The unequal impact of the pandemic at subnational levels and educational attainment-related inequalities in COVID-19 mortality, Brazil, 2020-2021

OBJECTIVES

We estimated COVID-19 mortality indicators in 2020-2021 to show the epidemic's impact at subnational levels and to analyze educational attainment-related inequalities in COVID-19 mortality in Brazil.

STUDY DESIGN

This was an ecological study with secondary mortality information.

METHODS

Crude and age-standardized COVID-19 mortality rates were calculated by gender, major regions, and states. The COVID-19 proportional mortality (percentage) was estimated by gender and age in each region. Measures of education-related inequalities in COVID-19 mortality were calculated per state, in each of which the COVID-19 maternal mortality rate (MMR) was estimated by the number of COVID-19 maternal deaths per 100,000 live births (LBs).

RESULTS

The analysis of mortality rates at subnational levels showed critical regional differences. The North region proved to be the most affected by the pandemic, followed by the Center-West, with age-standardized COVID-19 mortality rates above 2 per 1000 inhabitants. The peak of COVID-19 mortality occurred in mid-March/April 2021 in all regions. Great inequality by educational level was found, with the illiterate population being the most negatively impacted in all states. The proportional mortality showed that males and females aged 50-69 years were the most affected. The MMR reached critical values (>100/100,000 LB) in several states of the North, Northeast, Southeast, and Center-West regions.

CONCLUSIONS

This study highlights stark regional and educational disparities in COVID-19 mortality in Brazil. Exacerbated by the pandemic, these inequalities reveal potential areas for intervention to reduce disparities. The results also revealed high MMRs in certain states, underscoring pre-existing healthcare access challenges that worsened during the pandemic.

A systematic review of the epidemiology and the public health implications of stroke in Sub-Saharan Africa

BACKGROUND

With approximately 11 million strokes occurring annually worldwide, and over 6.5 million deaths annually, stroke has made its place as one of the major killers in the world. Although developing countries make up more than 4/5 of the global stroke burden, well-grounded information on stroke epidemiology remains lacking there.

AIMS

This systematic review study aimed to provide a synthesis of studies on the incidence and prevalence of stroke among adults in sub-Saharan Africa (SSA), subsequently deduce the associated risk factors and public health implications (mortality rates and economic costs) of the disease on the population of this region.

METHODS

A systematic review of studies carried out in the region and published on PUBMED. Eligibility criteria were established using the PEO (Population/Patient, Exposure, Outcome) format. Research articles investigating either (or all) of the following: ischemic or haemorrhagic stroke, incidence, prevalence, and risk factors of stroke in adults (≥ 18 years old), in at least one region of SSA were included. Exclusion criteria comprised studies involving populations younger than 18 years old, research conducted outside the designated research region, and articles inaccessible in full text. The PRISMA guidelines were used for the search strategy.

RESULTS

Fifty-two studies were included review. Among them, over 11 studies investigated the prevalence of the disease. Some older studies within the continent (Nigeria, 2011) showed a prevalence of 1.3 per 100 while more recent studies (Zambia, 2021) showed a prevalence of 4.3 per 1000. The highest prevalence noted in this region was in Madagascar (2017) with 48.17 per 100, while the lowest was recorded in (Zimbabwe, 2017) with 0.61 per 100. The study in Tanzania showed a crude incidence of 94·5 per 100 000 (76·0-115·0) while the study in Ghana in 2018 showed an incidence of 14.19 events per 1000 person-years [10.77-18.38]. The identified risk factors included hypertension, diabetes, smoking, alcohol consumption, physical inactivity, poor diets (more salt, less vegetables), dyslipidaemia, HIV/AIDS co-infection, heart disease (cardiomyopathies, cardiac arrhythmias), obesity, previous stroke and/or family history of stroke. Over 21 studies investigated the mortality rates due to stroke in SSA, with most of the studies being in West Africa. These studies revealed mortality rates as high as 43.3% in Ghana, and as low as 10.9% in Cameroon. Few studies reported on the economic costs of stroke in the region; two in Benin, two in Nigeria and one in Tanzania.

CONCLUSION

The increasing incidence/prevalence, lifestyle factors and interactions with other diseases, including major communicable diseases, stroke is becoming a pressing public health problem for SSA. Reducing the incidence of stroke in Africa will surely lower mortality, morbidity, disability, and the neurological as well as cognitive aftereffects of stroke, as is clear from the experience of higher-income nations. We recommend a collective intervention involving the governments of nations, international organizations, civil society, and the private sector for greater impact and sustainable outcomes reducing the epidemiology and implications of stroke in SSA.

Mortality After Alcohol Septal Ablation vs. Septal Myectomy in Patients With Obstructive Hypertrophic Cardiomyopathy

Background: Alcohol septal ablation (ASA) and septal myectomy (SM) are 2 options for septal reduction therapy (SRT) to treat medication-resistant symptomatic obstructive hypertrophic cardiomyopathy (HCM). Because differences in mortality rates after these different SRT methods have not been extensively investigated in real-world settings, in this study compared the 1-year mortality rates after ASA and SM using population-based database. Methods and Results: Utilizing New York Statewide Planning and Research Cooperative System (SPARCS) data from 2005 to 2016, we performed a comparative effectiveness study of ASA vs. SM in patients with HCM. The outcome was all-cause death up to 360 days after SRT. We constructed a multivariable logistic regression model and performed sensitivity analysis with propensity score (PS)-matching and inverse probability of treatment weighting (IPTW) methods. We identified 755 patients with HCM who underwent SRT: 348 with ASA and 407 with SM. The multivariable analysis showed that all-cause deaths were significantly fewer in the ASA group at 360 days after SRT (adjusted odds ratio=0.34; 95% confidence interval [CI] 0.13-0.84; P=0.02). The PS-matching and IPTW methods also supported a lower mortality rate in the ASA group at 360 days post-SRT. Conclusions: In this population-based study of patients with HCM who underwent SRT in a real-world setting, the 1-year all-cause mortality rate was significantly lower in patients who underwent ASA compared with SM.

Food insecurity, environment, institutional quality, and health outcomes: evidence from South Asia

BACKGROUND

Food insecurity and environmental degradation pose significant threats to health outcomes in South Asia, necessitating effective policy interventions. Therefore, this study aims to examine the impact of food insecurity and environmental degradation on health outcome indicators amidst global inflationary shocks and institutional quality arrangements. Additionally, it aims to explore the intricate moderating role of institutional quality on the relationship between food insecurity, endogenous variables, and external shocks.

METHOD

In alignment with the study's objectives, a set of panel data spanning from 2000 to 2021 is compiled for South Asia. The study introduces a novel variable representing inflationary shock, crafted through the integration of inflation datapoints and the application of the generalized autoregressive conditional heteroskedasticity model. Additionally, a distinctive aggregate institutional quality index is formulated, drawing from six key measures of the Worldwide Governance indicators. To scrutinize the effects of food insecurity, environmental degradation, and other explanatory variables, the study employs the two-step system generalized method of moment technique, offering a robust analytical approach to uncover complex relationships and dynamics in the region.

RESULTS

The results indicate that the prevalence of undernourishment, inequality in per capita calorie intake, and CO2 emissions significantly reduce life expectancy and increase mortality rates. Additionally, it shows that per capita kilocalorie supply, per capita GDP, per capita health expenditures, and urbanization are statistically significant for increasing life expectancy and decreasing mortality rates. The findings reveal that inflationary shocks severely affect food insecurity and environmental factors, exerting further pressure on contemporary life expectancy and mortality rates. In rebuttal, the institutional quality index is found to have significant effects on increasing and decreasing life expectancy and mortality rates, respectively. Furthermore, the institutional quality index is effective in moderating the nexus between food insecurity, environmental degradation, and health outcomes while also neutralizing the negative impact of inflationary shocks on the subject.

CONCLUSION

The results verify triple health constraints such as food insecurity, environmental factors, and economic vulnerability to global shocks, which impose severe effects on life expectancy and mortality rates. Furthermore, poor institutional quality is identified as a hindrance to health outcomes in South Asia. The findings suggest specific policy implications that are explicitly discussed.

The Association Between Gender and Clinical Outcomes in Patients With Moderate to Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis

INTRODUCTION

Traumatic brain injuries (TBIs) are a significant cause of morbidity and mortality in the United States. but have a disproportionate impact on patients based on gender. This systematic review and meta-analysis aim to compare gender differences in clinical outcomes between male and female adult trauma patients with moderate and severe TBI.

METHODS

Studies assessing gender differences in outcomes following TBIs on PubMed, Google Scholar, EMBASE, and ProQuest were searched. Meta-analysis was performed for outcomes including in-hospital mortality, hospital length of stay, intensive care unit length of stay, and Glasgow outcome scale (GOS) at 6 mo.

RESULTS

Eight studies were included for analysis with 26,408 female and 63,393 male patients. Meta-analysis demonstrated that males had a significantly lower risk of mortality than females (RR: 0.88; 95% CI 0.78, 0.99; P = 0.0001). Females had a shorter hospital length of stay (mean difference -1.4 d; 95% CI - 1.6 d, -1.2 d). No significant differences were identified in intensive care unit length of stay (mean difference -3.0 d; 95% CI -7.0 d, 1.1 d; P = 0.94) or GOS at 6 mo (mean difference 0.2 d; 95% CI -0.9 d, 1.4 d; P = 1).

CONCLUSIONS

Compared to male patients, female patients with moderate and severe TBI had a significantly higher in-hospital mortality risk. There were no significant differences in long-term outcomes between genders based on GOS at 6 mo. These findings warrant further investigation into the etiology of these gender disparities and their impact on additional clinical outcome measures.

Association Between Changes in Racial Residential and School Segregation and Trends in Racial Health Disparities, 2000-2020: A Life Course Perspective

INTRODUCTION

Most studies of the relationship between racial segregation and racial health disparities have focused on residential segregation. School-based racial segregation is an additional form of segregation that may be associated with racial disparities in health. This study examines the relationship between both residential segregation and school segregation and racial health disparities among non-Hispanic Black compared to non-Hispanic White persons at the county level in the United States. It also examines the relationship between changes in residential and school segregation and subsequent trajectories in a variety of racial health disparities across the life course.

METHODS

Using the CDC WONDER Multiple Case of Death database, we derived an annual estimate of race-specific death rates and rate ratios for each county during the period 2000-2020. We then examined the relationship between baseline levels of residential and school segregation in 1991 as well as changes between 1991-2000 and the trajectories of the observed racial health disparities between 2000 and 2020. We used latent trajectory analysis to identify counties with similar patterns of residential and school segregation over time and to identify counties with similar trajectories in each racial health disparity. Outcomes included life expectancy, early mortality (prior to age 65), infant mortality, firearm homicide, total homicide, and teenage pregnancy rates.

RESULTS

During the period 1991-2020, racial residential segregation remained essentially unchanged among the 1051 counties in our sample; however, racial school segregation increased during this period. Increases in school segregation from 1991 to 2000 were associated with higher racial disparities in each of the health outcomes during the period 2000-2020 and with less progress in reducing these disparities.

CONCLUSION

This paper provides new evidence that school segregation is an independent predictor of racial health disparities and that reducing school segregation-even in the face of high residential segregation-could have a long-term impact on reducing racial health disparities. Furthermore, it suggests that the health consequences of residential segregation have not been eliminated from our society but are now being exacerbated by a new factor: school-based segregation. Throughout this paper, changes in school-based segregation not only show up as a consistent significant predictor of greater racial disparities throughout the life course, but at times, an even stronger predictor of health inequity than residential segregation.

Mortality risk and causes of death among people who use opioids in a take-home naloxone cohort

BACKGROUND

People who use opioids (PWUO) have an excess mortality from a range of causes. The cumulative effect of behavioral, social, and health risk factors complicates the interpretation of the effects of suitable interventions. This study explores mortality causes among a cohort of PWUO in the take-home naloxone (THN) program.

METHODS

This was a prospective cohort study of PWUO who received THN between 2015 and 2023. Participant data was linked with death registry data. Crude mortality rates and standardized mortality ratios (SMRs) were calculated for all causes, internal causes, and accidental opioid overdoses (AOOs). In addition to age and gender, risk factors like main route of administration, polydrug use, self-experienced overdoses, and using while alone were fitted in a Cox Regression model to explore factors associated with mortality.

RESULTS

The 2194 participants had a considerably higher mortality ratio for all causes investigated when compared to the general population (SMR=10.9, 95 % CI = 9.3,12.6). AOOs were the most prevalent cause of death (49 %). Those who reported frequent opioid use while alone had an elevated risk of dying of 2.6 (95 % CI = 1.1,6.4) compared to those who never used while alone.

CONCLUSIONS

Frequent opioid use while alone was associated with elevated mortality risk, supporting the importance of overdose prevention education with naloxone distribution, and additional efforts to improve environmental and social areas for safer drug-use practices among PWUO. The variety of mortality causes found in this study illustrates the need for multifaceted and targeted interventions for people at risk of overdosing.

Chronic obstructive pulmonary disease mortality in Spain between 1999 and 2019

INTRODUCTION

Mortality from COPD has decreased in Spain in recent years, but it is unknown whether this decline has been homogeneous among the different regions.

METHODS

From the Statistical Portal of the Ministry of Health of Spain we obtained the age-adjusted mortality rates/100,000 inhabitants for men and women in Spain and the Autonomous Communities for the years 1999-2019, using the coding of the International Classification of Diseases (ICD 10, sections J40-J44). With the adjusted rates we performed a jointpoint regression analysis to estimate an annual percentage change (APC), as well as identify possible points of trend change. Statistical significance was considered for a value of p<0.05.

RESULTS

During the study period, COPD mortality rates adjusted in Spain decreased from 28.77 deaths/100,000 inhabitants in 1999 to 12.14 deaths/100,000 inhabitants in 2019. We observed a linear decline in COPD mortality in men at national level of -3.67% per year (95% CI -4.1 to -3.4; p<0.001), with differences between the Autonomous Communities. Mortality in women also experienced a decrease in mortality in two phases, with a first period from 1999 to 2006 with a fall of -6.8% per year (95% CI -8.6 to -5.0; p<0.001) and a second period from 2006 to 2019 with a decrease in mortality of -2.1% (95% CI -2.8 to -1.3; p<0.001), with again differences between the Autonomous Communities.

CONCLUSION

Mortality rates from COPD have decreased heterogeneously among the different Autonomous Communities in both men and women.

One Provider Anesthesia Model in Oral and Maxillofacial Surgery

The one provider anesthesia model used in oral and maxillofacial surgery (OMS) practices has been a subject of debate due to concerns about patient safety, inadequate attention, and mortality and morbidity rates. Historically, OMS specialists have made significant contributions to modern anesthesia; however, recent changes in Centers for Medicare and Medicaid Services have led to increased scrutiny of the OMS anesthesia model. Proponents argue that the model is safe and effective, thanks to well-trained Dental Anesthesia Assistants and OMS surgeons' extensive experience in dental anesthesia cases.

Changes in frailty among patients hospitalized for spine pathologies during the COVID-19 pandemic in Germany-a nationwide observational study

PURPOSE

In spine care, frailty is associated with poor outcomes. The aim of this study was to describe changes in frailty in spine care during the coronavirus disease 2019 (COVID-19) pandemic and their relation to surgical management and outcomes.

METHODS

Patients hospitalized for spine pathologies between January 1, 2019, and May 17, 2022, within a nationwide network of 76 hospitals in Germany were retrospectively included. Patient frailty, types of surgery, and in-hospital mortality rates were compared between pandemic and pre-pandemic periods.

RESULTS

Of the 223,418 included patients with spine pathologies, 151,766 were admitted during the pandemic and 71,652 during corresponding pre-pandemic periods in 2019. During the pandemic, the proportion of high-frailty patients increased from a range of 5.1-6.1% to 6.5-8.8% (p < 0.01), while the proportion of low frailty patients decreased from a range of 70.5-71.4% to 65.5-70.1% (p < 0.01). In most phases of the pandemic, the Elixhauser comorbidity index (ECI) showed larger increases among high compared to low frailty patients (by 0.2-1.8 vs. 0.2-0.8 [p < 0.01]). Changes in rates of spine surgery were associated with frailty, most clearly in rates of spine fusion, showing consistent increases among low frailty patients (by 2.2-2.5%) versus decreases (by 0.3-0.8%) among high-frailty patients (p < 0.02). Changes in rates of in-hospital mortality were not associated with frailty.

CONCLUSIONS

During the COVID-19 pandemic, the proportion of high-frailty patients increased among those hospitalized for spine pathologies in Germany. Low frailty was associated with a rise in rates of spine surgery and high frailty with comparably larger increases in rates of comorbidities.

Trends in frailty in brain tumor care during the COVID-19 pandemic in a nationwide hospital network in Germany

PURPOSE

Among brain tumor patients, frailty is associated with poor outcomes. The COVID-19 pandemic has led to increased frailty in the general population. To date, evidence on changes in frailty among brain tumor patients during the pandemic is lacking. We aimed to compare frailty among brain tumor patients in Germany during the COVID-19 pandemic to the pre-pandemic era and to assess potential effects on brain tumor care.

METHODS

In this retrospective observational study, we compared frailty among brain tumor patients hospitalized during the COVID-19 pandemic in years 2020 through 2022 to pre-pandemic years 2016 through 2019 based on administrative data from a nationwide network of 78 hospitals in Germany. Using the Hospital Frailty Risk Score (HFRS), frailty was categorized as low, intermediate, or high. We examined changes in frailty, patient demographics, the burden of comorbidity, rates of surgery, and mortality rates for different frailty groups during the pandemic and compared them to pre-pandemic levels.

RESULTS

Of the 20,005 included hospitalizations for brain tumors, 7979 were during the pandemic (mean age 60.0 years (± 18.4); females: 49.8%), and 12,026 in the pre-pandemic period (mean age: 59.0 years [± 18.4]; females: 49.2%). Average daily admissions decreased from 8.2 (± 5.1) during pre-pandemic years to 7.3 (± 4.5) during the pandemic (p < 0.01). The overall median HFRS decreased from 3.1 (IQR: 0.9-7.3) during the pre-pandemic years to 2.6 (IQR: 0.3-6.8) during the pandemic (p < 0.01). At the same time, the Elixhauser Comorbidity Index (ECI) decreased from 17.0 (± 12.4) to 16.1 (± 12.0; p < 0.01), but to a larger degree among high compared to low frailty cases (by 1.8 vs. 0.3 points; p = 0.04). In the entire cohort, the mean length of stay was significantly shorter in the pandemic period (9.5 days [± 10.7]) compared with pre-pandemic levels (10.2 days [± 11.8]; p < 0.01) with similar differences in the three frailty groups. Rates of brain tumor resection increased from 29.9% in pre-pandemic years to 36.6% during the pandemic (p < 0.001) without differences between frailty levels. Rates of in-hospital mortality did not change during the pandemic (6.1% vs. 6.7%, p = 0.07), and there was no interaction with frailty.

CONCLUSION

Even though our findings are limited in that the HFRS is validated only for patients ≥ 75 years of age, our study among patients of all ages hospitalized for brain tumors in Germany suggests a marked decrease in levels of frailty and in the burden of comorbidities during the COVID-19 pandemic.

Canine mortality in Umbria Region (Central Italy): a population-based analysis

Companion dogs may be valuable sentinels to better understand the environmental determinants of morbidity and mortality in humans. This study aimed to assess the dog population and mortality in Umbria Region. The source of data was the local Canine Registry. Attribute-specific crude mortality rates by sex, age, and breed were produced on a five-year basis (2014-2018). The human ICD-10 was employed to code the causes of deaths. Over 2014-2018, an annual average population of 226,875 specimens and a total of 46,743 deaths were estimated. Mortality rate was higher in young males than in young females. A specific cause of death was reported for 5,209 dogs; the 62.8 per cent (95%CI = 61.4-64.1) was due to external causes. Neoplasms were the fourth cause of death. Differences in mortality between sexes were consistent with human ones. The death registration procedure needs improvement by a systematic coding of the causes. An adjustment of the human ICD could address the lack of a coding system until the introduction of international standards for animals.

The hidden toll of war: a comprehensive study of orthopedic injuries in Yemen

BACKGROUND

Yemen has been experiencing a protracted civil war and humanitarian crisis since 2015, which has resulted in many war-related injuries. However, there is a lack of data on the epidemiology, characteristics, and outcomes of these injuries, especially the orthopedic ones. This study aimed to describe the war-related orthopedic injuries in Yemen and their impact on the patients' health and function.

METHODS

This was a retrospective study based on medical records and trauma registries of 3930 patients who were admitted to three major trauma centers in Sana'a city with war-related orthopedic injuries from January 2015 to December 2020. We collected data on demographics, injury mechanisms, injury types and locations, surgical procedures, complications, mortality, and functional outcomes using the Musculoskeletal Function Assessment questionnaire. We used descriptive and inferential statistics to analyze the data and performed a logistic regression analysis to identify the factors associated with mortality.

RESULTS

Most of the patients were young males and civilians who suffered from complex and severe injuries involving multiple body regions, especially the lower extremities. The main mechanisms of injury were gunshot wounds, blast injuries, and landmine explosions. The patients required multiple surgical procedures and implants, and had high rates of complications and mortality. The most common complications were infection, nonunion, malunion, and amputation. The most common cause of death was sepsis. The functional outcomes were poor, as indicated by the high mean MFA score. The logistic regression analysis showed that older age, blast injuries, spine injuries, vascular injuries, and infection were significant predictors of mortality.

CONCLUSION

This study provides valuable information on the war-related orthopedic injuries in Yemen and their impact on the patients' health and function. It also identifies some areas for future research, such as exploring the risk factors for infection and nonunion/malunion, evaluating the effectiveness and cost-effectiveness of different surgical procedures and implants, assessing the long-term outcomes and quality of life of the patients, and developing novel strategies to enhance bone and soft-tissue healing.

Trends in mortality from non-natural causes in children and adolescents (0-19 years) in Europe from 2000 to 2018

BACKGROUND

Non-natural mortality in children and adolescents is a global public health problem that varies widely from country to country. Data on child and adolescent maltreatment are not readily available, and mortality due to violent causes is also underestimated.

METHODS

Injury-related mortality rates (overall and by specific causes) from 2000 to 2018 in selected European countries were analysed to observe mortality patterns in children and adolescents using data from the Eurostat database. Age-standardized mortality rates per 100,000 person-years were calculated for each country. Joinpoint regression analysis with a significance level of 0.05 and 95% confidence intervals was performed for mortality trends.

RESULTS

Children and adolescent mortality from non-natural causes decreased significantly in Europe from 10.48 around 2005 to 5.91 around 2015. The Eastern countries (Romania, Bulgaria, Poland, Slovakia, Czech Republic) had higher rates; while Spain, Denmark, Italy, and the United Kingdom had the lowest. Rates for European Country declined by 5.10% per year over the entire period. Larger downward trends were observed in Ireland, Spain and Portugal; smaller downward trends were observed for Eastern countries (Bulgaria, Czech Republic, Poland, Slovakia) and Finland. Among specific causes of death, the largest decreases were observed for accidental causes (-5.9%) and traffic accidents (-6.8%).

CONCLUSIONS

Mortality among children and adolescents due to non-natural causes has decreased significantly over the past two decades. Accidental events and transport accidents recorded the greatest decline in mortality rates, although there are still some European countries where the number of deaths among children and adolescents from non-natural causes is high. Social, cultural, and health-related reasons may explain the observed differences between countries.

Association Between Changes in Racial Residential Segregation and Trends in Racial Disparities in Early Mortality in 220 Metropolitan Areas, 2001-2018

INTRODUCTION

Racial residential segregation has been shown to affect the absolute levels of racial disparities in a wide variety of health outcomes in the USA but it is not known whether changes in segregation also influence these racial health disparities. This study examines the relationship between changes in racial residential segregation over four decades (1980-2020) and trends in racial disparities in early mortality (under age 65) rates among non-Hispanic Black and non-Hispanic White persons across a wide range of health outcomes in 220 metropolitan statistical areas (MSAs) during the period 2001-2018.

METHODS

Using the CDC WONDER Underlying Cause of Death database, we derived annual estimates of race-specific death rates and rate ratios for each MSA. We used latent trajectory analysis to examine the relationship between the level of segregation and changes in segregation over time in an MSA and trends in death rate disparities in that MSA.

RESULTS

The trajectory analysis resulted in a linear, three group model in which trajectory Groups 1 and 2 had decreasing trends in the ratios of Black to White death rates over time while in Group 3, the disparity remained almost constant over time. Increases in the level of segregation in an MSA from 1980 to 2000 were significantly associated with the likelihood that the MSA was in Group 3 and experienced no improvement in racial health disparities in mortality over time.

CONCLUSION

This paper provides new evidence that changes in segregation are related to trends in racial health disparities in mortality rates over time.

Mortality Trends Among Patients with Rheumatoid Arthritis in Western Australia

INTRODUCTION

With scarce comparative data on mortality in Australian patients with rheumatoid arthritis (RA), we investigated temporal changes in standardized mortality rates for patients with RA using longitudinal linked population-wide health data in Western Australia (WA) over the period 1980 to 2015.

METHODS

The study included 17,125 patients with a first-time hospital contact for RA (ICD-10-AM M05.00-M06.99 and ICD-9-AM 714.00-714.99) in the study period. Standardized mortality rate ratios (SMRRs) for the RA cohort versus the WA general population was estimated using direct age standardization. We analyzed temporal trends over with dates and causes provided by the WA Death Registry.

RESULTS

During 356,069 patient-years of follow-up, a total of 8955 (52%) deaths occurred in the RA cohort. The SMRR was 2.24 (95% CI 2.15-2.34) in males and 3.09 (95% CI 3.00-3.19) in females over the study period. SMRR decreased since 2000 to 1.59 (95% CI 1.39-1.81) for the period 2011-2015. Median survival was 26.80 years (95% CI 26.30-27.30), where age and comorbidity independently increased the risk of death. The leading causes of deaths were cardiovascular diseases (26.60%), cancer (16.80%), rheumatic diseases (5.80%), chronic pulmonary disease 491 (5.50%), dementia (3.00%), and diabetes 235 (2.6%).

CONCLUSIONS

The mortality rate in patients with RA in WA has decreased but remains 1.59-times higher than in community counterparts, suggesting that there is room for further improvement. Comorbidity is the main modifiable risk factor to further reduce mortality in patients with RA.

Chronic exposure to fine particles (PM2.5) and mortality: Evidence from Chile

Many Chilean cities suffer from high air pollution from industrial, mobile, and residential wood-burning sources. Several studies have linked PM2.5 air pollution exposure to higher mortality risk from cardiovascular, pulmonary, and lung cancer causes. In recent years, Chile has developed an extensive air pollution monitoring network to enforce air quality standards for PM2.5, allowing the study of the medium-term association between PM2.5 and mortality.

Methods

A negative binomial regression model was used to study the association between 3-year average PM2.5 concentrations and age-adjusted mortality rates for 105 of the 345 municipalities in Chile. Models were fitted for all (ICD10 A to Q codes), cardiopulmonary (I and J), cardiovascular (I), pulmonary (J), cancer (C), and lung cancer (C33-C34) causes; controlling for meteorological, socioeconomic, and demographic characteristics.

Results

A significant association of PM2.5 exposure with cardiopulmonary (relative risk for 10 µg/m3 PM2.5: 1.06; 95% confidence interval = 1.00, 1.13) and pulmonary (1.11; 1.02, 1.20) age-adjusted mortality rates was found. Cardiovascular (1.06; 0.99, 1.13) and all causes (1.02; 0.98, 1.07) were positive, but not significant. No significant association was found between cancer and lung cancer. The positive associations remained even when controlling for multiple confounding factors, model specifications, and when considering different methods for exposure characterization. These estimates are in line with results from cohort studies from the United States and European studies.

Conclusion

Three-year average PM2.5 exposure is positively associated with the age-adjusted mortality rate for cardiopulmonary and cardiovascular causes in Chile. This provides evidence of the medium-term exposure effect of fine particles on long-term mortality rates.

Real-time monitoring of honeybee colony daily activity and bee loss rates can highlight the risk posed by a pesticide

Information on honeybee foraging performance and especially bee loss rates at the colony level are crucial for evaluating the magnitude of effects due to pesticide exposure, thereby ensuring that protection goals for honeybee colonies are met (i.e. threshold of acceptable effects). However, current methods for monitoring honeybee foraging activity and mortality are very approximate (visual records) or are time-limited and mostly based on single cohort analysis. We therefore assess the potential of bee counters, that enable a colony-level and continuous monitoring of bee flight activity and mortality, in pesticide risk assessment. After assessing the background activity and bee loss rates, we exposed colonies to two concentrations of sulfoxaflor (a neurotoxic insecticide) in sugar syrup: a concentration that was considered to be field realistic (0.59 μg/ml) and a higher concentration (2.36 μg/ml) representing a worst-case exposure scenario. We did not find any effect of the field-realistic concentration on flight activity and bee loss rates. However, a two-fold decrease in daily flight activity and a 10-fold increase in daily bee losses were detected in colonies exposed to the highest sulfoxaflor concentration as compared to before exposure. When compared to the theoretical trigger values associated with the specific protection goal of 7 % colony-size reduction, the observed fold changes in daily bee losses were often found to be at risk for colonies. In conclusion, the real-time and colony-level monitoring of bee loss rates, combined with threshold values indicating at which levels bee loss rates threaten the colony, have great potential for improving regulatory pesticide risk assessments for honeybees under field conditions.

Unanticipated Changes in Drug Overdose Death Rates in Canada During the Opioid Crisis

Escalating drug overdose death rates in Canada are of ever-increasing concern. To better understand the extent of this health threat, we obtained mortality statistics and population figures for the years 2000 to 2020, and examined rates of overdose deaths, coded (using ICD-10) as accidental, suicide or "undetermined intent." The drug deemed as primarily responsible for the death was categorized as opioid, non-opioid, or unspecified. Age patterns of drug deaths were graphed. Joinpoint analysis was used to test the significance of changes in death rates. Accidental opioid and stimulant overdose death rates in Canada have climbed faster since 2011, though not as high as corresponding US rates. Unknown cause death rates have increased. However, opioid and non-opioid suicide rates have decreased significantly since 2011, and there have been fewer drug deaths of undetermined intent. Increased attention to the possibility that some suicides are being misclassified is warranted.

Factors Influencing Elevated Mortality Rates of Patients with Schizophrenia Hospitalized with COVID

Work completed since the pandemic began has repeatedly demonstrated elevated mortality rates in people with schizophrenia hospitalized with COVID. They are a vulnerable group due to multiple issues-for example high co-morbidity rates of medical illness, often impaired insight and judgment, barriers to obtaining health care, and trouble understanding and implementing preventive measures. The objective of this study was to evaluate if a diagnosis of schizophrenia in the context of COVID-19 requiring hospitalization increased the risk for people with a diagnosis of schizophrenia to be intubated, admitted to the ICU or die when compared to people hospitalized with COVID-19 who did not have schizophrenia. This was accomplished by doing a retrospective chart review of 123 people with schizophrenia and matched controls. Although we found elevated rates of these outcomes in the patients with schizophrenia, our analysis attributed these differences to congregate living, rather than the illness itself.

Epidemiology of Urological Cancers in Brazil: Trends in Mortality Rates Over More Than Two Decades

Background

Considering the socioeconomic disparities and inequalities observed in the healthcare resources among the Brazilian regions, we aimed to analyze the mortality trends of urological cancers in Brazil to identify areas with differential risks.

Methods

Deaths related to prostate (PCa), bladder (BCa), kidney (KC), penile (PeC), and testis (TCa) cancers from 1996 to 2019 were retrieved from the Mortality Information System database (Brazil). Geographic and temporal patterns were analyzed using age-standardized mortality rates (ASMRs). A joinpoint regression model was used to identify changes in the trends and calculate the average annual percentage change (AAPC) for each region.

Results

In Brazil, the ASMRs (per 100,000 persons/year) were 11.76 for PCa; 1.37, BCa; 1.13, KC; 0.33, and PeC; 0.26, TCa over the period. Increasing mortality trends were registered for BCa (AAPC = 0.45 in men; 0.57 in women), KC (AAPC = 2.03 in men), PeC (AAPC = 1.01), and TCa (AAPC = 2.06). The PCa mortality presented a significant reduction after 2006. The Northeast and North regions showed the highest increases in the PCa mortality. The South registered the highest ASMRs for BCa and KC, but the highest increasing trends occurred in the men from the Northeast. The North presented the highest ASMR for PeC, while the South registered the highest ASMR for TCa.

Conclusion

Differences among regions may be partly explained by disparities in the healthcare systems. Over the study period, the North and Northeast regions presented more discrepant mortality rates. Efforts should be made to ensure access to the healthcare resources for people at risk, particularly in these regions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44197-022-00042-8.

End stage renal disease patients undergoing hip fracture surgery have increased length of stay, acute hospital bill size, and reduced survivorship-implications on a bundled care program

End stage renal disease (ESRD) is an independent risk factor for the development of hip fractures and is associated with a higher mortality and complication rates. As these patients significantly skew healthcare financing in a bundled care payment (BCP) program, a risk stratified approach to BCPs could be done to take into account the difference in resources required.

INTRODUCTION

End stage renal disease (ESRD) is an independent risk factor for the development of hip fractures and is associated with a higher mortality and complication rate. Hip fracture patients with ESRD may significantly skew healthcare financing in a bundled care payment (BCP) program.

MATERIALS AND METHODS

ESRD patients undergoing hip fracture surgery from June 2007 to June 2012 within a tertiary hospital in Singapore were identified and matched to two other controls without ESRD based on secondary features of sex, age, fracture type, and surgery performed. Data was collected for American Society of Anesthesiologist (ASA) score, duration of surgery (DOS), length of stay (LOS), 30-day and 1-year mortality, and the presence of 10 other comorbidities: diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), ischemic heart disease (IHD), arrhythmia (ARR), cerebrovascular disease (CVA), dementia (DEM), asthma (ASTH), peripheral vascular disease (PVD), and anemia (ANE) from electronic medical records. Costs were retrieved from the gross acute hospitalization bill.

RESULTS

Forty-one ESRD patients were successfully matched with 82 controls. Patients with ESRD had higher ASA scores (3 vs 2, p = 0.0001), had 75% higher LOS (21 vs 12 days, p < 0.0001), were associated with 67% higher healthcare expenditure (median $20542 vs $12236, p < 0.0001), and 1-year mortality (OR: 19.6, p < 0.0001). ESRD patients had an average of 4.1 comorbidities per patient compared to 1.84 in the control group.

CONCLUSION

ESRD is an outsized factor on the outcome of hip fracture patients who have markedly higher and more variable healthcare utilization.

Modeling mortality rates and environmental degradation in Asia and the Pacific: does income group matter?

This two-dimensional study makes significant incursions into the health-environment literature by interrogating whether non-renewable energy moderates the impact of environmental degradation on mortality rates. It further aligns with the 2030 United Nations Sustainable Development Goals and 11, which aim to ensure healthy lives and promote well-being for all at all ages and make cities and human settlements inclusive, safe, resilient and sustainable. It contributes to the health-environment literature by investigating the intrinsic relationships among mortality rates, carbon emissions (environmental degradation), and non-renewable energy consumption. The study uses an unbalanced sample of 42 Asia and Pacific countries to determine (1) whether carbon emissions exaggerate the incidence of mortality rates and (2) if the interaction of non-renewable energy with carbon emissions enhances or alters the impact of carbon emissions on mortality rates. Consistent findings from the panel spatial correlation consistent least-squares dummy variables (PSCC-LSDV) and two-step system generalized method of moments (GMM) techniques reveal that (i) carbon emissions exacerbate mortality rates; (ii) non-renewable energy consumption exhibit mortality-reducing properties; (iii) non-renewable energy attenuates the impact of carbon emissions on mortality rates, (iv) persistency in mortalities occurs; and (v) the health-environment-energy dynamics differ across income groups. The paper's conjecture is expected to channel a new line of discourse on how non-renewable energy influences the environment and health outcomes.

Circulating Proprotein Convertase Subtilisin/Kexin type 9 level independently predicts incident cardiovascular events and all-cause mortality in hemodialysis black Africans patients

Background

Cardiovascular (CV) disease is the leading cause of mortality in patients with end-stage kidney disease (ESKD). The aim of the present study was to determine whether Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) could be an independent predictor of CV events and all-cause mortality in black African haemodialysis patients.

Methods

We carried out a prospective cohort study of all consecutive hemodialysis (HD) patients between August 2016 and July 2020, admitted in six hemodialysis centers of Kinshasa, Democratic Republic of Congo. Independent determinants of plasma PCSK-9 measured by ELISA were sought using multiple linear regression analysis. Kaplan-Meier’s method described the incidence of CV events while competitive and proportional risk models looked for independent risk factors for death at the .05 significance level.

Results

Out of 207 HD patients, 91 (43.9%) died; 116 (56.1%) have survived. PCSK9 level was significantly higher in deceased patients compared to survivors: 28.0 (24.0–31.0) ng/l vs 9.6 (8.6–11.6) ng/ml (p <  0.001). Patients with plasma PCSK9 levels in tertile 3 had a higher incidence of CV events and mortality compared to patients with plasma PCSK9 levels in tertile 2 or tertile 1 (p <  0.001). Tertile 3 negatively influence survival rates (26.6%) compared to tertile 2 (54.7%) and tertile 1 (85.3%). Patients in tertile 3 and tertile 2 had a 4-fold higher risk of death than patients in tertile 1. After adjustment for all parameters, competitive risk analysis showed that mortality was 2 times higher in patients with stroke. Similarly, serum albumin < 3.5 g/dL or PCSK9 in tertile 3 were respectively associated with 2 or 6 times higher rates of deaths.

Conclusion

Elevated plasma PCSK9 level is an independent major predictor of incident CV events and all-cause mortality in black African HD patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02748-0.

All-cause mortality and cardiovascular events in a Spanish nonagenarian cohort according to type 2 diabetes mellitus status and established cardiovascular disease

Background

Despite the progressive aging of the population in industrialized countries, few studies have focused on the natural history of cardiovascular disease in the very old, and recommendations on prevention of cardiovascular disease in this population are lacking. We aimed to analyze all-cause mortality and cardiovascular events according to prevalent type 2 diabetes mellitus and established cardiovascular disease in nonagenarians from a Mediterranean population.

Methods

We analyzed the primary health records of all nonagenarians living in the Community of Madrid (N = 59,423) and collected data for 4 groups: Group 1, individuals without T2DM or established CVD (T2DM-, CVD-); Group 2, individuals without T2DM but with established CVD (T2DM-, CVD +); Group 3, individuals with T2DM but without established CVD (T2DM + , CVD-); and Group 4, individuals with both T2DM and established CVD (T2DM + , CVD +), taking into account the influence of sex on the outcomes. Follow-up was 2.5 years. The primary outcomes were cumulative incidence and incidence density rates for all-cause mortality, non-fatal myocardial infarction, non-fatal stroke (the first composite primary outcome [CPO1]), combined with heart failure (CPO2). We evaluated the adjusted effect of each group on all-cause mortality (Cox regression).

Results

Mean age was 93.3 ± 2.8 years (74.2% women). Hypertension, dyslipidemia, heart failure, albuminuria, and estimated glomerular filtration rate < 60 mL/min/1.73 m2 were significantly more prevalent in G4 than in the other groups (all p values < 0.001). We observed significantly higher cumulative incidence rates for all-cause mortality, CPO1, and CPO2 in participants belonging to G4 (all p values ≤ 0.001). People in G2 presented higher rates of all-cause mortality, heart failure, CPO1, and CPO2 than people in G3 (all p values ≤ 0.001). In the fully adjusted model, G4 independently predicted all-cause mortality (HR = 1.48 [95% CI, 1.40 to 1.57] vs reference G1 [p < 0.01]). In addition, significant HRs were recorded for cardiovascular disease alone (G2) and type 2 diabetes mellitus alone (G3) (1.13 and 1.14, respectively; both p values < 0.01).

Conclusions

In Spanish nonagenarians, established cardiovascular disease and type 2 diabetes mellitus conferred a modest risk of all-cause mortality. However, the simultaneous presence of both conditions conferred the highest risk of all-cause mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02893-z.

Mortality rates for hip fracture patients managed surgically and conservatively in a dedicated unit in Singapore

INTRODUCTION

At our hospital, an unusually high proportion of patients and families opted for conservative management of hip fractures. This study aimed to compare the mortality rates of patients with hip fractures treated conservatively to that of operatively managed patients in a dedicated hip fracture unit.

MATERIALS AND METHODS

Retrospective analysis was done for patients who were treated for hip fractures between January 2015 and October 2017 in a Hip Fracture Unit at a tertiary hospital. Patients were managed non-operatively or surgically after discussion with the multi-disciplinary team.

RESULTS

233 patients were treated conservatively and 781 underwent operative management for hip fractures. Patients managed non-operatively had a higher inpatient, 30-day and 1-year mortality rates. Inpatient mortality was 6.01% for conservatively managed compared to 0% for operative management. 30-day mortality for conservatively managed patients was 8.58% as compared to 0% for operatively managed patients, and 1-year mortality was 33.05% as opposed to 8.96%. There was an association seen with the type of management of hip fractures and that of inpatient death (p = 0.000), death in 30 days (p = 0.000) and death in 1 year (p = 0.000). The type of management was a predictive factor in 1-year mortality (p = 0.000). The average number of co-morbidities in conservatively managed patients was 5.2 compared to surgically managed patients of 4.0. Conservatively managed hip patients had a higher prevalence of stroke, chronic kidney disease and ischemic heart disease. Complications during hospital stay were comparable for both groups. The mean length of hospital stay was similar for both groups.

CONCLUSION

Surgical intervention for hip fractures is associated with lower inpatient, 30-day and 1-year mortality rates. However, patient co-morbidities and pre-morbid conditions should also be considered.

LEVEL OF EVIDENCE

IV.

Effect of altitude on COVID-19 mortality in Ecuador: an ecological study

Background

The SARS-CoV-2/COVID-19 pandemic has claimed nearly 900,000 lives worldwide and infected more than 27 million people. Researchers worldwide are studying ways to decrease SARS-CoV-2 transmission and COVID-19 related deaths. Several studies found altitude having a negative association with both COVID-19 incidence and deaths. Ecuadorian data was used to explore the relationship between altitude and COVID-19.

Methods

This is an ecological study examining province-level data. To explore a relationship between altitude and COVID-19, this study utilized publicly available COVID-19 data and population statistics. ANOVA, correlation statistics, and a multivariate linear model explored the relationship between different Ecuadorian altitudes against incidence, mortality, and case-fatality rates. Population statistics attributed to COVID-19 were included in the linear model to control for confounding factors.

Results

Statistically significant differences were observed in the regions of Amazónica, Sierra, Costa of Ecuador for incidence, mortality, and case fatality rates, suggesting an association between altitude and SARS-CoV-2 transmission and COVID-19 disease severity (p-value ≤0.05). In univariate analysis, altitude had a negative association to mortality rate with a 1-unit change in altitude resulting in the decrease of 0.006 units in mortality rate (p-value = 0.03). The multiple linear models adjusted for population statistics showed a statistically significant negative association of altitude with mortality rate (p-value = 0.01) with a 1-unit change in altitude resulting in the decrease in mortality rate by 0.015 units. Overall, the model helped in explaining 50% (R² = 0.4962) of the variance in mortality rate.

Conclusion

Altitude may have an effect on COVID-19 mortality rates. However, based on our model and R² value, the relationship between our variables of interest and COVID-19 mortality may be nonlinear. More research is needed to understand why altitude may have a protective effect against COVID-19 mortality and how this may be applicable in a clinical setting.

Optimising the cost of roadkill surveys based on an analysis of carcass persistence

Reliable estimates of wildlife mortality due to wildlife-vehicle collisions are key to understanding its impact on wildlife populations and developing strategies to prevent or reduce collisions. Standardised approaches for monitoring roadkill are needed to derive robust and unbiased estimates of mortality that are comparable across different study systems and ecological contexts. When designing surveys, there is a trade-off between survey frequency (and hence logistical effort and financial cost) and carcass detection. In this regard, carcass persistence (the period a carcass remains detectable before being removed by decomposition or scavengers) is important; the longer a carcass persists, the greater the likelihood it will be detected with lower survey effort by conducting more infrequent surveys. Using multi-taxon carcass data collected over a month of repeated driven surveys, combined with five covariates (species functional group, body weight, carcass position on road, carcass condition [either flattened or not after impact], and rainfall prior to each survey), we explored the drivers of carcass persistence with the overall aim of providing information to optimise the design of carcass surveys along linear infrastructure. Our methodological approach included a survival analysis to determine carcass persistence, linear regressions to test the effect of covariates, a subsampling analysis (using field data and a simulation exercise) to assess how the proportion of carcasses detected changes according to survey frequency, and an analysis to compare the costs of surveys based on study duration, transect length and survey frequency. Mean overall carcass persistence was 2.7 days and was significantly correlated with position on road and within-functional group body weight. There was no evidence for a significant effect of rainfall, while the effect of carcass condition was weakly non-significant. The proportion of carcasses detected decreased sharply when survey intervals were longer than three days. However, we showed that survey costs can be reduced by up to 80% by conducting non-daily surveys. Expanding on the call for a standardised methodology for roadkill surveys, we propose that carcass persistence be explicitly considered during survey design. By carefully considering the objectives of the survey and characteristics of the focal taxa, researchers can substantially reduce logistical costs. In addition, we developed an R Shiny web app that can be used by practitioners to compare survey costs across a variety of survey characteristics. This web app will allow practitioners to easily assess the trade-off between carcass detection and logistical effort.

Pandemic backsliding: Violations of democratic standards during Covid-19

The widespread adoption of emergency powers during Covid-19 raises important questions about what constitutes a (un)democratic response to crises. While the institutions and practices of democracy during normal times are well established, democratic standards during emergencies have yet to be conceptualized in the literature. This makes it difficult to systematically answer questions like - How do states' responses to Covid-19 violate democratic standards? Do such violations make states' responses more effective? Drawing on international treaties, norms, and academic scholarship, we propose a novel conceptualization of democratic standards for emergency measures. We then identify which government responses to Covid-19 qualify as a violation of democratic standards within the framework of illiberal and authoritarian practices, introducing a dataset covering 144 countries from March 2020 onward. In this article, we provide an overview of the extent to which states violated democratic standards in their response to Covid-19 during 2020. We find no relationship between violations of democratic standards and reported Covid-19 mortality. Illiberal and authoritarian practices in response to the Covid-19 pandemic do not correlate with better public health outcomes. Rather, such crisis-driven violations should be carefully observed as they could signal autocratization.

Home Health And Postacute Care Use In Medicare Advantage And Traditional Medicare

This article compares patterns of postacute care-including care provided by skilled nursing facilities, inpatient rehabilitation facilities, and home health agencies-under Medicare Advantage and traditional Medicare. Overall, Medicare Advantage enrollees received less postacute care, both institutional and home health, than traditional Medicare enrollees did for three common conditions.

Spain's suicide statistics: do we believe them?

PURPOSE

There is a widespread belief that suicides around the world are under-counted. A substantial proportion of suicides may have been inappropriately registered as accidental or of undetermined cause or intent. There is reason to explore to what extent low suicide rates in some nations could be partly attributable to under-counting.

METHODS

Mortality statistics of most countries are available on-line. Numbers of suicide deaths in Spain, and in England and Wales (E & W), in male and female 5-year age groups, in each year between 2014 and 2018, were documented, along with deaths coded to ICD-10 accident or 'undetermined death' categories. Crude mortality rates were calculated using official population figures. Single year suicide, undetermined death, and non-transport accidental death rates of 12 other nations were calculated.

RESULTS

Spain's crude suicide rate per 100,000 remains low (7.89) compared to other nations; its event of undetermined intent (EUI) death rate was 0.09 (contrasting with E & W's 1.74). Its accidental poisoning rate is much lower than that of E & W. The study showed much higher rates of ill-defined/unknown cause deaths in late life in Spain (both genders) than in E & W, and age-associated increases in accidental drowning rates parallel with increased suicide by drowning.

CONCLUSIONS

Reportedly low suicide rates in Spain could be partly attributable to increased rates of 'hidden suicide' (accidental drowning, male accidental poisoning, and possibly ill-defined/unknown cause deaths, but not EUIs). It would be appropriate (and not just in Spain) to increase numbers of verbal and/or forensic autopsies in questionable 'undetermined' cases.

Six years of colorectal cancer mortality surveillance in the screening population for a risk stratified screening program

OBJECTIVE

To evaluate the impact of a colorectal cancer (CRC) risk predicting system on CRC mortality rates.

METHOD

An organized population screening program targeted at all the subjects (n = 102,076) at age 40-74 in nine towns of Jiashan county, China was conducted from 2007 to 2012. All of the screening participants were first triaged into high-risk & low-risk groups by a questionnaire and two fecal immunuochemical tests, only the high-risk subjects were subject to colonocopy. The screening participants were surveyed death caused by CRC for a total of six years after the enrollment. The CRC mortality in subgroups of the screening population was analyzed.

RESULTS

A total of 82,184 (80.51 % of the targeted population) screening participants were identified. CRC death were recorded for 142 subjects (28.819 per 10⁵ person-years). The age-adjusted relative risk(RR) of CRC death in the high-risk subjects (n = 12862, 84.48 per 10⁵ person-years) was 3.92 (95 % CI = 2.81-5.49) compared with the low-risk subjects (n = 69322, 18.52 per 10⁵ person-years). In the high-risk group, the age-adjusted RR of CRC death for those accepted colonoscopies (51.44 per 10⁵ person-years) compared with those refused colonoscopies (187.94 per 10⁵ person-years, P < 0.0001) was 0.34 (95 % CI = 0.21-0.56). The first three years after screening has seen the largest difference of CRC death hazard in both comparing groups.

CONCLUSION

The high-risk subjects triaged by the risk predicting system have a higher CRC mortality rate than the low-risk subjects, especially in the first three years after screening. Refusal of colonoscopy is risky behavior for the high-risk subject.

Gender disparities in clinical presentation, treatment, and outcomes in metastatic spine disease

BACKGROUND

The incidence of metastatic spine disease (MSD) is increasing among cancer patients. Given the poor outcomes and high rates of morbidity associated with MSD, it is important to determine demographic factors that could impact interventions and outcomes for this patient population. The objectives of this study were to compare in-hospital mortality and complication rates, clinical presentation, and interventions between female and male patients diagnosed with MSD.

METHODS

Patient data were collected from the United States National Inpatient Sample (NIS) database from the years 2012-2014. Descriptive statistics were used to compare data from 51,800 cases; subsequently, multivariable logistic regression analyses were conducted to assess the effect of gender on outcomes.

RESULTS

Males had significantly higher rates of in-hospital mortality (OR 1.30; 95 % CI 1.09-1.56, p = 0.004) and were more likely to have received surgical intervention than females (OR 1.34; 95 % CI 1.16-1.55, p < 0.001). Additionally, female patients were more likely to present with vertebral compression fracture (p < 0.001), while metastatic spinal cord compression (MSCC) and paralysis were more common in male patients (p < 0.001). There was no significant difference in rates of in-hospital complications between female and male patients.

CONCLUSION

Given the significant differences in mortality, disease course, treatment, and in-hospital complications between female and male patients diagnosed with MSD, additional prospective studies are necessary to understand how to meaningfully incorporate these differences into clinical care and prognostication going forward.

Exploring the neighbourhood-level correlates of Covid-19 deaths in London using a difference across spatial boundaries method

This paper explores neighbourhood-level correlates of the Covid-19 deaths in London during the initial rise and peak of the pandemic within the UK - the period March 1 to April 17, 2020. It asks whether the person-level predictors of Covid-19 that are identified in reports by Public Health England and by the Office of National Statistics also hold at a neighbourhood scale, remaining evident in the differences between neighbours. In examining this, the paper focuses on localised differences in the number of deaths, putting forward an innovative method of analysis that looks at the differences between places that share a border. Specifically, a difference across spatial boundaries method is employed to consider whether a higher number of deaths in one neighbourhood, when compared to its neighbours, is related to other differences between those contiguous locations. It is also used to map localised 'hot spots' and to look for spatial variation in the regression coefficients. The results are compared to those for a later period, April 18 - May 31. The findings show that despite some spatial diffusion of the disease, a greater number of deaths continues to be associated with Asian and Black ethnic groups, socio-economic disadvantage, very large households (likely indicative of residential overcrowding), and fewer from younger age groups. The analysis adds to the evidence showing that age, wealth/deprivation, and ethnicity are key risk factors associated with higher mortality rates from Covid-19.

US Firearm-Related Mortality: National, State, And Population Trends, 1999-2017

Nationwide firearm-related mortality rates increased in 2015-17 after remaining relatively stable in 1999-2014. Recent increases are reflected across most states and demographics to varying degrees, which suggests a worsening epidemic of firearm mortality that is geographically and demographically broad. In both time periods the fractions of firearm deaths due to suicide and homicide remained consistent.

Increases In Women's Political Representation Associated With Reductions In Child Mortality In Brazil

We assessed the effects of female political representation on mortality among children younger than age five in Brazil and the extent to which this effect operates through coverage with conditional cash transfers and primary care services. We combined data on under-five mortality rates with data on women elected as mayors or representatives in state and federal legislatures for 3,167 municipalities during 2000–15. Results from fixed-effects regression models suggest that the election of a female mayor and increases in the shares of women elected to state legislatures and to the federal Chamber of Deputies to 20 percent or more were significantly associated with declines in under-five mortality. Increasing the political representation of women was likely associated with beneficial effects on child mortality through pathways that expanded access to primary health care and conditional cash transfer programs.

Practical considerations for reducing mortality rates in alloxan-induced diabetic rabbits

Chemically-induced diabetic animal models have been employed in many areas of diabetes mellitus (DM) research, but managing post-induction animal survival rates remains one of the main downsides.

The aim of the present study was to propose a reliable approach to animal management and monitoring after DM induction in a rabbit model in order to reduce animal mortality rates.

DM was induced by injecting alloxan in 12 New Zealand White rabbits. A preventive subcutaneous glucose administration to counteract a potentially lethal hypoglycemic phase following alloxan injection was performed on individual bases. Blood glucose level (BGL) was checked hourly for the first 36 h, then every 2 h until the hyperglycemic state was confirmed.

All 12 rabbits survived a 48-hour post-induction phase. The critical hypoglycemic phase's start points and duration differed significantly among the rabbits, lasting from 6.7 to 37 h (19.75 ± 8.44). The rabbits entered the final hyperglycemic phase 18 h at the earliest and 42 h at the latest after induction (26.63 ± 7.07). The average daily BGLs throughout the study period ranged from 268 to 512 mg/dL (413.73 ± 76.69). Eleven rabbits survived until the end of the experiment.

The variability of rabbits' responses to alloxan injection emphasizes the importance of monitoring rabbit behavior and thoroughly checking BGLs, followed by a preventive glucose administration based on rabbits' individual needs for up to 36 h after alloxan injection. The proposed approach seems to reduce animal mortality.

Are black and Hispanic persons disproportionately affected by COVID-19 because of higher obesity rates?

Background

On March 13, 2020, the World Health Organization declared COVID-19 a pandemic. Shortly after that, it was reported that mortality rates in New York City (NYC), the epicenter of the pandemic in the United States, were found to be significantly higher in black and Hispanic populations.

Objectives

The aim of this article is to evaluate the mortality rates in NYC among the different ethnic groups and the different boroughs as they relate to the obesity rates to see whether this issue merits further evaluation.

Setting

NYC.

Methods

COVID-19 data were obtained from the official New York authorities in relation to total number of cases in the different boroughs of NYC. Age-adjusted COVID-19–related mortality rates of the different ethnic groups were also obtained. These data were cross-compared with historic community health data on obesity rates previously published and also obesity rates among the different ethnic groups in NYC.

Results

The 2 NYC boroughs that have the highest mortality rates are the Bronx (6%) and Brooklyn (5.4%). Both the Bronx and Brooklyn were also found to have the highest obesity rates at 32% and 27%, respectively. The 2 ethnic groups with the highest obesity rates (Hispanic and black) were also found to have the highest age-adjusted mortality rates per 100,000 compared with the other ethnic groups (22.8% and 19.8%, respectively).

Conclusions

The Hispanic and black populations in NYC seem to be disproportionately affected by the COVID-19 pandemic because of the higher incidence of mortality rates. Obesity may have played a role in the high incidence of mortality in those ethnic groups.

Improving The Accuracy Of Hospital Quality Ratings By Focusing On The Association Between Volume And Outcome

The Centers for Medicare and Medicaid Services (CMS) uses hierarchical modeling to stabilize its hospital quality star ratings by shrinking the performance of low-volume hospitals toward the performance of average hospitals. Responding to criticism that the methodology may distort the performance of low-volume hospitals, a CMS expert panel recommended that the agency consider using "shrinkage targets" to more accurately classify hospital quality performance. To test the "shrinkage targets" approach, we created two parallel sets of performance measures. We found that there was moderate-to-substantial agreement between the standard CMS approach and the approach based on shrinkage targets in hospital star ratings for all but the lowest-volume hospitals. These findings suggest that the standard CMS risk-adjustment methodology does not distort the star ratings of hospitals as long as case volumes exceed the current cutoff (twenty-five cases) used by CMS for public reporting.

Effect of tuberculosis infection on mortality of HIV-infected patients in Northern Tanzania

Background

TB and HIV are public health problems, which have a synergistic effect to each other. Despite the decreasing burden of these two diseases they still make a significant contribution to mortality. Tanzania is among the 30 high TB and HIV burden countries.

Methods

Routine data over 6 years from people living with HIV (PLHIV) attending health facilities in three regions of Northern Tanzania were analyzed, showing mortality trends from 2012 to 2017 for HIV and HIV/TB subpopulations. Poisson regression with frailty model adjusting for clustering at health facility level was used to analyze the data to determine mortality rate ratios (RR) and 95% confidence intervals (95%CI).

Results

Among all PLHIV the overall mortality rate was 28.4 (95% CI 27.6–29.2) deaths per 1000 person-years. For PLHIV with no evidence of TB the mortality rates was 26.2 (95% CI 25.4–27.0) per 1000 person-years, and for those with HIV/TB co-infection 57.8 (95% CI 55.6–62.3) per 1000 person-years. After adjusting for age, sex, residence, WHO stage, and bodyweight, PLHIV with TB co-infection had 40% higher mortality than those without TB (RR 1.4; 95% CI 1.24–1.67).

Conclusions

Over the 6-year period mortality rates for HIV/TB patients were consistently higher than for PLHIV who have no TB. More efforts should be directed into improving nutritional status among HIV patients, as it has destructive interaction with TB for mortality. This will improve patients’ body weight and CD4 counts which are protective against mortality. Among PLHIV attention should be given to those who are in WHO HIV stage 3 or 4 and having TB co-infection.

Multiple simultaneous fractures are associated with higher all-cause mortality: results from a province-wide fracture liaison service

Mortality rates in our fracture liaison service ranged from 2.7% at year 1 to 14.8% at year 5 post-screening. Presentation with multiple simultaneous fractures at screening was associated with higher risk of death. This finding indicates the need for increased focus on this high-risk group.

PURPOSE

To examine all-cause mortality rates in a provincial fracture liaison service (FLS) and the association between the index fracture type, particularly multiple simultaneous fractures, and the risk of death at follow-up.

METHODS

This cohort study includes fragility fracture patients aged 50+, enrolled in a provincial FLS in Ontario, Canada, between 2007 and 2010. All-cause mortality was assessed using administrative data. Multivariable Cox proportional hazards model was used to examine the risk of death 5 years after screening.

RESULTS

Crude mortality rates for 6543 fragility fracture patients were 2.7% at year 1, 5.6% at year 2, and 14.8% at year 5 after screening. After adjusting for age and sex, and relative to distal radius fracture, patients with multiple (simultaneous) fractures at screening had a higher risk of dying (HR = 1.8, 95%CI 1.3-2.4), followed by those with a hip fracture (HR = 1.5, 95%CI 1.3-1.8), a proximal humerus fracture (HR = 1.4, 95%CI 1.2-1.7), and other single fractures (HR = 1.4, 95%CI 1.1-1.7). Having an index ankle fracture was not associated with the risk of death over a distal radius fracture. As compared to the 50-65 age group, patients 66 years and older had a higher risk of death (for 66-70 age group: HR = 2.5, 95%CI 1.9-3.3; for 71-80: HR = 4.3, 95%CI 3.5-5.4; and for 81+: HR = 10.6, 95%CI 8.7-13.0). Females had a lower risk of death (HR = 0.5, 95%CI 0.5-0.6) than males.

CONCLUSIONS

Presenting with multiple fractures was an indicator of higher risk of death relative to a distal radius fracture. This finding indicates the need for increased focus on this high-risk group.

Higher US Rural Mortality Rates Linked To Socioeconomic Status, Physician Shortages, And Lack Of Health Insurance

All-cause mortality rates in rural areas have exceeded those in urban areas of the US since the 1980s, and the gap continues to widen. Yet no definitive causes of this difference are known, and within-state differences that might be amenable to state-level policy have not been explored. An analysis of 2016 state-level data indicated that rural mortality exceeded urban mortality in all but three states, with substantial variability in both rates across states. Overall, higher rural mortality at the state level can be mainly explained by three factors: socioeconomic deprivation, physician shortages, and lack of health insurance. To a certain degree, these factors reflect a state's health policies, such as expansion of eligibility for Medicaid, health infrastructure, and socioeconomic conditions. Our findings suggest that state and federal policy efforts to address rural-urban disparities in these areas could alleviate the higher rates of all-cause mortality faced by rural US residents.

Regional inequalities in benzene exposures across the European petrochemical industry: A Bayesian multilevel modelling approach

BACKGROUND

Pollutants released from the petrochemical industry are thought to increase the risk of mortality in fence-line communities, yet the results from previous studies are often inconsistent and lack a global perspective, hampered by the absence of cohesive cross-country research.

OBJECTIVES

To provide the first Pan-European analysis of benzene exposures from the petrochemical industry, connecting polluting practices to pollution episodes and disparities in regional mortality rates, identifying the measures of best environmental practice to mitigate adverse outcomes.

METHODS

The activity, classification and location of onshore petrochemical facilities within EU-28 Member States were extracted from the 'European Pollutant Release and Transfer Register' (E-PRTR), which holds records on 31,753 industrial operations for the reporting period of 2007-15. Parent company records were collected from the Moody's Analytics Amadeus database of 487,338 active companies across Europe. The EUROSTAT census provided records of income, life expectancy, and the underlying demographics used to calculate standardised health outcomes based on 9,936 sub-populations within the NUTS2 regions. The European Environment Agency provided ambient concentrations of benzene from 579 air quality stations. Bayesian multilevel models were constructed to account for variability caused by spatial hierarchical structures, uncertainty in the estimates, and to incorporate both individual and group-level influences.

RESULTS

Higher levels of benzene emissions from petrochemical operations, both overall and in terms of specific pollution events, were associated with increased mortality rates for nearby residential populations, particularly in areas with socioeconomic deprivation. We identify uneven patterns of polluting practices within the industry, and locations that require epidemiological studies.

CONCLUSIONS

While petrochemical facilities in all European Union regions are regulated to be compliant with the annual average benzene limit of 5 μg/m3, uneven exposures still present regional health inequalities. We recommend extending benzene regulations to an hourly or daily limit, alongside the strengthening of regulation for other toxic petrochemical releases.

Road traffic injuries in Poland: magnitude and risk factors

INTRODUCTION

The article presents the epidemiology of road traffic injuries and fatalities in Poland in the years 2004-2014. In Poland, every fourth death caused by external reasons is the result of a road traffic crash and Poland has one of the highest road fatality rates in relation to vehicle ownership in Europe, with an average 23 deaths per million residents. This rate is two times higher than most other European Union countries.

MATERIALS AND METHODS

The research is based on a secondary analysis of data contained in multiple Polish governmental reports, including those of the Prevention and Analysis Office of Road Traffic Headquarters of Police, National Road Safety Program-GAMBIT 2005, National Road Safety Program 2013 to 2020, and Strategy for Efficient State in 2020, plus previous publications describing road safety in Poland. Data were analysed in two steps. First, the data were described using means and frequencies, and tabulated according to variables. Second, we considered the time frame (day, month, and year of the occurrence), the place and the circumstances of fatal road crashes, the kind of event, and types of road crashes.

RESULTS

Between 2004 and 2014, there were 475,591 traffic crashes on Polish roads. 52,217 people were killed and 597,191 people were injured. Traffic-related injuries represent the leading cause of death for Polish men up to 44 years of age. The most common cause of road crashes in Poland was failure to comply with the rules of the road traffic, such as through excessive speeding. We also found drivers poorly assessed road situations, faced a lack of adequate road infrastructure, and maintained many vehicles in poor condition.

DISCUSSION

Despite the variety of measures undertaken to improve safety on Polish roads, including modifications of the law as well as improving road quality, the number of fatalities and injuries resulting from motor vehicle crashes is still considerable, and the losses incurred by Polish society are still substantial.

CONCLUSIONS

The number of fatalities and injuries as a result of road crashes in Poland remains very high. Multifaceted action to improve safety on the roads in Poland should continue.

Increasing pancreatic cancer is not paralleled by pancreaticoduodenectomy volumes in Brazil: A time trend analysis

BACKGROUND

Currently, surgical resection represents the only curative treatment for pancreatic cancer (PC), however, the majority of tumors are no longer resectable by the time of diagnosis. The aim of this study was to describe time trends and distribution of pancreaticoduodenectomies (PDs) performed for treating PC in Brazil in recent years.

METHODS

Data were retrospectively obtained from Brazilian Health Public System (namely DATASUS) regarding hospitalizations for PC and PD in Brazil from January 2008 to December 2015. PC and PD rates and their mortalities were estimated from DATASUS hospitalizations and analyzed for age, gender and demographic characteristics.

RESULTS

A total of 2364 PDs were retrieved. Albeit PC incidence more than doubled, the number of PDs increased only 37%. Most PDs were performed in men (52.2%) and patients between 50 and 69 years old (59.5%). Patients not surgically treated and those 70 years or older had the highest in-hospital mortality rates. The most developed regions (Southeast and South) as well as large metropolitan integrated municipalities registered 76.2% and 54.8% of the procedures, respectively. LMIM PD mortality fluctuated, ranging from 13.6% in 2008 to 11.8% in 2015.

CONCLUSIONS

This study suggests a trend towards regionalization and volume-outcome relationships for PD due to PC, as large metropolitan integrated municipalities registered most of the PDs and more stable mortality rates. The substantial differences between PD and PC increasing rates reveals a limiting step on the health system resoluteness. Reduction in the number of hospital beds and late access to hospitalization, despite improvement in diagnostic methods, could at least in part explain these findings.

The cyclicality of government health expenditure and its effects on population health

Scholars have raised concerns that cutbacks on government health expenditure (GHE) during recessions may jeopardise population health. The present research investigates the extent to which population health outcomes are affected by responses of GHE to business cycles, i.e., cyclicality of GHE. We estimate GHE cyclicality by regressing detrended GHE on detrended gross domestic product (GDP). Our analysis of data for 1995 through 2014 from 135 developing countries shows that mean cyclicality is 0.61, or that a one percent deviation from the GDP trend is positively correlated with a 0.61 percent deviation from the GHE trend. Further, countries in which GHE is less procyclical appear to have shorter life expectancies and higher adult mortality rates. These results suggest that reducing procyclicality of GHE by protecting GHE in bad times may generate substantial health gains. Importantly, our results show that increasing the weight of social security funds in health budgets, and improving institutional quality, can be critical to breaking the procyclical pattern of GHE.

Pandemic 2009 influenza A (H1N1)-associated deaths among children in China: A retrospective analysis

Importance

A cluster of influenza-associated deaths occurred among children during pandemic 2009 influenza A (H1N1) in China, but the risk factors and causes for death have not been clarified.

Objective

We describe the clinical findings regarding 2009 influenza A (H1N1)-associated pediatric deaths in China, including the risk factors for death.

Methods

The definition of 2009 influenza A (H1N1)-associated pediatric death is death in a child who is younger than 14 years and has laboratory-confirmed influenza. We collected data of total 810 hospitalized patients with 2009 influenza A (H1N1) infection from September 2009 to February 2010 in 17 hospitals across China. The clinical characteristics, laboratory abnormalities, and treatment course were retrospectively studied.

Results

Of the 810 patients hospitalized with 2009 influenza A (H1N1) infection, 19 (2.3%) died. Ten patients died from severe pneumonia and acute respiratory distress syndrome; eight died from encephalopathy/encephalitis; one died from secondary fungal meningitis. Patients who died were more likely than patients who survived to have neutrophilia, lymphopenia, elevated C-reactive protein, and elevations of lactate dehydrogenase, creatine kinase, creatine kinase-MB, aspartate aminotransferase and alanine aminotransferase. There were no significant differences in the median age, median time from onset of illness to admission, underlying chronic disease, and initiation of antiviral therapy within 48 hours of illness onset, between patients who died and those who survived.

Interpretation

The risk factors for pediatric death associated with 2009 influenza A (H1N1) infection are different from those of seasonal influenza. The most common causes of death are viral pneumonia, acute respiratory distress syndrome, and encephalopathy/encephalitis.

Regional differences in the mid-Victorian diet and their impact on health

The aim of this study was to examine the impact of regional diets on the health of the poor in mid-Victorian Britain. Contemporary surveys of regional diets and living condition were reviewed. This information was compared with mortality data from Britain over the same period. Although there was an overall improvement in life expectancy during the latter part of the 19th century, there were large regional differences in lifestyle, diet and mortality rates. Dietary surveys showed that the poor labouring population in isolated rural areas of England, in the mainland and islands of Scotland and in the west of Ireland enjoyed the most nutritious diets. These regions also showed the lowest mortality rates in Britain. This was not simply the result of better sanitation and less mortality from food and waterborne infections but also fewer deaths from pulmonary tuberculosis, which is typically associated with better nutrition. These more isolated regions where a peasant-style culture provided abundant locally produced cheap foodstuffs such as potatoes, vegetables, whole grains, and milk and fish, were in the process of disappearing in the face of increasing urbanisation. This was to the detriment of many rural poor during the latter half of the century. Conversely, increasing urbanisation, with its improved transport links, brought greater availability and diversity of foods to many others. It was this that that led to an improved nutrition and life expectancy for the majority in urbanising Britain, despite the detrimental effects of increasing food refinement.