Diabetes disparities in the United States: Trends by educational attainment from 2001 to 2020.

INTRODUCTION: Tracking changes in socioeconomic disparities in diabetes in the US is important to evaluate progress in health equity and guide prevention efforts. Disparities in diabetes prevalence by educational attainment from 2001 to 2020 were investigated. METHODS: Using a serial cross-sectional design, data from 33,220 adults aged 30 to 79 assessed in nine rounds of the National Health and Nutrition Examination Surveys between 2001 to 2020 were analyzed in 2023-4. Diabetes was defined as self-reported prior diagnosis, elevated glycated hemoglobin (HbA1c≥6.5%), or use of diabetes medications. Marginalized age- and covariate-adjusted prevalence differences (PD) and prevalence ratios (PR) of diabetes by educational attainment (less than high school graduation, high school graduation, some college education or associate degree, or college graduation [reference]) by calendar period (2001-04, 2005-08, 2009-12, 2013-16, 2017-20) were derived from logistic regression models. RESULTS: From 2001 to 2020, age-adjusted diabetes prevalence was consistently higher among adults without a college degree. Adults without a high school diploma exhibited the largest disparities in both 2001-04 (PD 8.0%; 95%CI 5.6-10.5 and PR 2.1; 95%CI 1.5-2.6) and 2017-20 (PD 11.0%; 95%CI 6.7-15.2 and PR 2.1; 95%CI 1.5-2.7). Between 2001-04 and 2017-20, the absolute disparity in diabetes increased only among adults with a high school diploma (PD 1.7% 95%CI -0.5-3.9 vs PD 8.8%; 4.1-13.4, respectively), while the PR did not change in any group. Education-related disparities in diabetes were attenuated after accounting for socio-demographic factors and BMI. CONCLUSIONS: From 2001 to 2020, national education-related disparities in diabetes prevalence have shown no signs of narrowing.

The "double jeopardy" of midlife and old age mortality trends in the United States.

Since 2010, US life expectancy growth has stagnated. Much research on US mortality has focused on working-age adults given adverse trends in drug overdose deaths, other external causes of death, and cardiometabolic deaths in midlife. We show that the adverse mortality trend at retirement ages (65+ y) has in fact been more consequential to the US life expectancy stagnation since 2010, as well as excess deaths and years of life lost in 2019, than adverse mortality trends at working ages. These results reveal that the United States is experiencing a "double jeopardy" that is driven by both mid-life and older-age mortality trends, but more so by older-age mortality. Understanding and addressing the causes behind the worsening mortality trend in older ages will be essential to returning to the pace of life expectancy improvements that the United States had experienced for decades.

Impact of the COVID-19 pandemic on Ukrainian mortality, 2020-2021.

The mortality impact of the COVID-19 pandemic in Ukraine has remained incomplete. We estimated excess deaths associated with the pandemic in Ukraine during 2020 and 2021. Excess deaths may be attributed directly to SARS-CoV-2 infection or indirectly to deaths associated with social and economic upheavals resulting from the pandemic. Data on all deaths registered in government-controlled Ukraine from 2016-2021 (N = 3,657,475) were utilized. Using a model-based approach, we predicted monthly excess deaths in 2020 and 2021. We estimated 47,578 excess deaths in 2020 as a whole (7.71% of all recorded deaths). This figure reflects both positive (higher than expected) excess deaths from June-December and negative (lower than expected) deaths in January and March-May. From June-December 2020, we estimated 59,363 excess deaths (15.75% of all recorded deaths in those months). In 2021, we estimated 150,049 excess deaths (21.01% of all recorded deaths). Positive excess deaths were detected across age groups even groups younger than 40 years. The number of excess deaths exceeded that of deaths with COVID-19 coded on the death certificate by more than two-fold in 2020, but that difference narrowed in 2021. We furthermore provide provisional estimates of the effect of low vaccine coverage on excess deaths in 2021 drawing from European cross-national evidence and provisional estimates of the hypothetical evolution of the pandemic in 2022 to serve as a rough basis for future studies analyzing the joint impacts of the COVID-19 pandemic and the Russian invasion on Ukrainian demography.

Obesity as a Main Threat to Future Improvements in Population Health: Policy Opportunities and Challenges.

Policy Points Obesity has emerged as a main threat to future improvements in population health, and there is little evidence that the epidemic is retreating. The traditional model of "calories in, calories out," which has guided public health policy for decades, is increasingly viewed as far too simple a framing to explain the evolution of the epidemic or guide public policy. Advances in the science of obesity, coming from many fields, highlight the structural nature of the risk, which has provided an evidence base to justify and guide policies toward addressing the social and environmental drivers of obesity. Societies and researchers need to play the long game in that widespread reductions in obesity in the short run are unlikely. Nonetheless, there are opportunities. Policies specifically targeting the food environment such as taxing high-calorie beverages and foods, restricting the marketing of junk foods to children, enhancing food labeling, and improving the dietary environment at schools may yield long-run benefits.

Anatomic Region of Cutaneous Melanoma Impacts Survival and Clinical Outcomes: A Population-Based Analysis.

PURPOSE: The objective was to determine the effects of the anatomic site of a cutaneous melanoma on the survival outcomes of diagnosed individuals. METHODS: We conducted a cross-sectional study using data from the Surveillance, Epidemiology, and End Results Program (SEER) Database from 2004-2014 and included 178,892 cases of individuals diagnosed with cutaneous melanoma. Overall survival (OS) for each anatomic site as well as associated demographics, primary site, stage, and pathologic prognostic factors (Breslow's depth of invasion (DOI), level of mitoses, and ulceration), were analyzed. RESULTS: Lower extremity melanoma (LEM) was the most likely to have locoregional nodal spread, yet head and neck melanoma (HNM) was the most likely to present at the most advanced stage of disease (IV). Independent of other factors, HNM was associated with the greatest risk of death (HR 1.90 [95% CI, 1.85-1.96]) compared to other sites, and males experienced worse overall survival (OS) (HR 1.74 [95% CI, 1.70-1.78]) compared to females. The last and greatest risk of death is associated with LEM and HNM, respectively. CONCLUSION: Given these survival differences, consideration should be given to incorporating the primary site of melanoma into staging to ensure treatment is efficacious as possible.

Work at Age 62: Expectations and Realisations among Recent Cohorts of Americans.

Much remains unknown about how the 2008 Great Recession, coupled with the ageing baby boomer cohort, have shaped retirement expectations and realized retirement timing across diverse groups of older Americans. Using the Health and Retirement Study (1992-2016), we compared expectations about full-time work at age 62 (reported at ages 51-61) with realized labor force status at age 62. Of the 12,049 respondents, 34 per cent reported no chance of working full time at 62 (zero probability) and 21 per cent reported it was very likely (90-100 probability). Among those reporting no chance of working, there was a 0.111 probability of unmet expectations; among those with high expectations of working, there was a 0.430 probability of unmet expectations. Black and Hispanic Americans were more likely than whites to have unmet expectations of both types. Educational attainment was associated with higher probability of unexpectedly working and lower probability of unexpectedly not working. Baby boomers experienced fewer unmet expectations than prior cohorts but more uncertainty about work status at 62. Our findings highlight the unpredictability of retirement timing for significant segments of the U.S. population and the role of the Great Recession in contributing to uncertainty. Given the individual and societal benefits of long work lives, special attention should be paid to the high rates of unexpectedly not working at age 62.

Obesity Incidence in U.S. Children and Young Adults: A Pooled Analysis.

INTRODUCTION: Obesity prevalence among children and adolescents has risen sharply, yet there is a limited understanding of the age-specific dynamics of obesity as there is no single nationally representative cohort following children into young adulthood. Investigators constructed a pooled data set of 5 nationally representative panels and modeled age-specific obesity incidence from childhood into young adulthood. METHODS: This longitudinal prospective follow-up used 718,560 person-years of observation in a pooled data set of 5 high-quality nationally representative panels-National Longitudinal Survey of Youth 1979 and 1997, National Longitudinal Study of Adolescent Health, and Early Childhood Longitudinal Study-Kindergarten cohorts of 1998 and 2011-constructed by the authors, covering 1980-2016. Differences in obesity incidence across birth cohorts and disparities in obesity incidence by sex and race/ethnicity (non-Hispanic Black, Hispanic, and non-Hispanic White) were tested in multivariate models. Data were analyzed from September 2018 to October 2021. RESULTS: Obesity incidence increased by approximately 6% for each 1 year of age (hazard ratio=1.06, 95% CI=1.05, 1.07); however, incidence was nonlinear, exhibiting an inverted "U"-shaped pattern before 15 years of age and then rising from adolescence through 30 years. Obesity incidence more than doubled between the cohorts born in 1957-1965 and those born in 1974-1985 during adolescence. There was no significant change among those born in 1991-1994 and 2003-2006 up to age 15 years. Compared with non-Hispanic White children, non-Hispanic Black and Hispanic children had higher obesity incidence in all study cohorts. The magnitude of these disparities on the relative scale remained stable throughout the study period. CONCLUSIONS: Although many children become obese before the age of 10, obesity incidence rises from about 15 years into early adulthood, suggesting that interventions are required at multiple developmental stages.

Pathogenesis and Etiology of Ménière Disease: A Scoping Review of a Century of Evidence.

IMPORTANCE: Ménière disease is a rare chronic benign disorder of the inner ear with a natural history of multiple clinical phenotypes of variable severity and a tendency to burnout with time. Although multiple treatment modalities have been shown to improve the disease process-some adversely affecting cochleovestibular function-it remains uncertain whether one, several separate, or a combination of pathophysiologic mechanisms affect the disease process. A scoping review of the evidence underlying proposed pathophysiologic mechanisms of Ménière disease is needed to determine which processes are most likely to be etiopathogenic factors. OBSERVATIONS: Of the 4602 relevant articles found through Embase, Ovid, and PubMed, 444 met inclusion criteria. The most common reported causes of Ménière disease were autoimmune or immune-mediated, genetic, or structural dysfunction of the inner ear. During the study period from inception to March 2021, etiologic theories shifted from structural dysfunction to autoimmune and genetic causes of Ménière disease. CONCLUSIONS AND RELEVANCE: This scoping review found that Ménière disease is a multifactorial disease with lifelong comorbidities and loss of quality-associated life-years whose most commonly reported causes were structural dysfunction, immunologic damage, and genetic susceptibility. Recent studies have examined how autoinflammatory processes and vestibular migraine may be associated with Ménière disease. Large heterogeneity among studies may be explained by historical differences in the clinical understanding of the disease, as well as evolving intervention methodologies and practitioner expertise. Ménière disease is a multifactorial disease with lifelong comorbidities and loss of quality-associated life-years; therefore, future studies of reliable biomarkers of endolymphatic hydrops and real-time imaging are warranted to improve understanding and treatment.

The growing rural-urban divide in US life expectancy: contribution of cardiovascular disease and other major causes of death.

BACKGROUND: The US rural disadvantage in life expectancy (LE) relative to urban areas has grown over time. We measured the contribution of cardiovascular disease (CVD), drug-overdose deaths (DODs) and other major causes of death to LE trends in rural and urban counties and the rural-urban LE gap. METHODS: Counterfactual life tables and cause-of-death decompositions were constructed using data on all US deaths in 1999-2019 (N = 51 998 560) from the Centers for Disease Control and Prevention. RESULTS: During 1999-2009, rural and urban counties experienced robust LE gains, but urban LE increased by 1.19 years more in women and 0.86 years more in men compared with rural LE. During 2010-2019, rural counties experienced absolute declines in LE (women -0.20, men -0.30 years), whereas urban counties experienced modest increases (women 0.55, men 0.29 years). Counterfactual analysis showed that slowed CVD-mortality declines, particularly in ages 65+ years, were the main reason why rural LE stopped increasing after 2010. However, slow progress in CVD-mortality influenced LE trends more in urban areas. If CVD-mortality had continued to decline at its pre-2010 pace, the rural-urban LE gap would have grown even more post 2010. DODs and other causes of death also contributed to the LE trends and differences in each period, but their impact in comparison to that of CVD was relatively small. CONCLUSIONS: Rural disadvantage in LE continues to grow, but at a slower pace than pre 2010. This slowdown is more attributable to adverse trends in CVD and DOD mortality in urban areas than improvements in rural areas.

Demographic Variation in Chronic Rhinosinusitis by Subtype and Region: A Systematic Review.

BACKGROUND: Chronic rhinosinusitis (CRS) describes a heterogenous group of diseases including CRS with (CRSwNP) or without nasal polyps (CRSsNP), aspirin-exacerbated respiratory disease (AERD), and allergic fungal rhinosinusitis (AFRS). It affects 10 to 15% of the US population and is more common in women and White patients. However, these estimates are based on survey and database studies with innate diagnostic inaccuracy. Additionally, few studies report subtype-specific demographics. We explore the demographic differences of CRS in the U.S. by subtype and region. OBJECTIVE: To characterize demographic differences between the CRS population and the overall US population, and also between different CRS subtype populations. METHODS: We performed a systematic review for articles reporting on US demographics of adults with CRS. Study participants were required to have been diagnosed using consensus criteria. Data on demographics, geographic region, and CRS subtype were analyzed. RESULTS: Our study analyzed 31 unique studies representing 8409 patients with 50.7% females and weighted mean age of 48.0 years. Compared to the overall US population, CRS patients were predominantly White (78.5%) and non-Hispanic (94.5%) with under-representation of other races. Grouped by subtype, CRSwNP affected a significantly higher proportion of men (59.8%). AFRS affected a significantly higher proportion of Black patients (53.8%) while CRSsNP was more prevalent in White patients (84.2%). When grouped by region, the South had a significantly higher proportion of female (53%) and Black (17.8%) CRS patients. The West had a significantly higher proportion of Asian (4.5%) and Hispanic (12.3%) patients. CONCLUSIONS: Significant demographic differences exist in CRS patients based on subtype and region. These data provide an estimation of the demographic make-up of CRS, but further high-level demographic studies are needed.

Unmet Expectations About Work at Age 62 and Depressive Symptoms.

OBJECTIVES: Exiting the labor force earlier or later than planned is common, with predictable economic consequences. However, the mental health ramifications of such off-time events are not known but are important to promoting well-being in retirement. METHODS: Using the Health and Retirement Study (1992-2016), we created 6 groups based on the alignment of expectations about full-time work at age 62 (reported at ages 51-61) with realized labor force status after reaching age 62 (N = 10,421). Negative binomial models estimated the adjusted association between unmet expectations about work and depressive symptoms. RESULTS: Unexpectedly not working was associated with higher depressive symptoms than working as expected after adjusting for sociodemographic, economic, and health factors at the time of expectations (incidence rate ratio = 1.35, 95% confidence interval: 1.17-1.56). Additionally, adjusting for health declines and marriage dissolution between expectations and age 62 partially attenuated the association, but unexpectedly not working remained significantly associated with a 1.16 increase in the incidence rate of depressive symptoms. Unexpectedly working at 62 was not associated with depressive symptoms. Race/ethnicity interacted with expectation alignment (F(15,42) = 2.44, p = .0118) in that Hispanic respondents experienced an increase in depressive symptoms when working after unmet and unsure expectations compared to met expectations, whereas White respondents did not. DISCUSSION: Unlike working longer than expected, unexpectedly not working at age 62 was associated with depressive symptoms, even after accounting for health declines. Public and employer policies should assist workers in remaining in the labor force as long as planned and offer mental health supports for unexpected work exits.

Head and Neck Injury Patterns among American Football Players.

IMPORTANCE: American football is a popular high-impact sport, leading to 2.7 million injuries in the United States annually. Recent evidence in football-related neurological damage has spurred national interest in player-safety. Football players injure their head and neck in up to 26% of total injuries. Variation in injury patterns between age groups and correlated hospitalizations for football-related head and neck injury has yet to be characterized. OBJECTIVE: Our aim is to evaluate injury patterns among American-football related head and neck trauma. METHODS: A retrospective cohort study of patients with football-related head and neck injury in the National Electronic Injury Surveillance System (NEISS). RESULTS: Nearly 100 000 ED visits for football-related head and neck injuries occur annually. Males comprised 95% of patients, with a median age of 13. The head comprised 70% of injuries followed by the face (13%). The most common diagnoses were concussions (39%), internal organ injury (26%), and lacerations (11%). Pediatric patients were more likely to sustain concussions while adults experienced more lacerations (P < .05%). Fractures and nerve damage were rare injuries but caused a disproportionate share of hospitalizations. CONCLUSION: Pediatric males are most likely to present for emergency care from football-related injury to the head and neck. Evaluating physicians can anticipate concussions, internal organ injury, and lacerations among presenting patients. Concussions, facial fractures, and nerve damage are injuries most likely to lead to hospitalization.

Medical Management for Eustachian Tube Dysfunction in Adults: A Systematic Review and Meta-Analysis.

OBJECTIVE: Medical treatment for eustachian tube dysfunction (ETD) is varied, with physician preference driving treatment choice and limited guidance for these options. An evaluation of the efficacy of medical management (MM) for ETD is warranted. METHODS: A systematic review of three databases (PubMed, Scopus, and Embase) was performed through December 2020. Adults treated nonsurgically for ETD were included. Exclusion criteria were as follows: patulous ETD, ETD deriving from craniofacial anomalies, or surgical treatment. Data were extracted independently by two reviewers according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A meta-analysis of continuous measures, proportions, and risk ratio was conducted. RESULTS: Twelve articles were identified by systematic review, with either level 2 or 3 evidence. A meta-analysis of available data was performed on nine studies. A pooled cohort found 50.3% (95% confidence interval [CI], 41.7-59.0) of patients experienced symptomatic improvement with MM. ETDQ-7 scores improved in a clinically nonsignificant manner by -0.88 (95% CI, -1.12 to -0.64) following medical treatment. Further, MM benefited from subacute and chronic symptoms in 30% to 64% and 11% to 50% of cases, respectively. Intranasal corticosteroids (INCS) were not efficacious, improving only 11% to 18% of chronic cases. Therapies such as Politzer devices and Valsalva therapy had minimally beneficial results. CONCLUSION: Our review did not find any level 1 evidence for MM of ETD in adults. Available evidence indicates INCS are ineffective for chronic symptoms and the efficacy of nonsurgical options for subacute ETD has yet to be determined. Further randomized controlled trials are needed to discern efficacy of single-agent medical therapies. Laryngoscope, 132:849-856, 2022.

Immune Checkpoint Inhibitors for Advanced Cutaneous Squamous Cell Carcinoma: A Systematic Review with Meta-Analysis.

BACKGROUND: Results of early trials led to FDA approval of immune checkpoint inhibitors (ICIs) for advanced and recurrent/metastatic (R/M) cutaneous squamous cell carcinoma (CSCC). Updated data from these trials are pending and extent of survival outcomes is undetermined. OBJECTIVE: The aim of this study was to assess the efficacy of ICIs in advanced CSCC, comprising locally advanced (LA), locoregionally advanced (LR), and recurrent or metastatic (R/M) disease. PATIENTS AND METHODS: A systematic review of four databases (PubMed, Scopus, OVID, Cochrane) and meta-analysis of proportions was performed. Phase I and II prospective clinical trials were included. RESULTS: Six trials evaluating cemiplimab (n = 3) and pembrolizumab (n = 3) were eligible for inclusion. Overall survival (OS) was not reached at data-cutoff. Pooled analysis of 392 patients demonstrated that ICIs conferred an objective response rate (ORR) of 42.43% (95% CI 37.53-47.45) and disease control rate (DCR) of 58.05% (95% CI 53.04-62.95). Patients with LR or distant metastatic lesions achieved equivalent ORRs and DCRs. Duration of response (DOR) was not reached in all trials and 92% of all responders continued to have therapeutic response at data cut-off. Tolerability was favorable, with only 27.12% (95% CI 10.89-47.38) of patients experiencing grade ≥ 3 adverse events. CONCLUSION: Surgical treatment of CSCC remains the guideline-based standard of care for curative intent of local, LA, and LR disease. ICIs demonstrate promising results for LA, LR, and R/M CSCC not amenable to surgery. Endpoints assessing survival and durability of response have not been reached, warranting additional trials exploring neoadjuvant or adjuvant therapy in combination with local treatment.

Trend Analysis of Cutaneous Squamous Cell Carcinoma of the External Lip From 1975 to 2016.

Importance: Cutaneous squamous cell carcinoma (cSCC) is the second most common nonmelanoma skin cancer and commonly affects the head and neck. Increasing regional reports of aggressive cases warrant an analysis of population-based trends of cSCC of the head and neck. Objective: To assess demographic, clinical, and survival trends among patients with cSCC of the external lip. Design, Setting, and Participants: This was a retrospective, population-based cohort study of 15 171 cases of cSCC of the external lip registered in the Surveillance, Epidemiology, and End Results (SEER) database between 1975 and 2016. Statistical analyses were conducted in October 2020. Main Outcomes and Measures: The primary outcome was clinical characteristics (tumor site, stage, and tumor grade). Demographic characteristics, incidence, treatment characteristics, and survival outcomes were also assessed. Results: In total, 15 171 cases of cSCC were extracted from the SEER database (80.3% of patients were male, and 97.0% identified as being of White race/ethnicity). Incidence among male patients decreased from 4.4 to 0.8 per 100 000 during the study period, whereas the female patients' share cases increased from 8.4% in 1975 to 1979 to 26.1% by 2016. Cases increased in the US Pacific Coast and eastern regions, and along the 30° to 39° N latitudinal range, while decreasing in the southwestern region. Of 15 171 cases, 51.2% cases presented at stage I, and 96.2% were nonmetastatic. Cases of grade II and grade III tumors increased between 1975 and 2016. Five-year disease-specific survival remained stable at 95.9%; however, patients older than 75 years experienced worse disease-specific survival (93.2%) associated with decreasing survival trends among patients older than 85 years. Conclusion and Relevance: This population-based cohort study found that incidence of cSCC of the external lip decreased among men; however, cases increased along US coastal regions and in more northern US latitudes. Tumor grades were increasingly advanced, and patients older than 85 years should be given special prognosis and treatment consideration.

Pathways to Educational Disparities in Disability Incidence: The Contributions of Excess Body Mass Index, Smoking, and Manual Labor Involvement.

OBJECTIVES: In the United States, educational disparities in disability are large and increasing, but the mechanisms underlying them are not well understood. We estimate the proportion of population-level educational disparities in disability incidence explained by excess body mass index (BMI), smoking, and manual labor. METHOD: We use waves 2003-2015 of the nationally representative Panel Study of Income Dynamics to calculate observed disability incidence and counterfactual incidence absent the key mediators (3,129 individuals; 13,168 observations). We take advantage of earlier-life measures, including childhood socioeconomic status, 1986 BMI, and occupational history between 1968 and 2001. To account for distinct processes in women and men at middle versus older ages, we stratify by gender and at age 65. RESULTS: Educational disparities in disability incidence were evident in women and men at younger and older ages, and were largest among older women. Together, the mediators of interest were estimated to explain roughly 60% of disparities in younger women, 65%-70% in younger men, 40% in older women, and 20%-60% in older men. The main contributors to disparities appeared to be excess BMI and smoking in younger women; manual labor and smoking in younger men; excess BMI in older women; and smoking in older men. DISCUSSION: These mediators explain much of disparities in earlier-age disability; successful interventions to address these factors may substantially reduce them. However, a considerable proportion of disparities remained unexplained, particularly at older ages, reflecting the myriad pathways by which educational attainment can influence disability status.