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Luangsinsiri C, Youngkong S, Chaikledkaew U, Pattanaprateep O, Thavorncharoensap M. Economic costs of alcohol consumption in Thailand, 2021. Glob Health Res Policy 2023; 8:51. [PMID: 38072945 PMCID: PMC10712089 DOI: 10.1186/s41256-023-00335-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Alcohol is one of the leading risk factors contributing to avoidable economic loss worldwide. Estimates from the economic cost of alcohol consumption studies play an important role in prioritizing healthcare resource use, supporting policy decisions, and justifying budgets for alcohol policy. This study aimed to estimate the economic burden associated with alcohol consumption in Thailand in 2021. METHODS Prevalence-based cost of illness methodology was employed. The following costs were included in the analysis: healthcare costs; cost of law enforcement; cost of property damage due to road traffic accidents; cost of premature mortality; and cost of absenteeism from out-patient hospital visits and hospitalization. Human capital approach was adopted. All costs were presented in Thai baht, 2021. RESULTS Alcohol consumption incurred a total estimated economic cost of 165,450.5 million baht, equivalent to 1.02% of Gross Domestic Product (GDP) and 2500 baht per capita. Cost of premature mortality was estimated at 157,918.7 million baht and accounted for the largest proportion of the total cost (95.45%). Healthcare cost was found to be the second highest share representing 4370.1 million baht (2.7% of the total cost). The number of premature death attributable to alcohol consumption in 2021 was estimated at 22,804. CONCLUSIONS Alcohol continues to impose a substantial economic burden in Thailand. Enforcement of existing well-formulated alcohol control policies is urgently required to mitigate the economic impact of alcohol consumption in the country.
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Affiliation(s)
- Chaisiri Luangsinsiri
- Doctor of Philosophy Program in Social, Economic, and Administrative Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
- Department of Clinical Pharmacy, Faculty of Pharmacy, Srinakharinwirot University, Nakhon Nayok, Thailand
| | - Sitaporn Youngkong
- Mahidol University Health Technology Assessment (MUHTA) International Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Excellence Research (SAPER) Unit, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri-Ayudhaya Rd., Rajathewi, Phayathai, Bangkok, 10400, Thailand
| | - Usa Chaikledkaew
- Mahidol University Health Technology Assessment (MUHTA) International Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Excellence Research (SAPER) Unit, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri-Ayudhaya Rd., Rajathewi, Phayathai, Bangkok, 10400, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Montarat Thavorncharoensap
- Mahidol University Health Technology Assessment (MUHTA) International Graduate Program, Mahidol University, Bangkok, Thailand.
- Social and Administrative Pharmacy Excellence Research (SAPER) Unit, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri-Ayudhaya Rd., Rajathewi, Phayathai, Bangkok, 10400, Thailand.
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Lampert J, Vaid A, Whang W, Koruth J, Miller MA, Langan MN, Musikantow D, Turagam M, Maan A, Kawamura I, Dukkipati S, Nadkarni GN, Reddy VY. A Novel ECG-Based Deep Learning Algorithm to Predict Cardiomyopathy in Patients With Premature Ventricular Complexes. JACC Clin Electrophysiol 2023; 9:1437-1451. [PMID: 37480862 DOI: 10.1016/j.jacep.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/17/2023] [Accepted: 05/24/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Premature ventricular complexes (PVCs) are prevalent and, although often benign, they may lead to PVC-induced cardiomyopathy. We created a deep-learning algorithm to predict left ventricular ejection fraction (LVEF) reduction in patients with PVCs from a 12-lead electrocardiogram (ECG). OBJECTIVES This study aims to assess a deep-learning model to predict cardiomyopathy among patients with PVCs. METHODS We used electronic medical records from 5 hospitals and identified ECGs from adults with documented PVCs. Internal training and testing were performed at one hospital. External validation was performed with the others. The primary outcome was first diagnosis of LVEF ≤40% within 6 months. The dataset included 383,514 ECGs, of which 14,241 remained for analysis. We analyzed area under the receiver operating curves and explainability plots for representative patients, algorithm prediction, PVC burden, and demographics in a multivariable Cox model to assess independent predictors for cardiomyopathy. RESULTS Among the 14,241-patient cohort (age 67.6 ± 14.8 years; female 43.8%; White 29.5%, Black 8.6%, Hispanic 6.5%, Asian 2.2%), 22.9% experienced reductions in LVEF to ≤40% within 6 months. The model predicted reductions in LVEF to ≤40% with area under the receiver operating curve of 0.79 (95% CI: 0.77-0.81). The gradient weighted class activation map explainability framework highlighted the sinus rhythm QRS complex-ST segment. In patients who underwent successful PVC ablation there was a post-ablation improvement in LVEF with resolution of cardiomyopathy in most (89%) patients. CONCLUSIONS Deep-learning on the 12-lead ECG alone can accurately predict new-onset cardiomyopathy in patients with PVCs independent of PVC burden. Model prediction performed well across sex and race, relying on the QRS complex/ST-segment in sinus rhythm, not PVC morphology.
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Affiliation(s)
- Joshua Lampert
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Akhil Vaid
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William Whang
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jacob Koruth
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marc A Miller
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marie-Noelle Langan
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Daniel Musikantow
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohit Turagam
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Abhishek Maan
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Iwanari Kawamura
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Srinivas Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Girish N Nadkarni
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; The Division of Data Driven and Digital Medicine (D3M), The Charles Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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3
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Chrystoja BR, Rehm J, Manthey J, Probst C, Wettlaufer A, Shield KD. A systematic comparison of the global comparative risk assessments for alcohol. Addiction 2021; 116:2026-2038. [PMID: 33449382 DOI: 10.1111/add.15413] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/15/2020] [Accepted: 01/06/2021] [Indexed: 12/12/2022]
Abstract
AIMS To compare systematically the alcohol-attributable mortality and burden of disease estimates for 2016 from a recent study by Shield and colleagues and the Global Burden of Disease study 2017 (GBD). METHOD This study compared estimates of alcohol-attributable mortality and disability adjusted life years (DALYs) lost for 2016 with regards to absolute and relative differences, by region and by cause of disease or injury. Relative differences between the two studies are reported herein as percentage (%) differences. A difference of 10% or more was considered meaningful. RESULTS The studies estimated similar global levels of overall alcohol-attributable mortality for 2016 (Shield and colleagues estimated 5.1% more alcohol-attributable mortality than the GBD study) but not alcohol-attributable DALYs lost (18.3% difference). There were marked differences by region and cause of disease or injury. Compared with the results from Shield and colleagues, the GBD study estimated a lower alcohol-attributable burden in Eastern Europe by 252 770 alcohol-attributable deaths (45.2% difference) and 6.1 million alcohol-attributable DALYs lost (32.9% difference) and in Western sub-Saharan Africa by 124 200 alcohol-attributable deaths (55.7% difference) and 7.0 million alcohol-attributable DALYs lost (63.4% difference), and estimated a higher alcohol-attributable burden in East Asia by 227 100 alcohol-attributable deaths (48.0% difference) and 2.2 million DALYs lost (11.0% difference). With regard to the cause of disease or injury, Shield and colleagues attributed an overall detrimental effect to alcohol on ischaemic heart disease mortality, whereas the GBD study attributed a net beneficial effect. The GBD study, as compared with Shield and colleagues' study, estimated a lower alcohol-attributable mortality because of liver cirrhosis and injuries by 262 500 (44.6% difference) and 398 800 (46.2% difference), respectively. CONCLUSIONS Differences in estimates of the alcohol-attributable burden of disease in two recent studies indicate the need to improve the accuracy of underlying data and risk relations to obtain more consistent estimates and to formulate, advocate for, and implement alcohol policies more effectively.
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Affiliation(s)
- Bethany R Chrystoja
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jürgen Rehm
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Institute of Clinical Psychology and Psychotherapy and Center for Clinical Epidemiology and Longitudinal Studies, Technische Universität Dresden, Dresden, Germany.,Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Jakob Manthey
- Institute of Clinical Psychology and Psychotherapy and Center for Clinical Epidemiology and Longitudinal Studies, Technische Universität Dresden, Dresden, Germany.,Centre for Interdisciplinary Addiction Research, Hamburg, Germany.,Department of Psychiatry, Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Charlotte Probst
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg, Germany
| | - Ashley Wettlaufer
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Kevin D Shield
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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4
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Li Z, Hu Z, Meng Y, Xu H, Wei Y, Shen D, Bai H, Yuan H, Chen L. miR-155-5p upregulation ameliorates myocardial insulin resistance via mTOR signaling in chronic alcohol drinking rats. PeerJ 2021; 9:e10920. [PMID: 33868799 PMCID: PMC8029671 DOI: 10.7717/peerj.10920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/19/2021] [Indexed: 11/28/2022] Open
Abstract
Background Chronic alcohol intake is associated with an increased risk of alcoholic cardiomyopathy, which may present with pathological changes such as myocardial insulin resistance, leading to ventricular dilation and cardiac dysfunction. Although a correlation between microRNA-155 (miR-155) and insulin signaling has been identified, the underlying mechanism has not been elucidated to date. The purpose of the study was to determine whether overexpression of miR-155-5p in vivo could ameliorate chronic alcohol-induced myocardial insulin resistance and cardiac dysfunction. Material and Methods Wistar rats were fed with either alcohol or water for 20 weeks to establish chronic alcohol intakes model. Then the alcohol group were divided into three groups: model group, miRNA-155 group and AAV-NC group. Rats undergoing alcohol treatment were injected with AAV-miRNA-155 (adeno-associated virus 9) or its negative control AAV-NC, respectively. Gene expression was determined by real-time PCR, and protein expression was determined by western blot. Echocardiography was performed to assess terminal cardiac function. Insulin responsiveness was determined through the quantification of phosphorylated insulin receptor substrate 1 (ser 307) and phosphorylated insulin receptor (Tyr 1185) levels. Results We found that cardiac function was attenuated in chronic alcohol intake rats, with an activated mammalian target of rapamycin (mTOR) signaling pathway, accompanied by an increase in p-IRS1(ser 307) and a decrease in p-IR (Tyr 1185) level in myocardial tissue. Also, alcohol drinking significantly up-regulated miR-155-5p level and its overexpression decreased p-IRS1 (ser 307) and increased p-IR (Tyr 1185) levels, and meanwhile inhibited the mTOR signaling pathway. Conclusion miR-155-5p upregulation ameliorates myocardial insulin resistance via the mTOR signaling in chronic alcohol drinking rats. We propose that miR-155 may serve as a novel potential therapeutic target for alcoholic heart disease.
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Affiliation(s)
- Zhaoping Li
- Department of Clinical Nutrition, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.,Department of Clinical Nutrition, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Zhenzhen Hu
- Department of Toxicology and Nutrition, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yan Meng
- Department of Clinical Nutrition, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.,Department of Clinical Nutrition, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Hongzhao Xu
- Department of Toxicology and Nutrition, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yali Wei
- Department of Toxicology and Nutrition, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Deqiang Shen
- Department of Clinical Nutrition, Lianyungang Hospital Affiliated to Xuzhou Medical University, Lianyungang, Jiangsu, China
| | - Hao Bai
- Department of Epidemiology and Biostatistics, School of Public Health, Zhejiang University, Hangzhou, Zhejiang, China
| | - Huacai Yuan
- Department of Clinical Nutrition, Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Liyong Chen
- Department of Clinical Nutrition, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.,Department of Clinical Nutrition, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
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Disrupted H 2S Signaling by Cigarette Smoking and Alcohol Drinking: Evidence from Cellular, Animal, and Clinical Studies. Antioxidants (Basel) 2021; 10:antiox10010049. [PMID: 33401622 PMCID: PMC7824711 DOI: 10.3390/antiox10010049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/21/2020] [Accepted: 12/30/2020] [Indexed: 12/20/2022] Open
Abstract
The role of endogenous hydrogen sulfide (H2S) as an antioxidant regulator has sparked interest in its function within inflammatory diseases. Cigarette and alcohol use are major causes of premature death, resulting from chronic oxidative stress and subsequent tissue damage. The activation of the Nrf2 antioxidant response by H2S suggests that this novel gasotransmitter may function to prevent or potentially reverse disease progression caused by cigarette smoking or alcohol use. The purpose of this study is to review the interrelationship between H2S signaling and cigarette smoking or alcohol drinking. Based on the databases of cellular, animal, and clinical studies from Pubmed using the keywords of H2S, smoking, and/or alcohol, this review article provides a comprehensive insight into disrupted H2S signaling by alcohol drinking and cigarette smoking-caused disorders. Major signaling and metabolic pathways involved in H2S-derived antioxidant and anti-inflammatory responses are further reviewed. H2S supplementation may prove to be an invaluable asset in treating or preventing diseases in those suffering from cigarette or alcohol addiction.
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6
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Chalak A, Ghandour L, Anouti S, Nakkash R, Yassin N, Afifi R. The impact of broad-based vs targeted taxation on youth alcohol consumption in Lebanon. Health Policy Plan 2020; 35:625-634. [DOI: 10.1093/heapol/czaa018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2020] [Indexed: 11/15/2022] Open
Abstract
Abstract
This study aims to model youth’s off-premise alcohol demand and forecasts ethanol intake responsiveness to alcohol taxes. Using stated preference alcohol purchase data from a survey of 1024 university students in Lebanon, we derive price elasticities that we use to forecast the effects of two excise tax scenarios on overall ethanol intake. The first scenario imposes a broad-based 20% tax on all types of alcoholic beverages, and the second scenario imposes a targeted 20% tax only on the high ethanol content, while exempting the lower ethanol beverages. Overall, targeted taxes are found to achieve a reduction in ethanol intake that is nearly three times that achieved by broad taxes (15.7% vs 5.3%). For ‘past-month binge drinkers’, targeted taxes would decrease alcohol intake by 16.3%, while broad taxes increase it by 3.3%. Finally, ethanol intake among participants who prefer low ethanol content would decrease under targeted taxes by more than five times as much as under broad taxes. For ‘high-ethanol drinkers’, targeted taxes decrease alcohol intake by an even larger proportion than for ‘low-ethanol drinkers’ (19.0% vs 15.6%), while broad taxes increase their ethanol intake by ∼16.0%. This study contributes evidence that taxation policy substantially reduces alcohol consumption and that alcohol consumption patterns should be accounted for when designing taxes.
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Affiliation(s)
- Ali Chalak
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut 1107-2020, Lebanon
| | - Lilian Ghandour
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon
| | - Sirine Anouti
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon
| | - Nasser Yassin
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon
| | - Rima Afifi
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA 52246, USA
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Mogos MF, Salemi JL, Phillips SA, Piano MR. Contemporary Appraisal of Sex Differences in Prevalence, Correlates, and Outcomes of Alcoholic Cardiomyopathy. Alcohol Alcohol 2020; 54:386-395. [PMID: 31206165 DOI: 10.1093/alcalc/agz050] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 05/19/2019] [Accepted: 06/07/2019] [Indexed: 11/14/2022] Open
Abstract
AIMS The aims of this study were to: examine differences in alcoholic cardiomyopathy (ACM) prevalence, temporal trends and the distribution of socio-demographic factors and comorbidities by sex; and investigate differences in selected inpatient outcomes between women and men with ACM. METHODS We used the 2002-2014 Nationwide Inpatient Sample databases. Overall and sex-specific rates of ACM were estimated across sociodemographic, clinical, and hospital characteristics. Joinpoint regression was used to estimate temporal trends (annual percent change [APC]) of ACM-related hospitalization by sex and race/ethnicity. Adjusted odds ratios (AOR) representing associations between sex and selected ACM outcomes were calculated using survey logistic regression. RESULTS The rate of ACM among all inpatient men and women was 128 per 100,000 and 17 per 100,000 hospitalizations, respectively. Among women, the rate of ACM remained unchanged during the study period, while for men, there was 1.2% annual reduction from 2002-2010 (APC -1.3, 95% CI: -1.7, -0.8). Women with ACM were more likely than men with ACM to experience depression (AOR=2.24, 95% CI: 2.06-2.43) and anxiety (AOR=1.94, 95% CI: 1.75-2.15), while men with ACM were 21% and 24% more likely than women with ACM to experience 'any heart failure (HF)' and HF with reduced ejection fraction respectively. One in 1,471 hospitalizations were related to ACM with a male-to-female ratio of 8:1. CONCLUSION Individuals with ACM are at increased likelihood of adverse outcomes. Women with ACM are at increased risk of depression and anxiety, while men are at increased risk of HF.
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Affiliation(s)
- Mulubrhan F Mogos
- Department of Women, Children and Family Health Science, University of Illinois at Chicago, Chicago, IL, USA
| | - Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Shane A Phillips
- Department of Physical Therapy, Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Mariann R Piano
- Center for Research Development and Scholarship, Vanderbilt School of Nursing, Nashville, TN, USA
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8
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Mortality from Alcoholic Cardiomyopathy: Exploring the Gap between Estimated and Civil Registry Data. J Clin Med 2019; 8:jcm8081137. [PMID: 31370237 PMCID: PMC6722687 DOI: 10.3390/jcm8081137] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/22/2019] [Accepted: 07/29/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Based on civil registries, 26,000 people died from alcoholic cardiomyopathy (ACM) in 2015 globally. In the Global Burden of Disease (GBD) 2017 study, garbage coded deaths were redistributed to ACM, resulting in substantially higher ACM mortality estimates (96,669 deaths, 95% confidence interval: 82,812–97,507). We aimed to explore the gap between civil registry and GBD mortality data, accounting for alcohol exposure as a cause of ACM. Methods: ACM mortality rates were obtained from civil registries and GBD for n = 77 countries. The relationship between registered and estimated mortality rates was assessed by sex and age groups, using Pearson correlation coefficients, in addition to comparing mortality rates with population alcohol exposure—the underlying cause of ACM. Results: Among people aged 65 years or older, civil registry mortality rates of ACM decreased markedly whereas GBD mortality rates increased. The widening gap of registered and estimated mortality rates in the elderly is reflected in a decrease of correlations. The age distribution of alcohol exposure is more consistent with the distribution of civil registry rather than GBD mortality rates. Conclusions: Among older adults, GBD mortality estimates of ACM seem implausible and are inconsistent with alcohol exposure. The garbage code redistribution algorithm should include alcohol exposure for ACM and other alcohol-attributable diseases.
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9
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Peltier MR, Verplaetse TL, Mineur YS, Petrakis IL, Cosgrove KP, Picciotto MR, McKee SA. Sex differences in stress-related alcohol use. Neurobiol Stress 2019; 10:100149. [PMID: 30949562 PMCID: PMC6430711 DOI: 10.1016/j.ynstr.2019.100149] [Citation(s) in RCA: 230] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/30/2019] [Accepted: 01/30/2019] [Indexed: 01/12/2023] Open
Abstract
Rates of alcohol use disorder (AUD) have increased in women by 84% over the past ten years relative to a 35% increase in men. This substantive increase in female drinking is alarming given that women experience greater alcohol-related health consequences compared to men. Stress is strongly associated with all phases of alcohol addiction, including drinking initiation, maintenance, and relapse for both women and men, but plays an especially critical role for women. The purpose of the present narrative review is to highlight what is known about sex differences in the relationship between stress and drinking. The critical role stress reactivity and negative affect play in initiating and maintaining alcohol use in women is addressed, and the available evidence for sex differences in drinking for negative reinforcement as it relates to brain stress systems is presented. This review discusses the critical structures and neurotransmitters that may underlie sex differences in stress-related alcohol use (e.g., prefrontal cortex, amygdala, norepinephrine, corticotropin releasing factor, and dynorphin), the involvement of sex and stress in alcohol-induced neurodegeneration, and the role of ovarian hormones in stress-related drinking. Finally, the potential avenues for the development of sex-appropriate pharmacological and behavioral treatments for AUD are identified. Overall, women are generally more likely to drink to regulate negative affect and stress reactivity. Sex differences in the onset and maintenance of alcohol use begin to develop during adolescence, coinciding with exposure to early life stress. These factors continue to affect alcohol use into adulthood, when reduced responsivity to stress, increased affect-related psychiatric comorbidities and alcohol-induced neurodegeneration contribute to chronic and problematic alcohol use, particularly for women. However, current research is limited regarding the examination of sex in the initiation and maintenance of alcohol use. Probing brain stress systems and associated brain regions is an important future direction for developing sex-appropriate treatments to address the role of stress in AUD.
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Affiliation(s)
| | | | - Yann S. Mineur
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06519, USA
| | - Ismene L. Petrakis
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06519, USA
- VA Connecticut Healthcare System, West Haven, CT, 06516, USA
| | - Kelly P. Cosgrove
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06519, USA
- Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT, 06519, USA
| | - Marina R. Picciotto
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06519, USA
| | - Sherry A. McKee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06519, USA
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10
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Schultheiss HP, Fairweather D, Caforio ALP, Escher F, Hershberger RE, Lipshultz SE, Liu PP, Matsumori A, Mazzanti A, McMurray J, Priori SG. Dilated cardiomyopathy. Nat Rev Dis Primers 2019; 5:32. [PMID: 31073128 PMCID: PMC7096917 DOI: 10.1038/s41572-019-0084-1] [Citation(s) in RCA: 322] [Impact Index Per Article: 64.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Dilated cardiomyopathy (DCM) is a clinical diagnosis characterized by left ventricular or biventricular dilation and impaired contraction that is not explained by abnormal loading conditions (for example, hypertension and valvular heart disease) or coronary artery disease. Mutations in several genes can cause DCM, including genes encoding structural components of the sarcomere and desmosome. Nongenetic forms of DCM can result from different aetiologies, including inflammation of the myocardium due to an infection (mostly viral); exposure to drugs, toxins or allergens; and systemic endocrine or autoimmune diseases. The heterogeneous aetiology and clinical presentation of DCM make a correct and timely diagnosis challenging. Echocardiography and other imaging techniques are required to assess ventricular dysfunction and adverse myocardial remodelling, and immunological and histological analyses of an endomyocardial biopsy sample are indicated when inflammation or infection is suspected. As DCM eventually leads to impaired contractility, standard approaches to prevent or treat heart failure are the first-line treatment for patients with DCM. Cardiac resynchronization therapy and implantable cardioverter-defibrillators may be required to prevent life-threatening arrhythmias. In addition, identifying the probable cause of DCM helps tailor specific therapies to improve prognosis. An improved aetiology-driven personalized approach to clinical care will benefit patients with DCM, as will new diagnostic tools, such as serum biomarkers, that enable early diagnosis and treatment.
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Affiliation(s)
- Heinz-Peter Schultheiss
- Institute for Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany. .,Department of Cardiology, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
| | - DeLisa Fairweather
- Mayo Clinic, Department of Cardiovascular Medicine, Jacksonville, FL, USA.
| | - Alida L. P. Caforio
- 0000 0004 1757 3470grid.5608.bDivision of Cardiology, Department of Cardiological Thoracic and Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Felicitas Escher
- grid.486773.9Institute for Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany ,0000 0001 2218 4662grid.6363.0Department of Cardiology, Charité–Universitaetsmedizin Berlin, Berlin, Germany ,0000 0004 5937 5237grid.452396.fDZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Ray E. Hershberger
- 0000 0001 2285 7943grid.261331.4Divisions of Human Genetics and Cardiovascular Medicine in the Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH USA
| | - Steven E. Lipshultz
- 0000 0004 1936 9887grid.273335.3Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY USA ,0000 0000 9958 7286grid.413993.5Oishei Children’s Hospital, Buffalo, NY USA ,Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
| | - Peter P. Liu
- 0000 0001 2182 2255grid.28046.38University of Ottawa Heart Institute, Ottawa, Ontario Canada
| | - Akira Matsumori
- grid.410835.bClinical Research Center, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Andrea Mazzanti
- 0000 0004 1762 5736grid.8982.bDepartment of Molecular Medicine, University of Pavia, Pavia, Italy ,Department of Molecular Cardiology, IRCCS ICS Maugeri, Pavia, Italy
| | - John McMurray
- 0000 0001 2193 314Xgrid.8756.cBritish Heart Foundation (BHF) Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Silvia G. Priori
- 0000 0004 1762 5736grid.8982.bDepartment of Molecular Medicine, University of Pavia, Pavia, Italy ,Department of Molecular Cardiology, IRCCS ICS Maugeri, Pavia, Italy
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Trias-Llimós S, Martikainen P, Mäkelä P, Janssen F. Comparison of different approaches for estimating age-specific alcohol-attributable mortality: The cases of France and Finland. PLoS One 2018; 13:e0194478. [PMID: 29566081 PMCID: PMC5864025 DOI: 10.1371/journal.pone.0194478] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 03/05/2018] [Indexed: 12/19/2022] Open
Abstract
Background Accurate estimates of the impact of alcohol on overall and age-specific mortality are crucial for formulating health policies. However, different approaches to estimating alcohol-attributable mortality provide different results, and a detailed comparison of age-specific estimates is missing. Methods Using data on cause of death, alcohol consumption, and relative risks of mortality at different consumption levels, we compare eight estimates of sex- and age-specific alcohol-attributable mortality in France (2010) and Finland (2013): five estimates using cause-of-death approaches (with one accounting for contributory causes), and three estimates using attributable fraction (AF) approaches. Results AF-related approaches and the approach based on alcohol-related underlying and contributory causes of death provided estimates of alcohol-attributable mortality that were twice as high as the estimates found using underlying cause-of-death approaches in both countries and sexes. The differences across the methods were greatest among older age groups An inverse U-shape in age-specific alcohol-attributable mortality (peaking at around age 65) was observed for cause-of-death approaches, with this shape being more pronounced in Finland. AF-related approaches resulted in different estimates at older ages: i.e., mortality was found to increase with age in France; whereas in Finland mortality estimates depended on the underlying assumptions regarding the effects of alcohol consumption on cardiovascular mortality. Conclusions While the most detailed approaches (i.e., the AF-related approach and the approach that includes underlying and contributory causes) are theoretically able to provide more accurate estimates of alcohol-attributable mortality, they–especially the AF approaches- depend heavily on data availability and quality. To enhance the reliability of alcohol-attributable mortality estimates, data quality for older age groups needs to be improved.
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Affiliation(s)
- Sergi Trias-Llimós
- Population Research Centre, Faculty of Spatial Sciences, University of Groningen, Groningen, The Netherlands
- * E-mail:
| | - Pekka Martikainen
- Population Research Unit, Department of Social Research, University of Helsinki, Helsinki, Finland
- Centre for Health Equity Studies (CHESS), Stockholm University and Karolinska Institutet, Stockholm, Sweden
- Max Planck Institute for Demographic Research, Rostock, Germany
| | - Pia Mäkelä
- Alcohol, Drugs and Addictions Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Fanny Janssen
- Population Research Centre, Faculty of Spatial Sciences, University of Groningen, Groningen, The Netherlands
- Netherlands Interdisciplinary Demographic Institute, The Hague, The Netherlands
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Abstract
OBJECTIVES (1) A comprehensive mortality assessment of alcoholic cardiomyopathy (ACM) and (2) examination of under-reporting using vital statistics data. METHODS A modelling study estimated sex-specific mortality rates for each country, which were subsequently aggregated by region and globally. Input data on ACM mortality were obtained from death registries for n=91 countries. For n=99 countries, mortality estimates were predicted using aggregate alcohol data from WHO publications. Descriptive additional analyses illustrated the scope of under-reporting. RESULTS In 2015, there were an estimated 25 997 (95% CI 17 385 to 49 096) global deaths from ACM. This translates into 6.3% (95% CI 4.2% to 11.9%) of all global deaths from cardiomyopathy being caused by alcohol. There were large regional variations with regard to mortality burden. While the majority of ACM deaths were found in Russia (19 749 deaths, 76.0% of all ACM deaths), for about one-third of countries (n=57) less than one ACM death was found. Under-reporting was identified for nearly every second country with civil registration data. Overall, two out of three global ACM deaths might be misclassified. CONCLUSIONS The variation of ACM mortality burden is greater than for other alcohol-attributable diseases, and partly may be the result of stigma and lack of detection. Misclassification of ACM fatalities is a systematic phenomenon, which may be caused by low resources, lacking standards and stigma associated with alcohol-use disorders. Clinical management may be improved by including routine alcohol assessments. This could contribute to decrease misclassifications and to provide the best available treatment for affected patients.
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Affiliation(s)
- Jakob Manthey
- Institute for Clinical Psychology and Psychotherapy, TU Dresden, Dresden, Germany
| | - Charlotte Probst
- Institute for Clinical Psychology and Psychotherapy, TU Dresden, Dresden, Germany.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Margaret Rylett
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Jürgen Rehm
- Institute for Clinical Psychology and Psychotherapy, TU Dresden, Dresden, Germany.,Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Institute of Medical Science (IMS), University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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14
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Rehm J, Gmel GE, Gmel G, Hasan OSM, Imtiaz S, Popova S, Probst C, Roerecke M, Room R, Samokhvalov AV, Shield KD, Shuper PA. The relationship between different dimensions of alcohol use and the burden of disease-an update. Addiction 2017; 112:968-1001. [PMID: 28220587 PMCID: PMC5434904 DOI: 10.1111/add.13757] [Citation(s) in RCA: 633] [Impact Index Per Article: 90.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/19/2016] [Accepted: 01/09/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Alcohol use is a major contributor to injuries, mortality and the burden of disease. This review updates knowledge on risk relations between dimensions of alcohol use and health outcomes to be used in global and national Comparative Risk Assessments (CRAs). METHODS Systematic review of reviews and meta-analyses on alcohol consumption and health outcomes attributable to alcohol use. For dimensions of exposure: volume of alcohol use, blood alcohol concentration and patterns of drinking, in particular heavy drinking occasions were studied. For liver cirrhosis, quality of alcohol was additionally considered. For all outcomes (mortality and/or morbidity): cause of death and disease/injury categories based on International Classification of Diseases (ICD) codes used in global CRAs; harm to others. RESULTS In total, 255 reviews and meta-analyses were identified. Alcohol use was found to be linked causally to many disease and injury categories, with more than 40 ICD-10 three-digit categories being fully attributable to alcohol. Most partially attributable disease categories showed monotonic relationships with volume of alcohol use: the more alcohol consumed, the higher the risk of disease or death. Exceptions were ischaemic diseases and diabetes, with curvilinear relationships, and with beneficial effects of light to moderate drinking in people without heavy irregular drinking occasions. Biological pathways suggest an impact of heavy drinking occasions on additional diseases; however, the lack of medical epidemiological studies measuring this dimension of alcohol use precluded an in-depth analysis. For injuries, except suicide, blood alcohol concentration was the most important dimension of alcohol use. Alcohol use caused marked harm to others, which has not yet been researched sufficiently. CONCLUSIONS Research since 2010 confirms the importance of alcohol use as a risk factor for disease and injuries; for some health outcomes, more than one dimension of use needs to be considered. Epidemiological studies should include measurement of heavy drinking occasions in line with biological knowledge.
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Affiliation(s)
- Jürgen Rehm
- Institute for Mental Health Policy Research, CAMHTorontoOntarioCanada
- Campbell Family Mental Health Research Institute, CAMHTorontoOntarioCanada
- Institute of Medical Science (IMS)University of TorontoTorontoOntarioCanada
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
- Institute for Clinical Psychology and Psychotherapy, TU DresdenDresdenGermany
| | - Gerhard E. Gmel
- Institute for Mental Health Policy Research, CAMHTorontoOntarioCanada
- Alcohol Treatment CenterLausanne University HospitalLausanneSwitzerland
- Addiction SwitzerlandLausanneSwitzerland
- University of the West of EnglandBristolUK
| | - Gerrit Gmel
- Institute for Mental Health Policy Research, CAMHTorontoOntarioCanada
| | - Omer S. M. Hasan
- Institute for Mental Health Policy Research, CAMHTorontoOntarioCanada
| | - Sameer Imtiaz
- Institute for Mental Health Policy Research, CAMHTorontoOntarioCanada
- Institute of Medical Science (IMS)University of TorontoTorontoOntarioCanada
| | - Svetlana Popova
- Institute for Mental Health Policy Research, CAMHTorontoOntarioCanada
- Institute of Medical Science (IMS)University of TorontoTorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
- Factor‐Inwentash Faculty of Social WorkUniversity of TorontoOntarioCanada
| | - Charlotte Probst
- Institute for Mental Health Policy Research, CAMHTorontoOntarioCanada
- Institute for Clinical Psychology and Psychotherapy, TU DresdenDresdenGermany
| | - Michael Roerecke
- Institute for Mental Health Policy Research, CAMHTorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | - Robin Room
- Centre for Alcohol Policy ResearchLa Trobe UniversityMelbourneVictoriaAustralia
- Centre for Social Research on Alcohol and DrugsStockholm UniversityStockholmSweden
| | - Andriy V. Samokhvalov
- Institute for Mental Health Policy Research, CAMHTorontoOntarioCanada
- Institute of Medical Science (IMS)University of TorontoTorontoOntarioCanada
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | - Kevin D. Shield
- Section of Cancer SurveillanceInternational Agency for Research on CancerLyonFrance
| | - Paul A. Shuper
- Institute for Mental Health Policy Research, CAMHTorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
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15
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Rehm J, Gmel GE, Gmel G, Hasan OSM, Imtiaz S, Popova S, Probst C, Roerecke M, Room R, Samokhvalov AV, Shield KD, Shuper PA. The relationship between different dimensions of alcohol use and the burden of disease-an update. ADDICTION (ABINGDON, ENGLAND) 2017. [PMID: 28220587 DOI: 10.1111/add.13757.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Alcohol use is a major contributor to injuries, mortality and the burden of disease. This review updates knowledge on risk relations between dimensions of alcohol use and health outcomes to be used in global and national Comparative Risk Assessments (CRAs). METHODS Systematic review of reviews and meta-analyses on alcohol consumption and health outcomes attributable to alcohol use. For dimensions of exposure: volume of alcohol use, blood alcohol concentration and patterns of drinking, in particular heavy drinking occasions were studied. For liver cirrhosis, quality of alcohol was additionally considered. For all outcomes (mortality and/or morbidity): cause of death and disease/injury categories based on International Classification of Diseases (ICD) codes used in global CRAs; harm to others. RESULTS In total, 255 reviews and meta-analyses were identified. Alcohol use was found to be linked causally to many disease and injury categories, with more than 40 ICD-10 three-digit categories being fully attributable to alcohol. Most partially attributable disease categories showed monotonic relationships with volume of alcohol use: the more alcohol consumed, the higher the risk of disease or death. Exceptions were ischaemic diseases and diabetes, with curvilinear relationships, and with beneficial effects of light to moderate drinking in people without heavy irregular drinking occasions. Biological pathways suggest an impact of heavy drinking occasions on additional diseases; however, the lack of medical epidemiological studies measuring this dimension of alcohol use precluded an in-depth analysis. For injuries, except suicide, blood alcohol concentration was the most important dimension of alcohol use. Alcohol use caused marked harm to others, which has not yet been researched sufficiently. CONCLUSIONS Research since 2010 confirms the importance of alcohol use as a risk factor for disease and injuries; for some health outcomes, more than one dimension of use needs to be considered. Epidemiological studies should include measurement of heavy drinking occasions in line with biological knowledge.
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Affiliation(s)
- Jürgen Rehm
- Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Campbell Family Mental Health Research Institute, CAMH, Toronto, Ontario, Canada.,Institute of Medical Science (IMS), University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Psychology and Psychotherapy, TU Dresden, Dresden, Germany
| | - Gerhard E Gmel
- Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Alcohol Treatment Center, Lausanne University Hospital, Lausanne, Switzerland.,Addiction Switzerland, Lausanne, Switzerland.,University of the West of England, Bristol, UK
| | - Gerrit Gmel
- Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada
| | - Omer S M Hasan
- Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada
| | - Sameer Imtiaz
- Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Institute of Medical Science (IMS), University of Toronto, Toronto, Ontario, Canada
| | - Svetlana Popova
- Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Institute of Medical Science (IMS), University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Factor-Inwentash Faculty of Social Work, University of Toronto, Ontario, Canada
| | - Charlotte Probst
- Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Institute for Clinical Psychology and Psychotherapy, TU Dresden, Dresden, Germany
| | - Michael Roerecke
- Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Robin Room
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Victoria, Australia.,Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm, Sweden
| | - Andriy V Samokhvalov
- Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Institute of Medical Science (IMS), University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Kevin D Shield
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Paul A Shuper
- Institute for Mental Health Policy Research, CAMH, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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