in 1993 . BoostinA confusion matrix is used to evaluate the performance of a classification model on a set of test data for which the true values are known. When the classification problem has two categories, the confusion matrix obtained is as listed in Evaluation of the correctness of the classification model in the supervised learning algorithm and the correct rate of future predictions can reveal the degree of confidence in the classification in the prediction model and can be used to select specific classifications.The evaluation indicators used in the classification model employed in this study had the following three points. First, follows .LR (+) t and chi-square tests, respectively. After confirming the absence of a significant difference in age and gender between the experimental and control groups, the incidence of CRC and liver cancer was analyzed. The ORs were calculated using logistic regression, and CRC and liver cancer risks were analyzed. These results are listed in All statistical analyses were performed using SPSS . According to the Ministry of Health and Welfare statistics, cancer incidence is affected by age and gender. Therefore, the odds ratios (ORs) for cancer in the experimental group (with liver abscess) should be calculated according to age and gender. The intergroup differences in the effects of age and gender were determined using As shown in We demonstrated that the ORs for cancer in the experimental group were higher than those in the control group. Therefore, the risks of CRC and liver cancer in patients with PLA were higher than those in the average person. Thus, PLA was used as a research variable in a predictive model, which was compared to the prediction model with PLA as an established prediction model. We used the C5.0 decision tree method in SPSS to extract classification rules from the data.First, the PLA variable was added to establish a prediction model, which was named decision tree model 1 (with PLA). The overall tree diagram of this model is illustrated in The explanation was based on Rule 1 of CRC. When the AFP check value was 12.3 (ng/mL) and the colonoscopy polyp = 3 (an adenoma is identified using colonoscopy), the decision tree identified eight people, which reflected the confidence of the rule. The standard was 87.5%.The PLA variable was then removed and was used in the established prediction model. The model was named decision tree model 1 (without PLA), and the overall tree diagram of this model is illustrated in The models model 1 (with PLA) and model 1 (without PLA) demonstrated that the classification rules for liver cancer were almost identical to the classification rules for CRC. However, these models exhibited a considerable difference, which indicated a relationship between PLA and CRC. Therefore, this study also established a predictive model for CRC and compared the addition of the variable related to bacterial liver abscess to understand whether bacterial liver abscess would increase the accuracy of classification.The PLA variable was included in the prediction model of CRC. The model was named decision tree model 2 (with PLA). The overall tree diagram of this model is illustrated in A CRC prediction model was established without the PLA variable, named decision tree model 2 (without PLA). The overall tree diagram of this model is illustrated in Two approaches were used to determine the optimal predictive model. The correct rate and the application surface were determined based on the sensitivity, specificity, and overall classification accuracy of the 10-fold cross-validation, and whether it accorded with the current situation and had a reference value was assessed.The classification rule of the CRC model of model 2 (without PLA variants) was too simple because it judged using only one factor. This classification rule categorized polyps in colonoscopy as having no CRC. However, Garborg et al. (2013) reported that adenomas may not be necessary for the development of CRC . FurtherFrom the sensitivity and specificity of the model and the overall prediction accuracy, we determined that the accuracy of the two models were similar. After discussing our findings with a doctor involved in this study, it was determined that the clinical situation could be diagnosed using fewer factors. Implementing these changes would improve the predictive power of the model. Therefore, the model with PLA in decision tree model 1 was the optimal model presented in this study.The main risk factors for HCC include chronic hepatitis caused by HBV or HCV, alcoholic liver disease, and nonalcoholic liver disease (NAFLD) ,26. SeveNAFLD is mainly a consequence of excess caloric intake and lack of physical activity . A low cSince the prevalence of obesity and its related comorbidities has increased globally in recent decades, NAFLD has become progressively more common. Currently, there is no effective drug therapy for NAFLD . TherefoThis study revealed that patients with PLA had higher rates of liver cancer and CRC than other hospitalized patients. The OR for CRC was 6.838 , and the OR for liver cancer was 3.751 . CRC and liver cancer are chronic diseases, with few symptoms during their early stages. Therefore, most colorectal and liver cancers are discovered in the middle and late stages. However, when these cancers are discovered in the early stages, survival rates are very high. This study aimed to establish preventive interventions by establishing guidelines for prevention and early detection. In the decision tree used to identify the optimal model, two rules for CRC and liver cancers were identified. The classification rules for CRC could be classified with fewer factors and had greater prediction accuracy than the classification rule without the addition of PLA. Therefore, the potential risk factor for liver abscess is key in identifying high-risk individuals for CRC.A rule among CRC in patients with PLA was identified from the two most accurate CRC rules, which could be used by physicians to assist in the early diagnosis of CRC for patients who present the following characteristics: AFP < 12.3 ng/mL, polyps in colonoscopy, heme = 9.2–11.3 g/dL, and presence of PLA. The tumor index AFP is principally used for hepatocarcinoma testing, and the pattern of model 2 (with PLA variants) suggested that this indicator is unnecessary for CRC prediction. Therefore, when caring for patients with PLA, clinicians should pay particular attention to hemoglobins and the presence of a large intestine polyp.The relationship between PLA and CRC or liver cancer has scarcely been discussed in the literature. However, this relationship warrants further exploration. This study is limited by research limitations and gaps in the research process. Therefore, we provided suggestions for subsequent research. First, the data enrolled 315 PLA cases and 2634 control cases including eight CRC and four liver cancer cases with a history of PLA and ten CRC and nine liver cancer cases without a history of PLA. The sample size was still insufficient. If more cases were obtained, the diagnostic models presented could be assessed with less variability and bias. Second, data were collected from medical records and databases. Therefore, certain risk factors for cancer, such as living habits, genetic factors, and alcohol abuse, could not be identified in the clinical database. With these factors, the analysis would lead to a more comprehensive model. Third, the research variables were factors related to CRC and liver cancer and known related factors. Assessing general health-related information may reveal factors that have not been identified and provide new reference indicators for medical personnel.


This study draws on Bourdieu’s theory of capitals to analyze the relative importance of economic, cultural, and social capital on health behaviors in Chinese middle-aged and older adults. Based on data from the China Family Panel Studies of 2016 , we first harnessed a binary logistic regression model to discuss the associations between the three capitals and four types of health behaviors . Using the sheaf coefficients technique, we then compared the relative effects of three of the capitals on health behaviors. The results suggest that cultural capital is the most influential one, which would significantly increase physical exercise and stay-up behaviors, and reduce smoking and binge drinking behaviors. Economic capital is also an important predictor, that may reduce smoking behavior but increase binge drinking and stay-up behaviors. Social capital has shown the least importance, although it would still be saliently associated with physical exercise, smoking and stay-up behaviors. In addition, some significant group disparities are also identified. This article is one of the first to explain health behavior inequalities through a Bourdieusian capital-based approach in Chinese contexts. With China’s economic growth and accelerated industrialization, profound changes have taken place in people’s lifestyles, as well as in the spectrum of diseases. As per the China Country Assessment Report on Ageing and Health, the main threat to population health has shifted away from maternal, child and acute infectious disorders to chronic non-communicable diseases, which is expected to be associated with at least a 40% increase in the burden of disease by the year 2030 . Such chIn the existing literature, scholars often apply the Andersen’s health behavioral model to analyze the possible constraints on individuals’ health behaviors , which cBased on Bourdieu’s theory of capitals, the present paper tries to analyze the determinants of health behaviors among Chinese middle-aged and elderly people. In general, Bourdieu’s theoretical orientation places health behaviors within the family and social environment, with the particular emphasis that the components of individual capital structure, consisting of economic, cultural and social capital, could simultaneously impose complex effects on health behaviors ,22,23,24Bourdieu’s capital theory argues that different capitals owned by individuals can determine their positions in the social stratification structure, and further influence the pattern of social behaviors. More specifically, there are three forms of capital, namely economic, social, and cultural capital. The acquisition and accumulation of different capitals is bound by individual socialization experience  . HoweverEconomic capital refers to the material wealth and financial assets owned by individuals or families. Personal/family income and assets are often used to measure the scale of individual’s economic resources. Prior studies reported significant associations between economic capital and health behaviors. For example, empirical evidence has shown that individuals with more income tend to smoke less , have loSocial capital is also an important social determinant of health that has been widely discussed. Bourdieu defined social capital as the “aggregate of the actual or potential resources which are linked to the possession of a durable network of more or less institutionalized relationships of mutual acquaintance and recognition” . RelevanCultural capital is a special kind of capital in Bourdieu’s capital theory. It refers to the non-material things held and shared by people, which can serve as a symbolic representation of an individual’s socioeconomic status. It has three forms of existence: (1) The embodied state, which means the disposition acquired over the life course. For example, one’s behavioral habits can be formed through the process of parental instruction; (2) The institutionalized state, such as formal academic certificate; (3) The objectified state, which exists in the form of cultural objects  . GeneralIn short, Bourdieu’s capital theory has been widely used to theoretically or empirically analyze health-related issues ,38,41,42Even so, we still have to acknowledge that China has such social problems as remarkable regional variations, an uneven distribution of natural and human resources , and hug(1)Do economic, social, and cultural capital have significant influence on health behaviors in Chinese middle-aged and older adults? Which form of capital matters more?(2)Are the effects of individual capitals on different health behaviors consistent across urban/rural, gender, and age groups?This study is based on the China Family Panel Studies (CFPS) of 2016 jointly conducted by the China Social Science Survey Center of Peking University and the Survey and Research Center of the University of Michigan. CFPS is a nation-wide longitudinal survey started in 2010, and follow-up interviews are carried out every other year. A multiple-stage implicit stratification sampling design is used to collect the information of respondents aged 16 and above. CFPS mainly aims to provide a nationally representative sample that reflects Chinese family conditions, as well as the changes in Chinese residents’ education, ideology, health status and other aspects . In our Economic capital. Compared with household wealth, personal income and occupation may become less important in the later years of life [ of life . TherefoCultural capital. According to Bourdieu’s viewpoint [iewpoint , culturaiewpoint ,24, i.e.iewpoint , and it iewpoint , which wSocial capital. To measure social capital, we utilized general trust, special trust, and neighborhood cohesion, in line with prior relevant research [research ,37. SpecHealth behaviors. Four measurements of health behavior were included in this study. Smoking behavior was a dichotomy variable . Drinking three times or more per week in the recent month was considered as binge drinking behavior . Falling asleep between 23:00 o’clock and 17:00 o’clock the next day was treated as stay-up behavior . It is worth mentioning that daytime sleepers usually have nightshifts or all-night behavior, so they were treated as having stay-up behavior. The physical exercise variable was measured through the question of whether the respondent had participated in physical activity in the past week . Control variables. We controlled for gender, age, household registration, urban/rural residence, marital status, political status, work status, self-rated health (SRH), chronic disease and depression , Pr represents the probability of each of the health behaviors. Secondly, based on the above-mentioned logistic regression model, we further used the sheaf coefficients technique proposed by Heise . SupposiThus, Equation (1) can be rewritten into the following alternative form:Equation (5) is the equivalent form of Equation (1) using the iterative method. p < 0.05 was considered to be statistically significant in this study, and data were weighted to yield a nationally representative result. STATA version 15.0 was used to perform the binary logistic regression and “sheafcoef” command. p < 0.05). Meanwhile, more family assets were negatively related to smoking behavior but positively associated with staying up behavior; every additional unit of family assets decreased the probability of smoking by 4.2%  and increased the probability of staying up by 7.7% .p < 0.001), but it also increased the likelihood of staying up by 4.4% . Besides, every additional unit of embodied cultural capital increased the odds of physical exercise by 14.4% ; for staying up behavior, this value was 8.5% . By contrast, institutionalized cultural capital was evidently related to all outcome variables. Every additional unit of institutionalized cultural capital increased the probability of physical exercise by 5.5% , and reduced the probability of smoking and binge drinking by 3.3% and 2.4%, respectively . Meanwhile, it also increased the odds of staying up by 2.1% .Objectified and embodied cultural capitals were significantly associated with physical exercise and staying up behaviors in our samples of analysis. Every additional unit of objectified cultural capital increased the likelihood of physical exercise by 6.0% . Moreover, every additional unit of special trust decreased the probability of smoking by 1.3% , while every additional unit of neighborhood cohesion increased the probability of physical exercise by 4.1%  and decreased the probability of staying up by 3.3% .Investigating the contribution of social capital, we observed that it was significantly associated with physical exercise, smoking, and staying up behaviors. Compared with samples with low-level general trust, those with high-level general trust had a lower probability of staying up late  and health behaviors.p < 0.001). Models 2 and 3 show that cultural capital had a larger relative effect on smoking and binge drinking behaviors than economic and social capital; however, no statistically significant difference was observed among the three capitals. By contrast, Model 4 shows that economic and cultural capital had a larger effect on staying up behavior than social capital ; the effect of economic capital on staying up was 2.298 (0.216/0.094) times that of social capital, while the effect of cultural capital on staying up was 2.021 (0.190/0.094) times that of social capital.To examine which capital is more influential for health behaviors, this study further utilized the sheaf coefficients model to evaluate the relative effects of three capitals on health behaviors in Chinese middle-aged and older adults. In We used p < 0.001 in males; χ2 = 47.09, p < 0.001 in females). Besides, cultural capital had a stronger relationship with physical exercise in females than in males. In addition, significant differences in the relationships between three capitals and staying up behavior were found in females ; furthermore, economic and cultural capital seemed more important than social capital in female stay-up behavior. However, no significant difference in the male group was observed.To be specific, p < 0.001; sheafcoef = 0.385, p < 0.001), and social capital had a stronger association with physical exercise in rural samples  than in their urban counterparts ; in addition, economic capital had almost no impact on physical exercise in both urban and rural areas.Panel B indicates that the relationships between capitals and health behaviors were obviously different among urban and rural middle-aged and older adults. Cultural capital was highly related to physical exercise in both urban and rural samples , but the differences were nonsignificant in the older group. Moreover, in middle-aged adults, the effect sizes of economic and cultural capital on staying up behavior were 3.192 (0.249/0.078) and 3.090 (0.241/0.078) times that of social capital, respectively.Panel C suggests that the relationships between capitals and health behaviors were not consistent in different age groups. Cultural capital was still the most influential factor in both age groups, and its impact on all health behaviors declined with age. The relationships between the three capitals and staying up behavior were obviously different in the middle-aged group  is specifically mentioned in Bourdieu’s capital theory, which may influence the mode of health behavior ,25. NeveFor years, research on the determinants of health behaviors had been limited to micro-level characteristics. Recently, public health scholars have paid more attention to the broader socio-cultural environment wherein health behaviors occur ,57. Our In future studies, since Bourdieu’s analytic framework is in essence “relational”, we need to relationally penetrate and explain how a structure of interdependent positions or the distribution of capitals within the social field of health affects patterns of health practice . Moreove


Females had a 2.69-fold higher risk for migraine than males . In summary, CP is associated with an increased risk of subsequent migraine in Taiwan.Migraine is considered to be a neurovascular disease that manifests as a throbbing headache, possibly caused by the activation of the trigeminovascular system. Several studies have supported the role of inflammation in the pathogenesis of migraine. Chronic periodontitis (CP) is an infectious inflammatory disease triggered by bacterial products evoking an immune response which could result in the destruction of the periodontium. However, little is known about the longitudinal association between CP and migraine. In this study, we designed a nationwide population-based cohort study to investigate the risk of migraine and CP exposure in Taiwan. In total, 68,282 patients with CP were identified from the National Health Insurance Research Database (NHIRD), and 68,282 comparisons were randomly captured and matched by age, sex, monthly income, urbanization and comorbidities. The association between CP exposure and migraine risk was evaluated by Cox proportional hazards regression models. In this study, 785 migraine patients were identified in the CP cohort, and 641 migraine cases were found in the non-CP cohort. The incidence rate of migraine was significantly higher in the CP cohort than the non-CP cohort (adjusted HR: 1.21, 95% CI: 1.09–1.34,  Migraine is a neurological disorder that involves a throbbing headache on one side, usually accompanied by nausea, allodynia and sensitivity to sound or light ,2. The pChronic periodontitis (CP) is an infectious inflammatory disease caused by periodontal pathogens that can escape the host’s immunological defense system, resulting in periodontal tissue destruction, alveolar bone loss and even tooth loss. In Taiwan, the prevalence of periodontitis significantly increased from 1997 to 2013 , cardiovAlthough CP and migraine share a similar pathogenesis, such as chronic inflammation, endothelial dysfunction and immunological reaction, as described above, the specific association between CP and migraine still needs to be investigated further. Recently, a case–control study matched by age and gender reported the association between CP and chronic migraine in Spain . The resThe National Health Insurance (NHI) program in Taiwan is a single-payer insurance system provided by the government. In 2014, almost all of the Taiwanese population was enrolled in this compulsory and universal health insurance program . The NatIn this study, the Longitudinal Health Insurance Database 2010 (LHID2010), a subset of the NHIRD, was used to clarify the association between CP exposure and migraine risk over a 13-year period. The LHID2010 incorporates 1 million patients’ insurance claims data from the total of 23 million Taiwan NHI beneficiaries in the year 2010. There are no demographic characteristic differences between the LHID2010 and the original NHIRD ,17. The The longitudinal association between CP and migraine was interpreted with the cohort design. The study flow diagram of inclusion and exclusion criteria is shown in Subjects without periodontitis were randomly selected from the data set and identified as healthy controls. The comparison group included participations who were not diagnosed with CP from 2000 to 2013. First of all, using 1:4 matching by age, gender was used to provide an index date for the comparison group that corresponded to that of the CP cohort in order to have the same starting time for both groups. The fitting method of 1:4 matching did not eliminate too many subjects with CP and resulted in more control subjects. In order to reduce the confounding bias, we used propensity score matching to select controls. The propensity score of participants, which predicted the probability of CP exposure, was estimated by the logistic regression model. The predictors involved age, sex, monthly income, urbanization and comorbidities at baseline. By matching the propensity score, we could balance the heterogeneity between the two groups. The 1:1 matched comparisons were selected with the same propensity score as the exposure subjects. Patients diagnosed with any type of periodontal diseases before 2001 were also excluded.The patients in both CP and non-CP cohorts were followed up until diagnosis with migraine, withdrawal from insurance or the end of 2013; whichever occurred first. Migraine was defined by ICD-9 code 346. Only patients with newly diagnosed migraine were recruited with outpatient visits more than or equal to two times or admission more than or equal to one time assigned by the neurologist.The potential baseline comorbidities were determined for each patient by ICD-9 codes, including hypertension (401–405), hyperlipidemia (272.0–272.4), diabetes (250), asthma (493), coronary artery disease (410–414), stroke (430–438), alcohol-related disorder , anxiety (300.00), depression , psoriasis (696.1), obesity (278) and insomnia (780.52).t-test was applied for continuous variables. Hazard ratios (HR) that were used to calculate the effect of CP over time were estimated by Cox proportional hazard models, and the estimates of association were presented with 95% confidence intervals. Probability levels of <0.05 were considered significant.SPSS version 18  was used for all data processing and statistical analyses. To examine the differences between the CP and the non-CP cohorts, a Chi-squared test was used for categorical variables such as sex, age, monthly income, urbanization and comorbidities. The Student’s p > 0.05). In addition, the percentage of comorbidities also showed no significant differences between CP and comparison cohorts (p > 0.05). No differences between CP and controls were expected due to the propensity score matching.The flowchart in p < 0.001) after adjustment for sex, age, monthly income, urbanization and comorbidities.As shown in p < 0.001). Comorbidities of hyperlipidemia , stroke , anxiety  and insomnia  revealed an increased risk of migraine. However, there was no significant risk for migraine with monthly income, urbanization, hypertension, diabetes, asthma, coronary artery disease, alcohol-related disorder, depression, psoriasis and obesity in the adjusted model.The age-specific adjusted HR of migraine decreased 0.52 fold for ages ≥65 years as compared with the 20–64 year-old group . The femThe mean follow-up duration and time to migraine between the CP and non-CP groups is shown in p < 0.001).p < 0.001). In the male subgroup, the CP patients had a 1.50-fold increased migraine risk  compared to non-CP patients. The HR for subsequent migraine was significantly higher in subjects with CP for both sexes compared with that in the control subjects (p for interaction = 0.022).The stratified analysis of age and gender is presented in This research is the first large population-based cohort study demonstrating that patients with CP have a significantly higher subsequent risk of migraine than those without CP in a full adjustment model. Kaplan–Meier analysis revealed a significant difference between the CP subjects and controls regarding the risk of developing migraine over the 13-year follow-up period. Two previous studies have reported an association between CP and chronic migraine with a case–control observation study . HoweverOur study analyzed the potential risk factors related to the subsequent occurrence of migraine, such as sex, hyperlipidemia, stroke, anxiety and insomnia. In this study, women displayed a significantly higher risk of migraine than men. The findings were consistent with two review articles that the prevalence of migraine is generally higher among women than among men ,20. MigrAlthough the association between CP and migraine still remains unclear, several factors may be involved. The possible mechanisms may involve the same potential inflammatory mediators linked with the two diseases. Leptin, an adipocyte-derived hormone/cytokine, is expressed during inflammation and infection. It could enhance pro-inflammatory cytokine production during infection as an immune-modulator . The conMigraine, a painful neurological condition, is believed to be associated with trigeminal sensory system hypersensitivity. Migraine may be the result of neurogenic inflammation . During Migraine is proposed to be linked to vascular inflammation manifested by elevated inflammatory mediators . IncreasHelicobacter pylori (H. pylori), the Gram-negative, microaerophilic, rod-shaped bacteria, is considered to be one of the most common bacterial infections associated with chronic gastritis, duodenal ulcer and gastric cancer [H. pylori [H. pylori was found to a potential risk factor for the development of CP [H. pylori among patients who received periodontal therapy [H. pylori infection in patients with migraine [H. pylori could play a role as a key pathogenetic connector between CP and migraine. Regular dental check-ups and prophylaxis might be of benefit for migraine. Dental professions should therefore pay more attention to periodontitis patients with migraine.c cancer . In the . pylori . Recentlnt of CP . In addi therapy . Interesmigraine . Taken tThe strengths of this study included the nationwide population-based design, a low loss rate in follow-up for both cohorts and the up to 13 years of follow-up, which could reduce the selection bias. However, some limitations need to be addressed for this study. First, the diagnosis of migraine and CP was based on ICD-9 codes. However, there was no corresponding ICD-9 code for any particular type of migraine with and without aura. The severity of CP also could not be obtained from NHIRD. Therefore, the severity of CP as a risk factor for developing a particular type of migraine could not be explored. Second, there is no record of over-the-counter medicines in NHIRD. Those who suffered from migraine without regular anti-migraine agents may have made additional use of painkillers with non-official prescriptions. Third, our report is a registry-based study. There might be some patients with undiagnosed periodontitis in the comparison group. However, the use of propensity score matching in this study may reduce the selection bias and avoid the confounding variates. Fourth, relative confounding factors such as lifestyle, cigarette smoking, alcohol consumption, dietary habits and environmental factors are not provided in the LHID2010. The information about whether pain medications may affect migraine development is also incomplete in this databank. Fifth, the data presented in this study were observational; therefore, potential unknown or unmeasured confounding variables might bias the results. Nevertheless, the single-payer insurance system from the Taiwanese government, the standard clinical diagnosis criteria by ICD-9 and the strictly surveyed peer review of the medical specialists allow the NHIRD to accurately represent the sample for the general population in Taiwan. However, the actual cause–relation or bi-direction speculation is necessary for further investigation. Lastly, the ethnicity of the population in this study was Taiwanese, meaning that the results may not be applicable to other populations.The results of this study indicated that individuals with CP exhibited a higher risk of migraine than those without CP. Females had a higher risk of migraine than males. Dental professionals and medical doctors should be more aware of the correlation of CP and migraine. Further clinical and molecular studies will be necessary to confirm our observations and to provide a better understanding of this potential association.


Surgical treatment is the most important part of therapy for endometrial cancer. The aim of the study was to define factors having the most significant impact on surgical treatment of endometrial cancer when using traditional and laparoscopic methods. In the study, we evaluated 75 females who were treated for endometrial cancer via laparoscopic surgery in 2019 and used a historical control of 70 patients treated by laparotomy in 2011. The evaluated risk factors included the method of surgery, type of lymphadenectomy, patient’s age, various obesity parameters, histological grading, cancer clinical staging, pelvic dimensions, previous abdominal surgeries, comorbidities, and number of deliveries. The duration of hospitalization, operation time, loss of hemoglobin, and procedure-related complications were used as parameters of perioperative outcomes. Multivariable linear regression analysis confirmed the following factors as being predictors of worse perioperative outcomes: laparotomy, abdominal obesity (waist circumstance and waist-to-hip ratio), range of lymphadenectomy, prior abdominal surgeries, and larger pelvic dimensions. Abdominal obesity is a significant risk factor in the treatment of endometrial cancer. Laparotomy continues to be utilized frequently in the management of endometrial cancer in Poland as well as elsewhere, and adopting a minimally invasive approach is likely to be beneficial for patient outcome. Endometrial cancer is the most common gynecological cancer in developed countries, and the fourth most common cancer in women . During In randomized controlled trials, it has been shown that laparoscopy tends to be the preferred treatment for early stage endometrial cancer in obese patients, as it is associated with less postoperative pain, shorter hospitalization, and a faster return to daily activities compared with open surgery ,4. In thThe study included 145 patients with endometrioid cancer who qualified for surgery based on histopathological results, physical examination, transvaginal ultrasound, laboratory tests, and computed tomography of abdominal and pelvic cavity, in some cases. Preoperative histopathological diagnosis was made on the basis of tissues obtained mainly by targeted biopsy during hysteroscopy, and in some cases, by curettage . The research was an observational prospective study of surgical treatment for endometrioid cancer performed at an oncological gynecology center. The operations were performed under the supervision of three specialists in oncological gynecology, all with 20–30 years of experience in surgical gynecology, including approximately 20 years in laparoscopic surgery. This was a non-randomized, prospective cohort study followed by observation limited to hospitalization duration and 30 days post-discharge. During hospitalization, the loss of hemoglobin related to the procedure and the duration of the procedure and hospitalization were assessed, while in the periprocedural period and for up to 30 days following discharge, the presence of postoperative complications was assessed, such as gastrointestinal obstruction or infection of the postoperative wound with impaired healing. The study was conducted in two stages. During the first stage in 2011, approximately 90% of endometrial cancer cases were treated with open surgery in our hospital. The course of treatment for 70 patients with endometrial cancer operated on using the traditional method was analyzed. In less than a decade, this proportion has practically reversed, and now, the vast majority of endometrial cancer cases are qualified for laparoscopic treatment. The second stage of research was carried out in 2019, when 75 patients approved for laparoscopic treatment of endometrial cancer were included in the study. Before surgery, thorough clinical assessment and physical examination were performed. The clinical interview included age, number of deliveries, education in years, previous abdominal surgeries, and comorbidities. During the clinical examination, height and body mass, waist and hip circumference in centimeters using a tape measure, and pelvic bone dimensions using pelvic meter were measured. Body mass index (BMI) and waist-to-hip ratio (WHR) were also calculated during preoperative examination. The protocol is compliant with the Declaration of Helsinki and has been approved by the local ethics committee at the University of Rzeszów (No. 4/12/2011).Patients were qualified for the treatment according to applicable Polish guidelines . Open suThe range of lymphadenectomy has been divided into three classes for statistical purposes: class 1—selective lymphadenectomy in laparotomy or sentinel node procedure in laparoscopy, class 2—pelvic lymphadenectomy, and class 3—pelvic and para-aortic lymphadenectomy. Similarly, for statistical purposes, numbers were assigned to stages of endometrial cancer according to FIGO : 1-Ia, 2-Ib, 3-II, 4-IIIa, 5-IIIb, 6-IIIc1, 7-IIIc2, 8-IVa, and 9-IVb.In the perioperative period, the parameters considered as determinants regarding hospital outcomes of surgery were monitored: duration of the procedure (in minutes), the loss of hemoglobin—the difference in the serum concentration before surgery and on the second day after surgery .t-test, where applicable. Categorical variables were compared with the use of the chi-square test. Univariate and multivariate linear regression analyses were used to find significant predictors of the selected study endpoints. All potential predictors with clinical values were included in multiple regression modelling. The best models for prediction of hospitalization and procedure duration, as well as hemoglobin loss were obtained using backward elimination with Akaike Information Criterion as a target. If two variables were highly correlated (correlation coefficient >0.7), the strongest predictor was selected. The final results were presented as point estimates with 95% confidence intervals and p-values. R2 coefficients were calculated. Bootstrap model validation was performed with 1000 iterations. Model assessment was carried out by the examination of residuals. Statistical analysis was executed in R version 3.6.2 . The p-value of <0.05 was considered statistically significant.Continuous variables are expressed as mean ± standard deviation. Categorical variables are introduced as numbers and percentages. Normality was assessed with the Shapiro–Wilk test. The Mann–Whitney continuous variables in selected groups of patients were compared using the Welch test, Kruskal–Wallis test, and the Student’s p = 0.55)  .p = 0.13), number of prior abdominal surgeries (0.65 ± 0.8 vs. 0.57 ± 0.6), or concomitant diseases . Although there was a significant difference in WHR, which was greater among patients treated with laparoscopy compared with the group undergoing traditional surgery , this difference did not appear to be clinically relevant. There were also no significant differences in external conjugate (p = 0.21), interspinous (p = 0.15), intercristal (p = 0.56), and intertrochanteric diameters (p = 0.15) between the groups of patients treated by laparoscopy and open surgery. These and other anthropometric measurements are presented in There was no significant difference in the mean body mass index value between both assessed groups of patients (32.2 ± 8.0 kg/mp = 0.007). This was mainly attributed to the higher percentage of patients from the first and third classes in the laparoscopy group when compared to the traditional procedure group (p < 0.001). However, the more frequent lymphadenectomy did not contribute to the increased detection of lymph node metastases . When considering staging according to the FIGO classification, it was also greater in the laparoscopic group when compared to the group subjected to the traditional method . In the postoperative histopathological results, patients treated with laparoscopy were statistically more often diagnosed as IB stage, and less often as stage IA, according to FIGO .There were ten perioperative complications. In the group of patients treated with laparoscopy, five complications occurred: infection of the postoperative wound with impaired healing in one patient, infection of vaginal wound requiring prolonged systemic antimicrobial therapy in two patients, conversion to open surgery due to abdominal obesity and preperitoneal entry and insufflation in one patient, and omental damage and bleeding in one patient. All of these complications occurred in obese females. There were also five perioperative complications in the group of patients treated with laparotomy: infection of the postoperative wound with impaired healing in two patients, intraoperative bladder injury in one patient, gastrointestinal obstruction in one case, and intraoperative bleeding with the need of internal iliac artery ligation in one patient. There was no significant difference in the procedure-related complication frequency between both groups of patients . These durations appear longer than in some other centers [The duration of hospitalization in patients treated with laparotomy was significantly longer compared with laparoscopy . In the overall group of patients, there was significant positive correlation between the duration of operation and the following: body mass, BMI, waist and hip circumference, WHR, intertrochanteric diameter, and interspinous, intercristal, and external conjugate diameters. Multivariable linear regression analysis confirmed the following to be significant predictors of longer surgery duration: laparoscopy, waist circumference and intertrochanteric diameter, higher staging according to FIGO, and greater number of deliveries . In the overall group of patients, procedure-related hemoglobin was significantly and positively correlated with body mass, BMI, waist and hip circumference, as well as external conjugate diameter. Multivariable linear regression analysis confirmed the following significant predictors of greater procedure-related hemoglobin loss: traditional mode of hysterectomy, WHR, greater range of lymphadenectomy, and external conjugate diameter , operation duration (waist-to-hip ratio), and loss of hemoglobin (waist circumference). Chronic inflammation and metabolic disorders, more common in abdominal obesity, may also contribute to infections or longer healing of wounds, as well as circulatory and respiratory disorders . Ucella 2 .There is an interesting relationship between the dimensions of the pelvic bones and the duration of surgery, as well as hemoglobin loss. This dependence may be related to the fact that larger distances between the pelvic bones reduce the precision of movements, which is especially visible in laparoscopy when it is necessary to operate with longer instruments. Moreover, larger pelvic dimensions are more common in obese women.Multiple linear regression also indicates that a greater number of previous abdominal surgeries and longer surgery time are predictors of extended hospitalization. The greater number of deliveries was associated with a shorter hospitalization, which may be due to a lower number of comorbidities in patients with such a history. On the other hand, a greater number of deliveries correlated with longer operation time, which could be associated with a different structure of the pelvis, or more adhesions after caesarean sections.n = 313) also confirmed that women in the laparoscopy group lost significantly less blood than women in the laparotomy group [It is worth noting that the choice of the traditional surgical method is a predictor of longer hospitalization duration and greater loss of hemoglobin. In the presented study, there was no significant difference in the incidence of postoperative complications between the group of patients undergoing traditional surgery and those undergoing laparoscopy. Ucella et al. , in a mumy group . Ruan etmy group . The submy group .It was also confirmed by multivariate linear regression analysis that the extent of lymphadenectomy is a significant factor increasing hemoglobin loss. The lowest hemoglobin loss was found during sentinel node surgery using laparoscopy, and the highest during pelvic and para-aortic lymphadenectomy in laparotomy. Laparoscopic lymphadenectomy does not show less oncological efficacy than open surgery, also in the treatment of patients with early , moderatThis study can be referred to as a developmental study because it was carried out on a small group of patients. This study is limited by the use of a historical control group treated by laparotomy. The obtained results are greatly influenced by the local experience and skills of individual operators as well as by the equipment at facilities. To confirm our results, a study should be carried out on a much larger group of patients, preferably multicenter in nature, including centers with different volumes and experience of operators. The study included only patients with endometrioid cancer. The analysis was focused on the trends and correlations of individual indicators and treatment results.The frequency of complications occurring in patients treated with traditional or laparoscopic methods does not significantly differ. The course of surgical treatment using the classical method is associated with a significantly greater loss of hemoglobin and decisively longer hospitalization time. Abdominal obesity is a significant risk factor in the treatment of endometrial cancer. Obesity is associated with longer surgery duration and hospitalization, as well as greater blood loss in both laparoscopic and classic treatments. The crucial obesity-related parameters influencing the treatment of endometrial cancer are the parameters of abdominal obesity: waist circumference and WHR. The extent of lymphadenectomy is an important risk factor in hemoglobin loss. The sentinel node procedure is associated with the lowest hemoglobin loss during surgical treatment of endometrial cancer compared with other methods of lymphadenectomy. This study is limited by the use of a historical control group treated by laparotomy. However, the percentage of patients treated with laparotomy is still significant in Poland and at other centers around the world ,33. In t


Although many studies have focused on leisure time physical activity (LTPA), household physical activity (HPA) can contribute to health benefits. This study aimed to compare LTPA and HPA patterns and to examine the association of these types of activities with the risk of mortality in Korea.A total of 125,299 participants 40 to 69 years old and enrolled in the Health Examinees (HEXA) study from 2004 to 2012 were included in this study. The sex-specific LTPA and HPA categories were defined based on a questionnaire. A multinomial logistic regression was used to examine the LTPA and HPA correlates. Hazard ratios (HR) with 95% confidence intervals (95% CIs) of all-cause mortality were estimated using the Cox proportional hazard model.Overall, the LTPA and HPA patterns differed by age, income, and history of chronic diseases. LTPA reduced the risk of death, and lower risks were observed in more time spent engaged in or a vigorous LTPA intensity. The subjects who participated only in HPA and were not involved in LTPA also had lower risks of mortality  than those who did not participate in both LTPA and HPA.HPA reduced the risks of mortality in middle-aged Korean adults and could even decrease the risk of death in those who did not participate in LTPA. Participation in moderate intensity physical activity (PA) for at least 150 minutes a week was recommended by the World Health Organization for improving health benefits –15. HowePA can be divided into several domains, such as LTPA, walking/transportation, occupational PA, and household PA (HPA). Each type of PA has different characteristics and intensities. For example, HPA mainly uses the upper body and is less active, whereas LTPA is more active and aerobic , 17. NevAlthough a few studies have investigated the association between HPA and the risk of mortality, they had a relatively small number of study participants, and most of the studies focused on elderly people (over 60 years old) , 21–24. This study included the participants in the Health Examinees-Gem (HEXA-G) study who were derived from the Health Examinees study, a component of the Korean Genome and Epidemiology Study (KoGES_HEXA). The KoGES_HEXA study was a large-scale genomic cohort study that recruited participants who were aged 40 to 69 years old between 2004 and 2013 from 38 general hospitals and health examination centers. The further details of the surveys are described elsewhere , 26. AllThe HEXA-G study consisted of 139,345 participants after excluding 30,382 subjects with the following exclusion criteria: they participated only in the pilot study years 2004–2006, they did not meet the HEXA biospecimen quality control criteria , and they participated in the study for less than two years . After eParticipation in LTPA and HPA was investigated using interviewer-administered questionnaires. Information concerning LTPA was collected by assessing the frequency of participation in a week and with a duration of average minutes at a time. Four types of HPA, including washing clothes by hand, cleaning, dishwashing, and gardening, were included in the questionnaire. Information on the participation in each type of HPA, the frequency of participation per week, and the duration of the time spent in these activities was collected. To calculate the total amount of time that was spent in LTPA per week, the answers concerning frequency were multiplied by the duration in minutes.The LTPA level was classified into three group , according to the World Health Organization , the LTPTo examine the domain-specific effects, we categorized the men and women separately into three groups: “Inactive” (those who did not participate in either HPA or LTPA), “HPA only” (those who participated in HPA but not in LTPA), and “Doing LTPA” (those who participated in LTPA) for men, and “Minimum obligatory HPA” (those who participated in 2 or less types of HPA and did not participate in LTPA), “HPA only” (those who participated in 3 or 4 types of HPA but not in LTPA), and “Doing LTPA” (those who participated in LTPA) for women.The study for validation of HEXA-G study’s physical activity questionnaire (PAQ) is in progress. Validity of the PAQ was tested and was reported in a previous conference. In the validation study, 223 subjects who were 40 to 69 years of age were included. They completed the HEXA-G study’s PAQ and the total time of participation in PA was objectively measured by wearing an Actigraph for 7 days. The total time of LTPA from PAQ was compared to total time of moderate to vigorous PA (MVPA) from the Actigraph and the total time of HPA from PAQ was compared to light intensity PA from the Actigraph. The LTPA and HPA data from the HEXA-G study’s PAQ were positively correlated with the objective measures from the Actigraph and showed moderate correlation coefficients values: rho = 0.399, p < 0.001 (LTPA with MVPA), and rho = 0.311, p < 0.001 (HPA with light PA), respectively. We observed that time of LTPA and HPA in HEXA-G study’s PAQ was less than the total time of MVPA and light intensity PA from the Actigraph through Bland-Altman analysis: mean difference between MVPA and LTPA (MVPA–LTPA) = 33.405 minutes per day (limits of agreement: -32.180 to 98.991 minutes per day) and mean difference between light intensity PA and HPA = 255.179 minutes per day (limits of agreement: 46.308 to 464.049 minutes per day).Information such as age, sex, education level, income level, marital status, current occupation, smoking status, drinking habits, total energy intake, and history of chronic diseases was also collected using questionnaires. These variables were selected as a priori potential covariates. The total energy intake  was calculated from a 106-item, self-administered Food Frequency Questionnaire (FFQ) via a food composition table developed by the Korean Health and Industry of Development Institute . This coA univariate analysis was conducted to examine the proportions of participants, the means of the total participation time per week (with standard deviations), and the medians of the total participation time per week (with interquartile ranges) in each PA category.Next, the associations between each factor of the baseline characteristics and the participation in LTPA or HPA were estimated using a multinomial logistic regression to examine the correlates of participation in different types of PA. After the univariate analysis, a fully adjusted model was fitted into the multinomial logistic regression, adjusting for age, education level, income, marital status, occupation, body mass index (BMI), smoking status, drinking status, total energy intake, disease history, and LTPA or HPA, reciprocally. A heterogeneity test was conducted to evaluate the differences in the estimated odds ratios (ORs) between LTPA and HPA using the Q-test . The difHazard ratios (HRs) with 95% confidence intervals (95% CIs) of all-cause mortality were estimated using the Cox regression analysis with age as the time scale. After the examination of the associations between each covariate and all-cause mortality, a fully adjusted model was determined by adjusting for education level, income, marital status, occupation, BMI, smoking status, drinking status, total energy intake, and disease history. These variables were potential confounders that were correlates of participation in LTPA and HPA and also exhibited associations with the risk of all-cause mortality. Further analyses examined the domain-specific effects according to the following categories: “Inactive (reference),” “HPA only,” and “Doing LTPA” for men and “Minimum obligatory HPA (reference),” “HPA only,” and “Doing LTPA” for women. The analyses for all-cause mortality were repeated after the exclusion of the first two years of follow-up to rule out potential confounding effects by the presence of diseases at baseline. The proportional hazard assumption was graphically tested by plotting the scaled Schoenfeld residuals and the log-log survival plots. All of the analyses were conducted using SAS version 9.4  from January to May 2019.In middle-aged Korean adults, 56.2% of men and 49.6% of women participated in LTPA, and 43% of men and 37.4% of women achieved recommendation levels of PA .There was a considerable difference in the proportions and participation times in HPA between men and women. Most of the women participated in HPA (96.2%), whereas fewer than half of the men participated in HPA (42.6%). Moreover, the women spent considerably more time performing HPA (737.8 minutes per week on average) than the men (331.8 minutes per week on average).The LTPA and HPA participation patterns differed in terms of age, income, and history of chronic disease for both sexes. The subjects who were older, had higher incomes, and had a history of chronic disease at baseline were more likely to participate in LTPA , while they were less likely to participate in HPA . In addition, women who received more education tended to participate more in LTPA ; however, they participated less in HPA . Men who were living alone were less likely to participate in LTPA , while they more likely to participate in HPA . These LTPA participation patterns were consistent when the subjects were classified into three groups according to the LTPA intensity, the level of LTPA participation, and the PA domain  Tables.The mean follow-up time was 5.2 years, and 2,007 deaths occurred during this time period Tables .The risk of all-cause mortality was higher when the participants had lower education and income levels, were ever smokers, were former drinkers, and had disease histories at baseline. Men who were living alone, unemployed (or worked at home), manual workers, and underweight showed higher risks of mortality, whereas the women did not exhibit these associations .Participation in LTPA and the achievement of recommendation levels reduced the risk of mortality, although the association was attenuated in the adjusted model for women . Both meWhen the participants were stratified into the PA domains, the risk of mortality for men who participated only in HPA decreased compared with those who were inactive. A lower risk of mortality was also observed in men who participated in LTPA; however, this association was attenuated in the multivariable model. Women who participated in 3 or 4 types of HPA exhibited marginally lower risks of mortality than those who participated in the minimum obligatory HPA. When women also participated in LTPA, the risk of mortality was more reduced: HR = 0.81, 95% CIs: 0.68–0.97 .The proportional hazard assumption was graphically tested by plotting the scaled Schoenfeld residuals and the log-log survival plots. Although LTPA for men exhibited a nonzero slope and a correlation with time in the Schoenfeld residual plot, a parallel graph was observed in the log-log survival plots, and an interaction with time was not observed. The other variables were not violated in the proportional hazard assumption.All of the results for mortality were robust even after the exclusion of the first 2 years of follow-up .In this study, the correlates between HPA and LTPA differed with regard to age, income, and history of chronic disease in both men and women. Education level was a differentiating factor between LTPA and HPA only for women, whereas marital status distinguished the tendency of participation between LTPA and HPA only for men. The participation in LTPA decreased the risk of mortality, and this risk was lower when the subjects spent more time in or were involved in a vigorous intensity of activity. The participation in HPA also decreased the mortality risk; interestingly, the risk of mortality was reduced even when they participated only in HPA and did not participate in LTPA.A recent review reported the correlates of PA by the domains . AlthougThe HPA patterns in our study of unemployed people or housewives, individuals who had never smoked, and those who were more active during leisure time as well as more educated men, men living alone, less educated women, and married women who exhibited more participation in HPA were similar to other populations , 47. AltIn the present study, all-cause mortality similarly decreased up to 17% in men who participated in HPA and in women who participated in more than 2 types of HPA, in contrast to previous studies that reported an inverse association between HPA and the risk of all-cause mortality only in women , 22 or wTo the best of our knowledge, this was the first study to examine the effect of HPA solely for risk of mortality compared with a totally inactive group through domain-specific categories. This study was conducted in a larger study population than previous studies to examine the association between HPA and the risk of mortality. Finally, when the PA patterns that are based on regional and cultural characteristics are considered , 43–46, This study had several limitations. First, we used only LTPA and HPA among the various PA domains. The HEXA-G questionnaire also included occupational PA and transportation; however, this information was collected during a limited time period. Second, the PA information was collected using self-reported questionnaires. This strategy might have led to a recall bias of LTPA and HPA participation . AlthougThis study found that participation in HPA had a meaningful effect on health benefits, even in the subjects who did not participate in LTPA. Woodcock et al. demonstrated that nonvigorous PA could also reduce the risk of all-cause mortality and that the transition from no activity to a low level of activity had the most considerable benefits . CurrentS1 Fig(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.


The combination of Chinese patent medicine Wenxin Granules (WXG) and antiarrhythmic drugs has been widely used in the treatment of atrial fibrillation (AF), but the results are controversial. This study will conduct a network meta-analysis (NMA) based on data from randomized controlled trials to evaluate the efficacy and safety of WXG combined with ADDs  in the treatment of AF, which will perform comparisons or rankings of efficacy among the currently available therapeutic schemes in order to provide evidence to determine the optimal threshold and treatment regimen to AF patients.A comprehensive systematic literature search will be conducted in Cochrane Library, PubMed, Web of Science, EMBASE, Chinese Biomedical Literature Database (SinoMed), Chinese National Knowledge Infrastructure (CNKI), and WanFang database for randomized controlled trials about the WXG with ADDs. The NMA will be conducted following the PRISMA-NMA guidelines. Statistical analyses will be conducted by using Stata software (version 14.0) and RevMan software (version 5.3).The results of this NMA will provide a high-quality evidence for the efficacy of WXG combined with ADDs in the treatment of AF, and a ranking of the therapeutic classes will also be presented.The protocol will provide updated evidence for the application of WXG for AF. In 2010, the number of men and women suffering from AF worldwide was as high as 20.9 million and 12.6 million, respectively.–4 In Europe and the United States, the proportion of adults over 40 years of age who develop AF can reach a quarter.–7 It is estimated that by 2030, the number of patients with AF in Europe will be approximately 17 million, and there will be 1.2 to 2.1 million newly diagnosed AF patients each year. AF has become a major public health problem that affects the health of national residents, which hinders social and economic development. The prevention and treatment of AF has become one of the main battlefields in the field of cardiovascular disease.Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. The results of many clinical randomized controlled trials show that supplementary and alternative drugs have similar antiarrhythmic effects with AAD, and the incidence of adverse events is low.–11 Among them, Wenxin granule (WXG), which is composed of 5 kinds of Chinese herbal medicines, including Ginseng (ren shen), Polygonatum (huang jing), pseudo-ginseng (san qi), lamber (hu po), and Nardostachys Chinensis (gan song), is commonly used in AF treatment practice. The formula of WXG is based on the traditional Chinese medicine theories of tonifying Qi, nourishing Yin, promoting blood circulation to remove the obstructions to calm the mind.Current treatments for AF include radiofrequency ablation, conventional surgery, and drug therapy. In 2014, the guidelines issued by the American Heart Association/American College of Cardiology/American Heart Rate Association (AHA/ACC/HRS) recommended that patients with symptomatic AF use at least 1 class I or class III antiarrhythmic drugs after they are ineffective and recommend catheterization Radiofrequency ablation (Class I recommendation).There are many clinical studies on the treatment of AF with WXG, but there is still a lack of comprehensive collation and systematic evaluation of the efficacy and safety of WXG intervention in AF. Therefore, the purpose of this study is to conduct a comprehensive and systematic evaluation of the effectiveness and safety of WXG combined with AADs in the treatment of AF.22.1 and we had registered the protocol on the PROSPERO International (No. CRD42020163601).We will conduct this network meta-analysis of clinical trials in conformity with the guidelines put forth by the Preferred Reporting Items for Network Meta- (PRISMA-NMA) statement,2.2In this study, we will search 7 commonly used databases: Cochrane Library, PubMed, Web of Science, EMBASE, Chinese Biomedical Literature Database (SinoMed), Chinese National Knowledge Infrastructure, and WanFang database. The retrieval time begins on the database's build date and ends in November 2020. In addition, the reference documents of the included studies will be traced back to supplement the acquisition of relevant documents. The search strategy will be adjusted according to the characteristics of different databases. Table 2.32.3.1Randomized controlled trials regarding WXG combined with AADs  for AF will be included. There are no restrictions on the patient's previous disease, course of disease, age, gender, and race.2.3.2 will be included.Patients who have undergone an ECG or 24-hour Holter examination and meet the AF diagnostic criteria  of AHA/ACC/HRS 2019 Atrial Fibrillation Treatment Guidelines2.3.3On the basis of conventional treatment, the experimental group will be treated with WXG combined with AADs . Conventional treatments include antiplatelet agents, β-receptor blockers, renin-angiotensin aldosterone inhibitors, blood lipids and blood pressure regulating drugs, and symptomatic treatment drugs for patients with other diseases.2.3.4Patients in the control group are those who only have received AADs treatment without WXG.2.3.5The primary outcomes will be the clinical efficacy, clinical symptom efficacy, conversion success rate, sinus rhythm maintenance rate, number of AF episodes, P wave dispersion, and P wave maximum time.The secondary outcomes will be the indicators of cardiac function, such as left ventricular ejection fraction (LVEF), left ventricular end diastolic diameter (LVEDD), left atrial diameter (LAd), ventricular rate, and the occurrence of adverse reactions.2.4Two medical workers (SQS and YGC) engaged in the clinical treatment of AF will conduct a literature search respectively. We will strictly follow the pre-established inclusion and exclusion criteria for the preliminary screening and secondary screening of the literature. At the same time, the 2 researchers will independently extract the data, and finally submit it to the third researcher (YHH) conducts the comparison. If there is any fallacy or disagreement, the third researcher will make a judgment. If there are missing data or information in the literature, we will try to contact the author by email or phone to complete it. The literature retrieval process of our study will use the PRISMA flowchart, as shown in Figure The main data or materials extracted from the literature data of this study include: the title of the paper, the first author, the year of publication, the sample size of each arm, the precautionary measures, the age, the course of treatment, the follow-up time, the related items of the literature quality evaluation and the related outcome indicators.2.5 The tool includes evaluation in 7 areas: random sequence generation, allocation hiding, blinding of participants and personnel, blinding of outcome measurers, incomplete result data, selective reports, and other biases. The risk of bias in each area will be judged as low, high, or unclear. In a study, if the risk in all areas is low, then the overall risk of bias will be classified as low risk. If the risk in one or more areas is high, then the overall risk of bias will be classified as high risk. Otherwise, it will be classified as an unclear risk.This study will use Cochrane Handbook 5.1.0 risk bias tool for the quality assessment.2.6 As corresponding, count data will use odds ratio and the 95% confidence interval of odds ratio as the effect size of statistical data. In this study, the χ2 test will be used to test the heterogeneity of the included studies. P > .05 and I2 < 50% will be used as the criteria for heterogeneity test. When the above 2 statistical conditions are met, it indicates that the combined effect size performed has good homogeneity, and the fixed effects model is used. If after the heterogeneity test, as long as one of them does not meet, it indicates that the homogeneity of the combined effect size is not ideal, and the random effects model needs to be used for statistics.In the statistical analysis, for continuous variables, the weighted mean difference after treatment will be used as the effect size, and the 95% confidence interval  of weighted mean difference will be calculated. The node splitting method (node-splitting measurement) will be used for consistency test. If the difference is not statistically significant (P > .05), it indicates that the results of direct comparison and indirect comparison are consistent, then Stata14.0 will be used to test each closed loop for consistency. In this study, the cumulative ranking probability of each treatment scheme will be calculated by using surface under the Cumulative ranking (SUCRA). The larger the value of SUCRA, the better the effect of this intervention.Stata 14.0 software  will be used to draw the network evidence relationship diagram, forest diagram, rank probability diagram, funnel diagram, and corresponding statistics.2.7P > .05, it means that there is no publication bias. If P < .05, it means that there is publication bias. When conducting sensitivity analysis, after excluding the research with low quality, high weight, and different results from other studies, we will calculate the combined statistics and compare with the combined statistics before the exclusion. If the 2 results are the same, then result of meta-analysis is stable, conversely, the results would be unstable.The Begg test will be used to analyze the potential publication bias. If 2.8It is not necessary for ethical approval because it is based on published studies. The protocol will be disseminated in a peer-reviewed journal or presented at a topic-related conference.3 which have a significant inhibitory effect on AF induced by acetylcholine, through inhibiting matrix remodeling after atrial ablation. At the same time, clinical studies confirmed that WXG combined with low-dose amiodarone to maintain sinus rhythm therapy after radiofrequency in patients with AF can improve heart function, reduce drug side effects, and obtain more clinical benefits. Our network meta-analysis will conduct a detailed summary and analysis of WXG combined with AADs in the treatment of AF to find the best treatment plan. A particular advantage of our study will be to increase the safety analysis of various antiarrhythmic treatments, and we will collect data on drug-related side effects in our study to assess the tolerance of different treatments. The results of this meta-analysis may help physicians determine the best treatment options for AF patients.As a common clinical arrhythmia disease, AF is accompanied by high prevalence, high disability, and high mortality. In recent years, studies have suggested that WXG can selectively affect atrial muscle action potentials,Conceptualization: Shuqing Shi, Qiulei Jia.Data curation: Shuqing Shi, Yuguang Chu.Methodology: Yuguang Chu.Project administration: Yuanhui Hu.Writing – original draft: Shuqing Shi, Yuguang Chu.Writing – review & editing: Shuqing Shi, Qiulei Jia.