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Alvarado M, Adams J, Penney T, Murphy MM, Abdool Karim S, Egan N, Rogers NT, Carters-White L, White M. A systematic scoping review evaluating sugar-sweetened beverage taxation from a systems perspective. Nat Food 2023; 4:986-995. [PMID: 37857862 PMCID: PMC10661741 DOI: 10.1038/s43016-023-00856-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 09/08/2023] [Indexed: 10/21/2023]
Abstract
Systems thinking can reveal surprising, counterintuitive or unintended reactions to population health interventions (PHIs), yet this lens has rarely been applied to sugar-sweetened beverage (SSB) taxation. Using a systematic scoping review approach, we identified 329 papers concerning SSB taxation, of which 45 considered influences and impacts of SSB taxation jointly, involving methodological approaches that may prove promising for operationalizing a systems informed approach to PHI evaluation. Influences and impacts concerning SSB taxation may be cyclically linked, and studies that consider both enable us to identify implications beyond a predicted linear effect. Only three studies explicitly used systems thinking informed methods. Finally, we developed an illustrative, feedback-oriented conceptual framework, emphasizing the processes that could result in an SSB tax being increased, maintained, eroded or repealed over time. Such a framework could be used to synthesize evidence from non-systems informed evaluations, leading to novel research questions and further policy development.
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Affiliation(s)
- Miriam Alvarado
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK.
| | - Jean Adams
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
| | - Tarra Penney
- Global Food System and Policy Research, School of Global Health, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Madhuvanti M Murphy
- George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, The University of the West Indies, Bridgetown, Barbados
| | | | - Nat Egan
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
| | - Nina Trivedy Rogers
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
| | - Lauren Carters-White
- SPECTRUM Consortium, Usher Institute of Population Health Sciences and Informatics, Old Medical School, University of Edinburgh, Edinburgh, UK
| | - Martin White
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
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Alvarado M, Marten R, Garcia L, Kwamie A, White M, Adams J. Using systems thinking to generate novel research questions for the evaluation of sugar-sweetened beverage taxation policies. BMJ Glob Health 2023; 8:e012060. [PMID: 37813450 PMCID: PMC10565209 DOI: 10.1136/bmjgh-2023-012060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/21/2023] [Indexed: 10/13/2023] Open
Affiliation(s)
- Miriam Alvarado
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
- George Alleyne Chronic Disease Research Centre, The University of the West Indies, Bridgetown, Barbados
| | - Robert Marten
- Alliance For Health Policy and System Research, Geneva, Switzerland
| | - Leandro Garcia
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Aku Kwamie
- Alliance For Health Policy and System Research, Geneva, Switzerland
| | - Martin White
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Jean Adams
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
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Alvarado M, Penney TL, Astbury CC, Forde H, White M, Adams J. Making integration foundational in population health intervention research: why we need 'Work Package Zero'. Public Health 2022; 211:1-4. [PMID: 35985222 DOI: 10.1016/j.puhe.2022.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We aimed to identify when and how integration should take place within evaluations of complex population health interventions (PHIs). STUDY DESIGN Descriptive analytical approach. METHODS We draw on conceptual insights that emerged through (1) a working group on integration and (2) a diverse range of literature on case studies, small-n evaluations and mixed methods evaluation studies. RESULTS We initially sought techniques to integrate analyses at the end of a complex PHI evaluation. However, this conceptualization of integration proved limiting. Instead, we found value in conceptualizing integration as a process that commences at the beginning of an evaluation and continues throughout. Many methods can be used for this type of integration, including process tracing, realist evaluation, congruence analysis, general elimination methodology/modus operandi, pattern matching and contribution analysis. Clearly signposting when integrative methods should commence within an evaluation should be of value to the PHI evaluation community, as well as to funders and related stakeholders. CONCLUSIONS Rather than being a tool used at the end of an evaluation, we propose that integration is more usefully conceived as a process that commences at the start of an evaluation and continues throughout. To emphasize the importance of this timing, integration can be described as comprising 'Work Package Zero' within evaluations of complex PHIs.
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Affiliation(s)
- M Alvarado
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom.
| | - T L Penney
- Global Food System and Policy Research, School of Global Health, Faculty of Health, York University, 4700 Keele Street, Toronto, Canada
| | - C C Astbury
- Global Food System and Policy Research, School of Global Health, Faculty of Health, York University, 4700 Keele Street, Toronto, Canada
| | - H Forde
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
| | - M White
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
| | - J Adams
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
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Roche M, Alvarado M, Sandoval RC, Gomes FDS, Paraje G. Comparing taxes as a percentage of sugar-sweetened beverage prices in Latin America and the Caribbean. Lancet Reg Health Am 2022; 11:None. [PMID: 35875252 PMCID: PMC9290324 DOI: 10.1016/j.lana.2022.100257] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Excise taxes can be used to reduce the consumption of sugar-sweetened beverages (SSBs), an important preventable risk factor for noncommunicable diseases. This study aimed to compare novel standardized indicators of the level of taxes applied on SSBs as a percentage of the price across beverage categories in Latin America and the Caribbean. Methods We used a method developed by the Pan American Health Organization and adapted from the World Health Organization's tobacco tax share. The analysis focused on the most sold brand of five categories of non-alcoholic beverages. Data were collected by surveying ministries of finance and reviewing tax legislation in effect as of March 2019. Findings Of the 27 countries analyzed, 17 applied excise taxes on SSBs. Of these, median excise taxes represented the highest share of the price for large sugar-sweetened carbonated drinks (6·5%) and the lowest for energy drinks (2·3%). In countries where excise taxes were applied on bottled waters, tax incidence exceeded the one applied on most SSBs. Overall, excise tax shares were higher in Latin America than in the Caribbean. Including all other indirect taxes (e.g., value added tax), median total tax shares were between 12·8% and 17·5%. At least two countries earmarked part of SSB excise tax revenues for health purposes. Interpretation Excise tax levels are generally low in the region. From a public health perspective, tax rates could be increased, and tax designs improved (e.g., excluding bottled waters). The method describe here provides a feasible and informative way to monitor SSB taxation and could be replicated in other regions and over time. Funding Bloomberg Philanthropies through the Global Health Advocacy Incubator.
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Key Words
- CIF, Cost, insurance, and freight
- Fiscal policies
- Health economics
- IMF, International Monetary Fund
- LAC, Latin America and the Caribbean
- NCD, Noncommunicable disease
- Noncommunicable diseases
- Nutrition policy
- Obesity
- PAHO, Pan American Health Organization
- PPP, Purchasing power parity
- SSB, Sugar-sweetened beverage
- Sugar-sweetened beverages
- VAT, Value added or sales taxes
- WHO, World Health Organization
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Affiliation(s)
- Maxime Roche
- Centre for Health Economics and Policy Innovation (CHEPI), Imperial College Business School, Exhibition Rd, London SW7 2AZ, UK
| | - Miriam Alvarado
- MRC Epidemiology Unit, Cambridge Biomedical Campus, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, UK
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Sandoval RC, Roche M, Belausteguigoitia I, Alvarado M, Galicia L, Gomes FS, Paraje G. [Excise taxes on sugar-sweetened beverages in Latin America and the CaribbeanImposto especial de consumo sobre bebidas açucaradas na América Latina e no Caribe]. Rev Panam Salud Publica 2021; 45:e124. [PMID: 34539768 PMCID: PMC8442714 DOI: 10.26633/rpsp.2021.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/01/2020] [Indexed: 11/26/2022] Open
Abstract
Objetivo. Caracterizar el diseño de los impuestos selectivos al consumo de bebidas azucaradas en América Latina y el Caribe, y evaluar las oportunidades de aumentar su impacto en el consumo y la salud. Métodos. Se llevó a cabo una búsqueda y una evaluación exhaustivas de legislaciones vigentes a marzo del 2019, recopiladas mediante las herramientas de seguimiento ya existentes de la Organización Panamericana de la Salud y de la Organización Mundial de la Salud, fuentes secundarias, así como mediante una encuesta a ministerios de finanzas. El análisis se centró en el tipo de productos gravados y la estructura y la base de estos impuestos selectivos. Resultados. De los 33 países evaluados, en 21 se aplican impuestos selectivos al consumo de bebidas azucaradas. En siete países también se aplican impuestos selectivos sobre el agua embotellada y en al menos cuatro, se aplican tales impuestos sobre las bebidas lácteas azucaradas. Diez de estos impuestos selectivos al consumo son de tipo ad valorem con algunas bases imponibles fijadas en las primeras etapas de la cadena de valor, siete son de tipo específico y cuatro son de estructura combinada o mixta. En tres países se aplican impuestos selectivos al consumo en función de la concentración de azúcares del producto. Conclusiones. Si bien el número de países en que se aplican impuestos selectivos al consumo de bebidas azucaradas es prometedor, existe una gran heterogeneidad en su diseño en cuanto a la estructura, la base imponible y los productos gravados. Se podrían aprovechar aún más los impuestos selectivos existentes para tener un mayor impacto sobre el consumo de bebidas azucaradas y la salud si se incluyeran todas las categorías de bebidas azucaradas, excluyendo el agua embotellada, y si se recurriera más a impuestos específicos ajustados regularmente según la inflación y basados posiblemente en la concentración de azúcares del producto. Todos los países se beneficiarían si hubiera mayor orientación. Futuras investigaciones deberían tener como objetivo abordar esta brecha.
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Affiliation(s)
- Rosa Carolina Sandoval
- Organización Panamericana de la Salud Washington, D.C. Estados Unidos de América Organización Panamericana de la Salud, Washington, D.C. Estados Unidos de América
| | - Maxime Roche
- Organización Panamericana de la Salud Washington, D.C. Estados Unidos de América Organización Panamericana de la Salud, Washington, D.C. Estados Unidos de América
| | | | - Miriam Alvarado
- Universidad de Cambridge Cambridge Reino Unido Universidad de Cambridge, Cambridge, Reino Unido
| | - Luis Galicia
- Ministerio de Salud Pública del Uruguay Montevideo Uruguay Ministerio de Salud Pública del Uruguay, Montevideo, Uruguay
| | - Fabio S Gomes
- Organización Panamericana de la Salud Washington, D.C. Estados Unidos de América Organización Panamericana de la Salud, Washington, D.C. Estados Unidos de América
| | - Guillermo Paraje
- Universidad Adolfo Ibáñez Santiago Chile Universidad Adolfo Ibáñez, Santiago, Chile
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Affiliation(s)
- M Alvarado
- Servicio de Medicina Física y Rehabilitación, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, España
| | - Y Lin-Miao
- Servicio de Neurología, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, España
| | - M Carrillo-Arolas
- Servicio de Medicina Física y Rehabilitación, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, España
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Alvarado M, Lin-Miao Y, Carrillo-Arolas M. Parsonage-Turner syndrome post-infection by SARS-CoV-2: a case report. Neurologia 2021; 36:568-571. [PMID: 34315680 PMCID: PMC8295025 DOI: 10.1016/j.nrleng.2021.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/25/2021] [Indexed: 01/31/2023] Open
Affiliation(s)
- M. Alvarado
- Servicio de Medicina Física y Rehabilitación, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, Spain,Corresponding author
| | - Y. Lin-Miao
- Servicio de Neurología, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - M. Carrillo-Arolas
- Servicio de Medicina Física y Rehabilitación, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, Spain
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Alvarado M, Penney TL, Unwin N, Murphy MM, Adams J. Evidence of a health risk 'signalling effect' following the introduction of a sugar-sweetened beverage tax. Food Policy 2021; 102:102104. [PMID: 34404960 PMCID: PMC8346947 DOI: 10.1016/j.foodpol.2021.102104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 06/13/2023]
Abstract
Consuming sugar-sweetened beverages (SSBs) has been associated with increased rates of obesity and type 2 diabetes, making SSBs an increasingly popular target for taxation. In addition to changing prices, the introduction of an SSB tax may convey information about the health risks of SSBs (a signalling effect). If SSB taxation operates in part by producing a health risk signal, there may be important opportunities to amplify this effect. Our aim was to assess whether there is evidence of a risk signalling effect following the introduction of the Barbados SSB tax. We used process tracing to assess the existence of a signalling effect around sodas and sugar-sweetened juices (juice drinks). We used three data sources: 611 archived transcripts of local television news, 30 interviews with members of the public, and electronic point of sales data (46 months) from a major grocery store chain. We used directed content analysis to assess the qualitative data and an interrupted time series analysis to assess the quantitative data. We found evidence consistent with a risk signalling effect following the introduction of the SSB tax for sodas but not for juice drinks. Consistent with risk signalling theory, the findings suggest that consumers were aware of the tax, believed in a health rationale for the tax, understood that sodas were taxed and perceived that sodas and juice drinks were unhealthy. However consumers appear not to have understood that juice drinks were taxed, potentially reducing tax effectiveness from a health perspective. In addition, the tax may have incentivised companies to increase advertising around juice drinks (undermining any signalling effect) and to introduce low-cost SSB product lines. Policymakers can maximize the impact of risk signals by being clear about the definition of taxed SSBs, emphasizing the health rationale for introducing such a policy, and introducing co-interventions (e.g. marketing restrictions) that reduce opportunities for industry countersignals. These actions may amplify the impact of an SSB tax.
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Affiliation(s)
- Miriam Alvarado
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
| | - Tarra L. Penney
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
- Global Health Program, Faculty of Health, York University, 4700 Keele Street, Toronto, Canada
| | - Nigel Unwin
- Global Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
- European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, United Kingdom
- George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, The University of the West Indies, Bridgetown, Barbados
| | - Madhuvanti M. Murphy
- George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, The University of the West Indies, Bridgetown, Barbados
| | - Jean Adams
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
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Sandoval RC, Roche M, Belausteguigoitia I, Alvarado M, Galicia L, Gomes FS, Paraje G. Excise taxes on sugar-sweetened beverages in Latin America and the Caribbean. Rev Panam Salud Publica 2021; 45:e21. [PMID: 33727907 PMCID: PMC7954193 DOI: 10.26633/rpsp.2021.21] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/01/2020] [Indexed: 01/05/2023] Open
Abstract
Objective To characterize the design of excise taxes on sugar-sweetened beverages (SSBs) in Latin America and the Caribbean and assess opportunities to increase their impact on SSB consumption and health. Methods A comprehensive search and review of the legislation in effect as of March 2019, collected through existing Pan American Health Organization and World Health Organization monitoring tools, secondary sources, and surveying ministries of finance. The analysis focused on the type of products taxed, and the structure and base of these excise taxes. Results Out of the 33 countries analyzed, 21 apply excise taxes on SSBs. Seven countries also apply excise taxes on bottled water and at least four include sugar-sweetened milk drinks. Ten of these excise taxes are ad valorem with some tax bases set early in the value chain, seven are amount-specific, and four have either a combined or mixed structure. Three countries apply excise taxes based on sugar concentration. Conclusions While the number of countries applying excise taxes on SSBs is promising, there is great heterogeneity in design in terms of structure, tax base, and products taxed. Existing excise taxes could be further leveraged to improve their impact on SSB consumption and health by including all categories of SSBs, excluding bottled water, and relying more on amount-specific taxes regularly adjusted for inflation and possibly based on sugar concentration. All countries would benefit from additional guidance. Future research should aim to address this gap.
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Affiliation(s)
- Rosa Carolina Sandoval
- Pan American Health Organization Washington D.C. United States of America Pan American Health Organization, Washington D.C., United States of America
| | - Maxime Roche
- Pan American Health Organization Washington D.C. United States of America Pan American Health Organization, Washington D.C., United States of America
| | - Itziar Belausteguigoitia
- University of Lancaster Lancaster United Kingdom University of Lancaster, Lancaster, United Kingdom
| | - Miriam Alvarado
- University of Cambridge Cambridge United Kingdom University of Cambridge, Cambridge, United Kingdom
| | - Luis Galicia
- Ministry of Health of Uruguay Montevideo Uruguay Ministry of Health of Uruguay, Montevideo, Uruguay
| | - Fabio S Gomes
- Pan American Health Organization Washington D.C. United States of America Pan American Health Organization, Washington D.C., United States of America
| | - Guillermo Paraje
- Universidad Adolfo Ibáñez Santiago Chile Universidad Adolfo Ibáñez, Santiago, Chile
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Shimizu S, Alvarado M. A New Genus and Two New Species of the Subfamily Nesomesochorinae Ashmead (Insecta: Hymenoptera: Ichneumonidae). Neotrop Entomol 2020; 49:704-712. [PMID: 32607900 DOI: 10.1007/s13744-020-00778-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/13/2020] [Indexed: 06/11/2023]
Abstract
Nesomesochorinae is a rather small subfamily of Darwin wasps (Insecta: Hymenoptera: Ichneumonidae), only with three described genera. We recognize a fourth nesomesochorine genus from Perú and describe it as a new genus, Bina Shimizu & Alvarado gen. nov. The new genus is distinguished from previously described genera of Nesomesochorinae by the following combination of character states: mandible parallel-sided proximally and abruptly strongly narrowed ventroapically so that its lower apical tooth is much smaller and sharper than upper tooth; propodeum with lateromedian longitudinal carinae between anterior and posterior transverse carinae developed on more than posterior 0.9 so that the area superomedia is more or less enclosed; thyridium of 2nd metasomal tergite sometimes very large; 1st metasomal tergite stout and arched; body highly shiny. Bina gen. nov. comprises two species also described as new to science: B. huayrurae Shimizu & Alvarado sp. nov. (type species of Bina gen. nov.) and B. nigra Shimizu & Alvarado sp. nov. Identification keys to genera of Nesomesochorinae and to species of Bina gen. nov. are provided.
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Affiliation(s)
- S Shimizu
- Lab of Insect Biodiversity and Ecosystem Science, Graduate School of Agricultural Science, Kôbe Univ, Rokkôdaichô 1-1, Nada, Kôbe, Hyôgo,, 657-8501, Japan.
- Dept of Life Sciences, The Natural History Museum, London, UK.
- Research Fellow (DC and Overseas Challenge Program for Young Researchers), Japan Society for the Promotion of Science (JSPS), Tôkyô, Japan.
| | - M Alvarado
- Depto de Entomología, Museo de Historia Natural, Univ Nacional Mayor de San Marcos, Av. Arenales 1256 Jesús María, Lima 14, Peru
- Bosque Llaqta, Av. Confraternidad Internacional Este No. 364, Huaraz, Peru
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Alvarado M, Harris R, Rose A, Unwin N, Hambleton I, Imamura F, Adams J. Using nutritional survey data to inform the design of sugar-sweetened beverage taxes in low-resource contexts: a cross-sectional analysis based on data from an adult Caribbean population. BMJ Open 2020; 10:e035981. [PMID: 32912976 PMCID: PMC7485232 DOI: 10.1136/bmjopen-2019-035981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Sugar-sweetened beverage (SSB) taxes have been implemented widely. We aimed to use a pre-existing nutritional survey data to inform SSB tax design by assessing: (1) baseline consumption of SSBs and SSB-derived free sugars, (2) the percentage of SSB-derived free sugars that would be covered by a tax and (3) the extent to which a tax would differentiate between high-sugar SSBs and low-sugar SSBs. We evaluated these three considerations using pre-existing nutritional survey data in a developing economy setting. METHODS We used data from a nationally representative cross-sectional survey in Barbados (2012-2013, prior to SSB tax implementation). Data were available on 334 adults (25-64 years) who completed two non-consecutive 24-hour dietary recalls. We estimated the prevalence of SSB consumption and its contribution to total energy intake, overall and stratified by taxable status. We assessed the percentage of SSB-derived free sugars subject to the tax and identified the consumption-weighted sugar concentration of SSBs, stratified by taxable status. FINDINGS Accounting for sampling probability, 88.8% of adults (95% CI 85.1 to 92.5) reported SSB consumption, with a geometric mean of 2.4 servings/day (±2 SD, 0.6, 9.2) among SSB consumers. Sixty percent (95% CI 54.6 to 65.4) of SSB-derived free sugars would be subject to the tax. The tax did not clearly differentiate between high-sugar beverages and low-sugar beverages. CONCLUSION Given high SSB consumption, targeting SSBs was a sensible strategy in this setting. A substantial percentage of free sugars from SSBs were not covered by the tax, reducing possible health benefits. The considerations proposed here may help policymakers to design more effective SSB taxes.
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Affiliation(s)
- Miriam Alvarado
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Rachel Harris
- Faculty of Medical Sciences, University of the West Indies, Cave Hill, Barbados
| | - Angela Rose
- George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, University of the West Indies at Cave Hill, Bridgetown, Barbados
- Epidemiology Department, Epiconcept, Paris, France
| | - Nigel Unwin
- Global Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
- College of Medicine and Health, University of Exeter, Truro, UK
| | - Ian Hambleton
- George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, University of the West Indies at Cave Hill, Bridgetown, Barbados
| | - Fumiaki Imamura
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Jean Adams
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
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Avila M, Alvarado M, Axtell A, Goff J, Funston J, Lentz S. Universal immunohistochemistry testing in endometrial cancer tumors maximizes Lynch Syndrome identification among affected individuals. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.03.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Salyer C, Lentz S, Dontsi M, Armstrong M, Butt A, Hoodfar E, Alvarado M, Landers E, Avila M, Nguyen N, Powell CB. Comparison of effectiveness of two strategies to identify Lynch Syndrome in women with endometrial cancer. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.03.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Salyer C, Lentz S, Dontsi M, Armstrong M, Hoodfar E, Alvarado M, Powell B. Surveillance testing and cancer outcomes among endometrial cancer patients with Lynch syndrome. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.04.478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Salyer C, Lentz S, Dontsi M, Armstrong M, Hoodfar E, Alvarado M, Landers E, Avila M, Nguyen N, Powell B. Lynch syndrome in women with endometrial cancer: Comparison of universal and age-based strategies in a California healthcare system. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.04.479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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16
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Fahrner-Scott KE, Wong JM, Piper M, Ewing C, Alvarado M, Esserman LJ, Hylton N, Mukhtar RA. Abstract P1-15-15: Accuracy of MRI after neoadjuvant therapy for invasive lobular carcinoma of the breast. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p1-15-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Invasive lobular carcinoma of the breast (ILC) has higher rates of false negative imaging than invasive ductal carcinoma, and lower rates of neoadjuvant therapy (NAT) use. We evaluated the accuracy of Breast Imaging Reporting And Data System (BIRADS) findings on magnetic resonance imaging (MRI) after either neoadjuvant chemotherapy or endocrine therapy, and determined whether imaging change correlates with disease free survival.
Methods: We queried a database of 674 ILC cases treated at UCSF from 1981-2017 and identified all patients treated with NAT. We reviewed MRI reports and recorded BIRADS descriptors of findings, maximal tumor diameter for mass or non-mass enhancement (NME), and subjective radiologist comments on progression or improvement. We used the t-test, chi-squared test, Pearson's correlation, and Kaplan Meier survival estimates to evaluate the accuracy of MRI after NAT compared to true tumor size on pathology, and the relationship between imaging change and disease free interval in Stata 14.2.
Results: Of 136 patients with ILC treated with NAT, we included 101 women who had a post-treatment breast MRI report available. Of these, 58.4% received neoadjuvant chemotherapy, and 41.6% neoadjuvant endocrine therapy. After NAT, MRI findings were mass only in 43%, both mass/NME in 33%, NME only in 18%, and neither in 5%. Maximal diameter of mass on post-treatment MRI underestimated true size by a mean of 3.3 cm (range -3.6 to 15.3 cm). NME size on post-treatment MRI underestimated true size by a mean of 1.87 cm (range -7.2 to 9.7 cm). Mass size on MRI underestimated true size by ≥1 cm in 61.5% of cases; this size discrepancy was associated with increased positive margins (46.4% versus 20%, p=0.011). NME size on MRI underestimated true size by at ≥1 cm in 65.6%. The correlation coefficient between mass size on MRI and true size was 0.34 (p=0.0041), which increased to 0.67 (p<0.0001) when excluding those with associated NME. The correlation coefficient between NME size on MRI and true size was 0.28 (p=0.1239). Subjective progression on post-treatment MRI was associated with increased recurrence rates (80% versus 18.3%, p=0.001). In those with subjective improvement on MRI, there was a trend towards longer disease free interval (89% versus 73% disease free at 4 years, p=0.13).
Table 1.Patient and tumor characteristics. Neoadjuvant chemotherapy (n=59)Neoadjuvant endocrine therapy (n=42)P valueMean age (yrs, 95% CI)53.6 (50.9-56.3)61.3 (58.4-64.1)0.0002Subtype 0.105ER+ PR+ HER2-29 (53.7%)23 (62.16%) ER+ PR- HER2-14 (25.9%)13 (35.14%) ER- PR- HER2-1 (1.85%)0 HER2+10 (18.5%)1 (2.7%) Grade 0.076114 (25%)16 (38.1%) 237 (66.1%)26 (61.9%) 35 (8.93%)0 Surgical stage <0.001I17 (28.81%)28 (66.67%) II26 (44.07%)6 (14.29%) III16 (27.12%)8 (19.1%) Mean follow-up time (yrs, 95% CI)5.6 (4.53-6.75)5.1 (3.84-6.27)0.48
Conclusions: Maximal tumor diameter on MRI after NAT in ILC vastly underestimates true tumor size. While these findings suggest using caution when using an MRI for surgical planning in patients with ILC, particularly if there is associated NME, the trend towards improved disease free survival in those with a subjective improvement is intriguing and suggests that MRI changes could become an early predictor of outcomes.
Citation Format: Fahrner-Scott KE, Wong JM, Piper M, Ewing C, Alvarado M, Esserman LJ, Hylton N, Mukhtar RA. Accuracy of MRI after neoadjuvant therapy for invasive lobular carcinoma of the breast [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-15.
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Affiliation(s)
| | - JM Wong
- University of California, San Francisco, San Francisco, CA
| | - M Piper
- University of California, San Francisco, San Francisco, CA
| | - C Ewing
- University of California, San Francisco, San Francisco, CA
| | - M Alvarado
- University of California, San Francisco, San Francisco, CA
| | - LJ Esserman
- University of California, San Francisco, San Francisco, CA
| | - N Hylton
- University of California, San Francisco, San Francisco, CA
| | - RA Mukhtar
- University of California, San Francisco, San Francisco, CA
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Magbanua MJM, Yau C, Wolf D, Lee JS, Chattopadhyay A, Scott JH, Yoder E, Hwang S, Alvarado M, Ewing CA, Delson AL, van't Veer L, Esserman L, Park JW. Abstract P3-01-02: Detection of circulating tumor cells (CTC) in blood and disseminated tumor cells (DTC) in bone marrow at surgery identifies breast cancer patients (pts) with long-term risk of distant recurrence and breast cancer-specific death. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p3-01-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
We examined the prognostic impact of CTCs and DTCs detected at the time of definitive surgery in pts diagnosed with early breast cancer (EBC).
Methods: Blood and bone marrow samples from 742 treatment-naïve EBC pts, not eligible for neoadjuvant therapy, were collected immediately prior to surgery. 87% were hormone receptor (HR)-positive, and 71% were node-negative. DTCs (n=584) were enumerated using an EPCAM-based method involving immunomagnetic enrichment and flow cytometry (IE/FC). CTCs were enumerated either by IE/FC (n=288) or CellSearch (n=380). Optimal cutoffs for CTC-/DTC-positivity were selected using Monte-Carlo cross validation. Multivariate Cox regression analysis was performed to determine correlation between levels of CTCs/DTCs vs. distant recurrence-free survival (DRFS) and breast cancer-specific survival (BCSS). The overall median follow-up was 7.1 years for DRFS and and 9.1 years for BCSS, but extended up to 13.3 years in subset analyses (Table 1).
Results: CTC-positivity by CellSearch was associated with HER2-positivity (Fisher p=0.01). Using optimized cutoffs in multivariate analyses, we found that CTC-positive pts by CellSearch had a statistically significant increased risk of distant recurrence (HR 4.93, p=0.0067). Moreover, pts who were CTC-positive by IE/FC had a statistically significant increased risk of breast cancer-specific death (HR=3.54, p=0.0138). DTC status, by itself, was not prognostic; however, when combined with CTC status by IE/FC (n=273), positive detection for both (CTC+DTC+) was significantly associated with increased risk of distant recurrence (HR=3.09, p=0.0270) and breast cancer-specific death (HR=4.55, p=0.0205).
Table 1.Multivariate analysis to determine the prognostic significance of CTCs and DTCs detected at the time of surgery in treatment naive early breast cancer patients. Adjusted for age at diagnosis, tumor size, pathologic stage, HR and HER2 status, node status and grade. DRFS BCSS Variable and Method% positiveHR [95% CI]Wald p-valueMedian f/u [range] Years*HR [95% CI]Wald p-valueMedian f/u [range] Years*CTC+ vs. CTC- by CellSearch94.93[1.56-15.6]0.00676.4 [0.16-13.8]4.50[0.76-26.5]0.09627.5 [0.71-15.0]CTC+ vs. CTC- by IE/FC401.92[0.93-3.95]0.07599.8 [0.09-18.5]3.54[1.29-9.72]0.013813.3 [1.93-18.5]DTC+ vs. DTC- by IE/FC181.46[0.75-2.81]0.26317.5 [0.09-18.5]1.48[0.64-3.42]0.35429.8 [1.55-18.5]CTC+DTC+ vs. CTC-DTC- by IE/FC8**3.09[1.14-8.40]0.02709.8 [0.09-18.5]4.55[1.26-16.39]0.020513.3 [1.93-18.5]*f/u - follow-up; **double positive
Conclusions: We demonstrate the impact of quantitative evaluation of CTCs and DTCs by IE/FC. Our large single institution dataset, in which CTCs and DTCs have been contemporaneously quantitated, has the longest patient follow-up. Simultaneous detection of CTCs and DTCs at the time of definitive surgery in treatment naïve EBC pts is an independent prognostic factor associated with increased long-term risk of distant recurrence and death due to breast cancer. Given the lack of early endpoints for low-risk patients, liquid biopsy may be an important consideration for future studies.
Citation Format: Magbanua MJM, Yau C, Wolf D, Lee JS, Chattopadhyay A, Scott JH, Yoder E, Hwang S, Alvarado M, Ewing CA, Delson AL, van't Veer L, Esserman L, Park JW. Detection of circulating tumor cells (CTC) in blood and disseminated tumor cells (DTC) in bone marrow at surgery identifies breast cancer patients (pts) with long-term risk of distant recurrence and breast cancer-specific death [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-01-02.
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Affiliation(s)
- MJM Magbanua
- University of California San Francisco, San Francisco; Duke University, Durham
| | - C Yau
- University of California San Francisco, San Francisco; Duke University, Durham
| | - D Wolf
- University of California San Francisco, San Francisco; Duke University, Durham
| | - JS Lee
- University of California San Francisco, San Francisco; Duke University, Durham
| | - A Chattopadhyay
- University of California San Francisco, San Francisco; Duke University, Durham
| | - JH Scott
- University of California San Francisco, San Francisco; Duke University, Durham
| | - E Yoder
- University of California San Francisco, San Francisco; Duke University, Durham
| | - S Hwang
- University of California San Francisco, San Francisco; Duke University, Durham
| | - M Alvarado
- University of California San Francisco, San Francisco; Duke University, Durham
| | - CA Ewing
- University of California San Francisco, San Francisco; Duke University, Durham
| | - AL Delson
- University of California San Francisco, San Francisco; Duke University, Durham
| | - L van't Veer
- University of California San Francisco, San Francisco; Duke University, Durham
| | - L Esserman
- University of California San Francisco, San Francisco; Duke University, Durham
| | - JW Park
- University of California San Francisco, San Francisco; Duke University, Durham
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Alvarado M, Unwin N, Sharp SJ, Hambleton I, Murphy MM, Samuels TA, Suhrcke M, Adams J. Assessing the impact of the Barbados sugar-sweetened beverage tax on beverage sales: an observational study. Int J Behav Nutr Phys Act 2019; 16:13. [PMID: 30700311 PMCID: PMC6354371 DOI: 10.1186/s12966-019-0776-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/22/2019] [Indexed: 01/11/2023] Open
Abstract
Background The World Health Organization has advocated for sugar-sweetened beverage (SSB) taxes as part of a broader non-communicable disease prevention strategy, and these taxes have been recently introduced in a wide range of settings. However, much is still unknown about how SSB taxes operate in various contexts and as a result of different tax designs. In 2015, the Government of Barbados implemented a 10% ad valorem (value-based) tax on SSBs. It has been hypothesized that this tax structure may inadvertently encourage consumers to switch to cheaper sugary drinks. We aimed to assess whether and to what extent there has been a change in sales of SSBs following implementation of the SSB tax. Methods We used electronic point of sale data from a major grocery store chain and applied an interrupted time series (ITS) design to assess grocery store SSB and non-SSB sales from January 2013 to October 2016. We controlled for the underlying time trend, seasonality, inflation, tourism and holidays. We conducted sensitivity analyses using a cross-country control (Trinidad and Tobago) and a within-country control (vinegar). We included a post-hoc stratification by price tertile to assess the extent to which consumers may switch to cheaper sugary drinks. Results We found that average weekly sales of SSBs decreased by 4.3% (95%CI 3.6 to 4.9%) compared to expected sales without a tax, primarily driven by a decrease in carbonated SSBs sales of 3.6% (95%CI 2.9 to 4.4%). Sales of non-SSBs increased by 5.2% (95%CI 4.5 to 5.9%), with bottled water sales increasing by an average of 7.5% (95%CI 6.5 to 8.3%). The sensitivity analyses were consistent with the uncontrolled results. After stratifying by price, we found evidence of substitution to cheaper SSBs. Conclusions This study suggests that the Barbados SSB tax was associated with decreased sales of SSBs in a major grocery store chain after controlling for underlying trends. This finding was robust to sensitivity analyses. We found evidence to suggest that consumers may have changed their behaviour in response to the tax by purchasing cheaper sugary drinks, in addition to substituting to untaxed products. This has important implications for the design of future SSB taxes. Electronic supplementary material The online version of this article (10.1186/s12966-019-0776-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Miriam Alvarado
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK.
| | - Nigel Unwin
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Stephen J Sharp
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Ian Hambleton
- George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, University of the West Indies, Bridgetown, Barbados
| | - Madhuvanti M Murphy
- Faculty of Medical Sciences, Cave Hill Campus, University of the West Indies, Bridgetown, Barbados
| | - T Alafia Samuels
- George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, University of the West Indies, Bridgetown, Barbados
| | - Marc Suhrcke
- Centre for Health Economics, University of York, York, UK
| | - Jean Adams
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
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Foster N, Thow AM, Unwin N, Alvarado M, Samuels TA. Regulatory measures to fight obesity in Small Island Developing States of the Caribbean and Pacific, 2015 - 2017. Rev Panam Salud Publica 2018; 42:e191. [PMID: 31093218 PMCID: PMC6386011 DOI: 10.26633/rpsp.2018.191] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 09/06/2018] [Indexed: 01/22/2023] Open
Abstract
This report examines the experiences of Small Island Developing States in the Caribbean— Barbados, Dominica, Jamaica, and in the Pacific— Fiji, Nauru, and Tonga with specific governmental regulatory measures to reduce the risk of obesity and associated diet-related chronic noncommunicable diseases (NCDs), as well as the obstacles and opportunities encountered. Guided by the diet-related indicators of the World Health Organization (WHO) Noncommunicable Diseases Progress Monitor 2017, the authors reviewed legislation, country reports, articles, and the databases of WHO and the World Trade Organization to identify relevant regulatory measures and to establish the extent of implementation in the selected countries. Obesity prevalence ranged from 25.9% in Dominica to 41.1% in Tonga. The principal diet-related measures implemented by the selected countries were fiscal measures, such as sugar-sweetened beverage taxes and import duties to encourage greater consumption of healthy foods. Governmental action was weakest in the area of restrictions on marketing of unhealthy foods. If they are to reduce their current high rates of obesity and associated NCDs, Caribbean and Pacific states need to intensify implementation of diet-related regulatory measures, particularly in the area of marketing of unhealthy foods and beverages to children. Key implementation challenges include financial and staffing constraints and the need for increased political will to counter industry opposition and to allocate adequate financial resources to keep advancing this agenda.
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Affiliation(s)
- Nicole Foster
- Faculty of Law, The University of the West Indies, Bridgetown, Barbados
| | - Anne Marie Thow
- Menzies Centre for Health Policy, Charles Perkins Centre and Sydney School of Public Health, The University of Sydney, New South Wales, Australia
| | - Nigel Unwin
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Miriam Alvarado
- Centre for Diet and Activity Research, Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - T Alafia Samuels
- George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, The University of the West Indies, Bridgetown, Barbados
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Huang RJ, Mukhtar RA, Alvarado M. Abstract P4-10-19: Disparities in use of adjuvant radiotherapy following lumpectomy among California regions. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p4-10-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
Women undergoing lumpectomy for invasive breast cancer typically receive radiotherapy (RT) to reduce risk of recurrence. Previous studies have reported disparities in the utilization of RT by race, socioeconomic status (SES), and age. In this study, we evaluate whether various sociodemographic factors are associated with use of RT in the different regions of California.
Methods
Utilizing data from the California Cancer Registry, the authors identified cases of women whose first primary invasive breast cancer was diagnosed between January 1, 2007 and December 31, 2012, whose primary surgery was breast conserving surgery, and for whom information was complete (n = 71,767). Multivariate logistic regression was used to determine whether demographic factors (SES, race, payer status, age) were significantly associated with use of RT following lumpectomy (p < .05), adjusting for tumor characteristics (size, stage, grade, hormone receptor status, and nodal status).
Results
In three out of eight regions in California, black race was associated with decreased odds of RT use (San Francisco, OR = 0.79, 95% CI = 0.68-0.92; Desert Sierra, OR = 0.72, 95% CI = 0.58-0.90; Los Angeles, OR = 0.78, 95% CI = 0.70-0.87). In Sacramento and Los Angeles regions, lower socioeconomic status was associated with declined odds of RT use. Age (70 years or older) was also associated with lower likelihood of RT use across all regions.
Conclusions
Even after accounting for payer status, racial and socioeconomic disparities persist in the use of RT. These disparities, previously documented in the time period of 2000-2007, have not disappeared. Hispanic race was not shown to be associated with decreased odds of RT use in Los Angeles, contrary to the results of a previous study. Women aged 70 years or older are less likely to receive RT.
Citation Format: Huang RJ, Mukhtar RA, Alvarado M. Disparities in use of adjuvant radiotherapy following lumpectomy among California regions [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-19.
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Affiliation(s)
- RJ Huang
- University of California, San Francisco, San Francisco, CA
| | - RA Mukhtar
- University of California, San Francisco, San Francisco, CA
| | - M Alvarado
- University of California, San Francisco, San Francisco, CA
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21
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Quispe D, Alvarado M, Rivas D, Gonzales I. [Extramedullary intradural tuberculosis: a case report and review of the literature]. Rev Neurol 2018; 66:21-24. [PMID: 29251339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Central nervous system tuberculosis is a common chronic infection in developing countries, being the most frequent forms: tuberculous meningitis and intracranial tuberculosis. Extramedullary intradural tuberculosis is a rare entity with few cases described in the world literature, and is usually associated with a history of tuberculous meningitis or during antituberculosis treatment. CASE REPORT A 17 years-old male patient, without history of tuberculosis, with subacute onset and progressive course of compressive myelopathy. Spinal magnetic resonance imaging revealed an intradural extramedullary mass lesion between the C4 and T8 spinal levels. Surgical resection of tuberculoma was realized, followed by chemotherapy. The histopathological study confirmed the diagnostic. CONCLUSIONS Tuberculosis of the central nervous system is an entity of high incidence in developing countries, and intradural extramedullary tuberculoma should be included in the differential diagnosis of expansive spinal cord injuries, especially if the patient is young and there is a history of pulmonary tuberculosis or tuberculous meningitis. It is also important to take it into account as part of a paradoxical reaction after the initiation of specific treatment. Although surgical resection improves compressive medullary symptoms, medical therapy remains the mainstay in the treatment of tuberculomas.
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Affiliation(s)
- D Quispe
- Instituto Nacional de Ciencias Neurologicas, Lima, Peru
| | - M Alvarado
- Instituto Nacional de Ciencias Neurologicas, Lima, Peru
| | - D Rivas
- Instituto Nacional de Ciencias Neurologicas, Lima, Peru
| | - I Gonzales
- Instituto Nacional de Ciencias Neurologicas, Lima, Peru
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Alvarado M, Kostova D, Suhrcke M, Hambleton I, Hassell T, Samuels TA, Adams J, Unwin N. Trends in beverage prices following the introduction of a tax on sugar-sweetened beverages in Barbados. Prev Med 2017; 105S:S23-S25. [PMID: 28716655 DOI: 10.1016/j.ypmed.2017.07.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 07/07/2017] [Accepted: 07/12/2017] [Indexed: 11/20/2022]
Abstract
A 10% excise tax on sugar sweetened beverages (SSBs) was implemented in Barbados in September 2015. A national evaluation has been established to assess the impact of the tax. We present a descriptive analysis of initial price changes following implementation of the SSB tax using price data provided by a major supermarket chain in Barbados over the period 2014-2016. We summarize trends in price changes for SSBs and non-SSBs before and after the tax using year-on-year mean price per liter. We find that prior to the tax, the year-on-year growth of SSB and non-SSB prices was very similar (approximately 1%). During the quarter in which the tax was implemented, the trends diverged, with SSB price growth increasing to 3% and that of non-SSBs decreasing slightly. The growth of SSB prices outpaced non-SSBs prices in each quarter thereafter, reaching 5.9% compared to <1% for non-SSBs. Future analyses will assess the trends in prices of SSBs and non-SSBs over a longer period and will integrate price data from additional sources to assess heterogeneity of post-tax price changes. A continued examination of the impact of the SSB tax in Barbados will expand the evidence base available to policymakers worldwide in considering SSB taxes as a lever for reducing the consumption of added sugar at the population level.
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Affiliation(s)
- Miriam Alvarado
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Barbados; Centre for Diet & Activity Research, MRC Epidemiology Unit, University of Cambridge, UK
| | - Deliana Kostova
- Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Marc Suhrcke
- Centre for Health Economics, University of York, UK
| | - Ian Hambleton
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Barbados
| | - Trevor Hassell
- Healthy Caribbean Coalition, and National NCD Commission, Barbados
| | - T Alafia Samuels
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Barbados.
| | - Jean Adams
- Centre for Diet & Activity Research, MRC Epidemiology Unit, University of Cambridge, UK
| | - Nigel Unwin
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Barbados; Centre for Diet & Activity Research, MRC Epidemiology Unit, University of Cambridge, UK
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Lander B, Alvarado M, Alvarez IC, Armas E, Chique-Alfonzo G, Hernandez F, Labarca R, Leon R, Molina O, Monasterios I, Ramirez CI, Rubio E, Torres B, Viso-Barroso R, Simmonds Z, Soto A. [Venezuelan consensus guidelines on the use of magnetic resonance in diagnosis and follow up of patients with multiple sclerosis]. Rev Neurol 2017; 65:117-126. [PMID: 28699154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION The clinical use of magnetic resonance (MR) in patients with multiple sclerosis (MS) has advanced markedly over the past few years. Several groups around the world have developed consensus guidelines about the role of MR in MS at diagnosis and during follow up. However, in some regions is difficult to extrapolate the recommendations. AIM To provide recommendations for the implementation of MR in MS patients at diagnosis and follow up in Venezuela. DEVELOPMENT A group of experts from Venezuela that included neurologists and radiologists, by using the online surveys methodology as well as face to face meetings developed the intended consensus for the use of MR during the diagnosis and follow up of MS patients in Venezuela. Seventeen recommendations were established based on published evidence and the expert opinion. Recommendations focused on the role of conventional MR techniques and brain atrophy measurement in MS patients both at diagnosis and during follow-up. CONCLUSIONS The recommendations of this consensus guidelines attempts to optimize the health care and management of patients with MS in Venezuela.
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Affiliation(s)
- B Lander
- Universidad Central de Caracas, Caracas, Venezuela
| | - M Alvarado
- Universidad Central de Caracas, Caracas, Venezuela
| | | | - E Armas
- Universidad Central de Caracas, Caracas, Venezuela
| | | | - F Hernandez
- Hospital Universitario de Maracaibo, Maracaibo, Venezuela
| | - R Labarca
- Hospital Universitario de Maracaibo, Maracaibo, Venezuela
| | - R Leon
- Instituto de Salud del Estado Carabobo, Valencia, Venezuela
| | - O Molina
- Hospital Universitario de Maracaibo, Maracaibo, Venezuela
| | | | - C I Ramirez
- Instituto Autonomo Hospital Universitario de Los Andes (IAHULA), Merida, Venezuela
| | - E Rubio
- Hospital Dr. Domingo Luciani, Caracas, Venezuela
| | - B Torres
- Hospital Central de Maracay, Maracay, Venezuela
| | | | - Z Simmonds
- Hospital Universitario Dr. Luis Razetti, Barcelona, Venezuela
| | - A Soto
- Centro Medico Docente La Trinidad, Caracas, Venezuela
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Alvarado M, Cason L, Cooper J. Implementing a Model of Behavioral Change to Reduce Hospital-Onset Clostridium difficile. Am J Infect Control 2017. [DOI: 10.1016/j.ajic.2017.04.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Brown CR, Hambleton IR, Hercules SM, Alvarado M, Unwin N, Murphy MM, Harris EN, Wilks R, MacLeish M, Sullivan L, Sobers-Grannum N. Social determinants of breast cancer in the Caribbean: a systematic review. Int J Equity Health 2017; 16:60. [PMID: 28381227 PMCID: PMC5382386 DOI: 10.1186/s12939-017-0540-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 02/21/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Breast cancer is the leading cause of cancer deaths among women in the Caribbean and accounts for >1 million disability adjusted life years. Little is known about the social inequalities of this disease in the Caribbean. In support of the Rio Political Declaration on addressing health inequities, this article presents a systematic review of evidence on the distribution, by social determinants, of breast cancer risk factors, frequency, and adverse outcomes in Caribbean women. METHODS MEDLINE, EMBASE, SciELO, CINAHL, CUMED, LILACS, and IBECS were searched for observational studies reporting associations between social determinants and breast cancer risk factors, frequency, or outcomes. Based on the PROGRESS-plus checklist, we considered 8 social determinant groups for 14 breast cancer endpoints, which totalled to 189 possible ways ('relationship groups') to explore the role of social determinants on breast cancer. Studies with >50 participants conducted in Caribbean territories between 2004 and 2014 were eligible for inclusion. The review was conducted according to STROBE and PRISMA guidelines and results were planned as a narrative synthesis, with meta-analysis if possible. RESULTS Thirty-four articles were included from 5,190 screened citations. From these included studies, 75 inequality relationships were reported examining 30 distinct relationship groups, leaving 84% of relationship groups unexplored. Most inequality relationships were reported for risk factors, particularly alcohol and overweight/obesity which generally showed a positive relationship with indicators of lower socioeconomic position. Evidence for breast cancer frequency and outcomes was scarce. Unmarried women tended to have a higher likelihood of being diagnosed with breast cancer when compared to married women. While no association was observed between breast cancer frequency and ethnicity, mortality from breast cancer was shown to be slightly higher among Asian-Indian compared to African-descent populations in Trinidad (OR 1.2, 95% CI 1.1-1.4) and Guyana (OR 1.3, 95% CI 1.0-1.6). CONCLUSION Study quantity, quality, and variability in outcomes and reporting limited the synthesis of evidence on the role of social determinants on breast cancer in the Caribbean. This report represents important current evidence on the region, and can guide future research priorities for better describing and understanding of Caribbean breast cancer inequalities.
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Affiliation(s)
| | | | | | | | - Nigel Unwin
- Chronic Disease Research Centre, Bridgetown, Barbados
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Alvarado M, Bold R, Gittleman M, Beitsch P, Blair S, Harmer Q, Kivilaid K, Teshome M, Thompson A, Mittendorf E, Hunt K. Abstract P2-01-11: SentimagIC: A non-inferiority trial comparing super paramagnetic iron oxide vs. Tc99 and blue dye in the detection of axillary sentinel nodes in patients with early stage breast cancer. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p2-01-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Sentinel lymph node biopsy (SLNB), performed using radioisotope tracer with or without blue dye, is a highly accurate method for staging the axilla in early breast cancer. A radioisotope tracer with or without blue dye is the most commonly used technique for SLNB. Superparamagnetic iron oxide mapping agents detected by a handheld magnetic probe have been explored to overcome the disadvantages of the standard technique which include the short half-life, availability, handling and disposal issues for radioisotope, and the risk of allergic reactions to blue dye. Iron oxide mapping agents have been shown to be non-inferior to the standard technique in European studies. The SentimagIC trial was designed to establish the non-inferiority of a new formulation of the magnetic tracer, SiennaXP, to the combination of radioisotope and blue dye and was required to support a US regulatory submission.
Methods: Between January and December 2015, 160 patients with clinically node negative early stage breast cancer were recruited from six centers in the United States. Subjects received radioisotope injection then an intraoperative subareolar injection of SiennaXP and isosulfan blue dye prior to SLNB being performed. The sentinel node identification rate was compared between SiennaXP and the standard technique to evaluate concordance and non-inferiority.
Results: 147 procedures were completed in 147 subjects. A total of 369 histologically confirmed nodes were excised. The nodal detection rate was 94.3% (348/369) with SiennaXP and 93.5% (345/369) with the standard technique (difference 0.8%, 95% binomial confidence interval lower bound -2.1%). The per-subject detection rate was 99.3% (145/146) with SiennaXP and 98.6% (144/146) with the standard technique (one subject excluded due to not contributing any analyzable nodes). There were 22 subjects with positive SLNs, of whom 21 (95.4%) were detected by both SiennaXP and the standard tracers. In one subject, a positive node was not identified by any tracer, but was removed as clinically suspicious. The number of nodes excised per subject was 2.4 for both SiennaXP and for the standard combined technique.
Conclusion: This study showed SiennaXP is non-inferior to the standard dual technique of radioisotope and blue dye for axillary sentinel lymph node detection in early stage breast cancer and this provides a potential alternative to radioisotope and blue dye.
Citation Format: Alvarado M, Bold R, Gittleman M, Beitsch P, Blair S, Harmer Q, Kivilaid K, Teshome M, Thompson A, Mittendorf E, Hunt K. SentimagIC: A non-inferiority trial comparing super paramagnetic iron oxide vs. Tc99 and blue dye in the detection of axillary sentinel nodes in patients with early stage breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-11.
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Affiliation(s)
- M Alvarado
- University of California San Francisco, San Francisco, CA; University of California Davis; BreastCare Specialists Allentown; Dallas Surgical Group; University California San Diego; Endomagnetics; RCRI; University of Texas MD Anderson
| | - R Bold
- University of California San Francisco, San Francisco, CA; University of California Davis; BreastCare Specialists Allentown; Dallas Surgical Group; University California San Diego; Endomagnetics; RCRI; University of Texas MD Anderson
| | - M Gittleman
- University of California San Francisco, San Francisco, CA; University of California Davis; BreastCare Specialists Allentown; Dallas Surgical Group; University California San Diego; Endomagnetics; RCRI; University of Texas MD Anderson
| | - P Beitsch
- University of California San Francisco, San Francisco, CA; University of California Davis; BreastCare Specialists Allentown; Dallas Surgical Group; University California San Diego; Endomagnetics; RCRI; University of Texas MD Anderson
| | - S Blair
- University of California San Francisco, San Francisco, CA; University of California Davis; BreastCare Specialists Allentown; Dallas Surgical Group; University California San Diego; Endomagnetics; RCRI; University of Texas MD Anderson
| | - Q Harmer
- University of California San Francisco, San Francisco, CA; University of California Davis; BreastCare Specialists Allentown; Dallas Surgical Group; University California San Diego; Endomagnetics; RCRI; University of Texas MD Anderson
| | - K Kivilaid
- University of California San Francisco, San Francisco, CA; University of California Davis; BreastCare Specialists Allentown; Dallas Surgical Group; University California San Diego; Endomagnetics; RCRI; University of Texas MD Anderson
| | - M Teshome
- University of California San Francisco, San Francisco, CA; University of California Davis; BreastCare Specialists Allentown; Dallas Surgical Group; University California San Diego; Endomagnetics; RCRI; University of Texas MD Anderson
| | - A Thompson
- University of California San Francisco, San Francisco, CA; University of California Davis; BreastCare Specialists Allentown; Dallas Surgical Group; University California San Diego; Endomagnetics; RCRI; University of Texas MD Anderson
| | - E Mittendorf
- University of California San Francisco, San Francisco, CA; University of California Davis; BreastCare Specialists Allentown; Dallas Surgical Group; University California San Diego; Endomagnetics; RCRI; University of Texas MD Anderson
| | - K Hunt
- University of California San Francisco, San Francisco, CA; University of California Davis; BreastCare Specialists Allentown; Dallas Surgical Group; University California San Diego; Endomagnetics; RCRI; University of Texas MD Anderson
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Alvarado M. A remarkable new species of Sicophion Gauld, 1979 (Hymenoptera: Ichneumonidae) from Peru, with a key to the species. Zootaxa 2016; 4138:195-200. [PMID: 27470761 DOI: 10.11646/zootaxa.4138.1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Indexed: 11/04/2022]
Abstract
The small Neotropical genus Sicophion currently comprises two described species. The genus is recorded for the first time in Peru and S. yana sp. n. is described. A key to species is also presented.
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Affiliation(s)
- M Alvarado
- Division of Entomology, Natural History Museum, and Department of Ecology & Evolutionary Biology, 1501 Crestline Drive - Suite 140, University of Kansas, Lawrence, Kansas, 66045, USA Departamento de Entomología, Museo de Historia Natural, UNMSM. Av. Arenales 1256 Jesús María, Lima 14, Perú.;
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Alvarado M, Tiller GE, Kershberg H, Solomon SR, Mullineaux L, Haque R. Abstract P2-09-26: Women without significant claus model breast cancer risks may warrant breast MRI when a pathogenic/likely-pathogenic variant (PV/LPV) is detected in a hereditary cancer moderate risk gene. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p2-09-26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Hereditary cancer gene panel testing can assess breast cancer risk for women with significant family histories. The Claus risk model is another method to determine which women qualify for annual breast MRIs based on family history, and can be used for those with BRCA negative status or for those who do not qualify for BRCA testing. In July 2014, Kaiser Permanente Southern California, a large integrated health plan, began using hereditary cancer panels comprised of moderate and high-risk breast cancer genes (GeneDx). At the time of implementation, no clinical management guidelines existed for patients with PV/LPV in moderate risk genes. In March 2015, the National Comprehensive Cancer Network (NCCN) amended the Genetic/Familial High Risk Assessment Breast and Ovarian guidelines to include breast cancer surveillance for patients with PV/LPV in moderate risk genes including ATM, CHEK2 and PALB2.
Objective: To determine if the identification of PV/LPV in moderate risk genes versus Claus model calculation increases the number of women warranting breast MRI in a managed care setting.
Methods: We performed a retrospective query of our gene panel results from 6/2014 to 5/2015 to identify patients with ATM, CHEK2 and PALB2 PV/LPV. Personal and family histories were obtained from the test requisitions. Patients with personal histories of breast cancer were excluded from analysis. We calculated the lifetime breast cancer risk using the Claus model for all eligible female patients with a moderate risk gene PV/LPV. To calculate the risk, the Claus model included family history of breast cancer in first and second-degree relatives. A lifetime breast cancer risk of >20% indicates "high" risk.
Results: A total of 19 female patients without breast cancer had a PV/LPV detected in a moderate risk gene (ATM, CHEK2, and PALB2. Claus model calculation was feasible in 12 patients. Of these 12, 4 had a PV/LPV in ATM, 6 in CHEK2 and 2 in PALB2. Only one out of these 12 women was identified with >20% risk of breast cancer based on the Claus model, and was recommended a breast MRI.
A review of electronic medical records (EMR) notes to date (June 1, 2015) revealed that breast MRI was recommended for 10 of the 12 patients above, and completed in 6. MRI identified a suspicious breast lesion in one patient. Follow-up tests and lumpectomy revealed atypical ductal hyperplasia and she will be followed with annual MRI and mammogram. The remaining 2 of12 women had no mention of MRI in their EMR, and will be flagged for follow-up to determine MRI status.
Conclusions: Eleven out of 12 women with a PV/LVP in a moderate risk gene would not have been identified as having an increased breast cancer risk by the Claus model. In our small sample, utilization of a High/Moderate Risk Gene Panel identified more patients potentially warranting enhanced breast cancer surveillance with annual breast MRI than the Claus model. This finding suggests that the use of hereditary cancer gene panel testing may impact the medical management of women with a familial risk for breast cancer. Larger studies with outcome data are needed to determine optimal surveillance guidelines.
Citation Format: Alvarado M, Tiller GE, Kershberg H, Solomon SR, Mullineaux L, Haque R. Women without significant claus model breast cancer risks may warrant breast MRI when a pathogenic/likely-pathogenic variant (PV/LPV) is detected in a hereditary cancer moderate risk gene. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-09-26.
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Affiliation(s)
- M Alvarado
- Kaiser Permanente Southern California, Pasadena, CA; GeneDx, Gaithersburg, MD
| | - GE Tiller
- Kaiser Permanente Southern California, Pasadena, CA; GeneDx, Gaithersburg, MD
| | - H Kershberg
- Kaiser Permanente Southern California, Pasadena, CA; GeneDx, Gaithersburg, MD
| | - SR Solomon
- Kaiser Permanente Southern California, Pasadena, CA; GeneDx, Gaithersburg, MD
| | - L Mullineaux
- Kaiser Permanente Southern California, Pasadena, CA; GeneDx, Gaithersburg, MD
| | - R Haque
- Kaiser Permanente Southern California, Pasadena, CA; GeneDx, Gaithersburg, MD
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Hyslop T, Alvarado M, Forero A, Golshan M, Hieken T, Horton J, Hudis C, McGuire K, Meric-Bernstam F, Nanda R, Zagar T, Hwang S. Abstract S3-06: Treatment outcomes in patients with invasive breast cancer treated with neoadjuvant systemic therapy and breast MR imaging: Results of a secondary analysis of TBCRC 017. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-s3-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background:Neoadjuvant chemotherapy (NCT) is used frequently to downstage locally advanced tumors and facilitate breast conservation. However, we have previously reported that achievement of radiographic complete response (rCR) or pathologic complete response (pCR) does not impact choice of surgery for many patients. This secondary analysis reports treatment outcomes across 9 NCI comprehensive cancer centers in women receiving both NCT and breast MR imaging to assess whether treatment outcomes among women receiving NCT differs according to choice of locoregional treatment.
Methods:1077 women from 9 institutions were retrospectively identified as having undergone NCT with MR imaging obtained both before and after systemic treatment. Systemic treatment regimen was not prespecified, but receipt of at least 80% of all planned cycles was required prior to final MR imaging. We performed a univariate analysis as well as a multivariable Cox proportional hazard regression to identify covariates associated with overall survival (OS), disease-free survival (DFS) and time to recurrence (TTR). rCR was defined as no residual enhancement on post-treatment breast MRI.
Results:1077 patients diagnosed and treated with NCT for stage I-III invasive breast cancer from January 1, 2002 to June 16, 2014 were analyzed for all endpoints. Median follow-up was 4.2 years, (range 0.1 to 13 years). Median age of the cohort was 50 years, (range 19-87 years). 473 (43.9%) had ER(+) and/or PR(+)/HER2(-) disease, 348 (32.3%) had HER2(+) disease, and 256 (23.8%) had ER(-)/PR(-)/HER2(-) (triple negative) disease. Mastectomy or breast conserving therapy (BCT) was recorded as the definitive surgery in 675 (62.7%) and 402 (37.3%) of patients, respectively. Radiation receipt was confirmed in 84.1% of BCT and 68.3% of mastectomy patients. Overall there were 134 recurrences, 168 disease events and 89 deaths. Among patients with pCR, there were 7/161 (7.2%) recurrences in those undergoing mastectomy and 6/143 (5.1%) in those undergoing lumpectomy (p=0.81). Among patients who achieved an rCR, there were recurrences in 5% of those undergoing mastectomy and 2.9% in those undergoing lumpectomy (p=0.53). In multivariable analysis of the entire cohort, only clinical stage, ER status and pCR remained independently associated with DFS. Notably, subset analysis showed that lumpectomy was independently associated with improved TTR (HR 0.40; 95% CI 0.17-0.97) in the triple negative group only, but this did not translate into improved DFS with lumpectomy in this group. Radiographic CR as determined by breast MRI accurately predicted presence or absence of pCR in 74% of cases, but was not independently associated with DFS, OS or TTP.
Conclusions:Among a contemporary cohort of women receiving neoadjuvant systemic therapy and breast MR imaging at 9 NCI designated cancer centers, type of surgery did not impact DFS, OS or TTP. The only exception was found in the triple negative group in which the lumpectomy group had a more favorable TTP compared to the mastectomy group. These findings provide additional evidence that in women who are appropriate candidates for lumpectomy after NCT, BCT does not compromise long-term cancer outcomes.
Citation Format: De Los Santos J, Hyslop T, Alvarado M, Forero A, Golshan M, Hieken T, Horton J, Hudis C, McGuire K, Meric-Bernstam F, Nanda R, Zagar T, Hwang S. Treatment outcomes in patients with invasive breast cancer treated with neoadjuvant systemic therapy and breast MR imaging: Results of a secondary analysis of TBCRC 017. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr S3-06.
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Affiliation(s)
- T Hyslop
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - M Alvarado
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - A Forero
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - M Golshan
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - T Hieken
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - J Horton
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - C Hudis
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - K McGuire
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - F Meric-Bernstam
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - R Nanda
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - T Zagar
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - S Hwang
- University of Alabama at Birmingham, Birmingham, AL; Duke Cancer Institute, Durham, NC; University of California San Francisco, San Francisco, CA; Dana-Farber Cancer Institute, Boston, MA; Mayo Clinic, Rochester, MN; Duke University School of Medicine, Durham, NC; Memorial Sloan Kettering Cancer Center, NY, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; The University of Texas MD Anderson Cancer Center, Houston, TX; The University of Chicago Medicine, Chicago, IL; University of North Carolina at Chapel Hill, Chapel Hill, NC
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Sears M, Warren Peled A, Wang F, Foster RD, Alvarado M, Wong J, Ewing CA, Esserman LJ, Sbitany H, Fowble B. Abstract P2-13-03: Complications following total skin-sparing mastectomy and expander-implant reconstruction: Effects of radiation therapy on the stages of reconstruction. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p2-13-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
BACKGROUND
With increasing numbers of patients requiring post-mastectomy radiation therapy (PMRT), many patients undergoing total-skin sparing mastectomy (TSSM) and immediate two-staged expander-implant (TE-I) reconstruction will receive radiation therapy (XRT) during the course of their reconstruction. Additionally, many patients undergoing TSSM for recurrent cancer have a history of prior lumpectomy and XRT. While the increased risk of reconstructive complications in the setting of XRT has been well-documented, few studies have looked at the impact of XRT on the stages of TE-I reconstruction.
METHODS
All patients undergoing TSSM and immediate two-staged TE-I reconstruction between 2006 and 2013 were identified from a prospectively maintained database. The incidences of TE-I loss and severe infection requiring admission for IV antibiotics were assessed in the subsets of patients with a prior history of XRT and those who received PMRT. Complications were divided into those following the first stage of reconstruction (TSSM and TE placement) and those following the second stage (TE-I exchange).
RESULTS
A total of 218 TSSM and TE-I reconstruction cases were included in the analysis, 85 (39%) with prior XRT and 133 (61%) with PMRT, all of whom who received PMRT prior to TE-I exchange. Mean follow-up time was 2.5 years. Nearly all cases of prior XRT occurred in patients who developed a local recurrence and then underwent TSSM; mean time from prior XRT to TSSM was 7 years (range: 2 months to 22 years). Patients with prior XRT were much more likely to develop complications following the first stage of reconstruction than after the second stage (TE-I loss: 15% vs. 4%, p = 0.02; infection: 20% vs. 8%, p = 0.02). Patients who received PMRT had low rates of complications following the first stage of reconstruction, when they had not yet received any radiation exposure (TE-I loss: 3%; infection: 8%). However, rates increased significantly following TE-I exchange, with an 18% TE-I loss and 30% rate of infection, which was nearly 4-fold higher than patients with a prior history of XRT.
CONCLUSIONS
Patients with prior XRT are at significantly increased risk of reconstructive complications following the first stage of TE-I reconstruction after TSSM, even with a remote history of XRT. However, if these patients are able to successfully maintain their reconstruction through tissue expansion, their risk of complications at the second stage is comparable to patients without radiation exposure and significantly lower than patients receiving PMRT. Careful patient selection and appropriate pre-operative counseling for TSSM and TE-I reconstruction is critical to optimize outcomes and set appropriate expectations.
Citation Format: Sears M, Warren Peled A, Wang F, Foster RD, Alvarado M, Wong J, Ewing CA, Esserman LJ, Sbitany H, Fowble B. Complications following total skin-sparing mastectomy and expander-implant reconstruction: Effects of radiation therapy on the stages of reconstruction. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-03.
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Affiliation(s)
- M Sears
- University of California, San Francisco
| | | | - F Wang
- University of California, San Francisco
| | - RD Foster
- University of California, San Francisco
| | | | - J Wong
- University of California, San Francisco
| | - CA Ewing
- University of California, San Francisco
| | | | - H Sbitany
- University of California, San Francisco
| | - B Fowble
- University of California, San Francisco
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Haque R, Alvarado M, Ahmed SA, Chung J, Tiller GE. Abstract P2-09-04: Implementation of next generation cancer gene panel testing in a large HMO. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p2-09-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Next generation cancer gene panel testing is fairly new in clinical practice. Little is known about the diagnostic yield of multigene cancer panel testing in community based hospitals.
Objective: To describe characteristics of a diverse cohort who underwent high/moderate risk multigene panel testing for either a personal or a family history of cancer in a large health plan, and report the proportion of pathogenic/likely pathogenic variants (PV/LPV) and variants of unknown clinical significance (VUS) by race/ethnicity.
Methods: Subjects included all 586 female patients who were referred for genetic counseling and underwent multigene panel testing between July 2014 and January 2015. Based on a literature review, the custom-designed high/moderate risk gene panel included 20 cancer susceptibility genes (described below). All tests were performed by the same commercial laboratory (GeneDx).
Results: Of the 586 women, 78 (13.3%) tested positive PV/LPV316 (53.9%) tested negative; and 192 (32.8%) carried one or more VUS. Age at testing ranged from 22-81 years (median 50 years). More women with PV/LPV results tended to be obese than those who tested negative (39.7% vs. 31.2%), and had greater comorbidity (Charlson Index of >3, 35.9% vs. 33.2%).
Of 586 women, 305 (52.0%) had a cancer diagnosis, mainly first primary breast cancer (n=290, 95.1%), while some also had a second primary breast cancer (n=67, 11.4%). Of the 305 women with cancer, 131 (42.9%) were diagnosed prior to the multigene testing implementation (1987-2013), while 174 (57.1%) were diagnosed after implementation.
The cohort was diverse in terms of race/ethnicity: Western/Northern European (31.2%), Latina/Caribbean (30.0%), Asian (14.8%), African-American (7.2%), Ashkenazi Jewish (6.3%), Native American (5.9%), and other (14.9%) (percent exceeds 100% due to mixed race/ethnicity). Of the 192 women who carried a VUS, 60.4% were Western/Northern European, and 46.4% were Latina/Caribbean. Pathogenic or likely pathogenic mutations were higher in Latina /Caribbean women (37.2%), followed by Western/Northern European (26.7%), and African (10.3%). We identified a total of 84 pathogenic mutations among the 78 women with PV/LPV in the following genes: BRCA1 (n=22), BRCA2 (n=17), MUTYH (n=16; all heterozygous), CHEK2 (n=9), ATM (n=4), PALB2 (n=4), PMS2 (n=3), MLH1 (n=2), VHL (n=2), and one mutation in each of the following genes: APC, CDH1, PTEN, TP53, and STK11. VUS were detected in 192 patients (32.7%) of the 586 tested. VUS in ATM (n=57), APC (n=32) and CHEK2 (n=25) comprised 59.4% of all VUS detected.
Discussion: The large percent of VUS was surprising, given that our panel included only high/moderate risk cancer genes. The over-representation of BRCA1/2 among all mutations (45.1%) likely reflected a greater proportion of patients referred for genetic counseling with a personal and/or family breast cancer history. Given that 35% of our positive results were dominant-acting pathogenic or suspected pathogenic mutations, our results suggest that multigene cancer panel testing is an appropriate method for detecting germline mutations in a high-risk cohort in a managed care setting.
Citation Format: Haque R, Alvarado M, Ahmed SA, Chung J, Tiller GE. Implementation of next generation cancer gene panel testing in a large HMO. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-09-04.
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Affiliation(s)
- R Haque
- Kaiser Permanente Southern California, Pasadena, CA
| | - M Alvarado
- Kaiser Permanente Southern California, Pasadena, CA
| | - SA Ahmed
- Kaiser Permanente Southern California, Pasadena, CA
| | - J Chung
- Kaiser Permanente Southern California, Pasadena, CA
| | - GE Tiller
- Kaiser Permanente Southern California, Pasadena, CA
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Gallant E, Ewing C, Wong J, Esserman L, Alvarado M. Abstract P3-01-10: Sentinel lymph node biopsy after neoadjuvant chemotherapy for patients with clinically node-positive breast cancer: A single institution retrospective evaluation. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p3-01-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: In patients with clinically node-negative breast cancer sentinel lymph node biopsy (SLNB) offers accurate staging information with considerably less morbidity than a full axillary lymph node dissection (ALND). However, for clinically node-positive (cN1) patients who undergo neoadjuvant chemotherapy SLNB is thought to have a high false-negative rate and not suitable for this population. We sought to evaluate the false-negative rate (FNR) of SLNB following chemotherapy in patients initially presenting with cN1 breast cancer at a single institution.
Methods: Patients undergoing neoadjuvant chemotherapy diagnosed with cN1 breast cancer between October 2004 and February 2014 were identified from the University of California, San Francisco cancer registry. All patients underwent single agent mapping with Tc99 and SLNB followed by completion axillary lymph node dissection (ALND). Pathologic complete response, number of sentinel nodes removed and FNR were calculated.
Results: Of the 80 patients who underwent SLNB and ALND, 43 had residual metastatic disease in the nodes producing a nodal pCR of 46.25% (95%CI. 35.0%-57.8%). In 14 patients, cancer was not identified in the SLNs but was discovered in the lymph nodes retrieved by ALND, resulting in an overall FNR of 32.6% (95% CI, 19.1%-48.5%). 49 patients had only 1 SLN removed. Of the patients with only 1 SLN removed, a false-negative SLN was identified in 9 of the 21 patients with a positive node for a FNR of 42.9% (95% CI, 21.8%-66.0%). Of the patient with more than 1 SLN removed, 5 of 18 patients with a positive node had a false-negative SLN yielding a FNR of 27.8% (95% CI, 9.7%-53.5%). Only 14 patients had more than two SLNs excised.
Conclusion: Recent studies including the French GANEA 2 and ACOSOG Z1071 trials demonstrated a significant decrease in FNR when more than 1 SLN was excised. In this retrospective study however a single SLN was sampled from most patients. The FNR from this study was more than three times the generally accepted threshold of 10%. This substantial FNR further supports the need to remove more than 1 SLN during surgery in order to accurately assess nodal disease. Furthermore the implementation of a dual mapping technique would likely facilitate this process.
Citation Format: Gallant E, Ewing C, Wong J, Esserman L, Alvarado M. Sentinel lymph node biopsy after neoadjuvant chemotherapy for patients with clinically node-positive breast cancer: A single institution retrospective evaluation. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-10.
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Affiliation(s)
- E Gallant
- University of California, San Francisco, San Francisco, CA
| | - C Ewing
- University of California, San Francisco, San Francisco, CA
| | - J Wong
- University of California, San Francisco, San Francisco, CA
| | - L Esserman
- University of California, San Francisco, San Francisco, CA
| | - M Alvarado
- University of California, San Francisco, San Francisco, CA
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Alvarado M, Murphy MM, Guell C. Barriers and facilitators to physical activity amongst overweight and obese women in an Afro-Caribbean population: A qualitative study. Int J Behav Nutr Phys Act 2015. [PMID: 26215108 PMCID: PMC4517402 DOI: 10.1186/s12966-015-0258-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background The proportion of obese women is nearly twice the proportion of obese men in Barbados, and physical inactivity may be a partial determinant. Using qualitative interviews and ‘semi-structured’ participant observation, the aim of this study was to identify modifiable barriers to physical activity and to explore the factors that facilitate physical activity amongst overweight and obese women in this low-resourced setting. Methods Seventeen women aged 25 to 35 years with a BMI ≥25, purposefully sampled from a population-based cross-sectional study conducted in Barbados, were recruited in 2014 to participate in in-depth semi-structured interviews. Twelve of these women participated in one or more additional participant observation sessions in which the researcher joined and observed a routine activity chosen by the participant. More than 50 hours of participant observation data collection were accumulated and documented in field notes. Thematic content analysis was performed on transcribed interviews and field notes using the software Dedoose. Results Social, structural and individual barriers to physical activity were identified. Social factors related to gender norms and expectations. Women tended to be active with their female friends rather than partners or male peers, and reported peer support but also alienation. Being active also competed with family responsibilities and expectations. Structural barriers included few opportunities for active commuting, limited indoor space for exercise in the home, and low perceived access to convenient and affordable exercise classes. Several successful strategies associated with sustained activity were observed, including walking and highly social, low-cost exercise groups. Individual barriers related to healthy living strategies included perceptions about chronic disease and viewing physical activity as a possible strategy for desired weight loss but less effective than dieting. Conclusions It is important to understand why women face barriers to physical activity, particularly in low-resourced settings, and to investigate how this could be addressed. This study highlights the role that gender norms and health beliefs play in shaping experiences of physical activity. In addition, structural barriers reflect a mix of resource-scarce and resource-rich factors which are likely to be seen in a wide variety of developing contexts.
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Affiliation(s)
- Miriam Alvarado
- Chronic Disease Research Centre, Tropical Medicine Research Institute, University of the West Indies, Bridgetown, Barbados.
| | - Madhuvanti M Murphy
- Faculty of Medical Sciences, University of the West Indies, Bridgetown, Barbados.
| | - Cornelia Guell
- MRC Epidemiology Unit and UKCRC Centre for Diet and Physical Activity Research, University of Cambridge, Cambridge, UK.
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Vaidya J, Bulsara M, Wenz F, Tobias J, Joseph D, Massarut S, Flyger H, Eiermann W, Saunders C, Alvarado M, Brew-Graves C, Potyka I, Williams N, Baum M. OC-0472: Whole breast radiotherapy does not affect growth of cancer foci in other quadrants: results from the TARGIT Atrial. Radiother Oncol 2015. [DOI: 10.1016/s0167-8140(15)40467-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Llovet JM, Bruix J, Lim S, Shibuya K, Aboyans V, Abraham J, Adair T, Aggarwal R, Ahn SY, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Barker-Collo S, Bartels DH, Bell ML, Benjamin EJ, Bennett D, Bhalla K, Bikbov B, Bin Abdulhak A, Birbeck G, Blyth F, Bolliger I, Boufous S, Bucello C, Burch M, Burney P, Carapetis J, Chen H, Chou D, Chugh SS, Coffeng LE, Colan SD, Colquhoun S, Colson KE, Condon J, Connor MD, Cooper LT, Corriere M, Cortinovis M, de Vaccaro KC, Couser W, Cowie BC, Criqui MH, Cross M, Dabhadkar KC, Dahodwala N, De Leo D, Degenhardt L, Delossantos A, Denenberg J, Des Jarlais DC, Dharmaratne SD, Dorsey ER, Driscoll T, Duber H, Ebel B, Erwin PJ, Espindola P, Ezzati M, Feigin V, Flaxman AD, Forouzanfar MH, Fowkes FGR, Franklin R, Fransen M, Freeman MK, Gabriel SE, Gakidou E, Gaspari F, Gillum RF, Gonzalez-Medina D, Halasa YA, Haring D, Harrison JE, Havmoeller R, Hay RJ, Hoen B, Hotez PJ, Hoy D, Jacobsen KH, James SL, Jasrasaria R, Jayaraman S, Johns N, Karthikeyan G, Kassebaum N, Keren A, Khoo JP, Knowlton LM, Kobusingye O, Koranteng A, Krishnamurthi R, Lipnick M, Lipshultz SE, Ohno SL, Mabweijano J, MacIntyre MF, Mallinger L, March L, Marks GB, Marks R, Matsumori A, Matzopoulos R, Mayosi BM, McAnulty JH, McDermott MM, McGrath J, Mensah GA, Merriman TR, Michaud C, Miller M, Miller TR, Mock C, Mocumbi AO, Mokdad AA, Moran A, Mulholland K, Nair MN, Naldi L, Narayan KMV, Nasseri K, Norman P, O'Donnell M, Omer SB, Ortblad K, Osborne R, Ozgediz D, Pahari B, Pandian JD, Rivero AP, Padilla RP, Perez-Ruiz F, Perico N, Phillips D, Pierce K, Pope CA, Porrini E, Pourmalek F, Raju M, Ranganathan D, Rehm JT, Rein DB, Remuzzi G, Rivara FP, Roberts T, De León FR, Rosenfeld LC, Rushton L, Sacco RL, Salomon JA, Sampson U, Sanman E, Schwebel DC, Segui-Gomez M, Shepard DS, Singh D, Singleton J, Sliwa K, Smith E, Steer A, Taylor JA, Thomas B, Tleyjeh IM, Towbin JA, Truelsen T, Undurraga EA, Venketasubramanian N, Vijayakumar L, Vos T, Wagner GR, Wang M, Wang W, Watt K, Weinstock MA, Weintraub R, Wilkinson JD, Woolf AD, Wulf S, Yeh PH, Yip P, Zabetian A, Zheng ZJ, Lopez AD, Murray CJL, AlMazroa MA, Memish ZA. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014. [PMID: 25530442 DOI: 10.1016/s0140-6736] [Citation(s) in RCA: 467] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Up-to-date evidence on levels and trends for age-sex-specific all-cause and cause-specific mortality is essential for the formation of global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013) we estimated yearly deaths for 188 countries between 1990, and 2013. We used the results to assess whether there is epidemiological convergence across countries. METHODS We estimated age-sex-specific all-cause mortality using the GBD 2010 methods with some refinements to improve accuracy applied to an updated database of vital registration, survey, and census data. We generally estimated cause of death as in the GBD 2010. Key improvements included the addition of more recent vital registration data for 72 countries, an updated verbal autopsy literature review, two new and detailed data systems for China, and more detail for Mexico, UK, Turkey, and Russia. We improved statistical models for garbage code redistribution. We used six different modelling strategies across the 240 causes; cause of death ensemble modelling (CODEm) was the dominant strategy for causes with sufficient information. Trends for Alzheimer's disease and other dementias were informed by meta-regression of prevalence studies. For pathogen-specific causes of diarrhoea and lower respiratory infections we used a counterfactual approach. We computed two measures of convergence (inequality) across countries: the average relative difference across all pairs of countries (Gini coefficient) and the average absolute difference across countries. To summarise broad findings, we used multiple decrement life-tables to decompose probabilities of death from birth to exact age 15 years, from exact age 15 years to exact age 50 years, and from exact age 50 years to exact age 75 years, and life expectancy at birth into major causes. For all quantities reported, we computed 95% uncertainty intervals (UIs). We constrained cause-specific fractions within each age-sex-country-year group to sum to all-cause mortality based on draws from the uncertainty distributions. FINDINGS Global life expectancy for both sexes increased from 65.3 years (UI 65.0-65.6) in 1990, to 71.5 years (UI 71.0-71.9) in 2013, while the number of deaths increased from 47.5 million (UI 46.8-48.2) to 54.9 million (UI 53.6-56.3) over the same interval. Global progress masked variation by age and sex: for children, average absolute differences between countries decreased but relative differences increased. For women aged 25-39 years and older than 75 years and for men aged 20-49 years and 65 years and older, both absolute and relative differences increased. Decomposition of global and regional life expectancy showed the prominent role of reductions in age-standardised death rates for cardiovascular diseases and cancers in high-income regions, and reductions in child deaths from diarrhoea, lower respiratory infections, and neonatal causes in low-income regions. HIV/AIDS reduced life expectancy in southern sub-Saharan Africa. For most communicable causes of death both numbers of deaths and age-standardised death rates fell whereas for most non-communicable causes, demographic shifts have increased numbers of deaths but decreased age-standardised death rates. Global deaths from injury increased by 10.7%, from 4.3 million deaths in 1990 to 4.8 million in 2013; but age-standardised rates declined over the same period by 21%. For some causes of more than 100,000 deaths per year in 2013, age-standardised death rates increased between 1990 and 2013, including HIV/AIDS, pancreatic cancer, atrial fibrillation and flutter, drug use disorders, diabetes, chronic kidney disease, and sickle-cell anaemias. Diarrhoeal diseases, lower respiratory infections, neonatal causes, and malaria are still in the top five causes of death in children younger than 5 years. The most important pathogens are rotavirus for diarrhoea and pneumococcus for lower respiratory infections. Country-specific probabilities of death over three phases of life were substantially varied between and within regions. INTERPRETATION For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries. Important gaps exist in the empirical data for cause of death estimates for some countries; for example, no national data for India are available for the past decade. FUNDING Bill & Melinda Gates Foundation.
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Alvarado M, Prasad C, Rothney M, Cherbavaz D, Sing A, Svedman C, Markopoulos C. A Laboratory Comparison of the 21-Gene Assay and Pam50-Ror. Ann Oncol 2014. [DOI: 10.1093/annonc/mdu327.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hotez PJ, Alvarado M, Basáñez MG, Bolliger I, Bourne R, Boussinesq M, Brooker SJ, Brown AS, Buckle G, Budke CM, Carabin H, Coffeng LE, Fèvre EM, Fürst T, Halasa YA, Jasrasaria R, Johns NE, Keiser J, King CH, Lozano R, Murdoch ME, O'Hanlon S, Pion SDS, Pullan RL, Ramaiah KD, Roberts T, Shepard DS, Smith JL, Stolk WA, Undurraga EA, Utzinger J, Wang M, Murray CJL, Naghavi M. The global burden of disease study 2010: interpretation and implications for the neglected tropical diseases. PLoS Negl Trop Dis 2014; 8:e2865. [PMID: 25058013 PMCID: PMC4109880 DOI: 10.1371/journal.pntd.0002865] [Citation(s) in RCA: 660] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Peter J. Hotez
- National School of Tropical Medicine at Baylor College of Medicine, Houston, Texas, United States of America
- Sabin Vaccine Institute and Texas Children's Hospital Center for Vaccine Development, Houston, Texas, United States of America
- James A. Baker III Institute at Rice University, Houston, Texas, United States of America
- * E-mail: (PJH); (CJLM); (MN)
| | - Miriam Alvarado
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | | | - Ian Bolliger
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - Rupert Bourne
- Vision and Eye Research Unit, Anglia Ruskin University, Cambridge, United Kingdom
| | | | - Simon J. Brooker
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ami Shah Brown
- Inovio Pharmaceuticals, Inc., Blue Bell, Pennsylvania, United States of America
| | - Geoffrey Buckle
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Hélène Carabin
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Luc E. Coffeng
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Eric M. Fèvre
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- International Livestock Research Institute, Nairobi, Kenya
| | - Thomas Fürst
- Imperial College London, London, United Kingdom
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Yara A. Halasa
- Brandeis University, Waltham, Massachusetts, United States of America
| | - Rashmi Jasrasaria
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - Nicole E. Johns
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - Jennifer Keiser
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Charles H. King
- Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Rafael Lozano
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | | | | | | | - Rachel L. Pullan
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Thomas Roberts
- Stanford University School of Medicine, Stanford, California, United States of America
| | - Donald S. Shepard
- Brandeis University, Waltham, Massachusetts, United States of America
| | - Jennifer L. Smith
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Wilma A. Stolk
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Jürg Utzinger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Mengru Wang
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - Christopher J. L. Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
- * E-mail: (PJH); (CJLM); (MN)
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
- * E-mail: (PJH); (CJLM); (MN)
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Alvarado M, Mukhtar R, Hwang J, Rounds K. Abstract P3-14-12: Risk factors for local regional recurrence in patients undergoing breast conserving surgery following neoadjuvant chemotherapy and validation of the MD Anderson prognostic index. Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-p3-14-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Breast conserving surgery (BCS) is a primary goal of neoadjuvant chemotherapy (NAC) in patients with locally advanced breast cancer, especially with recent improvements in tumor response. Patient selection for BCS following NAC may be different than classic local regional recurrence (LRR) risk factors. Here we investigate risk factors for LRR and attempt to validate the MD Anderson Prognostic Index (MDAPI) for LRR in a single institution series.
Methods: Data were analyzed for 178 consecutive patients treated at one institution who underwent NAC followed by BCS and whole breast radiotherapy between the years 1999 and 2011. Using univariate and multivariate analysis, multiple clinicopathologic factors were investigated, as well as the subgroups of the MDAPI. Chi-square tests were used to compare the LRR-free survival rates between subgroups.
Results: The median follow-up was 70.33 months and the 5-year LRR-free survival was 93.18%. Multivariate analysis demonstrated that clinical stage and pathologic stage were both statistically significant for LRR-free survival, while pattern of residual disease was of borderline statistical significance. The MDAPI was not significantly associated with LRR-free survival (MDAPI low 93.80%, Intermediate 88.23%, High 88.89%).
Five-Year Local Regional Recurrence -Free Survival According to Clinicopathologic Factors # Patients5yr LRR-Free SurvivalPathologic Stage p = 0.03301580.0%14292.5%27692.5%3994.6%pCR38100%Clinical Stage p = 0.0291580.0%213796.3%33883.8%MDAPI Score P = 0.506Low (0 or 1)12993.80%Int (2)3488.23%High (3)988.89%*MDAPI Score Factors cN Stage P = 0.305cN0-N116593.3%cN2-N31070%LVI P = 0.453No-LVI15793.5%Yes-LVI2390.9%pT>2cm P = 0.158Residual Tumor Morphology P = 0.055Multifocal Resid Tumor5996.5%Solitary Mass6690.6%No Resid Tumor5394.3%*These factors make up the MDA Prognostic Index
Conclusion: Overall the 5-year LRR-free survival was high at 93.18%, which compares favorably to similar neoadjuvant patient cohorts who receive mastectomy instead of BCS. Our analysis indicates clinical stage and pathologic stage are significant in predicting LRR. Of the four predictive factors utilized by the MDAPI, only multifocal residual disease showed weak predictive power (p = 0.055) in our population; however, it correlated with higher LRR-free survival, the opposite of its indication in the MDAPI. The MDAPI was not useful in our patient population; the risk groups did not significantly correlate with LRR-free survival. This may be secondary to low total number of recurrence events and also the small number of patients in the MDAPI-high group (9 patients had an MDAPI score of 3, and none had a score of 4). As further data emerge regarding biology of tumors and recurrence, it may be a combination of molecular profiling and residual cancer burden that is a better predictor for LRR.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-12.
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Affiliation(s)
- M Alvarado
- University of California San Francisco, San Francisco, CA
| | - R Mukhtar
- University of California San Francisco, San Francisco, CA
| | - J Hwang
- University of California San Francisco, San Francisco, CA
| | - K Rounds
- University of California San Francisco, San Francisco, CA
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Natoli J, Alvarado M. P100 IHC Testing For Sebaceous Neoplasms: A Rapid Review Of Screening Accuracy And Application Of GRADE. BMJ Qual Saf 2013. [DOI: 10.1136/bmjqs-2013-002293.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Alvarado M, Rodriguez-Berrio A. Four new species of the genus Synosis Townes (Hymenoptera: Ichneumonidae) from the eastern Andes of Peru and key for the New World species. J NAT HIST 2013. [DOI: 10.1080/00222933.2013.768912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- M. Alvarado
- Division of Entomology, Department of Ecology and Evolutionary Biology, Natural History Museum, University of Kansas, Lawrence, KS, 66045, USA
- Departamento de Entomología, Museo de Historia Natural, Universidad Nacional Mayor de San Marcos, Lima, Perú
| | - A. Rodriguez-Berrio
- Departamento Académico de Entomología, Facultad de Agronomía, Universidad Nacional Agraria La Molina, Lima, Perú
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Navarro D, Alvarado M, Morte B, Berbel D, Sesma J, Pacheco P, Morreale de Escobar G, Bernal J, Berbel P. Late maternal hypothyroidism alters the expression of Camk4 in neocortical subplate neurons: a comparison with Nurr1 labeling. Cereb Cortex 2013; 24:2694-706. [PMID: 23680840 DOI: 10.1093/cercor/bht129] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Maternal thyroid hormones (THs) are essential for normal offspring's neurodevelopment even after onset of fetal thyroid function. This is particularly relevant for preterm children who are deprived of maternal THs following birth, are at risk of suffering hypothyroxinemia, and develop attention-deficit/hyperactivity disorder. Expression of neocortical Ca(2+)/calmodulin kinase IV (Camk4), a genomic target of thyroid hormone, and nuclear receptor-related 1 protein (Nurr1), a postnatal marker of cortical subplate (SP) cells, was studied in euthyroid fetuses and in pups born to dams thyroidectomized in late gestation (LMH group, a model of prematurity), and compared with control and developmentally hypothyroid pups (C and MMI groups, respectively). In LMH pups, the extinction of heavy Camk4 expression in an SP was 1-2 days delayed postnatally compared with C pups. The heavy Camk4 and Nurr1 expression in the SP was prolonged in MMI pups, whereas heavy Camk4 and Nurr1 expression in layer VIb remains at P60. The abnormal expression of Camk4 in the cortical SP and in layer VIb might cause altered cortical connectivity affecting neocortical function.
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Affiliation(s)
- D Navarro
- Department Histology and Anatomy, Universidad Miguel Hernández, Sant Joan d'Alacant, Alicante, Spain
| | - M Alvarado
- Department Histology and Anatomy, Universidad Miguel Hernández, Sant Joan d'Alacant, Alicante, Spain Instituto de Neuroetología, Universidad Veracruzana, Xalapa, Veracruz 91100, México
| | - B Morte
- Instituto de Investigaciones Biomédicas Alberto Sols, Consejo Superior de Investigaciones Científicas (CSIC) and Universidad Autónoma de Madrid, Madrid, Spain Center for Biomedical Research on Rare Diseases (CIBERER), Madrid, Spain
| | - D Berbel
- Department Histology and Anatomy, Universidad Miguel Hernández, Sant Joan d'Alacant, Alicante, Spain
| | - J Sesma
- Department Histology and Anatomy, Universidad Miguel Hernández, Sant Joan d'Alacant, Alicante, Spain
| | - P Pacheco
- Instituto de Neuroetología, Universidad Veracruzana, Xalapa, Veracruz 91100, México
| | - G Morreale de Escobar
- Instituto de Investigaciones Biomédicas Alberto Sols, Consejo Superior de Investigaciones Científicas (CSIC) and Universidad Autónoma de Madrid, Madrid, Spain Center for Biomedical Research on Rare Diseases (CIBERER), Madrid, Spain
| | - J Bernal
- Instituto de Investigaciones Biomédicas Alberto Sols, Consejo Superior de Investigaciones Científicas (CSIC) and Universidad Autónoma de Madrid, Madrid, Spain Center for Biomedical Research on Rare Diseases (CIBERER), Madrid, Spain
| | - P Berbel
- Department Histology and Anatomy, Universidad Miguel Hernández, Sant Joan d'Alacant, Alicante, Spain
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Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, Abraham J, Adair T, Aggarwal R, Ahn SY, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Barker-Collo S, Bartels DH, Bell ML, Benjamin EJ, Bennett D, Bhalla K, Bikbov B, Bin Abdulhak A, Birbeck G, Blyth F, Bolliger I, Boufous S, Bucello C, Burch M, Burney P, Carapetis J, Chen H, Chou D, Chugh SS, Coffeng LE, Colan SD, Colquhoun S, Colson KE, Condon J, Connor MD, Cooper LT, Corriere M, Cortinovis M, de Vaccaro KC, Couser W, Cowie BC, Criqui MH, Cross M, Dabhadkar KC, Dahodwala N, De Leo D, Degenhardt L, Delossantos A, Denenberg J, Des Jarlais DC, Dharmaratne SD, Dorsey ER, Driscoll T, Duber H, Ebel B, Erwin PJ, Espindola P, Ezzati M, Feigin V, Flaxman AD, Forouzanfar MH, Fowkes FGR, Franklin R, Fransen M, Freeman MK, Gabriel SE, Gakidou E, Gaspari F, Gillum RF, Gonzalez-Medina D, Halasa YA, Haring D, Harrison JE, Havmoeller R, Hay RJ, Hoen B, Hotez PJ, Hoy D, Jacobsen KH, James SL, Jasrasaria R, Jayaraman S, Johns N, Karthikeyan G, Kassebaum N, Keren A, Khoo JP, Knowlton LM, Kobusingye O, Koranteng A, Krishnamurthi R, Lipnick M, Lipshultz SE, Ohno SL, Mabweijano J, MacIntyre MF, Mallinger L, March L, Marks GB, Marks R, Matsumori A, Matzopoulos R, Mayosi BM, McAnulty JH, McDermott MM, McGrath J, Mensah GA, Merriman TR, Michaud C, Miller M, Miller TR, Mock C, Mocumbi AO, Mokdad AA, Moran A, Mulholland K, Nair MN, Naldi L, Narayan KMV, Nasseri K, Norman P, O'Donnell M, Omer SB, Ortblad K, Osborne R, Ozgediz D, Pahari B, Pandian JD, Rivero AP, Padilla RP, Perez-Ruiz F, Perico N, Phillips D, Pierce K, Pope CA, Porrini E, Pourmalek F, Raju M, Ranganathan D, Rehm JT, Rein DB, Remuzzi G, Rivara FP, Roberts T, De León FR, Rosenfeld LC, Rushton L, Sacco RL, Salomon JA, Sampson U, Sanman E, Schwebel DC, Segui-Gomez M, Shepard DS, Singh D, Singleton J, Sliwa K, Smith E, Steer A, Taylor JA, Thomas B, Tleyjeh IM, Towbin JA, Truelsen T, Undurraga EA, Venketasubramanian N, Vijayakumar L, Vos T, Wagner GR, Wang M, Wang W, Watt K, Weinstock MA, Weintraub R, Wilkinson JD, Woolf AD, Wulf S, Yeh PH, Yip P, Zabetian A, Zheng ZJ, Lopez AD, Murray CJL, AlMazroa MA, Memish ZA. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2013. [PMID: 23245604 DOI: 10.1016/s01406736(12)61728-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. METHODS We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. FINDINGS In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. INTERPRETATION Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Rafael Lozano
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
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Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, Abraham J, Adair T, Aggarwal R, Ahn SY, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Barker-Collo S, Bartels DH, Bell ML, Benjamin EJ, Bennett D, Bhalla K, Bikbov B, Bin Abdulhak A, Birbeck G, Blyth F, Bolliger I, Boufous S, Bucello C, Burch M, Burney P, Carapetis J, Chen H, Chou D, Chugh SS, Coffeng LE, Colan SD, Colquhoun S, Colson KE, Condon J, Connor MD, Cooper LT, Corriere M, Cortinovis M, de Vaccaro KC, Couser W, Cowie BC, Criqui MH, Cross M, Dabhadkar KC, Dahodwala N, De Leo D, Degenhardt L, Delossantos A, Denenberg J, Des Jarlais DC, Dharmaratne SD, Dorsey ER, Driscoll T, Duber H, Ebel B, Erwin PJ, Espindola P, Ezzati M, Feigin V, Flaxman AD, Forouzanfar MH, Fowkes FGR, Franklin R, Fransen M, Freeman MK, Gabriel SE, Gakidou E, Gaspari F, Gillum RF, Gonzalez-Medina D, Halasa YA, Haring D, Harrison JE, Havmoeller R, Hay RJ, Hoen B, Hotez PJ, Hoy D, Jacobsen KH, James SL, Jasrasaria R, Jayaraman S, Johns N, Karthikeyan G, Kassebaum N, Keren A, Khoo JP, Knowlton LM, Kobusingye O, Koranteng A, Krishnamurthi R, Lipnick M, Lipshultz SE, Ohno SL, Mabweijano J, MacIntyre MF, Mallinger L, March L, Marks GB, Marks R, Matsumori A, Matzopoulos R, Mayosi BM, McAnulty JH, McDermott MM, McGrath J, Mensah GA, Merriman TR, Michaud C, Miller M, Miller TR, Mock C, Mocumbi AO, Mokdad AA, Moran A, Mulholland K, Nair MN, Naldi L, Narayan KMV, Nasseri K, Norman P, O'Donnell M, Omer SB, Ortblad K, Osborne R, Ozgediz D, Pahari B, Pandian JD, Rivero AP, Padilla RP, Perez-Ruiz F, Perico N, Phillips D, Pierce K, Pope CA, Porrini E, Pourmalek F, Raju M, Ranganathan D, Rehm JT, Rein DB, Remuzzi G, Rivara FP, Roberts T, De León FR, Rosenfeld LC, Rushton L, Sacco RL, Salomon JA, Sampson U, Sanman E, Schwebel DC, Segui-Gomez M, Shepard DS, Singh D, Singleton J, Sliwa K, Smith E, Steer A, Taylor JA, Thomas B, Tleyjeh IM, Towbin JA, Truelsen T, Undurraga EA, Venketasubramanian N, Vijayakumar L, Vos T, Wagner GR, Wang M, Wang W, Watt K, Weinstock MA, Weintraub R, Wilkinson JD, Woolf AD, Wulf S, Yeh PH, Yip P, Zabetian A, Zheng ZJ, Lopez AD, Murray CJL, AlMazroa MA, Memish ZA. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2013. [PMID: 23245604 DOI: 10.1016/s0140-6736(12)61728-0s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. METHODS We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. FINDINGS In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. INTERPRETATION Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Rafael Lozano
- Institute for Health Metrics and Evaluation, Seattle, WA, USA
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Warren PA, Hwang ES, Ewing CA, Alvarado M, Esserman LJ. Abstract P4-14-04: Total skin-sparing mastectomy in BRCA mutation carriers. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p4-14-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
BACKGROUND: Total skin-sparing mastectomy (TSSM) with preservation of the nipple-areolar complex skin has become increasingly accepted as an oncologically safe procedure for both prophylactic and therapeutic indications. The goal of this study was to evaluate the oncologic outcomes after TSSM in BRCA mutation carriers.
METHODS: We identified 53 BRCA-positive patients who underwent bilateral TSSM for prophylactic (27 patients) or therapeutic (26 patients) indications from 2001 to 2011. Cases were age-matched (for prophylactic cases) or age- and stage-matched (for therapeutic cases) with non-BRCA-positive patients who underwent bilateral TSSM during this time period. Outcomes included tumor involvement of the resected nipple tissue, the development of new breast cancers in patients who underwent bilateral risk-reducing TSSM, and the development of any local-regional recurrence in patients who underwent therapeutic TSSM.
RESULTS: Outcomes from 212 TSSM procedures in 53 cases and 53 controls were analyzed. In patients undergoing TSSM for prophylactic indications, in situ cancer was found in 1 (1.9%) of the nipple specimens in the BRCA-positive patients vs. 2 specimens (3.7%) in the non-BRCA-positive cohort (p = 1). At a mean follow-up of 56 months, no new cancers developed in the BRCA-positive or the non-BRCA-positive cohorts. In patients undergoing TSSM for therapeutic indications, in situ or invasive cancer was found in 0 of the nipple specimens in the BRCA-positive patients vs. 2 specimens (3.9%) in the non-BRCA-positive cohort (p = 0.49). At a mean follow-up of 33 months, there were no local-regional recurrences in the BRCA-positive cohort.
CONCLUSIONS: TSSM is an oncologically safe procedure in BRCA-positive patients, as is evidenced by the low rates of tumor involvement of the nipple tissue and local-regional recurrence after therapeutic mastectomy. In BRCA-positive patients undergoing TSSM as a risk-reducing strategy, five-year follow-up demonstrates no increased risk for the development of new breast cancers; longer-term follow-up is anticipated to further confirm its safety.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-04.
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Affiliation(s)
- Peled A Warren
- University of California, San Francisco; Duke University Medical Center
| | - ES Hwang
- University of California, San Francisco; Duke University Medical Center
| | - CA Ewing
- University of California, San Francisco; Duke University Medical Center
| | - M Alvarado
- University of California, San Francisco; Duke University Medical Center
| | - LJ Esserman
- University of California, San Francisco; Duke University Medical Center
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Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J, Ackerman I, Aggarwal R, Ahn SY, Ali MK, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Bahalim AN, Barker-Collo S, Barrero LH, Bartels DH, Basáñez MG, Baxter A, Bell ML, Benjamin EJ, Bennett D, Bernabé E, Bhalla K, Bhandari B, Bikbov B, Bin Abdulhak A, Birbeck G, Black JA, Blencowe H, Blore JD, Blyth F, Bolliger I, Bonaventure A, Boufous S, Bourne R, Boussinesq M, Braithwaite T, Brayne C, Bridgett L, Brooker S, Brooks P, Brugha TS, Bryan-Hancock C, Bucello C, Buchbinder R, Buckle G, Budke CM, Burch M, Burney P, Burstein R, Calabria B, Campbell B, Canter CE, Carabin H, Carapetis J, Carmona L, Cella C, Charlson F, Chen H, Cheng ATA, Chou D, Chugh SS, Coffeng LE, Colan SD, Colquhoun S, Colson KE, Condon J, Connor MD, Cooper LT, Corriere M, Cortinovis M, de Vaccaro KC, Couser W, Cowie BC, Criqui MH, Cross M, Dabhadkar KC, Dahiya M, Dahodwala N, Damsere-Derry J, Danaei G, Davis A, De Leo D, Degenhardt L, Dellavalle R, Delossantos A, Denenberg J, Derrett S, Des Jarlais DC, Dharmaratne SD, Dherani M, Diaz-Torne C, Dolk H, Dorsey ER, Driscoll T, Duber H, Ebel B, Edmond K, Elbaz A, Ali SE, Erskine H, Erwin PJ, Espindola P, Ewoigbokhan SE, Farzadfar F, Feigin V, Felson DT, Ferrari A, Ferri CP, Fèvre EM, Finucane MM, Flaxman S, Flood L, Foreman K, Forouzanfar MH, Fowkes FGR, Franklin R, Fransen M, Freeman MK, Gabbe BJ, Gabriel SE, Gakidou E, Ganatra HA, Garcia B, Gaspari F, Gillum RF, Gmel G, Gosselin R, Grainger R, Groeger J, Guillemin F, Gunnell D, Gupta R, Haagsma J, Hagan H, Halasa YA, Hall W, Haring D, Haro JM, Harrison JE, Havmoeller R, Hay RJ, Higashi H, Hill C, Hoen B, Hoffman H, Hotez PJ, Hoy D, Huang JJ, Ibeanusi SE, Jacobsen KH, James SL, Jarvis D, Jasrasaria R, Jayaraman S, Johns N, Jonas JB, Karthikeyan G, Kassebaum N, Kawakami N, Keren A, Khoo JP, King CH, Knowlton LM, Kobusingye O, Koranteng A, Krishnamurthi R, Lalloo R, Laslett LL, Lathlean T, Leasher JL, Lee YY, Leigh J, Lim SS, Limb E, Lin JK, Lipnick M, Lipshultz SE, Liu W, Loane M, Ohno SL, Lyons R, Ma J, Mabweijano J, MacIntyre MF, Malekzadeh R, Mallinger L, Manivannan S, Marcenes W, March L, Margolis DJ, Marks GB, Marks R, Matsumori A, Matzopoulos R, Mayosi BM, McAnulty JH, McDermott MM, McGill N, McGrath J, Medina-Mora ME, Meltzer M, Mensah GA, Merriman TR, Meyer AC, Miglioli V, Miller M, Miller TR, Mitchell PB, Mocumbi AO, Moffitt TE, Mokdad AA, Monasta L, Montico M, Moradi-Lakeh M, Moran A, Morawska L, Mori R, Murdoch ME, Mwaniki MK, Naidoo K, Nair MN, Naldi L, Narayan KMV, Nelson PK, Nelson RG, Nevitt MC, Newton CR, Nolte S, Norman P, Norman R, O'Donnell M, O'Hanlon S, Olives C, Omer SB, Ortblad K, Osborne R, Ozgediz D, Page A, Pahari B, Pandian JD, Rivero AP, Patten SB, Pearce N, Padilla RP, Perez-Ruiz F, Perico N, Pesudovs K, Phillips D, Phillips MR, Pierce K, Pion S, Polanczyk GV, Polinder S, Pope CA, Popova S, Porrini E, Pourmalek F, Prince M, Pullan RL, Ramaiah KD, Ranganathan D, Razavi H, Regan M, Rehm JT, Rein DB, Remuzzi G, Richardson K, Rivara FP, Roberts T, Robinson C, De Leòn FR, Ronfani L, Room R, Rosenfeld LC, Rushton L, Sacco RL, Saha S, Sampson U, Sanchez-Riera L, Sanman E, Schwebel DC, Scott JG, Segui-Gomez M, Shahraz S, Shepard DS, Shin H, Shivakoti R, Singh D, Singh GM, Singh JA, Singleton J, Sleet DA, Sliwa K, Smith E, Smith JL, Stapelberg NJC, Steer A, Steiner T, Stolk WA, Stovner LJ, Sudfeld C, Syed S, Tamburlini G, Tavakkoli M, Taylor HR, Taylor JA, Taylor WJ, Thomas B, Thomson WM, Thurston GD, Tleyjeh IM, Tonelli M, Towbin JA, Truelsen T, Tsilimbaris MK, Ubeda C, Undurraga EA, van der Werf MJ, van Os J, Vavilala MS, Venketasubramanian N, Wang M, Wang W, Watt K, Weatherall DJ, Weinstock MA, Weintraub R, Weisskopf MG, Weissman MM, White RA, Whiteford H, Wiersma ST, Wilkinson JD, Williams HC, Williams SRM, Witt E, Wolfe F, Woolf AD, Wulf S, Yeh PH, Zaidi AKM, Zheng ZJ, Zonies D, Lopez AD, Murray CJL, AlMazroa MA, Memish ZA. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:2163-96. [PMID: 23245607 PMCID: PMC6350784 DOI: 10.1016/s0140-6736(12)61729-2] [Citation(s) in RCA: 5394] [Impact Index Per Article: 449.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs). METHODS Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis. FINDINGS Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350,000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient -0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa. INTERPRETATION Rates of YLDs per 100,000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Theo Vos
- School of Population Health, Brisbane, QLD, Australia
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Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J, Ackerman I, Aggarwal R, Ahn SY, Ali MK, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Bahalim AN, Barker-Collo S, Barrero LH, Bartels DH, Basáñez MG, Baxter A, Bell ML, Benjamin EJ, Bennett D, Bernabé E, Bhalla K, Bhandari B, Bikbov B, Bin Abdulhak A, Birbeck G, Black JA, Blencowe H, Blore JD, Blyth F, Bolliger I, Bonaventure A, Boufous S, Bourne R, Boussinesq M, Braithwaite T, Brayne C, Bridgett L, Brooker S, Brooks P, Brugha TS, Bryan-Hancock C, Bucello C, Buchbinder R, Buckle G, Budke CM, Burch M, Burney P, Burstein R, Calabria B, Campbell B, Canter CE, Carabin H, Carapetis J, Carmona L, Cella C, Charlson F, Chen H, Cheng ATA, Chou D, Chugh SS, Coffeng LE, Colan SD, Colquhoun S, Colson KE, Condon J, Connor MD, Cooper LT, Corriere M, Cortinovis M, de Vaccaro KC, Couser W, Cowie BC, Criqui MH, Cross M, Dabhadkar KC, Dahiya M, Dahodwala N, Damsere-Derry J, Danaei G, Davis A, De Leo D, Degenhardt L, Dellavalle R, Delossantos A, Denenberg J, Derrett S, Des Jarlais DC, Dharmaratne SD, Dherani M, Diaz-Torne C, Dolk H, Dorsey ER, Driscoll T, Duber H, Ebel B, Edmond K, Elbaz A, Ali SE, Erskine H, Erwin PJ, Espindola P, Ewoigbokhan SE, Farzadfar F, Feigin V, Felson DT, Ferrari A, Ferri CP, Fèvre EM, Finucane MM, Flaxman S, Flood L, Foreman K, Forouzanfar MH, Fowkes FGR, Fransen M, Freeman MK, Gabbe BJ, Gabriel SE, Gakidou E, Ganatra HA, Garcia B, Gaspari F, Gillum RF, Gmel G, Gonzalez-Medina D, Gosselin R, Grainger R, Grant B, Groeger J, Guillemin F, Gunnell D, Gupta R, Haagsma J, Hagan H, Halasa YA, Hall W, Haring D, Haro JM, Harrison JE, Havmoeller R, Hay RJ, Higashi H, Hill C, Hoen B, Hoffman H, Hotez PJ, Hoy D, Huang JJ, Ibeanusi SE, Jacobsen KH, James SL, Jarvis D, Jasrasaria R, Jayaraman S, Johns N, Jonas JB, Karthikeyan G, Kassebaum N, Kawakami N, Keren A, Khoo JP, King CH, Knowlton LM, Kobusingye O, Koranteng A, Krishnamurthi R, Laden F, Lalloo R, Laslett LL, Lathlean T, Leasher JL, Lee YY, Leigh J, Levinson D, Lim SS, Limb E, Lin JK, Lipnick M, Lipshultz SE, Liu W, Loane M, Ohno SL, Lyons R, Mabweijano J, MacIntyre MF, Malekzadeh R, Mallinger L, Manivannan S, Marcenes W, March L, Margolis DJ, Marks GB, Marks R, Matsumori A, Matzopoulos R, Mayosi BM, McAnulty JH, McDermott MM, McGill N, McGrath J, Medina-Mora ME, Meltzer M, Mensah GA, Merriman TR, Meyer AC, Miglioli V, Miller M, Miller TR, Mitchell PB, Mock C, Mocumbi AO, Moffitt TE, Mokdad AA, Monasta L, Montico M, Moradi-Lakeh M, Moran A, Morawska L, Mori R, Murdoch ME, Mwaniki MK, Naidoo K, Nair MN, Naldi L, Narayan KMV, Nelson PK, Nelson RG, Nevitt MC, Newton CR, Nolte S, Norman P, Norman R, O'Donnell M, O'Hanlon S, Olives C, Omer SB, Ortblad K, Osborne R, Ozgediz D, Page A, Pahari B, Pandian JD, Rivero AP, Patten SB, Pearce N, Padilla RP, Perez-Ruiz F, Perico N, Pesudovs K, Phillips D, Phillips MR, Pierce K, Pion S, Polanczyk GV, Polinder S, Pope CA, Popova S, Porrini E, Pourmalek F, Prince M, Pullan RL, Ramaiah KD, Ranganathan D, Razavi H, Regan M, Rehm JT, Rein DB, Remuzzi G, Richardson K, Rivara FP, Roberts T, Robinson C, De Leòn FR, Ronfani L, Room R, Rosenfeld LC, Rushton L, Sacco RL, Saha S, Sampson U, Sanchez-Riera L, Sanman E, Schwebel DC, Scott JG, Segui-Gomez M, Shahraz S, Shepard DS, Shin H, Shivakoti R, Singh D, Singh GM, Singh JA, Singleton J, Sleet DA, Sliwa K, Smith E, Smith JL, Stapelberg NJC, Steer A, Steiner T, Stolk WA, Stovner LJ, Sudfeld C, Syed S, Tamburlini G, Tavakkoli M, Taylor HR, Taylor JA, Taylor WJ, Thomas B, Thomson WM, Thurston GD, Tleyjeh IM, Tonelli M, Towbin JA, Truelsen T, Tsilimbaris MK, Ubeda C, Undurraga EA, van der Werf MJ, van Os J, Vavilala MS, Venketasubramanian N, Wang M, Wang W, Watt K, Weatherall DJ, Weinstock MA, Weintraub R, Weisskopf MG, Weissman MM, White RA, Whiteford H, Wiebe N, Wiersma ST, Wilkinson JD, Williams HC, Williams SRM, Witt E, Wolfe F, Woolf AD, Wulf S, Yeh PH, Zaidi AKM, Zheng ZJ, Zonies D, Lopez AD, AlMazroa MA, Memish ZA. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:2197-223. [PMID: 23245608 DOI: 10.1016/s0140-6736(12)61689-4] [Citation(s) in RCA: 5812] [Impact Index Per Article: 484.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time. METHODS We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights. FINDINGS Global DALYs remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions. INTERPRETATION Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results. FUNDING Bill & Melinda Gates Foundation.
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Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, Abraham J, Adair T, Aggarwal R, Ahn SY, AlMazroa MA, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Barker-Collo S, Bartels DH, Bell ML, Benjamin EJ, Bennett D, Bhalla K, Bikbov B, Abdulhak AB, Birbeck G, Blyth F, Bolliger I, Boufous S, Bucello C, Burch M, Burney P, Carapetis J, Chen H, Chou D, Chugh SS, Coffeng LE, Colan SD, Colquhoun S, Colson KE, Condon J, Connor MD, Cooper LT, Corriere M, Cortinovis M, de Vaccaro KC, Couser W, Cowie BC, Criqui MH, Cross M, Dabhadkar KC, Dahodwala N, Leo DD, Degenhardt L, Delossantos A, Denenberg J, Jarlais DCD, Dharmaratne SD, Dorsey ER, Driscoll T, Duber H, Ebel B, Erwin PJ, Espindola P, Ezzati M, Feigin V, Flaxman AD, Forouzanfar MH, Fowkes FGR, Franklin R, Fransen M, Freeman MK, Gabriel SE, Gakidou E, Gaspari F, Gillum RF, Gonzalez-Medina D, Halasa YA, Haring D, Harrison JE, Havmoeller R, Hay RJ, Hoen B, Hotez PJ, Hoy D, Jacobsen KH, James SL, Jasrasaria R, Jayaraman S, Johns N, Karthikeyan G, Kassebaum N, Keren A, Khoo JP, Knowlton LM, Kobusingye O, Koranteng A, Krishnamurthi R, Lipnick M, Lipshultz SE, Ohno SL, Mabweijano J, MacIntyre MF, Mallinger L, March L, Marks GB, Marks R, Matsumori A, Matzopoulos R, Mayosi BM, McAnulty JH, McDermott MM, McGrath J, Memish ZA, Mensah GA, Merriman TR, Michaud C, Miller M, Miller TR, Mock C, Mocumbi AO, Mokdad AA, Moran A, Mulholland K, Nair MN, Naldi L, Narayan KMV, Nasseri K, Norman P, O’Donnell M, Omer SB, Ortblad K, Osborne R, Ozgediz D, Pahari B, Pandian JD, Rivero AP, Padilla RP, Perez-Ruiz F, Perico N, Phillips D, Pierce K, Pope CA, Porrini E, Pourmalek F, Raju M, Ranganathan D, Rehm JT, Rein DB, Remuzzi G, Rivara FP, Roberts T, De León FR, Rosenfeld LC, Rushton L, Sacco RL, Salomon JA, Sampson U, Sanman E, Schwebel DC, Segui-Gomez M, Shepard DS, Singh D, Singleton J, Sliwa K, Smith E, Steer A, Taylor JA, Thomas B, Tleyjeh IM, Towbin JA, Truelsen T, Undurraga EA, Venketasubramanian N, Vijayakumar L, Vos T, Wagner GR, Wang M, Wang W, Watt K, Weinstock MA, Weintraub R, Wilkinson JD, Woolf AD, Wulf S, Yeh PH, Yip P, Zabetian A, Zheng ZJ, Lopez AD, Murray CJL. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:2095-128. [PMID: 23245604 PMCID: PMC10790329 DOI: 10.1016/s0140-6736(12)61728-0] [Citation(s) in RCA: 9117] [Impact Index Per Article: 759.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. METHODS We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. FINDINGS In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. INTERPRETATION Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Rafael Lozano
- Institute for Health Metrics and Evaluation (Prof R Lozano MD, M Naghavi PhD, S S Lim PhD, S Y Ahn MPH, M Alvarado BA, K G Andrews MPH, C Atkinson BS, I Bolliger AB, D Chou BA, K E Colson BA, A Delossantos BS, Prof S D Dharmaratne MBBS, A D Flaxman PhD, M H Forouzanfar MD, M K Freeman BA, E Gakidou PhD, D Gonzalez-Medina BA, D Haring BS, S L James MPH, R Jasrasaria BA, N Johns BA, S Lockett Ohno BA, M F MacIntyre EdM, L Mallinger MPH, A A Mokdad MD, M N Nair MD, K Ortblad BA, D Phillips BS, K Pierce BA, D Ranganathan BS, T Roberts BA, L C Rosenfeld MPH, E Sanman BS, M Wang MPH, S Wulf MPH, Prof C J L Murray MD), Department of Anesthesiology and Pain Medicine (N Kassebaum MD), Department of Epidemiology, School of Public Health (L M Anderson PhD), University of Washington, Seattle, WA, USA (Prof W Couser MD, H Duber MD, B Ebel MD, Prof C Mock MD, Prof F P Rivara MD, B Thomas MD); School of Public Health (Prof M Ezzati PhD), Imperial College London, London, UK (K Foreman MPH, Prof P Burney MD, L Rushton PhD); Department of Global Health, University of Tokyo, Tokyo, Japan (Prof K Shibuya MD); Department of Cardiology, Dupuytren University Hospital, Limoges, France (Prof V Aboyans MD); School of Medicine, University of Texas, San Antonio, TX, USA (J Abraham MPH); School of Population Health (T Adair PhD, Prof A D Lopez PhD, Prof T Vos PhD), Queensland Centre for Mental Health Research (J-P Khoo MBBS), Queensland Brain Institute, University of Queensland, Brisbane, QLD, Australia (Prof J McGrath MD); Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India (Prof R Aggarwal MD); Ministry of Health, Riyadh, Saudi Arabia (M A AlMazroa MD, Prof Z A Memish MD); St George’s, University of London, London, UK (Prof H R Anderson MD); Mayo Clinic, Rochester, MN, USA (Prof L M Baddour MD, P J Erwin MLS, Prof S E Gabriel MD); University of Auckland, Auckland, New Zealand (S Barker-Collo PhD); Brigham and Women’s Hospital (S Jayaraman MD), Harvard Medical School (D H Bartels BA, Prof S D Colan MD), Harvard Humanitarian Initiative (L M Knowlton MD), School of Public Health (M Miller MD, Prof J A Salomon PhD), Harvard University, Boston, MA, USA (K Bhalla PhD); Global Partners in Anesthesia and Surgery (D Ozgediz MD), Yale University, New Haven, CT, USA (Prof M L Bell PhD); Boston University, Boston, MA, USA (Prof E J Benjamin MD); Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK (D Bennett PhD); Research Institute of Transplantology and Artificial Organs, Moscow State University of Medicine and Dentistry, Moscow, Russia (B Bikbov MD); King Fahad Medical City, Riyadh, Saudi Arabia (A Bin Abdulhak MD, I M Tleyjeh MD); Michigan State University, East Lansing, MI, USA (Prof G Birbeck MD); School of Public Health (T Driscoll PhD), Faculty of Health Sciences (M Fransen PhD), Department of Rheumatology, Northern Clinical School (E Smith PhD), Institute of Bone and Joint Research (Prof L March MD), University of Sydney, Sydney, NSW, Australia (F Blyth PhD, Prof G B Marks PhD, M Cross PhD); Transport and Road Safety Research (S Boufous PhD), National Drug and Alcohol Research Centre (J Singleton MIPH, Prof L Degenhardt PhD), University of New South Wales, Sydney, NSW, Australia (C Bucello BPsych); Great Ormond Street Hospital, London, UK (M Burch MD); Telethon Institute for Child Health Research, Centre for Child Health Research (Prof J Carapetis MBBS), University of Western Australia, Perth, WA, Australia (Prof P Norman MD); National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA (H Chen PhD); Cedars-Sinai Medical Center, Los Angeles, CA, USA (Prof S S Chugh MD, R Havmoeller MD); Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands (L E Coffeng MD); Menzies School of Health Research, Darwin, NT, Australia (S Colquhoun MPH, J Condon PhD); National Health Services, Fife, Edinburgh, UK (M D Connor PhD); University of Edinburgh, Edinburgh, UK (M D Connor, Prof F G R Fowkes FRCPE); University of the Witwatersrand, Johannesburg, South Africa (M D Connor); Loyola University Medical School, Chicago, IL, USA (Prof L T Cooper MD); Department of Epidemiology, School of Public Health Sciences, Wake Forest University, Winston-Salem, NC, USA (M Corriere MD); Mario Negri Institute for Pharmacological Research, Bergamo, Italy (M Cortinovis BiotechD, F Gaspari ChemD, N Perico MD, Prof G Remuzzi MD); Hospital Dr Gustavo N Collado, Puerto Chitre, Panama (K Courville de Vaccaro MD); Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC, Australia (B C Cowie MBBS); University of California, San Diego, San Diego, CA, USA (Prof M H Criqui MD, J Denenberg MA); Schools of Public Health and Medicine (S B Omer MBBS), Emory University, Atlanta, GA, USA (K C Dabhadkar MBBS, A Zabetian MD, K M V Narayan MD); University of Pennsylvania, Philadelphia, PA, USA (N Dahodwala MD); Griffith University, Brisbane, QLD, Australia (Prof D De Leo DSc); Beth Israel Medical Center, New York City, NY, USA (D C Des Jarlais PhD); University of Peradeniya, Peradeniya, Sri Lanka (Prof S D Dharmaratne); Johns Hopkins University, Baltimore, MD, USA (E R Dorsey MD); Hospital Maciel, Montevideo, Uruguay (P Espindola MD); MRC-HPA Centre for Environment and Health, London, UK (Prof M Ezzati PhD); National Institute for Stroke and Applied Neurosciences, Auckland Technical University, Auckland, New Zealand (Prof V Feigin MD, R Krishnamurthi PhD); Royal Life Saving Society, Sydney, NSW, Australia (R Franklin PhD); James Cook University, Townsville, QLD, Australia (K Watt PhD, R Franklin PhD); Howard University College of Medicine, Washington, DC, USA (Prof R F Gillum MD); Brandeis University, Waltham, MA, USA (Y A Halasa DDS, Prof D S Shepard PhD, E A Undurraga PhD); Flinders University, Adelaide, SA, Australia (Prof J E Harrison MBBS); Karolinska University Hospital, Stockholm, Sweden (R Havmoeller MD); King’s College Hospital NHS Trust, King’s College, London, UK (Prof R J Hay DM); Université de Franche-Comté, Besançon, France (Prof B Hoen MD); Centre Hospitalier Régional Universitaire de Basençon, Besançon, France (Prof B Hoen); National School of Tropical Medicine, Baylor College of Medicine, Houston, TX, USA (Prof P J Hotez MD); Monash University, Melbourne, VIC, Australia (D Hoy PhD); George Mason University, Fairfax, VA, USA (K H Jacobsen PhD); All India Institute of Medical Sciences, New Delhi, India (G Karthikeyan MD); Department of Cardiology, Hebrew University Hadassah Medical School, Jerusalem, Israel (Prof A Keren MD); School of Public Health (O Kobusingye MMed), Makerere University, Kampala, Uganda (J Mabweijano MMed); University of South Africa, Johannesburg, South Africa (O Kobusingye MMed); Kwame Nkrumah University of Science and Technology, Kumasi, Ghana (A Koranteng MSc); University of California, San Francisco, San Francisco, CA, USA (M Lipnick MD); University of Miami Miller School of Medicine, Miami, FL, USA (Prof S E Lipshultz MD, Prof R L Sacco MD, Prof J D Wilkinson MD); Mulago Hospital, Kampala, Uganda (J Mabweijano MMed); Centre for International Child Health (A Steer MBBS), Department of Paediatrics, Royal Children’s Hospital (R Weintraub MBBS), University of Melbourne, Melbourne, VIC, Australia (Prof R Marks MBBS); Asian Pacific Society of Cardiology, Kyoto, Japan (A Matsumori MD); Medical Research Council, Tygerberg, South Africa (R Matzopoulos MPhil); Hatter Institute (Prof K Sliwa MD), Department of Medicine (Prof G A Mensah MD), University of Cape Town, Cape Town, South Africa (R Matzopoulos, Prof B M Mayosi DPhil); Legacy Health System, Portland, OR, USA (J H McAnulty MD); Northwestern University Feinberg School of Medicine, Evanston, IL, USA (Prof M M McDermott MD); College of Medicine, Alfaisal University, Riyadh, Saudi Arabia (Prof Z A Memish); University of Otago, Dunedin, New Zealand (T R Merriman PhD); China Medical Board, Boston, MA, USA (C Michaud MD); Pacific Institute for Research and Evaluation, Calverton, MD, USA (T R Miller PhD); National Institute of Health, Maputo, Mozambique (Prof A O Mocumbi MD); University Eduardo Mondlane, Maputo, Mozambique (Prof A O Mocumbi); Columbia University, New York City, NY, USA (A Moran MD); London School of Hygiene and Tropical Medicine, London, UK (Prof K Mulholland MD); Centro Studi GISED, Bergamo, Italy (L Naldi MD); School of Public Health, University of Liverpool, Liverpool, UK (Prof K Nasseri DVM); HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland, UK (M O’Donnell PhD); Deakin University, Melbourne, VIC, Australia (Prof R Osborne PhD); B P Koirala Institute of Health Sciences, Dharan, Nepal (B Pahari MD); Betty Cowan Research and Innovation Center, Ludhiana, India (J D Pandian MD); Hospital Juan XXIII, La Paz, Bolivia (A Panozo Rivero MD); Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico (R Perez Padilla MD); Hospital Universitario Cruces, Barakaldo, Spain (F Perez-Ruiz MD); Brigham Young University, Provo, UT, USA (Prof C A Pope III PhD); Hospital Universitario de Canarias, Tenerife, Spain (E Porrini MD); Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada (F Pourmalek MD); Mason Eye Institute, University of Missouri, Columbia, MO, USA (M Raju PhD); Centre for Addiction and Mental Health, Toronto, ON, Canada (Prof J T Rehm PhD); National Opinion Research Center, University of Chicago, Chicago, IL, USA (D B Rein PhD); Complejo Hospitalario Caja De Seguro Social, Panama City, Panama (F Rodriguez de León MD); Vanderbilt University, Nashville, TN, USA (Prof U Sampson MD); University of Alabama at Birmingham, Birmingham, AL, USA (Prof D C Schwebel PhD); Ministry of Interior, Madrid, Spain (M Segui-Gomez MD); Queens Medical Center, Honolulu, HI, USA (D Singh MD); Drexel University School of Public Health, Philadelphia, PA, USA (J A Taylor PhD); Cincinnati Children’s Hospital, Cincinnati, OH, USA (Prof J A Towbin MD); Department of Neurology, Copenhagen University Hospital, Herlev, Denmark (T Truelsen MD); National University of Singapore, Singapore, (N Venketasubramanian FRCP); Voluntary Health Services, Sneha, Chennai, India (Prof L Vijayakumar MBBS); National Institute for Occupational Safety and Health, Baltimore, MD, USA (G R Wagner MD); Beijing Neurosurgical Institute, Capital Medical University, Beijing, China (Prof W Wang MD); Brown University, Providence, RI, USA (Prof M A Weinstock MD); Royal Cornwall Hospital, Truro, UK (Prof A D Woolf MBBS); London School of Economics, London, UK (P-H Yeh MS); Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Prof P Yip PhD); and School of Public Health, Shanghai Jiao Tong University, Shanghai, China (Prof Z-J Zheng MD
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation (Prof R Lozano MD, M Naghavi PhD, S S Lim PhD, S Y Ahn MPH, M Alvarado BA, K G Andrews MPH, C Atkinson BS, I Bolliger AB, D Chou BA, K E Colson BA, A Delossantos BS, Prof S D Dharmaratne MBBS, A D Flaxman PhD, M H Forouzanfar MD, M K Freeman BA, E Gakidou PhD, D Gonzalez-Medina BA, D Haring BS, S L James MPH, R Jasrasaria BA, N Johns BA, S Lockett Ohno BA, M F MacIntyre EdM, L Mallinger MPH, A A Mokdad MD, M N Nair MD, K Ortblad BA, D Phillips BS, K Pierce BA, D Ranganathan BS, T Roberts BA, L C Rosenfeld MPH, E Sanman BS, M Wang MPH, S Wulf MPH, Prof C J L Murray MD), Department of Anesthesiology and Pain Medicine (N Kassebaum MD), Department of Epidemiology, School of Public Health (L M Anderson PhD), University of Washington, Seattle, WA, USA (Prof W Couser MD, H Duber MD, B Ebel MD, Prof C Mock MD, Prof F P Rivara MD, B Thomas MD); School of Public Health (Prof M Ezzati PhD), Imperial College London, London, UK (K Foreman MPH, Prof P Burney MD, L Rushton PhD); Department of Global Health, University of Tokyo, Tokyo, Japan (Prof K Shibuya MD); Department of Cardiology, Dupuytren University Hospital, Limoges, France (Prof V Aboyans MD); School of Medicine, University of Texas, San Antonio, TX, USA (J Abraham MPH); School of Population Health (T Adair PhD, Prof A D Lopez PhD, Prof T Vos PhD), Queensland Centre for Mental Health Research (J-P Khoo MBBS), Queensland Brain Institute, University of Queensland, Brisbane, QLD, Australia (Prof J McGrath MD); Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India (Prof R Aggarwal MD); Ministry of Health, Riyadh, Saudi Arabia (M A AlMazroa MD, Prof Z A Memish MD); St George’s, University of London, London, UK (Prof H R Anderson MD); Mayo Clinic, Rochester, MN, USA (Prof L M Baddour MD, P J Erwin MLS, Prof S E Gabriel MD); University of Auckland, Auckland, New Zealand (S Barker-Collo PhD); Brigham and Women’s Hospital (S Jayaraman MD), Harvard Medical School (D H Bartels BA, Prof S D Colan MD), Harvard Humanitarian Initiative (L M Knowlton MD), School of Public Health (M Miller MD, Prof J A Salomon PhD), Harvard University, Boston, MA, USA (K Bhalla PhD); Global Partners in Anesthesia and Surgery (D Ozgediz MD), Yale University, New Haven, CT, USA (Prof M L Bell PhD); Boston University, Boston, MA, USA (Prof E J Benjamin MD); Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK (D Bennett PhD); Research Institute of Transplantology and Artificial Organs, Moscow State University of Medicine and Dentistry, Moscow, Russia (B Bikbov MD); King Fahad Medical City, Riyadh, Saudi Arabia (A Bin Abdulhak MD, I M Tleyjeh MD); Michigan State University, East Lansing, MI, USA (Prof G Birbeck MD); School of Public Health (T Driscoll PhD), Faculty of Health Sciences (M Fransen PhD), Department of Rheumatology, Northern Clinical School (E Smith PhD), Institute of Bone and Joint Research (Prof L March MD), University of Sydney, Sydney, NSW, Australia (F Blyth PhD, Prof G B Marks PhD, M Cross PhD); Transport and Road Safety Research (S Boufous PhD), National Drug and Alcohol Research Centre (J Singleton MIPH, Prof L Degenhardt PhD), University of New South Wales, Sydney, NSW, Australia (C Bucello BPsych); Great Ormond Street Hospital, London, UK (M Burch MD); Telethon Institute for Child Health Research, Centre for Child Health Research (Prof J Carapetis MBBS), University of Western Australia, Perth, WA, Australia (Prof P Norman MD); National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA (H Chen PhD); Cedars-Sinai Medical Center, Los Angeles, CA, USA (Prof S S Chugh MD, R Havmoeller MD); Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands (L E Coffeng MD); Menzies School of Health Research, Darwin, NT, Australia (S Colquhoun MPH, J Condon PhD); National Health Services, Fife, Edinburgh, UK (M D Connor PhD); University of Edinburgh, Edinburgh, UK (M D Connor, Prof F G R Fowkes FRCPE); University of the Witwatersrand, Johannesburg, South Africa (M D Connor); Loyola University Medical School, Chicago, IL, USA (Prof L T Cooper MD); Department of Epidemiology, School of Public Health Sciences, Wake Forest University, Winston-Salem, NC, USA (M Corriere MD); Mario Negri Institute for Pharmacological Research, Bergamo, Italy (M Cortinovis BiotechD, F Gaspari ChemD, N Perico MD, Prof G Remuzzi MD); Hospital Dr Gustavo N Collado, Puerto Chitre, Panama (K Courville de Vaccaro MD); Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC, Australia (B C Cowie MBBS); University of California, San Diego, San Diego, CA, USA (Prof M H Criqui MD, J Denenberg MA); Schools of Public Health and Medicine (S B Omer MBBS), Emory University, Atlanta, GA, USA (K C Dabhadkar MBBS, A Zabetian MD, K M V Narayan MD); University of Pennsylvania, Philadelphia, PA, USA (N Dahodwala MD); Griffith University, Brisbane, QLD, Australia (Prof D De Leo DSc); Beth Israel Medical Center, New York City, NY, USA (D C Des Jarlais PhD); University of Peradeniya, Peradeniya, Sri Lanka (Prof S D Dharmaratne); Johns Hopkins University, Baltimore, MD, USA (E R Dorsey MD); Hospital Maciel, Montevideo, Uruguay (P Espindola MD); MRC-HPA Centre for Environment and Health, London, UK (Prof M Ezzati PhD); National Institute for Stroke and Applied Neurosciences, Auckland Technical University, Auckland, New Zealand (Prof V Feigin MD, R Krishnamurthi PhD); Royal Life Saving Society, Sydney, NSW, Australia (R Franklin PhD); James Cook University, Townsville, QLD, Australia (K Watt PhD, R Franklin PhD); Howard University College of Medicine, Washington, DC, USA (Prof R F Gillum MD); Brandeis University, Waltham, MA, USA (Y A Halasa DDS, Prof D S Shepard PhD, E A Undurraga PhD); Flinders University, Adelaide, SA, Australia (Prof J E Harrison MBBS); Karolinska University Hospital, Stockholm, Sweden (R Havmoeller MD); King’s College Hospital NHS Trust, King’s College, London, UK (Prof R J Hay DM); Université de Franche-Comté, Besançon, France (Prof B Hoen MD); Centre Hospitalier Régional Universitaire de Basençon, Besançon, France (Prof B Hoen); National School of Tropical Medicine, Baylor College of Medicine, Houston, TX, USA (Prof P J Hotez MD); Monash University, Melbourne, VIC, Australia (D Hoy PhD); George Mason University, Fairfax, VA, USA (K H Jacobsen PhD); All India Institute of Medical Sciences, New Delhi, India (G Karthikeyan MD); Department of Cardiology, Hebrew University Hadassah Medical School, Jerusalem, Israel (Prof A Keren MD); School of Public Health (O Kobusingye MMed), Makerere University, Kampala, Uganda (J Mabweijano MMed); University of South Africa, Johannesburg, South Africa (O Kobusingye MMed); Kwame Nkrumah University of Science and Technology, Kumasi, Ghana (A Koranteng MSc); University of California, San Francisco, San Francisco, CA, USA (M Lipnick MD); University of Miami Miller School of Medicine, Miami, FL, USA (Prof S E Lipshultz MD, Prof R L Sacco MD, Prof J D Wilkinson MD); Mulago Hospital, Kampala, Uganda (J Mabweijano MMed); Centre for International Child Health (A Steer MBBS), Department of Paediatrics, Royal Children’s Hospital (R Weintraub MBBS), University of Melbourne, Melbourne, VIC, Australia (Prof R Marks MBBS); Asian Pacific Society of Cardiology, Kyoto, Japan (A Matsumori MD); Medical Research Council, Tygerberg, South Africa (R Matzopoulos MPhil); Hatter Institute (Prof K Sliwa MD), Department of Medicine (Prof G A Mensah MD), University of Cape Town, Cape Town, South Africa (R Matzopoulos, Prof B M Mayosi DPhil); Legacy Health System, Portland, OR, USA (J H McAnulty MD); Northwestern University Feinberg School of Medicine, Evanston, IL, USA (Prof M M McDermott MD); College of Medicine, Alfaisal University, Riyadh, Saudi Arabia (Prof Z A Memish); University of Otago, Dunedin, New Zealand (T R Merriman PhD); China Medical Board, Boston, MA, USA (C Michaud MD); Pacific Institute for Research and Evaluation, Calverton, MD, USA (T R Miller PhD); National Institute of Health, Maputo, Mozambique (Prof A O Mocumbi MD); University Eduardo Mondlane, Maputo, Mozambique (Prof A O Mocumbi); Columbia University, New York City, NY, USA (A Moran MD); London School of Hygiene and Tropical Medicine, London, UK (Prof K Mulholland MD); Centro Studi GISED, Bergamo, Italy (L Naldi MD); School of Public Health, University of Liverpool, Liverpool, UK (Prof K Nasseri DVM); HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland, UK (M O’Donnell PhD); Deakin University, Melbourne, VIC, Australia (Prof R Osborne PhD); B P Koirala Institute of Health Sciences, Dharan, Nepal (B Pahari MD); Betty Cowan Research and Innovation Center, Ludhiana, India (J D Pandian MD); Hospital Juan XXIII, La Paz, Bolivia (A Panozo Rivero MD); Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico (R Perez Padilla MD); Hospital Universitario Cruces, Barakaldo, Spain (F Perez-Ruiz MD); Brigham Young University, Provo, UT, USA (Prof C A Pope III PhD); Hospital Universitario de Canarias, Tenerife, Spain (E Porrini MD); Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada (F Pourmalek MD); Mason Eye Institute, University of Missouri, Columbia, MO, USA (M Raju PhD); Centre for Addiction and Mental Health, Toronto, ON, Canada (Prof J T Rehm PhD); National Opinion Research Center, University of Chicago, Chicago, IL, USA (D B Rein PhD); Complejo Hospitalario Caja De Seguro Social, Panama City, Panama (F Rodriguez de León MD); Vanderbilt University, Nashville, TN, USA (Prof U Sampson MD); University of Alabama at Birmingham, Birmingham, AL, USA (Prof D C Schwebel PhD); Ministry of Interior, Madrid, Spain (M Segui-Gomez MD); Queens Medical Center, Honolulu, HI, USA (D Singh MD); Drexel University School of Public Health, Philadelphia, PA, USA (J A Taylor PhD); Cincinnati Children’s Hospital, Cincinnati, OH, USA (Prof J A Towbin MD); Department of Neurology, Copenhagen University Hospital, Herlev, Denmark (T Truelsen MD); National University of Singapore, Singapore, (N Venketasubramanian FRCP); Voluntary Health Services, Sneha, Chennai, India (Prof L Vijayakumar MBBS); National Institute for Occupational Safety and Health, Baltimore, MD, USA (G R Wagner MD); Beijing Neurosurgical Institute, Capital Medical University, Beijing, China (Prof W Wang MD); Brown University, Providence, RI, USA (Prof M A Weinstock MD); Royal Cornwall Hospital, Truro, UK (Prof A D Woolf MBBS); London School of Economics, London, UK (P-H Yeh MS); Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Prof P Yip PhD); and School of Public Health, Shanghai Jiao Tong University, Shanghai, China (Prof Z-J Zheng MD
| | - Kyle Foreman
- Institute for Health Metrics and Evaluation (Prof R Lozano MD, M Naghavi PhD, S S Lim PhD, S Y Ahn MPH, M Alvarado BA, K G Andrews MPH, C Atkinson BS, I Bolliger AB, D Chou BA, K E Colson BA, A Delossantos BS, Prof S D Dharmaratne MBBS, A D Flaxman PhD, M H Forouzanfar MD, M K Freeman BA, E Gakidou PhD, D Gonzalez-Medina BA, D Haring BS, S L James MPH, R Jasrasaria BA, N Johns BA, S Lockett Ohno BA, M F MacIntyre EdM, L Mallinger MPH, A A Mokdad MD, M N Nair MD, K Ortblad BA, D Phillips BS, K Pierce BA, D Ranganathan BS, T Roberts BA, L C Rosenfeld MPH, E Sanman BS, M Wang MPH, S Wulf MPH, Prof C J L Murray MD), Department of Anesthesiology and Pain Medicine (N Kassebaum MD), Department of Epidemiology, School of Public Health (L M Anderson PhD), University of Washington, Seattle, WA, USA (Prof W Couser MD, H Duber MD, B Ebel MD, Prof C Mock MD, Prof F P Rivara MD, B Thomas MD); School of Public Health (Prof M Ezzati PhD), Imperial College London, London, UK (K Foreman MPH, Prof P Burney MD, L Rushton PhD); Department of Global Health, University of Tokyo, Tokyo, Japan (Prof K Shibuya MD); Department of Cardiology, Dupuytren University Hospital, Limoges, France (Prof V Aboyans MD); School of Medicine, University of Texas, San Antonio, TX, USA (J Abraham MPH); School of Population Health (T Adair PhD, Prof A D Lopez PhD, Prof T Vos PhD), Queensland Centre for Mental Health Research (J-P Khoo MBBS), Queensland Brain Institute, University of Queensland, Brisbane, QLD, Australia (Prof J McGrath MD); Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India (Prof R Aggarwal MD); Ministry of Health, Riyadh, Saudi Arabia (M A AlMazroa MD, Prof Z A Memish MD); St George’s, University of London, London, UK (Prof H R Anderson MD); Mayo Clinic, Rochester, MN, USA (Prof L M Baddour MD, P J Erwin MLS, Prof S E Gabriel MD); University of Auckland, Auckland, New Zealand (S Barker-Collo PhD); Brigham and Women’s Hospital (S Jayaraman MD), Harvard Medical School (D H Bartels BA, Prof S D Colan MD), Harvard Humanitarian Initiative (L M Knowlton MD), School of Public Health (M Miller MD, Prof J A Salomon PhD), Harvard University, Boston, MA, USA (K Bhalla PhD); Global Partners in Anesthesia and Surgery (D Ozgediz MD), Yale University, New Haven, CT, USA (Prof M L Bell PhD); Boston University, Boston, MA, USA (Prof E J Benjamin MD); Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK (D Bennett PhD); Research Institute of Transplantology and Artificial Organs, Moscow State University of Medicine and Dentistry, Moscow, Russia (B Bikbov MD); King Fahad Medical City, Riyadh, Saudi Arabia (A Bin Abdulhak MD, I M Tleyjeh MD); Michigan State University, East Lansing, MI, USA (Prof G Birbeck MD); School of Public Health (T Driscoll PhD), Faculty of Health Sciences (M Fransen PhD), Department of Rheumatology, Northern Clinical School (E Smith PhD), Institute of Bone and Joint Research (Prof L March MD), University of Sydney, Sydney, NSW, Australia (F Blyth PhD, Prof G B Marks PhD, M Cross PhD); Transport and Road Safety Research (S Boufous PhD), National Drug and Alcohol Research Centre (J Singleton MIPH, Prof L Degenhardt PhD), University of New South Wales, Sydney, NSW, Australia (C Bucello BPsych); Great Ormond Street Hospital, London, UK (M Burch MD); Telethon Institute for Child Health Research, Centre for Child Health Research (Prof J Carapetis MBBS), University of Western Australia, Perth, WA, Australia (Prof P Norman MD); National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA (H Chen PhD); Cedars-Sinai Medical Center, Los Angeles, CA, USA (Prof S S Chugh MD, R Havmoeller MD); Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands (L E Coffeng MD); Menzies School of Health Research, Darwin, NT, Australia (S Colquhoun MPH, J Condon PhD); National Health Services, Fife, Edinburgh, UK (M D Connor PhD); University of Edinburgh, Edinburgh, UK (M D Connor, Prof F G R Fowkes FRCPE); University of the Witwatersrand, Johannesburg, South Africa (M D Connor); Loyola University Medical School, Chicago, IL, USA (Prof L T Cooper MD); Department of Epidemiology, School of Public Health Sciences, Wake Forest University, Winston-Salem, NC, USA (M Corriere MD); Mario Negri Institute for Pharmacological Research, Bergamo, Italy (M Cortinovis BiotechD, F Gaspari ChemD, N Perico MD, Prof G Remuzzi MD); Hospital Dr Gustavo N Collado, Puerto Chitre, Panama (K Courville de Vaccaro MD); Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC, Australia (B C Cowie MBBS); University of California, San Diego, San Diego, CA, USA (Prof M H Criqui MD, J Denenberg MA); Schools of Public Health and Medicine (S B Omer MBBS), Emory University, Atlanta, GA, USA (K C Dabhadkar MBBS, A Zabetian MD, K M V Narayan MD); University of Pennsylvania, Philadelphia, PA, USA (N Dahodwala MD); Griffith University, Brisbane, QLD, Australia (Prof D De Leo DSc); Beth Israel Medical Center, New York City, NY, USA (D C Des Jarlais PhD); University of Peradeniya, Peradeniya, Sri Lanka (Prof S D Dharmaratne); Johns Hopkins University, Baltimore, MD, USA (E R Dorsey MD); Hospital Maciel, Montevideo, Uruguay (P Espindola MD); MRC-HPA Centre for Environment and Health, London, UK (Prof M Ezzati PhD); National Institute for Stroke and Applied Neurosciences, Auckland Technical University, Auckland, New Zealand (Prof V Feigin MD, R Krishnamurthi PhD); Royal Life Saving Society, Sydney, NSW, Australia (R Franklin PhD); James Cook University, Townsville, QLD, Australia (K Watt PhD, R Franklin PhD); Howard University College of Medicine, Washington, DC, USA (Prof R F Gillum MD); Brandeis University, Waltham, MA, USA (Y A Halasa DDS, Prof D S Shepard PhD, E A Undurraga PhD); Flinders University, Adelaide, SA, Australia (Prof J E Harrison MBBS); Karolinska University Hospital, Stockholm, Sweden (R Havmoeller MD); King’s College Hospital NHS Trust, King’s College, London, UK (Prof R J Hay DM); Université de Franche-Comté, Besançon, France (Prof B Hoen MD); Centre Hospitalier Régional Universitaire de Basençon, Besançon, France (Prof B Hoen); National School of Tropical Medicine, Baylor College of Medicine, Houston, TX, USA (Prof P J Hotez MD); Monash University, Melbourne, VIC, Australia (D Hoy PhD); George Mason University, Fairfax, VA, USA (K H Jacobsen PhD); All India Institute of Medical Sciences, New Delhi, India (G Karthikeyan MD); Department of Cardiology, Hebrew University Hadassah Medical School, Jerusalem, Israel (Prof A Keren MD); School of Public Health (O Kobusingye MMed), Makerere University, Kampala, Uganda (J Mabweijano MMed); University of South Africa, Johannesburg, South Africa (O Kobusingye MMed); Kwame Nkrumah University of Science and Technology, Kumasi, Ghana (A Koranteng MSc); University of California, San Francisco, San Francisco, CA, USA (M Lipnick MD); University of Miami Miller School of Medicine, Miami, FL, USA (Prof S E Lipshultz MD, Prof R L Sacco MD, Prof J D Wilkinson MD); Mulago Hospital, Kampala, Uganda (J Mabweijano MMed); Centre for International Child Health (A Steer MBBS), Department of Paediatrics, Royal Children’s Hospital (R Weintraub MBBS), University of Melbourne, Melbourne, VIC, Australia (Prof R Marks MBBS); Asian Pacific Society of Cardiology, Kyoto, Japan (A Matsumori MD); Medical Research Council, Tygerberg, South Africa (R Matzopoulos MPhil); Hatter Institute (Prof K Sliwa MD), Department of Medicine (Prof G A Mensah MD), University of Cape Town, Cape Town, South Africa (R Matzopoulos, Prof B M Mayosi DPhil); Legacy Health System, Portland, OR, USA (J H McAnulty MD); Northwestern University Feinberg School of Medicine, Evanston, IL, USA (Prof M M McDermott MD); College of Medicine, Alfaisal University, Riyadh, Saudi Arabia (Prof Z A Memish); University of Otago, Dunedin, New Zealand (T R Merriman PhD); China Medical Board, Boston, MA, USA (C Michaud MD); Pacific Institute for Research and Evaluation, Calverton, MD, USA (T R Miller PhD); National Institute of Health, Maputo, Mozambique (Prof A O Mocumbi MD); University Eduardo Mondlane, Maputo, Mozambique (Prof A O Mocumbi); Columbia University, New York City, NY, USA (A Moran MD); London School of Hygiene and Tropical Medicine, London, UK (Prof K Mulholland MD); Centro Studi GISED, Bergamo, Italy (L Naldi MD); School of Public Health, University of Liverpool, Liverpool, UK (Prof K Nasseri DVM); HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland, UK (M O’Donnell PhD); Deakin University, Melbourne, VIC, Australia (Prof R Osborne PhD); B P Koirala Institute of Health Sciences, Dharan, Nepal (B Pahari MD); Betty Cowan Research and Innovation Center, Ludhiana, India (J D Pandian MD); Hospital Juan XXIII, La Paz, Bolivia (A Panozo Rivero MD); Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico (R Perez Padilla MD); Hospital Universitario Cruces, Barakaldo, Spain (F Perez-Ruiz MD); Brigham Young University, Provo, UT, USA (Prof C A Pope III PhD); Hospital Universitario de Canarias, Tenerife, Spain (E Porrini MD); Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada (F Pourmalek MD); Mason Eye Institute, University of Missouri, Columbia, MO, USA (M Raju PhD); Centre for Addiction and Mental Health, Toronto, ON, Canada (Prof J T Rehm PhD); National Opinion Research Center, University of Chicago, Chicago, IL, USA (D B Rein PhD); Complejo Hospitalario Caja De Seguro Social, Panama City, Panama (F Rodriguez de León MD); Vanderbilt University, Nashville, TN, USA (Prof U Sampson MD); University of Alabama at Birmingham, Birmingham, AL, USA (Prof D C Schwebel PhD); Ministry of Interior, Madrid, Spain (M Segui-Gomez MD); Queens Medical Center, Honolulu, HI, USA (D Singh MD); Drexel University School of Public Health, Philadelphia, PA, USA (J A Taylor PhD); Cincinnati Children’s Hospital, Cincinnati, OH, USA (Prof J A Towbin MD); Department of Neurology, Copenhagen University Hospital, Herlev, Denmark (T Truelsen MD); National University of Singapore, Singapore, (N Venketasubramanian FRCP); Voluntary Health Services, Sneha, Chennai, India (Prof L Vijayakumar MBBS); National Institute for Occupational Safety and Health, Baltimore, MD, USA (G R Wagner MD); Beijing Neurosurgical Institute, Capital Medical University, Beijing, China (Prof W Wang MD); Brown University, Providence, RI, USA (Prof M A Weinstock MD); Royal Cornwall Hospital, Truro, UK (Prof A D Woolf MBBS); London School of Economics, London, UK (P-H Yeh MS); Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Prof P Yip PhD); and School of Public Health, Shanghai Jiao Tong University, Shanghai, China (Prof Z-J Zheng MD
| | - Stephen Lim
- Institute for Health Metrics and Evaluation (Prof R Lozano MD, M Naghavi PhD, S S Lim PhD, S Y Ahn MPH, M Alvarado BA, K G Andrews MPH, C Atkinson BS, I Bolliger AB, D Chou BA, K E Colson BA, A Delossantos BS, Prof S D Dharmaratne MBBS, A D Flaxman PhD, M H Forouzanfar MD, M K Freeman BA, E Gakidou PhD, D Gonzalez-Medina BA, D Haring BS, S L James MPH, R Jasrasaria BA, N Johns BA, S Lockett Ohno BA, M F MacIntyre EdM, L Mallinger MPH, A A Mokdad MD, M N Nair MD, K Ortblad BA, D Phillips BS, K Pierce BA, D Ranganathan BS, T Roberts BA, L C Rosenfeld MPH, E Sanman BS, M Wang MPH, S Wulf MPH, Prof C J L Murray MD), Department of Anesthesiology and Pain Medicine (N Kassebaum MD), Department of Epidemiology, School of Public Health (L M Anderson PhD), University of Washington, Seattle, WA, USA (Prof W Couser MD, H Duber MD, B Ebel MD, Prof C Mock MD, Prof F P Rivara MD, B Thomas MD); School of Public Health (Prof M Ezzati PhD), Imperial College London, London, UK (K Foreman MPH, Prof P Burney MD, L Rushton PhD); Department of Global Health, University of Tokyo, Tokyo, Japan (Prof K Shibuya MD); Department of Cardiology, Dupuytren University Hospital, Limoges, France (Prof V Aboyans MD); School of Medicine, University of Texas, San Antonio, TX, USA (J Abraham MPH); School of Population Health (T Adair PhD, Prof A D Lopez PhD, Prof T Vos PhD), Queensland Centre for Mental Health Research (J-P Khoo MBBS), Queensland Brain Institute, University of Queensland, Brisbane, QLD, Australia (Prof J McGrath MD); Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India (Prof R Aggarwal MD); Ministry of Health, Riyadh, Saudi Arabia (M A AlMazroa MD, Prof Z A Memish MD); St George’s, University of London, London, UK (Prof H R Anderson MD); Mayo Clinic, Rochester, MN, USA (Prof L M Baddour MD, P J Erwin MLS, Prof S E Gabriel MD); University of Auckland, Auckland, New Zealand (S Barker-Collo PhD); Brigham and Women’s Hospital (S Jayaraman MD), Harvard Medical School (D H Bartels BA, Prof S D Colan MD), Harvard Humanitarian Initiative (L M Knowlton MD), School of Public Health (M Miller MD, Prof J A Salomon PhD), Harvard University, Boston, MA, USA (K Bhalla PhD); Global Partners in Anesthesia and Surgery (D Ozgediz MD), Yale University, New Haven, CT, USA (Prof M L Bell PhD); Boston University, Boston, MA, USA (Prof E J Benjamin MD); Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK (D Bennett PhD); Research Institute of Transplantology and Artificial Organs, Moscow State University of Medicine and Dentistry, Moscow, Russia (B Bikbov MD); King Fahad Medical City, Riyadh, Saudi Arabia (A Bin Abdulhak MD, I M Tleyjeh MD); Michigan State University, East Lansing, MI, USA (Prof G Birbeck MD); School of Public Health (T Driscoll PhD), Faculty of Health Sciences (M Fransen PhD), Department of Rheumatology, Northern Clinical School (E Smith PhD), Institute of Bone and Joint Research (Prof L March MD), University of Sydney, Sydney, NSW, Australia (F Blyth PhD, Prof G B Marks PhD, M Cross PhD); Transport and Road Safety Research (S Boufous PhD), National Drug and Alcohol Research Centre (J Singleton MIPH, Prof L Degenhardt PhD), University of New South Wales, Sydney, NSW, Australia (C Bucello BPsych); Great Ormond Street Hospital, London, UK (M Burch MD); Telethon Institute for Child Health Research, Centre for Child Health Research (Prof J Carapetis MBBS), University of Western Australia, Perth, WA, Australia (Prof P Norman MD); National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA (H Chen PhD); Cedars-Sinai Medical Center, Los Angeles, CA, USA (Prof S S Chugh MD, R Havmoeller MD); Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands (L E Coffeng MD); Menzies School of Health Research, Darwin, NT, Australia (S Colquhoun MPH, J Condon PhD); National Health Services, Fife, Edinburgh, UK (M D Connor PhD); University of Edinburgh, Edinburgh, UK (M D Connor, Prof F G R Fowkes FRCPE); University of the Witwatersrand, Johannesburg, South Africa (M D Connor); Loyola University Medical School, Chicago, IL, USA (Prof L T Cooper MD); Department of Epidemiology, School of Public Health Sciences, Wake Forest University, Winston-Salem, NC, USA (M Corriere MD); Mario Negri Institute for Pharmacological Research, Bergamo, Italy (M Cortinovis BiotechD, F Gaspari ChemD, N Perico MD, Prof G Remuzzi MD); Hospital Dr Gustavo N Collado, Puerto Chitre, Panama (K Courville de Vaccaro MD); Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC, Australia (B C Cowie MBBS); University of California, San Diego, San Diego, CA, USA (Prof M H Criqui MD, J Denenberg MA); Schools of Public Health and Medicine (S B Omer MBBS), Emory University, Atlanta, GA, USA (K C Dabhadkar MBBS, A Zabetian MD, K M V Narayan MD); University of Pennsylvania, Philadelphia, PA, USA (N Dahodwala MD); Griffith University, Brisbane, QLD, Australia (Prof D De Leo DSc); Beth Israel Medical Center, New York City, NY, USA (D C Des Jarlais PhD); University of Peradeniya, Peradeniya, Sri Lanka (Prof S D Dharmaratne); Johns Hopkins University, Baltimore, MD, USA (E R Dorsey MD); Hospital Maciel, Montevideo, Uruguay (P Espindola MD); MRC-HPA Centre for Environment and Health, London, UK (Prof M Ezzati PhD); National Institute for Stroke and Applied Neurosciences, Auckland Technical University, Auckland, New Zealand (Prof V Feigin MD, R Krishnamurthi PhD); Royal Life Saving Society, Sydney, NSW, Australia (R Franklin PhD); James Cook University, Townsville, QLD, Australia (K Watt PhD, R Franklin PhD); Howard University College of Medicine, Washington, DC, USA (Prof R F Gillum MD); Brandeis University, Waltham, MA, USA (Y A Halasa DDS, Prof D S Shepard PhD, E A Undurraga PhD); Flinders University, Adelaide, SA, Australia (Prof J E Harrison MBBS); Karolinska University Hospital, Stockholm, Sweden (R Havmoeller MD); King’s College Hospital NHS Trust, King’s College, London, UK (Prof R J Hay DM); Université de Franche-Comté, Besançon, France (Prof B Hoen MD); Centre Hospitalier Régional Universitaire de Basençon, Besançon, France (Prof B Hoen); National School of Tropical Medicine, Baylor College of Medicine, Houston, TX, USA (Prof P J Hotez MD); Monash University, Melbourne, VIC, Australia (D Hoy PhD); George Mason University, Fairfax, VA, USA (K H Jacobsen PhD); All India Institute of Medical Sciences, New Delhi, India (G Karthikeyan MD); Department of Cardiology, Hebrew University Hadassah Medical School, Jerusalem, Israel (Prof A Keren MD); School of Public Health (O Kobusingye MMed), Makerere University, Kampala, Uganda (J Mabweijano MMed); University of South Africa, Johannesburg, South Africa (O Kobusingye MMed); Kwame Nkrumah University of Science and Technology, Kumasi, Ghana (A Koranteng MSc); University of California, San Francisco, San Francisco, CA, USA (M Lipnick MD); University of Miami Miller School of Medicine, Miami, FL, USA (Prof S E Lipshultz MD, Prof R L Sacco MD, Prof J D Wilkinson MD); Mulago Hospital, Kampala, Uganda (J Mabweijano MMed); Centre for International Child Health (A Steer MBBS), Department of Paediatrics, Royal Children’s Hospital (R Weintraub MBBS), University of Melbourne, Melbourne, VIC, Australia (Prof R Marks MBBS); Asian Pacific Society of Cardiology, Kyoto, Japan (A Matsumori MD); Medical Research Council, Tygerberg, South Africa (R Matzopoulos MPhil); Hatter Institute (Prof K Sliwa MD), Department of Medicine (Prof G A Mensah MD), University of Cape Town, Cape Town, South Africa (R Matzopoulos, Prof B M Mayosi DPhil); Legacy Health System, Portland, OR, USA (J H McAnulty MD); Northwestern University Feinberg School of Medicine, Evanston, IL, USA (Prof M M McDermott MD); College of Medicine, Alfaisal University, Riyadh, Saudi Arabia (Prof Z A Memish); University of Otago, Dunedin, New Zealand (T R Merriman PhD); China Medical Board, Boston, MA, USA (C Michaud MD); Pacific Institute for Research and Evaluation, Calverton, MD, USA (T R Miller PhD); National Institute of Health, Maputo, Mozambique (Prof A O Mocumbi MD); University Eduardo Mondlane, Maputo, Mozambique (Prof A O Mocumbi); Columbia University, New York City, NY, USA (A Moran MD); London School of Hygiene and Tropical Medicine, London, UK (Prof K Mulholland MD); Centro Studi GISED, Bergamo, Italy (L Naldi MD); School of Public Health, University of Liverpool, Liverpool, UK (Prof K Nasseri DVM); HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland, UK (M O’Donnell PhD); Deakin University, Melbourne, VIC, Australia (Prof R Osborne PhD); B P Koirala Institute of Health Sciences, Dharan, Nepal (B Pahari MD); Betty Cowan Research and Innovation Center, Ludhiana, India (J D Pandian MD); Hospital Juan XXIII, La Paz, Bolivia (A Panozo Rivero MD); Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico (R Perez Padilla MD); Hospital Universitario Cruces, Barakaldo, Spain (F Perez-Ruiz MD); Brigham Young University, Provo, UT, USA (Prof C A Pope III PhD); Hospital Universitario de Canarias, Tenerife, Spain (E Porrini MD); Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada (F Pourmalek MD); Mason Eye Institute, University of Missouri, Columbia, MO, USA (M Raju PhD); Centre for Addiction and Mental Health, Toronto, ON, Canada (Prof J T Rehm PhD); National Opinion Research Center, University of Chicago, Chicago, IL, USA (D B Rein PhD); Complejo Hospitalario Caja De Seguro Social, Panama City, Panama (F Rodriguez de León MD); Vanderbilt University, Nashville, TN, USA (Prof U Sampson MD); University of Alabama at Birmingham, Birmingham, AL, USA (Prof D C Schwebel PhD); Ministry of Interior, Madrid, Spain (M Segui-Gomez MD); Queens Medical Center, Honolulu, HI, USA (D Singh MD); Drexel University School of Public Health, Philadelphia, PA, USA (J A Taylor PhD); Cincinnati Children’s Hospital, Cincinnati, OH, USA (Prof J A Towbin MD); Department of Neurology, Copenhagen University Hospital, Herlev, Denmark (T Truelsen MD); National University of Singapore, Singapore, (N Venketasubramanian FRCP); Voluntary Health Services, Sneha, Chennai, India (Prof L Vijayakumar MBBS); National Institute for Occupational Safety and Health, Baltimore, MD, USA (G R Wagner MD); Beijing Neurosurgical Institute, Capital Medical University, Beijing, China (Prof W Wang MD); Brown University, Providence, RI, USA (Prof M A Weinstock MD); Royal Cornwall Hospital, Truro, UK (Prof A D Woolf MBBS); London School of Economics, London, UK (P-H Yeh MS); Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Prof P Yip PhD); and School of Public Health, Shanghai Jiao Tong University, Shanghai, China (Prof Z-J Zheng MD
| | - Kenji Shibuya
- Institute for Health Metrics and Evaluation (Prof R Lozano MD, M Naghavi PhD, S S Lim PhD, S Y Ahn MPH, M Alvarado BA, K G Andrews MPH, C Atkinson BS, I Bolliger AB, D Chou BA, K E Colson BA, A Delossantos BS, Prof S D Dharmaratne MBBS, A D Flaxman PhD, M H Forouzanfar MD, M K Freeman BA, E Gakidou PhD, D Gonzalez-Medina BA, D Haring BS, S L James MPH, R Jasrasaria BA, N Johns BA, S Lockett Ohno BA, M F MacIntyre EdM, L Mallinger MPH, A A Mokdad MD, M N Nair MD, K Ortblad BA, D Phillips BS, K Pierce BA, D Ranganathan BS, T Roberts BA, L C Rosenfeld MPH, E Sanman BS, M Wang MPH, S Wulf MPH, Prof C J L Murray MD), Department of Anesthesiology and Pain Medicine (N Kassebaum MD), Department of Epidemiology, School of Public Health (L M Anderson PhD), University of Washington, Seattle, WA, USA (Prof W Couser MD, H Duber MD, B Ebel MD, Prof C Mock MD, Prof F P Rivara MD, B Thomas MD); School of Public Health (Prof M Ezzati PhD), Imperial College London, London, UK (K Foreman MPH, Prof P Burney MD, L Rushton PhD); Department of Global Health, University of Tokyo, Tokyo, Japan (Prof K Shibuya MD); Department of Cardiology, Dupuytren University Hospital, Limoges, France (Prof V Aboyans MD); School of Medicine, University of Texas, San Antonio, TX, USA (J Abraham MPH); School of Population Health (T Adair PhD, Prof A D Lopez PhD, Prof T Vos PhD), Queensland Centre for Mental Health Research (J-P Khoo MBBS), Queensland Brain Institute, University of Queensland, Brisbane, QLD, Australia (Prof J McGrath MD); Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India (Prof R Aggarwal MD); Ministry of Health, Riyadh, Saudi Arabia (M A AlMazroa MD, Prof Z A Memish MD); St George’s, University of London, London, UK (Prof H R Anderson MD); Mayo Clinic, Rochester, MN, USA (Prof L M Baddour MD, P J Erwin MLS, Prof S E Gabriel MD); University of Auckland, Auckland, New Zealand (S Barker-Collo PhD); Brigham and Women’s Hospital (S Jayaraman MD), Harvard Medical School (D H Bartels BA, Prof S D Colan MD), Harvard Humanitarian Initiative (L M Knowlton MD), School of Public Health (M Miller MD, Prof J A Salomon PhD), Harvard University, Boston, MA, USA (K Bhalla PhD); Global Partners in Anesthesia and Surgery (D Ozgediz MD), Yale University, New Haven, CT, USA (Prof M L Bell PhD); Boston University, Boston, MA, USA (Prof E J Benjamin MD); Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK (D Bennett PhD); Research Institute of Transplantology and Artificial Organs, Moscow State University of Medicine and Dentistry, Moscow, Russia (B Bikbov MD); King Fahad Medical City, Riyadh, Saudi Arabia (A Bin Abdulhak MD, I M Tleyjeh MD); Michigan State University, East Lansing, MI, USA (Prof G Birbeck MD); School of Public Health (T Driscoll PhD), Faculty of Health Sciences (M Fransen PhD), Department of Rheumatology, Northern Clinical School (E Smith PhD), Institute of Bone and Joint Research (Prof L March MD), University of Sydney, Sydney, NSW, Australia (F Blyth PhD, Prof G B Marks PhD, M Cross PhD); Transport and Road Safety Research (S Boufous PhD), National Drug and Alcohol Research Centre (J Singleton MIPH, Prof L Degenhardt PhD), University of New South Wales, Sydney, NSW, Australia (C Bucello BPsych); Great Ormond Street Hospital, London, UK (M Burch MD); Telethon Institute for Child Health Research, Centre for Child Health Research (Prof J Carapetis MBBS), University of Western Australia, Perth, WA, Australia (Prof P Norman MD); National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA (H Chen PhD); Cedars-Sinai Medical Center, Los Angeles, CA, USA (Prof S S Chugh MD, R Havmoeller MD); Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands (L E Coffeng MD); Menzies School of Health Research, Darwin, NT, Australia (S Colquhoun MPH, J Condon PhD); National Health Services, Fife, Edinburgh, UK (M D Connor PhD); University of Edinburgh, Edinburgh, UK (M D Connor, Prof F G R Fowkes FRCPE); University of the Witwatersrand, Johannesburg, South Africa (M D Connor); Loyola University Medical School, Chicago, IL, USA (Prof L T Cooper MD); Department of Epidemiology, School of Public Health Sciences, Wake Forest University, Winston-Salem, NC, USA (M Corriere MD); Mario Negri Institute for Pharmacological Research, Bergamo, Italy (M Cortinovis BiotechD, F Gaspari ChemD, N Perico MD, Prof G Remuzzi MD); Hospital Dr Gustavo N Collado, Puerto Chitre, Panama (K Courville de Vaccaro MD); Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC, Australia (B C Cowie MBBS); University of California, San Diego, San Diego, CA, USA (Prof M H Criqui MD, J Denenberg MA); Schools of Public Health and Medicine (S B Omer MBBS), Emory University, Atlanta, GA, USA (K C Dabhadkar MBBS, A Zabetian MD, K M V Narayan MD); University of Pennsylvania, Philadelphia, PA, USA (N Dahodwala MD); Griffith University, Brisbane, QLD, Australia (Prof D De Leo DSc); Beth Israel Medical Center, New York City, NY, USA (D C Des Jarlais PhD); University of Peradeniya, Peradeniya, Sri Lanka (Prof S D Dharmaratne); Johns Hopkins University, Baltimore, MD, USA (E R Dorsey MD); Hospital Maciel, Montevideo, Uruguay (P Espindola MD); MRC-HPA Centre for Environment and Health, London, UK (Prof M Ezzati PhD); National Institute for Stroke and Applied Neurosciences, Auckland Technical University, Auckland, New Zealand (Prof V Feigin MD, R Krishnamurthi PhD); Royal Life Saving Society, Sydney, NSW, Australia (R Franklin PhD); James Cook University, Townsville, QLD, Australia (K Watt PhD, R Franklin PhD); Howard University College of Medicine, Washington, DC, USA (Prof R F Gillum MD); Brandeis University, Waltham, MA, USA (Y A Halasa DDS, Prof D S Shepard PhD, E A Undurraga PhD); Flinders University, Adelaide, SA, Australia (Prof J E Harrison MBBS); Karolinska University Hospital, Stockholm, Sweden (R Havmoeller MD); King’s College Hospital NHS Trust, King’s College, London, UK (Prof R J Hay DM); Université de Franche-Comté, Besançon, France (Prof B Hoen MD); Centre Hospitalier Régional Universitaire de Basençon, Besançon, France (Prof B Hoen); National School of Tropical Medicine, Baylor College of Medicine, Houston, TX, USA (Prof P J Hotez MD); Monash University, Melbourne, VIC, Australia (D Hoy PhD); George Mason University, Fairfax, VA, USA (K H Jacobsen PhD); All India Institute of Medical Sciences, New Delhi, India (G Karthikeyan MD); Department of Cardiology, Hebrew University Hadassah Medical School, Jerusalem, Israel (Prof A Keren MD); School of Public Health (O Kobusingye MMed), Makerere University, Kampala, Uganda (J Mabweijano MMed); University of South Africa, Johannesburg, South Africa (O Kobusingye MMed); Kwame Nkrumah University of Science and Technology, Kumasi, Ghana (A Koranteng MSc); University of California, San Francisco, San Francisco, CA, USA (M Lipnick MD); University of Miami Miller School of Medicine, Miami, FL, USA (Prof S E Lipshultz MD, Prof R L Sacco MD, Prof J D Wilkinson MD); Mulago Hospital, Kampala, Uganda (J Mabweijano MMed); Centre for International Child Health (A Steer MBBS), Department of Paediatrics, Royal Children’s Hospital (R Weintraub MBBS), University of Melbourne, Melbourne, VIC, Australia (Prof R Marks MBBS); Asian Pacific Society of Cardiology, Kyoto, Japan (A Matsumori MD); Medical Research Council, Tygerberg, South Africa (R Matzopoulos MPhil); Hatter Institute (Prof K Sliwa MD), Department of Medicine (Prof G A Mensah MD), University of Cape Town, Cape Town, South Africa (R Matzopoulos, Prof B M Mayosi DPhil); Legacy Health System, Portland, OR, USA (J H McAnulty MD); Northwestern University Feinberg School of Medicine, Evanston, IL, USA (Prof M M McDermott MD); College of Medicine, Alfaisal University, Riyadh, Saudi Arabia (Prof Z A Memish); University of Otago, Dunedin, New Zealand (T R Merriman PhD); China Medical Board, Boston, MA, USA (C Michaud MD); Pacific Institute for Research and Evaluation, Calverton, MD, USA (T R Miller PhD); National Institute of Health, Maputo, Mozambique (Prof A O Mocumbi MD); University Eduardo Mondlane, Maputo, Mozambique (Prof A O Mocumbi); Columbia University, New York City, NY, USA (A Moran MD); London School of Hygiene and Tropical Medicine, London, UK (Prof K Mulholland MD); Centro Studi GISED, Bergamo, Italy (L Naldi MD); School of Public Health, University of Liverpool, Liverpool, UK (Prof K Nasseri DVM); HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland, UK (M O’Donnell PhD); Deakin University, Melbourne, VIC, Australia (Prof R Osborne PhD); B P Koirala Institute of Health Sciences, Dharan, Nepal (B Pahari MD); Betty Cowan Research and Innovation Center, Ludhiana, India (J D Pandian MD); Hospital Juan XXIII, La Paz, Bolivia (A Panozo Rivero MD); Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico (R Perez Padilla MD); Hospital Universitario Cruces, Barakaldo, Spain (F Perez-Ruiz MD); Brigham Young University, Provo, UT, USA (Prof C A Pope III PhD); Hospital Universitario de Canarias, Tenerife, Spain (E Porrini MD); Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada (F Pourmalek MD); Mason Eye Institute, University of Missouri, Columbia, MO, USA (M Raju PhD); Centre for Addiction and Mental Health, Toronto, ON, Canada (Prof J T Rehm PhD); National Opinion Research Center, University of Chicago, Chicago, IL, USA (D B Rein PhD); Complejo Hospitalario Caja De Seguro Social, Panama City, Panama (F Rodriguez de León MD); Vanderbilt University, Nashville, TN, USA (Prof U Sampson MD); University of Alabama at Birmingham, Birmingham, AL, USA (Prof D C Schwebel PhD); Ministry of Interior, Madrid, Spain (M Segui-Gomez MD); Queens Medical Center, Honolulu, HI, USA (D Singh MD); Drexel University School of Public Health, Philadelphia, PA, USA (J A Taylor PhD); Cincinnati Children’s Hospital, Cincinnati, OH, USA (Prof J A Towbin MD); Department of Neurology, Copenhagen University Hospital, Herlev, Denmark (T Truelsen MD); National University of Singapore, Singapore, (N Venketasubramanian FRCP); Voluntary Health Services, Sneha, Chennai, India (Prof L Vijayakumar MBBS); National Institute for Occupational Safety and Health, Baltimore, MD, USA (G R Wagner MD); Beijing Neurosurgical Institute, Capital Medical University, Beijing, China (Prof W Wang MD); Brown University, Providence, RI, USA (Prof M A Weinstock MD); Royal Cornwall Hospital, Truro, UK (Prof A D Woolf MBBS); London School of Economics, London, UK (P-H Yeh MS); Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Prof P Yip PhD); and School of Public Health, Shanghai Jiao Tong University, Shanghai, China (Prof Z-J Zheng MD
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ali A Mokdad
- Institute for Health Metrics and Evaluation (Prof R Lozano MD, M Naghavi PhD, S S Lim PhD, S Y Ahn MPH, M Alvarado BA, K G Andrews MPH, C Atkinson BS, I Bolliger AB, D Chou BA, K E Colson BA, A Delossantos BS, Prof S D Dharmaratne MBBS, A D Flaxman PhD, M H Forouzanfar MD, M K Freeman BA, E Gakidou PhD, D Gonzalez-Medina BA, D Haring BS, S L James MPH, R Jasrasaria BA, N Johns BA, S Lockett Ohno BA, M F MacIntyre EdM, L Mallinger MPH, A A Mokdad MD, M N Nair MD, K Ortblad BA, D Phillips BS, K Pierce BA, D Ranganathan BS, T Roberts BA, L C Rosenfeld MPH, E Sanman BS, M Wang MPH, S Wulf MPH, Prof C J L Murray MD), Department of Anesthesiology and Pain Medicine (N Kassebaum MD), Department of Epidemiology, School of Public Health (L M Anderson PhD), University of Washington, Seattle, WA, USA (Prof W Couser MD, H Duber MD, B Ebel MD, Prof C Mock MD, Prof F P Rivara MD, B Thomas MD); School of Public Health (Prof M Ezzati PhD), Imperial College London, London, UK (K Foreman MPH, Prof P Burney MD, L Rushton PhD); Department of Global Health, University of Tokyo, Tokyo, Japan (Prof K Shibuya MD); Department of Cardiology, Dupuytren University Hospital, Limoges, France (Prof V Aboyans MD); School of Medicine, University of Texas, San Antonio, TX, USA (J Abraham MPH); School of Population Health (T Adair PhD, Prof A D Lopez PhD, Prof T Vos PhD), Queensland Centre for Mental Health Research (J-P Khoo MBBS), Queensland Brain Institute, University of Queensland, Brisbane, QLD, Australia (Prof J McGrath MD); Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India (Prof R Aggarwal MD); Ministry of Health, Riyadh, Saudi Arabia (M A AlMazroa MD, Prof Z A Memish MD); St George’s, University of London, London, UK (Prof H R Anderson MD); Mayo Clinic, Rochester, MN, USA (Prof L M Baddour MD, P J Erwin MLS, Prof S E Gabriel MD); University of Auckland, Auckland, New Zealand (S Barker-Collo PhD); Brigham and Women’s Hospital (S Jayaraman MD), Harvard Medical School (D H Bartels BA, Prof S D Colan MD), Harvard Humanitarian Initiative (L M Knowlton MD), School of Public Health (M Miller MD, Prof J A Salomon PhD), Harvard University, Boston, MA, USA (K Bhalla PhD); Global Partners in Anesthesia and Surgery (D Ozgediz MD), Yale University, New Haven, CT, USA (Prof M L Bell PhD); Boston University, Boston, MA, USA (Prof E J Benjamin MD); Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK (D Bennett PhD); Research Institute of Transplantology and Artificial Organs, Moscow State University of Medicine and Dentistry, Moscow, Russia (B Bikbov MD); King Fahad Medical City, Riyadh, Saudi Arabia (A Bin Abdulhak MD, I M Tleyjeh MD); Michigan State University, East Lansing, MI, USA (Prof G Birbeck MD); School of Public Health (T Driscoll PhD), Faculty of Health Sciences (M Fransen PhD), Department of Rheumatology, Northern Clinical School (E Smith PhD), Institute of Bone and Joint Research (Prof L March MD), University of Sydney, Sydney, NSW, Australia (F Blyth PhD, Prof G B Marks PhD, M Cross PhD); Transport and Road Safety Research (S Boufous PhD), National Drug and Alcohol Research Centre (J Singleton MIPH, Prof L Degenhardt PhD), University of New South Wales, Sydney, NSW, Australia (C Bucello BPsych); Great Ormond Street Hospital, London, UK (M Burch MD); Telethon Institute for Child Health Research, Centre for Child Health Research (Prof J Carapetis MBBS), University of Western Australia, Perth, WA, Australia (Prof P Norman MD); National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA (H Chen PhD); Cedars-Sinai Medical Center, Los Angeles, CA, USA (Prof S S Chugh MD, R Havmoeller MD); Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands (L E Coffeng MD); Menzies School of Health Research, Darwin, NT, Australia (S Colquhoun MPH, J Condon PhD); National Health Services, Fife, Edinburgh, UK (M D Connor PhD); University of Edinburgh, Edinburgh, UK (M D Connor, Prof F G R Fowkes FRCPE); University of the Witwatersrand, Johannesburg, South Africa (M D Connor); Loyola University Medical School, Chicago, IL, USA (Prof L T Cooper MD); Department of Epidemiology, School of Public Health Sciences, Wake Forest University, Winston-Salem, NC, USA (M Corriere MD); Mario Negri Institute for Pharmacological Research, Bergamo, Italy (M Cortinovis BiotechD, F Gaspari ChemD, N Perico MD, Prof G Remuzzi MD); Hospital Dr Gustavo N Collado, Puerto Chitre, Panama (K Courville de Vaccaro MD); Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC, Australia (B C Cowie MBBS); University of California, San Diego, San Diego, CA, USA (Prof M H Criqui MD, J Denenberg MA); Schools of Public Health and Medicine (S B Omer MBBS), Emory University, Atlanta, GA, USA (K C Dabhadkar MBBS, A Zabetian MD, K M V Narayan MD); University of Pennsylvania, Philadelphia, PA, USA (N Dahodwala MD); Griffith University, Brisbane, QLD, Australia (Prof D De Leo DSc); Beth Israel Medical Center, New York City, NY, USA (D C Des Jarlais PhD); University of Peradeniya, Peradeniya, Sri Lanka (Prof S D Dharmaratne); Johns Hopkins University, Baltimore, MD, USA (E R Dorsey MD); Hospital Maciel, Montevideo, Uruguay (P Espindola MD); MRC-HPA Centre for Environment and Health, London, UK (Prof M Ezzati PhD); National Institute for Stroke and Applied Neurosciences, Auckland Technical University, Auckland, New Zealand (Prof V Feigin MD, R Krishnamurthi PhD); Royal Life Saving Society, Sydney, NSW, Australia (R Franklin PhD); James Cook University, Townsville, QLD, Australia (K Watt PhD, R Franklin PhD); Howard University College of Medicine, Washington, DC, USA (Prof R F Gillum MD); Brandeis University, Waltham, MA, USA (Y A Halasa DDS, Prof D S Shepard PhD, E A Undurraga PhD); Flinders University, Adelaide, SA, Australia (Prof J E Harrison MBBS); Karolinska University Hospital, Stockholm, Sweden (R Havmoeller MD); King’s College Hospital NHS Trust, King’s College, London, UK (Prof R J Hay DM); Université de Franche-Comté, Besançon, France (Prof B Hoen MD); Centre Hospitalier Régional Universitaire de Basençon, Besançon, France (Prof B Hoen); National School of Tropical Medicine, Baylor College of Medicine, Houston, TX, USA (Prof P J Hotez MD); Monash University, Melbourne, VIC, Australia (D Hoy PhD); George Mason University, Fairfax, VA, USA (K H Jacobsen PhD); All India Institute of Medical Sciences, New Delhi, India (G Karthikeyan MD); Department of Cardiology, Hebrew University Hadassah Medical School, Jerusalem, Israel (Prof A Keren MD); School of Public Health (O Kobusingye MMed), Makerere University, Kampala, Uganda (J Mabweijano MMed); University of South Africa, Johannesburg, South Africa (O Kobusingye MMed); Kwame Nkrumah University of Science and Technology, Kumasi, Ghana (A Koranteng MSc); University of California, San Francisco, San Francisco, CA, USA (M Lipnick MD); University of Miami Miller School of Medicine, Miami, FL, USA (Prof S E Lipshultz MD, Prof R L Sacco MD, Prof J D Wilkinson MD); Mulago Hospital, Kampala, Uganda (J Mabweijano MMed); Centre for International Child Health (A Steer MBBS), Department of Paediatrics, Royal Children’s Hospital (R Weintraub MBBS), University of Melbourne, Melbourne, VIC, Australia (Prof R Marks MBBS); Asian Pacific Society of Cardiology, Kyoto, Japan (A Matsumori MD); Medical Research Council, Tygerberg, South Africa (R Matzopoulos MPhil); Hatter Institute (Prof K Sliwa MD), Department of Medicine (Prof G A Mensah MD), University of Cape Town, Cape Town, South Africa (R Matzopoulos, Prof B M Mayosi DPhil); Legacy Health System, Portland, OR, USA (J H McAnulty MD); Northwestern University Feinberg School of Medicine, Evanston, IL, USA (Prof M M McDermott MD); College of Medicine, Alfaisal University, Riyadh, Saudi Arabia (Prof Z A Memish); University of Otago, Dunedin, New Zealand (T R Merriman PhD); China Medical Board, Boston, MA, USA (C Michaud MD); Pacific Institute for Research and Evaluation, Calverton, MD, USA (T R Miller PhD); National Institute of Health, Maputo, Mozambique (Prof A O Mocumbi MD); University Eduardo Mondlane, Maputo, Mozambique (Prof A O Mocumbi); Columbia University, New York City, NY, USA (A Moran MD); London School of Hygiene and Tropical Medicine, London, UK (Prof K Mulholland MD); Centro Studi GISED, Bergamo, Italy (L Naldi MD); School of Public Health, University of Liverpool, Liverpool, UK (Prof K Nasseri DVM); HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland, UK (M O’Donnell PhD); Deakin University, Melbourne, VIC, Australia (Prof R Osborne PhD); B P Koirala Institute of Health Sciences, Dharan, Nepal (B Pahari MD); Betty Cowan Research and Innovation Center, Ludhiana, India (J D Pandian MD); Hospital Juan XXIII, La Paz, Bolivia (A Panozo Rivero MD); Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico (R Perez Padilla MD); Hospital Universitario Cruces, Barakaldo, Spain (F Perez-Ruiz MD); Brigham Young University, Provo, UT, USA (Prof C A Pope III PhD); Hospital Universitario de Canarias, Tenerife, Spain (E Porrini MD); Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada (F Pourmalek MD); Mason Eye Institute, University of Missouri, Columbia, MO, USA (M Raju PhD); Centre for Addiction and Mental Health, Toronto, ON, Canada (Prof J T Rehm PhD); National Opinion Research Center, University of Chicago, Chicago, IL, USA (D B Rein PhD); Complejo Hospitalario Caja De Seguro Social, Panama City, Panama (F Rodriguez de León MD); Vanderbilt University, Nashville, TN, USA (Prof U Sampson MD); University of Alabama at Birmingham, Birmingham, AL, USA (Prof D C Schwebel PhD); Ministry of Interior, Madrid, Spain (M Segui-Gomez MD); Queens Medical Center, Honolulu, HI, USA (D Singh MD); Drexel University School of Public Health, Philadelphia, PA, USA (J A Taylor PhD); Cincinnati Children’s Hospital, Cincinnati, OH, USA (Prof J A Towbin MD); Department of Neurology, Copenhagen University Hospital, Herlev, Denmark (T Truelsen MD); National University of Singapore, Singapore, (N Venketasubramanian FRCP); Voluntary Health Services, Sneha, Chennai, India (Prof L Vijayakumar MBBS); National Institute for Occupational Safety and Health, Baltimore, MD, USA (G R Wagner MD); Beijing Neurosurgical Institute, Capital Medical University, Beijing, China (Prof W Wang MD); Brown University, Providence, RI, USA (Prof M A Weinstock MD); Royal Cornwall Hospital, Truro, UK (Prof A D Woolf MBBS); London School of Economics, London, UK (P-H Yeh MS); Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Prof P Yip PhD); and School of Public Health, Shanghai Jiao Tong University, Shanghai, China (Prof Z-J Zheng MD
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Christopher J L Murray
- Corresponding author: Correspondence to: Prof Christopher J L Murray, Institute for Health Metrics and Evaluation, University of Washington, 2301 Fifth Avenue, Suite 600, Seattle, WA 98121, USA,
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Warren PA, Wang F, Stover AC, Rugo HS, Melisko ME, Park JW, Alvarado M, Ewing CA, Esserman LJ, Fowble B, Hwang ES. Abstract P4-16-07: Selective use of post-mastectomy radiation therapy in the neoadjuvant setting. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p4-16-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Neoadjuvant chemotherapy, once reserved for locally advanced breast cancer, has become more common in Stage II disease. While one of its proven benefits is an increase in the frequency of breast conserving surgery, many women will undergo mastectomy despite an excellent clinical response. Indications for post-mastectomy radiation (PMRT) following neoadjuvant therapy are not well defined. Some studies have suggested that certain subgroups of women (young age, triple negative disease) with negative nodes or 1–3 positive nodes after chemotherapy have a significant risk of local-regional failure without PMRT. We conducted a single-institution retrospective study of women undergoing neoadjuvant chemotherapy and mastectomy without PMRT to assess clinical outcomes among this cohort.
Methods: 101 women with initial stage I-III disease (20% stage I, 72% stage II, 8% stage III) received neoadjuvant chemotherapy (doxorubicin-based +/− taxane) followed by mastectomy without PMRT between 2005 and 2011. Mean age was 49 years (range 22–81 years). 16% were BRCA+. 66 patients (65%) had clinically negative axillary nodes at presentation, 34% had N1 disease and 1% had N2 disease. Subtype by IHC was 61% luminal A, 11% luminal B (ER+, Her2+), 20% triple negative and 8% ER−, Her2+. At the time of surgery, 81% were node negative and 19% had 1–3 positive nodes. Pathologic complete response (pCR) (breast + axilla) occurred in 28%. Median follow-up was 34 months (range 5.5–84.5 months).
Results: There were 2 (2%) local-regional failures (1 axillary recurrence at 52 months after mastectomy and 1 chest wall recurrence at 10 months). Both of these recurrences were in patients with negative nodes and luminal A tumors; patients had 2.2 and 2.5 cm of residual invasive cancer, respectively, and negative margins at mastectomy. There were no local-regional failures in women with triple negative cancers, those with 1–3 positive nodes, or patients younger than 40. Additionally, there were no failures in women with a pCR, including those with initial stage IIIA-B disease.
Conclusions: Among carefully selected patients fulfilling low risk criteria for local-regional recurrence, PMRT following neoadjuvant chemotherapy may be omitted without compromising local-regional control.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-16-07.
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Affiliation(s)
- Peled A Warren
- University of California, San Francisco; Duke University Medical Center
| | - F Wang
- University of California, San Francisco; Duke University Medical Center
| | - AC Stover
- University of California, San Francisco; Duke University Medical Center
| | - HS Rugo
- University of California, San Francisco; Duke University Medical Center
| | - ME Melisko
- University of California, San Francisco; Duke University Medical Center
| | - JW Park
- University of California, San Francisco; Duke University Medical Center
| | - M Alvarado
- University of California, San Francisco; Duke University Medical Center
| | - CA Ewing
- University of California, San Francisco; Duke University Medical Center
| | - LJ Esserman
- University of California, San Francisco; Duke University Medical Center
| | - B Fowble
- University of California, San Francisco; Duke University Medical Center
| | - ES Hwang
- University of California, San Francisco; Duke University Medical Center
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Haque R, Alvarado M, Ahmed SA, Shi JM, Chung JWL, Avila CC, Zheng CX, Tiller GE. Abstract P3-08-06: Triple Negative Breast Cancer and BRCA Status: Implications for Genetic Counseling. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p3-08-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
BACKGROUND: Controversy exists whether women newly diagnosed with triple negative breast cancer (TNBC) should be referred to genetic counseling as they may be more likely to be BRCA carriers. However, prior studies included small numbers of carriers and their results have had limited influence on practice guidelines. The objective of this study was to determine the association of breast cancer molecular subtype and BRCA status in a large group of medically insured women.
METHODS: We examined a cohort of 2,105 women with breast cancer history tested for BRCA mutations in a large California health plan from 1997–2011. BRCA test results were recorded in the health plan's clinical genetics registry. Of the 2,105 breast cancer patients, 249 were BRCA mutation carriers (143 BRCA1 carriers, and 106 BRCA2 carriers). We conducted data linkages of all patients with the health plan's NCI-SEER affiliated tumor registry and identified ER, PR, and HER2. HER2 status was also captured from pathology reports using natural language processing. ER, PR, and HER2 status were assessed by immunohistochemical or FISH techniques. Patients were classified into four main biologic subtypes: triple negative (ER−/PR−/HER2−); luminal A (ER+ and/or PR+/HER2−); luminal B (ER+ and/or PR+/HER2+); and HER2-enriched (HER2+/ER−). We examined the association between molecular subtypes (collapsed into TNBC vs. non TNBC categories) and BRCA1/2 mutation status using contingency table analyses. P-values (two-sided) were estimated using chi-square analysis. Multivariable logistic regression was used to estimated adjusted odds ratios (OR) and 95% confidence intervals.
RESULTS: TNBC subtype was strongly associated with BRCA status (P < 0.0001). Women with TNBC tumors were five-fold more likely to be BRCA carriers than women who had non-TNBC breast tumors (OR = 5.6, 95% CI: 4.1–7.5). Specifically, the association of TNBC with BRCA1 was more robust (OR = 12.2, 95% CI: 8.3–17.9). Adjusting for age and stage of breast cancer diagnosis and race/ethnicity did not materially modify the association between TNBC and BRCA1 status. TNBC was not associated with BRCA2 status (OR = 1.6, 95% CI: 0.9–2.7).
CONCLUSION: TNBC was strongly associated with BRCA1 status, but not with BRCA2 status. Statistically significant numbers of patients with BRCA mutations have a TNBC profile. These patients should therefore be referred to clinical genetics for further evaluation and possible testing.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-08-06.
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Affiliation(s)
- R Haque
- Kaiser Permanente Southern California, Pasadena, CA
| | - M Alvarado
- Kaiser Permanente Southern California, Pasadena, CA
| | - SA Ahmed
- Kaiser Permanente Southern California, Pasadena, CA
| | - JM Shi
- Kaiser Permanente Southern California, Pasadena, CA
| | - JWL Chung
- Kaiser Permanente Southern California, Pasadena, CA
| | - CC Avila
- Kaiser Permanente Southern California, Pasadena, CA
| | - CX Zheng
- Kaiser Permanente Southern California, Pasadena, CA
| | - GE Tiller
- Kaiser Permanente Southern California, Pasadena, CA
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Calaf G, Zhang P, Alvarado M, Estrada S, Russo J. C-ha-ras enhances the neoplastic transformation of human breast epithelial-cells treated with chemical carcinogens. Int J Oncol 2012; 6:5-11. [PMID: 21556493 DOI: 10.3892/ijo.6.1.5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The present study was carried out with the purpose of analyzing the additive effect of c-Ha-ras oncogene on tumorigenesis in human breast epithelial cells (HBEC) treated with chemical carcinogens. A human breast epithelial cell (HBEC) line, MCF-10F, previously treated with dimethylbenz(a) anthracene (DMBA) and benzo(a)pyrene (BP) was used in these studies. The MCF-10F cells, DMBA and/or BP-transformed cells originated from the clones D3-1 and BP1 which were transfected with the plasmid pH06T1 containing the human T24 mutated c-Ha-ras oncogene and termed MCF-10F-Tras, D3-1-Tras and BP1-Tras, respectively. Whereas the c-Ha-ras transfected cells presented altered morphology, increased anchorage independent growth in agar-methocel, invasiveness and tumorigenicity, the MCF-10F cells, the clones D3 and BP1 were not tumorigenic. Importantly, whereas MCF-10F-Tras was slightly tumorigenic, the D3-1-Tras and BP1-Tras transfected cells were 100% tumorigenic in the SCID mice; and the tumors thus obtained were poorly differentiated carcinomas. DNA fingerprinting confirmed that the tumors derived originated from the cell lineage used. It was concluded that c-Ha ras induces an additive effect on the expression of tumorigenesis in human breast epithelial cell line MCF-10F treated with chemical carcinogens. Our work provide a model for analyzing the role of c-Ha-ras in human breast cancer.
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Affiliation(s)
- G Calaf
- FOX CHASE CANC CTR,PHILADELPHIA,PA 19111
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