Risk Factor For Premature Death Research Articles

Managing hypertension in rural Gambia and Kenya: Protocol for a qualitative study exploring the experiences of patients, health care workers, and decision-makers

Background Hypertension is the single leading risk factor for premature death in Sub-Saharan Africa (SSA). Prevalence is high, but awareness, treatment, and control are low. Community-centred interventions show promise for effective hypertension management, but embedding such interventions sustainably requires a good understanding of the wider context within which they are being introduced. This study aims to conduct a systematic health system assessment exploring the micro (patients/carers), meso (health care workers and facilities), and macro (broader system) contexts in rural Gambia and Kenya. Methods This study will utilise various qualitative approaches. We will conduct (i) focus group discussions with people living with hypertensive to map a ‘typical’ patient journey through health systems, and (ii) in-depth interviews with patients and family carers, health care workers, decision-makers, and NCD partners to explore their experiences of managing hypertension and assess the capacity and readiness of the health systems to strengthen hypertension management. We will also review national guidelines and policy documents to map the organisation of services and guidance on hypertension management. We will use thematic analysis to analyse data, guided by the cumulative complexity model, and theories of organisational readiness and dissemination of innovations. Expected findings This study will describe the current context for the management of hypertension from the perspective of those involved in seeking (patients), delivering (health care workers) and overseeing (decision-makers) health services in rural Gambia and Kenya. It will juxtapose what should be happening according to health system guidance and what is happening in practice, drawing on the experiences of study participants. It will outline the various barriers to and facilitators of hypertension management, as perceived by patients, providers, and decision-makers, and the conditions that would need to be in place for effective and sustainable implementation of a community-centred intervention to improve the management of hypertension in rural settings.

Towards objective measurements of habitual dietary intake patterns: comparing NMR metabolomics and food frequency questionnaire data in a population-based cohort

BackgroundLow-quality, non-diverse diet is a main risk factor for premature death. Accurate measurement of habitual diet is challenging and there is a need for validated objective methods. Blood metabolite patterns reflect direct or enzymatically diet-induced metabolites. Here, we aimed to evaluate associations between blood metabolite patterns and a priori and data-driven food intake patterns.Methods1, 895 participants in the Northern Sweden Health and Disease Study, a population-based prospective cohort study, were included. Fasting plasma samples were analyzed with 1H Nuclear Magnetic Resonance. Food intake data from a 64-item validated food frequency questionnaire were summarized into a priori Healthy Diet Score (HDS), relative Mediterranean Diet Score (rMDS) and a set of plant-based diet indices (PDI) as well as data driven clusters from latent class analyses (LCA). Orthogonal projections to latent structures (OPLS) were used to explore clustering patterns of metabolites and their relation to reported dietary intake patterns.ResultsAge, sex, body mass index, education and year of study participation had significant influence on OPLS metabolite models. OPLS models for healthful PDI and LCA-clusters were not significant, whereas for HDS, rMDS, PDI and unhealthful PDI significant models were obtained (CV-ANOVA p < 0.001). Still, model statistics were weak and the ability of the models to correctly classify participants into highest and lowest quartiles of rMDS, PDI and unhealthful PDI was poor (50%/78%, 42%/75% and 59%/70%, respectively).ConclusionAssociations between blood metabolite patterns and a priori as well as data-driven food intake patterns were poor. NMR metabolomics may not be sufficiently sensitive to small metabolites that distinguish between complex dietary intake patterns, like lipids.

Managing hypertension in rural Gambia and Kenya: Protocol for a qualitative study exploring the experiences of patients, health care workers, and decision-makers

Background Hypertension is the single leading risk factor for premature death in Sub-Saharan Africa (SSA). Prevalence is high, but awareness, treatment, and control are low. Community-centred interventions show promise for effective hypertension management, but embedding sustainably such interventions requires a good understanding of the wider context within which they are being introduced. This study aims to conduct a systematic health system assessment exploring the micro (patients/carers), meso (health care workers and facilities), and macro (broader system) contexts in rural Gambia and Kenya. Methods This study will utilise various qualitative approaches. We will conduct focus group discussions with hypertensive patients to map a ‘typical’ patient journey through health systems. We will conduct in-depth interviews with patients, health care workers, and decision-makers to explore their experiences of managing hypertension and assess the capacity and readiness of the health systems to strengthen hypertension management in rural Gambia and Kenya. We will also review national guidelines and policy documents to map the organisation of services and guidance on hypertension diagnosis and control. Thematic analysis approach will be used to analyse data, guided by the cumulative complexity model, and theories of organisational readiness and dissemination of innovations. Expected findings This study will describe the current context for the diagnosis and management of hypertension from the perspective of those involved in seeking (patients), delivering (health care workers) and overseeing (decision-makers) health services in rural Gambia and Kenya. It will juxtapose what should be happening according to health system guidance and what is happening in practice. It will outline the various barriers to and facilitators of hypertension control, as perceived by patients, providers, and decision-makers, and the conditions that would need to be in place for effective and sustainable implementation of a community-centred intervention to improve the diagnosis and management of hypertension in rural settings.

Gender equality and smoking among 15 to 25 year olds-a time-based ecological analysis of developments in Germany from 1960 to 2005.

Smoking is a major risk factor for premature death and health problems in which there are significant gender differences in the prevalence of smoking. This ecological study examines the correlation between changes in gender equality and prevalence of smoking among young adults (15-25 years old) in Germany over a period of 45 years (1960-2005). Gender inequality was measured using the United Nations Gender Inequality Index (GII), which is composed of three dimensions; health, empowerment and labour market. It was calculated for the entire registered German population in five-year intervals with values between 0 and 1 (1 = highest inequality). The smoking prevalence of young women and men in Germany was established using a reconstruction method. A gender smoking ratio (GSR) with values between 0 and 1 was determined (1 = identical smoking prevalence among men and women). The smoking behaviour was illustrated and stratified by education. The correlation between the GII and the GSR was analysed. The GII decreased from 0.98 to 0.56 between 1960 and 2005. The GSR increased from 0.34 to 0.93. There was a strong negative correlation between the GII and the GSR (r = -0.71). The strength of the correlation fell slightly as the level of education decreased. An increase in gender equality as measured by the GII came along with similarities of smoking prevalence between young women and young men. Successful tobacco prevention among young women and men may benefit from involving experts in gender-specific public health research to develop counter-advertising and gender-specific information as needed.

Efficacy and safety of mineralocorticoid receptor antagonists for the treatment of low-renin hypertension: a systematic review and meta-analysis

Hypertension is the leading risk factor for premature death. The optimal treatment of low-renin hypertension (LRH), present in 30% of hypertensive individuals, is not known. LRH likely reflects a state of excess salt, expanded volume and/or mineralocorticoid receptor (MR) activation. Therefore, targeted treatment with MR antagonists (MRA) may be beneficial. The objective of this systematic review was to assess the efficacy of MRA therapy in LRH. MEDLINE, Embase and Cochrane databases were searched for randomised controlled trials of adults with LRH that compared the efficacy of MRA to placebo or other antihypertensive treatments. Risk of bias was assessed using the Cochrane risk of bias tool. A meta-analysis was performed using a random-effects model to estimate the difference in blood pressure and the certainty of evidence was assessed using the GRADE approach. The protocol is registered on PROSPERO (CRD42022318763). From the 1612 records identified, 17 studies met the inclusion criteria with a total sample size of 1043 participants. Seven studies (n = 345) were assessed as having a high risk of bias. Meta-analysis indicated that MRA reduced systolic blood pressure by −6.8 mmHg (95% confidence interval −9.6 to −4.1) and −4.8 mmHg (95% confidence interval −11.9 to 2.4) compared to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) and diuretics. The certainty of the evidence was assessed as moderate and very low, respectively. The findings of this systematic review suggest that MRA is effective in lowering blood pressure in LRH and may be better than ACEi/ARB. Translation to clinical practice is limited by the uncertainty of evidence.

Premature mortality risk in individuals with convulsive epilepsy: Results from a longitudinal, prospective, population-based study

ObjectiveTo assess premature mortality and identify associated risk factors among individuals with convulsive epilepsy in resource-poor settings using a longitudinal, prospective, population-based approach. MethodThe study recruited people with convulsive epilepsy who underwent assessment and management of epilepsy at primary healthcare centers in rural Northwest China, including newly diagnosed individuals and previously identified prevalent cases. All participants were confirmed to have epilepsy by neurologists according to strict criteria and were followed up monthly by primary care physicians. Demographic data and cause of death (COD) were obtained from death certificates or verbal autopsies conducted by neurologists, following the International Classification of Diseases, 10th Edition. The standardized mortality ratio (SMR) and proportionate mortality ratio (PMR) for each cause of death were estimated using the Cause-Of-Death Surveillance Dataset of China (2020). Survival analysis was used to identify risk factors associated with all-cause mortality and death directly due to epilepsy. ResultsDuring 5.9 years of follow-up with 40,947 person-years, there were 781 (11.2%) deaths among 6967 participants. The risk of premature death in people with convulsive epilepsy was 2.7-fold higher than that in the general population. Young participants had a significantly higher risk (standardized mortality ratio 26.5–52.5) of premature death. The proportionate mortality ratio was higher for cerebrovascular disease (15%), sudden unexpected death in epilepsy (SUDEP) (13.4%), cardiovascular disease (11.7%), status epilepsy (SE) (11.3%), and epilepsy-related accidents (14.0%) than other premature mortality cause of deaths. Additionally, the highest standardized proportional mortality ratio (SPMR) was observed from drowning in all cause of death (10.4, 95% confidence interval [CI]: 7.6–13.8), followed by burning (9.0, 95% CI: 3.7–18.9). Factors that increased the risk of all-cause mortality included male sex, late age of onset, short disease duration, high body mass index, monotherapy, and the frequency of generalized tonic-clonic seizures (GTCS). High frequency of generalized tonic-clonic seizures (> 3 attacks in the last year) was an independent risk factor for premature death directly due to epilepsy (including sudden unexpected death in epilepsy, status epilepsy, and epilepsy-related accidents), while early age of onset (≤ 14 years) and long duration of epilepsy (> 20 years) were independent risk factors for sudden unexpected death in epilepsy. In addition, short duration of epilepsy (≤ 20 years) was an independent risk factor for status epilepsy. ConclusionsThis study demonstrated that individuals with poorly controlled seizures are more likely to experience premature death, with most deaths being epilepsy-related and preventable. These findings underline the importance of effective seizure treatment and the potential impact on reducing premature mortality among people with convulsive epilepsy.

Screening for alcohol use in primary care: assessing French general practitioner practices.

Alcohol use is a leading risk factor for premature death and disability. To tackle this issue, more systematic and accurate screening for at-risk consumption is needed in healthcare systems, especially by general practitioners (GPs). We assessed the frequency of at-risk consumption screening by GPs in France. We also identified characteristics associated with more frequent screening and greater use of validated screening tools by these healthcare providers. A cross-sectional survey was conducted among a representative sample of French GPs. Multinomial logistic regressions were used to identify factors associated with more frequent screening and greater use of validated screening tools. Response rate was of 73%. Of the 2412 participants, 42.8% screened all their patients systematically and repeatedly, while 48.0% never used standardized tools to screen potentially at-risk patients. Among other characteristics, being aware of and using the "early identification and brief intervention" screening strategy, and feeling absolutely comfortable talking with patients about reducing or stopping their alcohol use, were both associated with more frequent screening and use of standardized tools. Our results on at-risk alcohol use screening highlight an improvement over data from previous studies. Nevertheless, better training of French GPs in good alcohol screening practices-specifically, increased screening frequency and greater use of standardized tools-may improve identification of at-risk patients.

Elevated systolic pulmonary artery pressure is a substantial predictor of increased mortality after transcatheter aortic valve replacement in males, not in females

BackgroundWhile pulmonary hypertension (PH) in patients with severe aortic valve stenosis (AS) is associated with increased mortality after transcatheter aortic valve replacement (TAVR), there is limited data on gender differences in the effects on long-term survival.ObjectiveThe aim of this retrospective, multicenter study was to investigate the prognostic impact of pre-interventional PH on survival of TAVR patients with respect to gender.Methods303 patients undergoing TAVR underwent echocardiography to detect PH prior to TAVR via measurement of systolic pulmonary artery pressure (sPAP). Different cut-off values were set for the presence of PH. The primary endpoint was all-cause mortality at 1, 3 and 5 years.ResultsKaplan–Meier analysis by gender showed that only males exhibited significant increased mortality at elevated sPAP values during the entire follow-up period of 5 years (sPAP ≥ 40 mmHg: p ≤ 0.001 and sPAP ≥ 50 mmHg: p ≤ 0.001 in 1- to 5-year survival), whereas high sPAP values had no effect on survival in females. In Cox regression analysis based on the selected sPAP thresholds, male gender was an independent risk factor for long-term mortality after TAVR in all time courses.ConclusionMale gender was an isolated risk factor for premature death after TAVR in patients with echocardiographic evidence of PH and severe AS. This could mean that, the indication for TAVR should be discussed more critically in men with severe AS and an elevated sPAP, while in females, PH should not be an exclusion criterion for TAVR.Graphical abstractGraphical abstract of the study (Created with BioRender.com)Image material of CoreValve™ Evolut™ was kindly provided by © Medtronic Inc.

Effect of leisure-time physical activity on blood pressure in people with hypertension: a systematic review and meta-analysis

High blood pressure is a major risk factor for premature death. Leisure-time physical activities have been recommended to control hypertension. Studies examining how leisure-time physical activity affects blood pressure have found mixed results. We aimed to conduct a systematic review examining the effect of leisure-time physical activity (LTPA) on lowering blood pressure among adults living with hypertension. We searched studies in Embase, Medline/PubMed, Web of Science, Physical Education Index, Scopus and CENTRAL (the Cochrane Library). The primary outcome variables were systolic blood pressure (SBP) and diastolic blood pressure (DBP). This systematic review is registered on PROSPERO (CRD42021260751). We included 17 studies out of 12,046 screened articles in this review. Moderate-intensity LTPA (all types) reduced SBP compared to the non-intervention control group (MD −5.35 mm Hg, 95% CI −8.06 to −2.65, nine trials, n = 531, low certainty of the evidence). Mean DBP was reduced by −4.76 mm Hg (95% CI −8.35 to −1.17, nine trials, n = 531, low certainty of the evidence) in all types of LTPA (moderate intensity) group compared to the non-intervention control group. Leisure-time walking reduced mean SBP by −8.36 mmHg, 95% CI −13.39 to −3.32, three trials, n = 128, low certainty of the evidence). Walking during leisure time reduced −5.03 mmHg mean DBP, 95% CI −8.23 to −1.84, three trials, n = 128, low certainty of the evidence). Performing physical activity during free time probably reduces SBP and DBP (low certainty of the evidence) among adults with hypertension.

When asking ‘how are you?’ may not be enough: The relationship between stress and alcohol use

The onset of the COVID-19 pandemic was accompanied by an increase in alcohol use in a third of the population worldwide. As alcohol use is the greatest risk factor for premature death in people ages 15 to 49, it is important to understand its predictors. To date, the literature shows that subjective stress predicts increased alcohol use. However, no studies have investigated the effect of physiological stress (via the stress hormone cortisol) on alcohol use during the pandemic. This study aimed to identify the predictive value of cortisol and subjective stress on alcohol use over the course of a long-lasting stressor (COVID-19 pandemic). Every three months, between June 2020 and March 2021, 94 healthy adults (ages 19-54) answered questionnaires assessing alcohol use. In June, participants reported pre-pandemic alcohol use, subjective stress measures, and provided a hair sample. The latter allowed us to quantify the cumulative levels of cortisol produced in the three months prior to and following the start of the mandatory lockdown in March 2020 in Quebec, Canada. While controlling for sex, age, and pre-pandemic cortisol levels, multilevel linear regressions revealed a triple interaction between time, pandemic-related cortisol levels, and subjective stress. Analyses revealed that alcohol use increased only among people with concomitant high subjective stress and high pandemic-related cortisol concentrations. Moreover, this increased alcohol use remained elevated one year later. This study documents the importance of simultaneously considering subjective and physiological stress systems to identify people at risk of increasing their alcohol use during the pandemic.

#3559 THE IMPACT OF OBESITY ON CLINICAL OUTCOMES IN VARIOUS LEVELS OF CO-MORBIDITY OF NON-DIALYSIS CHRONIC KIDNEY DISEASE PATIENTS

Abstract Background and Aims Obesity is a major issue with an estimated prevalence of 1.9 billion adults worldwide. Obesity is an important risk factor for premature death and the development of non-communicable diseases such as diabetes mellitus (DM), heart diseases, and chronic kidney disease (CKD). However, mounting evidence in the literature describes a reverse association whereby obesity may have a protective effect on mortality; this is sometimes referred to as the “obesity paradox”. Several reports question the concept of obesity paradox claiming methodology flaws such as collider stratification bias. In this study, we aimed to examine the effects of obesity on the combined outcomes of all-cause mortality (ACM) and renal replacement therapy (RRT) incidence in a cohort of patients with non-dialysis dependent CKD (NDD-CKD) by correcting for major risk factors to reduce the risk of bias. Method This retrospective study was undertaken on all patients with a documented body mass index (BMI) in the Salford Kidney Study database from October 2002 until December 2016. Patients were grouped according to their BMI into normal weight [BMI 18.5-24.9 kg/m2], overweight [BMI 25–29.9 kg/m2 and obese [BMI&amp;gt; 30 kg/m2]. Patients were also grouped according to their level of co-morbidity into 4 groups: group 1 had CKD only; group 2 had CKD and heart failure (HF); group 3 had CKD and DM; and group 4 had CKD, DM, and HF. Univariate Cox regression as well as three stepwise models of multivariate analysis were performed to study the strength of association between BMI categories and combined outcomes (incidence of RRT and ACM) across the 4 groups of different clusters of co-morbidity. Results A total of 2416 patients were included in the analysis. The median age of the cohort was 67.3 years [IQR 55.9-75.6], 61.8% were male, and 96.4% were of white ethnicity. The median BMI was 28.1 kg/m2 [IQR 24.7-32.6] and the median estimated glomerular filtration rate (eGFR) was 30.7 ml/min/1.73m2 [IQR 20.4-43.5]. At baseline, patients with increasing level of co-morbidity tended to be older with higher prevalence of hypertension (HTN), angina, myocardial infarction (MI), and stroke with lower baseline eGFR. The risk of combined outcomes followed the same trend in the three BMI groups, risk is higher with higher index of co-morbidity (p &amp;lt;0.001). Further analysis of four subgroups of co-morbidity was undertaken. A univariate Cox regression analysis for group 1 [CKD only, n = 1351], and group 2 [CKD and HF, n = 227] showed that patients with obesity had significant lower rates of combined outcomes compared to patients with normal BMI (HR 0.75; 95%CI = 0.63-0.89; p = 0.001 and HR 0.56; 95%CI = 0.38-0.82; p = 0.003 for group 1 and group 2 respectively). In multivariate models, obesity consistently proved to be a strong protective factor against combined outcomes (HR 0.77; 95%CI = 0.65-0.92; p = 0.005 for group 1 and HR 0.53; 95%CI = 0.34-0.83; p = 0.005 for group 2). This was independent of age, gender, HTN, angina, stroke, MI, and prescription of statins and angiotensin converting enzyme inhibitors. For group 3 [CKD and DM, n = 614], and group 4 [CKD, DM, and HF, n = 190], there was no significant difference in the combined outcomes between the different BMI groups when using univariate Cox regression analysis (for patients with obesity: HR 0.78; 95%CI = 0.61-1.01; p = 0.060 and HR 0.70; 95%CI = 0.43-1.16; p = 0.166 for both groups respectively). There was no significant difference in the incidence of RRT in any of the four groups. Conclusion In our largely white NDD-CKD cohort of patients, there was evidence of increasing risk of RRT or ACM as comorbidity increased irrespective of BMI. This is not surprising as ACM would be expected to increase as the burden of disease increases. However, when comparing the effect of BMI within groups, obesity was protective against combined outcomes in group 1 (CKD only) and group 2 (CKD+HF). This ‘protective’ effect was not seen in patients who had concomitant diabetes. These data suggest that diabetes is a potent predictor of outcomes irrespective of BMI, however, in patients without diabetes, obesity may play a protective role.

Socioeconomic determinants of household stove use and stove stacking patterns in Ghana

Air pollution is the fourth-highest risk factor for premature deaths globally and the second-highest risk factor for premature deaths in Ghana. Understanding the socioeconomic correlates of cooking stove/fuel choices and stove stacking patterns is a precursor to designing effective household air pollution interventions. The study applies the multinomial logit model (MNL) to identify socio-economic determinants of household cooking stoves in three unique analyses. In the first analysis, the study examines socio-economic determinants of primary stove choice for LPG, charcoal, and three-stone stoves. Secondly, the study examines determinants of stove choice for primary and secondary stoves when the order is not taken into account: LPG-charcoal, LPG-3-stone, and charcoal-3-stone. The third analysis examines determinants of stove use patterns among stove stackers when the order is taken into consideration: LPG-charcoal, LPG-3-stone, charcoal-3-stone, charcoal-LPG, 3-stone-LPG, and 3-stone-charcoal stove combinations. A cross-sectional design is used to collect data from sampled districts in all 16 regions of Ghana, covering about 7400 household-level respondents in 370 enumeration areas (EAs); across 177 urban EAs and 193 rural EAs.The results show that primary cooks with higher education, smaller, wealthier, and urban households are more likely to use LPG; more likely to use a stacking mix that includes LPG, and more likely to use a stacking combination where LPG is the primary stove-fuel used. Ghana is currently undertaking a National LPG Promotion Programme (NLPGPP) that seeks to increase LPG access by providing subsidized “starter kits” (stoves, regulators and cylinders) to periurban and rural households. Our findings can aid in targeting households effectively. Our results suggest that households that are female-headed; have less educated household heads; have household heads who double as the primary cook; have larger family sizes, have lower socio-economic status, and are rural, will have an increased probability of adopting and using a cleaner stack of cooking technologies and have an increased probability of using LPG long term, conditional on receiving a starter kit. Such a targeted intervention with a multifaceted approach to shifting households to a cleaner stack of cooking technologies could result in widespread adoption and contribute to significant reductions of CO and PM2.5 emissions in Ghana. A cleaner stack of cooking technologies, given the socio-demographics that are least likely to adopt and sustain use, will have a significant impact on health, the environment, and climate change.

Corn Silk Flavonoids Ameliorate Hyperuricemia via PI3K/AKT/NF-κB Pathway.

Hyperuricemia (HUA) is a widespread metabolic disease marked by an elevated level of uric acid, and is a risk factor for premature death. The protective effect of corn silk flavonoids (CSF) against HUA and its potential mechanisms were explored. Five important apoptosis and inflammation-related signaling pathways were identified by network pharmacological analysis. The CSF exhibited significant uric acid (UA)-lowering activity in vitro by decreasing xanthine oxidase (XOD) and increasing hypoxanthine-guanine phosphoribosyl transferase levels. In a potassium oxonate-induced HUA in vivo, CSF treatment effectively inhibited XOD activity and promoted UA excretion. Furthermore, it decreased the levels of TNF-α and IL-6 and restored pathological damage. In summary, CSF is a functional food component to improve HUA by reducing inflammation and apoptosis through the down-regulating PI3K/AKT/NF-κB pathway.

High quality diet attenuated the positive association between polychlorinated biphenyls and premature mortality among middle-aged and older adults

ObjectivePolychlorinated biphenyls (PCBs) have been reported to be a risk factor for premature death, while a high diet quality is thought to lower mortality risk. We aimed to examine whether PCBs were associated with higher all-cause and cause-specific mortality risk and whether such associations could be modified by the diet quality among US middle-aged and older adults. MethodsIncluded were 1259 participants aged 40 years or older from the 1999–2004 National Health and Nutrition Examination surveys. Exposure to PCBs was assessed in non-fasting serum samples, and mortality status was ascertained through December 31, 2019 using the public-use, linked mortality files. Diet quality was assessed using the Healthy Eating Index-2015 based on 24-h dietary recalls. Cox proportional hazard regression was applied to assess the associations of different PCB congener groups with mortality and the modifying effect by the diet quality. ResultsDuring a median follow-up of 17.75 years, 419 deaths occurred, including 131 from cardiovascular disease (CVD) and 102 from cancer. Serum concentrations of dioxin-like PCBs and non-dioxin-like PCBs were significantly associated with all-cause mortality, with hazard ratios (HRs) of 1.84 (95% confidence interval [CI], 1.10, 2.99) and 1.82 (1.09, 3.03) for extreme-tertile comparisons. A significant interaction was noted between dioxin-like PCBs and diet quality (P for interaction: 0.012), with a substantially more pronounced association among participants with a low diet quality (HR, 3.47; 95% CI: 1.29, 9.32), compared to those with a high diet quality (HR, 0.98; 95% CI: 0.40, 2.43). A similar weaker association was observed for total PCBs in participants with a high diet quality (P for interaction: 0.032). However, effect modifications by diet quality were not noted for the associations between different PCB groups and CVD mortality. ConclusionsWhile our findings need to be validated in other populations and mechanistic studies, they may suggest that a high quality diet could potentially attenuate the harmful effects of chronic PCB exposure.

Double or triple combination therapy in systemic arterial hypertension: to whom, when and with what?

La hipertensión arterial sistémica (HAS) es el principal factor de riesgo para muerte prematura en el mundo y en México.1 Se estima que existen 15.2 millones de mexicanos con diagnóstico de HAS, de los cuales 7.48 millones son derechohabientes del IMSS (evaluación de los riesgos financieros considerados en el Programa de Administración de Riesgos Institucionales, ENSANUT, 2018).2

Age, Period, and Cohort Analysis of Smoking Intensity Among Current Smokers in Malaysia, 1996-2015.

Tobacco use is one of the major preventable risk factors for premature death and disability worldwide. Understanding the trend of tobacco use over time is important for informed policy making. The present study aimed to examine the changes in mean daily cigarette consumption among random samples of the Malaysian current smoker population over 20 years using an age-period-cohort (APC) approach. We conducted APC analysis using a multilevel hierarchical age-period-cohort model and data from four nationally representative, repeated cross-sectional surveys (National Health and Morbidity Survey) conducted in 1996, 2006, 2011, and 2015 among individuals aged 18 to 80 years. Analyses were also stratified by gender and ethnicity. Overall, mean daily cigarette consumption (smoking intensity) among current smokers increased with age until 60, after which a drop was observed. There were increases in daily cigarette consumption across birth cohorts. Age and cohort trends did not vary by gender but by ethnicity. The decreasing cigarette consumption after age 60 among the current smoker population was consistent with those observed among the Chinese and Indians, a trend that was not observed in Malays and other aborigines. In contrast, the increasing cohort trend was consistent with those observed among the Malays and other bumiputras. The present study highlighted important ethnic-specific trends for mean daily cigarette consumption among the current smoker population in Malaysia. These findings are essential in guiding the formulation of interventional strategies or implementation of national tobacco control policies and help achieve the Ministry of Health Malaysia's 2025 and 2045 targets for smoking prevalence. This is the first APC study on smoking intensity among current smokers in a multiracial, middle-income nation. Very few studies had performed gender- and ethnic-stratified APC analyses. The ethnic-stratified APC analyses provide useful insights into the overall age and cohort trends observed among the current smoker population in Malaysia. Therefore, the present study could add evidence to the existing literature on the APC trends of smoking intensity. The APC trends are also important in guiding the government to develop, implement, and evaluate antismoking strategies.

Long-term exposure to elemental components of fine particulate matter and all-natural and cause-specific mortality in a Danish nationwide administrative cohort study

BackgroundFine particulate matter (PM2.5) is a well-recognized risk factor for premature death. However, evidence on which PM2.5 components are most relevant is unclear. MethodsWe evaluated the associations between mortality and long-term exposure to eight PM2.5 elemental components [copper (Cu), iron (Fe), zinc (Zn), sulfur (S), nickel (Ni), vanadium (V), silicon (Si), and potassium (K)]. Studied outcomes included death from diabetes, chronic kidney disease (CKD), dementia, and psychiatric disorders as well as all-natural causes, cardiovascular disease (CVD), respiratory diseases (RD), and lung cancer. We followed all residents in Denmark (aged ≥30 years) from January 1, 2000 to December 31, 2017. We used European-wide land-use regression models at a 100 × 100 m scale to estimate the residential annual mean levels of exposure to PM2.5 components. The models were developed with supervised linear regression (SLR) and random forest (RF). The associations were evaluated by Cox proportional hazard models adjusting for individual- and area-level socioeconomic factors and total PM2.5 mass. ResultsOf 3,081,244 individuals, we observed 803,373 death from natural causes during follow-up. We found significant positive associations between all-natural mortality with Si and K from both exposure modeling approaches (hazard ratios; 95% confidence intervals per interquartile range increase): SLR-Si (1.04; 1.03–1.05), RF-Si (1.01; 1.00–1.02), SLR-K (1.03; 1.02–1.04), and RF-K (1.06; 1.05–1.07). Strong associations of K and Si were detected with most causes of mortality except CKD and K, and diabetes and Si (the strongest associations for psychiatric disorders mortality). In addition, Fe was relevant for mortality from RD, lung cancer, CKD, and psychiatric disorders; Zn with mortality from CKD, RD, and lung cancer, and; Ni and V with lung cancer mortality. ConclusionsWe present novel results of the relevance of different PM2.5 components for different causes of death, with K and Si seeming to be most consistently associated with mortality in Denmark.

The Effects of Trash, Residential Biofuel, and Open Biomass Burning Emissions on Local and Transported PM2.5 and Its Attributed Mortality in Africa.

Long-term exposure to ambient fine particulate matter (PM2.5) is the second leading risk factor of premature death in Sub-Saharan Africa. We use GEOS-Chem to quantify the effects of (a) trash burning, (b) residential solid-fuel burning, and (c) open biomass burning (BB) (i.e., landscape fires) on ambient PM2.5 and PM2.5-attributable mortality in Africa. Using a series of sensitivity simulations, we excluded each of the three combustion sources in each of five African regions. We estimate that in 2017 emissions from these three combustion sources within Africa increased global ambient PM2.5 by 2%, leading to 203,000 (95% confidence interval: 133,000-259,000) premature mortalities yr-1 globally and 167,000 premature mortalities yr-1 in Africa. BB contributes more ambient PM2.5-related premature mortalities per year (63%) than residential solid-fuel burning (29%) and trash burning (8%). Open BB in Central Africa leads to the largest number of PM2.5-attributed mortalities inside the region, while trash burning in North Africa and residential solid-fuel burning in West Africa contribute the most regional mortalities for each source. Overall, Africa has a unique ambient air pollution profile because natural sources, such as windblown dust and BB, contribute strongly to ambient PM2.5 levels and PM2.5-related mortality. Air pollution policies may need to focus on taking preventative measures to avoid exposure to ambient PM2.5 from these less-controllable sources.

Time in therapeutic range: timely in hypertension therapeutics?

Elevated blood pressure ranks among the most important modifiable risk factors for premature death, and disability from hypertension mediated organ damage in the world. Many studies attest to the value of lifestyle adjustments and pharmacologic therapy in improving outcomes in patients with hypertension. Since blood pressure is a dynamic vitals sign, variability in visit-to-visit measurements is expected. While guidelines recommend a goal blood pressure, increasing attention is centered on how often a patient's blood pressure is found to be not only below the recommended goal value, but also how much of the time the blood pressure is below what is considered a safe lower goal threshold for blood pressure. In this Perspective we review a relatively new technique in addressing adequacy of blood pressure treatment, the time in therapeutic range, and provide examples supporting the clinical relevance of this novel metric.

A Source Apportionment and Emission Scenario Assessment of PM2.5- and O3-Related Health Impacts in G20 Countries.

Exposure to air pollution is a leading risk factor for premature death globally; however, the complexity of its formation and the diversity of its sources can make it difficult to address. The Group of Twenty (G20) countries are a collection of the world's largest and most influential economies and are uniquely poised to take action to reduce the global health burden associated with air pollution. We present a framework capable of simultaneously identifying regional and sectoral sources of the health impacts associated with two air pollutants, fine particulate matter (PM2.5) and ozone (O3) in G20 countries; this framework is also used to assess the health impacts associated with emission reductions. This approach combines GEOS-Chem adjoint sensitivities, satellite-derived data, and a new framework designed to better characterize the non-linear relationship between O3 exposures and nitrogen oxides emissions. From this approach, we estimate that a 50% reduction of land transportation emissions by 2040 would result in 251 thousand premature deaths avoided in G20 countries. These premature deaths would be attributable equally to reductions in PM2.5 and O3 exposure which make up 51% and 49% of the potential benefits, respectively. In our second application, we estimate that the energy generation related co-benefits associated with G20 countries staying on pace with their net-zero carbon dioxide targets would be 290 thousand premature deaths avoided in 2040; action by India (47%) would result in the most benefits of any country and a majority of these avoided deaths would be attributable to reductions in PM2.5 exposure (68%).