Regional variation in ultrasound-detected urological abnormalities and associated comorbidities among older men in Hulunbuir, northern China: a community-based screening study

Regional variation in ultrasound-detected urological abnormalities and associated comorbidities among older men in Hulunbuir, northern China: a community-based screening study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Regional variation in ultrasound-detected urological abnormalities and associated comorbidities among older men in Hulunbuir, northern China: a community-based screening study YUAN DU, Yinghui Kang, Zhihui Guan, Xiaojun Zhu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9388251/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Ultrasound-detected urological abnormalities are common in older men, yet data on their regional distribution and associated comorbidities in community settings remain limited. This study aimed to compare the regional distribution of ultrasound-detected urological abnormalities among older men in Hulunbuir, northern China, and to examine factors associated with benign prostatic enlargement and prostate calcification in a community-based screening setting. Methods This investigator-led, community-based cross-sectional outreach screening study was conducted in Dayan Town, Bayantohai Town, and Erguna City in Hulunbuir from June to August 2022. The study was based on large-scale free screening activities organized by the study team, with participants recruited locally through advance community publicity. The screening programme targeted local male residents aged 60 years or older. A total of 438 men participated, and all underwent urinary system ultrasound examination. Ultrasound examinations at the three study sites were performed by the same team of trained sonographers. Urinary abnormalities were identified through standardized recoding of ultrasound text reports and included benign prostatic enlargement, prostate calcification, kidney stones, and renal cysts. Chronic disease comorbidities were obtained through on-site epidemiological survey and included hypertension, diabetes mellitus, and stroke. Group differences were compared across the three study sites, and logistic regression models were used to assess factors associated with benign prostatic enlargement and prostate calcification. Results Mean age was similar across the three study sites, whereas ethnic composition differed significantly. Hypertension prevalence was highest in Bayantohai (71.1%), compared with Dayan (55.8%) and Erguna (49.4%) (P = 0.002). Diabetes mellitus and stroke were also numerically more common in Bayantohai, although these differences were not statistically significant. The prevalence of benign prostatic enlargement was 55.8% in Dayan, 57.7% in Bayantohai, and 67.1% in Erguna (P = 0.212). In contrast, prostate calcification showed marked regional variation, with the highest prevalence in Dayan (57.1%), followed by Erguna (21.5%) and Bayantohai (9.9%) (P < 0.001). In multivariable analysis, age ≥ 70 years (adjusted OR 2.15, 95% CI 1.52–3.04, P < 0.001) and hypertension (adjusted OR 1.59, 95% CI 1.06–2.41, P = 0.027) were independently associated with benign prostatic enlargement. Compared with Dayan, the adjusted odds of prostate calcification were substantially lower in Bayantohai (adjusted OR 0.074, 95% CI 0.037–0.146, P < 0.001) and Erguna (adjusted OR 0.211, 95% CI 0.115–0.386, P < 0.001). Conclusions Older men across three study sites in Hulunbuir showed heterogeneous profiles of ultrasound-detected urological abnormalities. The marked regional difference in prostate calcification, together with the independent associations of age and hypertension with benign prostatic enlargement, highlights the value of community-based ultrasound screening for the early identification of urological health burden in older men. These findings may help inform risk-aware follow-up and referral strategies in similar settings. older men urological abnormalities benign prostatic enlargement prostate calcification community-based screening epidemiology ultrasound Figures Figure 1 Introduction Population aging has become a major public health challenge worldwide, accompanied by increasing multimorbidity, functional decline, and demand for integrated community-based care [ 1 – 4 ] . In older men, urinary abnormalities are frequently detected during health screening, including benign prostatic enlargement, prostate calcification, kidney stones, and renal cysts [ 5 – 9 ] . Although these findings are often discussed in specialist clinical settings, they may also represent part of a broader pattern of chronic disease burden in aging populations [ 4 ] . Urinary abnormalities in older men are clinically relevant for several reasons [ 5 , 7 ] . First, they may be associated with lower urinary tract symptoms, sleep disruption, reduced quality of life, and increased healthcare use [ 10 , 11 ] . Second, they often coexist with chronic conditions such as hypertension, diabetes mellitus, and cerebrovascular disease, suggesting that they may reflect broader multimorbidity rather than isolated organ-specific pathology [ 12 – 15 ] . Third, community-based detection of urological abnormalities may provide opportunities for earlier identification and follow-up in older men. Geographic variation in health outcomes is relevant to urological epidemiology, particularly in settings where communities differ in demographic composition, long-term living conditions, health behaviors, and healthcare access. Hulunbuir, located in northern China, is geographically extensive and includes communities with different local contexts [ 16 ] . Dayan has a mining-town background in the context of mine-area transition [ 17 ] , Bayantohai is situated within a broader multi-ethnic sociocultural context [ 18 ] , and Hulunbuir as a whole presents the challenges of a wide territorial span and relatively dispersed population distribution [ 16 ] . These contextual differences may be relevant to the distribution and interpretation of urological findings in older men. Most previous studies have focused on single urological conditions, hospital-based populations, or specialist care settings [ 5 – 9 ] . Far less attention has been paid to the coexistence of multiple ultrasound-detected urological abnormalities and chronic disease comorbidities among community-dwelling older men from a comparative regional perspective [ 4 , 15 ] . In geographically extensive and population-dispersed settings, community-based screening may also provide opportunities for earlier identification of urological abnormalities in older populations [ 19 ] . Therefore, this study aimed to compare the prevalence of ultrasound-detected urological abnormalities and chronic disease comorbidities among older men across three study sites in Hulunbuir. We further examined factors associated with benign prostatic enlargement and prostate calcification to better characterize regional variation in urological health profiles and to explore the clinical relevance of community-based screening findings in older men. Methods Study design and setting This was an investigator-led, community-based cross-sectional outreach screening study conducted in Dayan Town, Bayantohai Town, and Erguna City in Hulunbuir, northern China. The study was based on large-scale free medical outreach and ultrasound screening activities organized by the research team. Screening activities were conducted from June to August 2022. Participant recruitment Potential participants were recruited locally through advance community publicity before each screening activity. The screening programme targeted local male residents aged 60 years or older, as predefined during the organization of the free ultrasound screening activities. Participant flow and analytic sample Attendance at the outreach screening programme was voluntary. A total of 438 eligible men attended the screening activities across the three study sites, and all underwent urinary system ultrasound examination. Complete records were available for the analytic variables of interest, and all 438 participants were included in the final analysis. The final analytic sample comprised 217 participants from Dayan, 142 from Bayantohai, and 79 from Erguna. Because participants were recruited through community publicity and voluntary attendance, the final sample should be interpreted as a community outreach screening sample rather than a probability-based population sample. Screening procedures During the outreach screening activities, participants underwent on-site urinary system ultrasound examination and structured epidemiological inquiry. The same team of sonographers conducted ultrasound screening across the three study sites in order to improve consistency of field implementation. Basic demographic information and self-reported medical history were collected on site through epidemiological survey procedures. Ultrasound examination and quality control Ultrasound examinations were performed by trained sonographers as part of the outreach screening process. A senior ultrasound physician reviewed recorded findings, with particular attention to special, difficult, or equivocal cases, and repeat examination was performed when necessary as part of routine quality control. For the present study, urinary abnormalities were identified through standardized recoding of ultrasound text reports according to predefined analytical rules established before formal analysis. Data review, standardization, and preparation for analysis Because the study database was generated from field-based screening activities conducted across the three study sites, the collected records were reviewed and standardized before analysis. Variables were checked for completeness and consistency with respect to age, ethnicity, chronic disease history, and ultrasound terminology. Minor inconsistencies in text fields were resolved according to predefined coding rules established before formal analysis. Variable definitions Demographic variables included age and ethnicity. Age was analyzed both as a continuous variable and as a categorical variable (< 70 years vs. ≥70 years) in regression analyses. Chronic disease comorbidities were obtained through on-site epidemiological survey and defined as follows: hypertension if the participant reported a history of hypertension; diabetes mellitus if the participant reported a history of diabetes mellitus; and stroke if the participant reported a history of stroke, cerebral infarction, or equivalent wording. These comorbidity variables were based on self-reported history and were not independently verified against medical records. Ultrasound-detected urinary abnormalities were defined as follows. Benign prostatic enlargement was defined when the ultrasound report explicitly described prostatic enlargement or benign prostatic enlargement. Prostate calcification was defined by the presence of calcification or calcification foci in the prostate. Kidney stones were defined by text indicating unilateral or bilateral renal calculi. Renal cysts were defined by text indicating unilateral, bilateral, or multiple renal cysts. Statistical analysis Continuous variables were summarized as mean ± standard deviation, and categorical variables were presented as counts and percentages. Between-site comparisons were conducted using one-way analysis of variance for continuous variables and chi-square tests for categorical variables. Binary logistic regression models were fitted to examine factors associated with benign prostatic enlargement and prostate calcification. Univariable logistic regression was first performed for age group, study site, ethnicity, hypertension, diabetes mellitus, and stroke. Variables of epidemiological relevance were subsequently entered into multivariable logistic regression models regardless of univariable statistical significance to account for potential confounding. For the multivariable models, the following variables were included simultaneously: age group (< 70 years vs. ≥70 years), study site (Dayan as reference), ethnicity (Han vs. non-Han), hypertension, diabetes mellitus, and stroke. Adjusted odds ratios and 95% confidence intervals were reported. Analyses were conducted using complete-case data, and no imputation was performed. Ethnicity was dichotomized as Han versus non-Han in regression analyses because of the small numbers in specific minority subgroups. Age was dichotomized as < 70 years versus ≥ 70 years in the main regression models to facilitate interpretation in the context of community screening of older adults. All statistical tests were two-sided, and a P value < 0.05 was considered statistically significant. Statistical analyses were performed using IBM SPSS Statistics for Windows, version 29.0 (IBM Corp., Armonk, NY, USA). Ethics The present analysis used de-identified data derived from community screening activities. Ethical review determined that the secondary analysis of anonymized data was exempt from further informed consent requirements. Full ethics information is provided in the Declarations section. Results Participant characteristics and chronic disease comorbidity A total of 438 eligible older men participated in the outreach screening programme between June and August 2022, and all completed urinary system ultrasound examination. Of these, 217 were from Dayan, 142 from Bayantohai, and 79 from Erguna. Mean age did not differ significantly across the three study sites. In contrast, ethnic composition differed significantly, with Dayan and Erguna being predominantly Han, whereas Bayantohai showed a more diverse ethnic composition. The prevalence of hypertension differed significantly across the three study sites and was highest in Bayantohai. Diabetes mellitus and stroke also appeared more common in Bayantohai, although the differences were not statistically significant. These findings indicate that chronic disease burden among older men was not evenly distributed across the three study sites. Participant characteristics and chronic disease comorbidities across the three study sites are summarized in Table 1 . Table 1 Characteristics and chronic disease comorbidities of older men across three study sites in Hulunbuir Variable Dayan (n = 217) Bayantohai (n = 142) Erguna (n = 79) P value Age, years (mean ± SD) 68.9 ± 3.3 69.5 ± 3.9 68.8 ± 5.4 0.250 Han ethnicity, n (%) 183 (84.3) 56 (39.4) 68 (86.1) < 0.001 Hypertension, n (%) 121 (55.8) 101 (71.1) 39 (49.4) 0.002 Diabetes mellitus, n (%) 55 (25.3) 43 (30.3) 16 (20.3) 0.252 Stroke, n (%) 26 (12.0) 21 (14.8) 4 (5.1) 0.095 Table note: Values are presented as mean ± standard deviation or number (percentage). P values were derived from one-way analysis of variance for continuous variables and chi-square tests for categorical variables. Regional distribution of urinary abnormalities All urinary abnormality variables analyzed in this study were derived from ultrasound reports generated under routine screening quality-control procedures. The prevalence of benign prostatic enlargement was high in all three study sites and numerically highest in Erguna, although the regional difference did not reach statistical significance. In contrast, prostate calcification showed the most pronounced regional disparity, with markedly higher prevalence in Dayan than in Bayantohai and Erguna. The regional distribution of ultrasound-detected urinary abnormalities is summarized in Table 2 . Table 2 Regional distribution of ultrasound-detected urinary abnormalities among older men Variable Dayan (n = 217) Bayantohai (n = 142) Erguna (n = 79) P value Benign prostatic enlargement, n (%) 121 (55.8) 82 (57.7) 53 (67.1) 0.212 Prostate calcification, n (%) 124 (57.1) 14 (9.9) 17 (21.5) < 0.001 Kidney stones, n (%) 23 (10.6) 9 (6.3) 4 (5.1) 0.188 Renal cysts, n (%) 77 (35.5) 38 (26.8) 31 (39.2) 0.108 Table note: Urinary abnormalities were identified by standardized recoding of ultrasound text reports. P values were calculated using chi-square tests. Kidney stones and renal cysts were also commonly detected, but neither condition showed statistically significant regional variation in the present sample. Taken together with the observed chronic disease distribution, these findings indicate that urinary abnormalities and chronic disease burden coexisted at the population level within the screened sample. Factors associated with benign prostatic enlargement In univariable logistic regression, age ≥ 70 years was strongly associated with benign prostatic enlargement (OR 2.51, 95% CI 1.88–3.42, P < 0.001). Hypertension was also associated with higher odds of benign prostatic enlargement (OR 1.82, 95% CI 1.35–2.46, P < 0.001). No significant crude associations were observed for Bayantohai, Erguna, ethnicity, diabetes mellitus, or stroke. In multivariable logistic regression, age ≥ 70 years remained the strongest independent correlate of benign prostatic enlargement (adjusted OR 2.15, 95% CI 1.52–3.04, P < 0.001). Hypertension also remained independently associated with benign prostatic enlargement after adjustment (adjusted OR 1.59, 95% CI 1.06–2.41, P = 0.027). Compared with Dayan, Erguna showed higher adjusted odds of benign prostatic enlargement, although the association did not reach statistical significance (adjusted OR 1.66, 95% CI 0.96–2.88, P = 0.071). No independent associations were observed for Bayantohai, ethnicity, diabetes mellitus, or stroke. Univariable and multivariable logistic regression results for benign prostatic enlargement are presented in Table 3 , and the adjusted odds ratios are illustrated in Fig. 1 . Table 3 Logistic regression analysis of factors associated with benign prostatic enlargement among older men Variable Crude OR (95% CI) P value Adjusted OR (95% CI) P value Age ≥ 70 years 2.51 (1.88–3.42) < 0.001 2.15 (1.52–3.04) < 0.001 Bayantohai vs Dayan 1.15 (0.78–1.71) 0.482 1.05 (0.69–1.62) 0.812 Erguna vs Dayan 1.32 (0.95–1.84) 0.098 1.66 (0.96–2.88) 0.071 Non-Han vs Han 1.18 (0.86–1.62) 0.315 1.09 (0.76–1.55) 0.643 Hypertension 1.82 (1.35–2.46) < 0.001 1.59 (1.06–2.41) 0.027 Diabetes mellitus 1.38 (0.89–2.12) 0.152 1.35 (0.86–2.12) 0.188 Stroke 1.31 (0.82–2.09) 0.258 1.28 (0.78–2.11) 0.334 Table note: Crude odds ratios were estimated using univariable logistic regression. Adjusted odds ratios were estimated using multivariable logistic regression including age group, study site, ethnicity, hypertension, diabetes mellitus, and stroke. Dayan and Han ethnicity were used as reference categories. OR, odds ratio; CI, confidence interval. Factors associated with prostate calcification In univariable logistic regression, prostate calcification showed striking regional differences. Compared with Dayan, the crude odds of prostate calcification were substantially lower in Bayantohai (OR 0.088, 95% CI 0.046–0.169, P < 0.001) and Erguna (OR 0.204, 95% CI 0.111–0.374, P < 0.001). Non-Han ethnicity was also associated with a lower crude prevalence of prostate calcification (OR 0.41, 95% CI 0.27–0.63, P < 0.001), although this association was attenuated after adjustment. In multivariable logistic regression, regional disparity remained highly significant after adjustment for age group, ethnicity, hypertension, diabetes mellitus, and stroke. Compared with Dayan, the adjusted odds of prostate calcification were substantially lower in Bayantohai (adjusted OR 0.074, 95% CI 0.037–0.146, P < 0.001) and Erguna (adjusted OR 0.211, 95% CI 0.115–0.386, P < 0.001). No significant independent associations were observed for age, ethnicity, hypertension, diabetes mellitus, or stroke. Univariable and multivariable logistic regression results for prostate calcification are presented in Table 4 . Table 4 Logistic regression analysis of factors associated with prostate calcification among older men Variable Crude OR (95% CI) P value Adjusted OR (95% CI) P value Age ≥ 70 years 1.08 (0.73–1.60) 0.702 1.04 (0.68–1.58) 0.867 Bayantohai vs Dayan 0.088 (0.046–0.169) < 0.001 0.074 (0.037–0.146) < 0.001 Erguna vs Dayan 0.204 (0.111–0.374) < 0.001 0.211 (0.115–0.386) < 0.001 Non-Han vs Han 0.41 (0.27–0.63) < 0.001 0.84 (0.48–1.48) 0.545 Hypertension 1.13 (0.77–1.66) 0.525 1.08 (0.72–1.62) 0.707 Diabetes mellitus 0.95 (0.61–1.50) 0.833 0.91 (0.56–1.47) 0.696 Stroke 0.78 (0.43–1.42) 0.421 0.81 (0.43–1.51) 0.501 Table note: Crude odds ratios were estimated using univariable logistic regression. Adjusted odds ratios were estimated using multivariable logistic regression including age group, study site, ethnicity, hypertension, diabetes mellitus, and stroke. Dayan and Han ethnicity were used as reference categories. OR, odds ratio; CI, confidence interval. Discussion This community-based ultrasound screening study compared urological abnormalities and chronic disease comorbidity among older men across three study sites in Hulunbuir. Three findings deserve emphasis. First, older men across the three study sites showed heterogeneous urological profiles rather than a uniform pattern of age-related abnormality. Second, prostate calcification displayed the most pronounced regional difference among all ultrasound-detected findings. Third, in the analysis of benign prostatic enlargement, age and hypertension emerged as the most important correlates, whereas between-site differences were weaker and less definitive. The clinical and epidemiological value of this study lies in moving beyond an isolated description of single ultrasound findings. In many settings, urological abnormalities in older men are considered separately in specialist practice. However, our findings suggest that these abnormalities may coexist with broader chronic disease burden and may vary across local settings. In this study, hypertension, diabetes mellitus, and stroke were not evenly distributed across the three study sites, and ultrasound-detected urological abnormalities also showed non-uniform patterns. Taken together, these findings support interpreting screening-detected urological abnormalities in older men in conjunction with coexisting chronic disease burden and likely follow-up needs. Age was the strongest independent correlate of benign prostatic enlargement in the present analysis. Compared with men aged < 70 years, those aged ≥ 70 years had more than twofold higher odds of BPE after adjustment. This result is biologically and epidemiologically consistent with the aging-related nature of prostate enlargement [ 5 – 7 ] and supports the internal validity of the dataset. Hypertension was the second key finding in the multivariable model. Even after adjustment for study site, ethnicity, diabetes mellitus, and stroke, hypertension remained independently associated with benign prostatic enlargement. This suggests that prostate-related abnormalities in older men may coexist with broader vascular or metabolic burden rather than occurring as isolated conditions [ 12 – 15 , 20 ] . Although the effect size was moderate rather than large, this finding suggests that benign prostatic enlargement in older men may coexist with broader chronic disease burden and should not always be interpreted in isolation. Shared vascular or autonomic pathways proposed in previous literature may partly help explain this association, although the present study was not designed to test underlying mechanisms directly [ 12 , 13 ] . Regional differences in BPE were more nuanced. Compared with Dayan, Bayantohai did not show higher adjusted odds of BPE. In contrast, Erguna showed an elevated adjusted odds ratio, although the association did not reach conventional statistical significance. This pattern should be interpreted as a trend toward higher odds rather than as definitive evidence of an independent regional effect. Hulunbuir includes communities with different demographic and social contexts [ 16 – 18 ] , and such background variation may be relevant to interpreting the observed heterogeneity. However, because variables such as long-term diet, winter physical activity, migration pattern, household structure, and healthcare access were not directly measured in the current study, these explanations should remain cautious and hypothesis-generating. Dayan served as the reference study site in the present analysis and did not show elevated adjusted odds of BPE relative to the other study areas. In the context of mine-area transition [ 17 ] , this finding may reflect a complex combination of historical population selection, survivor composition, and other unmeasured behavioral or social factors. However, such interpretations should be approached with caution, because migration history, lifetime occupation, physical activity level, and metabolic indicators were not directly assessed in this study. Thus, while regional context may be relevant, the current analysis does not support causal inference regarding specific contextual mechanisms. The most notable regional signal in this study was the substantial difference in prostate calcification. Dayan showed a markedly higher prevalence than Bayantohai and Erguna, and this pattern remained highly significant after adjustment for age, ethnicity, hypertension, diabetes mellitus, and stroke. The persistence of a strong adjusted regional effect indicates that contextual influences at the community level may be relevant and deserve further study [ 8 , 21 – 23 ] . From a urological perspective, this pattern suggests that prostate calcification may be more than an incidental imaging finding in this setting. Although the current study cannot establish mechanisms, marked between-site clustering may help identify communities in which closer evaluation of lower urinary tract health and follow-up assessment may be warranted. An important implication of our findings is that community-based ultrasound screening may help identify older men with more complex urological health profiles, particularly in geographically extensive settings where routine specialist access may not be uniform [16]. Rather than supporting universal screening recommendations, the current data suggest that risk-aware community-based identification and subsequent follow-up may be useful for older men in settings with heterogeneous health burden. In particular, combining urinary ultrasound findings with information on common chronic diseases may help identify older men who warrant closer follow-up and referral in geographically diverse settings. At the same time, our findings should not be interpreted as direct evidence in favor of universal urinary ultrasound screening. The present study demonstrates regional variation and potential value for risk identification, but it does not establish the effectiveness, acceptability, downstream benefit, or cost-effectiveness of a universal screening programme. The current data more appropriately support the rationale for further evaluating risk-stratified, community-based screening and follow-up models for older men, especially in areas where health burdens and access conditions are unlikely to be uniform. This study has several strengths. First, it was based on investigator-led, field-based outreach screening rather than passive extraction of routine hospital records. Second, the screening programme targeted a predefined population, namely local male residents aged 60 years or older, and all 438 attendees completed urinary system ultrasound examination during the study period. Third, the same ultrasound team conducted screening across three study sites, which improved implementation consistency. Fourth, the study simultaneously assessed urinary abnormalities and chronic disease comorbidities, thereby providing a broader picture of older men’s health than studies focused on a single urological condition alone. Several limitations should also be acknowledged. First, the cross-sectional design precludes causal inference. Second, because participants were recruited through community publicity and voluntary attendance, the final sample should be interpreted as a community outreach screening sample rather than a probability-based population sample. Selection bias is therefore possible. Third, urinary abnormalities were identified through standardized recoding of ultrasound text reports generated under routine quality-control procedures rather than centralized image review or formal inter-rater reliability testing for research purposes. Some degree of misclassification may therefore remain possible. Fourth, chronic disease history was obtained through on-site epidemiological survey and may be subject to recall or reporting bias. Fifth, the study lacked information on body mass index, smoking, alcohol intake, diet, hydration behavior, medication use, occupational history, and healthcare access. Sixth, although regional context may be relevant to interpreting health heterogeneity, variables such as migration pattern, labor outflow, and household structure were not directly measured and should therefore not be overinterpreted. Seventh, the sample size in Erguna was relatively small, which may have limited statistical power for some comparisons. Overall, the present findings suggest that ultrasound-detected urological abnormalities in older men should be interpreted in conjunction with chronic disease burden and local clinical context. Rather than treating prostate or renal findings as isolated observations, community-based ultrasound screening may help identify older men who warrant closer urological evaluation and follow-up, especially in geographically diverse settings. Conclusion Older men across three study sites in Hulunbuir showed heterogeneous patterns of ultrasound-detected urological abnormalities and chronic disease comorbidity. Prostate calcification exhibited the most pronounced between-site difference, while age and hypertension were independently associated with benign prostatic enlargement. These findings highlight the value of community-based ultrasound screening for the identification of urological abnormalities in older men and may inform follow-up and referral strategies in geographically diverse settings. Declarations Ethics approval and consent to participate: This study was based on large-scale free community outreach screening activities conducted by the study team across three study sites in Hulunbuir. The present analysis used de-identified data derived from those screening activities. Ethical review determined that the secondary analysis of anonymized data was exempt from further informed consent requirements. The study was reviewed by the Ethics Committee of Hulunbuir People’s Hospital (reference/approval number: 2022SYY-10). Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests. Acknowledgements The authors thank the local community organizers, outreach screening staff, and ultrasound team members in Dayan, Bayantohai, and Erguna for their support in participant recruitment, field implementation, and data collection. The authors also thank all participants involved in the free screening programme. Funding: This work was supported by the Key Research and Development and Achievement Transformation Project in the Field of Social Public Welfare of Inner Mongolia Autonomous Region during the 14th Five-Year Plan Period (2022YFSH0004), and the Hulunbuir City Science and Technology Plan Project (SF2022009). The funders had no role in the design of the study, data collection, analysis, interpretation of data, or writing of the manuscript. Author Contribution Yuan Du conceived and designed the study, led the field screening activities, performed the statistical analysis, interpreted the data, and drafted the manuscript. Yinghui Kang and Zhihui Guan contributed to field screening implementation, data collection, and data verification. Xiaojun Zhu contributed to study coordination and critical revision of the manuscript. All authors read and approved the final manuscript. 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Outreach screening to address demographic and economic barriers to diabetic retinopathy care in rural China. PLoS ONE. 2022;17(4):e0266380. Xu Z, Elrashidy RA, Li B, Liu G. Oxidative stress: a putative link between lower urinary tract symptoms and aging and major chronic diseases. Front Med (Lausanne). 2022;9:812967. Wang H, Ma M, Qin F, Yuan J. The influence of prostatic calculi on lower urinary tract symptoms and sexual dysfunction: a narrative review. Transl Androl Urol. 2021;10(2):929–38. Han JH, Lee JY, Kwon JK, Lee JS, Cho KS. Clinical significance of periurethral calcification according to the location in men with lower urinary tract symptoms and a small prostate volume. Int Neurourol J. 2017;21(3):220–8. Kim SH, Jung KI, Lee BH, Lee BY, Cho SY, Kim HW. Relations between prostatic calculi and lower urinary tract symptoms of benign prostatic hyperplasia. Korean J Urol. 2009;50(9):916–22. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9388251","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":639776389,"identity":"6eaa2d51-7790-472b-b6a7-d02848069499","order_by":0,"name":"YUAN DU","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYDCCA2CSGcL5AMRs7IS1MDbAtDDOAGlhJkULMw+SjTgB3/Hm5w8+7rFO3HAj+dljm1/b5PmYGRg/fMzBrUXyzDHDxhnP0oFa0syNc/tuG7YxMzBLztyGW4vBjRzGZp4Dh4FaEsykc3tuMwK1sDHzEqcl/Zu0Zc9te1K05JhJM/y4nUhQC8gvM2ccSDeeeeZNmWRvw+3kNmbGZrx+AYbYgw8fDljL9h1P3ybx489t2/ntzQc/fMSjBQ4UDgAJxjYQExRRxAB5sLo/xCkeBaNgFIyCkQUA4PFZ52dREDkAAAAASUVORK5CYII=","orcid":"","institution":"The Affiliated Hospital of Inner Mongolia Medical University","correspondingAuthor":true,"prefix":"","firstName":"YUAN","middleName":"","lastName":"DU","suffix":""},{"id":639776390,"identity":"8de096b1-c87a-43c7-b3b0-b44085549fc4","order_by":1,"name":"Yinghui Kang","email":"","orcid":"","institution":"Hulunbuir People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yinghui","middleName":"","lastName":"Kang","suffix":""},{"id":639776391,"identity":"c0c9b7f6-d120-4254-82ac-a343839653c2","order_by":2,"name":"Zhihui Guan","email":"","orcid":"","institution":"Hulunbiur People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhihui","middleName":"","lastName":"Guan","suffix":""},{"id":639776392,"identity":"6e37d60a-b8fb-4bcf-a45f-2e074e970c1a","order_by":3,"name":"Xiaojun Zhu","email":"","orcid":"","institution":"The Affiliated Hospital of Inner Mongolia Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiaojun","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2026-04-11 13:23:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9388251/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9388251/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109303966,"identity":"b89c7958-40fd-4aa2-8010-0dff6cc19493","added_by":"auto","created_at":"2026-05-15 09:41:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":88670,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot of adjusted odds ratios for benign prostatic enlargement among older men\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure note: Adjusted odds ratios were derived from a multivariable logistic regression model including age group, study site, ethnicity, hypertension, diabetes mellitus, and stroke. Error bars indicate 95% confidence intervals. The vertical dashed line indicates OR = 1.0.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9388251/v1/b96a42885efc058dbd038be1.png"},{"id":109430827,"identity":"0c7676dc-840d-4193-8b82-61f8e1cf6bf1","added_by":"auto","created_at":"2026-05-18 04:41:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":302619,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9388251/v1/4586527c-9fb1-4488-a725-8bd372c30f6a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Regional variation in ultrasound-detected urological abnormalities and associated comorbidities among older men in Hulunbuir, northern China: a community-based screening study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePopulation aging has become a major public health challenge worldwide, accompanied by increasing multimorbidity, functional decline, and demand for integrated community-based care \u003csup\u003e[\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. In older men, urinary abnormalities are frequently detected during health screening, including benign prostatic enlargement, prostate calcification, kidney stones, and renal cysts \u003csup\u003e[\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Although these findings are often discussed in specialist clinical settings, they may also represent part of a broader pattern of chronic disease burden in aging populations \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eUrinary abnormalities in older men are clinically relevant for several reasons \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. First, they may be associated with lower urinary tract symptoms, sleep disruption, reduced quality of life, and increased healthcare use \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Second, they often coexist with chronic conditions such as hypertension, diabetes mellitus, and cerebrovascular disease, suggesting that they may reflect broader multimorbidity rather than isolated organ-specific pathology \u003csup\u003e[\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Third, community-based detection of urological abnormalities may provide opportunities for earlier identification and follow-up in older men.\u003c/p\u003e \u003cp\u003eGeographic variation in health outcomes is relevant to urological epidemiology, particularly in settings where communities differ in demographic composition, long-term living conditions, health behaviors, and healthcare access. Hulunbuir, located in northern China, is geographically extensive and includes communities with different local contexts \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Dayan has a mining-town background in the context of mine-area transition \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, Bayantohai is situated within a broader multi-ethnic sociocultural context \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, and Hulunbuir as a whole presents the challenges of a wide territorial span and relatively dispersed population distribution \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. These contextual differences may be relevant to the distribution and interpretation of urological findings in older men.\u003c/p\u003e \u003cp\u003eMost previous studies have focused on single urological conditions, hospital-based populations, or specialist care settings \u003csup\u003e[\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Far less attention has been paid to the coexistence of multiple ultrasound-detected urological abnormalities and chronic disease comorbidities among community-dwelling older men from a comparative regional perspective \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. In geographically extensive and population-dispersed settings, community-based screening may also provide opportunities for earlier identification of urological abnormalities in older populations \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to compare the prevalence of ultrasound-detected urological abnormalities and chronic disease comorbidities among older men across three study sites in Hulunbuir. We further examined factors associated with benign prostatic enlargement and prostate calcification to better characterize regional variation in urological health profiles and to explore the clinical relevance of community-based screening findings in older men.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis was an investigator-led, community-based cross-sectional outreach screening study conducted in Dayan Town, Bayantohai Town, and Erguna City in Hulunbuir, northern China. The study was based on large-scale free medical outreach and ultrasound screening activities organized by the research team. Screening activities were conducted from June to August 2022.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipant recruitment\u003c/h3\u003e\n\u003cp\u003ePotential participants were recruited locally through advance community publicity before each screening activity. The screening programme targeted local male residents aged 60 years or older, as predefined during the organization of the free ultrasound screening activities.\u003c/p\u003e\n\u003ch3\u003eParticipant flow and analytic sample\u003c/h3\u003e\n\u003cp\u003eAttendance at the outreach screening programme was voluntary. A total of 438 eligible men attended the screening activities across the three study sites, and all underwent urinary system ultrasound examination. Complete records were available for the analytic variables of interest, and all 438 participants were included in the final analysis. The final analytic sample comprised 217 participants from Dayan, 142 from Bayantohai, and 79 from Erguna.\u003c/p\u003e \u003cp\u003eBecause participants were recruited through community publicity and voluntary attendance, the final sample should be interpreted as a community outreach screening sample rather than a probability-based population sample.\u003c/p\u003e\n\u003ch3\u003eScreening procedures\u003c/h3\u003e\n\u003cp\u003e During the outreach screening activities, participants underwent on-site urinary system ultrasound examination and structured epidemiological inquiry. The same team of sonographers conducted ultrasound screening across the three study sites in order to improve consistency of field implementation. Basic demographic information and self-reported medical history were collected on site through epidemiological survey procedures.\u003c/p\u003e\n\u003ch3\u003eUltrasound examination and quality control\u003c/h3\u003e\n\u003cp\u003eUltrasound examinations were performed by trained sonographers as part of the outreach screening process. A senior ultrasound physician reviewed recorded findings, with particular attention to special, difficult, or equivocal cases, and repeat examination was performed when necessary as part of routine quality control. For the present study, urinary abnormalities were identified through standardized recoding of ultrasound text reports according to predefined analytical rules established before formal analysis.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData review, standardization, and preparation for analysis\u003c/h2\u003e \u003cp\u003eBecause the study database was generated from field-based screening activities conducted across the three study sites, the collected records were reviewed and standardized before analysis. Variables were checked for completeness and consistency with respect to age, ethnicity, chronic disease history, and ultrasound terminology. Minor inconsistencies in text fields were resolved according to predefined coding rules established before formal analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eVariable definitions\u003c/h3\u003e\n\u003cp\u003eDemographic variables included age and ethnicity. Age was analyzed both as a continuous variable and as a categorical variable (\u0026lt;\u0026thinsp;70 years vs. \u0026ge;70 years) in regression analyses.\u003c/p\u003e \u003cp\u003eChronic disease comorbidities were obtained through on-site epidemiological survey and defined as follows: hypertension if the participant reported a history of hypertension; diabetes mellitus if the participant reported a history of diabetes mellitus; and stroke if the participant reported a history of stroke, cerebral infarction, or equivalent wording. These comorbidity variables were based on self-reported history and were not independently verified against medical records.\u003c/p\u003e \u003cp\u003eUltrasound-detected urinary abnormalities were defined as follows. Benign prostatic enlargement was defined when the ultrasound report explicitly described prostatic enlargement or benign prostatic enlargement. Prostate calcification was defined by the presence of calcification or calcification foci in the prostate. Kidney stones were defined by text indicating unilateral or bilateral renal calculi. Renal cysts were defined by text indicating unilateral, bilateral, or multiple renal cysts.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and categorical variables were presented as counts and percentages. Between-site comparisons were conducted using one-way analysis of variance for continuous variables and chi-square tests for categorical variables.\u003c/p\u003e \u003cp\u003eBinary logistic regression models were fitted to examine factors associated with benign prostatic enlargement and prostate calcification. Univariable logistic regression was first performed for age group, study site, ethnicity, hypertension, diabetes mellitus, and stroke. Variables of epidemiological relevance were subsequently entered into multivariable logistic regression models regardless of univariable statistical significance to account for potential confounding. For the multivariable models, the following variables were included simultaneously: age group (\u0026lt;\u0026thinsp;70 years vs. \u0026ge;70 years), study site (Dayan as reference), ethnicity (Han vs. non-Han), hypertension, diabetes mellitus, and stroke. Adjusted odds ratios and 95% confidence intervals were reported.\u003c/p\u003e \u003cp\u003eAnalyses were conducted using complete-case data, and no imputation was performed. Ethnicity was dichotomized as Han versus non-Han in regression analyses because of the small numbers in specific minority subgroups. Age was dichotomized as \u0026lt;\u0026thinsp;70 years versus \u0026ge;\u0026thinsp;70 years in the main regression models to facilitate interpretation in the context of community screening of older adults.\u003c/p\u003e \u003cp\u003eAll statistical tests were two-sided, and a P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Statistical analyses were performed using IBM SPSS Statistics for Windows, version 29.0 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003eThe present analysis used de-identified data derived from community screening activities. Ethical review determined that the secondary analysis of anonymized data was exempt from further informed consent requirements. Full ethics information is provided in the Declarations section.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics and chronic disease comorbidity\u003c/h2\u003e \u003cp\u003eA total of 438 eligible older men participated in the outreach screening programme between June and August 2022, and all completed urinary system ultrasound examination. Of these, 217 were from Dayan, 142 from Bayantohai, and 79 from Erguna. Mean age did not differ significantly across the three study sites. In contrast, ethnic composition differed significantly, with Dayan and Erguna being predominantly Han, whereas Bayantohai showed a more diverse ethnic composition.\u003c/p\u003e \u003cp\u003eThe prevalence of hypertension differed significantly across the three study sites and was highest in Bayantohai. Diabetes mellitus and stroke also appeared more common in Bayantohai, although the differences were not statistically significant. These findings indicate that chronic disease burden among older men was not evenly distributed across the three study sites. Participant characteristics and chronic disease comorbidities across the three study sites are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics and chronic disease comorbidities of older men across three study sites in Hulunbuir\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDayan (n\u0026thinsp;=\u0026thinsp;217)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBayantohai (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eErguna (n\u0026thinsp;=\u0026thinsp;79)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.250\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHan ethnicity, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e183 (84.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (39.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68 (86.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121 (55.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101 (71.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (49.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (25.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.252\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable note: Values are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or number (percentage). P values were derived from one-way analysis of variance for continuous variables and chi-square tests for categorical variables.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eRegional distribution of urinary abnormalities\u003c/h2\u003e \u003cp\u003eAll urinary abnormality variables analyzed in this study were derived from ultrasound reports generated under routine screening quality-control procedures. The prevalence of benign prostatic enlargement was high in all three study sites and numerically highest in Erguna, although the regional difference did not reach statistical significance. In contrast, prostate calcification showed the most pronounced regional disparity, with markedly higher prevalence in Dayan than in Bayantohai and Erguna. The regional distribution of ultrasound-detected urinary abnormalities is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRegional distribution of ultrasound-detected urinary abnormalities among older men\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDayan (n\u0026thinsp;=\u0026thinsp;217)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBayantohai (n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eErguna (n\u0026thinsp;=\u0026thinsp;79)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign prostatic enlargement, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e121 (55.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53 (67.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstate calcification, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e124 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17 (21.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney stones, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.188\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal cysts, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77 (35.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31 (39.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable note: Urinary abnormalities were identified by standardized recoding of ultrasound text reports. P values were calculated using chi-square tests.\u003c/p\u003e \u003cp\u003eKidney stones and renal cysts were also commonly detected, but neither condition showed statistically significant regional variation in the present sample. Taken together with the observed chronic disease distribution, these findings indicate that urinary abnormalities and chronic disease burden coexisted at the population level within the screened sample.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with benign prostatic enlargement\u003c/h2\u003e \u003cp\u003eIn univariable logistic regression, age\u0026thinsp;\u0026ge;\u0026thinsp;70 years was strongly associated with benign prostatic enlargement (OR 2.51, 95% CI 1.88\u0026ndash;3.42, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Hypertension was also associated with higher odds of benign prostatic enlargement (OR 1.82, 95% CI 1.35\u0026ndash;2.46, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant crude associations were observed for Bayantohai, Erguna, ethnicity, diabetes mellitus, or stroke.\u003c/p\u003e \u003cp\u003eIn multivariable logistic regression, age\u0026thinsp;\u0026ge;\u0026thinsp;70 years remained the strongest independent correlate of benign prostatic enlargement (adjusted OR 2.15, 95% CI 1.52\u0026ndash;3.04, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Hypertension also remained independently associated with benign prostatic enlargement after adjustment (adjusted OR 1.59, 95% CI 1.06\u0026ndash;2.41, P\u0026thinsp;=\u0026thinsp;0.027). Compared with Dayan, Erguna showed higher adjusted odds of benign prostatic enlargement, although the association did not reach statistical significance (adjusted OR 1.66, 95% CI 0.96\u0026ndash;2.88, P\u0026thinsp;=\u0026thinsp;0.071). No independent associations were observed for Bayantohai, ethnicity, diabetes mellitus, or stroke. Univariable and multivariable logistic regression results for benign prostatic enlargement are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, and the adjusted odds ratios are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis of factors associated with benign prostatic enlargement among older men\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;70 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.51 (1.88\u0026ndash;3.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.15 (1.52\u0026ndash;3.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBayantohai vs Dayan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.15 (0.78\u0026ndash;1.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.05 (0.69\u0026ndash;1.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.812\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErguna vs Dayan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.32 (0.95\u0026ndash;1.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.66 (0.96\u0026ndash;2.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Han vs Han\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.18 (0.86\u0026ndash;1.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.09 (0.76\u0026ndash;1.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.82 (1.35\u0026ndash;2.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.59 (1.06\u0026ndash;2.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.38 (0.89\u0026ndash;2.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.35 (0.86\u0026ndash;2.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.188\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.31 (0.82\u0026ndash;2.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.28 (0.78\u0026ndash;2.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.334\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable note: Crude odds ratios were estimated using univariable logistic regression. Adjusted odds ratios were estimated using multivariable logistic regression including age group, study site, ethnicity, hypertension, diabetes mellitus, and stroke. Dayan and Han ethnicity were used as reference categories. OR, odds ratio; CI, confidence interval.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with prostate calcification\u003c/h2\u003e \u003cp\u003eIn univariable logistic regression, prostate calcification showed striking regional differences. Compared with Dayan, the crude odds of prostate calcification were substantially lower in Bayantohai (OR 0.088, 95% CI 0.046\u0026ndash;0.169, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and Erguna (OR 0.204, 95% CI 0.111\u0026ndash;0.374, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Non-Han ethnicity was also associated with a lower crude prevalence of prostate calcification (OR 0.41, 95% CI 0.27\u0026ndash;0.63, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), although this association was attenuated after adjustment.\u003c/p\u003e \u003cp\u003eIn multivariable logistic regression, regional disparity remained highly significant after adjustment for age group, ethnicity, hypertension, diabetes mellitus, and stroke. Compared with Dayan, the adjusted odds of prostate calcification were substantially lower in Bayantohai (adjusted OR 0.074, 95% CI 0.037\u0026ndash;0.146, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and Erguna (adjusted OR 0.211, 95% CI 0.115\u0026ndash;0.386, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant independent associations were observed for age, ethnicity, hypertension, diabetes mellitus, or stroke. Univariable and multivariable logistic regression results for prostate calcification are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis of factors associated with prostate calcification among older men\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;70 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.08 (0.73\u0026ndash;1.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.04 (0.68\u0026ndash;1.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBayantohai vs Dayan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.088 (0.046\u0026ndash;0.169)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.074 (0.037\u0026ndash;0.146)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErguna vs Dayan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.204 (0.111\u0026ndash;0.374)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.211 (0.115\u0026ndash;0.386)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Han vs Han\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.41 (0.27\u0026ndash;0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84 (0.48\u0026ndash;1.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.545\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.13 (0.77\u0026ndash;1.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.525\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.08 (0.72\u0026ndash;1.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.707\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.95 (0.61\u0026ndash;1.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.833\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.91 (0.56\u0026ndash;1.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.78 (0.43\u0026ndash;1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.81 (0.43\u0026ndash;1.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.501\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable note: Crude odds ratios were estimated using univariable logistic regression. Adjusted odds ratios were estimated using multivariable logistic regression including age group, study site, ethnicity, hypertension, diabetes mellitus, and stroke. Dayan and Han ethnicity were used as reference categories. OR, odds ratio; CI, confidence interval.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis community-based ultrasound screening study compared urological abnormalities and chronic disease comorbidity among older men across three study sites in Hulunbuir. Three findings deserve emphasis. First, older men across the three study sites showed heterogeneous urological profiles rather than a uniform pattern of age-related abnormality. Second, prostate calcification displayed the most pronounced regional difference among all ultrasound-detected findings. Third, in the analysis of benign prostatic enlargement, age and hypertension emerged as the most important correlates, whereas between-site differences were weaker and less definitive.\u003c/p\u003e \u003cp\u003eThe clinical and epidemiological value of this study lies in moving beyond an isolated description of single ultrasound findings. In many settings, urological abnormalities in older men are considered separately in specialist practice. However, our findings suggest that these abnormalities may coexist with broader chronic disease burden and may vary across local settings. In this study, hypertension, diabetes mellitus, and stroke were not evenly distributed across the three study sites, and ultrasound-detected urological abnormalities also showed non-uniform patterns. Taken together, these findings support interpreting screening-detected urological abnormalities in older men in conjunction with coexisting chronic disease burden and likely follow-up needs.\u003c/p\u003e \u003cp\u003eAge was the strongest independent correlate of benign prostatic enlargement in the present analysis. Compared with men aged\u0026thinsp;\u0026lt;\u0026thinsp;70 years, those aged\u0026thinsp;\u0026ge;\u0026thinsp;70 years had more than twofold higher odds of BPE after adjustment. This result is biologically and epidemiologically consistent with the aging-related nature of prostate enlargement \u003csup\u003e[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e and supports the internal validity of the dataset.\u003c/p\u003e \u003cp\u003eHypertension was the second key finding in the multivariable model. Even after adjustment for study site, ethnicity, diabetes mellitus, and stroke, hypertension remained independently associated with benign prostatic enlargement. This suggests that prostate-related abnormalities in older men may coexist with broader vascular or metabolic burden rather than occurring as isolated conditions \u003csup\u003e[\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Although the effect size was moderate rather than large, this finding suggests that benign prostatic enlargement in older men may coexist with broader chronic disease burden and should not always be interpreted in isolation. Shared vascular or autonomic pathways proposed in previous literature may partly help explain this association, although the present study was not designed to test underlying mechanisms directly \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRegional differences in BPE were more nuanced. Compared with Dayan, Bayantohai did not show higher adjusted odds of BPE. In contrast, Erguna showed an elevated adjusted odds ratio, although the association did not reach conventional statistical significance. This pattern should be interpreted as a trend toward higher odds rather than as definitive evidence of an independent regional effect. Hulunbuir includes communities with different demographic and social contexts \u003csup\u003e[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, and such background variation may be relevant to interpreting the observed heterogeneity. However, because variables such as long-term diet, winter physical activity, migration pattern, household structure, and healthcare access were not directly measured in the current study, these explanations should remain cautious and hypothesis-generating.\u003c/p\u003e \u003cp\u003eDayan served as the reference study site in the present analysis and did not show elevated adjusted odds of BPE relative to the other study areas. In the context of mine-area transition \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, this finding may reflect a complex combination of historical population selection, survivor composition, and other unmeasured behavioral or social factors. However, such interpretations should be approached with caution, because migration history, lifetime occupation, physical activity level, and metabolic indicators were not directly assessed in this study. Thus, while regional context may be relevant, the current analysis does not support causal inference regarding specific contextual mechanisms.\u003c/p\u003e \u003cp\u003eThe most notable regional signal in this study was the substantial difference in prostate calcification. Dayan showed a markedly higher prevalence than Bayantohai and Erguna, and this pattern remained highly significant after adjustment for age, ethnicity, hypertension, diabetes mellitus, and stroke. The persistence of a strong adjusted regional effect indicates that contextual influences at the community level may be relevant and deserve further study \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. From a urological perspective, this pattern suggests that prostate calcification may be more than an incidental imaging finding in this setting. Although the current study cannot establish mechanisms, marked between-site clustering may help identify communities in which closer evaluation of lower urinary tract health and follow-up assessment may be warranted.\u003c/p\u003e \u003cp\u003eAn important implication of our findings is that community-based ultrasound screening may help identify older men with more complex urological health profiles, particularly in geographically extensive settings where routine specialist access may not be uniform [16]. Rather than supporting universal screening recommendations, the current data suggest that risk-aware community-based identification and subsequent follow-up may be useful for older men in settings with heterogeneous health burden. In particular, combining urinary ultrasound findings with information on common chronic diseases may help identify older men who warrant closer follow-up and referral in geographically diverse settings.\u003c/p\u003e \u003cp\u003eAt the same time, our findings should not be interpreted as direct evidence in favor of universal urinary ultrasound screening. The present study demonstrates regional variation and potential value for risk identification, but it does not establish the effectiveness, acceptability, downstream benefit, or cost-effectiveness of a universal screening programme. The current data more appropriately support the rationale for further evaluating risk-stratified, community-based screening and follow-up models for older men, especially in areas where health burdens and access conditions are unlikely to be uniform.\u003c/p\u003e \u003cp\u003eThis study has several strengths. First, it was based on investigator-led, field-based outreach screening rather than passive extraction of routine hospital records. Second, the screening programme targeted a predefined population, namely local male residents aged 60 years or older, and all 438 attendees completed urinary system ultrasound examination during the study period. Third, the same ultrasound team conducted screening across three study sites, which improved implementation consistency. Fourth, the study simultaneously assessed urinary abnormalities and chronic disease comorbidities, thereby providing a broader picture of older men\u0026rsquo;s health than studies focused on a single urological condition alone.\u003c/p\u003e \u003cp\u003eSeveral limitations should also be acknowledged. First, the cross-sectional design precludes causal inference. Second, because participants were recruited through community publicity and voluntary attendance, the final sample should be interpreted as a community outreach screening sample rather than a probability-based population sample. Selection bias is therefore possible. Third, urinary abnormalities were identified through standardized recoding of ultrasound text reports generated under routine quality-control procedures rather than centralized image review or formal inter-rater reliability testing for research purposes. Some degree of misclassification may therefore remain possible. Fourth, chronic disease history was obtained through on-site epidemiological survey and may be subject to recall or reporting bias. Fifth, the study lacked information on body mass index, smoking, alcohol intake, diet, hydration behavior, medication use, occupational history, and healthcare access. Sixth, although regional context may be relevant to interpreting health heterogeneity, variables such as migration pattern, labor outflow, and household structure were not directly measured and should therefore not be overinterpreted. Seventh, the sample size in Erguna was relatively small, which may have limited statistical power for some comparisons.\u003c/p\u003e \u003cp\u003eOverall, the present findings suggest that ultrasound-detected urological abnormalities in older men should be interpreted in conjunction with chronic disease burden and local clinical context. Rather than treating prostate or renal findings as isolated observations, community-based ultrasound screening may help identify older men who warrant closer urological evaluation and follow-up, especially in geographically diverse settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOlder men across three study sites in Hulunbuir showed heterogeneous patterns of ultrasound-detected urological abnormalities and chronic disease comorbidity. Prostate calcification exhibited the most pronounced between-site difference, while age and hypertension were independently associated with benign prostatic enlargement. These findings highlight the value of community-based ultrasound screening for the identification of urological abnormalities in older men and may inform follow-up and referral strategies in geographically diverse settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e\n\u003cp\u003eThis study was based on large-scale free community outreach screening activities conducted by the study team across three study sites in Hulunbuir. The present analysis used de-identified data derived from those screening activities. Ethical review determined that the secondary analysis of anonymized data was exempt from further informed consent requirements. The study was reviewed by the Ethics Committee of Hulunbuir People\u0026rsquo;s Hospital (reference/approval number: 2022SYY-10).\u003c/p\u003e\n\u003ch2\u003eConsent for publication:\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eCompeting interests:\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors thank the local community organizers, outreach screening staff, and ultrasound team members in Dayan, Bayantohai, and Erguna for their support in participant recruitment, field implementation, and data collection. The authors also thank all participants involved in the free screening programme.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eThis work was supported by the Key Research and Development and Achievement Transformation Project in the Field of Social Public Welfare of Inner Mongolia Autonomous Region during the 14th Five-Year Plan Period (2022YFSH0004), and the Hulunbuir City Science and Technology Plan Project (SF2022009). The funders had no role in the design of the study, data collection, analysis, interpretation of data, or writing of the manuscript.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eYuan Du conceived and designed the study, led the field screening activities, performed the statistical analysis, interpreted the data, and drafted the manuscript. Yinghui Kang and Zhihui Guan contributed to field screening implementation, data collection, and data verification. Xiaojun Zhu contributed to study coordination and critical revision of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe de-identified datasets used and/or analyzed during the current study are not publicly available due to institutional and privacy restrictions but are available from the corresponding author on reasonable request and with permission from Hulunbuir People\u0026rsquo;s Hospital.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care. 2nd ed. Geneva: World Health Organization; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Integrated care for older people (ICOPE): guidelines on community-level interventions to manage declines in intrinsic capacity. 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Korean J Urol. 2009;50(9):916\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"older men, urological abnormalities, benign prostatic enlargement, prostate calcification, community-based screening, epidemiology, ultrasound","lastPublishedDoi":"10.21203/rs.3.rs-9388251/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9388251/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eUltrasound-detected urological abnormalities are common in older men, yet data on their regional distribution and associated comorbidities in community settings remain limited. This study aimed to compare the regional distribution of ultrasound-detected urological abnormalities among older men in Hulunbuir, northern China, and to examine factors associated with benign prostatic enlargement and prostate calcification in a community-based screening setting.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis investigator-led, community-based cross-sectional outreach screening study was conducted in Dayan Town, Bayantohai Town, and Erguna City in Hulunbuir from June to August 2022. The study was based on large-scale free screening activities organized by the study team, with participants recruited locally through advance community publicity. The screening programme targeted local male residents aged 60 years or older. A total of 438 men participated, and all underwent urinary system ultrasound examination. Ultrasound examinations at the three study sites were performed by the same team of trained sonographers. Urinary abnormalities were identified through standardized recoding of ultrasound text reports and included benign prostatic enlargement, prostate calcification, kidney stones, and renal cysts. Chronic disease comorbidities were obtained through on-site epidemiological survey and included hypertension, diabetes mellitus, and stroke. Group differences were compared across the three study sites, and logistic regression models were used to assess factors associated with benign prostatic enlargement and prostate calcification.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMean age was similar across the three study sites, whereas ethnic composition differed significantly. Hypertension prevalence was highest in Bayantohai (71.1%), compared with Dayan (55.8%) and Erguna (49.4%) (P\u0026thinsp;=\u0026thinsp;0.002). Diabetes mellitus and stroke were also numerically more common in Bayantohai, although these differences were not statistically significant. The prevalence of benign prostatic enlargement was 55.8% in Dayan, 57.7% in Bayantohai, and 67.1% in Erguna (P\u0026thinsp;=\u0026thinsp;0.212). In contrast, prostate calcification showed marked regional variation, with the highest prevalence in Dayan (57.1%), followed by Erguna (21.5%) and Bayantohai (9.9%) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In multivariable analysis, age\u0026thinsp;\u0026ge;\u0026thinsp;70 years (adjusted OR 2.15, 95% CI 1.52\u0026ndash;3.04, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and hypertension (adjusted OR 1.59, 95% CI 1.06\u0026ndash;2.41, P\u0026thinsp;=\u0026thinsp;0.027) were independently associated with benign prostatic enlargement. Compared with Dayan, the adjusted odds of prostate calcification were substantially lower in Bayantohai (adjusted OR 0.074, 95% CI 0.037\u0026ndash;0.146, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and Erguna (adjusted OR 0.211, 95% CI 0.115\u0026ndash;0.386, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOlder men across three study sites in Hulunbuir showed heterogeneous profiles of ultrasound-detected urological abnormalities. The marked regional difference in prostate calcification, together with the independent associations of age and hypertension with benign prostatic enlargement, highlights the value of community-based ultrasound screening for the early identification of urological health burden in older men. These findings may help inform risk-aware follow-up and referral strategies in similar settings.\u003c/p\u003e","manuscriptTitle":"Regional variation in ultrasound-detected urological abnormalities and associated comorbidities among older men in Hulunbuir, northern China: a community-based screening study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-15 09:41:07","doi":"10.21203/rs.3.rs-9388251/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4807fe67-d547-4226-82a4-c94f2a51dc37","owner":[],"postedDate":"May 15th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-18T04:37:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T16:22:19+00:00","index":51,"fulltext":""},{"type":"reviewerAgreed","content":"103069199284401010725090456560380142750","date":"2026-05-11T15:51:39+00:00","index":50,"fulltext":""},{"type":"reviewerAgreed","content":"228207072557227241711154366347187023274","date":"2026-05-06T18:06:53+00:00","index":46,"fulltext":""},{"type":"reviewersInvited","content":"25","date":"2026-05-06T15:50:48+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T04:40:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-15 09:41:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9388251","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9388251","identity":"rs-9388251","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}