Data-Driven Simulations to Assess the Impact of Study Imperfections in Time-to-Event Analyses.

Quantitative bias analysis (QBA) permits assessment of the expected impact of various imperfections of the available data on the results and conclusions of a particular real-world study. This article extends QBA methodology to multivariable time-to-event analyses with right-censored endpoints, possibly including time-varying exposures or covariates. The proposed approach employs data-driven simulations, which preserve important features of the data at hand while offering flexibility in controlling the parameters and assumptions that may affect the results. First, the steps required to perform data-driven simulations are described, and then two examples of real-world time-to-event analyses illustrate their implementation and the insights they may offer. The first example focuses on the omission of an important time-invariant predictor of the outcome in a prognostic study of cancer mortality, and permits separating the expected impact of confounding bias from non-collapsibility. The second example assesses how imprecise timing of an interval-censored event - ascertained only at sparse times of clinic visits - affects its estimated association with a time-varying drug exposure. The simulation results also provide a basis for comparing the performance of two alternative strategies for imputing the unknown event times in this setting. The R scripts that permit the reproduction of our examples are provided.

Impact of Decarceration Plus Alcohol, Substance Use, and Mental Health Screening on Life Expectancies of Black Sexual Minority Men and Black Transgender Women Living With HIV in the United States: A Simulation Study Based on HPTN 061.

BACKGROUND: Given the disproportionate rates of incarceration and lower life expectancy (LE) among Black sexual minority men (BSMM) and Black transgender women (BTW) with HIV, we modeled the impact of decarceration and screening for psychiatric conditions and substance use on LE of US BSMM/BTW with HIV. METHODS: We augmented a microsimulation model previously validated to predict LE and leading causes of death in the US with estimates from the HPTN 061 cohort and the Veteran's Aging Cohort Studies. We estimated independent associations among psychiatric and substance use disorders, to simulate the influence of treatment of one condition on improvement on others. We used this augmented simulation to estimate LE for BSMM/BTW with HIV with a history of incarceration under alternative policies of decarceration (ie, reducing the fraction exposed to incarceration), screening for psychiatric conditions and substance use, or both. RESULTS: Baseline LE was 61.3 years. Reducing incarceration by 25%, 33%, 50%, and 100% increased LE by 0.29, 0.31, 0.53, and 1.08 years, respectively, versus no reductions in incarceration. When reducing incarceration by 33% and implementing screening for alcohol, tobacco, substance use, and depression, in which a positive screen triggers diagnostic assessment for all psychiatric and substance use conditions and linkage to treatment, LE increased by 1.52 years compared with no screening or decarceration. DISCUSSION: LE among BSMM/BTW with HIV is short compared with other people with HIV. Reducing incarceration and improving screening and treatment of psychiatric conditions and substance use could substantially increase LE in this population.

CanCHD Study of Hematopoietic Cancers in Children With and Without Genetic Syndromes.

BACKGROUND: Individuals with genetic syndromes can manifest both congenital heart disease (CHD) and cancer attributable to possible common underlying pathways. To date, reliable risk estimates of hematopoietic cancer (HC) among children with CHD based on large population-based data remain scant. This study sought to quantify the risk of HC by the presence of genetic syndrome among children with CHD. METHODS AND RESULTS: Data sources were the Canadian CHD database, a nationwide database on CHD (1999-2017), and the CCR (Canadian Cancer Registry). Standardized incidence ratios were calculated for comparing HC incidences in children with CHD with the general pediatric population. A modified Kaplan-Meier curve was used to estimate the cumulative incidence of HC with death as a competing risk. A total of 143 794 children (aged 0-17 years) with CHD were followed up from birth to age 18 years for 1 314 603 person-years. Of them, 8.6% had genetic syndromes, and 898 HC cases were observed. Children with known syndromes had a substantially higher risk of incident HC than the general pediatric population (standardized incidence ratio, 13.4 [95% CI, 11.7-15.1]). The cumulative incidence of HC was 2.44% (95% CI, 2.11-2.76) among children with a syndrome and 0.79% (95% CI, 0.72-0.87) among children without a syndrome. Acute myeloid leukemia had a higher cumulative incidence during early childhood than acute lymphoblastic leukemia. CONCLUSIONS: This is the first large population-based analysis documenting that known genetic syndromes in children with CHD are a significant predictor of HC. The finding could be essential in informing risk-stratified policy recommendations for cancer surveillance in children with CHD.

Uncovering the impact of COVID-19 on the place of death of cancer patients in South America.

The COVID-19 pandemic has significantly impacted healthcare systems worldwide, especially on the management of chronic diseases such as cancer. This study explores the effects of COVID-19 on cancer mortality trends in Brazil, Chile, and Peru. The monthly age-standardized mortality rates in different places of death (hospital/clinic or home) were estimated using vital statistics and death certificate databases. An interrupted time series analysis was performed for each country, using the date of lockdown implementation as the intervention point. Overall cancer mortality rates reduced after the implementation of pandemic restrictions, with a significant decrease in Brazil. In total, 75.3%, 55.4%, and 45.7% of deaths in Brazil, Peru, and Chile, respectively, occurred in hospitals. After lockdowns were implemented, at-home deaths increased in all countries, and in-hospital deaths correspondingly decreased only in Chile. Our results suggest that COVID-19 has significantly affected rates of cancer mortality and place of death in Latin America.

Associations between police harassment and distrust in and reduced access to healthcare among Black sexual minority men: A longitudinal analysis of HPTN 061.

OBJECTIVE: Evaluate associations between racialized and homophobia-based police harassment (RHBPH) and healthcare distrust and utilization among Black Sexual Minority Men (BSMM). METHODS: We utilized data from a longitudinal cohort study from HIV Prevention Trials Network (HPTN) 061 with baseline, six and 12 month follow-up assessments. Using multivariable analysis, we evaluated associations between RHBPH and healthcare distrust and utilization reported at the 6 and 12 month visits. RESULTS: Of 1553 BSMM present at baseline, 1160 were available at six-month follow-up. In multivariable analysis, increasing frequency of RHBPH was associated with increasing levels of distrust in healthcare providers (aOR 1.31, 95% CI: 1.00, 1.74) and missing 50% or more of healthcare visits at six-month follow-up (aOR 1.93, 95% CI: 1.09, 3.43). CONCLUSIONS: Recent experiences of RHBPH are associated with reduced trust in and access to healthcare among BSMM, with more frequent RHBPH associated with greater vulnerability.

Reevaluating the protective effect of smoking on preeclampsia risk through the lens of bias.

Preeclampsia is a hypertensive disorder that is usually diagnosed after 20 weeks' gestation. Despite the deleterious effect of smoking on cardiovascular disease, it has been frequently reported that smoking has a protective effect on preeclampsia risk and biological explanations have been proposed. However, in this manuscript, we present multiple sources of bias that could explain this association. First, key concepts in epidemiology are reviewed: confounder, collider, and mediator. Then, we describe how eligibility criteria, losses of women potentially at risk, misclassification, or performing incorrect adjustments can create bias. We provide examples to show that strategies to control for confounders may fail when they are applied to variables that are not confounders. Finally, we outline potential approaches to manage this controversial effect. We conclude that there is probably no single epidemiological explanation for this counterintuitive association.

Uncovering the impact of COVID-19 on the place of death of cancer patients in South America / Descobrindo o impacto da COVID-19 no local de morte de pacientes com câncer na América do Sul / Descubriendo el impacto de la COVID-19 en el local del fallecimiento de pacientes con cáncer en América del Sur

Abstract: The COVID-19 pandemic has significantly impacted healthcare systems worldwide, especially on the management of chronic diseases such as cancer. This study explores the effects of COVID-19 on cancer mortality trends in Brazil, Chile, and Peru. The monthly age-standardized mortality rates in different places of death (hospital/clinic or home) were estimated using vital statistics and death certificate databases. An interrupted time series analysis was performed for each country, using the date of lockdown implementation as the intervention point. Overall cancer mortality rates reduced after the implementation of pandemic restrictions, with a significant decrease in Brazil. In total, 75.3%, 55.4%, and 45.7% of deaths in Brazil, Peru, and Chile, respectively, occurred in hospitals. After lockdowns were implemented, at-home deaths increased in all countries, and in-hospital deaths correspondingly decreased only in Chile. Our results suggest that COVID-19 has significantly affected rates of cancer mortality and place of death in Latin America.

Resumo: A pandemia de COVID-19 impactou significativamente os sistemas de saúde ao redor do mundo, especialmente no manejo de doenças crônicas, como o câncer. Este estudo explora os efeitos da COVID-19 nas tendências de mortalidade por câncer no Brasil, Chile e Peru. As taxas de mortalidade mensais padronizadas por idade em diferentes locais de morte (hospital/clínica ou domicílio) foram estimadas usando estatísticas vitais e bancos de dados de atestados de óbito. Uma análise de série temporal interrompida foi realizada para cada país, tendo como ponto de intervenção a data de implementação do lockdown. As taxas gerais de mortalidade por câncer reduziram após a implementação das restrições, com uma queda significativa no Brasil. No total, 75,3%, 55,4% e 45,7% dos óbitos no Brasil, Peru e Chile, respectivamente, ocorreram em hospitais. Depois da implementação dos lockdowns, as mortes em domicílio aumentaram em todos os países, e as mortes hospitalares diminuíram de forma correspondente apenas no Chile. Nossos resultados sugerem que a COVID-19 afetou significativamente as taxas de mortalidade por câncer e o local de morte na América Latina.

Resumen: La pandemia de COVID-19 impactó significativamente los sistemas de salud de todo el mundo, sobre todo en el manejo de enfermedades crónicas, como el cáncer. Este estudio explora los efectos de la COVID-19 en las tendencias de mortalidad por cáncer en Brasil, Chile y Perú. Las tasas de mortalidad mensuales estandarizadas por edad en diferentes locales de fallecimiento (hospital/clínica o domicilio) se estimaron utilizando estadísticas vitales y base de datos de certificados de defunción. Se realizó un análisis de serie temporal interrumpida para cada país, teniendo como punto de intervención la fecha de implementación del lockdown. Las tasas generales de mortalidad por cáncer redujeron tras la implementación de las restricciones, con una disminución significativa en Brasil. En total, el 75,3% de los óbitos ocurrieron en hospitales en Brasil, el 55,4% en Perú y el 45,7% en Chile. Tras la implementación del lockdown, las muertes domiciliarias aumentaron en todos los países, y las muertes hospitalarias solo redujeron de forma correspondiente en Chile. Nuestros resultados sugieren que la COVID-19 afectó significativamente las tasas de mortalidad por cáncer y el local del fallecimiento en América Latina.

Burden of diseases and injuries attributable to alcohol consumption in the Middle East and North Africa region, 1990-2019.

Alcohol consumption is associated with a number of diseases and injuries, including cardiovascular diseases, cancers, mental and neurological disorders, as well as transport-related injuries. This article reports the alcohol-attributable burden of diseases and injuries at the regional and national levels in the Middle East and North Africa (MENA) region between 1990 and 2019, by sex, age, underlying cause, and Socio-demographic Index (SDI). The regional deaths and disability-adjusted life-years (DALYs) attributable to alcohol consumption were reported for the MENA region, between 1990 and 2019, using the methodological framework and analytical strategies adopted by the Global Burden of Disease (GBD) study 2019. The estimates were all reported as counts, population-attributable fractions, and age-standardised rates per 100,000 population, along with their corresponding 95% uncertainty intervals (UIs). Also, the average annual percentage changes were used to represent the trends of age-standardised rates. In 2019, there were an estimated 22.0 thousand deaths (95% UI: 16.1-29.4) and 1.1 million DALYs (0.8-1.3) attributable to alcohol consumption in the MENA region. The number of DALYs attributable to alcohol consumption were much higher in men (878.0 thousand, 691.4-1104.8) than among women (181.8, 138.6-232.0). The overall age-standardised death and DALY rates attributable to alcohol consumption decreased by 34.5% (13.2-48.3) and 31.9% (16.9-42.5), respectively, over the study period. Egypt (10.1 [5.7-16.6]) and Kuwait (1.1 [0.8-1.5]) had the highest and lowest age-standardised death rates attributable to alcohol consumption, respectively. In 2019, the number of deaths and DALYs in the MENA region were highest in those aged 60-64 and 50-54 years, respectively. A negative association was observed between a country's SDI and their corresponding age-standardised DALY rates over the period 1990 to 2019. Digestive diseases were the main contributor to the alcohol-attributable burden. Over 1990-2019, the regional deaths and DALYs of diseases and injuries attributable to alcohol consumption decreased with AAPC of - 1.45 (- 1.78 to - 1.12) and - 1.31 (- 1.46 to - 1.15), respectively. The death and DALY rates attributable to alcohol consumption in the MENA region have decreased over the past three decades. Further decreases can be facilitated by implementing country-level policies and increasing public awareness.

Global, Regional and National Burden of Cancers Attributable to High Fasting Plasma Glucose in 204 Countries and Territories, 1990-2019.

Background: To report the burden of cancers attributable to high fasting plasma glucose (HFPG) by sex, age, location, cancer type and Socio-demographic Index (SDI) over the period 1990 to 2019 for 204 countries and territories. Methods: Using the Comparative Risk Assessment approach of Global Burden of Disease (GBD) study 2019, the burden of cancers attributable to HFPG was reported in 1990 and 2019. Results: Globally, in 2019 there were an estimated 419.3 thousand cancer deaths (95% UI: 115.7 to 848.5) and 8.6 million cancer DALYs (2.4 to 17.6) attributable to HFPG. By sex, 4.6 (1.1 to 9.9) and 4.0 (1.1 to 8.4) million global cancer DALYs were attributable to HFPG in men and women, respectively. The global age-standardized death and DALY rates of cancers attributable to HFPG (per 100,000) have increased by 27.8% (20.5 to 38.7%) and 24.5% (16.4 to 35.6%), respectively, since 1990. High-income North America (9.5 [2.7 to 18.8]) and Eastern Sub-Saharan Africa (2.0 [0.5 to 4.2]) had the highest and lowest regional age-standardized death rates, respectively, for cancers attributable to HFPG. In 2019, the global number of attributable cancer DALYs were highest in 65-69 age group. Moreover, there was an overall positive association between SDI and the regional age-standardized DALY rate for HFPG-attributable cancers. Conclusions: HFPG was associated with more burden in 2019. Preventive programs for diabetes and screening of individuals with diabetes for cancers, especially in older males living in developed countries, are required to arrest the large increases in HFPG-attributable cancers.

Burden of chronic obstructive pulmonary disease and its attributable risk factors in 204 countries and territories, 1990-2019: results from the Global Burden of Disease Study 2019.

OBJECTIVE: To report the global, regional, and national burden of chronic obstructive pulmonary disease (COPD) and its attributable risk factors between 1990 and 2019, by age, sex, and sociodemographic index. DESIGN: Systematic analysis. DATA SOURCE: Global Burden of Disease Study 2019. MAIN OUTCOME MEASURES: Data on the prevalence, deaths, and disability adjusted life years (DALYs) of COPD, and its attributable risk factors, were retrieved from the Global Burden of Disease 2019 project for 204 countries and territories, between 1990 and 2019. The counts and rates per 100 000 population, along with 95% uncertainty intervals, were presented for each estimate. RESULTS: In 2019, 212.3 million prevalent cases of COPD were reported globally, with COPD accounting for 3.3 million deaths and 74.4 million DALYs. The global age standardised point prevalence, death, and DALY rates for COPD were 2638.2 (95% uncertainty intervals 2492.2 to 2796.1), 42.5 (37.6 to 46.3), and 926.1 (848.8 to 997.7) per 100 000 population, which were 8.7%, 41.7%, and 39.8% lower than in 1990, respectively. In 2019, Denmark (4299.5), Myanmar (3963.7), and Belgium (3927.7) had the highest age standardised point prevalence of COPD. Egypt (62.0%), Georgia (54.9%), and Nicaragua (51.6%) showed the largest increases in age standardised point prevalence across the study period. In 2019, Nepal (182.5) and Japan (7.4) had the highest and lowest age standardised death rates per 100 000, respectively, and Nepal (3318.4) and Barbados (177.7) had the highest and lowest age standardised DALY rates per 100 000, respectively. In men, the global DALY rate of COPD increased up to age 85-89 years and then decreased with advancing age, whereas for women the rate increased up to the oldest age group (≥95 years). Regionally, an overall reversed V shaped association was found between sociodemographic index and the age standardised DALY rate of COPD. Factors contributing most to the DALYs rates for COPD were smoking (46.0%), pollution from ambient particulate matter (20.7%), and occupational exposure to particulate matter, gases, and fumes (15.6%). CONCLUSIONS: Despite the decreasing burden of COPD, this disease remains a major public health problem, especially in countries with a low sociodemographic index. Preventive programmes should focus on smoking cessation, improving air quality, and reducing occupational exposures to further reduce the burden of COPD.

Global, regional, and national burden of cancers attributable to tobacco smoking in 204 countries and territories, 1990-2019.

BACKGROUND: Cancers are leading causes of mortality and morbidity, with smoking being recognized as a significant risk factor for many types of cancer. We aimed to report the cancer burden attributable to tobacco smoking by sex, age, socio-demographic index (SDI), and cancer type in 204 countries and territories from 1990 to 2019. METHODS: The burden of cancers attributable to smoking was reported between 1990 and 2019, based upon the Comparative Risk Assessment approach used in the Global Burden of Disease (GBD) study 2019. RESULTS: Globally, in 2019 there were an estimated 2.5 million cancer-related deaths (95% UI: 2.3 to 2.7) and 56.4 million DALYs (51.3 to 61.7) attributable to smoking. The global age-standardized death and DALY rates of cancers attributable to smoking per 100,000 decreased by 23.0% (-29.5 to -15.8) and 28.6% (-35.1 to -21.5), respectively, over the period 1990-2019. Central Europe (50.4 [44.4 to 57.6]) and Western Sub-Saharan Africa (6.7 [5.7 to 8.0]) had the highest and lowest age-standardized death rates, respectively, for cancers attributable to smoking. In 2019, the age-standardized DALY rate of cancers attributable to smoking was highest in Greenland (2224.0 [1804.5 to 2678.8]) and lowest in Ethiopia (72.2 [51.2 to 98.0]). Also in 2019, the global number of DALYs was highest in the 65-69 age group and there was a positive association between SDI and the age-standardized DALY rate. CONCLUSIONS: The results of this study clearly illustrate that renewed efforts are required to increase utilization of evidence-based smoking cessation support in order to reduce the burden of smoking-related diseases.

Global, regional, and national cancer deaths and disability-adjusted life-years (DALYs) attributable to alcohol consumption in 204 countries and territories, 1990-2019.

BACKGROUND: Alcohol consumption is a risk factor for a number of communicable and non-communicable diseases, including several types of cancer. This article reports the burden of cancers attributable to alcohol consumption by age, sex, location, sociodemographic index (SDI), and cancer type from 1990 to 2019. METHODS: The Comparative Risk Assessment approach was used in the 2019 Global Burden of Disease study to report the burden of cancers attributable to alcohol consumption between 1990 and 2019. RESULTS: In 2019, there were globally an estimated 494.7 thousand cancer deaths (95% uncertainty interval [UI], 439.7 to 554.1) and 13.0 million cancer disability-adjusted life-years (DALYs; 95% UI, 11.6 to 14.5) that were attributable to alcohol consumption. The alcohol-attributable DALYs were much higher in men (10.5 million; 95% UI, 9.2 to 11.8) than women (2.5 million; 95% UI, 2.2 to 2.9). The global age-standardized death and DALY rates of cancers attributable to alcohol decreased by 14.7% (95% UI, 6.4% to 23%) and 18.1% (95% UI, 9.2% to 26.5%), respectively, over the study period. Central Europe had the highest age-standardized death rates that were attributable to alcohol consumption(10.3; 95% UI, 8.7 to12.0). Moreover, there was an overall positive association between SDI and the regional age-standardized DALY rate for alcohol-attributable cancers. CONCLUSIONS: Despite decreases in age-standardized deaths and DALYs, substantial numbers of cancer deaths and DALYs are still attributable to alcohol consumption. Because there is a higher burden in males, the elderly, and developed regions (based on SDI), these groups and regions should be prioritized in any prevention programs.

Prevalence, Deaths and Disability-Adjusted-Life-Years (DALYs) Due to Type 2 Diabetes and Its Attributable Risk Factors in 204 Countries and Territories, 1990-2019: Results From the Global Burden of Disease Study 2019.

Aim: To report the point prevalence, deaths and disability-adjusted-life-years (DALYs) due to type 2 diabetes and its attributable risk factors in 204 countries and territories during the period 1990-2019. Methods: We used the data of the Global Burden of Disease (GBD) Study 2019 to report number and age-standardised rates per 100 000 population of type 2 diabetes. Estimates were reported with 95% uncertainty intervals (UIs). Results: In 2019, the global age-standardised point prevalence and death rates for type 2 diabetes were 5282.9 and 18.5 per 100 000, an increase of 49% and 10.8%, respectively, since 1990. Moreover, the global age-standardised DALY rate in 2019 was 801.5 per 100 000, an increase of 27.6% since 1990. In 2019, the global point prevalence of type 2 diabetes was slightly higher in males and increased with age up to the 75-79 age group, decreasing across the remaining age groups. American Samoa [19876.8] had the highest age-standardised point prevalence rates of type 2 diabetes in 2019. Generally, the burden of type 2 diabetes decreased with increasing SDI (Socio-demographic Index). Globally, high body mass index [51.9%], ambient particulate matter pollution [13.6%] and smoking [9.9%] had the three highest proportions of attributable DALYs. Conclusion: Low and middle-income countries have the highest burden and greater investment in type 2 diabetes prevention is needed. In addition, accurate data on type 2 diabetes needs to be collected by the health systems of all countries to allow better monitoring and evaluation of population-level interventions.

Global, regional, and national burden of cancers attributable to excess body weight in 204 countries and territories, 1990 to 2019.

OBJECTIVE: The aim of this study was to report the level and trends of 13 cancers that are attributable to excess body weight (EBW) for 204 countries and territories from 1990 to 2019. METHODS: Using publicly available data, the burden of cancers attributable to EBW was reported from 1990 to 2019 based on the comparative risk assessment approach used in the Global Burden of Disease study 2019. [Correction added on 27 January 2022, after first online publication: 'Using publicly available data,' has been added before the first sentence and 'estimated' was corrected to 'reported'.] RESULTS: In 2019, EBW caused 11.2 million disability-adjusted life-years (DALYs), or 4.4% of all cancer-related DALYs. Between 1990 and 2019, the global EBW-attributable age-standardized cancer DALY rates (per 100,000) increased from 109.9 to 133.9, a relative increase of 21.9%. The age-standardized DALY rates (per 100,000) of cancers attributable to EBW in 2019 were highest and lowest in Mongolia (611.8) and Bangladesh (30.2), respectively. The 60- to 64-year age group had the highest number of DALYs attributable to EBW, whereas there were no large sex differences in the cancer-related burden attributable to EBW. Furthermore, the association between the age-standardized DALY rates and the sociodemographic index was generally positive. CONCLUSIONS: Overall, the EBW-attributable burden of cancers has increased in the past three decades. Public health efforts should focus on identifying appropriate preventive interventions at the population and individual levels, especially in the regions and countries with the highest burden.

Does weight mediate the effect of smoking on coronary heart disease? Parametric mediational g-formula analysis.

BACKGROUND: In settings in which there are time-varying confounders affected by previous exposure and a time-varying mediator, natural direct and indirect effects cannot generally be estimated unbiasedly. In the present study, we estimate interventional direct effect and interventional indirect effect of cigarette smoking as a time-varying exposure on coronary heart disease while considering body weight as a time-varying mediator. METHODS: To address this problem, the parametric mediational g-formula was proposed to estimate interventional direct effect and interventional indirect effect. We used data from the Multi-Ethnic Study of Atherosclerosis to estimate effect of cigarette smoking on coronary heart disease, considering body weight as time-varying mediator. RESULTS: Over a 11-years period, smoking 20 cigarettes per day compared to no smoking directly (not through weight) increased risk of coronary heart disease by an absolute difference of 1.91% (95% CI: 0.49%, 4.14%), and indirectly decreased coronary heart disease risk by -0.02% (95% CI: -0.05%, 0.04%) via change in weight. The total effect was estimated as an absolute 1.89% increase (95% CI: 0.49%, 4.13%). CONCLUSION: The overall absolute impact of smoking to incident coronary heart disease is modest, and we did not discern any important contribution to this effect relayed through changes to bodyweight. In fact, changes in weight because of smoking have no meaningful mediating effect on CHD risk.

Burden of ischemic heart disease and its attributable risk factors in 204 countries and territories, 1990-2019.

AIMS: To report the prevalence, deaths, and disability-adjusted life years (DALYs) associated with ischemic heart disease (IHD) and its attributable risk factors in 204 countries and territories from 1990 to 2019, by age, sex, and socio-demographic index (SDI). METHODS AND RESULTS: Ischemic heart disease was defined as acute myocardial infarction (MI) and chronic IHD (angina; asymptomatic IHD following MI). Cause of death ensemble modelling was used to produce fatality estimates. The prevalence of the non-fatal sequalae of IHD was estimated using DisMod MR 2.1. All estimates were presented as counts and age-standardized rates per 100 000 population. In 2019, IHD accounted for 197.2 million (177.7-219.5) prevalent cases, 9.1 million (8.4-9.7) deaths, and 182.0 million (170.2-193.5) DALYs worldwide. There were decreases in the global age-standardized prevalence rates of IHD [-4.6% (-5.7, -3.6)], deaths [-30.8% (-34.8, -27.2)], and DALYs [-28.6% (-33.3, -24.2)] from 1990 to 2019. In 2019, the global prevalence and death rates of IHD were higher among males across all age groups, while the death rate peaked in the oldest group for both sexes. A negative association was found between the age-standardized DALY rates and SDI. Globally, high systolic blood pressure (54.6%), high low-density lipoprotein cholesterol (46.6%), and smoking (23.9%) were the three largest contributors to the DALYs attributable to IHD. CONCLUSION: Although the global age-standardized prevalence, death, and DALY rates all decreased. Prevention and control programmes should be implemented to reduce population exposure to risk factors, reduce the risk of IHD in high-risk populations, and provide appropriate care for communities.

Prevalence, Deaths, and Disability-Adjusted Life-Years Due to Asthma and Its Attributable Risk Factors in 204 Countries and Territories, 1990-2019.

BACKGROUND: Understanding global trends in the point prevalence, deaths, and disability-adjusted life-years (DALYs) for asthma will facilitate evidence-based decision-making. RESEARCH QUESTION: What are the global, regional, and national burdens of asthma in 204 countries and territories between 1990 and 2019 by age, sex, and sociodemographic index (SDI)? STUDY DESIGN AND METHODS: Publicly available data from the Global Burden of Disease study from 1990 through 2019 were used. All estimates were presented as counts and age-standardized rates per 100,000, along with their associated uncertainty intervals. RESULTS: In 2019, the global age-standardized point prevalence and death rates for asthma were 3,415.5 and 5.8 per 100,000, which represent a 24% and 51.3% decrease since 1990, respectively. Moreover, in 2019, the global age-standardized DALY rate was 273.6 and the global point prevalence of asthma was highest in the group 5 to 9 years of age. Also in 2019, the United States (10,399.3) showed the highest age-standardized point prevalence rate of asthma. Generally, the burden of asthma decreased with increasing SDI. Globally, high BMI (16.9%), smoking (9.9%), and occupational asthmagens (8.8%) contributed to the 2019 asthma DALYs. INTERPRETATION: Asthma remains an important public health issue, particularly in regions with low socioeconomic development. Future research is needed to examine thoroughly the associations asthma has with its risk factors and the factors impeding optimal self-management. Further research also is needed to understand and implement better the interventions that have reduced the burden of asthma.

Evaluating the Impact and Rationale of Race-Specific Estimations of Kidney Function: Estimations from U.S. NHANES, 2015-2018.

BACKGROUND: Standard equations for estimating glomerular filtration rate (eGFR) employ race multipliers, systematically inflating eGFR for Black patients. Such inflation is clinically significant because eGFR thresholds of 60, 30, and 20 ml/min/1.73m2 guide kidney disease management. Racialized adjustment of eGFR in Black Americans may thereby affect their clinical care. In this study, we analyze and extrapolate national data to assess potential impacts of the eGFR race adjustment on qualification for kidney disease diagnosis, nephrologist referral, and transplantation listing. METHODS: Using population-representative cross-sectional data from the United States National Health and Nutrition Examination Survey (NHANES) from 2015-2018, eGFR values for Black Americans were calculated using the Modification of Diet in Renal Disease (MDRD) equation with and without the 1.21 race-specific coefficient using cohort data on age, sex, race, and serum creatinine. FINDINGS: Without the MDRD eGFR race adjustment, 3.3 million (10.4%) more Black Americans would reach a diagnostic threshold for Stage 3 Chronic Kidney Disease, 300,000 (0.7%) more would qualify for beneficial nephrologist referral, and 31,000 (0.1%) more would become eligible for transplant evaluation and waitlist inclusion. INTERPRETATION: These findings suggest eGFR race coefficients may contribute to racial differences in the management of kidney. We provide recommendations for addressing this issue at institutional and individual levels. FUNDING: No external funding was received for this study.

Burden of anemia and its underlying causes in 204 countries and territories, 1990-2019: results from the Global Burden of Disease Study 2019.

BACKGROUND: Anemia is a common disease which affects around 40% of children and 30% of reproductive age women and can have major health consequences. The present study reports the global, regional and national burden of anemia and its underlying causes between 1990 and 2019, by age, sex and socio-demographic index (SDI). METHODS: Publicly available data on the point prevalence and years lived with disability (YLDs) were retrieved from the global burden of disease (GBD) 2019 study for 204 countries and territories between 1990 and 2019. The point prevalence, YLD counts and rates per 100,000 population were presented, along with their corresponding 95% uncertainty intervals. RESULTS: In 2019, the global age-standardized point prevalence and YLD rates for anemia were 23,176.2 (22,943.5-23,418.6) and 672.4 (447.2-981.5) per 100,000 population, respectively. Moreover, the global age-standardized point prevalence and YLD rate decreased by 13.4% (12.1-14.5%) and 18.8% (16.9-20.8%), respectively, over the period 1990-2019. The highest national point prevalences of anemia were found in Zambia [49327.1 (95% UI: 46,838.5-51,700.1)], Mali [46890.1 (95% UI: 44,301.1-49,389.8)], and Burkina Faso [46117.2 (95% UI: 43,640.7-48,319.2)]. In 2019, the global point prevalence of anemia was highest in the 15-19 and 95+ age groups in females and males, respectively. Also, the burden of anemia was lower in regions with higher socio-economic development. Globally, most of the prevalent cases were attributable to dietary iron deficiency, as well as hemoglobinopathies and hemolytic anemias. CONCLUSIONS: Anemia remains a major health problem, especially among females in less developed countries. The implementation of preventive programs with a focus on improving access to iron supplements, early diagnosis and the treatment of hemoglobinopathies should be taken into consideration.

Changes in exposure to ambient fine particulate matter after relocating and long term survival in Canada: quasi-experimental study.

OBJECTIVE: To investigate the association between changes in long term residential exposure to ambient fine particulate matter (PM2.5) and premature mortality in Canada. DESIGN: Population based quasi-experimental study. SETTING: Canada. PARTICIPANTS: 663 100 respondents to the 1996, 2001, and 2006 Canadian censuses aged 25-89 years who had consistently lived in areas with either high or low PM2.5 levels over five years preceding census day and moved during the ensuing five years. INTERVENTIONS: Changes in long term exposure to PM2.5 arising from residential mobility. MAIN OUTCOME MEASURES: The primary outcome was deaths from natural causes. Secondary outcomes were deaths from any cardiometabolic cause, any respiratory cause, and any cancer cause. All outcomes were obtained from the national vital statistics database. RESULTS: Using a propensity score matching technique with numerous personal, socioeconomic, health, and environment related covariates, each participant who moved to a different PM2.5 area was matched with up to three participants who moved within the same PM2.5 area. In the matched groups that moved from high to intermediate or low PM2.5 areas, residential mobility was associated with a decline in annual PM2.5 exposure from 10.6 µg/m3 to 7.4 and 5.0 µg/m3, respectively. Conversely, in the matched groups that moved from low to intermediate or high PM2.5 areas, annual PM2.5 increased from 4.6 µg/m3 to 6.7 and 9.2 µg/m3. Five years after moving, individuals who experienced a reduction in exposure to PM2.5 from high to intermediate levels showed a 6.8% (95% confidence interval 1.7% to 11.7%) reduction in mortality (2510 deaths in 56 025 v 4925 deaths in 101 960). A greater decline in mortality occurred among those exposed to a larger reduction in PM2.5. Increased mortality was found with exposure to PM2.5 from low to high levels, and to a lesser degree from low to intermediate levels. Furthermore, the decreases in PM2.5 exposure were most strongly associated with reductions in cardiometabolic deaths, whereas the increases in PM2.5 exposure were mostly related to respiratory deaths. No strong evidence was found for the changes in PM2.5 exposure with cancer related deaths. CONCLUSIONS: In Canada, decreases in PM2.5 were associated with lower mortality, whereas increases in PM2.5 were associated with higher mortality. These results were observed at PM2.5 levels considerably lower than many other countries, providing support for continuously improving air quality.