Smoking, all-cause, and cause-specific mortality in individuals with diabetes in Mexico: an analysis of the Mexico city prospective study.

OBJECTIVE: Evidence from low- and middle-income countries regarding the effect of smoking in people with diabetes is lacking. Here, we report the association of smoking with mortality in a large cohort of Mexican adults with diabetes. METHODS: Participants with diabetes mellitus (self-reported diagnosis, use of antidiabetic medications or HbA1c ≥ 6.5%) aged 35-74 years when recruited into the Mexico City Prospective Study were included. Cox regression confounder-adjusted mortality rate ratios (RRs) associated with baseline smoking status were estimated. RESULTS: Among 15,975 women and 8225 men aged 35-74 years with diabetes but no other comorbidities at recruitment, 2498 (16%) women and 2875 (35%) men reported former smoking and 2753 (17%) women, and 3796 (46%) men reported current smoking. During a median of 17 years of follow-up there were 5087 deaths at ages 35-74 years. Compared with never smoking, all-cause mortality RR was 1.08 (95%CI 1.01-1.17) for former smoking, 1.11 (95%CI 1.03-1.20) for current smoking, 1.09 (95%CI 0.99-1.20) for non-daily smoking, 1.06 (95%CI 0.96-1.16) for smoking < 10 cigarettes/day (median during follow-up 4 cigarettes/day), and 1.28 (95% CI 1.14-1.43) for smoking ≥ 10 cigarettes/day (median during follow-up 15 cigarettes/day). Mortality risk among daily smokers was greatest for COPD, lung cancer, cardiovascular diseases, and acute diabetic complications. CONCLUSION: In this cohort of Mexican adults with diabetes, low-intensity daily smoking was associated with increased mortality, despite observing smoking patterns which are different from other populations, and over 5% of total deaths were associated with smoking.

Prediabetes as a risk factor for all-cause and cause-specific mortality: a prospective analysis of 115,919 adults without diabetes in Mexico City.

BACKGROUND: Prediabetes has been associated with increased all-cause and cardiovascular mortality. However, no large-scale studies have been conducted in Mexico or Latin America examining these associations. METHODS: We analyzed data from 115,919 adults without diabetes (diagnosed or undiagnosed) aged 35-84 years who participated in the Mexico City Prospective Study between 1998 and 2004. Participants were followed until January 1st, 2021 for cause-specific mortality. We defined prediabetes according to the American Diabetes Association (ADA, HbA1c 5.7% to 6.4%) and the International Expert Committee (IEC, HbA1c 6.0-6.4%) definitions. Cox regression adjusted for confounders was used to estimate all-cause and cause-specific mortality rate ratios (RR) at ages 35-74 years associated with prediabetes. FINDINGS: During 2,085,392 person-years of follow-up (median in survivors 19 years), there were 6,810 deaths at ages 35-74, including 1,742 from cardiovascular disease, 892 from renal disease and 108 from acute diabetic crises. Of 110,405 participants aged 35-74 years at recruitment, 28,852 (26%) had ADA-defined prediabetes and 7,203 (7%) had IEC-defined prediabetes. Compared with those without prediabetes, individuals with prediabetes had higher risk of all-cause mortality at ages 35-74 years (RR 1.13, 95% CI 1.07-1.19 for ADA-defined prediabetes and RR 1.28, 1.18-1.39 for IEC-defined prediabetes), as well as increased risk of cardiovascular mortality (RR 1.22 [1.10-1.35] and 1.42 [1.22-1.65], respectively), renal mortality (RR 1.35 [1.08-1.68] and 1.69 [1.24-2.31], respectively), and death from an acute diabetic crisis (RR 2.63 [1.76-3.94] and 3.43 [2.09-5.62], respectively). RRs were larger at younger than at older ages, and similar for men compared to women. The absolute excess risk associated with ADA and IEC-defined prediabetes at ages 35-74 accounted for6% and 3% of cardiovascular deaths respectively, 10% and 5% of renal deaths respectively, and 31% and 14% of acute diabetic deaths respectively. INTERPRETATION: Prediabetes is a significant risk factor for all-cause, cardiovascular, renal, and acute diabetic deaths in Mexican adults. Identification and timely management of individuals with prediabetes for targeted risk reduction could contribute to reducing premature mortality from cardiometabolic causes in this population. FUNDING: Wellcome Trust, the Mexican Health Ministry, the National Council of Science and Technology for Mexico, Cancer Research UK, British Heart Foundation, UK Medical Research Council. Instituto Nacional de Geriatría (Mexico City).

Characterising the contribution of rare protein-coding germline variants to prostate cancer risk and severity in 37,184 cases.

The etiology of prostate cancer, the second most common cancer in men globally, has a strong heritable component. While rare coding germline variants in several genes have been identified as risk factors from candidate gene and linkage studies, the exome-wide spectrum of causal rare variants remains to be fully explored. To more comprehensively address their contribution, we analysed data from 37,184 prostate cancer cases and 331,329 male controls from five cohorts with germline exome/genome sequencing and one cohort with imputed array data from a population enriched in low-frequency deleterious variants. Our gene-level collapsing analysis revealed that rare damaging variants in SAMHD1 as well as genes in the DNA damage response pathway (BRCA2, ATM and CHEK2) are associated with the risk of overall prostate cancer. We also found that rare damaging variants in AOX1 and BRCA2 were associated with increased severity of prostate cancer in a case-only analysis of aggressive versus non-aggressive prostate cancer. At the single-variant level, we found rare non-synonymous variants in three genes (HOXB13, CHEK2, BIK) significantly associated with increased risk of overall prostate cancer and in four genes (ANO7, SPDL1, AR, TERT) with decreased risk. Altogether, this study provides deeper insights into the genetic architecture and biological basis of prostate cancer risk and severity.

Educational and social inequalities and cause-specific mortality in Mexico City: a prospective study.

BACKGROUND: Social inequalities in adult mortality have been reported across diverse populations, but there is no large-scale prospective evidence from Mexico. We aimed to quantify social, including educational, inequalities in mortality among adults in Mexico City. METHODS: The Mexico City Prospective Study recruited 150 000 adults aged 35 years and older from two districts of Mexico City between 1998 and 2004. Participants were followed up until Jan 1, 2021 for cause-specific mortality. Cox regression analysis yielded rate ratios (RRs) for death at ages 35-74 years associated with education and examined, in exploratory analyses, the mediating effects of lifestyle and related risk factors. FINDINGS: Among 143 478 participants aged 35-74 years, there was a strong inverse association of education with premature death. Compared with participants with tertiary education, after adjustment for age and sex, those with no education had about twice the mortality rate (RR 1·84; 95% CI 1·71-1·98), equivalent to approximately 6 years lower life expectancy, with an RR of 1·78 (1·67-1·90) among participants with incomplete primary, 1·62 (1·53-1·72) with complete primary, and 1·34 (1·25-1·42) with secondary education. Education was most strongly associated with death from renal disease and acute diabetic crises (RR 3·65; 95% CI 3·05-4·38 for no education vs tertiary education) and from infectious diseases (2·67; 2·00-3·56), but there was an apparent higher rate of death from all specific causes studied with lower education, with the exception of cancer for which there was little association. Lifestyle factors (ie, smoking, alcohol drinking, and leisure time physical activity) and related physiological correlates (ie, adiposity, diabetes, and blood pressure) accounted for about four-fifths of the association of education with premature mortality. INTERPRETATION: In this Mexican population there were marked educational inequalities in premature adult mortality, which appeared to largely be accounted for by lifestyle and related risk factors. Effective interventions to reduce these risk factors could reduce inequalities and have a major impact on premature mortality. FUNDING: Wellcome Trust, the Mexican Health Ministry, the National Council of Science and Technology for Mexico, Cancer Research UK, British Heart Foundation, and the UK Medical Research Council Population Health Research Unit.

Multiancestry exome sequencing reveals INHBE mutations associated with favorable fat distribution and protection from diabetes.

Body fat distribution is a major, heritable risk factor for cardiometabolic disease, independent of overall adiposity. Using exome-sequencing in 618,375 individuals (including 160,058 non-Europeans) from the UK, Sweden and Mexico, we identify 16 genes associated with fat distribution at exome-wide significance. We show 6-fold larger effect for fat-distribution associated rare coding variants compared with fine-mapped common alleles, enrichment for genes expressed in adipose tissue and causal genes for partial lipodystrophies, and evidence of sex-dimorphism. We describe an association with favorable fat distribution (p = 1.8 × 10-09), favorable metabolic profile and protection from type 2 diabetes (~28% lower odds; p = 0.004) for heterozygous protein-truncating mutations in INHBE, which encodes a circulating growth factor of the activin family, highly and specifically expressed in hepatocytes. Our results suggest that inhibin ßE is a liver-expressed negative regulator of adipose storage whose blockade may be beneficial in fat distribution-associated metabolic disease.

Low-intensity daily smoking and cause-specific mortality in Mexico: prospective study of 150 000 adults.

BACKGROUND: Research is needed to determine the relevance of low-intensity daily smoking to mortality in countries such as Mexico, where such smoking habits are common. METHODS: Prospective study of 159 755 Mexican adults recruited from 1998-2004 and followed for cause-specific mortality to 1 January 2018. Participants were categorized according to baseline self-reported smoking status. Confounder-adjusted mortality rate ratios (RRs) at ages 35-89 were estimated using Cox regression, after excluding those with previous chronic disease (to avoid reverse causality). RESULTS: Among 42 416 men and 86 735 women aged 35-89 and without previous disease, 18 985 men (45%) and 18 072 women (21%) reported current smoking and 8866 men (21%) and 53 912 women (62%) reported never smoking. Smoking less than daily was common: 33% of male current smokers and 39% of female current smokers. During follow-up, the all-cause mortality RRs associated with the baseline smoking categories of <10 cigarettes per day (average during follow-up 4 per day) or ≥10 cigarettes per day (average during follow-up 10 per day), compared with never smoking, were 1.17 (95% confidence interval 1.10-1.25) and 1.54 (1.42-1.67), respectively. RRs were similar irrespective of age or sex. The diseases most strongly associated with daily smoking were respiratory cancers, chronic obstructive pulmonary disease and gastrointestinal and vascular diseases. Ex-daily smokers had substantially lower mortality rates than those who were current daily smokers at recruitment. CONCLUSIONS: In this Mexican population, low-intensity daily smoking was associated with increased mortality. Of those smoking 10 cigarettes per day on average, about one-third were killed by their habit. Quitting substantially reduced these risks.

Association of Blood Pressure With Cause-Specific Mortality in Mexican Adults.

Importance: Elevated blood pressure is a major cause of premature death, but there is little direct evidence demonstrating this association in studies of Hispanic populations. Objective: To assess the association between blood pressure and cause-specific mortality in a large cohort of Mexican adults with a high prevalence of uncontrolled diabetes. Design, Setting, and Participants: A total of 159 755 adults aged 35 years or older from 2 districts in Mexico City were recruited to this cohort study between April 1998 and September 2004 and followed up until January 2018. The present analyses focused on 133 613 participants who were aged 35 to 74 years and had no history of chronic disease besides diabetes. Exposure: Blood pressure. Main Outcomes and Measures: Cox regression, adjusted for confounders, yielded mortality rate ratios (RRs) for deaths of participants occurring between ages 35 and 74 years. Results: Of the 133 613 participants (43 263 [32.4%] men; mean [SD] age, 50 [11] years), 16 911 (12.7%) had self-reported previously diagnosed diabetes (including 8435 [6.3%] with uncontrolled diabetes, defined as hemoglobin A1c ≥9%) and 6548 (4.9%) had undiagnosed diabetes. Systolic blood pressure (SBP) was associated with vascular mortality between ages 35 to 74 years, with each 20 mm Hg lower usual SBP associated with 35% lower vascular mortality (RR, 0.65; 95% CI, 0.61-0.68), including 48% lower stroke mortality (RR, 0.52; 95% CI, 0.47-0.59) and 32% lower ischemic heart disease mortality (RR, 0.68; 95% CI, 0.63-0.74). These RRs were broadly similar in those with and without diabetes. Compared with those without diabetes and SBP less than 135 mm Hg at recruitment, the vascular mortality RR was 2.8 (95% CI, 2.4-3.3) for those without diabetes and SBP of 155 mm Hg or greater, 4.7 (95% CI, 4.1-5.4) for those with uncontrolled diabetes and SBP less than 135 mm Hg, and 8.9 (95% CI, 7.2-11.1) for those with uncontrolled diabetes and SBP of 155 mm Hg or greater. Lower SBP was also associated with decreased kidney-related mortality (RR per 20 mm Hg lower usual SBP, 0.69; 95% CI, 0.64-0.74), decreased mortality from infection (RR, 0.81; 95% CI, 0.71-0.91), and decreased mortality from hepatobiliary disease (RR, 0.87; 95% CI, 0.78-0.98), but not decreased neoplastic or respiratory mortality. SBP was more informative for vascular mortality than other blood pressure measures (eg, compared with SBP, diastolic blood pressure was only two-thirds as informative). Conclusions and Relevance: Blood pressure was most strongly associated with vascular and kidney-related mortality in this Mexican population, with particularly high absolute excess mortality rates among individuals with diabetes. The findings reinforce the need for more widespread use of blood pressure-lowering medication in Mexico, particularly among those with diabetes.

Panorama nacional del embarazo precoz en México: lecciones aprendidas en un sexenio / National panorama of adolescent pregnancy in Mexico: lessons learned in a six-year period

Resumen En el mundo, el embarazo adolescente constituye un grave problema de salud pública de índole multifactorial. Específicamente para la mujer conlleva diversas implicaciones educativas, económicas y sociales que afectan su proyecto de vida y amplían las brechas sociales en este grupo etario. Asimismo, las adolescentes son más vulnerables por el riesgo en salud que implica un embarazo a corta edad; según la Organización Mundial de la Salud, “la probabilidad de muerte materna es dos veces más en las adolescentes respecto a las mujeres que se encuentran entre los 20 y 30 años de edad, y para las menores de 15 años los riesgos son cinco veces mayores”. En general, las y los adolescentes experimentan una gran necesidad de educación en temas sobre salud sexual y reproductiva, la cual debe dirigirse al aumento de información y conocimientos sobre el uso correcto y acceso a métodos anticonceptivos modernos, así como a desmitificar los temores y creencias en torno a sus posibles efectos secundarios. Asegurar una consejería adecuada y con personal capacitado es igualmente vital. Las instituciones públicas tienen la responsabilidad social de respaldar los esfuerzos encaminados a prevenir el embarazo adolescente, con base en las líneas de acción y políticas sanitarias.

Abstract Globally, adolescent pregnancy constitutes a serious public health problem of a multifactorial nature. Specifically for women, it entails various educational, economic and social implications that affect their life project and widen the social gaps in this age group. Furthermore, adolescent girls are more vulnerable because of the health risk involved with pregnancy at a younger age. According to the World Health Organization, “the probability of maternal death is twice as high in adolescents in comparison with women aged between 20 and 30 years, and for those younger than 15 years, the risks are 5 times higher.” In general, adolescents are in great need for education on sexual and reproductive health issues, which should be aimed at increasing information and knowledge about correct use and access to modern contraceptive methods, as well as at demystifying fears and beliefs around their possible side effects. Ensuring proper counseling with trained personnel is equally vital. Public institutions have a social responsibility to support efforts aimed at preventing adolescent pregnancy, based on relevant lines of action and health policies.

Clinical-epidemiological profile of deaths from influenza with a history of timely vaccination, Mexico 2010-2018

Introduction: Influenza epidemics are of higher risk at the extremes of life and in people with comorbidities. Effective vaccination prevents the occurrence of serious cases and decreases mortality. Objective: To describe deaths from influenza with a history of timely vaccination, from the 2010 to the 2018 season in Mexico. Method: Cross-sectional, descriptive study where the Influenza Epidemiological Surveillance System database was used. Results: From 2010 to 2018, 65 vaccinated individuals died from influenza, from which 55% of cases (n = 36) were due to type A (H1N1), 51% (n = 33) were females, median age was 57 years, 21 % (n = 14) did not meet the operational definition of influenza-like illness or severe acute respiratory infection, 83% (n = 54) had at least one comorbidity, with the most common being diabetes mellitus and hypertension (32% each); 55% (n = 36) of deaths received antiviral treatment and only 8% (n = 5) had no comorbidities and received treatment with oseltamivir. Conclusions: Deaths from influenza with timely vaccination represent a very low percentage of the totality. Vaccination against influenza has been a specific prevention strategy that decreases disease burden.

General and Abdominal Adiposity and Mortality in Mexico City: A Prospective Study of 150 000 Adults.

Background: Some reports suggest that body mass index (BMI) is not strongly associated with mortality in Hispanic populations. Objective: To assess the causal relevance of adiposity to mortality in Mexican adults, avoiding reverse causality biases. Design: Prospective study. Setting: 2 Mexico City districts. Participants: 159 755 adults aged 35 years and older at recruitment, followed for up to 14 years. Participants with a hemoglobin A1c level of 7% or greater, diabetes, or other chronic diseases were excluded. Measurements: BMI, waist-to-hip ratio, waist circumference, and cause-specific mortality. Cox regression, adjusted for confounders, yielded mortality hazard ratios (HRs) after at least 5 years of follow-up and before age 75 years. Results: Among 115 400 participants aged 35 to <75 years at recruitment, mean BMI was 28.0 kg/m2 (SD, 4.1 kg/m2) in men and 29.6 kg/m2 (SD, 5.1 kg/m2) in women. The association of BMI at recruitment with all-cause mortality was J-shaped, with the minimum at 25 to <27.5 kg/m2. Above 25 kg/m2, each 5-kg/m2 increase in BMI was associated with a 30% increase in all-cause mortality (HR, 1.30 [95% CI, 1.24 to 1.36]). This association was stronger at ages 40 to <60 years (HR, 1.40 [CI, 1.30 to 1.49]) than at ages 60 to <75 years (HR, 1.24 [CI, 1.17 to 1.31]) but was not materially affected by sex, smoking, or other confounders. The associations of mortality with BMI and waist-to-hip ratio were similarly strong, and each was weakened only slightly by adjustment for the other. Waist circumference was strongly related to mortality and remained so even after adjustment for BMI and hip circumference. Limitation: Analyses were limited to mortality. Conclusion: General, and particularly abdominal, adiposity were strongly associated with mortality in this Mexican population. Primary Funding Source: Mexican Health Ministry, Mexican National Council of Science and Technology, Wellcome Trust, Medical Research Council, and Kidney Research UK.

Use of HPV testing in cervical cancer screening services in Mexico, 2008-2018: a nationwide database study / Uso de la prueba de VPH para la detección de cáncer cervical en México, 2008-2018: estudio de una base de datos nacional

Abstract: Objective: To describe the methods of a study aimed at evaluating high risk-HPV (hrHPV)-based screening and cervical cytology as triage compared to conventional cervical cytology as primary screening in the detection of grade 2+ cervical intraepithelial neoplasia in the National Cancer Screening Program (NCSP) of Mexico. Materials and methods: We will use information originated from the Womens Cancer Information System of Mexico regarding cervical cancer from 2008 to 2018. The database includes cytology results, diagnostic confirmation by histopathology and/or treatment colposcopy. We will then carry out statistical analyses on approximately 15 million hrHPV. Results: We will evaluate the overall performance of hrHPV-based screening as part of the NCSP and compare hrHPV-based to cytology-based screening under real-life conditions. To guarantee an unbiased comparison between hrHPV with cytology triage and conventional cytology we will use propensity score matching. Conclusion: Decision makers may use our results to identify areas of opportunity for improvement in NCSP processes.

Resumen: Objetivo: Describir los métodos de un estudio que busca comparar el beneficio de la introducción de la prueba de VPH de alto riesgo como prueba primaria frente a la citología convencional para la detección de la neoplasia intraepitelial cervical grado 2 o mayor, dentro del Programa de Prevención y Control del Cáncer de la Mujer, para el periodo de 2008 a 2018. Material y métodos: Se utilizarán los registros del Sistema de Información de Cáncer de la Mujer, se realizarán los análisis estadísticos con aproximadamente 15 millones de resultados de VPH-alto riesgo, además se utilizarán los resultados de citología, colposcopia, histología y los casos referenciados al centro oncológico para tratamiento. Para comparar ambos grupos usaremos "propensity score matching". Resultados: Se evaluará el desempeño general de la prueba de VPH-alto riesgo, en condiciones reales dentro del Programa Nacional de Prevención y Control de la Mujer y su tendencia en el tiempo. Conclusiones: Los resultados de estudio ayudarán a los tomadores de decisiones a identificar áreas de oportunidad para mejorar el programa en México.

Effect of diabetes duration and glycaemic control on 14-year cause-specific mortality in Mexican adults: a blood-based prospective cohort study.

BACKGROUND: Diabetes is a cause of at least a third of all deaths in Mexican adults aged 35-74 years, with the excess mortality due mainly to vascular disease, renal disease, infection, and acute diabetic crises. We aimed to analyse the effect of diabetes duration and glycaemic control on death rate ratios (RRs) for these causes and to assess the relevance to cause-specific mortality of undiagnosed diabetes. METHODS: About 100 000 women and 50 000 men aged 35 years or older from Mexico City were recruited into a blood-based prospective study between April 14, 1998, and Sept 28, 2004, and followed up until Jan 1, 2016, for cause-specific mortality. Participants who, at recruitment, reported any chronic disease other than diabetes and those who had missing data for HbA1c or diabetes duration were excluded. We used Cox models to estimate the associations of undiagnosed or previously diagnosed diabetes (almost all type 2) with risk of mortality from vascular disease, renal disease, and infection, exploring among those with previously diagnosed diabetes the independent relevance of diabetes duration (<5 years, ≥5 to <10 years, or ≥10 years) and HbA1c (<9%, ≥9% to <11%, or ≥11%). We also estimated the association of HbA1c with mortality in participants without diabetes at recruitment. FINDINGS: 133 662 participants were aged 35-74 years and had complete data and no other chronic disease. 16 940 (13%) had previously diagnosed diabetes, 6541 (5%) had undiagnosed diabetes, and 110 181 (82%) had no diabetes. Among participants with previously diagnosed diabetes, glycaemic control was poor (median HbA1c 8·9% [IQR 7·0-10·9]), and was worse in those with longer duration of disease at recruitment. Compared with participants without diabetes, the death RRs at ages 35-74 years for the combination of vascular, renal, or infectious causes were 3·0 (95% CI 2·7-3·4) in those with undiagnosed diabetes, 4·5 (4·0-5·0) for the 5042 participants with a diabetes duration of less than 5 years, 6·6 (6·1-7·1) for the 7713 participants with a duration of 5 years to less than 10 years, and 11·7 (10·7-12·7) for the 4185 participants with a duration of at least 10 years. Similarly, the death RRs were 5·2 (4·8-5·7) for those with HbA1c less than 9%, 6·8 (6·2-7·4) for those with HbA1c of 9% to less than 11%, and 10·5 (9·7-11·5) for those with HbA1c of at least 11%. Diabetes was not strongly associated with the combination of deaths from other causes apart from acute glycaemic crises. Among participants without diabetes, higher HbA1c was not positively related to mortality. INTERPRETATION: In Mexico, the rates of death from causes strongly associated with diabetes increased steeply with duration of diabetes and were higher still among people with poor glycaemic control. Delaying the onset of type 2 diabetes, as well as improving its treatment, is essential to reduce premature adult mortality in Mexico. FUNDING: Wellcome Trust, the Mexican Health Ministry, the Mexican National Council of Science and Technology, Cancer Research UK, British Heart Foundation, and the UK Medical Research Council Population Health Research Unit.

Use of HPV testing in cervical cancer screening services in Mexico, 2008-2018: a nationwide database study.

OBJECTIVE: To describe the methods of a study aimed at evaluating high risk-HPV (hrHPV)-based screening and cervical cytology as triage compared to conventional cervical cytology as primary screening in the detection of grade 2+ cervical intraepithelial neoplasia in the National Cancer Screening Program (NCSP) of Mexico. MATERIALS AND METHODS: We will use information originated from the Womens Cancer Information System of Mexico regarding cervical cancer from 2008 to 2018. The database includes cytology results, diagnostic confirmation by histopathology and/or treatment colposcopy. We will then carry out statistical analyses on approximately 15 million hrHPV. RESULTS: We will evaluate the overall performance of hrHPV-based screening as part of the NCSP and compare hrHPV-based to cytology-based screening under real-life conditions. To guarantee an unbiased comparison between hrHPV with cytology triage and conventional cytology we will use propensity score matching. CONCLUSIONS: ytology we will use propensity score matching. Conclusion. Decision makers may use our results to identify areas of opportunity for improvement in NCSP processe.

OBJETIVO: Describir los métodos de un estudio que busca comparar el beneficio de la introducción de la prueba de VPH de alto riesgo como prueba primaria frente a la citología convencional para la detección de la neoplasia intraepitelial cervical grado 2 o mayor, dentro del Programa de Prevención y Control del Cáncer de la Mujer, para el periodo de 2008 a 2018. MATERIAL Y MÉTODOS: Se utilizarán los registros del Sistema de Información de Cáncer de la Mujer, se realizarán los análisis estadísticos con aproximadamente 15 millones de resultados de VPH-alto riesgo, además se utilizarán los resultados de citología, colposcopia, histología y los casos referenciados al centro oncológico para tratamiento. Para comparar ambos grupos usaremos "propensity score matching". RESULTADOS: Se evaluará el desempeño general de la prueba de VPH-alto riesgo, en condiciones reales dentro del Programa Nacional de Prevención y Control de la Mujer y su tendencia en el tiempo. CONCLUSIONES: Los resultados de estudio ayudarán a los tomadores de decisiones a identificar áreas de oportunidad para mejorar el programa en México.

Caracterización clínica y epidemiológica de fiebre chikungunya en México / Clinical and epidemiological characterization of chikungunya fever in Mexico

RESUMEN El 6 de diciembre de 2013, la Organización Panamericana de la Salud (OPS) y la Organización Mundial de la Salud (OMS) notificaron la confirmación de los dos primeros casos de transmisión autóctona en la Región de las Américas de fiebre chikungunya (CHIK) en la isla de Saint Martin (Antillas Neerlandesas). Para el período 2013-2014, el total de casos confirmados fue de 25 627 distribuidos en 43 países, donde México reportó 155 casos en cinco estados. La información de los casos de CHIK en México se obtuvo de la base de datos de la Dirección General de Epidemiología, dependiente de la Secretaría de Salud de México. La distribución por sexo de los casos autóctonos confirmados de CHIK para el año 2015 indica 64% para el sexo femenino (5 583) y 36% para el sexo masculino (3 085). Los síntomas más frecuentes fueron: fiebre en 98% de los casos (8 564), seguido por cefalea con 91,6% (7 941), mialgias en 89,9% (7 792), artralgias leves en 73,5% (6 367), poliartralgias graves en 72,6% (6 295) y exantema en 58% (5 032). La presentación clínica de los casos autóctonos de CHIK en México ha mostrado algunas características clínicas diferentes de las que se han observado en los brotes de los países africanos, asiáticos y otras regiones de América, como por ejemplo un mayor porcentaje de casos con cefalea y mialgias y un menor porcentaje de casos con artralgias.(AU)

ABSTRACT On 6 December 2013, the Pan American Health Organization (PAHO) and the World Health Organization (WHO) reported confirmation of the first two cases of indigenous transmission of chikungunya fever (CHIK) in the Region of the Americas on the island of Sint Maarten (Netherlands Antilles). For the period 2013-2014, a total of 25 627 confirmed autochthonous cases were distributed in 43 countries, with Mexico reporting 155 cases in five states. Information on cases of CHIK in Mexico was obtained from the database of the General Directorate of Epidemiology (Ministry of Health of Mexico). The distribution of confirmed autochthonous cases of CHIK for 2015, by sex, was 64% female (5 583) and 36% male (3 085). The most frequent symptoms were fever in 98% of cases (8 564), followed by headache in 91.6% (7 941), myalgia in 89.9% (7 792), mild arthralgias in 73.5% (6 367), severe polyarthralgia in 72.6% (6 295), and exanthema in 58% (5 032). The clinical presentation of autochthonous cases of CHIK in Mexico has shown several clinical manifestations different from those seen in outbreaks in African and Asian countries and other regions in the Americas; for example, a greater percentage of cases with headache and myalgia and a smaller percentage of cases with arthralgia.(AU)

Diabetes and Cause-Specific Mortality in Mexico City.

BACKGROUND: Most large, prospective studies of the effects of diabetes on mortality have focused on high-income countries where patients have access to reasonably good medical care and can receive treatments to establish and maintain good glycemic control. In those countries, diabetes less than doubles the rate of death from any cause. Few large, prospective studies have been conducted in middle-income countries where obesity and diabetes have become common and glycemic control may be poor. METHODS: From 1998 through 2004, we recruited approximately 50,000 men and 100,000 women 35 years of age or older into a prospective study in Mexico City, Mexico. We recorded the presence or absence of previously diagnosed diabetes, obtained and stored blood samples, and tracked 12-year disease-specific deaths through January 1, 2014. We accepted diabetes as the underlying cause of death only for deaths that were due to acute diabetic crises. We estimated rate ratios for death among participants who had diabetes at recruitment versus those who did not have diabetes at recruitment; data from participants who had chronic diseases other than diabetes were excluded from the main analysis. RESULTS: At the time of recruitment, obesity was common and the prevalence of diabetes rose steeply with age (3% at 35 to 39 years of age and >20% by 60 years of age). Participants who had diabetes had poor glycemic control (mean [±SD] glycated hemoglobin level, 9.0±2.4%), and the rates of use of other vasoprotective medications were low (e.g., 30% of participants with diabetes were receiving antihypertensive medication at recruitment and 1% were receiving lipid-lowering medication). Previously diagnosed diabetes was associated with rate ratios for death from any cause of 5.4 (95% confidence interval [CI], 5.0 to 6.0) at 35 to 59 years of age, 3.1 (95% CI, 2.9 to 3.3) at 60 to 74 years of age, and 1.9 (95% CI, 1.8 to 2.1) at 75 to 84 years of age. Between 35 and 74 years of age, the excess mortality associated with previously diagnosed diabetes accounted for one third of all deaths; the largest absolute excess risks of death were from renal disease (rate ratio, 20.1; 95% CI, 17.2 to 23.4), cardiac disease (rate ratio, 3.7; 95% CI, 3.2 to 4.2), infection (rate ratio, 4.7; 95% CI, 4.0 to 5.5), acute diabetic crises (8% of all deaths among participants who had previously diagnosed diabetes), and other vascular disease (mainly stroke). Little association was observed between diabetes and mortality from cirrhosis, cancer, or chronic obstructive pulmonary disease. CONCLUSIONS: In this study in Mexico, a middle-income country with high levels of obesity, diabetes was common, glycemic control was poor, and diabetes was associated with a far worse prognosis than that seen in high-income countries; it accounted for at least one third of all deaths between 35 and 74 years of age. (Funded by the Wellcome Trust and others.).

Challenges in the development and implementation of the National Comprehensive Cancer Control Program in Mexico.

Chronic noncommunicable diseases (NCDs), including cancer, have become the leading cause of human morbidity and mortality. In Mexico, cancer is the third leading cause of death, with a high incidence among the economically active population, a high proportion of advanced stages at diagnosis and limited care coverage for patients. However, no public policy aimed at managing this important public health problem has been developed and implemented to date. This manuscript describes the first interinstitutional proposal of a National Program for Cancer Control, considering the known risk factors, early detection, treatment, palliative care and patient rehabilitation. This manuscript also outlines a series of thoughts on the difficulties and needs that the Mexican health system faces in achieving the main objectives of the program: to decrease the incidence of cancer, to increase survival and to improve the quality of life for this group of patients.

Challenges in the development and implementation of the National Comprehensive Cancer Control Program in Mexico / Retos del desarrollo e implementación del Programa Nacional de Control Integral del Cáncer en México

Abstract Chronic noncommunicable diseases (NCDs), including cancer, have become the leading cause of human morbidity and mortality. In Mexico, cancer is the third leading cause of death, with a high incidence among the economically active population, a high proportion of advanced stages at diagnosis and limited care coverage for patients. However, no public policy aimed at managing this important public health problem has been developed and implemented to date. This manuscript describes the first interinstitutional proposal of a National Program for Cancer Control, considering the known risk factors, early detection, treatment, palliative care and patient rehabilitation. This manuscript also outlines a series of thoughts on the difficulties and needs that the Mexican health system faces in achieving the main objectives of the program: to decrease the incidence of cancer, to increase survival and to improve the quality of life for this group of patients.

Resumen Las enfermedades crónicas no transmisibles (ECNT), incluido el cáncer, se han convertido en la principal causa de morbimortalidad de la humanidad. En México, el cáncer es la tercera causa de muerte, con una frecuencia elevada en población económicamente activa, una alta proporción de etapas avanzadas al momento del diagnóstico y una limitada cobertura de atención a quienes la padecen. No obstante, hasta el momento no se ha desarrollado e implementado una política pública dirigida al control de este importante problema de salud pública. Este manuscrito muestra la primera propuesta interinstitucional de un Programa Nacional para el Control del Cáncer, considerando los factores de riesgo conocidos, la detección temprana, el tratamiento y los cuidados paliativos y la rehabilitación del paciente. Asimismo se hacen una serie de reflexiones sobre las dificultades y necesidades a las que el sistema de salud mexicano se enfrenta para alcanzar los objetivos principales del programa: reducir la incidencia, incrementar la supervivencia y mejorar la calidad de vida de este grupo de pacientes.

Universalidad de los servicios de salud en México / Universal Coverage of Health Services in Mexico

Las reformas llevadas a cabo en años recientes al sistema de salud en México han reducido las inequidades en la atención a la salud de la población, pero han sido insuficientes para resolver todos los problemas del Sistema Nacional de Salud (SNS). Para que el derecho a la protección de la salud consagrado en la Constitución sea una realidad para todos los ciudadanos, México se encuentra ante la necesidad de garantizar el acceso universal y efectivo a los servicios de salud. En este trabajo se delinea una reforma de largo alcance para la consolidación de un sistema de salud, afín con estándares internacionales, que establezca las condiciones estructurales para reducir las desigualdades en cobertura. Esta reforma se plantea a partir de un "pluralismo estructurado" para evitar tanto el monopolio ejercido desde el sector público como la atomización en el sector privado, y no caer en los extremos de procedimientos autoritarios o ausencia de regulación. Esto implica sustituir la actual integración vertical con segregación de grupos sociales, por una organización horizontal con separación de funciones. Implica, asimismo, reformas de tipo jurídico y fiscal, fortalecimiento del SNS, reorganización de las instituciones de salud y formulación de los instrumentos normativos, técnicos y financieros que hagan operativo el esquema propuesto para hacer plenamente efectivo el derecho humano a la salud de los mexicanos.

The reforms made in recent years to the Mexican Health System have reduced inequities in the health care of the population, but have been insufficient to solve all the problems of the MHS. In order to make the right to health protection established in the Constitution a reality for every citizen, Mexico must warrant effective universal access to health services. This paper outlines a long-term reform for the consolidation of a health system that is akin to international standards and which may establish the structural conditions to reduce coverage inequity. This reform is based on a "structured pluralism" intended to avoid both a monopoly exercised within the public sector and fragmentation in the private sector, and to prevent falling into the extremes of authoritarian procedures or an absence of regulation. This involves the replacement of the present vertical integration and segregation of social groups by a horizontal organization with separation of duties. This also entails legal and fiscal reforms, the reinforcement of the MHS, the reorganization of health institutions, and the formulation of regulatory, technical and financial instruments to operationalize the proposed scheme with the objective of rendering the human right to health fully effective for the Mexican people.

Perfil epidemiológico general de las quejas médicas atendidas en la Comisión Nacional de Arbitraje Médico: 1996-2007 / Epidemiological general profile of complaints treated at the National Medical Arbitration Commission: 1996-2007

OBJECTIVE: To analyze medical complaints over a period of 11 years, for making recommendations for prevention and improving planning for responding. MATERIAL AND METHODS: We studied the medical complaints at the National Medical Arbitration Commission (Conamed, per its acronym in Spanish) between 1996 and 2007 using descriptive statistics to identify their general profile in relation to the variables of time, place and person. We also studied the frequency of evident medical malpractice as well as the severity of the damage it produces. RESULTS: The request for responses to medical complaints increased between 1996 and 2007 and there was less demand between July and December. Two states in the country account for 69.7 percent of the complaints and 74.0 percent are from public institutions. Fifty-eight percent come from women and the 25-34 and 65+ age groups have the highest percentage. We found in 27.0 percent of the complaints there is evidence of medical malpractice and obstetrics and gynecology have the highest percentage of complaints, physical harm and severity of injury. Complaints about treatment are nearly four times more than diagnosis. CONCLUSIONS: It is necessary to improve the quality of diagnosis and treatment and identify cost-effective measures to reduce medical malpractice and the severity of physical damage in patients.

OBJETIVO: Analizar las quejas médicas atendidas en un periodo de 11 años con el fin de formular recomendaciones para prevenirlas y mejorar la planeación para su atención. MATERIAL Y MÉTODOS: Se estudiaron las quejas de la Comisión Nacional de Arbitraje Médico (Conamed) recibidas entre 1996 y 2007 y se utilizaron medidas de estadística descriptiva para conocer su perfil general en relación con las variables de tiempo, lugar y persona. También se determinó la frecuencia de mala práctica médica evidente, así como la gravedad del daño que producen. RESULTADOS: La solicitud de atención de quejas se incrementó entre 1996 y 2007, y existió menor demanda de atención en julio y diciembre. Dos estados del país concentran 69.7 por ciento de las quejas y 74 por ciento proviene de instituciones públicas. El 58 por ciento son de mujeres y los grupos de 25 a 34, y de 65 y más años tienen el mayor porcentaje. En 27 por ciento de las quejas atendidas hay evidencia de mala práctica médica y ginecología y obstetricia presenta el mayor porcentaje de quejas, daño físico y gravedad del daño. Las quejas por tratamiento son casi cuatro veces más que las de diagnóstico. CONCLUSIONES: Es necesario mejorar la calidad del diagnóstico y el tratamiento e identificar medidas efectivas para el costo que reduzcan la mala práctica médica y la gravedad del daño físico en los pacientes.

The prevalence of chronic diseases and major disease risk factors at different ages among 150,000 men and women living in Mexico City: cross-sectional analyses of a prospective study.

BACKGROUND: While most of the global burden from chronic diseases, and especially vascular diseases, is now borne by low and middle-income countries, few large-scale epidemiological studies of chronic diseases in such countries have been performed. METHODS: From 1998-2004, 52 584 men and 106 962 women aged > or =35 years were visited in their homes in Mexico City. Self reported diagnoses of chronic diseases and major disease risk factors were ascertained and physical measurements taken. Age- and sex-specific prevalences and means were analysed. RESULTS: After about age 50 years, diabetes was extremely common - for example, 23.8% of men and 26.9% of women aged 65-74 reported a diagnosis. By comparison, ischaemic heart disease was reported by 4.8% of men and 3.0% of women aged 65-74, a history of stroke by 2.8% and 2.3%, respectively, and a history of cancer by 1.3% and 2.1%. Cancer history was generally more common among women than men - the excess being largest in middle-age, due to breast and cervical cancer. At older ages, the gap narrowed because of an increasing prevalence of prostate cancer. 51% of men and 25% of women aged 35-54 smoked cigarettes, while 29% of men and 41% of women aged 35-54 were obese (i.e. BMI > or =30 kg/m2). The prevalence of treated hypertension or measured blood pressure > or =140/90 mmHg increased about 50% more steeply with age among women than men, to 66% of women and 58% of men aged 65-74. Physical inactivity was highly prevalent but daily alcohol drinking was relatively uncommon. CONCLUSION: Diabetes, obesity and tobacco smoking are highly prevalent among adults living in Mexico City. Long-term follow-up of this and other cohorts will establish the relevance of such factors to the major causes of death and disability in Mexico.