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Anesthesia & Analgesia:
doi: 10.1213/ANE.0b013e31828e5cf0
Ambulatory Anesthesia: Research Report

Perioperative Smoking Behavior of Chinese Surgical Patients

Yu, Chunhua MD*; Shi, Yu MD, MPH†‡; Kadimpati, Sandeep BDS, MPH; Sheng, Yu PhD§; Jing, Jing BSN§; Schroeder, Darrell MS‡‖; Luo, Ailun MD*; Warner, David O. MD†‡

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From the *Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China; Department of Anesthesiology and Nicotine Research Center, Mayo Clinic, Rochester, Minnesota; §School of Nursing, Peking Union Medical College Hospital, Beijing, China; and Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.

Accepted for publication February 5, 2013.

Published ahead of print April 4, 2013

Funding: This work was supported by funds from Peking Union Medical Center Hospital, Beijing, China, and Mayo Clinic, Rochester, MN.

The authors declare no conflicts of interest.

Ailun Luo, MD and David O. Warner, MD contributed equally to this work.

Reprints will not be available from the authors.

Address correspondence to David O. Warner, MD, Department of Anesthesiology, Mayo Clinic, 200 First St. Southwest, Rochester, MN 55905. Address e-mail to warner.david@mayo.edu.

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Abstract

BACKGROUND: Surveys suggest that, consistent with a high smoking prevalence, Chinese smokers in the general population report little interest in quitting. In other cultures, surgery is a powerful teachable moment for smoking cessation, increasing the rate of spontaneous quitting. We determined the perioperative tobacco use behavior of Chinese patients scheduled for elective surgery who smoke cigarettes and factors associated with both preoperative intent to abstain and self-reported smoking behavior at 30 days postoperatively. Specifically, we tested the hypothesis that perception of the health risks of smoking would be independently associated with both preoperative intent to abstain and self-reported abstinence at 30 days postoperatively.

METHODS: Patients ≥18 years of age scheduled for elective noncardiovascular surgery at Peking Union Medical College Hospital in Beijing, China, were assessed preoperatively and up to 30 days postoperatively for factors associated with smoking behavior, including indices measuring knowledge of smoking-related health risks.

RESULTS: Of the 227 patients surveyed at baseline, most (164, 72%) intended to remain abstinent after hospital discharge. For the 204 patients contacted at 30 days postoperatively, 126 (62%) self-reported abstinence. In multivariate analysis, factors associated with preoperative intent to abstain after surgery included older age, self-efficacy for abstaining, and undergoing major surgery; factors associated with abstinence included older age, self-efficacy, major surgery, and preoperative intent to abstain. Higher perception of benefits from quitting was associated with intent, but not abstinence. Knowledge of the health risks caused by smoking was not found to be associated with either intent or abstinence, so that the hypothesis was not supported.

CONCLUSIONS: Both intent to quit and self-efficacy for maintaining abstinence appear to be much higher in Chinese surgical patients than in prior surveys of the general Chinese population, and the majority of surgical patients maintained abstinence for at least 30 days. These findings suggest that surgery can serve as a powerful teachable moment for smoking cessation in China.

Smokers comprise approximately one-third of the Chinese population, or approximately 300 million people (57% of men and 3% of women), representing one-third of the world’s smokers.1 The recent International Tobacco Control (ITC) China survey of the general Chinese population showed that most do not intend to quit smoking, but for those who do plan to quit the most common reason is illness.2,3 Data from other countries show that hospitalization is an excellent opportunity to deliver smoking interventions.4 Surgery provides a unique intervention opportunity for 2 reasons. First, smokers face the immediate consequences of smoking around the time of surgery, including an increased risk for cardiac, pulmonary, and wound-related complications.5,6 Current evidence suggests that perioperative abstinence can reduce risk.7 Second, surgery can be a “teachable moment” for smoking cessation (i.e., an event that prompts spontaneous behavioral change).8,9 Thus, surgery is an excellent opportunity to motivate smokers to attempt either short-term or long-term abstinence. However, no data are available regarding the smoking behavior of Chinese patients in the perioperative period, almost all of whom are hospitalized. As a first step in developing tobacco interventions directed at Chinese smokers undergoing surgery, it is important to understand the smoking behavior and the factors that may predict postoperative abstinence. For example, patients’ perceptions of how great a risk smoking may present to surgery is unknown. McBride 10 proposed a heuristic in which an event such as surgery is a teachable moment for behavior change to the extent that it increases perception of risk, among other factors. If this heuristic is valid, enhancement of risk perception could be an important goal of future intervention efforts.

The purpose of this study was to describe the perioperative tobacco use behavior of Chinese patients scheduled for elective noncardiovascular surgery who smoke cigarettes, including their attitudes, beliefs, and intentions. We further determined factors associated with both intent to abstain and self-reported smoking behavior at 30 days postoperatively. Specifically, we tested the hypothesis that perception of the perioperative risks caused by cigarette smoking would be independently associated with both preoperative intent to abstain and self-reported abstinence at 30 days postoperatively.

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METHODS

The study was conducted at Peking Union Medical College Hospital, a major referral center in Beijing, China, and was approved by its IRB. All patients scheduled for elective surgery are admitted to the hospital for at least 1 day and after the procedure, and smoking is not allowed in patient care areas. However, like most Chinese hospitals, there are specific areas where smoking is allowed so that both patients and staff can smoke on hospital grounds if they are able to access these areas. No smoking cessation counseling services are available for patients in this hospital. Eligibility criteria included current smoking (defined as >100-cigarette lifetime consumption and smoking every day or some days), being ≥18 years of age, and being scheduled for nonemergency, noncardiovascular surgery. Potentially eligible patients were approached at least 1 day before surgery on a convenience basis. Written informed consent was obtained from those patients who agreed to participate, and subjects received remuneration for completion of study assessments.

Subjects were assessed after hospital admission (initial assessment), the morning of surgery (preoperative assessment), and at 3 and 30 days after surgery. Patients were assessed in person by study personnel while in hospital and via telephone if discharged. Contacts were attempted up to 2 months after discharge or until subjects declined further participation. All assessments were presented verbally to subjects by 1 of 2 trained study nurses. Assessments were constructed in English, translated into Chinese, then back-translated to ensure accuracy of translation.

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Baseline Measures

Demographic information and comorbidity were abstracted from the medical record, with comorbidity defined as disease requiring pharmacotherapy. A baseline smoking history was administered, which included the Fagerström test for nicotine dependence (FTND),11 smoking behavior of friends and family, and information regarding prior quit attempts.

Several items queried potential changes in smoking behavior, including intent to quit smoking in the future (taken from the ITC China survey of the general population conducted in 2006),12 the Contemplation Ladder (a validated measure of readiness to quit),13 intent to remain abstinent after hospital discharge, and likelihood of abstinence after hospital discharge.14 Self-efficacy was assessed by the 12-item version of the Smoking Self-Efficacy Questionnaire (SEQ-12), which has been recently validated among Chinese cardiac patients who smoke.15 To facilitate comparisons with the prior ITC survey, self-efficacy was also assessed by the single item used in this survey (“How sure are you that you would succeed in quitting”).12

Two indices were constructed to measure knowledge of the health risks of smoking. Four items from the ITC China survey assessed knowledge of the general health risks of smoking (Health Risk Index).16 In addition, 4 questions related specifically to the risks of smoking on perioperative complications (e.g., increased risks of wound infections) were formulated on the basis of the ITC China survey items (Surgical Health Risk Index). Also from the ITC China survey, a single item queried knowledge of how secondhand smoke affected cancer risk, and 2 items were included related to the health benefits of quitting and how worried respondents were about potential damage of smoking to health. An additional measure (Social Support Index) was created to measure the importance of social support in assisting abstinence attempts, consisting of 6 items using a 5-point Likert scale.

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Subsequent Assessments

On the morning of surgery, interval smoking history (including the time of last cigarette) was assessed, as was the expired CO level (Micro Smokerlyzer®, Bedfont, Kent, United Kingdom). Interval smoking history was also obtained at subsequent assessments (postoperative days 3 and 30). Major surgeries were defined as those that involved opening a body cavity (including intracranial, intrathoracic, and intra-abdominal procedures), opening of a large joint (including total joint arthroplasty), spinal surgery which involved >2 segments, or major head and neck procedures (defined as requiring laryngectomy and/or tracheotomy). Other surgeries were classified as minor procedures. This categorization was made as surgical intensity is an important determinant of postoperative smoking behavior in other populations.17,18

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Data Analysis

The factor structure of each index was characterized by conducting principal component factor analysis with promax rotation. For the 6-item Social Support Index, a score was calculated by averaging the numerical values assigned to each response. For the two 4-item health risk indices, the number of “yes” responses for each 4-item scale was summed. The internal consistency of scales was quantified by calculating Cronbach coefficient α.

Continuous and 7-day point-prevalence smoking abstinence by patient self-report was assessed at 30 days postoperatively.19 Separate analyses were performed to determined characteristics associated with preoperative intent to abstain from smoking after hospital discharge and self-reported 7-day point-prevalence abstinence at 30 days postoperatively. Initial analyses were performed to assess the univariate association of candidate variables with each of these end points using logistic regression for continuous variables and the χ2 test for nominal variables. For continuous variables, we assessed the linearity assumption using the approach described by Hosmer and Lemeshow.20 In short, we divided each continuous variable into quintiles. Using the lowest quintile as the reference group, we fit a logistic regression model which included 4 design variables for the 2nd, 3rd, 4th, and 5th quintiles. The estimated coefficients (along with 95% upper and lower confidence bounds) were then plotted versus the quintile midpoints, and these plots were visually inspected to confirm that there were no obvious deviations from linearity. Characteristics found to be statistically significant in univariate analysis were considered for inclusion in a multivariate analysis. In cases where 2 or more candidate variables were highly correlated the variable with the strongest association from the univariate analysis was selected for the multivariable model. All potential 2-way interactions of the factors included in the multivariable model were assessed. In all cases, P ≤ 0.05 were considered statistically significant. Analyses were performed using SAS version 9.2 (SAS Institute Inc, Cary, NC) and JMP version 9.1 (SAS Institute Inc).

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RESULTS

From March to September 2011, 339 eligible patients were approached. Every patient approached met study criteria (including the availability for telephone follow-up) and was offered enrollment; 242 (71%) agreed to participate and completed the baseline questionnaire (Fig. 1). Surgeries were cancelled in 15 of these patients after enrollment, and their data are not further considered. Of the 227 remaining patients, 23 (10%) refused further contact after baseline assessment or could not be reached at 30 days postoperatively. Therefore, baseline assessments are reported in 227 patients, and data and analyses that depend on 30-day postoperative assessments are reported for 204 patients. The distribution of surgical procedures and other baseline characteristics (Table 1) were similar in those patients who did and did not receive follow-up at 30 days (data not shown).

Table 1
Table 1
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Figure 1
Figure 1
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Study patients were predominantly men and had a long smoking history (Tables 1 and 2). Nicotine dependence was pronounced, as indicated by the FTND (median value of 4 [interquartile range: 2–6], with 83 (37%) having a FTND ≥6 indicative of high dependence).21 The majority had never made a serious quit attempt, and few had made an attempt over the year before surgery. Nonetheless, nearly 3 of 4 planned to quit after hospital discharge, and 58% felt that they would be likely or very likely to succeed. This is consistent with the SEQ-12 scores, which indicated a relatively high level of self-efficacy (5.8 ± 2.4 of 10), and the Contemplation Ladder score (7.0 ± 3.0 of 10). Interest in tobacco interventions was also strong; 116 patients (50%) strongly or somewhat agreed that they would be interested in a program to help them stop smoking, and 122 (53%) strongly or somewhat agreed that they would be willing to seek help from a health care professional to do so.

Table 2
Table 2
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Factor analysis of the 3 indices (Social Support Index, Health Risk Index, and Surgical Health Risk Index) revealed acceptable loading of each indicator used to derive the index onto a single factor (parameter estimates ≥0.55 for each; values provided in Table 3), and acceptable internal consistency (α of 0.73, 0.72, and 0.81, respectively). Regarding the role of social support, subjects were more likely to agree with statements related to the importance of family in supporting cessation compared with those related to friends (Table4). Other household members smoked in 100 (43%) subjects, and 145 (63%) subjects reported that many or all of their friends smoked. Awareness of the health risks of smoking was highest for lung cancer and emphysema and lowest for the risk of heart disease and stroke (Table 5). Approximately half of subjects were aware of how smoking increased the risks of surgery (Table 5). The majority of subjects (141, 62%) felt that their overall health would benefit very much from quitting, and a near majority (100, 44%) reported being very worried that smoking would damage their health in the future.

Table 3
Table 3
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Table 4
Table 4
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Table 5
Table 5
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At the preoperative assessment, 206 of 227 (91% [95% confidence interval, 86%–94%]) patients reported not smoking the morning of surgery. This self-report was consistent with a low expired CO level measured preoperatively (2 ± 2 ppm, n = 227). At 30 days postoperatively, 126 of the 204 patients for whom follow-up was available (62% [55%–68%]) self-reported 7-day point prevalence abstinence, with 117 (57% [50%–64%]) reporting continuous abstinence since surgery. Very few patients (<1%) used medication or any other aids to help them to quit smoking.

Factors significantly associated with preoperative intent to maintain postoperative abstinence in univariate analysis included older age, higher educational attainment, higher perceptions of benefits from quitting and worry about health damage from smoking, higher Surgical Health Risk Index, higher Social Support Index, interest in getting help from providers and participating in a stop-smoking program, major surgery, and higher self-efficacy (as measured by the SEQ-12; Table 6). Factors significant in multivariate analysis included older age, higher perception of benefits from quitting, higher interest in a stop-smoking program, higher Social Support Index, receiving major surgery, and higher self-efficacy (Table 7) but not the Surgical Health Risk Index. Substitution of the related factor of worries about health damage for perceptions of benefits from quitting in the model did not qualitatively change the results, and this factor was statistically significant in this model (data not shown). The same was true when the factor of interest in provider help was substituted for interest in a smoking program (data not shown). No potential 2-way interaction of factors included in the multivariate model was statistically significant.

Table 7
Table 7
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Table 6
Table 6
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Factors significantly associated with abstinence at 30 days in univariate analysis included older age, having made a quit attempt in the last year, higher Social Support Index, receiving major surgery, intent to maintain abstinence, preoperative report of a higher likelihood of maintaining postoperative abstinence, and higher self-efficacy (Table 6). Factors significant in multivariate analysis included older age, higher self-efficacy, receiving major surgery, and intent to maintain abstinence (Table 7), but not the Surgical Health Risk Index. Substitution of the related factor of likelihood of maintaining abstinence for intent and self-efficacy (as measured by the SEQ-12) in the model did not qualitatively change the results, and this factor was statistically significant in this model (data not shown). Receipt of advice to not smoke by hospital personnel was not associated with either intent or abstinence (Table 6). No potential 2-way interaction of factors included in the multivariate model was statistically significant.

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DISCUSSION

The major finding of this study is that we found no evidence to support the hypothesis that perception of the surgical risks presented by cigarette smoking is independently associated with preoperative intent to abstain or self-reported abstinence at 30 days postoperatively. Nonetheless, a majority of Chinese cigarette smokers undergoing elective surgery self-report abstinence at 30 days postoperatively, even in the absence of systematic tobacco use interventions.

Preoperative smoking behavior of these surgical patients is consistent with that reported in the prior ITC survey of the general Chinese population,16,22 whose respondents reported similar demographic factors such as age, gender, and educational attainment. Also comparable is that approximately half of these surgical patients had never attempted to quit smoking. In contrast, the high levels of both intent and self-efficacy reported by these surgical patients differed markedly from the ITC survey results. The proportion of smokers intending to quit at some point in the future was much higher in these surgical patients compared with the ITC survey3 using the same item to assess intent (81% and 24%, respectively, P < 0.0001, χ2 test). Even for those who had resumed smoking at 30 days postoperatively, a majority (57%) planned on quitting in the future. Similarly, self-efficacy (measured by the proportion of subjects who answered the item “How sure are you that you would succeed in quitting” as very or extremely sure) was significantly higher in these surgical patients compared with the ITC survey (56% and 27%, respectively, P < 0.0001, χ2 test). A high 30-day self-reported quit rate was observed despite the fact that most had never made a quit attempt and received no assistance, and many were highly dependent on nicotine. This finding is consistent with prior findings that surgery is a teachable moment for smoking cessation, in that surgery prompts spontaneous behavioral change, in this case, quitting smoking.8,17,18,23 It is also consistent with prior studies indicating that illness is the most common factor motivating quit attempts in the Chinese population.2,3

The underlying factors that determine whether an event is a teachable moment remain largely unexplored. Based on the heuristic of McBride et al.,10 we hypothesized that perception of the health risks of smoking would be associated both with preoperative intent to abstain and actual postoperative abstinence. The level of knowledge in these surgical patients regarding individual general health risks was similar to the prior ITC survey.16 For each question posing the individual known perioperative risk of smoking, approximately half of the patients agreed it was true. However, knowledge of risk was not independently associated with the intent to quit. Rather, perception of benefit from quitting (or worry about health risks) was associated with intent, suggesting that affective responses to knowledge, rather than knowledge of risk itself, is determinative. This is consistent with prior work in the general Chinese population showing that benefit perception (and worries about risks) is associated with intent to quit22 and work in other settings linking health beliefs and intent.24 However, neither health risk knowledge nor the affective responses to that knowledge were associated with abstinence, a finding that does not support the hypothesis that heightened risk perception independently contributes to the teachable moment effect. This finding suggests that in the future development of any tobacco use interventions directed toward this population, attempts to heighten risk perception may not be useful in terms of promoting abstinence; and that attention could be directed toward other goals such as heightening self-efficacy.

This finding illustrates that not every factor associated with intent predicted behavior. Indeed, although there was a strong relationship between intent and abstinence in multivariate analysis, other factors also were independently associated with abstinence, which has been noted for many behaviors, including smoking.25 Three factors independently predicted abstinence, and each was also associated with intent. In many settings, older age is associated with intent and success in quitting,26–29 which was also the case in the current study. This is in contrast to the ITC China survey, which found no association between age and intent,16,22 but is consistent with a study in Taiwan.30 Self-efficacy as measured by the SEQ-12 (and the related measure of likelihood) was also associated with both intent and abstinence, consistent with prior work in Chinese cardiac patients who smoke15 and prior studies of other smokers.31–33 Finally, the intensity of surgery was predictive of both, again consistent with prior work in surgical patients,8,17 emphasizing the important role of the surgical experience itself in changing behavior.

Other factors were associated with intent, but not abstinence, including interest in a stop-smoking program and the perceived importance of social support. The latter finding is consistent with prior studies showing the importance of social support in maintaining abstinence after hospital discharge34,35 and data from the ITC China survey indicating that family disapproval is an important motivator of quit attempts.3 However, several factors associated with intent or abstinence in a variety of other settings,25,29,36 including cigarette consumption, nicotine dependence, and educational attainment, were not predictive in these surgical patients. Also, in contrast to the ITC China survey results,22 recent quit attempts (as assessed by a quit attempt within the last year) were not associated with intent to quit in these surgical patients. It is possible that the powerful influence of surgery itself, as indicated by the relatively high postoperative abstinence rates and the fact that surgical intensity was highly predictive of abstinence, may overwhelm these other factors, or that the fundamental processes involved in a planned quit attempt in an ambulatory setting compared with contemplating perioperative abstinence differ.

These results in Chinese surgical patients can be compared with a prior observational study of perioperative smoking behavior in US hospital inpatients.17 The preoperative smoking behavior of the 2 groups were similar, including cigarette consumption and nicotine dependence, although more Chinese smokers had never made a quit attempt (25% and 55% of US and Chinese patients, respectively, P < 0.0001, Fisher exact test). Relatively high proportions of both populations reported intent to quit smoking after surgery (60% and 72% of US and Chinese patients, respectively), but the Chinese patients were more likely to be abstinent at 30 days (28% and 62% of US and Chinese patients, P < 0.0001, Fisher exact test). Compared with the US, China is in an earlier phase of the tobacco epidemic,37 which is characterized by a high smoking prevalence in men (>50%). Tobacco control measures are relatively immature in China,2 and data from the current study and others show that many Chinese smokers have not yet considered or attempted quitting.3 This is in contrast to the US, where tobacco control efforts are relatively long-standing so that smoking prevalence is considerably lower (approximately 1 in 5 US men smokes cigarettes). Indeed, most US smokers want to quit and have attempted to do so38 but have not yet been successful. Thus, several characteristics of smokers in the general population differ between the 2 countries and those in the US who are still smoking may find it more difficult to quit.39 We speculate that because there is a larger proportion of Chinese smokers who have never considered quitting, the effects of surgery to prompt both attempts and success are relatively more potent.

This study has several limitations. The study population excluded cardiovascular surgery patients, which have a high rate of postoperative abstinence in other countries,4 so that the actual rate of postoperative abstinence in the overall surgical population may be underestimated. Although self-report of smoking status has been used in similar studies of surgical patients and is generally reliable in observational studies,19,40 it is possible that patients over-reported abstinence to conform to perceived expectations of the study team or prior statements of intent to quit. Finally, the study was conducted at a major tertiary referral center and may not reflect general surgical practice in China, which has substantial heterogeneity.

In conclusion, surgery is associated with a high rate of self-reported abstinence from smoking over the first 30 days after surgery in Chinese patients, even in the absence of tobacco interventions. Although we found several factors independently associated with both intent and abstinence, these did not include the perception of the perioperative risks of cigarette smoking. Both intent to quit and self-efficacy for maintaining abstinence appear to be much higher in Chinese surgical patients than in the overall Chinese population,16,22 suggesting that surgery serves as a powerful teachable moment for smoking cessation in China. This is a major opportunity to institute tobacco interventions to further increase abstinence rates. In a prior study, we have shown that there is considerable interest among Chinese anesthesiologists in perioperative tobacco control,41 who are in an ideal position to lead such efforts.

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DISCLOSURES

Name: Chunhua Yu, MD.

Contribution: This author helped design and conduct the study, collect the data, analyzed the data, and prepare the manuscript.

Attestation: This author approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript. This author is the archival author.

Name: Yu Shi, MD, MPH.

Contribution: This author helped design the study, analyze the data, and prepare the manuscript.

Attestation: This author approved the final manuscript.

Name: Sandeep Kadimpati, BDS, MPH.

Contribution: This author helped analyze the data and prepare the manuscript.

Attestation: This author approved the final manuscript.

Name: Yu Sheng, PhD.

Contribution: This author helped conduct the study and collect the data.

Attestation: This author approved the final manuscript.

Name: Jing Jing, BSN.

Contribution: This author helped conduct the study and collect the data.

Attestation: This author approved the final manuscript.

Name: Darrell Schroeder, MS.

Contribution: This author helped analyze the data and prepare the manuscript.

Attestation: This author approved the final manuscript.

Name: Ailun Luo, MD.

Contribution: This author helped design and conduct the study, collect the data, and provided oversight for the work performed at Peking Union Medical College Hospital.

Attestation: This author approved the final manuscript.

Name: David O. Warner, MD.

Contribution: This author helped design the study, analyze the data, and prepare the manuscript.

Attestation: This author approved the final manuscript and attests to the integrity of the original data and the analysis reported in this manuscript.

This manuscript was handled by: Peter S. A. Glass, MB, ChB and Steven L. Shafer, MD.

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