Global, regional, and national age-sex-specific mortality and life expectancy, 1950-2017: a systematic analysis for the Global Burden of Disease Study 2017

Short-term and long-term effects of major depressive disorder subtypes on obesity markers and impact of sex on these associations

BACKGROUND

Only a few studies with conflicting results have examined the effects of sex on the prospective association between depression and subsequent obesity.

OBJECTIVE

(1) To simultaneously assess the associations of the subtypes (atypical, melancholic, unspecified) of major depressive disorder (MDD) measured at baseline and subtypes of major depressive episodes (MDE) that emerged during a 5.5-year follow-up with changes in obesity markers (body mass index, waist circumference, fat mass) during this follow-up, and (2) to test the effect of sex on these associations.

METHODS

Data from CoLaus|PsyCoLaus, a population-based cohort study including 2702 participants (50.1% women, mean age 49.6 years). Criteria for mental disorders were elicited using semi-structured interviews.

RESULTS

History of atypical MDD at baseline was associated with a steeper increase in BMI and waist circumference, whereas atypical MDE during follow-up was associated with a steeper increase in the three studied obesity markers. Melancholic MDD at baseline was associated with a steeper increase in BMI. Several significant interactions with sex were found indicating higher increase in fat mass in men than in women following melancholic MDD reported at baseline, higher decrease in BMI and fat mass in women than in men related to melancholic MDE emerging during follow-up and higher increase in waist circumference in men than in women following unspecified MDD reported at baseline.

LIMITATIONS

Urban sample which may not be representative for the whole population.

CONCLUSIONS

Our results further advocate for the specific need of a thorough monitoring of obesity markers in patients with atypical MDD and suggest less favorable obesity marker changes mainly related to melancholic MDE in men.

Effect of an Integrative Mobile Health Intervention in Patients With Hypertension and Diabetes: Crossover Study

Background

Obesity, hypertension, and type 2 diabetes mellitus (T2DM) are worldwide epidemics that inflict burdens on both public health and health care costs. Self-management plays an important role in the proper management of these 3 chronic diseases, and in this context, mobile health (mHealth) can be a cost-effective self-management tool.

Objective

The aim of this pilot study is to evaluate the effects of an integrative mHealth approach for obesity, hypertension, and T2DM on body fat, blood pressure, and blood glucose levels and demonstrate the clinical outcomes. The participants were patients aged 40 to 70 years who were treated for T2DM (hemoglobin A_1c [HbA_1c] above 6.0%) without insulin or hypertension and obesity, controlled with pharmacotherapy.

Methods

This pilot study was performed using a controlled, randomized, 3-month, 2-period crossover design. A total of 37 participants were recruited from 2 university hospitals in South Korea. Integrative mHealth comprised 4 parts: self-measuring home devices for monitoring blood glucose and blood pressure; 2 smartphone apps, where one gathered lifestyle data, giving them feedback with health information, and the other provided drug information and reminders of the medication schedule; unmanned kiosks for official measurement of blood pressure and body composition; and web-based access to participants’ health information.

Results

Data from the 32 participants were analyzed. Their mean HbA_1c level was 7.5% (SD 0.8, ranging from 6.1% to 9.4%). Approximately 38% (12/32) of the participants had hypertension. BMIs of all participants except 1 were >23 kg/m². The input rates of food intake and exercise to the smartphone app were very low (24.9% and 5.3%, respectively). On the contrary, the input rate of medicine intake was high (84.0%). Moreover, there was no significant difference in the input rate of taking medicine irrespective of whether the mHealth period was before or after the conventional treatment period (80.3% and 87.3%, respectively; P=.06). Among the 3 input functions of food intake, exercise, and medicine intake in smartphone apps, the input of medicine intake was a more helpful, easier to use, and better-designed function than the others. There were no significant differences in changes in body weight (−0.519 kg vs 0 kg), BMI (−0.133 kg/m² vs −0.167 kg/m²), body composition (body fat −0.255% vs 0.172%), blood pressure (systolic −0.226 mm Hg vs −2.839 mm Hg), and HbA_1c (−0.269% vs –0.009%) between the integrative mHealth and conventional treatment groups. However, in proportion to the elevation in the input rate of taking medicine, body fat mass (P=.04) and HbA_1c (P=.03) were lower in the integrative mHealth group.

Conclusions

Although smartphone apps can influence body fat and blood glucose levels, they have failed to show clinical improvement. A higher input rate of taking medicine was related to significantly lower body fat mass and HbA_1c levels.

Body composition, physical capacity, and immuno-metabolic profile in community-acquired pneumonia caused by COVID-19, influenza, and bacteria: a prospective cohort study

BACKGROUND

Different pathogens can cause community-acquired pneumonia (CAP); however, the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19) has re-emphasized the vital role of respiratory viruses as a cause of CAP. The aim was to explore differences in metabolic profile, body composition, physical capacity, and inflammation between patients hospitalized with CAP caused by different etiology.

METHODS

A prospective study of Danish patients hospitalized with CAP caused by SARS-CoV-2, influenza, or bacteria. Fat (FM) and fat-free mass (FFM) were assessed with bioelectrical impedance analysis. Physical activity and capacity were assessed using questionnaires and handgrip strength. Plasma (p)-glucose, p-lipids, hemoglobin A1c (HbA1c), p-adiponectin, and cytokines were measured.

RESULTS

Among 164 patients with CAP, etiology did not affect admission levels of glucose, HbA1c, adiponectin, or lipids. Overall, 15.2% had known diabetes, 6.1% had undiagnosed diabetes, 51.3% had pre-diabetes, 81% had hyperglycemia, and 60% had low HDL-cholesterol, with no difference between groups. Body mass index, FM, and FFM were similar between groups, with 73% of the patients being characterized with abdominal obesity, although waist circumference was lower in patients with COVID-19. Physical capacity was similar between groups. More than 80% had low handgrip strength and low physical activity levels. Compared to patients with influenza, patients with COVID-19 had increased levels of interferon (IFN)-γ (mean difference (MD) 4.14; 95% CI 1.36-12.58; p = 0.008), interleukin (IL)-4 (MD 1.82; 95% CI 1.12-2.97; p = 0.012), IL-5 (MD 2.22; 95% CI 1.09-4.52; p = 0.024), and IL-6 (MD 2.41; 95% CI 1.02-5.68; p = 0.044) and increased IFN-γ (MD 6.10; 95% CI 2.53-14.71; p < 0.001) and IL-10 (MD 2.68; 95% CI 1.53-4.69; p < 0.001) compared to patients with bacterial CAP, but no difference in IL-1β, tumor necrosis factor-α, IL-8, IL-18, IL-12p70, C-reactive protein, and adiponectin.

CONCLUSION

Despite higher inflammatory response in patients with COVID-19, metabolic profile, body composition, and physical capacity were similar to patients with influenza and bacterial CAP.

Mortality and Years of Life Lost in Diabetes Mellitus and Its Subcategories in China and Its Provinces, 2005-2020

OBJECTIVES

To analyze diabetes mellitus (DM) mortality and years of life lost (YLL) in different years and different subgroups at the national and regional levels in China from 2005 to 2020.

METHODS

We estimated mortality and YLL of DM and its subcategories for 31 provinces in China during 2005-2020 using multisource data from the National Mortality Surveillance System (NMSS).

RESULTS

The age standardized mortality rate (ASMR) of DM increased from 12.18 per 100,000 in 2005 to 13.62 per 100,000 in 2020, which was an increase of 11.86%. The ASMR of type 2 diabetes mellitus (T2DM) was much higher than that of type 1 diabetes mellitus (T1DM). The ASMR of T1DM remained stable, but the rate of T2DM increased, and the increase in male patients was higher than that in their female counterparts. At the same time, the burden of premature death was highest in the group ≥ 80 years old, and ASMR increased from 236.02 per 100,000 in 2005 to 358.86 per 100,000 in 2020. In 2005, the eastern region had the highest ASMR of DM, but the western region's ASMR grew faster and eventually became the highest in 2020. In addition, the YLL rate in the eastern region showed a downward trend; however, in the middle and western regions the YLL rate continued to rise, with that of the western region rapidly increasing.

CONCLUSION

A dramatically upward trend in DM deaths can be seen in China from 2005 to 2020. DM remains a chronic disease in urgent need of prevention and control, especially in the elderly and people in less-affluent provinces. We must put forward more targeted policies to effectively allocate medical resources and focus on high-risk groups to reduce the premature-mortality burden of DM and its subcategories.

Frailty and Associated Factors among Chinese Centenarians

OBJECTIVES

The study aimed to apply the frailty index (FI) to assess frailty status among Chinese centenarians and analyse its associated factors.

DESIGN

The study was a cross-sectional study.

SETTING AND PARTICIPANTS

The study included 1043 centenarians (742 females and 301 males) aged ≥100 years from the 2018 wave of the China Longitudinal Healthy Longevity Survey.

MEASUREMENTS

All participants were assessed for frailty by the FI. Basic characteristics, including age, height, weight, calf circumference, waist circumference, hip circumference, sex, years of education, financial status, exercise, fall status, coresidence, smoking, alcohol consumption, number of natural teeth, denture use, toothache, and tooth brushing, were collected. Multivariate logistic regression was used to analyse the associations between risk factors and frailty.

RESULTS

The average age of the participants was 102.06±2.55 years (range: 100-117 years). The FI ranged between 0.00 and 0.63. The mean FI for all participants was 0.27±0.13 (median 0.25; interquartile range 0.20-0.35). Participants were divided into quartiles. The number of natural teeth and denture use, coresidence, sex, exercise, and financial status showed significant associations with frailty classes (all P<0.05). Multivariate logistic regression analysis indicated that having ≤20 natural teeth without dentures (OR, 95% CI= 1.89(0.004-1.246), P<0.05), having ≤20 natural teeth with dentures (OR, 95% CI=2.21(0.158,1.432), P=0.015), living alone or in an institution (OR, 95% CI=1.68(0.182-0.849), P=0.002), lacking exercise (OR, 95% CI=2.54(0.616-1.246), P<0.001), having insufficient financial resources (OR, 95% CI=2.9(0.664-1.468), P<0.001), and being female (OR, 95% CI=1.47(0.137,0.634), P=0.002) were independent risk factors for frailty.

CONCLUSION

Chinese centenarian women are frailer than men. Having fewer natural teeth, living alone or in an institution, lacking exercise, and having insufficient financial resources were the factors associated with frailty among Chinese centenarians. Family conditions and healthy lifestyles may be important for frailty status in centenarians.

Significance of upfront cytoreductive nephrectomy stratified by IMDC risk for metastatic renal cell carcinoma in targeted therapy era - a multi-institutional retrospective study

Background

This retrospective multicenter study aimed to evaluate the survival benefit of upfront cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (RCC) patients stratified by International Metastatic RCC Database Consortium (IMDC) risk criteria.

Methods

We reviewed the medical records in the Michinoku Database between 2008 and 2019. Patients who received upfront CN, systemic therapy without CN (no CN) and CN after drug therapy (deferred CN) were analyzed. To exclude selection bias due to patient characteristics, baseline clinical data were adjusted by inverse probability of treatment weighting (IPTW). Overall survival (OS) was compared between upfront CN and non-upfront CN (no CN plus deferred CN). Associations between time-varying covariates including systemic therapies and OS stratified by IMDC risk criteria were analyzed by IPTW-adjusted Cox regression method.

Results

Of 259 patients who fulfilled the selection criteria, 107 were classified in upfront CN and 152 in non-upfront CN group. After IPTW-adjusted analysis, upfront CN showed survival benefit compared to non-upfront CN in patients with IMDC intermediate risk (median OS: 52.5 versus 31.3 months, p < 0.01) and in patients with IMDC poor risk (27.2 versus 11.4 months, p < 0.01). In IPTW-adjusted Cox regression analysis of time-varying covariates, upfront CN was independently associated with OS benefit in patients with IMDC intermediate risk (hazard ratio 0.52, 95% confidence interval 0.29–0.93, p = 0.03) and in patients with IMDC poor risk (0.26, 0.11–0.59, p < 0.01).

Conclusions

Upfront CN may confer survival benefit in RCC patients with IMDC intermediate and poor risk.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10147-021-02091-8.

Decomposition of basic mortality indicators in Serbia 1990-2021

The research of thirty-year changes in the mortality of the population of Serbia (1990-2021) is given through two basic indicators of mortality. Using the decompose method to calculated the effect of population aging on the difference between crude mortality rates, as well as the contributions of specific mortality rates and leading causes of death in the changes in life expectancy. The crude death rate shows that the intensity of dying in Serbia is very high. The pandemic contributed to record values in the last two years. Overall, in the period 1990-2019, the negative contribution of the age structure is twice as intense as the positive effect of age-specific mortality rates. Aging is more intense in the female population, which explains the greater increase in the crude death rate in women. The data show that the importance of demographic aging has always been more pronounced. The main characteristic in the observed time interval is that mortality decreases at all ages and that all age groups had a positive effect on life expectancy, as well as that men and women in Serbia have a different pattern of decreasing mortality by age. The most significant effect on life expectancy was the reduction of infant mortality (a fifth of the total contribution), a common feature of the male and female populations. In other age groups, men have more pronounced contributions up to the age of 50, and women in older cohorts. Due to higher mortality rates, the space for improving mortality is greater in young and middle-aged men than in women, so the positive effects are more pronounced at these ages. The largest number of leading causes of death burdens the population of Serbia less now than three decades earlier. Cardiovascular diseases, as the leading cause of death, contributed the most to positive changes in mortality. The biggest effect of life expectancy is the reduction of mortality rates due to diseases of the circulatory system in the 65-79 year old population. Observed by gender, the effect is greater in the female population, where cardiovascular diseases contribute to the extension of life expectancy by as much as 67% or by 2.4 years, while in the male population the importance of cardiovascular diseases in the extension of life expectancy is lower and amounts to 42% or by 1.9 years. Tumors, as the second most common cause of death in Serbia, contribute negatively to those aged 50 and over and positively to younger age groups. The overall effect on life expectancy is positive, and mortality rates in men decline until the age of 60. In women, rates increase from age 50 or older, and of all causes of death, only tumors have an overall negative effect on life expectancy growth. Among the other causes, the importance of violent deaths and their positive effect should be singled out, due to the reduction of mortality rates at all ages, especially among the younger population. Positive changes in the age of 15-49 years in the male population contribute to an increase in life expectancy of even 1 year. In the female population, a positive contribution is also present at all ages, but the effect is significantly lower. The COVID-19 pandemic brought the highest increase in mortality in Serbia in the last 70 years. Mortality increased by 14% in the first year of the pandemic, and by 34% in the second, compared to the 2017-2019 average. The crude death rate has increased tremendously and for men in 2020 it is 18.0‰, and in 2021 it will show a maximum value of 21 deaths per 1,000 persons. For women, this mortality rate is 15.9‰ and 19.0‰ (in 2020 and 2021, respectively). Changes compared to the values from 2019, for both sexes, are solely the result of the increase in mortality by age, while changes in the distribution of the population by age had a negligible effect in this period. The last analyzed year (2021) brings a drop in life expectancy for men of as much as 3.4 years compared to the period before the pandemic. Women in Serbia have a slightly smaller decline in life expectancy in this period of 2.9 years.

The Causes of Death and Their Influence in Life Expectancy of Children Aged 5-14 Years in Low- and Middle-Income Countries From 1990 to 2019

INTRODUCTION

Although child and adolescent health is the core of the global health agenda, the cause of death and its expected contribution to life expectancy (LE) among those aged 5-14 are under-researched across countries, especially in low- and middle-income countries (LMICs).

METHODS

Death rates per 10 years age group including a 5-14-year-old group were calculated by the formula, which used the population and the number of deaths segmented by the cause of death and gender from the 2019 Global Burden of Disease (GBD) study. LE and cause-eliminated LE in 10-year intervals were calculated by using life tables.

RESULTS

In 2019, the global mortality rate for children and adolescents aged 5-14 years was 0.522 (0.476-0.575) per 1,000, and its LF was 71.377 years. In different-income regions, considerable heterogeneity remains in the ranking of cause of death aged 5-14 years. The top three causes of death in low-income countries (LICs) are enteric infections [0.141 (0.098-0.201) per 1,000], other infectious diseases [0.103 (0.073-0.148) per 1,000], and neglected tropical diseases and malaria [0.102 (0.054-0.172) per 1,000]. Eliminating these mortality rates can increase the life expectancy of the 5-14 age group by 0.085, 0.062, and 0.061 years, respectively. The top three causes of death in upper-middle income countries (upper MICs) are unintentional injuries [0.066 (0.061-0.072) per 1,000], neoplasm [0.046 (0.041-0.050) per 1,000], and transport injuries [0.045 (0.041-0.049) per 1,000]. Eliminating these mortality rates can increase the life expectancy of the 5-14 age group by 0.045, 0.031, and 0.030 years, respectively.

CONCLUSION

The mortality rate for children and adolescents aged 5-14 years among LMICs remains high. Considerable heterogeneity was observed in the main causes of death among regions. According to the main causes of death at 5-14 years old in different regions and countries at different economic levels, governments should put their priority in tailoring their own strategies to decrease preventable mortality.

The Effectiveness of Perturbation-Based Training in the Treatment of Patients With Stroke: A Systematic Review and Meta-Analysis

Purpose:

To investigate the effectiveness of perturbation-based training (PBT) on balance and balance confidence in patients with stroke.

Methods:

Systematic searching was performed from inception to November 2021. The inclusion criteria were RCTs assessed the effectiveness of PBT in patients with stroke. Data regarding participants, intervention parameters, outcome measures, follow-up, and main results were extracted. The outcomes were balance and balance confidence. Methodological quality and quality of evidence were assessed using the Physiotherapy Evidence Database (PEDro) scale and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system; respectively.

Data analysis:

A total of 7 articles )271 patients) were included. A meta-analysis using a random-effect model was performed on 6 studies. Standardized mean difference (SMD) with a 95% confidence interval was calculated for balance and balance confidence.

Results:

PEDro scale revealed 5 good-quality and 2 fair-quality studies. The currently available evidence showed significant effect of PBT in improving balance (SMD 0.60 [95% CI 0.15-1.06]; P = .01; very low-quality evidence) and non-significant in improving balance confidence (SMD 0.11 [95% CI −0.24 to 0.45]; P = .55; low-quality evidence).

Conclusion:

PBT may improve balance in patients with stroke, however its effect on balance confidence was limited. The quality of the evidence was low or very low with little confidence in the effect estimate, which suggests further high-quality trials are required.

Registration:

PROSPERO registration number (CRD42021291474).

Kidney biopsy-based epidemiologic analysis shows growing biopsy rate among the elderly

Systematic registration and examination of biopsy-related data in Central and Eastern Europe are scarce, while the health condition of the population is worse compared to other more developed countries. We aim to create a database and analyze the distribution and temporal variation of the renal biopsy diagnoses in Hungary, including the effect of the recent coronavirus pandemic. The diagnoses were standardized according to the recommendation of the European Renal Association. Native biopsy samples processed between January 1, 2006, and December 31, 2020, were analyzed. During the 15 years, 2140 native kidney biopsies were performed. The number of samples increased from 24.5 to 57.9 per million person-years and the median age from 37 to 51 years (p < 0.0001). The predominance of glomerular diseases was stable. The most frequent glomerulopathy was IgA nephropathy (21.5%), followed by focal segmental glomerulosclerosis (17.7%), and membranous nephropathy (15.7%). Trends showed the rise of ANCA-associated vasculitis. During the coronavirus pandemic, there was a decrease in the number of kidney biopsies and the proportion of membranous nephropathies. The diagnostic trends in our database showed increasing biopsy rates among the elderly and the growing frequencies of age-related diseases, which emphasizes the importance of altering medical focus according to demographic changes in this area.

Cost yield of different treatment strategies against Clonorchis sinensis infection

BACKGROUND

Clonorchiasis is attributed to the ingestion of raw freshwater fish harboring Clonorchis sinensis. Morbidity control is targeted through the administration of antihelminthics. This study modelled the cost yield indicated by effectiveness and utility of different treatment strategies against clonorchiasis.

METHODS

About 1000 participants were enrolled from each of 14 counties selected from four provincial-level administrative divisions namely Guangxi, Guangdong, Heilongjiang and Jilin in 2017. Fecal examination was adopted to detect C. sinensis infection, while behavior of ingesting raw freshwater fish was enquired. Counties were grouped into four categories based on prevalence, namely low prevalence group (< 1%), moderate prevalence group (1-9.9%), high prevalence group (10-19.9%) and very high prevalence group (≥ 20%), while population were divided into three subgroups, namely children aged below 14 years old, adult female and adult male both aged over 14 years old. The average of cost effectiveness indicated by the cost to treat single infected cases with C. sinensis and of cost utility indicated by the cost to avoid per disability-adjusted life years (DALYs) caused by C. sinensis infection was calculated. Comparisons were performed between three treatment schedules, namely individual treatment, massive and selective chemotherapy, in which different endemic levels and populations were considered.

RESULTS

In selective chemotherapy strategy, the cost to treat single infected case in very high prevalence group was USD 10.6 in adult male, USD 11.6 in adult female, and USD 13.2 in children. The cost increased followed the decrease of endemic level. In massive chemotherapy strategy, the cost per infected case in very high prevalence group was USD 14.0 in adult male, USD 17.1 in adult female, USD 45.8 in children, which were also increased when the endemic level decreased. In individual treatment strategy, the cost was USD 12.2 in adult male, USD 15.0 in adult female and USD 41.5 in children in very high prevalence group; USD 19.2 in adult male, USD 34.0 in adult female, and USD 90.1 in children in high prevalence group; USD 30.4 in adult male, USD 50.5 in adult female and over USD 100 in children in moderate prevalence group; and over USD 400 in any population in low prevalence group. As to cost utility, the differences by treatment strategies, populations and endemic levels were similar to those in cost effectiveness.

CONCLUSIONS

Both cost effectiveness and cost utility indicators are highly impacted by the prevalence and population, as well as the treatment schedules. Adults especially men in the areas with a prevalence over 10% should be prioritized, in which selective chemotherapy was best and massive chemotherapy was also cost effective. In moderate endemic areas, the yield is not ideal, but selective chemotherapy for adult male may also be adopted. In low endemic areas, all strategies were high costly and new strategies need to be developed.

Spatiotemporal trends in life expectancy and impacts of economic growth and air pollution in 134 countries: A Bayesian modeling study

Life expectancy (LE) varies across countries in space and time, and economic growth and air pollution are two important influence factors to LE. This study mainly aims to investigate spatiotemporal trends in LE in 134 countries from 1960 to 2016 by using Bayesian spatiotemporal modeling. Further, the relations between per capita gross domestic product (GDP_pc) and population-weighted fine particulate matter (pwPM_2.5) and LE are investigated from a global perspective from 1998 to 2016 by using the Bayesian regression model. The results illustrated the heterogeneity of spatiotemporal trends in LE globally. Specifically, Africa and South-East Asia show much lower LE levels, and the Americas, European, and Western Pacific exhibit a relatively higher LE level compared to the overall level. The countries with low overall levels of LE show a relatively stronger upward trend than the overall upward trend and vice versa. In addition, this study demonstrates that the spatial differences in effects of influence factors on LE in the six WHO regions in the 134 countries. Africa shows the highest positive regression coefficient of GDP_pc and lowest negative regression coefficient of pwPM_2.5 on LE than other regions in the world. Furthermore, it shows the complexity of the interaction between economic growth and air pollution on LE across six WHO regions. Our findings suggest the public policies to reduce the health damage caused by air pollution, especially in Africa, Eastern Mediterranean, and Europe where the pwPM_2.5 negatively affect the LE benefits from economic growth.

Global, regional, and national burden of cervical cancer for 195 countries and territories, 2007-2017: findings from the Global Burden of Disease Study 2017

BACKGROUND

Cervical cancer is one of the most common cancers among women worldwide. The formulation or evaluation on prevention strategies all require an accurate understanding of the burden for cervical cancer burden. We aimed to report the up-to-date estimates of cervical cancer burden at global, regional, and national levels.

METHODS

Data were extracted from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 study. The counts, age-standardized rates, and percentage changes of incidence, disability-adjusted life-years (DALYs), and death attributed to cervical cancer at the global, regional, and national levels in all 195 countries and territories from 21 regions during 2007 to 2017 by age and by Socio-demographic Index (SDI) were measured. All estimates were reported with 95% uncertainty intervals (UIs).

RESULTS

In 2017, 601,186 (95% UI 554,455 to 625,402) incident cases of cervical cancer were reported worldwide, which caused 8,061,667 (7,527,014 to 8,401,647) DALYs and 259,671 (241,128 to 269,214) deaths. The age-standardized rates for incidence, DALYs and death decreased by - 2.8% (- 7.8% to 0.6%), - 7.1% [- 11.8% to - 3.9%] and - 6.9% [- 11.5% to - 3.7%] from 2007 to 2017, respectively. The highest age-standardized incidence, DALYs and death rates in 2017 were observed in the low SDI quintile, Oceania, Central and Eastern Sub-Saharan Africa. During 2007 to 2017, only East Asia showed increase in these rates despite not significant. At the national level, the highest age-standardized rates for incidence, DALYs, and death in 2017 were observed in Kiribati, Somalia, Eritrea, and Central African Republic; and Georgia showed the largest increases in all these rates during 2007 to 2017.

CONCLUSION

Although the age-standardized rates for incidence, DALYs, and death of cervical cancer have decreased in most parts of the world from 2007 to 2017, cervical cancer remains a major public health concern in view of the absolute number of cervical cancer cases, DALYs, and deaths increased during this period. The challenge is more prone to in the low SDI quintile, Oceania, Central and Eastern Sub-Saharan Africa, East Asia, and some countries, suggesting an urgent to promote human papillomavirus vaccination in these regions.

Socioeconomic inequalities in child growth failure in Ethiopia: findings from the 2000 and 2016 Demographic and Health Surveys

OBJECTIVE

Socioeconomic inequalities in child growth failure (CGF) remain one of the main challenges in Ethiopia. This study examined socioeconomic inequalities in CGF and determinants that contributed to these inequalities in Ethiopia.

METHODS

The Ethiopia Demographic and Health Surveys 2000 and 2016 data were used in this study. A pooled unweighted sample of the two surveys yielded 21514 mother-child pairs (10873 in 2000 and 10641 in 2016). We assessed socioeconomic inequalities in CGF indicators using the concentration curve and concentration index (CI). We then decomposed the CI to identify percentage contribution of each determinant to inequalities.

RESULTS

Socioeconomic inequalities in CGF have increased in Ethiopia between 2000 and 2016. The CI increased from -0.072 and -0.139 for stunting, -0.088 and -0.131 for underweight and -0.015 and -0.050 for wasting between 2000 and 2016, respectively. Factors that mainly contributed to inequalities in stunting included geographical region (49.43%), number of antenatal care visits (31.40%) and child age in months (22.20%) in 2000. While in 2016, inequality in stunting was contributed mainly by wealth quintile (46.16%) and geographical region (-13.70%). The main contributors to inequality in underweight were geographical regions (82.21%) and wealth quintile (27.21%) in 2000, while in 2016, wealth quintile (29.18%), handwashing (18.59%) and access to improved water facilities (-17.55%) were the main contributors. Inequality in wasting was mainly contributed to by maternal body mass index (-66.07%), wealth quintile (-45.68%), geographical region (36.88%) and paternal education (33.55%) in 2000, while in 2016, wealth quintile (52.87%) and urban areas of residence (-17.81%) were the main driving factors.

CONCLUSIONS

This study identified substantial socioeconomic inequalities in CGF, and factors that relatively contributed to the disparities. A plausible approach to tackling rising disparities may involve developing interventions on the identified predictors and prioritising actions for the most socioeconomically disadvantaged groups.

Breast cancer burden in Africa: evidence from GLOBOCAN 2018

BACKGROUND

Breast cancer is the leading malignancy in African females. This study aims to examine the breast cancer burden in Africa using recently released GLOBOCAN 2018 estimates.

METHODS

The incidence and mortality estimates of age- and country-wise burden of breast cancer in 54 African countries were obtained from GLOBOCAN 2018.

RESULTS

In Africa, breast cancer caused 74 072 deaths, and 168 690 cases were estimated to have occurred in 2018. The age-standardized incidence rate stood at 37.9/100 000 in Africa, varying from 6.9/100 000 in the Gambia to 69.6/100 000 in Mauritius. The age-standardized mortality rate stood at 17.2/100 000 in 2018, ranging from 4/100 000 in the Gambia to 29.1/100 000 in Somalia in 2018. Nigeria was the leading country in terms of absolute burden with 26 310 cases and 11 564 deaths, followed by Egypt with 23 081 new cases and 9254 deaths. The mortality-to-incidence ratio for Africa stood at 0.44, varying from 0.24 in Libya to 0.68 in the Central African Republic.

CONCLUSION

To tackle breast cancer burden in Africa, the main challenges are late-stage disease presentation, lack of screening and therapeutic infrastructure, lack of awareness and limited resources.

Development and Validation of Decision Rules Models to Stratify Coronary Artery Disease, Diabetes, and Hypertension Risk in Preventive Care: Cohort Study of Returning UK Biobank Participants

Many predictive models exist that predict risk of common cardiometabolic conditions. However, a vast majority of these models do not include genetic risk scores and do not distinguish between clinical risk requiring medical or pharmacological interventions and pre-clinical risk, where lifestyle interventions could be first-choice therapy. In this study, we developed, validated, and compared the performance of three decision rule algorithms including biomarkers, physical measurements, and genetic risk scores for incident coronary artery disease (CAD), diabetes (T2D), and hypertension against commonly used clinical risk scores in 60,782 UK Biobank participants. The rules models were tested for an association with incident CAD, T2D, and hypertension, and hazard ratios (with 95% confidence interval) were calculated from survival models. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC), and Net Reclassification Index (NRI). The higher risk group in the decision rules model had a 40-, 40.9-, and 21.6-fold increased risk of CAD, T2D, and hypertension, respectively (p < 0.001 for all). Risk increased significantly between the three strata for all three conditions (p < 0.05). Based on genetic risk alone, we identified not only a high-risk group, but also a group at elevated risk for all health conditions. These decision rule models comprising blood biomarkers, physical measurements, and polygenic risk scores moderately improve commonly used clinical risk scores at identifying individuals likely to benefit from lifestyle intervention for three of the most common lifestyle-related chronic health conditions. Their utility as part of digital data or digital therapeutics platforms to support the implementation of lifestyle interventions in preventive and primary care should be further validated.

Trends and external causes of traumatic brain injury and spinal cord injury mortality in south China, 2014-2018: an ecological study

BACKGROUND

The epidemiological evidence of traumatic brain injury (TBI) and spinal cord injury (SCI) mortality in mainland China is lacking. We aimed to assess the trends of TBI and SCI mortality, and their association with sex, age, location and external causes of injury in south China.

METHODS

Mortality data were derived from the Disease Surveillance Points (DSPs) system of Guangdong province between 2014 and 2018. We examined the trends in mortality with Cochran-Armitage trend test, and the association between the socio-demographic factors and the TBI and SCI mortality by using negative binomial models. Subgroup analysis was performed by stratifying the external causes of TBI and SCI.

RESULTS

The age-standardized TBI mortality remained relatively stable (from 11.6 to 15.4 per 100,000), while the SCI mortality increased by 148.3% from 2014 to 2018. Compared with females and urban residents, the adjusted mortality rate ratios of males and rural residents were 2.3 and 2.0 for TBI, and 2.2 and 4.6 for SCI, respectively. TBI and SCI mortality increased substantially with age. Motor vehicle crashes and falls were the leading causes of TBI mortality in residents aged under 75 years and over 75 years, respectively. Falls were the most important external cause for SCI death of all ages.

CONCLUSIONS

Being male, rural and elderly residents are at higher risk of dying from TBI and SCI. The substantial burden of TBI and SCI caused by road traffic crashes and falls has called for the urgent need to improve injury prevention, pre-hospital aid, hospital treatment and recovery.

Population awareness of cardiovascular disease risk factors and health care seeking behavior in the UAE

OBJECTIVES

We aimed to determine the awareness, knowledge, and attitude of people residing in Dubai, United Arab Emirates, regarding cardiovascular disease (CVD) risk factors. Our aim was to further identify prospects to increase awareness of modifiable CVD risk factors and influence behavior.

METHODS

This observational study was conducted in Dubai: a global city in the United Arab Emirates. Participants were selected using simple randomization approach in primary health care centers, and a questionnaire was implemented based on literature review.

RESULTS

Out of 1020 individuals approached, 738 agreed to participate in the study (response rate of 72%).The majority of participants surveyed had good knowledge and attitude toward CVD (528, 71.5% and 445, 60% respectively); yet, poor/fair practice related to CVD risk factors (553, 75%). Predictive Margins of Knowledge Scores were significant for age (p<.01), academic level (p<.0001), and nationality (p<.0001) (Table 5). Participants aging 40-49, non-UAE subjects, and university/Postgraduate academic level scored better on the knowledge. Demographics predictor for practice score was highly significant for age (p=.0001) and BMI (p=.0001). Those aging ≥50 and obese participants scored higher on practice toward CVD risk factors. Knowledge score was significant predictor of practice and attitude toward CVD risk factors (p=.0001, p<.0001).

CONCLUSIONS

Although more than half of the current study participants had high knowledge and attitude toward CVD, their behaviors were not satisfactory. It is necessary to establish more effective educational interventions intended to promote positive health behaviors. Public health providers need to explain to the public that knowledge and proper actions regarding the reduction of risk factors are associated with reduced CVD and mortality.

Global antibiotic consumption and usage in humans, 2000-18: a spatial modelling study

BACKGROUND

Antimicrobial resistance (AMR) is a serious threat to global public health. WHO emphasises the need for countries to monitor antibiotic consumption to combat AMR. Many low-income and middle-income countries (LMICs) lack surveillance capacity; we aimed to use multiple data sources and statistical models to estimate global antibiotic consumption.

METHODS

In this spatial modelling study, we used individual-level data from household surveys to inform a Bayesian geostatistical model of antibiotic usage in children (aged <5 years) with lower respiratory tract infections in LMICs. Antibiotic consumption data were obtained from multiple sources, including IQVIA, WHO, and the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). The estimates of the antibiotic usage model were used alongside sociodemographic and health covariates to inform a model of total antibiotic consumption in LMICs. This was combined with a single model of antibiotic consumption in high-income countries to produce estimates of antibiotic consumption covering 204 countries and 19 years.

FINDINGS

We analysed 209 surveys done between 2000 and 2018, covering 284 045 children with lower respiratory tract infections. We identified large national and subnational variations of antibiotic usage in LMICs, with the lowest levels estimated in sub-Saharan Africa and the highest in eastern Europe and central Asia. We estimated a global antibiotic consumption rate of 14·3 (95% uncertainty interval 13·2-15·6) defined daily doses (DDD) per 1000 population per day in 2018 (40·2 [37·2-43·7] billion DDD), an increase of 46% from 9·8 (9·2-10·5) DDD per 1000 per day in 2000. We identified large spatial disparities, with antibiotic consumption rates varying from 5·0 (4·8-5·3) DDD per 1000 per day in the Philippines to 45·9 DDD per 1000 per day in Greece in 2018. Additionally, we present trends in consumption of different classes of antibiotics for selected Global Burden of Disease study regions using the IQVIA, WHO, and ESAC-net input data. We identified large increases in the consumption of fluoroquinolones and third-generation cephalosporins in North Africa and Middle East, and south Asia.

INTERPRETATION

To our knowledge, this is the first study that incorporates antibiotic usage and consumption data and uses geostatistical modelling techniques to estimate antibiotic consumption for 204 countries from 2000 to 2018. Our analysis identifies both high rates of antibiotic consumption and a lack of access to antibiotics, providing a benchmark for future interventions.

FUNDING

Fleming Fund, UK Department of Health and Social Care; Wellcome Trust; and Bill & Melinda Gates Foundation.

Long-term safety and efficacy of rilpivirine in combination with nucleoside/nucleotide reverse transcriptase inhibitors in HIV-1 infected patients: 336-week rollover study of phase 2b and 3 clinical studies

Background

To evaluate the long-term safety and efficacy of rilpivirine (RPV), a non-nucleoside reverse transcriptase inhibitor (NNRTI), in combination with nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) in human immunodeficiency virus (HIV)–infected patients.

Methods

RPV-treated HIV-infected patients from phase 2b or 3 studies rolled-over into this phase 3, open-label study and received RPV 25 mg once daily (QD) with choice of two NRTIs. Adverse events (AEs), plasma viral load, CD4+ cell count, and antiviral resistance were evaluated.

Results

Of the 482 patients treated, 437 (>90%) patients discontinued study treatment; 371 (77%) had switched to commercially available RPV, 14 (2.9%) discontinued due to AEs, and 6 (1.2%) had virologic failure. In this rollover study, patients were followed up to week 336, although data was limited beyond 288 weeks. Forty-five (9.3%) patients were still undergoing treatment at the time of data cut-off for the current analysis (8 February 2018). The most frequently reported AEs were pregnancy in 7 (1.5%) patients and syphilis in 5 (1.0%) patients. Grade 3–4 AEs were reported in 17 (3.5%) patients, and AEs possibly related to RPV in 23 (4.8%) patients. Over 288 weeks of treatment, 80.1% (95% CI: 74.9%; 84.3%) of patients maintained virologic suppression (HIV-1 RNA <50 copies/mL). The absolute CD4+ cell count increased over time until week 192 and remained constant thereafter.

Conclusions

RPV 25 mg QD in combination with an investigator-selected background regimen of two NRTIs demonstrated sustained long-term virologic suppression. The treatment was well-tolerated with no new safety findings.

Artificial Intelligence in Functional Food Ingredient Discovery and Characterisation: A Focus on Bioactive Plant and Food Peptides

Scientific research consistently demonstrates that diseases may be delayed, treated, or even prevented and, thereby, health may be maintained with health-promoting functional food ingredients (FFIs). Consumers are increasingly demanding sound information about food, nutrition, nutrients, and their associated health benefits. Consequently, a nutrition industry is being formed around natural foods and FFIs, the economic growth of which is increasingly driven by consumer decisions. Information technology, in particular artificial intelligence (AI), is primed to vastly expand the pool of characterised and annotated FFIs available to consumers, by systematically discovering and characterising natural, efficacious, and safe bioactive ingredients (bioactives) that address specific health needs. However, FFI-producing companies are lagging in adopting AI technology for their ingredient development pipelines for several reasons, resulting in a lack of efficient means for large-scale and high-throughput molecular and functional ingredient characterisation. The arrival of the AI-led technological revolution allows for the comprehensive characterisation and understanding of the universe of FFI molecules, enabling the mining of the food and natural product space in an unprecedented manner. In turn, this expansion of bioactives dramatically increases the repertoire of FFIs available to the consumer, ultimately resulting in bioactives being specifically developed to target unmet health needs.

Are sex disparities in COVID-19 a predictable outcome of failing men's health provision?

The COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus, has taken a catastrophic toll on society, health-care systems and the economy. Notably, COVID-19 has been shown to be associated with a higher mortality rate in men than in women. This disparity is likely to be a consequence of a failure to invest in men’s health, as it has also been established that men have a lower life expectancy and poorer outcomes from non-communicable diseases than women. A variety of biological, social and economic factors have contributed to the sex disparities in mortality from COVID-19. A streamlined men’s health programme — with the urologist as the gatekeeper of men’s health — is needed to help prevent future tragedies of this nature.

COVID-19 has been shown to be associated with a higher mortality rate in men than in women. In this Perspectives article, the authors posit that this disparity is due to a failure to invest in men’s health and discuss the biological, social and economic factors that have contributed to the sex disparities in mortality from COVID-19, as well as considering how a streamlined men’s health programme with the urologist in a central role could address these issues.

Time to death and its determinants among under-five children in Sub-Saharan Africa using the recent (2010-2018) demographic and health survey data: country-based shared frailty analyses

Background

Substantial global progress has been made in reducing under-five mortality since 1990, yet progress is insufficient to meet the sustainable development goal of 2030 which calls for ending preventable child deaths. There are disproportional survivals among children in the world. Therefore, the study aimed to assess the Survival status of under-five mortality and determinants in Sub-Saharan African Countries using the recent DHS data.

Methods

The data was retrieved from the birth record file from the standard Demographic and Health Survey dataset of Sub-Saharan Africa countries. Countries that have at least one survey between 2010 and 2018 were retrieved. Parametric shared frailty survival analysis was employed.

Results

A total of 27,221 (7.35%) children were died before celebrating their fifth birthday. Children at an early age were at higher risk of dying and then decrease proportionally with increased age. The risk of death among rich and middle family were lowered by 18 and 8% (AHR =0.82, 95% CI: 0.77-0.87) and (AHR = 0.92, 95% CI: 0.87-0.97) respectively, the hazard of death were 11, 19, 17, 90 and 55% (AHR = 1.06, 95% CI: 1.00-1.12), (AHR = 1.11,95%CI:1.04-1.19), (AHR = 1.17, 95% CI:1.12-1.23), (AHR = 1.90, 95%CI: 1.78-2.04) and (AHR = 1.55, 95% CI:1.47-1.63) higher than among children in rural, use unimproved water, delivered at home, born less than 18 months and between 18 and 23 months birth intervals respectively. The hazard of death was 7% among females and low birth weights (AHR = 0.93, 95%CI: 0.90 – 0.97) and (AHR = 0.93 95%CI: 0.89-0.97) respectively. There was also a significant association between multiple births and birth orders (AHR = 2.11, 95%CI: 2.51 – 2.90), (AHR = 3.01, 95%CI: 2.85-3.19) respectively.

Conclusions

Death rate among under-five children was higher at an early age then decreases as age advanced. Wealth status, residence, water source, place of delivery, sex of the child, plurality, birth size, preceding birth interval, and birth order were the most predictor variables. The health care program should be designed to encourage a healthy family structure. The health care providers should intervene in the community to inspire maternal health services.

Genitourinary Syndrome of Menopause: Epidemiology, Physiopathology, Clinical Manifestation and Diagnostic

Genitourinary syndrome of menopause (GSM) is a term used to define a compilation of signs and symptoms arising from decreased estrogenic stimulation of the vulvovaginal and lower urinary tract. Among 27–84% of women in postmenopausal are affected for symptoms of GSM, and these can unquestionably impair health, sexual function, consequently the quality of life of these women. The main signs and symptoms of GSM include, among others, burning, irritation, vulvovaginal dryness, dyspareunia, urinary symptoms of urgency, dysuria, or recurrent urinary tract infection. The diagnosis can be made through anamnesis, questionnaires, physical exams, and, sometimes, complementary exams. Objective vaginal assessment is essential and can be complemented by using the Vaginal Health Index (VHI), Vaginal Maturation Index (VMI), or vaginal pH measurement. The acknowledgment of this condition by health professionals is crucial for its identification and proper management and exclusion of other conditions that make a differential diagnosis with it.

Do epigenetic clocks provide explanations for sex differences in lifespan? A cross-sectional twin study

Background

The sex gap in life expectancy has been narrowing in Finland over the past 4–5 decades; however, on average, women still live longer than men. Epigenetic clocks are markers for biological aging which predict life span. In this study, we examined the mediating role of lifestyle factors on the association between sex and biological aging in younger and older adults.

Methods

Our sample consists of younger and older twins (21‒42 years, n = 1 477; 50‒76 years, n = 763) including 151 complete younger opposite-sex twin pairs (21‒30 years). Blood-based DNA methylation was used to compute epigenetic age acceleration by 4 epigenetic clocks as a measure of biological aging. Path modeling was used to study whether the association between sex and biological aging is mediated through lifestyle-related factors, that is, education, body mass index, smoking, alcohol use, and physical activity.

Results

In comparison to women, men were biologically older and, in general, they had unhealthier life habits. The effect of sex on biological aging was partly mediated by body mass index and, in older twins, by smoking. Sex was directly associated with biological aging and the association was stronger in older twins.

Conclusions

Previously reported sex differences in life span are also evident in biological aging. Declining smoking prevalence among men is a plausible explanation for the narrowing of the difference in life expectancy between the sexes. Data generated by the epigenetic clocks may help in estimating the effects of lifestyle and environmental factors on aging and in predicting aging in future generations.

Development and validation of a knowledge, attitude, and practice questionnaire regarding cardiovascular diseases in an Iranian general population

Background

Studies on knowledge, attitude, and practice (KAP) can be valuable for public health to help to develop targeted educational programs and assess the effectiveness of intervention programs. The purpose of this study was to develop and examine the validity and reliability of a questionnaire on knowledge, attitude, and practice (KAP) regarding cardiovascular diseases (CVDs), their risk factors, and symptoms among an Iranian general population.

Methods

This cross-sectional study was conducted on an Iranian population older than 20 years referred to some of Tehran’s healthcare centers. An initial 62-item questionnaire was developed, and the face, content, and construct validities were assessed.

Results

In all, 300 adults with a mean age (SD) of 39.79 (12.1) years participated in this study. Based on the results of the content validity, a questionnaire with 30 essential items was designed. Exploratory factor analysis suggested a four-factor subscale with 29 finalized items (CVD-KAP29), and acceptable goodness of fit indices was demonstrated by confirmatory factor analysis. The Cronbach’s alpha and McDonald’s ω coefficients were higher than 0.60 for all domains except the nutrition and smoking subscales.

Conclusions

Results provided evidence of the validity of the CVD-KAP29 for KAP studies for cardiovascular diseases in the general population.

Self-Protection as an Adaptive Female Strategy

Many male traits are well explained by sexual selection theory as adaptations to mating competition and mate choice, whereas no unifying theory explains traits expressed more in females. Anne Campbell's "staying alive" theory proposed that human females produce stronger self-protective reactions than males to aggressive threats because self-protection tends to have higher fitness value for females than males. We examined whether Campbell's theory has more general applicability by considering whether human females respond with greater self-protectiveness than males to other threats beyond aggression. We searched the literature for physiological, behavioral, and emotional responses to major physical and social threats, and found consistent support for females' responding with greater self-protectiveness than males. Females mount stronger immune responses to many pathogens; experience a lower threshold to detect, and lesser tolerance of, pain; awaken more frequently at night; express greater concern about physically dangerous stimuli; exert more effort to avoid social conflicts; exhibit a personality style more focused on life's dangers; react to threats with greater fear, disgust and sadness; and develop more threat-based clinical conditions than males. Our findings suggest that in relation to threat human females have relatively heightened protective reactions compared to males. The pervasiveness of this result across multiple domains suggests that general mechanisms might exist underlying females' unique adaptations. An understanding of such processes would enhance knowledge of female health and well-being.

The impact of chest pain center on treatment delay of STEMI patients: a time series study

Objective

To study the effect of the establishment of a Chest Pain Center (CPC) on the treatment delay of ST-elevation myocardial infarction (STEMI) patients and the influencing factors of treatment delay in a large hospital in China.

Methods

The study subjects are 318 STEMI patients admitted between August 2016 and July 2019 to a large general hospital in Henan, China. Data were extracted from the electronic medical records after removing personal identifiable information. The interrupted time series regression was used to analyze the treatment delay of patients before and after the CPC establishment.

Results

After the CPC establishment, the patients’ pre-hospital and in-hospital treatment delays were significantly reduced. SO-to-FMC (Symptom Onset to First Medical Contact time) decreased by 49.237 min and D-to-B (Door to Balloon time) decreased by 21.931 min immediately after the CPC establishment. In addition, SO-to-FMC delay is significantly correlated with age, occupation, nocturnal onset, and the way to hospital. D-to-B delay is significantly associated with time from initial diagnosis to informed consent of percutaneous coronary intervention (PCI), catheterization lab activation time, and time for PCI informed consent.

Conclusion

The CPC significantly reduced the treatment delay of STEMI patients undergoing PCI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00535-y.

Limited sensitivity and specificity of the ACR/EULAR-2019 classification criteria for SLE in JSLE?-observations from the UK JSLE Cohort Study

OBJECTIVES

This study aimed to test the performance of the new ACR and EULAR criteria, that include ANA positivity as entry criterion, in JSLE.

METHODS

Performance of the ACR/EULAR-2019 criteria were compared with Systemic Lupus International Collaborating Clinics (SLICC-2012), using data from children and young people (CYP) in the UK JSLE Cohort Study (n = 482), with the ACR-1997 criteria used as reference standard. An unselected cohort of CYP positive for ANA (n = 129) was used to calculate positive/negative predictive values of the criteria.

RESULTS

At both first and last visits, the number of patients fulfilling the different classification criteria varied significantly (P < 0.001). The sensitivity of the SLICC-2012 criteria was higher when compared with that of the ACR/EULAR-2019 criteria at first and last visits (98% vs 94% for first visit, and 98% vs 96% for last visit; P < 0.001), when all available CYP were considered. The ACR/EULAR-2019 criteria were more specific when compared with the SLICC-2012 criteria (77% vs 67% for first visit, and 81% vs 71% for last visit; P < 0.001). Significant differences between the classification criteria were mainly caused by the variation in ANA positivity across ages. In the unselected cohort of ANA-positive CYP, the ACR/EULAR-2019 criteria produced the highest false-positive classification (6/129, 5%).

CONCLUSION

In CYP, the ACR/EULAR-2019 criteria are not superior to those of the SLICC-2012 or ACR-1997 criteria. If classification criteria are designed to include CYP and adult populations, paediatric rheumatologists should be included in the consensus and evaluation process, as seemingly minor changes can significantly affect outcomes.

Global, regional, and national mortality among young people aged 10-24 years, 1950-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10-24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10-24 years by age group (10-14 years, 15-19 years, and 20-24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10-24 years with that in children aged 0-9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10-24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017).

FINDINGS

In 2019 there were 1·49 million deaths (95% uncertainty interval 1·39-1·59) worldwide in people aged 10-24 years, of which 61% occurred in males. 32·7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32·1% were due to communicable, nutritional, or maternal causes; 27·0% were due to non-communicable diseases; and 8·2% were due to self-harm. Since 1950, deaths in this age group decreased by 30·0% in females and 15·3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10-14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15-19 years was 1·3% in males and 1·6% in females, almost half that of males aged 1-4 years (2·4%), and around a third less than in females aged 1-4 years (2·5%). The proportion of global deaths in people aged 0-24 years that occurred in people aged 10-24 years more than doubled between 1950 and 2019, from 9·5% to 21·6%.

INTERPRETATION

Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10-24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group.

FUNDING

Bill & Melinda Gates Foundation.

Generic Drug Usage in Dentistry across Japan: Analysis Using a Japanese National Database

The aim of this study was to identify regional disparities in generic drug usage and to examine related factors. The database used for the analysis was the 2018 national health insurance claims data published on the Japanese Ministry of Health, Labour, and Welfare. The drugs that were targeted were a combination of brand-name and generic tetracycline ointments for periodontal treatment and lidocaine injection solution used for dental anesthesia. The usage of generic drugs was calculated and compared by prefecture based on the number of health insurance claims. The comparison of related factors was conducted using data from other national statistical survey. The results showed that the mean generic drug usage of tetracycline for periodontal treatment in all prefectures was 71.2 ± 8.1%, ranging from 45.8% to 85.3%. The mean generic lidocaine used for dental anesthesia was 47.6 ± 10.0%, ranging from 30.5% to 66.2%. The rank correlation coefficient between the two was 0.359 (p < 0.05), and the tendency of using both generic drugs was low in major metropolitan areas. Generic drug usage in Japan is low; thus, in order to reduce healthcare costs, generic drugs need to be actively used in dentistry.

Risk factors and their contribution to population health in the European Union (EU-28) countries in 2007 and 2017

BACKGROUND

The Global Burden of Disease (GBD) study has generated a wealth of data on death and disability outcomes in Europe. It is important to identify the disease burden that is attributable to risk factors and, therefore, amenable to interventions. This paper reports the burden attributable to risk factors, in deaths and disability-adjusted life years (DALYs), in the 28 European Union (EU) countries, comparing exposure to risks between them, from 2007 to 2017.

METHODS

Retrospective descriptive study, using secondary data from the GBD 2017 Results Tool. For the EU-28 and each country, attributable (all-cause) age-standardized death and DALY rates, and summary exposure values are reported.

RESULTS

In 2017, behavioural and metabolic risk factors showed a higher attributable burden compared with environmental risks, with tobacco, dietary risks and high systolic blood pressure standing out. While tobacco and air quality improved significantly between 2007 and 2017 in both exposure and attributable burden, others such as childhood maltreatment, drug use or alcohol use did not. Despite significant heterogeneity between EU countries, the EU-28 burden attributable to risk factors decreased in this period.

CONCLUSION

Accompanying the improvement of population health in the EU-28, a comparable trend is visible for attributable burden due to risk factors. Besides opportunities for mutual learning across countries with different disease/risk factors patterns, good practices (i.e. tobacco control in Sweden, air pollution mitigation in Finland) might be followed. On the opposite side, some concerning cases must be highlighted (i.e. tobacco in Bulgaria, Latvia and Estonia or drug use in Czech Republic).

The contributions of public health policies and healthcare quality to gender gap and country differences in life expectancy in the UK

Background

In many high-income countries, life expectancy (LE) has increased, with women outliving men. This gender gap in LE (GGLE) has been explained with biological factors, healthy behaviours, health status, and sociodemographic characteristics, but little attention has been paid to the role of public health policies that include/affect these factors. This study aimed to assess the contributions of avoidable causes of death, as a measure of public health policies and healthcare quality impacts, to the GGLE and its temporal changes in the UK. We also estimated the contributions of avoidable causes of death into the gap in LE between countries in the UK.

Methods

We obtained annual data on underlying causes of death by age and sex from the World Health Organization mortality database for the periods 2001–2003 and 2014–2016. We calculated LE at birth using abridged life tables. We applied Arriaga’s decomposition method to compute the age- and cause-specific contributions into the GGLE in each period and its changes between two periods as well as the cross-country gap in LE in the 2014–2016 period.

Results

Avoidable causes had greater contributions than non-avoidable causes to the GGLE in both periods (62% in 2001–2003 and 54% in 2014–2016) in the UK. Among avoidable causes, ischaemic heart disease (IHD) followed by injuries had the greatest contributions to the GGLE in both periods. On average, the GGLE across the UK narrowed by about 1.0 year between 2001–2003 and 2014–2016 and three avoidable causes of IHD, lung cancer, and injuries accounted for about 0.8 years of this reduction. England & Wales had the greatest LE for both sexes in 2014–2016. Among avoidable causes, injuries in men and lung cancer in women had the largest contributions to the LE advantage in England & Wales compared to Northern Ireland, while drug-related deaths compared to Scotland in both sexes.

Conclusion

With avoidable causes, particularly preventable deaths, substantially contributing to the gender and cross-country gaps in LE, our results suggest the need for behavioural changes by implementing targeted public health programmes, particularly targeting younger men from Scotland and Northern Ireland.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-021-00271-2.

Hypertension care cascade at a large urban HIV clinic in Uganda: a mixed methods study using the Capability, Opportunity, Motivation for Behavior change (COM-B) model

BACKGROUND

Persons living with HIV (PLHIV) receiving antiretroviral therapy (ART) have a high prevalence of hypertension (HTN) and increased risk of mortality from cardiovascular diseases. HTN and HIV care integration is recommended in Uganda, though its implementation has lagged. In this study, we sought to analyze the HTN and HIV care cascades and explore barriers and facilitators of HTN/HIV integration within a large HIV clinic in urban Uganda.

METHODS

We conducted an explanatory sequential mixed methods study at Mulago ISS clinic in Kampala, Uganda. We determined proportions of patients in HTN and HIV care cascade steps of screened, diagnosed, initiated on treatment, retained, and controlled. Guided by the Capability, Opportunity, Motivation and Behavior (COM-B) model, we then conducted semi-structured interviews and focus group discussions with healthcare providers (n = 13) and hypertensive PLHIV (n = 32). We coded the qualitative data deductively and analyzed the data thematically categorizing them as themes that influenced HTN care positively or negatively. These denoted barriers and facilitators, respectively.

RESULTS

Of 15,953 adult PLHIV, 99.1% were initiated on ART, 89.5% were retained in care, and 98.0% achieved control (viral suppression) at 1 year. All 15,953 (100%) participants were screened for HTN, of whom 24.3% had HTN. HTN treatment initiation, 1-year retention, and control were low at 1.0%, 15.4%, and 5.0%, respectively. Barriers and facilitators of HTN/HIV integration appeared in all three COM-B domains. Barriers included low patient knowledge of HTN complications, less priority by patients for HTN treatment compared to ART, sub-optimal provider knowledge of HTN treatment, lack of HTN treatment protocols, inadequate supply of anti-hypertensive medicines, and lack of HTN care performance targets. Facilitators included patients' and providers' interest in HTN/HIV integration, patients' interest in PLHIV peer support, providers' knowledge and skills for HTN screening, optimal ART adherence counseling, and availability of automated BP machines.

CONCLUSION

The prevalence of HTN among PLHIV is high, but the HTN care cascade is sub-optimal in this successful HIV clinic. To close these gaps, models of integrated HTN/HIV care are urgently needed. These findings provide a basis for designing contextually appropriate interventions for HTN/HIV integration in Uganda and other low- and middle-income countries.

Global changing trends in incidence and mortality of gastric cancer by age and sex, 1990-2019: Findings from Global Burden of Disease Study

Background: The global disease burden of gastric cancer (GC) is still heavy. Understanding the patterns and trends of the global GC burden is important for developing precise prevention strategies.

Materials and Methods: The data of GC burden were retrieved from the Global Burden of Disease Study (2019). The estimated annual percentage change (EAPC) was calculated to estimate the temporal trends of the age-standardized incidence and mortality rates (ASIR and ASMR) of global GC by age-specific groups (15-49, 50-69, and ≥70 years), sexes, socio-demographic indexes (SDIs), regions, and countries.

Results: In 2019, the ASIR and ASMR of global GC increased with age in both sexes, and reached a peak in the older 70 age group. The ASIR and ASMR in males were higher than those in females. From 1990 to 2019, the global number of GC incident cases increased in both sexes in all age-specific groups; while the ASIR of GC decreased, and the most significant decrease was observed in the 50-69 age group [males: EAPC=-1.34, 95% CI: (-1.49, -1.18); females: EAPC= -2.09, 95% CI: (-2.22, -1.96)]. During the study period, downward trends in ASIR of GC were observed in both sexes in most SDI regions, GBD regions, and countries. Similar trends in ASMR of GC were also observed.

Conclusion: The global GC incidence and mortality rates decreased from 1990 to 2019 in both sexes, most GBD regions, and most countries. However, the GC burden was still heavy in some GBD regions and countries in special age-specific groups. It is important to formulate and implement tertiary prevention strategies based on the GC burden of age-specific groups in different regions and countries.

Burden of multiple sclerosis in Iran from 1990 to 2017

Background

Multiple Sclerosis (MS) is a burdensome, chronic and autoimmune disease of the central nervous system. We aimed to report the incidence, prevalence, mortality, and Disability Adjusted Life Years (DALYs) of MS in Iran at a national level for different age and sex groups over a period of 28 years (1990–2017).

Methods

Data were extracted from the Global Burden of Disease study (GBD) from 1990 to 2017, published by the Institute for Health Metrics and Evaluation. The incidence of DALYs and prevalence of MS were estimated to report the burden of MS based on sex and age in Iran from 1990 to 2017.

Results

At the national level, the Age-Standardized Incidence Rate (ASIR), Age-Standardized Prevalence Rate (ASPR), Age-Standardized DALYs Rate (ASDR) and the Age-Standardized Mortality Rate (ASMR) in Iran in 2017 were 2.4 (95% Uncertainty Interval [UI]: 2.1 to 2.7), 69.5 (62.1 to 77.8), 29.1 (23.6 to 34.7), and 0.4 (0.3 to 0.4) per 100,000 population, respectively. During the period of 1990 to 2017, all measures increased, and were higher among females. The incidence rate began upward trend at the age of 20 and attained its highest level at the age of 25.

Conclusion

In Iran, all of the age-standardized MS rates have been increasing during the 28 years from 1990 to 2017. Our findings can help policy makers and health planners to design and communicate their plans and to have a better resource allocation, depending on the incidence and prevalence of the growing numbers of MS patients in Iran.

Life expectancy, healthy life expectancy, and burden of disease in older people in the Americas, 1990-2019: a population-based study

Objective.

To describe the life expectancy, healthy life expectancy, disease burden, and leading causes of mortality and disability in adults aged 65 years and older in the Region of the Americas from 1990 to 2019.

Methods.

We used estimates from the Global Burden of Disease Study 2019 to examine the level and trends of life expectancy, healthy life expectancy, years of life lost, years lived with disability, and disability-adjusted life years (DALYs).

Results.

Across the Region, life expectancy at 65 years increased from 17.1 years (95% uncertainty intervals (UI): 17.0–17.1) in 1990 to 19.2 years (95% UI: 18.9–19.4) in 2019 while healthy life expectancy increased from 12.2 years (95% UI: 10.9–12.4) to 13.6 years (95% UI: 12.2–14.9). All-cause DALY rates decreased in each older persons’ age group; however, absolute proportional DALYs increased from 22% to 32%. Ischemic heart disease, stroke, and chronic obstructive pulmonary disease were the leading causes of premature mortality. Diabetes mellitus, age-related and other hearing loss, and lower back pain were the leading causes of disability.

Conclusion.

The increase in life expectancy and decrease of DALYs indicate the positive effect of improvements in social conditions and health policies. However, the smaller increase in healthy life expectancy suggests that, despite living longer, people spend a substantial amount of time in their old age with disability and illness. Preventable and controllable diseases account for most of the disease burden in older adults in the Americas. Society-wide and life-course approaches, and adequate health services are needed to respond to the health needs of older people in the Region.

Stimuli-Responsive Nanoplatform-Assisted Photodynamic Therapy Against Bacterial Infections

Bacterial infections are common diseases causing tremendous deaths in clinical settings. It has been a big challenge to human beings because of the antibiotics abuse and the newly emerging microbes. Photodynamic therapy (PDT) is a reactive oxygen species-based therapeutic technique through light-activated photosensitizer (PS). Recent studies have highlighted the potential of PDT as an alternative method of antibacterial treatment for its broad applicability and high efficiency. However, there are some shortcomings due to the low selectivity and specificity of PS. Growing evidence has shown that drug delivery nanoplatforms have unique advantages in enhancing therapeutic efficacy of drugs. Particularly, stimuli-responsive nanoplatforms, as a promising delivery system, provide great opportunities for the effective delivery of PS. In the present mini-review, we briefly introduced the unique microenvironment in bacterial infection tissues and the application of PDT on bacterial infections. Then we review the stimuli-responsive nanoplatforms (including pH-, enzymes-, redox-, magnetic-, and electric-) used in PDT against bacterial infections. Lastly, some perspectives have also been proposed to further promote the future developments of antibacterial PDT.

Prevalence of chronic conditions and multimorbidity in Estonia: a population-based cross-sectional study

OBJECTIVES

Prevalence estimates for specific chronic conditions and multimorbidity (MM) in eastern Europe are scarce. This national study estimates the prevalence of MM by age group and sex in Estonia.

DESIGN

A population-based cross-sectional study, using administrative data.

SETTING

Data were collected on 55 chronic conditions from the Estonian Health Insurance Fund from 2015 to 2017. MM was defined as the coexistence of two or more conditions.

PARTICIPANTS

The Estonian Health Insurance Fund includes data for approximately 95% of the Estonian population receiving public health insurance.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence and 95% CIs for MM stratified by age group and sex.

RESULTS

Nearly half (49.1%) of the individuals (95% CI 49.0 to 49.3) had at least 1 chronic condition, and 30.1% (95% CI 30.0 to 30.2) had MM (2 or more chronic conditions). The number of conditions and the prevalence of MM increased with age, ranging from an MM prevalence of 3.5% (3.5%-3.6%) in the youngest (0-24 years) to as high as 80.4% (79.4%-81.3%) in the oldest (≥85 years) age group. Half of all individuals had MM by 60 years of age, and 75% of the population had MM by 75 years of age. Women had a higher prevalence of MM (34.9%, 95% CI 34.7 to 35.0) than men (24.4%, 95% CI 24.3 to 24.5). Hypertension was the most frequent chronic condition (24.5%), followed by chronic pain (12.4%) and arthritis (7.7%).

CONCLUSIONS

Hypertension is an important chronic condition amenable to treatment with lifestyle and therapeutic interventions. Given the established correlation between uncontrolled hypertension and exacerbation of other cardiovascular conditions as well as acute illnesses, this most common condition within the context of MM may be suitable for targeted public health interventions.

Disparities in the long-term survival of adolescent and young adult diffuse large B cell lymphoma survivors

PURPOSE

The population of adolescent and young adult (AYA, ages 15-39 years) diffuse large B-cell lymphoma (DLBCL) survivors is growing, however long-term overall survival patterns and disparities are largely unknown.

METHODS

The current study utilized the Surveillance, Epidemiology, and End Results (SEER) registry to assess the impact of race/ethnicity, sex, socioeconomic status, and rurality on long-term survival in 5-year DLBCL survivors using an accelerated failure time model.

RESULTS

Included were 4767 5-year survivors of AYA DLBCL diagnosed between the years 1980 and 2009 with a median follow-up time of 13.4 years. Non-Hispanic Black survivors had significantly worse long-term survival than non-Hispanic White survivors (Survival Time Ratio (STR): 0.53, p < 0.0001). Male sex (STR: 0.57, p < 0.0001) and older age at diagnosis were also associated with reduced long-term survival. There was no evidence that survival disparities improved over time.

CONCLUSIONS

Racial disparities persist well into survivorship among AYA DLBCL survivors. Studies investigating specific factors associated with survival disparities are urgently needed to better address these disparities.

Global Burden of Orofacial Clefts and the World Surgical Workforce

BACKGROUND

Orofacial clefts are one of the most common congenital anomalies, but this disease burden is unevenly distributed worldwide. The authors hypothesize that this burden falls disproportionately on the countries with the smallest surgical workforce or lowest Socio-Demographic Index, rather than those with the highest prevalence of disease.

METHODS

The authors estimated the prevalence and disease burden of orofacial clefting from 1990 to 2017 in 195 countries using the Global Burden of Disease methodology. Prevalence and disability-adjusted life-years were compared geographically, temporally, and against the size of the national surgical workforce, Socio-Demographic Index, and income status. Linear and logarithmic regressions were performed.

RESULTS

In 2017, the prevalence of orofacial clefting was estimated to be 10.8 million people, representing a disease burden of 652,084 disability-adjusted life-years, with most of this disease burden experienced by low- and middle-income countries (94.1%). From 1990 to 2017, there was a decrease in disease burden (-70.2%) and prevalence (-4.9%). There was negative logarithmic association between surgical workforce size and disease burden, with a surgical workforce of greater than six providers per 100,000 population (3.6 disability-adjusted life-years versus 22.4 disability-adjusted life-years per 100,000 population; p < 0.0001).

CONCLUSIONS

Burden of orofacial clefting has a strong negative association with the size of the surgical workforce, suggesting that strengthening the surgical workforce will help alleviate this burden. Epidemiologic data on countries and regions with inadequate surgical workforces and high disease burden should guide future research efforts and allocation of resources, and guide the treatment and educational goals of international charitable organizations.

Mortality and years of life lost of cardiovascular diseases in China, 2005-2020: Empirical evidence from national mortality surveillance system

OBJECTIVES

Cardiovascular disease (CVD) is leading cause of death in China. We aimed to provide national and subnational estimates and its change of premature mortality burden of CVD during 2005-2020.

METHODS

Data from multi-source on the basis of national mortality surveillance system (NMSS) was used to estimate mortality and years of life lost (YLL) of total CVD and its subcategories in Chinese population across 31 provinces during 2005-2020.

RESULTS

Estimated CVD deaths increased from 3.09 million in 2005 to 4.58 million in 2020; the age-standardized mortality rate (ASMR) decreased from 286.85 per 100,000 in 2005 to 245.39 per 100,000 in 2020. A substantial reduction of 19.27% of CVD premature mortality burden, as measured by age-standardized YLL rate, was observed. Ischemic heart disease (IHD), hemorrhagic stroke (HS) and ischemic stroke (IS) were leading 3 causes of CVD death. Marked differences were observed in geographical patterns for total CVD and its subcategories, and it appeared to be lower in areas with higher economic development. Population ageing was dominant driver contributed to CVD deaths increase, followed by population growth. And, age-specific mortality shifts contributed largely to CVD deaths decline in most provinces.

CONCLUSION

Substantial discrepancies were demonstrated in CVD premature mortality burden across China. Targeted considerations were needed to integrate primary care with clinical care through intensifying further strategies for reducing CVD mortality among specific subcategories, high risk population and regions with inadequate healthcare resources.

Anemia prevalence in women of reproductive age in low- and middle-income countries between 2000 and 2018

Anemia is a globally widespread condition in women and is associated with reduced economic productivity and increased mortality worldwide. Here we map annual 2000-2018 geospatial estimates of anemia prevalence in women of reproductive age (15-49 years) across 82 low- and middle-income countries (LMICs), stratify anemia by severity and aggregate results to policy-relevant administrative and national levels. Additionally, we provide subnational disparity analyses to provide a comprehensive overview of anemia prevalence inequalities within these countries and predict progress toward the World Health Organization's Global Nutrition Target (WHO GNT) to reduce anemia by half by 2030. Our results demonstrate widespread moderate improvements in overall anemia prevalence but identify only three LMICs with a high probability of achieving the WHO GNT by 2030 at a national scale, and no LMIC is expected to achieve the target in all their subnational administrative units. Our maps show where large within-country disparities occur, as well as areas likely to fall short of the WHO GNT, offering precision public health tools so that adequate resource allocation and subsequent interventions can be targeted to the most vulnerable populations.

Estimation of all-cause excess mortality by age-specific mortality patterns for countries with incomplete vital statistics: a population-based study of the case of Peru during the first wave of the COVID-19 pandemic

BACKGROUND

All-cause excess mortality is a comprehensive measure of the combined direct and indirect effects of COVID-19 on mortality. Estimates are usually derived from Civil Registration and Vital Statistics (CRVS) systems, but these do not include non-registered deaths, which may be affected by changes in vital registration coverage over time.

METHODS

Our analytical framework and empirical strategy account for registered mortality and under-registration. This provides a better estimate of the actual mortality impact of the first wave of the COVID-19 pandemic in Peru. We use population and crude mortality rate projections from Peru's National Institute of Statistics and Information (INEI, in Spanish), individual-level registered COVID-19 deaths from the Ministry of Health (MoH), and individual-level registered deaths by region and age since 2017 from the National Electronic Deaths Register (SINADEF, in Spanish).We develop a novel framework combining different estimates and using quasi-Poisson models to estimate total excess mortality across regions and age groups. Also, we use logistic mixed-effects models to estimate the coverage of the new SINADEF system.

FINDINGS

We estimate that registered mortality underestimates national mortality by 37•1% (95% CI 23% - 48•5%) across 26 regions and nine age groups. We estimate total all-cause excess mortality during the period of analysis at 173,099 (95% CI 153,669 - 187,488) of which 108,943 (95% CI 96,507 - 118,261) were captured by the vital registration system. Deaths at age 60 and over accounted for 74•1% (95% CI 73•9% - 74•7%) of total excess deaths, and there were fewer deaths than expected in younger age groups. Lima region, on the Pacific coast and including the national capital, accounts for the highest share of excess deaths, 87,781 (95% CI 82,294 - 92,504), while in the opposite side regions of Apurimac and Huancavelica account for less than 300 excess deaths.

INTERPRETATION

Estimating excess mortality in low- and middle-income countries (LMICs) such as Peru must take under-registration of mortality into account. Combining demographic trends with data from administrative registries reduces uncertainty and measurement errors. In countries like Peru, this is likely to produce significantly higher estimates of excess mortality than studies that do not take these effects into account.

FUNDING

None.

Lives and livelihoods: Estimates of the global mortality and poverty effects of the Covid-19 pandemic

We evaluate the global welfare consequences of increases in mortality and poverty generated by the Covid-19 pandemic. Increases in mortality are measured in terms of the number of years of life lost (LY) to the pandemic. Additional years spent in poverty (PY) are conservatively estimated using growth estimates for 2020 and two different scenarios for its distributional characteristics. Using years of life as a welfare metric yields a single parameter that captures the underlying trade-off between lives and livelihoods: how many PYs have the same welfare cost as one LY. Taking an agnostic view of this parameter, we compare estimates of LYs and PYs across countries for different scenarios. Three main findings arise. First, we estimate that, as of early June 2020, the pandemic (and the observed private and policy responses) had generated at least 68 million additional poverty years and 4.3 million years of life lost across 150 countries. The ratio of PYs to LYs is very large in most countries, suggesting that the poverty consequences of the crisis are of paramount importance. Second, this ratio declines systematically with GDP per capita: poverty accounts for a much greater share of the welfare costs in poorer countries. Finally, a comparison of these baseline results with mortality estimates in a counterfactual "herd immunity" scenario suggests that welfare losses would be greater in the latter in most countries.

Histone H3 lysine 27 acetylation profile undergoes two global shifts in undernourished children and suggests altered one-carbon metabolism

BACKGROUND

Stunting is a condition in which a child does not reach their full growth potential due to chronic undernutrition. It arises during the first 2 years of a child's life and is associated with developmental deficiencies and life-long health problems. Current interventions provide some benefit, but new approaches to prevention and treatment grounded in a molecular understanding of stunting are needed. Epigenetic analyses are critical as they can provide insight into how signals from a poor environment lead to changes in cell function.

RESULTS

Here we profiled histone H3 acetylation on lysine 27 (H3K27ac) in peripheral blood mononuclear cells (PBMCs) of 18-week-old (n = 14) and 1-year-old children (n = 22) living in an urban slum in Dhaka, Bangladesh. We show that 18-week-old children destined to become stunted have elevated levels of H3K27ac overall, functional analysis of which indicates activation of the immune system and stress response pathways as a primary response to a poor environment with high pathogen load. Conversely, overt stunting at 1-year-of age is associated with globally reduced H3K27ac that is indicative of metabolic rewiring and downregulation of the immune system and DNA repair pathways that are likely secondary responses to chronic exposure to a poor environment with limited nutrients. Among processes altered in 1-year-old children, we identified one-carbon metabolism, the significance of which is supported by integrative analysis with results from histone H3 trimethylation on lysine 4 (H3K4me3). Together, these results suggest altered one-carbon metabolism in this population of stunted children.

CONCLUSIONS

The epigenomes of stunted children undergo two global changes in H3K27ac within their first year of life, which are associated with probable initial hyperactive immune responses followed by reduced metabolic capacity. Limitation of one-carbon metabolites may play a key role in the development of stunting. Trial registration ClinicalTrials.gov NCT01375647. Registered 17 June 2011, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT01375647 .