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Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people

June 17, 2014 Comments off

Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1·25 million people
Source: The Lancet

Background
The associations of blood pressure with the different manifestations of incident cardiovascular disease in a contemporary population have not been compared. In this study, we aimed to analyse the associations of blood pressure with 12 different presentations of cardiovascular disease.

Methods
We used linked electronic health records from 1997 to 2010 in the CALIBER (CArdiovascular research using LInked Bespoke studies and Electronic health Records) programme to assemble a cohort of 1·25 million patients, 30 years of age or older and initially free from cardiovascular disease, a fifth of whom received blood pressure-lowering treatments. We studied the heterogeneity in the age-specific associations of clinically measured blood pressure with 12 acute and chronic cardiovascular diseases, and estimated the lifetime risks (up to 95 years of age) and cardiovascular disease-free life-years lost adjusted for other risk factors at index ages 30, 60, and 80 years. This study is registered at ClinicalTrials.gov, number NCT01164371.

Findings
During 5·2 years median follow-up, we recorded 83 098 initial cardiovascular disease presentations. In each age group, the lowest risk for cardiovascular disease was in people with systolic blood pressure of 90—114 mm Hg and diastolic blood pressure of 60—74 mm Hg, with no evidence of a J-shaped increased risk at lower blood pressures. The effect of high blood pressure varied by cardiovascular disease endpoint, from strongly positive to no effect. Associations with high systolic blood pressure were strongest for intracerebral haemorrhage (hazard ratio 1·44 [95% CI 1·32—1·58]), subarachnoid haemorrhage (1·43 [1·25—1·63]), and stable angina (1·41 [1·36—1·46]), and weakest for abdominal aortic aneurysm (1·08 [1·00—1·17]). Compared with diastolic blood pressure, raised systolic blood pressure had a greater effect on angina, myocardial infarction, and peripheral arterial disease, whereas raised diastolic blood pressure had a greater effect on abdominal aortic aneurysm than did raised systolic pressure. Pulse pressure associations were inverse for abdominal aortic aneurysm (HR per 10 mm Hg 0·91 [95% CI 0·86—0·98]) and strongest for peripheral arterial disease (1·23 [1·20—1·27]). People with hypertension (blood pressure ≥140/90 mm Hg or those receiving blood pressure-lowering drugs) had a lifetime risk of overall cardiovascular disease at 30 years of age of 63·3% (95% CI 62·9—63·8) compared with 46·1% (45·5—46·8) for those with normal blood pressure, and developed cardiovascular disease 5·0 years earlier (95% CI 4·8—5·2). Stable and unstable angina accounted for most (43%) of the cardiovascular disease-free years of life lost associated with hypertension from index age 30 years, whereas heart failure and stable angina accounted for the largest proportion (19% each) of years of life lost from index age 80 years.

Interpretation
The widely held assumptions that blood pressure has strong associations with the occurrence of all cardiovascular diseases across a wide age range, and that diastolic and systolic associations are concordant, are not supported by the findings of this high-resolution study. Despite modern treatments, the lifetime burden of hypertension is substantial. These findings emphasise the need for new blood pressure-lowering strategies, and will help to inform the design of randomised trials to assess them.

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Worldwide prevalence of non-partner sexual violence: a systematic review

February 17, 2014 Comments off

Worldwide prevalence of non-partner sexual violence: a systematic review
Source: The Lancet

Background
Several highly publicised rapes and murders of young women in India and South Africa have focused international attention on sexual violence. These cases are extremes of the wider phenomenon of sexual violence against women, but the true extent is poorly quantified. We did a systematic review to estimate prevalence.

Methods
We searched for articles published from Jan 1, 1998, to Dec 31, 2011, and manually search reference lists and contacted experts to identify population-based data on the prevalence of women’s reported experiences of sexual violence from age 15 years onwards, by anyone except intimate partners. We used random effects meta-regression to calculate adjusted and unadjusted prevalence for regions, which we weighted by population size to calculate the worldwide estimate.

Findings
We identified 7231 studies from which we obtained 412 estimates covering 56 countries. In 2010 7·2% (95% CI 5·2—9·1) of women worldwide had ever experienced non-partner sexual violence. The highest estimates were in sub-Saharan Africa, central (21%, 95%CI 4·5—37·5) and sub-Saharan Africa, southern (17·4%, 11·4—23·3). The lowest prevalence was for Asia, south (3·3%, 0—8·3). Limited data were available from sub-Saharan Africa, central, North Africa/Middle East, Europe, eastern, and Asia Pacific, high income.

Interpretation
Sexual violence against women is common worldwide, with endemic levels seen in some areas, although large variations between settings need to be interpreted with caution because of differences in data availability and levels of disclosure. Nevertheless, our findings indicate a pressing health and human rights concern.

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Alcohol and mortality in Russia: prospective observational study of 151 000 adults

February 5, 2014 Comments off

Alcohol and mortality in Russia: prospective observational study of 151 000 adults
Source: The Lancet

Background
Russian adults have extraordinarily high rates of premature death. Retrospective enquiries to the families of about 50 000 deceased Russians had found excess vodka use among those dying from external causes (accident, suicide, violence) and eight particular disease groupings. We now seek prospective evidence of these associations.

Methods
In three Russian cities (Barnaul, Byisk, and Tomsk), we interviewed 200 000 adults during 1999—2008 (with 12 000 re-interviewed some years later) and followed them until 2010 for cause-specific mortality. In 151 000 with no previous disease and some follow-up at ages 35—74 years, Poisson regression (adjusted for age at risk, amount smoked, education, and city) was used to calculate the relative risks associating vodka consumption with mortality. We have combined these relative risks with age-specific death rates to get 20-year absolute risks.

Findings
Among 57 361 male smokers with no previous disease, the estimated 20-year risks of death at ages 35—54 years were 16% (95% CI 15—17) for those who reported consuming less than a bottle of vodka per week at baseline, 20% (18—22) for those consuming 1—2·9 bottles per week, and 35% (31—39) for those consuming three or more bottles per week; trend p<0·0001. The corresponding risks of death at ages 55—74 years were 50% (48—52) for those who reported consuming less than a bottle of vodka per week at baseline, 54% (51—57) for those consuming 1—2·9 bottles per week, and 64% (59—69) for those consuming three or more bottles per week; trend p<0·0001. In both age ranges most of the excess mortality in heavier drinkers was from external causes or the eight disease groupings strongly associated with alcohol in the retrospective enquiries. Self-reported drinking fluctuated; of the men who reported drinking three or more bottles of vodka per week who were reinterviewed a few years later, about half (185 of 321) then reported drinking less than one bottle per week. Such fluctuations must have substantially attenuated the apparent hazards of heavy drinking in this study, yet self-reported vodka use at baseline still strongly predicted risk. Among male non-smokers and among females, self-reported heavy drinking was uncommon, but seemed to involve similar absolute excess risks.

Interpretation
This large prospective study strongly reinforces other evidence that vodka is a major cause of the high risk of premature death in Russian adults.

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Global burden of disease attributable to illicit drug use and dependence: findings from the Global Burden of Disease Study 2010

August 29, 2013 Comments off

Global burden of disease attributable to illicit drug use and dependence: findings from the Global Burden of Disease Study 2010
Source: The Lancet

Background
No systematic attempts have been made to estimate the global and regional prevalence of amphetamine, cannabis, cocaine, and opioid dependence, and quantify their burden. We aimed to assess the prevalence and burden of drug dependence, as measured in years of life lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life years (DALYs).

Methods
We conducted systematic reviews of the epidemiology of drug dependence, and analysed results with Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) Bayesian meta-regression technique (DisMod-MR) to estimate population-level prevalence of dependence and use. GBD 2010 calculated new disability weights by use of representative community surveys and an internet-based survey. We combined estimates of dependence with disability weights to calculate prevalent YLDs, YLLs, and DALYs, and estimated YLDs, YLLs, and DALYs attributable to drug use as a risk factor for other health outcomes.

Findings
Illicit drug dependence directly accounted for 20·0 million DALYs (95% UI 15·3—25·4 million) in 2010, accounting for 0·8% (0·6—1·0) of global all-cause DALYs. Worldwide, more people were dependent on opioids and amphetamines than other drugs. Opioid dependence was the largest contributor to the direct burden of DALYs (9·2 million, 95% UI 7·1—11·4). The proportion of all-cause DALYs attributed to drug dependence was 20 times higher in some regions than others, with an increased proportion of burden in countries with the highest incomes. Injecting drug use as a risk factor for HIV accounted for 2·1 million DALYs (95% UI 1·1—3·6 million) and as a risk factor for hepatitis C accounted for 502 000 DALYs (286 000—891 000). Suicide as a risk of amphetamine dependence accounted for 854 000 DALYs (291 000—1 791 000), as a risk of opioid dependence for 671 000 DALYs (329 000—1 730 000), and as a risk of cocaine dependence for 324 000 DALYs (109 000—682 000). Countries with the highest rate of burden (>650 DALYs per 100 000 population) included the USA, UK, Russia, and Australia.

Interpretation
Illicit drug use is an important contributor to the global burden of disease. Efficient strategies to reduce disease burden of opioid dependence and injecting drug use, such as delivery of opioid substitution treatment and needle and syringe programmes, are needed to reduce this burden at a population scale.

Funding
Australian National Health and Medical Research Council, Australian Government Department of Health and Ageing, Bill & Melinda Gates Foundation.

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Categories: drug abuse, The Lancet

Healthy life expectancy for 187 countries, 1990—2010: a systematic analysis for the Global Burden Disease Stud y 2010

December 13, 2012 Comments off

Healthy life expectancy for 187 countries, 1990—2010: a systematic analysis for the Global Burden Disease Study 2010

Source: The Lancet

Background

Healthy life expectancy (HALE) summarises mortality and non-fatal outcomes in a single measure of average population health. It has been used to compare health between countries, or to measure changes over time. These comparisons can inform policy questions that depend on how morbidity changes as mortality decreases. We characterise current HALE and changes over the past two decades in 187 countries.

Methods

Using inputs from the Global Burden of Disease Study (GBD) 2010, we assessed HALE for 1990 and 2010. We calculated HALE with life table methods, incorporating estimates of average health over each age interval. Inputs from GBD 2010 included age-specific information for mortality rates and prevalence of 1160 sequelae, and disability weights associated with 220 distinct health states relating to these sequelae. We computed estimates of average overall health for each age group, adjusting for comorbidity with a Monte Carlo simulation method to capture how multiple morbidities can combine in an individual. We incorporated these estimates in the life table by the Sullivan method to produce HALE estimates for each population defined by sex, country, and year. We estimated the contributions of changes in child mortality, adult mortality, and disability to overall change in population health between 1990 and 2010.

Findings

In 2010, global male HALE at birth was 58·3 years (uncertainty interval 56·7—59·8) and global female HALE at birth was 61·8 years (60·1—63·4). HALE increased more slowly than did life expectancy over the past 20 years, with each 1-year increase in life expectancy at birth associated with a 0·8-year increase in HALE. Across countries in 2010, male HALE at birth ranged from 27·9 years (17·3—36·5) in Haiti, to 68·8 years (67·0—70·4) in Japan. Female HALE at birth ranged from 37·1 years (26·9—43·7) in Haiti, to 71·7 years (69·7—73·4) in Japan. Between 1990 and 2010, male HALE increased by 5 years or more in 42 countries compared with 37 countries for female HALE, while male HALE decreased in 21 countries and 11 for female HALE. Between countries and over time, life expectancy was strongly and positively related to number of years lost to disability. This relation was consistent between sexes, in cross-sectional and longitudinal analysis, and when assessed at birth, or at age 50 years. Changes in disability had small effects on changes in HALE compared with changes in mortality.

Interpretation

HALE differs substantially between countries. As life expectancy has increased, the number of healthy years lost to disability has also increased in most countries, consistent with the expansion of morbidity hypothesis, which has implications for health planning and health-care expenditure. Compared with substantial progress in reduction of mortality over the past two decades, relatively little progress has been made in reduction of the overall effect of non-fatal disease and injury on population health. HALE is an attractive indicator for monitoring health post-2015.

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Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis

August 1, 2012 Comments off

Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis (PDF)

Source: The Lancet

Background

We did a meta-analysis to assess factors associated with disparities in HIV infection in black men who have sex with men (MSM) in Canada, the UK, and the USA.

Methods

We searched Embase, Medline, Google Scholar, and online conference proceedings from Jan 1, 1981, to Dec 31, 2011, for racial comparative studies with quantitative outcomes associated with HIV risk or HIV infection. Key words and Medical Subject Headings (US National Library of Medicine) relevant to race were cross-referenced with citations pertinent to homosexuality in Canada, the UK, and the USA. Data were aggregated across studies for every outcome of interest to estimate overall effect sizes, which were converted into summary ORs for 106 148 black MSM relative to 581 577 other MSM.

Finding

We analysed seven studies from Canada, 13 from the UK, and 174 from the USA. In every country, black MSM were as likely to engage similarly in serodiscordant unprotected sex as other MSM. Black MSM in Canada and the USA were less likely than other MSM to have a history of substance use (odds ratio, OR, 0·53, 95% CI 0·38–0·75, for Canada and 0·67, 0·50–0·92, for the USA). Black MSM in the UK (1·86, 1·58–2·18) and the USA (3·00, 2·06–4·40) were more likely to be HIV positive than were other MSM, but HIV-positive black MSM in each country were less likely (22% in the UK and 60% in the USA) to initiate combination antiretroviral therapy (cART) than other HIV-positive MSM. US HIV-positive black MSM were also less likely to have health insurance, have a high CD4 count, adhere to cART, or be virally suppressed than were other US HIV-positive MSM. Notably, despite a two-fold greater odds of having any structural barrier that increases HIV risk (eg, unemployment, low income, previous incarceration, or less education) compared with other US MSM, US black MSM were more likely to report any preventive behaviour against HIV infection (1·39, 1·23–1·57). For outcomes associated with HIV infection, disparities were greatest for US black MSM versus other MSM for structural barriers, sex partner demographics (eg, age, race), and HIV care outcomes, whereas disparities were least for sexual risk outcomes.

Interpretation

Similar racial disparities in HIV and sexually transmitted infections and cART initiation are seen in MSM in the UK and the USA. Elimination of disparities in HIV infection in black MSM cannot be accomplished without addressing structural barriers or differences in HIV clinical care access and outcomes.

Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy

July 19, 2012 Comments off

Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy

Source: The Lancet

Background

Strong evidence shows that physical inactivity increases the risk of many adverse health conditions, including major non-communicable diseases such as coronary heart disease, type 2 diabetes, and breast and colon cancers, and shortens life expectancy. Because much of the world’s population is inactive, this link presents a major public health issue. We aimed to quantify the effect of physical inactivity on these major non-communicable diseases by estimating how much disease could be averted if inactive people were to become active and to estimate gain in life expectancy at the population level.

Methods

For our analysis of burden of disease, we calculated population attributable fractions (PAFs) associated with physical inactivity using conservative assumptions for each of the major non-communicable diseases, by country, to estimate how much disease could be averted if physical inactivity were eliminated. We used life-table analysis to estimate gains in life expectancy of the population.

Findings

Worldwide, we estimate that physical inactivity causes 6% (ranging from 3·2% in southeast Asia to 7·8% in the eastern Mediterranean region) of the burden of disease from coronary heart disease, 7% (3·9—9·6) of type 2 diabetes, 10% (5·6—14·1) of breast cancer, and 10% (5·7—13·8) of colon cancer. Inactivity causes 9% (range 5·1—12·5) of premature mortality, or more than 5·3 million of the 57 million deaths that occurred worldwide in 2008. If inactivity were not eliminated, but decreased instead by 10% or 25%, more than 533 000 and more than 1·3 million deaths, respectively, could be averted every year. We estimated that elimination of physical inactivity would increase the life expectancy of the world’s population by 0·68 (range 0·41—0·95) years.

Interpretation

Physical inactivity has a major health effect worldwide. Decrease in or removal of this unhealthy behaviour could improve health substantially.

Funding

None.

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