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Background Understanding the impact of the burden of COVID-19 is key to successfully navigating the COVID-19 pandemic. As part of a larger investigation on COVID-19 mortality impact, this study aims to estimate the Potential Years of Life Lost (PYLL) in 17 countries and territories across the world (Australia, Brazil, Cape Verde, Colombia, Cyprus, France, Georgia, Israel, Kazakhstan, Peru, Norway, England & Wales, Scotland, Slovenia, Sweden, Ukraine, and the United States [USA]). Methods Age- and sex-specific COVID-19 death numbers from primary national sources were collected by an international research consortium. The study period was established based on the availability of data from the inception of the pandemic to the end of August 2020. The PYLL for each country were computed using 80 years as the maximum life expectancy. Results As of August 2020, 442,677 (range: 18–185,083) deaths attributed to COVID-19 were recorded in 17 countries which translated to 4,210,654 (range: 112–1,554,225) PYLL. The average PYLL per death was 8.7 years, with substantial variation ranging from 2.7 years in Australia to 19.3 PYLL in Ukraine. North and South American countries as well as England & Wales, Scotland and Sweden experienced the highest PYLL per 100,000 population; whereas Australia, Slovenia and Georgia experienced the lowest. Overall, males experienced higher PYLL rate and higher PYLL per death than females. In most countries, most of the PYLL were observed for people aged over 60 or 65 years, irrespective of sex. Yet, Brazil, Cape Verde, Colombia, Israel, Peru, Scotland, Ukraine, and the USA concentrated most PYLL in younger age groups. Conclusions Our results highlight the role of PYLL as a tool to understand the impact of COVID-19 on demographic groups within and across countries, guiding preventive measures to protect these groups under the ongoing pandemic. Continuous monitoring of PYLL is therefore needed to better understand the burden of COVID-19 in terms of premature mortality.

Background Diabetes mellitus (DM) patients are three times more likely to develop tuberculosis (TB) than the general population. Active TB screening in people with DM is part of a bidirectional approach. The aim of this study was to conduct pragmatic active TB screening among DM patients in four countries to inform policy. Methods DM patients were recruited in Indonesia (n=809), Peru (n=600), Romania (n=603) and South Africa (n=51). TB cases were diagnosed using an algorithm including clinical symptoms and chest X-ray. Presumptive TB patients were examined with sputum smear and culture. Results A total of 171 (8.3%) individuals reported ever having had TB (South Africa, 26%; Indonesia, 12%; Peru, 7%; Romania, 4%), 15 of whom were already on TB treatment. Overall, 14 (0.73% [95% confidence interval 0.40 to 1.23]) TB cases were identified from screening. Poor glucose control, smoking, lower body mass index, education and socio-economic status were associated with newly diagnosed/current TB. Thirteen of the 14 TB cases diagnosed from this screening would have been found using a symptom-based approach. Conclusions These data support the World Health Organization recommendation for routine symptom-based screening for TB in known DM patients in high TB-burden countries. DM patients with any symptoms consistent with TB should be investigated and diagnostic tools should be easily accessible.

Background Deficiencies in airway management skills and judgement contribute to poor outcomes. Airway management practice guidelines emphasise the importance of education. Little is known about the global uptake of guidelines, availability of equipment, provision of training, assessment of skills, and confidence with procedures. Methods We devised a survey to examine these issues. Initially, 24 127 anaesthetists were questioned in New Zealand, Canada, South Africa, UK, India, and Germany, representing the home countries of the members of the Worldwide Airway Meeting (2015) Education Group; however, the survey could be forwarded to others. The survey was open for a maximum of 90 days. Results We received 4948 fully or partially completed surveys from 61 countries: 33 high-income and 28 middle- or low-income countries. Most respondents were consultants (77.2%, n=4948), and the remainder trainees, with a male/female ratio of 1.8:1 (3105 males, n=4866). Of those responding, 1358 (76.6%, n=1798) were members of an airway interest group. Most respondents (91.3% of 2910) agreed with assessment of airway skills, fewer (2237; 59.7%, n=3750) reported requiring airway training for completion of training, and only 810 (33.6%, n=2408) reported it as a requirement for continuing medical education. Reported confidence was lowest for awake tracheal intubation, front-of-neck access, and retrograde intubation. Conclusions Global training is variable in its delivery and necessity. Confidence is limited in potentially life-saving techniques. The desire for assessment appears universal and may improve standards, but in resource- or time-limited environments this will be challenging.

This work was supported by the University of Nicosia Medical School (internal funding)., Achilleos S, Quattrocchi A, Gabel J, Heraclides A, Kolokotroni O, Constantinou C, Pagola Ugarte M, Nicolaou N, Rodriguez-Llanes JM, Bennett CM, Bogatyreva E, Schernhammer E, Zimmermann C, Costa AJL, Lobato JCP, Fernandes NM, Semedo-Aguiar AP, Jaramillo Ramirez GI, Martin Garzon OD, Mortensen LH, Critchley JA, Goldsmith LP, Denissov G, Rüütel K, Le Meur N, Kandelaki L, Tsiklauri S, O'Donnell J, Oza A, Kaufman Z, Zucker I, Ambrosio G, Stracci F, Hagen TP, Erzen I, Klepac P, Arcos González P, Fernández Camporro Á, Burström B, Pidmurniak N, Verstiuk O, Huang Q, Mehta NK, Polemitis A, Charalambous A, Demetriou CA.

OBJECTIVE Diabetes guidelines focus on target glycated hemoglobin (HbA1c) levels. Long-term variability in HbA1c may be predictive of hospitalization or mortality, but its importance at different average levels or trajectories is unclear. RESEARCH DESIGN AND METHODS Using English primary care data, 58,832 patients with type 2 diabetes had HbA1c average (mean of annual means), variability (coefficient of variation), and trajectory (annual regression slope) estimated during 2006–2009. Hazard ratios (HRs) for mortality and emergency hospitalization during 2010–2015, with adjustment for age, sex, smoking, BMI, duration of diabetes, and deprivation, were estimated using Cox regression. The simultaneous impact of HbA1c average, variability, and trajectory was estimated using percentiles. RESULTS In mutually adjusted models, HbA1c variability showed a consistent dose-response relationship with all-cause mortality, while average level was only important among individuals in the highest or lowest 10% of the distribution, and trajectory had no independent effect. Individuals with the most unstable HbA1c (top 10%) were almost twice as likely to die (HR 1.93 [95% CI 1.72–2.16]) than were those with the most stable (bottom 10%)—an association attenuated but not explained by hypoglycemia. For emergency hospitalizations, similar trends were seen except for coronary artery disease (CAD) and ischemic stroke (IS), where increasing average rather than variability was predictive. CONCLUSIONS HbA1c variability was strongly associated with overall mortality and emergency hospitalization and not explained by average HbA1c or hypoglycemic episodes. Only for CAD and IS hospitalizations was no association found, with average HbA1c strongly predictive. Targets should focus on both stability and absolute level of HbA1c.

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We developed a diabetes risk score using a novel analytical approach and tested its diagnostic performance to detect individuals at high risk of diabetes, by applying it to the Qatari population. A representative random sample of 5,000 Qataris selected at different time points was simulated using a diabetes mathematical model. Logistic regression was used to derive the score using age, sex, obesity, smoking, and physical inactivity as predictive variables. Performance diagnostics, validity, and potential yields of a diabetes testing program were evaluated. In 2020, the area under the curve (AUC) was 0.79 and sensitivity and specificity were 79.0% and 66.8%, respectively. Positive and negative predictive values (PPV and NPV) were 36.1% and 93.0%, with 42.0% of Qataris being at high diabetes risk. In 2030, projected AUC was 0.78 and sensitivity and specificity were 77.5% and 65.8%. PPV and NPV were 36.8% and 92.0%, with 43.0% of Qataris being at high diabetes risk. In 2050, AUC was 0.76 and sensitivity and specificity were 74.4% and 64.5%. PPV and NPV were 40.4% and 88.7%, with 45.0% of Qataris being at high diabetes risk. This model-based score demonstrated comparable performance to a data-derived score. The derived self-complete risk score provides an effective tool for initial diabetes screening, and for targeted lifestyle counselling and prevention programs.

Contains fulltext : 238090.pdf (Publisher’s version ) (Open Access) Diabetes Mellitus increases the risk of developing Tuberculosis (TB) disease by about three times; it also doubles the risk of death during TB treatment and other poor TB treatment outcomes. Diabetes may increase the risk of latent infection with Mycobacterium tuberculosis (LTBI), but the magnitude of this effect is less clear. Whilst this syndemic has received considerable attention, most of the published research has focussed on screening for undiagnosed diabetes in TB patients or observational follow-up of TB treatment outcomes by diabetes status. There are thus substantial research and policy gaps, particularly with regard to prevention of TB disease in people with diabetes and management of patients with TB-diabetes, both during TB treatment and after successful completion of TB treatment, when they likely remain at high risk of TB recurrence, mortality from TB and cardiovascular disease. Potential strategies to prevent development of TB disease might include targeted vaccination programmes, screening for LTBI and preventive therapy among diabetes patients or, perhaps ideally, improved diabetes management and prevention. The cost-effectiveness of each of these, and in particular how each strategy might compare with targeted TB prevention among other population groups at higher risk of developing TB disease, is also unknown. Despite research gaps, clinicians urgently need practical management advice and more research evidence on the choice and dose of different anti-diabetes medication and effective medical therapies to reduce cardiovascular risks (statins, anti-hypertensives and aspirin). Substantial health system strengthening and integration may be needed to prevent these at risk patients being lost to care at the end of TB treatment.

Diabetes mellitus (DM) is associated with worse tuberculosis (TB) treatment outcomes, especially among those with poor glycemic control. We examined whether a structured clinical algorithm could improve glycemic control in TB patients with DM.In an open label randomized trial, TB-DM patients were randomized to scheduled counselling, glucose monitoring, and adjustment of medication using a structured clinical algorithm (intervention arm) or routine DM management (control arm), with glycated hemoglobin (HbA1c) at month 6 as the primary end point.We randomized 150 pulmonary TB-DM patients (92% culture positive, 51.3% male, mean age 53 years). Baseline mean HbA1c was 11.0% in the intervention arm (n = 76) and 11.6% in the control arm (n = 74). At 6 months, HbA1c had decreased more in the intervention arm compared with the control arm (a difference of 1.82% HbA1c, 95% CI 0.82-2.83, p 0.001). Five patients were hospitalized in the intervention arm and seven in the control arm. There was more hypoglycemia (35.0% vs 11.8%; p = 0.002) in the intervention arm. Two deaths occurred in the intervention arm, one due to cardiorespiratory failure and one because of suspected septic shock and multiorgan failure.Regular monitoring and algorithmic adjustment of DM treatment led to improved glycemic control.

We aimed to characterize the type 2 diabetes mellitus (T2DM) epidemic and the role of key risk factors in Jordan between 1990–2050, and to forecast the T2DM-related costs. A recently-developed population-level T2DM mathematical model was adapted and applied to Jordan. The model was fitted to six population-based survey data collected between 1990 and 2017. T2DM prevalence was 14.0% in 1990, and projected to be 16.0% in 2020, and 20.6% in 2050. The total predicted number of T2DM cases were 218,326 (12,313 were new cases) in 1990, 702,326 (36,941 were new cases) in 2020, and 1.9 million (79,419 were new cases) in 2050. Out of Jordan’s total health expenditure, 19.0% in 1990, 21.1% in 2020, and 25.2% in 2050 was forecasted to be spent on T2DM. The proportion of T2DM incident cases attributed to obesity was 55.6% in 1990, 59.5% in 2020, and 62.6% in 2050. Meanwhile, the combined contribution of smoking and physical inactivity hovered around 5% between 1990 and 2050. Jordan’s T2DM epidemic is predicted to grow sizably in the next three decades, driven by population ageing and high and increasing obesity levels. The national strategy to prevent T2DM needs to be strengthened by focusing it on preventive interventions targeting T2DM and key risk factors.

Aims/Introduction To investigate and forecast type 2 diabetes mellitus epidemic, its related risk factors and cost in Oman by 2050. Materials and Methods An age‐structured mathematical model was used to characterize type 2 diabetes mellitus epidemiology and trends in Oman between 1990 and 2050. The model was parametrized using current and quality data, including six nationally representative population‐based epidemiological surveys for type 2 diabetes mellitus and its key risk factors. Results The projected type 2 diabetes mellitus prevalence increased from 15.2% in 2020 to 23.8% in 2050. The prevalence increased from 16.8 and 13.8% in 2020 among women and men to 26.3 and 21.4% in 2050, respectively. In 2020, 190,489 Omanis were living with type 2 diabetes mellitus compared with 570,227 in 2050. The incidence rate per 1,000 person‐years changed from 8.3 in 2020 to 12.1 in 2050. Type 2 diabetes mellitus’ share of Oman’s national health expenditure grew by 36% between 2020 and 2050 (from 21.2 to 28.8%). Obesity explained 56.7% of type 2 diabetes mellitus cases in 2020 and 71.4% in 2050, physical inactivity explained 4.3% in 2020 and 2.7% in 2050, whereas smoking accounted for, The prevalence of type 2 diabetes mellitus in Oman was projected to grow by 57% by 2050, whereas the incidence was projected to grow by 200% by 2050. By 2050, type 2 diabetes mellitus will consume 30% of Oman’s health expenditure. The type 2 diabetes mellitus epidemic in Oman is driven by the high obesity level.

IntroductionPrevalence of overweight, obesity and diabetes are high and rising across the Gulf Cooperation Council (GCC) countries (Oman, Bahrain, Kuwait, Qatar, Saudi Arabia and the United Arab Emirates). In parallel, physical activity (PA) levels are low relative to international standards. PA aids weight control and reduces risk of non-communicable diseases including diabetes and cardiovascular disease. It is likely interventions developed elsewhere will not translate to GCC countries due to unique environmental, social and cultural factors. This protocol is for a systematic review assessing the efficacy of interventions promoting PA within GCC countries among generally healthy adults and children. The primary outcome of interest is change in objectively measured or self-reported PA levels, the secondary outcomes of interest are changes in anthropometry or chronic disease risk factors (eg, blood pressure). Interventions will be compared with no intervention or those of differing PA intensity or duration. The relationships between PA change and the following will be assessed: intervention intensity or duration, season in which intervention occurs, sex, age, nationality and sustainability over time.Methods and analysisA systematic search strategy will identify indexed publications on the efficacy of interventions promoting PA. Randomised controlled trials and quasi-experimental studies recruiting predominantly healthy children and adults will be included. Studies of exercise rehabilitation will be excluded. Medline, Embase, Cinahl, Cochrane Library, SportDiscus, Web of Science, Index Medicus for the Eastern Mediterranean Region and Qscience will be searched. Clinical trial registries including the International Clinical Trials Registry Platform, the Iranian Registry of Clinical Trials and ClinicalTrials.gov will be searched for ongoing and unpublished studies. Searches will be ran from database inception until 1 May 2020 and be supplemented by checking references of key articles. Two reviewers will independently screen identified citations then full texts using prespecified inclusion and exclusion criteria. Piloted data extraction forms will be used in duplicate. Inconsistencies in screening or data extraction will be resolved by a third investigator or study author contact. Risk of bias will be independently assessed by two reviewers using validated tools. A narrative summary of findings will be produced supplemented with meta-analyses and exploration of heterogeneity as appropriate.Ethics and DisseminationThe review aims to strengthen the findings of the primary studies it incorporates and explore the impact of setting. It will synthesise existing published aggregate patient data. If publications or data with ethical concerns are identified, they will be excluded from the review. Results of the systematic review will be published in full and authors will engage directly with research audiences and key stakeholders to share findings.PROSPERO registration number131817.

BackgroundMost adults do not meet the recommended intake of five portions per day of fruit and vegetables (F&V) in England, but economic analyses of structural policies to change diet are sparse.MethodsUsing published data from official statistics and meta-epidemiological studies, we estimated the deaths, years-of-life lost (YLL) and the healthcare costs attributable to consumption of F&V below the recommended five portions per day by English adults. Then, we estimated the cost-effectiveness from governmental and societal perspectives of three policies: a universal 10% subsidy on F&V, a targeted 30% subsidy for low-income households and a social marketing campaign (SMC).FindingsConsumption of F&V below the recommended five portions a day accounted for 16 321 [10 091–23 516] deaths and 238 767 [170 350–311 651] YLL in England in 2017, alongside £705 951 [398 761–1 061 559] million in healthcare costs. All policies would increase consumption and reduce the disease burden attributable to low intake of F&V. From a societal perspective, the incremental cost-effectiveness ratios were £22 891 [22 300–25 079], £16 860 [15 589–19 763] and £25 683 [25 237–28 671] per life-year saved for the universal subsidy, targeted subsidy and SMC, respectively. At a threshold of £20 000 per life-year saved, the likelihood that the universal subsidy, the targeted subsidy and the SMC were cost-effective was 84%, 19% and 5%, respectively. The targeted subsidy would additionally reduce inequalities.ConclusionsLow intake of F&V represents a heavy health and care burden in England. All dietary policies can improve consumption of F&V, but only a targeted subsidy to low-income households would most likely be cost-effective.

OBJECTIVE Diabetes mellitus (DM) increases the risk of infections, but the effect of better control has not been thoroughly investigated. RESEARCH DESIGN AND METHODS With the use of English primary care data, average glycated hemoglobin (HbA1c) during 2008–2009 was estimated for 85,312 patients with DM ages 40–89 years. Infection rates during 2010–2015 compiled from primary care, linked hospital, and mortality records were estimated across 18 infection categories and further summarized as any requiring a prescription or hospitalization or as cause of death. Poisson regression was used to estimate adjusted incidence rate ratios (IRRs) by HbA1c categories across all DM, and type 1 and type 2 DM separately. IRRs also were compared with 153,341 age-sex-practice–matched controls without DM. Attributable fractions (AF%) among patients with DM were estimated for an optimal control scenario (HbA1c 6–7% [42–53 mmol/mol]). RESULTS Long-term infection risk rose with increasing HbA1c for most outcomes. Compared with patients without DM, those with DM and optimal control (HbA1c 6–7% [42–53 mmol/mol], IRR 1.41 [95% CI 1.36–1.47]) and poor control (≥11% [97 mmol/mol], 4.70 [4.24–5.21]) had elevated hospitalization risks for infection. In patients with type 1 DM and poor control, this risk was even greater (IRR 8.47 [5.86–12.24]). Comparisons within patients with DM confirmed the risk of hospitalization with poor control (2.70 [2.43–3.00]) after adjustment for duration and other confounders. AF% of poor control were high for serious infections, particularly bone and joint (46%), endocarditis (26%), tuberculosis (24%), sepsis (21%), infection-related hospitalization (17%), and mortality (16%). CONCLUSIONS Poor glycemic control is powerfully associated with serious infections and should be a high priority.

There is growing interest in the interaction between type 2 diabetes mellitus (DM) and TB, but many research questions remain unanswered. Epidemiologists, basic scientists, and clinical experts recently convened and identified priorities. This is the first of two reviews on this topic, summarizing priority areas of research regarding epidemiology, clinical management, and public health. First, from an epidemiologic point of view, more study is needed to determine the importance of transient hyperglycemia in patients with TB and on the importance of DM for the global epidemic of multidrug resistant (MDR)-TB. Second, regarding the screening and clinical management of combined TB and DM (TB-DM), clinical trials and large cohort studies should examine the benefits of improved DM care as well as prolonged or intensified TB treatment on the outcome of TB-DM and investigate the cost-effectiveness of screening methods for DM among patients newly diagnosed with TB. Third, from a public health and health systems point of view, the population health impact and cost-effectiveness of different interventions to prevent or treat DM and TB in high-burden populations should be examined, and health-system interventions should be developed for routine TB-DM screening, management of DM after completion of TB treatment, and better access to DM services worldwide. Studies are needed across different ethnicities and settings given the heterogeneity of metabolic perturbations, inflammatory responses, medications, and access to health care. Finally, studies should address interactions between TB, DM, and HIV because of the convergence of epidemics in sub-Saharan Africa and some other parts of the world.

There is growing interest in the re-emerging interaction between type 2 diabetes (DM) and TB, but the underlying biologic mechanisms are poorly understood despite their possible implications in clinical management. Experts in epidemiologic, public health, basic science, and clinical studies recently convened and identified research priorities for elucidating the underlying mechanisms for the co-occurrence of TB and DM. We identified gaps in current knowledge of altered immunity in patients with DM during TB, where most studies suggest an underperforming innate immunity, but exaggerated adaptive immunity to Mycobacterium tuberculosis. Various molecular mechanisms and pathways may underlie these observations in the DM host. These include signaling induced by excess advanced glycation end products and their receptor, higher levels of reactive oxidative species and oxidative stress, epigenetic changes due to chronic hyperglycemia, altered nuclear receptors, and/or differences in cell metabolism (immunometabolism). Studies in humans at different stages of DM (no DM, pre-DM, and DM) or TB (latent or active TB) should be complemented with findings in animal models, which provide the unique opportunity to study early events in the host-pathogen interaction. Such studies could also help identify biomarkers that will complement clinical studies in order to tailor the prevention of TB-DM, or to avoid the adverse TB treatment outcomes that are more likely in these patients. Such studies will also inform new approaches to host-directed therapies.

Diabetes is associated with failure of tuberculosis (TB) treatment, but it is unclear whether this is related to genotypic drug resistance of the infecting mycobacteria. We used whole genome sequencing (WGS) to examine 1365 known drug resistance mutations in 896 Mycobacterium tuberculosis isolates from TB patients that were screened for diabetes using HbA1c testing as part of the TANDEM project [1]. Ethical approval was received from the London School of Hygiene and Tropical Medicine and institutional review boards in Indonesia and Peru. In Peru we selected all available M. tuberculosis isolates from TANDEM patients (44 with and 445 without diabetes), and in Indonesia we selected all available isolates from diabetic patients (n=115) plus a subset of isolates from non-diabetic patients (n=292) from the same clinics, during the same time period, frequency-matched by age. We used TB Profiler version 0.3.8 [2] to determine M. tuberculosis lineage and drug resistance. A phylogeny was constructed using PhyML version 3.0 [3], and the minimum pairwise distance for isolates was calculated separately for patients with and without diabetes, stratified by country. We examined if diabetes was associated with genotypic drug resistance against individual drugs or with MDR-TB for the two countries separately and combined, with multilevel multivariable logistic regression, taking into account the country of origin and adjusting for age, gender, HIV-infection, previous TB treatment, and M. tuberculosis lineage

BackgroundDiabetes mellitus (DM) increases active tuberculosis (TB) risk and worsens TB outcomes, jeopardizing TB control especially in TB-endemic countries with rising DM prevalence rates. We assessed DM status and clinical correlates in TB patients across settings in Indonesia, Peru, Romania, and South Africa.MethodsAge-adjusted DM prevalence was estimated using laboratory glycated hemoglobin (HbA1c) or fasting plasma glucose in TB patients. Detailed and standardized sociodemographic, anthropometric, and clinical measurements were made. Characteristics of TB patients with or without DM were compared using multilevel mixed-effect regression models with robust standard errors.ResultsOf 2185 TB patients (median age 36.6 years, 61.2% male, 3.8% human immunodeficiency virus–infected), 12.5% (267/2128) had DM, one third of whom were newly diagnosed. Age-standardized DM prevalence ranged from 10.9% (South Africa) to 19.7% (Indonesia). Median HbA1c in TB–DM patients ranged from 7.4% (Romania) to 11.3% (Indonesia). Compared to those without DM, TB–DM patients were older and had a higher body mass index (BMI) (P value < .05). Compared to those with newly diagnosed DM, TB patients with diagnosed DM had higher BMI and HbA1c, less severe TB, and more frequent comorbidities, DM complications, and hypertension (P value < .05).ConclusionsWe show that DM prevalence and clinical characteristics of TB–DM vary across settings. Diabetes is primarily known but untreated, hyperglycemia is often severe, and many patients with TB–DM have significant cardiovascular disease risk and severe TB. This underlines the need to improve strategies for better clinical management of combined TB and DM.

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Background The aim of this study was to estimate the impact of reducing the prevalence of obesity, smoking, and physical inactivity, and introducing physical activity as an explicit intervention, on the burden of type 2 diabetes mellitus (T2DM), using Qatar as an example. Methods A population-level mathematical model was adapted and expanded. The model was stratified by sex, age group, risk factor status, T2DM status, and intervention status, and parameterized by nationally representative data. Modeled interventions were introduced in 2016, reached targeted level by 2031, and then maintained up to 2050. Diverse intervention scenarios were assessed and compared with a counter-factual no intervention baseline scenario. Results T2DM prevalence increased from 16.7% in 2016 to 24.0% in 2050 in the baseline scenario. By 2050, through halting the rise or reducing obesity prevalence by 10–50%, T2DM prevalence was reduced by 7.8–33.7%, incidence by 8.4–38.9%, and related deaths by 2.1–13.2%. For smoking, through halting the rise or reducing smoking prevalence by 10–50%, T2DM prevalence was reduced by 0.5–2.8%, incidence by 0.5–3.2%, and related deaths by 0.1–0.7%. For physical inactivity, through halting the rise or reducing physical inactivity prevalence by 10–50%, T2DM prevalence was reduced by 0.5–6.9%, incidence by 0.5–7.9%, and related deaths by 0.2–2.8%. Introduction of physical activity with varying intensity at 25% coverage reduced T2DM prevalence by 3.3–9.2%, incidence by 4.2–11.5%, and related deaths by 1.9–5.2%. Conclusions Major reductions in T2DM incidence could be accomplished by reducing obesity, while modest reductions could be accomplished by reducing smoking and physical inactivity, or by introducing physical activity as an intervention.

Background In context of the rapidly expanding diabetes mellitus (DM) epidemic in India and slowly declining tuberculosis (TB) incidence, we aimed to estimate the past, current, and future impact of DM on TB epidemiology. Methods An age-structured TB-DM dynamical mathematical model was developed and analyzed to assess the DM-on-TB impact. The model was calibrated using a literature review and meta-analyses. The DM-on-TB impact was analyzed using population attributable fraction metrics. Sensitivity analyses were conducted by accommodating less conservative effect sizes for the TB-DM interactions, by factoring the age-dependence of the TB-DM association, and by assuming different TB disease incidence rate trajectories. Results In 1990, 11.4% (95% uncertainty interval (UI) = 6.3%-14.4%) of new TB disease incident cases were attributed to DM. This proportion increased to 21.9% (95% UI = 12.1%-26.4%) in 2017, and 33.3% (95% UI = 19.0%-44.1%) in 2050. Similarly, in 1990, 14.5% (95% UI = 9.5%-18.2%) of TB-related deaths were attributed to DM. This proportion increased to 28.9% (95% UI = 18.9%-34.1%) in 2017, and 42.8% (95% UI = 28.7%-53.1%) in 2050. The largest impacts originated from the effects of DM on TB disease progression and infectiousness. Sensitivity analyses suggested that the impact could be even greater. Conclusions The burgeoning DM epidemic is predicted to become a leading driver of TB disease incidence and mortality over the coming decades. By 2050, at least one-third of TB incidence and almost half of TB mortality in India will be attributed to DM. This is likely generalizable to other Asian Pacific countries with similar TB-DM burdens. Targeting the impact of the increasing DM burden on TB control is critical to achieving the goal of TB elimination by 2050.

Introduction Tobacco smoking is a significant public health threat in the world, a risk factor for many diseases, and has been increasing in prevalence in many developing countries. In this study, we aimed to estimate the burden of premature deaths attributable to smoking among Tunisian men aged 35-69 years in 2009. Methods The number of deaths attributable to smoking was estimated using the population attributable risk fraction method. Smoking prevalence was obtained from a nationally representative survey. Causes of death were obtained from the registry of the National Public Health Institute. Relative risks were taken from the American Cancer Society Prevention Study (CPS-II). Results Total estimated premature deaths attributable to smoking among men in Tunisia were 2601 (95% CI: 2268-2877), accounting for 25% (95% CI: 23.3-26.6) of total male adult mortality. Cancer, cardiovascular and respiratory diseases were the major causes of premature deaths attributable to smoking with 1272 (95% CI: 1188-1329), 966 (95% CI: 779-1133) and 364 (300-415) deaths, respectively. Conclusions Tobacco smoking is highly relevant and is related to substantial premature mortality in Tunisia, around double that estimated for the region as a whole. This also has not decreased over the past 20 years. Urgent actions are needed to reduce this pandemic.

Background Data regarding the incidence of tuberculosis (TB) among people living with diabetes (PLWD) in TB-endemic settings are scarce. We examined TB incidence among PLWD in Indonesia who had previously been screened for latent TB infection (LTBI) and TB disease. Methods PLWD (≥18 y of age) in an urban setting were examined a mean 3.4 y after they had been screened for active TB and LTBI. Data on subsequent TB diagnosis were collected by interview and with chest X-ray, sputum smear and Mycobacterium tuberculosis culture. TB incidence rates were stratified for baseline LTBI status, as determined by the QuantiFERON interferon-gamma release assay (IGRA). Results Of 590 PLWD, 101 had died and 163 could not be contacted or refused. Among the 326 who were re-examined, 6 (1.8%; 95% confidence interval [CI] 0.7 to 4.0) reported being diagnosed already and a further 5 were diagnosed with active TB (1.5%; 95% CI 0.50 to 3.5). The TB incidence rate was 9.85 (95% CI 4.03 to 15.68) per 1000 person-years. TB incidence was higher among PLWD with baseline LTBI (17.13; 95% CI 5.25 to 29.00/1000 person-years) compared with those without LTBI (4.79; 95% CI −0.63 to 10.21), with an incidence rate ratio of 3.57 (95% CI 0.86 to 20.92; p=0.054). Conclusions PLWD with LTBI in Indonesia and similar settings are likely to benefit from TB preventive therapy.

BACKGROUND: Previous evidence synthesis has suggested diabetes mellitus (DM) worsens tuberculosis (TB) treatment outcomes. However, these reviews are limited by the number, robustness and conflicting results among the studies included. We conducted a systematic review to update earlier analyses and explore heterogeneity among studies.\ud \ud METHODS: MEDLINE, EMBASE, AIM, LILACS, IMEMR, IMSEAR and WPRIM were searched between 1 January 1980 and 23 July 2018 unrestricted by language or region. All cohort and case-control studies investigating the difference in TB treatment outcomes amongst TB-DM patients compared to those with TB alone were included. Two reviewers independently assessed titles, abstracts, and extracted data. Culture conversion at two/three months, all-cause mortality, treatment failure, relapse and multidrug-resistant TB (MDR-TB) were evaluated using random effects meta-analysis with generic inverse variance. Heterogeneity was explored using subgroup analyses and meta-regression.\ud \ud RESULTS: One hundred and four publications were identified. Sixty-four studies including 56 122 individuals with TB-DM and 243 035 with TB, reported on death. Some outcomes showed substantial heterogeneity between studies, which we could not fully explain, though confounding adjustment and country income level accounted for some of the differences. TB-DM patients had higher odds of death (OR 1.88, 95%CI 1.59–2.21) and relapse (OR 1.64, 95%CI 1.29–2.08) compared to TB patients. More limited evidence suggested TB-DM patients had double the risk of developing MDR-TB (OR 1.98, 95%CI 1.51–2.60).\ud \ud CONCLUSION: DM is associated with increased risks of poor TB treatment outcomes, particularly mortality, and may increase risk of developing primary MDR-TB. Cost-effectiveness of interventions to enhance TB-DM treatment should be assessed.

We aimed to develop a conceptual framework of diabetes mellitus (DM) effects on tuberculosis (TB) natural history and treatment outcomes, and to assess the impact of these effects on TB-transmission dynamics. The model was calibrated using TB data for India. A conceptual framework was developed based on a literature review, and then translated into a mathematical model to assess the impact of the DM-on-TB effects. The impact was analyzed using TB-disease incidence hazard ratio (HR) and population attributable fraction (PAF) measures. Evidence was identified for 10 plausible DM-on-TB effects. Assuming a flat change of 300% (meaning an effect size of 3.0) for each DM-on-TB effect, the HR ranged between 1.0 (Effect 9-Recovery) and 2.7 (Effect 2-Fast progression); most effects did not have an impact on the HR. Meanwhile, TB-disease incidence attributed directly and indirectly to each effect ranged between −4.6% (Effect 7-TB mortality) and 34.5% (Effect 2-Fast progression). The second largest impact was for Effect 6-Disease infectiousness at 29.9%. In conclusion, DM can affect TB-transmission dynamics in multiple ways, most of which are poorly characterized and difficult to assess in epidemiologic studies. The indirect (e.g. onward transmission) impacts of some DM-on-TB effects are comparable in scale to the direct impacts. While the impact of several effects on the HR was limited, the impact on the PAF was substantial suggesting that DM could be impacting TB epidemiology to a larger extent than previously thought.

We thank Drs Yates and Barr for their valuable comments. In our article [1], we were not attempting to assess the extent to which dysglycemia is causally associated with tuberculosis (TB). A number of prospective studies exist, among a body of evidence, supporting probabilistic causation between diabetes mellitus (DM) and TB [2, 3]. Rather, the aim of our study was to identify age-adjusted prevalence and clinical characteristics of DM and intermediate hyperglycemia among those with newly diagnosed TB across 4 TB-endemic settings. In our South African population, the prevalence of DM (10.9% [95% confidence interval, 7%–14.9%]) was the...

© 2019 Sobers et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Although most countries face increasing population levels of obesity and diabetes their effect on coronary heart disease (CHD) mortality has not been often studied in small island developing states (SIDs) where obesity rates are among the highest in the world. We estimated the relative contributions of treatments and cardiovascular risk factors to the decline in CHD mortality from 1990 to 2012 in the Caribbean island, Barbados. Methods We used the IMPACT CHD mortality model to estimate the effect of increased coverage of effective medical/surgical treatments and changes in major CHD risk factors on mortality trends in 2012 compared with 1990. We calculated deaths prevented or postponed (DPPs) for each model risk factor and treatment group. We obtained data from WHO Mortality database, population denominators from the Barbados Statistical Service stratified by 10-year age group (ages 25–34 up to 85 plus), population-based risk factor surveys, Global Burden of Disease and Barbados’ national myocardial infarction registry. Monte Carlo probabilistic sensitivity analysis was performed. Results In 1990 the age-standardized CHD mortality rate was 109.5 per 100,000 falling to 55.3 in 2012. Implementation of effective treatment accounted for 56% DPPs (95% (Uncertainty Interval (UI) 46%, 68%), mostly due to the introduction of treatments immediately after acute myocardial infarction (AMI) (14%) and unstable angina (14%). Overall, risk factors contributed 19% DPPs (95% UI 6% to 34%) mostly attributed to decline in cholesterol (18% DPPs, 95% UI 12%, 26%). Adverse trends in diabetes: 14% additional deaths(ADs) 95% UI 8% to 21% ADs) and BMI (2% ADs 95%UI 0 to 5% ADs) limited potential for risk factor gains. Conclusions Given the significant negative impact of obesity/diabetes on mortality in this analysis, research that explores factors affecting implementation of evidenced-based preventive strategies is needed. The fact that most of the decline in CHD mortality in Barbados was due to treatment provides an example for SIDs about the advantages of universal access to care and treatment.

Background: Anaemia is a major cause of morbidity and mortality in low-income countries. Primary health-care workers in resource-poor settings usually diagnose anaemia clinically, but this is inaccurate. The WHO Haemoglobin Colour Scale (HCS) is a simple, cheap quantitative method to assess haemoglobin concentration outside of the laboratory. We systematically reviewed the literature to assess the accuracy of the HCS in primary care to diagnose anaemia, and compared this with clinical assessment. Methods: We searched the electronic databases including MEDLINE, EMBASE, SCOPUS, Web of Science, Cochrane library, CINAHL plus, Popline, Reproductive Health Library, and Google Scholar and regional databases up to Nov 14, 2014, “haemoglobin colour scale” in alternative spellings published in any language. Two reviewers independently screened studies, extracted data, and assessed quality using the QUADAS-2 instrument. Statistical analyses were carried out in STATA using the bivariate model. Findings: Of 141 records and abstracts screened, 14 studies were included. The pooled sensitivity of the HCS to diagnose anaemia was 80% (95% CI 68–88) compared with 52% for clinical assessment ([95% CI 36–67]; p=0·008). Specificity was similar between the HCS (80% [95% CI 59–91]) and clinical assessment (75% [56–88]; p=0·8250). For severe anaemia, diagnostic accuracy was again higher overall for the HCS (p

Background. Mathematical models offer the potential to analyze and compare the effectiveness of very different interventions to prevent future cardiovascular disease. We developed a comprehensive Markov model to assess the impact of three interventions to reduce ischemic heart diseases (IHD) and stroke deaths: (i) improved medical treatments in acute phase, (ii) secondary prevention by increasing the uptake of statins, (iii) primary prevention using health promotion to reduce dietary salt consumption. Methods. We developed and validated a Markov model for the Tunisian population aged 35–94 years old over a 20-year time horizon. We compared the impact of specific treatments for stroke, lifestyle, and primary prevention on both IHD and stroke deaths. We then undertook extensive sensitivity analyses using both a probabilistic multivariate approach and simple linear regression (metamodeling). Results. The model forecast a dramatic mortality rise, with 111,134 IHD and stroke deaths (95% CI 106567 to 115048) predicted in 2025 in Tunisia. The salt reduction offered the potentially most powerful preventive intervention that might reduce IHD and stroke deaths by 27% (−30240 [−30580 to −29900]) compared with 1% for medical strategies and 3% for secondary prevention. The metamodeling highlighted that the initial development of a minor stroke substantially increased the subsequent probability of a fatal stroke or IHD death. Conclusions. The primary prevention of cardiovascular disease via a reduction in dietary salt consumption appeared much more effective than secondary or tertiary prevention approaches. Our simple but comprehensive model offers a potentially attractive methodological approach that might now be extended and replicated in other contexts and populations.

OBJECTIVE We describe in detail the burden of infections in adults with diabetes within a large national population cohort. We also compare infection rates between patients with type 1 and type 2 diabetes mellitus (T1DM and T2DM). RESEARCH DESIGN AND METHODS A retrospective cohort study compared 102,493 English primary care patients aged 40–89 years with a diabetes diagnosis by 2008 (n = 5,863 T1DM and n = 96,630 T2DM) with 203,518 age-sex-practice–matched control subjects without diabetes. Infection rates during 2008–2015, compiled from primary care and linked hospital and mortality records, were compared across 19 individual infection categories. These were further summarized as any requiring a prescription or hospitalization or as cause of death. Poisson regression was used to estimate incidence rate ratios (IRRs) between 1) people with diabetes and control subjects and 2) T1DM and T2DM adjusted for age, sex, smoking, BMI, and deprivation. RESULTS Compared with control subjects without diabetes, patients with diabetes had higher rates for all infections, with the highest IRRs seen for bone and joint infections, sepsis, and cellulitis. IRRs for infection-related hospitalizations were 3.71 (95% CI 3.27–4.21) for T1DM and 1.88 (95% CI 1.83–1.92) for T2DM. A direct comparison of types confirmed higher adjusted risks for T1DM versus T2DM (death from infection IRR 2.19 [95% CI 1.75–2.74]). We estimate that 6% of infection-related hospitalizations and 12% of infection-related deaths were attributable to diabetes. CONCLUSIONS People with diabetes, particularly T1DM, are at increased risk of serious infection, representing an important population burden. Strategies that reduce the risk of developing severe infections and poor treatment outcomes are under-researched and should be explored.

Background In the Global Burden of Disease Study 2013 (GBD 2013), knowledge about health and its determinants has been integrated into a comparable framework to inform health policy. Outputs of this analysis are relevant to current policy questions in England and elsewhere, particularly on health inequalities. We use GBD 2013 data on mortality and causes of death, and disease and injury incidence and prevalence to analyse the burden of disease and injury in England as a whole, in English regions, and within each English region by deprivation quintile. We also assess disease and injury burden in England attributable to potentially preventable risk factors. England and the English regions are compared with the remaining constituent countries of the UK and with comparable countries in the European Union (EU) and beyond. Methods We extracted data from the GBD 2013 to compare mortality, causes of death, years of life lost (YLLs), years lived with a disability (YLDs), and disability-adjusted life-years (DALYs) in England, the UK, and 18 other countries (the first 15 EU members [apart from the UK] and Australia, Canada, Norway, and the USA [EU15+]). We extended elements of the analysis to English regions, and subregional areas defined by deprivation quintile (deprivation areas). We used data split by the nine English regions (corresponding to the European boundaries of the Nomenclature for Territorial Statistics level 1 [NUTS 1] regions), and by quintile groups within each English region according to deprivation, thereby making 45 regional deprivation areas. Deprivation quintiles were defined by area of residence ranked at national level by Index of Multiple Deprivation score, 2010. Burden due to various risk factors is described for England using new GBD methodology to estimate independent and overlapping attributable risk for five tiers of behavioural, metabolic, and environmental risk factors. We present results for 306 causes and 2337 sequelae, and 79 risks or risk clusters. Findings Between 1990 and 2013, life expectancy from birth in England increased by 5·4 years (95% uncertainty interval 5·0-5·8) from 75·9 years (75·9-76·0) to 81·3 years (80·9-81·7); gains were greater for men than for women. Rates of age-standardised YLLs reduced by 41·1% (38·3-43·6), whereas DALYs were reduced by 23·8% (20·9-27·1), and YLDs by 1·4% (0·1-2·8). For these measures, England ranked better than the UK and the EU15+ means. Between 1990 and 2013, the range in life expectancy among 45 regional deprivation areas remained 8·2 years for men and decreased from 7·2 years in 1990 to 6·9 years in 2013 for women. In 2013, the leading cause of YLLs was ischaemic heart disease, and the leading cause of DALYs was low back and neck pain. Known risk factors accounted for 39·6% (37·7-41·7) of DALYs; leading behavioural risk factors were suboptimal diet (10·8% [9·1-12·7]) and tobacco (10·7% [9·4-12·0]). Interpretation Health in England is improving although substantial opportunities exist for further reductions in the burden of preventable disease. The gap in mortality rates between men and women has reduced, but marked health inequalities between the least deprived and most deprived areas remain. Declines in mortality have not been matched by similar declines in morbidity, resulting in people living longer with diseases. Health policies must therefore address the causes of ill health as well as those of premature mortality. Systematic action locally and nationally is needed to reduce risk exposures, support healthy behaviours, alleviate the severity of chronic disabling disorders, and mitigate the effects of socioeconomic deprivation. Funding Bill & Melinda Gates Foundation and Public Health England. © 2015 Newton et al. Open Access article distributed under the terms of CC BY. 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Tuberculosis (TB) remains one of the 10 leading causes of death worldwide, especially in low- and middle-income countries. We conducted a systematic review and meta-analysis including 88 studies examining the association between diabetes mellitus (DM) and TB treatment outcomes. However, we found several common methodological problems among them, including inappropriate adjustments for confounding factors, not using optimal statistical methods for ‘time to event' data, misclassification in exposure (DM) and outcomes (TB treatment outcomes) due to study design and non-standardisation of definitions, misunderstanding of basic study design concept, standardisation of TB treatment outcomes and quality control of publications. Many of these problems would apply more broadly to other ‘risk factors' for poor TB treatment outcomes. These issues need to be addressed and resolved to improve the quality of the studies and provide more accurate results for policy makers in the future to tackle the burden of TB.

Contains fulltext : 196372.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To describe the characteristics and management of Diabetes mellitus (DM) patients from low- and middle-income countries (LMIC). METHODS: We systematically characterised consecutive DM patients attending public health services in urban settings in Indonesia, Peru, Romania and South Africa, collecting data on DM treatment history, complications, drug treatment, obesity, HbA1c and cardiovascular risk profile; and assessing treatment gaps against relevant national guidelines. RESULTS: Patients (median 59 years, 62.9% female) mostly had type 2 diabetes (96%), half for >5 years (48.6%). Obesity (45.5%) and central obesity (females 84.8%; males 62.7%) were common. The median HbA1c was 8.7% (72 mmol/mol), ranging from 7.7% (61 mmol/mol; Peru) to 10.4% (90 mmol/mol; South Africa). Antidiabetes treatment included metformin (62.6%), insulin (37.8%), and other oral glucose-lowering drugs (34.8%). Disease complications included eyesight problems (50.4%), EGFR

To evaluate the performance of diagnostic tools for diabetes mellitus, including laboratory methods and clinical risk scores, in newly-diagnosed pulmonary tuberculosis patients from four middle-income countries.In a multicentre, prospective study, we recruited 2185 patients with pulmonary tuberculosis from sites in Indonesia, Peru, Romania and South Africa from January 2014 to September 2016. Using laboratory-measured glycated haemoglobin (HbA1c) as the gold standard, we measured the diagnostic accuracy of random plasma glucose, point-of-care HbA1c, fasting blood glucose, urine dipstick, published and newly derived diabetes mellitus risk scores and anthropometric measurements. We also analysed combinations of tests, including a two-step test using point-of-care HbA1cwhen initial random plasma glucose was ≥ 6.1 mmol/L.The overall crude prevalence of diabetes mellitus among newly diagnosed tuberculosis patients was 283/2185 (13.0%; 95% confidence interval, CI: 11.6-14.4). The marker with the best diagnostic accuracy was point-of-care HbA1c (area under receiver operating characteristic curve: 0.81; 95% CI: 0.75-0.86). A risk score derived using age, point-of-care HbA1c and random plasma glucose had the best overall diagnostic accuracy (area under curve: 0.85; 95% CI: 0.81-0.90). There was substantial heterogeneity between sites for all markers, but the two-step combination test performed well in Indonesia and Peru.Random plasma glucose followed by point-of-care HbA1c testing can accurately diagnose diabetes in tuberculosis patients, particularly those with substantial hyperglycaemia, while reducing the need for more expensive point-of-care HbA1c testing. Risk scores with or without biochemical data may be useful but require validation.Évaluer la performance des outils de diagnostic du diabète sucré, et notamment les méthodes de laboratoire et les cotes de risque clinique, chez les patients souffrant d'une tuberculose pulmonaire récemment diagnostiquée dans quatre pays à revenu intermédiaire.Dans le cadre d'une étude multicentrique et prospective, nous avons recruté 2185 patients atteints de tuberculose pulmonaire dans différents endroits en Afrique du Sud, en Indonésie, au Pérou et en Roumanie entre janvier 2014 et septembre 2016. En utilisant comme référence l'hémoglobine glyquée (HbA1c) mesurée en laboratoire, nous avons évalué la précision diagnostique de la glycémie aléatoire, de l'HbA1c sur le lieu d'intervention, de la glycémie à jeun, de la bandelette urinaire, des cotes de risque déjà publiées et récemment obtenues pour le diabète sucré et des mesures anthropométriques. Nous avons également analysé des combinaisons de tests, et notamment un test en deux étapes qui utilise l'HbA1c sur le lieu d'intervention lorsque la glycémie aléatoire initiale est ≥ 6,1 mmol/L.La prévalence brute générale du diabète sucré chez les patients souffrant d'une tuberculose récemment diagnostiquée était de 283/2185 (13,0%; intervalle de confiance, IC, à 95%: 11,6–14,4). Le marqueur fournissant la meilleure précision diagnostique était l'HbA1c sur le lieu d'intervention (aire sous la courbe ROC: 0,81; IC à 95%: 0,75–0,86). La meilleure précision diagnostique générale a été obtenue à l'aide d'une cote de risque calculée au moyen de l'âge, de l'HbA1c sur le lieu d'intervention et de la glycémie aléatoire (aire sous la courbe ROC: 0,85; IC à 95%: 0,81–0,90). Une forte hétérogénéité entre les différents endroits a été constatée pour tous les marqueurs, mais le test en deux étapes a donné de bons résultats en Indonésie et au Pérou.L'utilisation de la glycémie aléatoire suivie de l'HbA1c sur le lieu d'intervention permet de diagnostiquer avec précision le diabète chez les patients atteints de tuberculose, en particulier lorsqu'ils souffrent d'une importante hyperglycémie, tout en diminuant le besoin de tests HbA1c sur le lieu d'intervention, plus coûteux. Les cotes de risque associées ou non à des données biochimiques peuvent être utiles, mais doivent être validées.Evaluar el rendimiento de las herramientas de diagnóstico para la diabetes mellitus, incluidos los métodos de laboratorio y los índices de riesgo clínico, en pacientes recién diagnosticados con tuberculosis pulmonar de cuatro países de ingresos medios.En un estudio prospectivo multicéntrico, se seleccionaron 2185 pacientes con tuberculosis pulmonar de algunas regiones de Indonesia, Perú, Rumanía y Sudáfrica entre enero de 2014 y septiembre de 2016. Usando hemoglobina glicosilada medida en laboratorio (HbA1c) como el patrón de excelencia, se midió la precisión diagnóstica de glucosa plasmática al azar, estando HbA1c en el punto de atención, glucemia en sangre en ayunas, tira reactiva de orina, índices de riesgo de diabetes mellitus publicados recientemente y medidas antropométricas. También se analizaron combinaciones de pruebas, incluida una prueba de dos pasos con HbA1c en el punto de atención cuando la glucosa plasmática aleatoria inicial fue ≥ 6,1mmol/L.La prevalencia general cruda de diabetes mellitus entre los pacientes con tuberculosis recién diagnosticados fue de 283/2185 (13,0 %, intervalo de confianza del 95 %, IC: 11,6–14,4). El marcador con la mejor precisión diagnóstica fue la HbA1c en el punto de atención (área bajo la curva característica operativa del receptor: 0,81; IC del 95 %: 0,75–0,86). Un índice de riesgo derivado de la edad, la HbA1c en el punto de atención y la glucosa plasmática al azar obtuvieron la mejor precisión diagnóstica general (área bajo la curva: 0,85; IC del 95 %: 0,81–0,90). Hubo una heterogeneidad sustancial entre las regiones para todos los marcadores, pero la prueba combinada de dos pasos funcionó de manera correcta en Indonesia y Perú.La glucosa plasmática al azar seguida de la prueba de HbA1c en el punto de atención puede diagnosticar con precisión la diabetes en pacientes con tuberculosis, particularmente en aquellos con hiperglucemia sustancial, mientras se reduce la necesidad de pruebas más costosas de HbA1c en el punto de atención. Los índices de riesgo con o sin datos bioquímicos pueden ser útiles, pero requieren validación.تقييم أداء أدوات تشخيص مرض السكري، بما في ذلك الطرق المختبرية ودرجات المخاطر السريرية، لدى المرضى الذين تم تشخيص إصابتهم حديثاً بالسل الرئوي من أربعة بلدان متوسطة الدخل.في دراسة استباقية متعددة المراكز، قمنا بالاستعانة بـ 2185 مريضًا بمرض السل الرئوي من مواقع في إندونيسيا وبيرو وجنوب إفريقيا ورومانيا من يناير/كانون ثاني 2014 إلى سبتمبر/أيلول 2016. وعن طريق قياس الهيموغلوبين الغليكوزيلاتي في المختبر (HbA1c) كمعيار أساسي، قمنا بقياس مدى دقة تشخيص كل من جلوكوز البلازما العشوائي، واختبار HbA1c في أماكن الرعاية، وجلوكوز الدم أثناء الصيام، ومقياس البول، ودرجات المخاطر المنشورة والمستنبطة حديثا من داء السكري، والقياسات الأنثروبومترية. قمنا أيضا بتحليل مجموعات من الاختبارات، بما في ذلك اختبار من خطوتين باستخدام اختبار HbA1c في أماكن الرعاية عندما كان مستوى جلوكوز البلازما العشوائي أكبر من أو يساوي 6.1 مليمول/ لتر.كان معدل الانتشار الكلي لمرض السكري بين المرضى الذين تم تشخيص إصابتهم حديثًا بالسل هو 283/2185 (13.0%؛ بفاصل ثقة 95%، فاصل ثقة: 11.6 إلى 14.4).كانت العلامة ذات أفضل دقة تشخيصية هي اختبار HbA1c في أماكن الرعاية (المساحة تحت منحنى خاصية التشغيل للمستقبِل: 0.81؛ بفاصل ثقة 95%: 0.75 إلى 0.86). كانت درجة الخطر المشتقة باستخدام العمر، واختبار HbA1c في أماكن الرعاية، وجلوكوز البلازما العشوائي، هي أفضل دقة تشخيصية عامة (المساحة تحت المنحنى: 0.85؛ بفاصل ثقة 95%: 0.81 إلى 0.90). كانت هناك عدم تجانس واضح بين المواقع لكل العلامات، إلا أن الاختبار المكون من خطوتين قدم أداءً جيدًا في إندونيسيا وبيرو.يمكن لاختبار جلوكوز البلازما العشوائي، ويليه اختبار HbA1c في أماكن الرعاية، تشخيص مرض السكري بدقة في مرضى السل، وخاصة أولئك الذين يعانون من ارتفاع شديد في سكر الدم، مع تقليل الحاجة إلى اختبار HbA1c الأكثر تكلفة في أماكن الرعاية. قد تكون درجات الخطر مفيدة، سواء مع بيانات كيميائية حيوية أو بدونها، ولكنها تتطلب التحقق من الصحة.评估用于四个中等收入国家新诊断结核病患者的糖尿病诊断工具的表现，其中包括实验室方法和临床风险评分。.在这项多中心、前瞻性的研究中，自 2014 年 1 月起至 2016 年 9 月，我们从秘鲁、罗马尼亚、南非和印度尼西亚各地招募了 2185 名肺结核患者。使用实验室测量的糖化血红蛋白 (HbA1c) 为黄金标准，我们测量了随机血糖、糖化血红蛋白 (HbA1c) 床旁检测、空腹血糖、尿液常规检查、已发表的和新导出的糖尿病风险评分以及人体测量法的诊断准确度。我们还对组合检测法进行了分析，其中包括两步检测法：即在初始随机血糖为临界值 ≥6.1 mmol/L 时，进行糖化血红蛋白 (HbA1c) 床旁检测。.新诊断结核病患者中，糖尿病的整体患病率为 283/2185（13.0％；95％ 置信区间，CI：11.6–14.4）。最准确的诊断指标是糖化血红蛋白 (HbA1c) 床旁检测（受试者工作特征曲线下的区域：0.81；95％ 置信区间，CI：0.75-0.86）。使用年龄、糖化血红蛋白 (HbA1c) 床旁检测和随机血糖得出的风险评分整体诊断准确度最佳（受试者工作特征曲线下的区域：0.85；95％ 置信区间，CI：0.81-0.90）。不同地点的指标之间存在显著的异质性，但两步组合检测法在秘鲁和印度尼西亚表现良好。.在随机血糖检测后再进行糖化血红蛋白 (HbA1c) 床旁检测可以准确诊断结核病患者是否患有糖尿病（尤其针对患有严重高血糖的患者），同时减少对更为昂贵的糖化血红蛋白 (HbA1c) 床旁检测的需求。内附或未附生化指标的风险评分可能有用，但仍需验证。.Оценить эффективность инструментов диагностики сахарного диабета (включая лабораторные методы и показатели клинического риска) у пациентов с недавно диагностированным туберкулезом легких из четырех стран со средним уровнем доходов.С января 2014 года по сентябрь 2016 года авторы провели многоцентровое проспективное исследование, в котором приняли участие 2185 пациентов с туберкулезом легких, проживающих в Индонезии, Перу, Румынии и Южной Африке. Используя измеренный в лаборатории гликозилированный гемоглобин (HbA1c) в качестве общепринятого стандарта, авторы измерили диагностическую точность выборочного определения уровня глюкозы в плазме; уровня HbA1c, определяемого в месте предоставления медицинской помощи; уровня глюкозы в крови натощак и определения сахара в моче с помощью индикаторной полоски с учетом опубликованных и недавно полученных оценок риска заболевания сахарным диабетом и антропометрических измерений. Мы также проанализировали комбинации тестов, в том числе двухэтапный тест с использованием HbA1c, измеренного в месте предоставления медицинской помощи, при начальном случайном уровне глюкозы в плазме ≥ 6,1 ммоль/л.Общая распространенность сахарного диабета среди пациентов с недавно выявленным туберкулезом составила 283 случая на 2185 человек (13,0%, 95%-й доверительный интервал, ДИ: 11,6–14,4). Маркер с наибольшей диагностической точностью — HbA1c, измеренный в месте предоставления медицинской помощи (область под кривой ROC: 0,81; 95%-й ДИ: 0,75–0,86). Оценка риска в зависимости от возраста, HbA1c, измеренного в месте предоставления медицинской помощи, и выборочного определения глюкозы в плазме имела наилучшую общую диагностическую точность (область под кривой: 0,85; 95%-й ДИ: 0,81–0,90). В различных местах наблюдалась существенная гетерогенность всех маркеров, при этом двухступенчатый комбинированный тест дал хорошие показатели для Индонезии и Перу.Выборочно определяемый уровень глюкозы в плазме с последующим тестированием HbA1c в месте предоставления медицинской помощи может точно диагностировать диабет у пациентов с туберкулезом, особенно у пациентов с существенной гипергликемией, уменьшая необходимость в более дорогостоящем тестировании HbA1c в месте предоставления медицинской помощи. Оценки риска по данным биохимического анализа крови или без них могут быть полезными, но нуждаются в проверке.

The prevalence of obesity among adults in Saudi Arabia increased from 22% in 1990-1993 to 36% in 2005, and future projections of the prevalence of adult obesity are needed by health policy-makers. In a secondary analysis of published data, a number of assumptions were applied to estimate the trends and projections in the age-and sex-specific prevalence of adult obesity in Saudi Arabia over the period 1992-2022. Five studies conducted between 1989 and 2005 were eligible for inclusion, using body mass index (BMI) ≥ 30 kg/m(2) to define obesity. The overall prevalence of obesity was projected to increase from around 12% in 1992 to 41% by 2022 in men, and from 21% to 78% in women. Women had much higher projected prevalence than men, particularly in the age groups 35-44, 45-54 and 55-64 years. Effective national strategies are needed to reduce or halt the projected rise in obesity prevalence.

Objectives Dietary salt intake has been causally linked to high blood pressure and increased risk of cardiovascular events. Cardiovascular disease causes approximately 35% of total UK deaths, at an estimated annual cost of £30 billion. The World Health Organization and the National Institute for Health and Care Excellence have recommended a reduction in the intake of salt in people's diets. This study evaluated the cost-effectiveness of four population health policies to reduce dietary salt intake on an English population to prevent coronary heart disease (CHD). Methods The validated IMPACT CHD model was used to quantify and compare four policies: 1) Change4Life health promotion campaign, 2) front-of-pack traffic light labeling to display salt content, 3) Food Standards Agency working with the food industry to reduce salt (voluntary), and 4) mandatory reformulation to reduce salt in processed foods. The effectiveness of these policies in reducing salt intake, and hence blood pressure, was determined by systematic literature review. The model calculated the reduction in mortality associated with each policy, quantified as life-years gained over 10 years. Policy costs were calculated using evidence from published sources. Health care costs for specific CHD patient groups were estimated. Costs were compared against a "do nothing" baseline. Results All policies resulted in a life-year gain over the baseline. Change4life and labeling each gained approximately 1960 life-years, voluntary reformulation 14,560 life-years, and mandatory reformulation 19,320 life-years. Each policy appeared cost saving, with mandatory reformulation offering the largest cost saving, more than £660 million. Conclusions All policies to reduce dietary salt intake could gain life-years and reduce health care expenditure on coronary heart disease.

The purpose of this study is to estimate the prevalence and the number of people with type 2 diabetes (T2DM) in 2025 in Turkey and to evaluate the impact of possible policy options on T2DM prevalence. We developed a model to predict future prevalence of T2DM using trend data for adults aged 25–74 in Turkey from 1997 to 2025. The model integrates population, obesity and smoking trends to estimate the future T2DM prevalence using a Markov approach. T2DM prevalence was 7.5 % (95 % CI: 6.0–9.0 %) in 1997 increasing to 16.2 % (95 % CI: 15.5–21.1 %) in 2010. The forecasted prevalence for 2025 was 31.5 % (28.6 % in men and 35.1 % in women). If obesity prevalence declines by 10 % and smoking decreases by 20 % in 10 years from 2010, a 10 % relative reduction in diabetes prevalence (1,655,213 individuals) could be achieved by 2025. Diabetes burden is now a significant public health challenge, and our model predicts that its burden will increase significantly over the next two decades. Tackling obesity and other diabetes risk factors needs urgent action.

Background Consistent declines in coronary heart disease (CHD) death rates have been previously observed in Ireland since1985. Aims & Methods To use the previously validated Irish IMPACT CHD mortality model to further examine the subsequent CHD mortality falls from 1985 through to 2006, and to determine the contribution of risk factor changes and "evidence based" treatments to this decline by age and gender. Results CHD mortality rates fell by 68% in men (63% in 65–84years) and by 69% in women (66% in 65–84years). This resulted in approximately 6450 fewer CHD deaths than if mortality rates had not changed. Overall, approximately 40% (38% in men; 45% in women) of the CHD mortality decline could be attributed to improvements in treatment uptake, particularly secondary prevention (12%), angina (9%), and heart failure therapies (8%). Approximately 48% of the CHD mortality decline was attributable to risk factor improvements ( 54% in men; 37% in women); the biggest contributions came from falls in population systolic pressure (28%), cholesterol (24%), and physical inactivity levels (10%). Negative trends in diabetes and obesity levels generated an estimated 17% additional CHD deaths. The largest benefits from improvements in risk factors were seen in men aged 25–64years, while the greatest treatment benefits occurred in women aged 65–84years. The model explained approximately 88% of the observed mortality declines. Conclusion Falls in CHD mortality have continued in both sexes in Ireland, but with notable gender and age differences. The continued increase in diabetes and obesity levels is particularly worrying.

Summary Background The effects of corticosteroids are systemic, but their benefits in tuberculosis are thought to be organ specific, with clinicians using them routinely to treat some forms of tuberculosis (such as meningitis), but not others. We aimed to assess the effects of steroids on mortality attributable to all forms of tuberculosis across organ systems. Methods We did a systematic review and meta-analysis to estimate the efficacy of steroids for the prevention of mortality in all forms of tuberculosis, and to quantify heterogeneity in this outcome between affected organ systems. We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Central Register of Controlled Trials, Medline, Embase, and Literatura Latino-Americana e do Caribe em Ciencias da Saude (LILACS) for studies published up to Sept 6, 2012, and checked reference lists of included studies and relevant reviews. We included all trials in people with tuberculosis in any organ system, with tuberculosis defined clinically or microbiologically. There were no restrictions by age, comorbidity, publication language, or type, dose, or duration of steroid treatment. We used the Mantel-Haenszel method to summarise mortality across trials. Findings We identified 41 eligible trials, 18 of which assessed pulmonary tuberculosis. 20 of the 41 trials (including 13 of those for pulmonary tuberculosis) were done before the introduction of modern rifampicin-containing antituberculosis chemotherapy. Meta-analysis stratified by affected organ systems identified no heterogeneity; steroids reduced mortality by 17% (risk ratio [RR] 0·83, 95% CI 0·74–0·92; I 2 0%), consistent across all organ groups. In a sensitivity analysis that only included trials that used rifampicin-containing regimens, the results were similar (RR 0·85, 95% CI 0·74–0·98; I 2 21%). A sensitivity analysis in pulmonary tuberculosis that excluded trials with high potential risks of bias suggested a slight benefit, but the point estimate was closer to no effect and the difference was not significant (RR 0·93, 95% CI 0·60–1·44). Interpretation Steroids could be effective in reducing mortality for all forms of tuberculosis, including pulmonary tuberculosis. However, further evidence is needed since few recent trials have assessed the effectiveness of corticosteroids in patients with pulmonary tuberculosis. Funding UK Department for International Development.

Aims We developed and demonstrated a novel mathematical modeling approach to forecast the burden of type 2 diabetes mellitus (T2DM) and to investigate T2DM epidemiology for the purpose of informing public health policy and programming. Methods A population-level compartmental mathematical model was constructed and applied to Qatar. The model was stratified according to sex, age group, risk factor status, and T2DM status, and was parameterized by nationally-representative data. Results T2DM prevalence increased from 16.7% in 2012 to at least 24.0% by 2050. The rise in T2DM was most prominent among 45–54 years old. T2DM health expenditure was estimated to increase by 200–600% and to account for up to 32% of total health expenditure by 2050. Prevalence of obesity, smoking, and physical inactivity was predicted to increase from 41.4% to 51.0%, from 16.4% to 19.4%, and from 45.9% to 53.0%, respectively. The proportion of T2DM incidence attributed to obesity, smoking and physical inactivity was estimated at 57.5%, 1.8%, and 5.4%, respectively in 2012, and 65.7%, 2.1%, and 6.0%, respectively in 2050. Exploring different scenarios for the trends in risk factors, T2DM prevalence reached up to 37.7% by 2050. Conclusions Using our innovative approach, a rising T2DM epidemic is predicted to continue in the next decades, driven by population growth, ageing and adverse trends in risk factors. Obesity was the principal risk factor explaining two-thirds of T2DM incidence. T2DM must be a national priority addressed by preventive and therapeutic interventions targeting T2DM and its modifiable risk factors.

Background The authors aimed to determine whether, and by how much, diabetes mellitus (DM) increases the risk of tuberculosis (TB) and conversely whether TB increases the risk of DM. Methods Retrospective cohort analyses using data from two Oxford Record Linkage Study (ORLS) datasets, containing information on hospital admissions and day-case care between 1963 and 1998 (ORLS1) and between 1999 and 2005 (ORLS2), were carried out. The rate ratio (RR) for tuberculosis after admission to hospital with diabetes and for diabetes after hospital admission with tuberculosis was calculated. Results In ORLS1, the RR for TB in people admitted to hospital with DM, comparing the latter with a reference cohort, was 1.83 (95% CI 1.26 to 2.60), and in ORLS2 the RR was 3.11 (1.17 to 7.03). RRs for pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) within ORLS1 were similar at, respectively, 1.80 (1.16 to 2.67) and 1.98 (0.88 to 3.92). In ORLS 2 the RR for PTB was 2.63 (0.91 to 6.30). In ORLS1, there was no indication that TB was a risk factor for DM (RR 1.12, 0.76 to 1.60). The ORLS2 dataset was too small to analyse whether TB led to DM. Discussion DM was associated with a two- to threefold increased risk of TB within this predominantly white, English population. The authors found no evidence that TB increases the risk of DM. Our findings suggest that the risks of PTB and EPTB were both raised among individuals with DM. As DM prevalence rises, this association will become increasingly important for TB control and treatment.

Public policy plays a key role in improving population health and in the control of diseases, including non-communicable diseases. However, an evidence-based approach to formulating healthy public policy has been difficult to implement, partly on account of barriers that hinder integrated work between researchers and policy-makers. This paper describes a "policy effectiveness-feasibility loop" (PEFL) that brings together epidemiological modelling, local situation analysis and option appraisal to foster collaboration between researchers and policy-makers. Epidemiological modelling explores the determinants of trends in disease and the potential health benefits of modifying them. Situation analysis investigates the current conceptualization of policy, the level of policy awareness and commitment among key stakeholders, and what actually happens in practice, thereby helping to identify policy gaps. Option appraisal integrates epidemiological modelling and situation analysis to investigate the feasibility, costs and likely health benefits of various policy options. The authors illustrate how PEFL was used in a project to inform public policy for the prevention of cardiovascular diseases and diabetes in four parts of the eastern Mediterranean. They conclude that PEFL may offer a useful framework for researchers and policy-makers to successfully work together to generate evidence-based policy, and they encourage further evaluation of this approach.