Adjusted Mortality Rate Ratios Research Articles

Maternal BCG scars and mortality risk for male and female newborns: observational study from Guinea-Bissau.

Maternal priming with Bacille Calmette-Guérin (BCG) has been associated with reduced mortality in male offspring. We investigated this association in a cohort of healthy BCG-vaccinated neonates. Observational study within a randomized controlled trial comparing different BCG strains conducted in Guinea-Bissau from 2017-2020. As part of trial inclusion procedures, on the day of discharge from the maternity ward, maternal BCG scar status was evaluated by visual inspection, followed by offspring BCG and polio vaccination. Through mortality data collected at telephone interviews at six weeks and six months of age, we assessed all-cause mortality risk in Cox Proportional Hazards models adjusted for maternal schooling and BCG strain, providing adjusted Mortality Rate Ratios (aMRRs). 64% (11,070/17,275) of mothers had a BCG scar, which for females and overall was not associated with neither admission risk, admission severity nor all-cause mortality. By six months of age, the mortality rate (MR) was 4.1 (200 deaths/4,919 person-years) for the maternal BCG scar cohort and 5.2 (139 deaths/2,661 person-years) for no maternal scar, aMRR=0.86 (0.69-1.06). In males, six-month MRs were 4.3 (109/2,531) for maternal BCG scar vs 6.3 (87/1,376) for no scar, the maternal scar/no scar aMRR being 0.74 (0.56-0.99). In females, six-month MRs were 3.8 (91/2,388) vs 4.0 (52(1,286), the aMRR being 1.04 (0.74-1.47), p for interaction with sex=0.16. While we cannot rule out an association in females, being born to a mother with a BCG scar reduced the risk of death during early infancy for BCG-vaccinated males, reproducing findings from previous studies.

Trends in mortality in people with HIV from 1999 to 2020: a multi-cohort collaboration.

Mortality among people with HIV declined with the introduction of combination antiretroviral therapy. We investigated trends over time in all-cause and cause-specific mortality in people with HIV from 1999-2020. Data were collected from the D:A:D cohort from 1999 through January 2015 and RESPOND from October 2017 through 2020. Age-standardized all-cause and cause-specific mortality rates, classified using Coding Causes of Death in HIV (CoDe), were calculated. Poisson regression models were used to assess mortality trends over time. Among 55716 participants followed for a median of 6 years (IQR 3-11), 5263 participants died (crude mortality rate [MR] 13.7/1000 PYFU; 95%CI 13.4-14.1). Changing patterns of mortality were observed with AIDS as the most common cause of death between 1999- 2009 (n = 952, MR 4.2/1000 PYFU; 95%CI 4.0-4.5) and non-AIDS defining malignancy (NADM) from 2010 -2020 (n = 444, MR 2.8/1000 PYFU; 95%CI 2.5-3.1). In multivariable analysis, all-cause mortality declined over time (adjusted mortality rate ratio [aMRR] 0.97 per year; 95%CI 0.96, 0.98), mostly from 1999 through 2010 (aMRR 0.96 per year; 95%CI 0.95-0.97), and with no decline shown from 2011 through 2020 (aMRR 1·00 per year; 95%CI 0·96-1·05). Mortality due all known causes except NADM also declined over the entire follow-up period. Mortality among people with HIV in the D:A:D and/or RESPOND cohorts decreased between 1999 and 2009 and was stable over the period from 2010 through 2020. The decline in mortality rates was not fully explained by improvements in immunologic-virologic status or other risk factors.

Abstract 801: Severe housing cost burden and premature cancer mortality by state Medicaid expansion status

Abstract Introduction: The fraction of people living in unaffordable housing in the U.S. has grown, and prior studies have documented a relationship between housing cost burden and worsening health. Medicaid expansion has been suggested to improve housing financial stability by reducing health care costs and improving access to preventative care. However, the role of expanded access to Medicaid on the relationship between housing cost burden and cancer mortality remains poorly understood. We investigated the relationship between county-level severe housing cost burden and premature cancer mortality by state Medicaid expansion status for all cancers and leading sites. Methods: This ecological study used county-level data from 2016-2020 American Community Survey linked with county-level mortality data. Severe housing cost burden measured by percentage of households within a county that spend ≥50% of their income on housing categorized into quintiles (1=lowest, 5=highest) and state Medicaid expansion status (expanded and non-expanded). Age-adjusted cancer mortality rates and adjusted-mortality rate ratio (aRR) were estimated by sex. Results: Across quintiles of county-level severe housing cost burden, age-adjusted cancer mortality rates were largely greater in non-Medicaid expanded states than Medicaid expanded states among women and men. Among counties in the lowest quintile of severe housing cost burden, rates for overall cancer mortality in women were 9% (aRR=1.09; 95%CI 1.05-1.14) higher in non-Medicaid expanded states compared with expanded states. Additionally, among the third quintile of severe housing cost burden, colorectal cancer mortality rate was 8% higher (aRR=1.08; 95%CI 1.02-1.14) in non-Medicaid expanded states. Among men in the lowest quintile of severe housing cost burden, overall cancer mortality rates were 5% (aRR=1.05; 95%CI 1.02-1.09) higher in non-Medicaid expanded states than Medicaid expanded states. Further, among men in counties in the highest quintile of severe housing cost burden, colorectal cancer mortality rate was 8% higher (aRR=1.08; 95%CI 1.05-1.12) and lung cancer mortality was 13% higher (aRR=1.13; 95%CI 1.10-1.15) in non-Medicaid expanded states compared with expanded states. Conclusions: Counties with a lower fraction of households experiencing severe housing cost burden had greater premature cancer death rates within non-Medicaid expanded states than Medicaid expanded states. However, among men rates were also elevated in non-Medicaid expanded states in counties with the greatest severe housing cost burden. Citation Format: Wayne R. Lawrence, Neal D. Freedman, Jennifer K. McGee-Avila, Lee Mason, Yingxi Chen, Aldenise P. Ewing, Meredith S. Shiels. Severe housing cost burden and premature cancer mortality by state Medicaid expansion status [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 801.

Socioeconomic inequalities in avoidable mortality in Italy: results from a nationwide longitudinal cohort

BackgroundDisparities in avoidable mortality have never been evaluated in Italy at the national level. The present study aimed to assess the association between socioeconomic status and avoidable mortality.MethodsThe nationwide closed cohort of the 2011 Census of Population and Housing was followed up for 2012–2019 mortality. Outcomes of preventable and of treatable mortality were separately evaluated among people aged 30–74. Education level (elementary school or less, middle school, high school diploma, university degree or more) and residence macro area (North-West, North-East, Center, South-Islands) were the exposures, for which adjusted mortality rate ratios (MRRs) were calculated through multivariate quasi-Poisson regression models, adjusted for age at death. Relative index of inequalities was estimated for preventable, treatable, and non-avoidable mortality and for some specific causes.ResultsThe cohort consisted of 35,708,459 residents (48.8% men, 17.5% aged 65–74), 34% with a high school diploma, 33.5% living in the South-Islands; 1,127,760 deaths were observed, of which 65.2% for avoidable causes (40.4% preventable and 24.9% treatable). Inverse trends between education level and mortality were observed for all causes; comparing the least with the most educated groups, a strong association was observed for preventable (males MRR = 2.39; females MRR = 1.65) and for treatable causes of death (males MRR = 1.93; females MRR = 1.45). The greatest inequalities were observed for HIV/AIDS and alcohol-related diseases (both sexes), drug-related diseases and tuberculosis (males), and diabetes mellitus, cardiovascular diseases, and renal failure (females). Excess risk of preventable and of treatable mortality were observed for the South-Islands.ConclusionsSocioeconomic inequalities in mortality persist in Italy, with an extremely varied response to policies at the regional level, representing a possible missed gain in health and suggesting a reassessment of priorities and definition of health targets.

Severe housing cost burden and premature mortality from cancer.

Unaffordable housing has been associated with poor health. We investigated the relationship between severe housing cost burden and premature cancer mortality (death before 65 years of age) overall and by Medicaid expansion status. County-level severe housing cost burden was measured by the percentage of households that spend 50% or more of their income on housing. States were classified on the basis of Medicaid expansion status (expanded, late-expanded, nonexpanded). Mortality-adjusted rate ratios were estimated by cancer type across severe housing cost burden quintiles. Compared with the lowest quintile of severe housing cost burden, counties in the highest quintile had a 5% greater cancer mortality rate (mortality-adjusted rate ratio = 1.05, 95% confidence interval = 1.01 to 1.08). Within each severe housing cost burden quintile, cancer mortality rates were greater in states that did not expand Medicaid, though this association was significant only in the fourth quintile (mortality-adjusted rate ratio = 1.08, 95% confidence interval = 1.03 to 1.13). Our findings demonstrate that counties with greater severe housing cost burden had higher premature cancer death rates, and rates are potentially greater in non-Medicaid-expanded states than Medicaid-expanded states.

P1118 High Crohn’s Disease burden but disproportionally low use of biologics in Crohn’s Disease patients with Intestinal Failure: a longitudinal comparative study from 1973-2018

Abstract Background Patients with Crohn’s Disease (CD) complicated by Intestinal Failure (CDIF) are considered to be among those with the most severe form of CD. Their clinical course before IF onset has not been well characterised. We aimed to describe and compare CD-specific natural history, disease burden and treatment between CDIF patients and CD patients without IF over a 40-year period. Methods CDIF patients from Copenhagen Intestinal Failure Database (1973-2018) and a Danish nationwide CD cohort without IF (1977-2018) were followed from onset of CD until IF, death, or 31/12/2018. Hospital contacts, surgeries, prescription dispensation, employment and mortality data were extracted from multiple population-based registries. Groups were compared using logistic regression for proportions and Poisson regression for rates. Standard mortality ratio (SMR) was calculated against age, gender and year-matched Danish population references, and an adjusted mortality rate ratio between CDIF and CD patients was obtained from Cox models. Results 182 CDIF and 22845 CD patients were followed for 3035.7 and 293536.5 patient-years, respectively. At CD diagnosis, CDIF patients were younger (median age 24 years vs 35 years, p<0.0001), from earlier decades (71.5% vs 16.5% before 1991, p<0.0001), and had fewer comorbidities (6.9% vs 20.4%, p<0.0001). The 10-year cumulative incidence of IF declined from 2.7% in patients diagnosed with CD prior to 1980 to 0.2% in patients diagnosed after 2000, but the number of new CDIF patients has not declined over the decades (Table). A greater proportion CDIF patients received at least 1 course of steroids (70.8% versus 59.8%, p=0.02) and immunomodulators (59.3% vs 48.7%, p=0.03), had IBD-related hospital contacts (98.2% vs 55.2%, p<0.0001) and abdominal surgeries (94.9% vs 47.6%, p<0.0001), and stopped working for >6 months (65.8% vs 57.8% of working-age patients, p=0.05). However, in the biologics era (after 2000), CDIF patients were not treated with biologics more often (20.4% vs 21% had any biologics, p=ns). In those who were treated, CDIF patients had less cumulative time on biologics (3.9 years vs 11.2 years per 100 patient-years, p=0.001). CDIF and CD patients had a SMR of 3.7 (97.5% CI 2.79,4.72) and 1.7 (97.5% CI 1.61, 1.72), respectively. After adjusting for age, sex and co-morbidity, CDIF patients were at 3.42 times risk of dying compared to CD patients. Conclusion The incidence of CDIF has reduced in newly diagnosed CD patients, however the number of new CDIF patients has not yet declined due to increasing CD prevalence. Despite CDIF patients experiencing a significantly higher burden of CD before the onset of IF, they were not more likely to receive biologics. They also appear more refractory to biologics.

Abstract B099: Association between obesity and mortality by race, ethnicity, and sex in the United States, 1999-2018

Abstract Background The association between obesity and mortality risk is well established. This prospective cohort study will examine whether there are disparities in this across sex and race/ethnicity in the US and provide updated risk estimates for all-cause, cancer, and five other leading causes of death. Methods We created a cohort of 282,602 never-smoking participants using the National Health Interview Survey (NHIS) linked to the National Death Index that follows mortality up to December 31, 2019. We considered participants aged 25-84 years at enrollment, with at least 2 years follow up, and the following race/ethnicity groups: non-Hispanic White[White], non-Hispanic Black[Black], Hispanic, and other. Self-reported BMI values from NHIS were adjusted using the National Health and Nutrition Examination Survey objectively measured BMI averages by sex, race/ethnicity, and education. The adjusted BMI categories included 12-<18.5(underweight), 18.5-<25(healthy weight), 25-<30(overweight), 30-<40(obese), and 40-≤70(severely obese). Adjusted mortality rate ratios (RR) obtained by the Cox proportional hazard model using NHIS complex survey design compared individuals with healthy weight to those with lower or higher BMI by sex and race/ethnicity. Results A total of 22,591 deaths occurred in this study period, of which 4,539 were cancer. In men and women, obesity and severe obesity were associated with higher risk of cancer mortality. Compared to men with healthy weight, the risk of cancer mortality was higher among individuals who were underweight (RR=1.95,95%CI=1.06-3.58), overweight (RR=1.03,95%CI=0.88-1.19), obese (RR=1.30,95%CI=1.11-1.53), and severely obese (RR=1.68,95%CI=1.21-2.32). Among women, the risk for cancer mortality was higher among individuals who were underweight (RR=1.18,95%CI=0.78-1.80), overweight (RR=1.06,95%CI=0.95-1.18), obese (RR=1.17,95%CI=1.04-1.32), and severely obese (RR=1.62,95%CI=1.35-1.93) compared to the risk for those with healthy weight. In general, similar patterns were observed in all-cause and leading causes of death evaluated in this study. Similarly, being underweight, obese, and severely obese, as compared to being healthy weight, was generally associated with all-cause and cause-specific mortality among White and Hispanic populations. However, obesity and severe obesity were not significantly associated with cancer mortality among Black people likely due to sparse data. The magnitude of some mortality associations also differed by sex and race/ethnicity. For example, the association between obesity and all-cause mortality was stronger among Hispanic men (RR=1.64,95%CI=1.33-2.02) compared to Hispanic women (RR=1.10,95%CI=0.94-1.28). The all-cause RR for severe obesity among White females (RR=1.96,95%CI=1.78-2.17) was larger than among Black females (RR=1.52,95%CI=1.31-1.76). Conclusions Higher BMI was associated with higher risk of all-cause and leading causes of mortality by sex and race/ethnicity, emphasizing the importance of interventions to help reduce excess body weight and maintaining healthy body weight. Citation Format: Emily C. Marlow, Blake Thomson, Ahmedin Jemal, Farhad Islami. Association between obesity and mortality by race, ethnicity, and sex in the United States, 1999-2018 [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B099.

The intersection of race/ethnicity and socioeconomic status: inequalities in breast and cervical cancer mortality in 20,665,005 adult women from the 100 Million Brazilian Cohort

ABSTRACT Objectives There is limited evidence regarding the impact of race/racism and its intersection with socioeconomic status (SES) on breast and cervical cancer, the two most common female cancers globally. We investigated racial inequalities in breast and cervical cancer mortality and whether SES (education and household conditions) interacted with race/ethnicity. Design The 100 Million Brazilian Cohort data were linked to the Brazilian Mortality Database, 2004–2015 (n = 20,665,005 adult women). We analysed the association between self-reported race/ethnicity (White/‘Parda’(Brown)/Black/Asian/Indigenous) and cancer mortality using Poisson regression, adjusting for age, calendar year, education, household conditions and area of residence. Additive and multiplicative interactions were assessed. Results Cervical cancer mortality rates were higher among Indigenous (adjusted Mortality rate ratio = 1.80, 95%CI 1.39–2.33), Asian (1.63, 1.20–2.22), ‘Parda’(Brown) (1.27, 1.21–1.33) and Black (1.18, 1.09–1.28) women vs White women. Breast cancer mortality rates were higher among Black (1.10, 1.04–1.17) vs White women. Racial inequalities in cervical cancer mortality were larger among women of poor household conditions, and low education (P for multiplicative interaction <0.001, and 0.02, respectively). Compared to White women living in completely adequate (3–4) household conditions, the risk of cervical cancer mortality in Black women with 3–4, 1–2, and none adequate conditions was 1.10 (1.01–1.21), 1.48 (1.28–1.71), and 2.03 (1.56–2.63), respectively (Relative excess risk due to interaction-RERI = 0.78, 0.18–1.38). Among ‘Parda’(Brown) women the risk was 1.18 (1.11–1.25), 1.68 (1.56–1.81), and 1.84 (1.63–2.08), respectively (RERI = 0.52, 0.16–0.87). Compared to high-educated White women, the risk in high-, middle- and low-educated Black women was 1.14 (0.83–1.55), 1.93 (1.57–2.38) and 2.75 (2.33–3.25), respectively (RERI = 0.36, −0.05–0.77). Among ‘Parda’(Brown) women the risk was 1.09 (0.91–1.31), 1.99 (1.70–2.33) and 3.03 (2.61–3.52), respectively (RERI = 0.68, 0.48–0.88). No interactions were found for breast cancer. Conclusion Low SES magnified racial inequalities in cervical cancer mortality. The intersection between race/ethnicity, SES and gender needs to be addressed to reduce racial health inequalities.

Short-term outcomes following total colectomy for inflammatory bowel disease in Denmark after implementation of laparoscopy: a nationwide population-based study.

A laparoscopic approach to total colectomy (TC) for inflammatory bowel disease (IBD) is being increasingly used, but data on its comparative benefits over open TC are conflicting. The aim of this study was to examine 90-day outcomes following laparoscopic and open TC for IBD in a nationwide cohort after the introduction of laparoscopy. IBD patients undergoing TC in Denmark from 2005 to 2017 were identified from the Danish National Patient Registry. We used Kaplan-Meier methodology to estimate mortality and Cox regression analysis to estimate adjusted mortality rate ratios (aMRRs) and adjusted hazard ratios (aHRs) of reoperation, readmission and intensive care unit (ICU) transfer, comparing patients undergoing laparoscopic versus open TC. We identified 1095 patients undergoing laparoscopic TC and 1523 patients undergoing open TC. Following emergency TC, 90-day mortality was 2.8% (1.6%-4.9%) after laparoscopic TC and 9.1% (7.0%-11.8%) after open TC. Ninety-day mortality was 0.9% (0.3%-2.5%) after laparoscopic TC and 2.6% (1.5%-4.3%) after open elective TC. The aMRRs associated with laparoscopic TC were 0.45 (95% CI 0.25-0.80) in emergency cases and 0.29 (95% CI 0.10-0.86) in elective cases. Risks of readmission were comparable following laparoscopic versus open TC, both in emergency [aHR = 0.93 (95% CI 0.76-1.15)] and elective [aHR = 0.83 (95% CI 0.68-1.02)] cases, while risks of ICU transfer and reoperation were lower following laparoscopic TC, both in emergency cases [aHR = 0.53 (95% CI 0.35-0.82) and aHR = 0.26 (95% CI 0.15-0.47)] and elective [aHR = 0.58 (95% CI 0.35-0.95) and aHR = 0.37 (95% CI 0.21-0.66)] cases. The introduction of laparoscopic TC for IBD in Denmark was not associated with increased mortality or morbidity. In fact, laparoscopic TC for IBD may be associated with lower short-term mortality and morbidity compared with open TC.

Red cell distribution width as a predictor of mortality after hip fracture: a systematic review and meta-analysis.

This review examined the association between red cell distribution width (RDW) and mortality after hip fracture. PubMed, CENTRAL, Scopus, Web of Science, and Embase were searched up to 10th January 2023 for studies comparing mortality after hip fracture based on RDW. All cut-offs of RDW were accepted. Crude and adjusted mortality ratios were pooled separately. Nine studies with 5,274 patients were eligible. Meta-analysis of eight studies reporting crude mortality rates showed that patients with high RDW had a significantly higher risk of mortality than those with low RDW (RR: 2.81 95% CI: 2.05, 3.86 I2=82%). The results did not change in significance on subgroup analyses based on study location, sample size, the cut-off of RDW, and follow-up. Four studies reported adjusted mortality rates. Analysis of the same showed that high RDW was an independent predictor of mortality in hip fracture patients (HR: 3.14 95% CI: 1.38, 7.14 I2=95%). Within the limitations of the review, RDW was found to be an indicator of mortality in hip fracture patients. High RDW was significantly associated with increased mortality despite different cut-offs among studies. Further research is needed to generate more rigorous evidence.

Changes in Geographic Variation and Socioeconomic Inequalities in Esophageal Cancer Mortality in China, 1973-2017.

Geographic variability in esophageal cancer has been reported in China, but data are lacking at the local level. We aimed to investigate changes in disparities in esophageal cancer-related mortality among Chinese counties and whether county-level socioeconomic status was associated with this variation. We used data from a nationwide survey and population-based cancer registries to calculate esophageal cancer-related mortality rates for 782 Chinese counties for the periods of 1973-1975 and 2015-2017. We performed hotspot analysis to identify spatial clusters. We used a multivariable negative binomial regression model to estimate the associations between county-level socioeconomic factors and mortality. From 1973-1975 to 2015-2017, the age-standardized esophageal cancer-related mortality rate decreased from 27 to 8 per 100,000 person-years in China. By county, 577 (74%) of 782 counties experienced decreasing mortality. Geographic disparities in mortality substantially narrowed, with the gap in mortality rates between 90th and 10th percentile counties decreasing from 55 per 100,000 person-years in 1973-1975 to 16 in 2015-2017. However, clusters of elevated rates persisted across north-central China. Rurality [adjusted mortality rate ratio (MRR) 1.15; 95% confidence interval (CI), 1.10-1.21], per capita gross domestic product (adjusted MRR, 0.95; 95% CI, 0.91-0.98), and percentage of people with a high-school diploma (adjusted MRR, 0.86; 95% CI, 0.84-0.87) in a county were significantly associated esophageal cancer-related mortality rates. China has made substantial progress in reducing esophageal cancer-related mortality and disparities, but the intercounty differences remain large. Continued efforts are needed to address the geographical and socioeconomic disparities in esophageal cancer.

Using real-life data to model the impact of increasing BCG vaccination coverage and scar prevalence on all-cause infant mortality

PurposeEstimating the potential impact on infant mortality of increasing Bacille Calmette-Guérin (BCG) vaccination coverage and BCG scar prevalence. MethodsGuinea-Bissau Health and Demographic Surveillance System data on BCG vaccination coverage, scar status, and all-cause mortality were used for this study. Mortality risk (MR) by scar status was assessed in Cox models providing adjusted mortality rate ratios (aMRRs). Distributions were fitted for survival, vaccination coverage, and scar prevalence. Models for 12-month mortality were calculated. We utilized World Bank data on birth rates and mortality rates to assess the potential global impact of optimizing BCG vaccination programs. ResultsBCG coverage was 81% and scar prevalence 42% among 2-month-old infants, and the 1- to 12-month scar/no scar aMRR was 0.40 (0.22, 0.76). Modeling 2-month 99% vaccination coverage with 95% developing scars would change the 1- to 12-month MR by −8% (−21%, +12%). Globally, the reduction in the MR between 1- and 12-month would be −14% (−14%, −15%), corresponding to −208,075 (−214,453, −204,023) fewer infant deaths/year. ConclusionsWe confirmed previous observations: having a BCG scar markedly reduces infant MR. Increasing current global 2-month BCG vaccination coverage from 76% to 99%, and scar prevalence among vaccinated infants from 52% to 95% might reduce global infant mortality by >200,000 deaths/year. Thus, optimizing BCG vaccination programs to focus on increasing early BCG vaccination coverage and the overall scar prevalence would have major public health benefits.

Association Between Diabetes and Mortality Among Adult Patients Hospitalized With COVID-19: A Cohort Study of Hospitalized Adults in Ontario, Canada, and Copenhagen, Denmark

ObjectivesDiabetes has been reported to be associated with an increased risk of death among patients with COVID-19. However, the available studies lack detail on COVID-19 illness severity and measurement of relevant comorbidities. MethodsWe conducted a multicentre, retrospective cohort study of patients 18 years of age and older who were hospitalized with COVID-19 between January 1, 2020, and November 30, 2020, in Ontario, Canada, and Copenhagen, Denmark. Chart abstraction emphasizing comorbidities and disease severity was performed by trained research personnel. The association between diabetes and death was measured using Poisson regression. The main outcome measure was in-hospital 30-day risk of death. ResultsOur study included 1,133 hospitalized patients with COVID-19 in Ontario and 305 in Denmark, of whom 405 and 75 patients, respectively, had pre-existing diabetes. In both Ontario and Denmark, patients with diabetes were more likely to be older; have chronic kidney disease, cardiovascular disease, and higher troponin levels; and be receiving antibiotics, when compared with adults without diabetes. In Ontario, 24% (n=96) of adults with diabetes died compared with 15% (n=109) of adults without diabetes. In Denmark, 16% (n=12) of adults with diabetes died in hospital compared with 13% (n=29) of those without diabetes. In Ontario, the crude mortality ratio among patients with diabetes was 1.60 (95% confidence interval [CI], 1.24 to 2.07) and in the adjusted regression model it was 1.19 (95% CI, 0.86 to 1.66). In Denmark, the crude mortality ratio among patients with diabetes was 1.27 (95% CI, 0.68 to 2.36) and in the adjusted model it was 0.87 (95% CI, 0.49 to 1.54). Meta-analysis of the 2 rate ratios from each region resulted in a crude mortality ratio of 1.55 (95% CI, 1.22 to 1.96) and an adjusted mortality ratio of 1.11 (95% CI, 0.84 to 1.47). ConclusionThe presence of diabetes was not strongly associated with in-hospital COVID-19 mortality independent of illness severity and other comorbidities.

Risk Factors and Prognosis of Epilepsy Following Brain Abscess: A Nationwide Population-Based Cohort Study.

Epilepsy in patients with brain abscess is frequent, but risk factors and prognosis remain undetermined. This study examined risk factors of epilepsy among survivors of brain abscess and associated prognosis. Nationwide, population-based healthcare registries were used to compute cumulative incidences and cause-specific adjusted hazard rate ratios (adj. HRRs) with 95% CIs for epilepsy among 30-day survivors of brain abscess from 1982 through 2016. Data were enriched with clinical details by medical record review of patients hospitalized from 2007 through 2016. Adjusted mortality rate ratios (adj. MRRs) were examined using epilepsy as a time-dependent variable. The study included 1,179 30-day survivors of brain abscess among whom 323 (27%) developed new-onset epilepsy after a median of 0.76 years (interquartile range [IQR] 0.24-2.41). At admission for brain abscess, the median age was 46 years (IQR 32-59) in patients with epilepsy compared with 52 years (IQR 33-64) in those without epilepsy. The proportion of female individuals was similar in patients with and without epilepsy (37%). Adj. HRRs for epilepsy were 2.44 (95% CI 1.89-3.15) for aspiration or excision of brain abscess, 2.37 (1.56-3.60) for alcohol abuse, 1.75 (1.27-2.40) for previous neurosurgery or head trauma, 1.62 (1.17-2.25) for stroke, and 1.55 (1.04-2.32) for age group 20-39 years. Cumulative incidences were increased in patients with alcohol abuse (52% vs 31%), aspiration or excision of brain abscess (41% vs 20%), previous neurosurgery or head trauma (41% vs 31%), and stroke (46% vs 31%). Analysis using clinical details from medical record review of patients from 2007 through 2016 demonstrated adj. HRRs of 3.70 (2.24-6.13) for seizures at admission for brain abscess and 1.80 (1.04-3.11) for frontal lobe abscess. By contrast, adj. HRR was 0.42 (0.21-0.86) for occipital lobe abscess. Using the entire registry-based cohort, patients with epilepsy had an adj. MRR of 1.26 (1.01-1.57). Important risk factors of epilepsy were seizures during admission for brain abscess, neurosurgery, alcoholism, frontal lobe abscess, and stroke. Epilepsy was associated with an increased mortality. Antiepileptic treatment may be guided by individual risk profiles, and a specialized follow-up is highlighted by an increased mortality in survivors with epilepsy.

The association between sociodemographic status and COPD and asthma mortality, DALY and YLD in southern China, 2005–2015

BackgroundLittle is known about the disease burden of chronic obstructive pulmonary disease (COPD) and asthma in southern China. MethodWe calculated the mortality, disability-adjusted life-years (DALY), years lived with disability (YLD) and years of life lost (YLL) for COPD and asthma in Guangdong province between 2005 and 2015. We examined the significance of trends of mortality, DALY, YLD and YLL rates for COPD and asthma with the Cochran-Armitage trend test. We also analyzed their association with sociodemographic factors by negative binomial models. ResultThe age-standardized mortality, DALY, YLD and YLL rates of COPD and asthma decreased significantly in Guangdong, except for an increase of 11.3% in the age-standardized YLD rate of COPD between 2005 and 2015 (all P < 0.05). Compared with females, the respective adjusted mortality rate ratio of males was 2.11 for COPD, and 0.74 for asthma. Compared with other regions, the richest region, Pearl River Delta, had the lowest mortality, DALY, YLD and YLL rate ratios (RR) of COPD and asthma (all P < 0.05). COPD and asthma mortality, DALY, YLD and YLL rates increased substantially with age. Specifically, when compared with the 25–49 years age group, the respective adjusted DALY RR of asthma was 1.91, 2.02 and 22.21 for 0–24, 50–74 and ≥75 years age group; the respective adjusted YLD RR was 2.27, 1.33 and 7.17 for 0–24, 50–74 and ≥75 years age group. ConclusionsDisease burden of COPD and asthma decreased in Guangdong province in southern China between 2005 and 2015; however, a disproportionate burden of COPD and asthma in terms of age, sex and regions was observed. The relatively high disease burden and high rate of impaired public health from the less developed regions highlight the need for focused policy making to address the problem.

Association Between Smoking, Smoking Cessation, and Mortality by Race, Ethnicity, and Sex Among US Adults

Patterns of cigarette smoking and smoking cessation vary considerably across demographic groups in the US, but there is limited evidence on whether the hazards of smoking and benefits of quitting vary across these groups. Population-specific evidence on the benefits of quitting smoking may motivate cessation among groups historically underrepresented in medical research. To quantify the association between smoking, smoking cessation, and mortality by race, ethnicity, and sex. This nationally representative, prospective cohort study used data from the US National Health Interview Survey collected via questionnaire between January 1997 and December 2018 among adults aged 25 to 84 years at recruitment. Participants were followed up for cause-specific mortality through December 31, 2019. Self-reported smoking status at recruitment, age at quitting smoking, and years since quitting smoking. The main outcomes were all-cause mortality and mortality from cancer, cardiovascular disease, and lower respiratory disease. Adjusted mortality rate ratios comparing never, former, and current smokers were calculated using Cox proportional hazards regression. Weighted analyses were conducted by race, ethnicity, and sex as reported by participants. Among the 551 388 participants in the main analyses, the mean (SD) age at recruitment was 48.9 (15.3) years; 307 601 (55.8%) were women, 87 207 (15.8%) were Hispanic, 75 545 (13.7%) were non-Hispanic Black, 355 782 (64.5%) were non-Hispanic White, and 32 854 (6.0%) identified as other non-Hispanic race and ethnicity. There were 74 870 deaths among participants aged 25 to 89 years during follow-up (36 792 [49.1%] among men; 38 078 [50.9%] among women). The all-cause mortality rate ratio (RR) for current vs never smoking was 2.80 (95% CI, 2.73-2.88) overall. The RRs were similar by sex but varied by race and ethnicity: Hispanic, 2.01 (95% CI, 1.84-2.18); non-Hispanic Black, 2.19 (95% CI, 2.06-2.33); non-Hispanic White, 3.00 (95% CI, 2.91-3.10); and other non-Hispanic race and ethnicity, 2.16 (95% CI, 1.88-2.47). When comparing those who quit smoking before age 45 years with never smokers, all-cause mortality RRs were 1.15 (95% CI, 1.03-1.28) among Hispanic individuals, 1.16 (95% CI, 1.07-1.25) among non-Hispanic Black individuals, 1.11 (95% CI, 1.08-1.15) among non-Hispanic White individuals, and 1.17 (95% CI, 0.99-1.39) among other non-Hispanic individuals. In this prospective cohort study, among men and women from diverse racial and ethnic groups, current smoking was associated with at least twice the all-cause mortality rate of never smoking. Quitting smoking, particularly at younger ages, was associated with substantial reductions in the relative excess mortality associated with continued smoking.

Maternal Epilepsy and Long-term Offspring Mortality: A Nationwide Cohort Study.

ObjectiveWe examined how maternal epilepsy and use of antiseizure medications in pregnancy was associated with offspring mortality.MethodsThis population‐based cohort study included all live‐ and stillborn singletons in Denmark between 1981 and 2016. We used nation‐wide registers to retrieve information on pregnancy characteristics, epilepsy diagnoses, use of antiseizure medications, and mortality. Adjusted mortality rate ratios (MRR) were estimated using log‐linear Poisson regression.ResultsThe cohort consisted of 1,862,474 children. In total, 12,026 live‐born children died during follow‐up, of whom 170 (1.4%) were offspring of mothers with epilepsy. Overall mortality was increased in offspring of mothers with epilepsy compared to offspring of mothers without epilepsy (MRR = 1.46, 95% CI: 1.23–1.71), driven by an excess mortality only in the first year of life. Mortality was increased for natural deaths (MRR = 1.50, 95% CI: 1.25–1.78) but not from unnatural deaths (MRR = 1.38, 95% CI: 0.84–2.14), and only in offspring of women with epilepsy who used antiseizure medications during pregnancy (MRR = 1.51, 95% CI: 1.00–2.17), but not in offspring of women with epilepsy who did not use antiseizure medications while pregnant (MRR = 0.97, 95% CI: 0.69–1.31). When analyses were restricted to children born from 2000 and onwards, the excess mortality that was observed in the first year of life among children of mothers with epilepsy, was no longer evident.InterpretationDuring the 1981 to 1999 epoch, offspring of women with epilepsy were at increased risk of dying in the first year of life. However, this risk did not extend to children born after 2000. Future retrospective studies of the effects of maternal epilepsy on the health of the offspring should take this difference into account. ANN NEUROL 2022;91:455–465

Mortality Among Danish Patients with a Hospital Diagnosis of Overweight or Obesity Over a 40-Year Period.

PurposeData on long-term mortality among patients with hospital-diagnosed overweight/obesity are limited. Thus, we aim to examine 40-year mortality among patients with hospital-diagnosed overweight/obesity, including cause-specific deaths, secular time trends, and potential effect modification by age, comorbidity, and socioeconomic factors.Patients and MethodsFrom national registries, we identified all Danes with a first hospital-based overweight/obesity diagnosis (N=331,185), 1979–2018, and constructed an age- and gender-matched general population comparison cohort (N=1,655,925). We computed mortality rates (MRs) per 1000 person-years and adjusted mortality rate ratios (aMRRs) with 95% confidence intervals (CIs), using Cox regression with adjustment for comorbidities and educational level. We performed stratified analyses on age, comorbidities, and socioeconomic factors.ResultsThe overall aMRR was 1.70 (95% CI: 1.68–1.72) for patients with overweight/obesity, mainly due to diabetes and other endocrine diseases (aMRR=2.68 [95% CI: 2.57–2.81]), cardiovascular (aMRR=1.95 [95% CI: 1.91–1.98]), and respiratory diseases (aMRR=1.83 [95% CI: 1.77–1.89]). The 1–10-year aMRR decreased from 2.06 (95% CI: 2.01–2.11) in 1979–1989 to 1.29 (95% CI: 1.26–1.32) in 2000–2009. We found effect modification by age: age 18 to <30 years: aMRR=2.44 (95% CI: 2.24–2.66) vs age ≥70 years: 1.35 (95% CI: 1.33–1.37); comorbidities: baseline comorbidities: aMRR=1.13 (95% CI: 1.10–1.15) vs no comorbidities: aMRR=1.83 (95% CI: 1.80–1.85); and educational level: high educational level: aMRR=1.81 (95% CI: 1.74–1.88) vs low educational level: aMRR=1.70 (95% CI: 1.67–1.72).ConclusionPatients with overweight/obesity had a substantially increased long-term mortality, mainly due to diabetes, cardiovascular, and respiratory diseases. The excess mortality decreased during recent decades. Age, comorbidities, and socioeconomic factors modified the association.

Changes in type 2 diabetes incidence and mortality associated with introduction of HbA1c as diagnostic option: A Danish 24-year population-based study.

SummaryBackgroundIn 2011, the World Health Organization began recommending glycated haemoglobin (HbA1c) as a measure for diagnosing type 2 diabetes (T2D). This initiative may have changed basic T2D epidemiology. Consequently, we examined time changes in T2D incidence and mortality during 1995-2018.MethodsIn this population-based cohort study, we included 415,553 individuals with incident T2D. We calculated annual age-standardized incidence rates of T2D. We examined HbA1c testing and used Poisson-regression to investigate all-cause mortality among the T2D patients and a matched comparison cohort from the general population over successive 3-year periods.FindingsFrom 1995 to the 2012 introduction of HbA1c testing as a diagnostic option in Denmark, the annual standardized incidence rate (SIR) of T2D doubled, from 193 to 396 per 100,000 persons (4.1% increase annually). From 2012 onwards, the T2D incidence declined by 36%, reaching 253 per 100,000 persons in 2018 (5.7% decrease annually). This was driven by fewer patients starting treatment with an HbA1c measurement of <6·5% or without prior HbA1c testing. Mortality per 1,000 person-years following a T2D diagnosis decreased by 44% between 1995-1997 and 2010-2012, from 69 deaths to 38 deaths (adjusted mortality rate ratio: 0·55 (95% CI: 0·54-0·56)). After the low level during 2010-2012, mortality increased again by 27% to 48 per 1,000 person-years (95% CI: 46-50) by 2016-2018.InterpretationOur findings suggest that introducing HbA1c as a diagnostic option may have changed basic T2D epidemiology by leaving patients undiagnosed, that previously would have been diagnosed and treated.FundingAarhus University funded the study and had no further involvement.

Trends and external causes of traumatic brain injury and spinal cord injury mortality in south China, 2014\u20132018: an ecological study

BackgroundThe epidemiological evidence of traumatic brain injury (TBI) and spinal cord injury (SCI) mortality in mainland China is lacking. We aimed to assess the trends of TBI and SCI mortality, and their association with sex, age, location and external causes of injury in south China.MethodsMortality data were derived from the Disease Surveillance Points (DSPs) system of Guangdong province between 2014 and 2018. We examined the trends in mortality with Cochran–Armitage trend test, and the association between the socio-demographic factors and the TBI and SCI mortality by using negative binomial models. Subgroup analysis was performed by stratifying the external causes of TBI and SCI.ResultsThe age-standardized TBI mortality remained relatively stable (from 11.6 to 15.4 per 100,000), while the SCI mortality increased by 148.3% from 2014 to 2018. Compared with females and urban residents, the adjusted mortality rate ratios of males and rural residents were 2.3 and 2.0 for TBI, and 2.2 and 4.6 for SCI, respectively. TBI and SCI mortality increased substantially with age. Motor vehicle crashes and falls were the leading causes of TBI mortality in residents aged under 75 years and over 75 years, respectively. Falls were the most important external cause for SCI death of all ages.ConclusionsBeing male, rural and elderly residents are at higher risk of dying from TBI and SCI. The substantial burden of TBI and SCI caused by road traffic crashes and falls has called for the urgent need to improve injury prevention, pre-hospital aid, hospital treatment and recovery.