Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. Gates Foundation.
HomeHealth is a home-based, voluntary sector service supporting older people with mild frailty to maintain independence through behaviour change. Support workers discuss the person's priorities and enable setting/achieving goals around mobility, nutrition, socialising and/or psychological well-being. We tested clinical and cost-effectiveness of HomeHealth for maintaining independence in older people with mild frailty in a randomised controlled trial. Design: Single-blind, parallel randomised controlled trial open between 18 January 2021 and 4 July 2023, with mixed-methods process evaluation. Setting: Community-dwelling older people aged 65+ years with mild frailty from 27 general practices and community settings in London, Yorkshire and Hertfordshire. Randomisation: Participants were randomised 1 : 1 to receive HomeHealth or treatment as usual. Outcomes: Primary outcome was independence in activities of daily living (modified Barthel Index), analysed using linear mixed models. Secondary outcomes included frailty phenotype score, extended activities of daily living, well-being, psychological distress, loneliness, cognition, falls and mortality. Health economic outcomes included quality of life, capability and service use, including hospital admissions. Cost-effectiveness acceptability curves and cost-effectiveness planes were used to represent the probability of cost-effectiveness compared to treatment as usual. Process evaluation: We conducted semistructured interviews with participants receiving the intervention, HomeHealth workers and other stakeholders supporting service delivery. Interviews were thematically analysed. Fidelity of audio-recorded appointments was assessed by two independent raters. We evaluated potential mechanisms of impact using data from appointments attended, types of goals set and progress towards goals. We recruited 388 participants, mean age 81.4 years (standard deviation 6.5), 64% female and 94% White British/European. HomeHealth did not improve Barthel Index scores at 12 months (0.250, 95% confidence interval -0.932 to 1.432). At 6 months, we found small significant reductions in psychological distress (-1.237, 95% confidence interval -2.127 to -0.348), and frailty phenotype score (-0.252, 95% confidence interval -0.487 to -0.017). At 12 months, we found significant improvements in well-being (1.449, 95% confidence interval 0.124 to 2.775), reduced unplanned admissions (incidence rate ratio 0.65, 95% confidence interval 0.54 to 0.92) with lower associated costs (-£586/participant, 95% confidence interval -351 to -821). There were no differences in other outcomes. HomeHealth dominates treatment as usual with a negative point estimate for incremental costs (-796, 95% confidence interval -2016 to 424), positive point estimate for incremental quality-adjusted life-years (0.009, -0.021 to 0.039) and high probability of cost-effectiveness. Process evaluation: Sixty-four semistructured interviews were completed, including 49 participants and 15 HomeHealth workers/stakeholders. The service was acceptable and safe, with good fidelity of delivery. Participants made progress on personalised goals, most working on enhancing mobility. They found the service empowering, and received emotional/practical support. Engagement was more challenging when participants identified no need for change, had significant memory impairment or new/declining illness. Flexibility around varying symptoms and incorporating behaviour change into existing routines promoted engagement. HomeHealth did not improve independent functioning for older people with mild frailty. There were small significant improvements in frailty status, psychological distress and well-being and a 35% reduction in unplanned admissions, with high probability of cost-effectiveness. We used a pragmatic design with intervention delivery in real-world settings during/after the COVID-19 pandemic, potentially with more variability in delivery. Our findings might not apply to other geographical settings/healthcare systems. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128334. As we age, we may develop several health conditions that affect how we feel and our ability to manage without help. For some, it can mean they have less energy and muscle strength, and it is harder to do routine tasks such as shopping or cooking. Few services exist to prevent things getting worse. We designed a new service, ‘HomeHealth’, to enable older people to maintain their independence and activities they enjoy. Over six visits with a dedicated support worker, they identified concerns such as tiredness, low mood and anxiety, poor appetite, weakness and memory problems and developed goals and plans to address difficulties. Our research aimed to explore if HomeHealth helped people to stay independent for longer and provided value for money. Our study recruited 388 older people who were struggling with their everyday activities like cooking/shopping and getting out due to their health. Half were randomly allocated to the HomeHealth service, and half received usual care for 6 months. All participants were assessed by researchers at the beginning, 6 and 12 months later. We also interviewed 49 participants, and 15 people delivering the service about their experiences. We found that HomeHealth did not improve participants’ independence compared to usual care, though it showed small positive effects on mood and frailty at 6 months and well-being after 1 year. Those receiving the service were 35% less likely to be admitted to hospital for acute illness and had lower hospital care costs. The service was acceptable, safe, provided emotional and practical support and empowerment. Most older people made progress on goals to improve their health and well-being. Some found this more challenging, particularly those with worsening health or memory, or those who felt no need to change. The HomeHealth service is a promising intervention to reduce unplanned (emergency) hospital admissions.
Does transdermal testosterone treatment improve fertility-related quality of life (QOL) in women with diminished ovarian reserve (DOR)? Transdermal testosterone for 9 weeks at a dose of 5.5 mg per day did not result in improved fertility-related QOL compared with placebo in women with DOR. Reduced QOL is prevalent in women with infertility, many of whom have DOR. Several studies have shown a correlation between DOR and lower testosterone levels, and testosterone is frequently prescribed to women with DOR undergoing fertility treatment. Some studies have reported that testosterone therapy may improve wellbeing in pre- and post-menopausal women, though others have found no benefit. There are no studies evaluating the effect of testosterone on QOL in women undergoing fertility treatment. Pre-planned secondary analysis of a double-blind placebo-controlled randomized controlled trial that included 288 participants recruited between April 2015 and August 2022. Of these, 213 completed QOL surveys both before and after treatment and were eligible for inclusion in this analysis. Participants were women aged 18-43 years with DOR according to the Bologna criteria and planning to undergo IVF treatment at one of eight fertility clinics in Spain, Belgium, and Denmark. Participants were randomized to 5.5 mg of transdermal testosterone per day as 1% gel (n = 106) or an identical placebo (n = 107), applied for a median of 60 days prior to commencing ovarian stimulation. QOL was assessed using the FertiQoL instrument prior to commencing the intervention, and at the completion of the intervention but prior to commencing ovarian stimulation. QOL scores were compared using a one-way ANCOVA adjusted for age, BMI, parity, history of IVF treatment, and baseline FertiQoL scores. There were no significant differences in baseline characteristics between the testosterone (n = 106) and placebo (n = 107) groups. After adjustment, testosterone showed no benefit over placebo for the Total FertiQoL score (F(1,204)=0.07, P = 0.79), the Core and Treatment scores, nor for any of the included FertiQoL subscales. Total testosterone levels were higher in the testosterone group than the placebo group at the end of the treatment (3.2 ± 2.7 nmol/l vs 0.6 ± 0.4 nmol/l, P < 0.001). QOL was a secondary outcome in this trial, and participants were not recruited based on a low QOL. Considering the available evidence, including the current study, premenopausal women are unlikely to benefit from testosterone treatment with regard to wellbeing and QOL. This study provides further evidence that testosterone should not be seen as a treatment for low wellbeing or QOL. The study was supported by unrestricted grants and support from Besins Healthcare, Roche Diagnostics, and Ferring Pharmaceuticals. The study medication and placebo were provided by Besins Healthcare. Funders had no access to patient data and had no role in the interpretation of the data, nor in the writing or approval of the final manuscript. The researchers were independent of the funders and had full access to all the data in the study. S.J.L. has received honoraria from Merck, Organon, and Hologic, consulting fees from Merck, and travel support from Merck, Organon, Besins Healthcare, and Ferring Pharmaceuticals. S.R.D. has received grants from NHMRC Australia, MS Australia, MRFF Australia, the Australian Heart Foundation, and Lawley Pharmaceuticals, consulting fees from Besins Healthcare, Astellas, and Abbott, honoraria from Theramex, Astellas, and Bayer, travel support from Astellas, and drugs/placebo from Lawley Pharmaceuticals for clinical trials; she is an Executive Board Member of the Australian Academy of Health and Medical Sciences. C.B. has received honoraria from Ferring Pharmaceuticals, IBSA, Organon, Merck A/S, and Abbott. A.G. has received honoraria from Lab Seid and travel support from Merck Serono. P.H. has received honoraria from Merck, IBSA, Gedeon Richter, and Besins Healthcare. L.D.L.F. has received consulting fees from Gedeon Richter, Ferring Pharmaceuticals, and Organon, travel support (personal and to institution) from Gedeon Richter, Ferring Pharmaceuticals, IBSA, Merck, Organon, and Theramex, and educational support (to institution) from Gedeon Richter and Merck. A.P. has received grants from Gedeon Richter, Ferring Pharmaceuticals, and Merck A/S, consulting fees from Gedeon Richter and Ferring Pharmaceuticals, honoraria from Ferring Pharmaceuticals, Gedeon Richter, Merck A/S, Abbott, and Organon, and travel support from Gedeon Richter. D.S. has received grants from Organon, Ferring Pharmaceuticals, Besins Healthcare, Gedeon Richter, and Vitrolife, honoraria from Organon, Ferring Pharmaceuticals, Besins Healthcare, Gedeon Richter, and Merck, travel support from Organon, Ferring Pharmaceuticals, Besins Healthcare, Gedeon Richter, and Merck, and is President of the Belgian Society for Reproductive Medicine. N.P.P. has received grants from Merck Serono, Ferring Pharmaceuticals, Theramex, Organon, Besins Healthcare, and Gedeon Richter, consulting fees from Merck Serono, Besins Healthcare, Organon, IBSA, FertilAI, and Alife, and honoraria from Merck Serono, Theramex, IBSA, Ferring Pharmaceuticals, Organon, Roche Diagnostics, and Besins Healthcare. S.G.M., F.M., and F.F. have no interests to declare. NCT02418572 (ClinicalTrials.gov).
BACKGROUND: The concept of healthy aging centers on maintaining and enhancing older adults’ intrinsic capacities to optimize functionality. This study begins with intrinsic capacity, uses the WHO ICOPE framework to assess its decline, and examines the interrelationships among family function, intrinsic capacity, and quality of life among older adults residing in the community who have been diagnosed with type 2 diabetes. It also verifies the mediating effect of intrinsic capacity, which may inform interventions to improve their quality of life. METHODS: Older adults with type 2 diabetes from three communities in Jinzhou City, Liaoning Province, were selected as research subjects using convenience sampling. A self-designed questionnaire, Family Functioning Scale (FACES), Quality of Life Specific Scale for Diabetic Patients (DSQL), and an intrinsic capacity assessment tool were used. SPSS 27.0 and Amos 28.0 were used for data analysis. Applied a structural equation framework to explore directional links among constructs; indirect influence estimated via repeated resampling (Bootstrap). RESULTS: A total of 328 older adults (mean age 71.34, SD = 6.82) participated in the WHO ICOPE Step 1 brief screening. After Step 2, complete assessment, 75.0% (246) of subjects had a decline in intrinsic capacity, and 81.3% had impaired“vitality”. Family function is significantly negatively correlated with both quality of life (r= -0.572, P < 0.01) and intrinsic capacity (r=-0.460, P < 0.01), with higher scores indicating worse status. Intrinsic capacity exhibits a positive correlation with the quality of life (r = 0.542, P < 0.01). The functioning of the family unit was associated with quality of life and partially mediated by intrinsic capacity, accounting for 20.3% of the total effect. CONCLUSIONS: The intrinsic capacity of older adults with type 2 diabetes is generally impaired. Family function is directly and indirectly associated with quality of life. Routine implementation of the ICOPE assessment at the community level is recommended to identify early impairments in intrinsic capacity dimensions. By strengthening family adaptability and implementing personalized exercise and nutritional interventions, the intrinsic capacity and quality of life of older adults may be improved.
Despite the growing attention to health inequalities, there is no global consensus on how to measure socio-economic status. This study examined inequalities in health-related quality of life (HRQoL) during the early phase of the COVID-19 pandemic across six countries-China, Italy, the Netherlands, Sweden, the United Kingdom (UK), and the United States (US)-using three SES indicators: education level, income, and work status. Between April and June 2020, individuals aged 18-75 years old completed a web-based survey. HRQoL was measured using the EQ-5D-5L Level Sum Score (LSS), where higher scores indicate poorer health. Country-specific differences in LSS across SES groups were assessed using Kruskal-Wallis and Mann-Whitney U tests. Multiple linear regression models, adjusted for age, gender, and chronic conditions, were used to explore associations between SES indicators and HRQoL. No formal correction for multiple testing was applied. Data from 17,607 respondents were analyzed. In all countries except Italy, individuals with lower education levels reported significantly higher LSS scores. The largest disparity was observed in the UK. In the Netherlands, Sweden, the UK, and the US, lower-income groups also had higher LSS scores, while no such differences were observed in China or Italy. Across all countries, unemployed individuals consistently reported worse HRQoL. Regression analyses confirmed that younger age, chronic conditions, and unemployment were strongly associated with poorer HRQoL. Substantial SES-related health inequalities in HRQoL were observed during the COVID-19 pandemic, especially in the UK. Work status emerged as a particularly strong and consistent predictor across countries. This study looked at how people’s quality of life differed based on their social and economic situation during the early months of the COVID-19 pandemic. The people who participated in this study were from six countries: China, Italy, the Netherlands, Sweden, the UK, and the US. We measured people’s socioeconomic status (SES) in three ways: their education level, household income, and whether they were employed or not. More than 17,000 people who were aged 18 to 75 years completed an online survey between April and June 2020. Their quality of life was assessed using a questionnaire that is called the EQ-5D-5L. Based on the answers on the questionnaire, we could give each person a score—higher scores mean poorer quality of life. The results showed that in all countries except Italy, people with lower levels of education tended to report poorer quality of life. The biggest gap between low and high education levels was found in the UK. Income differences also mattered: people with lower incomes in the Netherlands, Sweden, the UK, and the US reported lower quality of life, but this was not the case in China or Italy. Across all six countries, people who were unemployed consistently had lower quality of life than those who were employed.
A breast cancer (BC) diagnosis may negatively affect health-related quality of life (HRQoL). However, there are few comparisons of HRQoL at several time points for women with BC, and particular when subdivided into invasive and in situ tumors. The purpose of this study was to investigate various aspects of HRQoL in women recently diagnosed with invasive BC or ductal carcinoma in situ (in situ) compared to age-matched BC free controls in a population-wide sample recruited through the Cancer Registry of Norway. This cross-sectional study utilized HRQoL data collected in 2020-2022 from a digital survey including 4117 cases (3867 women with invasive BC and 430 with in situ) and 2911 controls. HRQoL was assessed ≥ 21 days after diagnosis, using EORTC QLQ-C30. This includes scores assessing global quality of life (gHRQoL) and HRQoL functions and symptoms. Multivariable regression analyses were used to compare HRQoL between cases and controls and to identify factors associated with gHRQoL and fatigue. Additionally, HRQoL 14 months after diagnosis was analyzed in 1989 of the included cases and in 1212 of the controls. Score differences of ≥ 10 points were considered clinically relevant and thus presented in the results. Invasive BC cases had lower gHRQoL, role- and social functioning in addition to more fatigue than controls. In situ cases had lower role-and social functioning than controls. Invasive BC cases scored worse than in situ on all domains, but the differences were not considered clinically relevant. Physical activity was associated with better gHRQoL and less fatigue in invasive BC, in situ and controls. Both invasive BC and in situ cases improved their role- and social functioning scores from diagnosis to 14 months follow-up, however no improvement was seen for fatigue. Women with invasive BC and in situ reported lower role- and social functioning scores than controls right after diagnosis with improvements 14 months after diagnosis. Physical activity was associated with better gHRQoL and less fatigue and should, whenever possible, play a key role in the care for BC patients.
Falls are a leading cause of disability in older adults and often co-occur with sleep disturbance, balance impairment, concern about falling and reduced health-related quality of life. However, these domains are usually studied separately. This exploratory cross-sectional analysis assessed the interrelationships among sleep quality and duration, concern about falling, clinical balance and functional performance, and health-related quality of life in community-dwelling adults aged ≥45 years using seven prespecified binary outcomes: falls, high concern about falling, balance impairment, short sleep duration, poor physical health-related quality of life, current smoking, and weak grip strength. A community-based cross-sectional study was conducted among adults aged ≥45 years (N=52; mean age 61.10±12.55 years). Trained physiotherapists collected sociodemographic and clinical data, medications, morbidities, smoking, and administered standardized measures: grip strength, 30-s Sit-to-Stand (STS), Timed Up & Go (TUG), Berg Balance Scale (BBS), Falls Efficacy Scale-International (FES-I), SF-12 Physical and Mental, Pittsburgh Sleep Quality Index (PSQI), sleep duration, and the International Physical Activity Questionnaire (IPAQ). Seven prespecified binary outcomes were modelled using logistic regression adjusted for age and sex. Falls were common (46.2%), as were BBS impairment (36.5%), weak grip strength (73.1%), short sleep (63.5%), and poor sleep quality (86.5%). Current smoking was reported by 26.9% of participants. Fallers were more often ≥65 years, smokers, and on ≥5 medications, and showed worse STS, BBS, SF-12 Physical/Mental, and FES (all p≤.041). Falls were strongly associated with age (rho=.58), smoking (rho=.71), BBS impairment (rho=.66), and higher FES concern (rho=.60) (all p<.001). In logistic regression models adjusted for age and sex, BBS impairment predicted falls (OR=5.88, 95% CI 1.06-6.67, p=.043) and high FES concern (OR=1.68, 95% CI 1.40-3.28, p=.004). Short sleep duration strongly associated with BBS impairment (OR=4.71, 95% CI 2.82-6.02, p=.008), having ≥1 fall was associated with current smoking (OR=2.86, 95% CI 1.02-3.74, p=.048) and high FES concern was linked to poorer SF-12 Physical status (OR=0.18, 95% CI 0.05-0.74, p=.017). In this cohort, balance impairment, fall concern, short sleep and lower physical health-related quality of life were observed to cluster. BBS was identified as a key independent correlate of both falls and concern about falling, while short sleep duration was strongly associated with balance impairment, and concern about falling independently predicted lower SF-12 physical scores. Given these results, multidimensional assessment including balance testing, concern-about-falling assessment, sleep and health-related quality of life screening is supported, and confirmation in larger longitudinal cohorts is required.
Cancer significantly affects multiple dimensions of patients' well-being, making health-related quality of life (HRQoL) a key outcome in oncology. However, evidence on the clinical and socioeconomic determinants of HRQoL among cancer patients in Iran, particularly in southwestern regions, remains limited. This study aimed to assess HRQoL and to identify its clinical and socioeconomic determinants among cancer patients in southwestern Iran. This cross-sectional descriptive-analytical study was conducted in 2024 among cancer patients attending Shahid Jalil Hospital, Yasuj. A total of 166 eligible patients were recruited through consecutive sampling. HRQoL was assessed using the validated Persian version of the EORTC QLQ-C30. Sociodemographic, clinical, and treatment-related variables were collected through structured interviews and medical records. Data analysis was performed using SPSS 27. Median (IQR) values were reported for HRQoL domains. The Gamma regression model with log link was applied to identify predictors of overall HRQoL. Associations were expressed as Mean Ratios (MRs) with 95% confidence intervals. Participants had a mean age of 58.09 ± 16.08 years; 54.2% were male, and 58.5% had stage IV cancer. The lowest HRQoL scores were observed in cognitive functioning (median: 32.33), physical functioning (38), and role functioning (49), while social functioning showed higher scores (65.67). In multivariable analysis, stage IV cancer (MR = 0.33; 95% CI: 0.14-0.80) and metastatic disease (MR = 0.36; 95% CI: 0.17-0.77) were strongly associated with reduced HRQoL. Conversely, basic health insurance significantly improved HRQoL (MR = 2.15; 95% CI: 1.06-4.36). Other demographic variables were not significant predictors. Disease severity and insurance coverage are major determinants of HRQoL among cancer patients in southwestern Iran. Enhancing early detection, strengthening financial protection, and integrating supportive and palliative care services may improve patient outcomes. Longitudinal studies are recommended to better elucidate HRQoL trajectories.
Heart failure (HF) is a common disease among older individuals and is associated with poor quality of life and prognosis. Individuals at risk of developing HF are usually already patients in primary healthcare, but diagnosing HF at an early stage can be challenging. Identifying patients at risk of HF and initiating early treatment is crucial for their outcomes. Using the variables gender, age, multimorbidity (MM) level, and socioeconomic status (SES), we aimed to study the possibility of identifying individuals at high risk of HF diagnosis within two years. A longitudinal registry-based study, including 961,190 inhabitants aged from 20 years onwards without a HF diagnosis living in southern Sweden during 2015. Logistic regression was applied to estimate the OR of HF diagnosis within two years by adjusting for the variables gender, age, MM level, and SES. Linear predictions were made based on models by adding these variables in steps. Each model was compared with the previous model using a likelihood-ratio test. The optimal cutoff point for sensitivity and specificity was calculated using the Youden method. Age had the highest OR of HF diagnosis within two years, followed by MM level, gender, and SES. ROC (Receiver Operating Characteristic) analysis, including these variables in steps, generated an increasing AUC (area under the curve), from 0.5144 to 0.9379. When all four variables were included in the model, an optimal cutoff point according to Youden was established at 1.15%, which predicted the probability with a sensitivity of 87.69% and specificity of 78.48%. The positive predictive value was 4.78%, and the negative predictive value was 99.81% for the whole adult population; for those aged 70 years and older, it was 21.02% and 98.99%; and for those aged 80 years and older, it was 33.62% and 98.09%, respectively. Age was the most important factor for predicting the probability of HF diagnosis within two years in our study, followed by MM level, gender, and SES. These findings may help identify population groups at increased risk of HF in whom targeted case-finding strategies could be evaluated in future studies.
BACKGROUND: Cancer remains a leading cause of morbidity and mortality worldwide, with low- and middle-income countries like Bangladesh facing a dual burden of rising incidence and limited healthcare infrastructure. Socioeconomic disparities, particularly economic social class, may exacerbate the adverse effects of cancer on health-related quality of life (HRQoL) (e.g., health utility scores). This study aimed to evaluate inequalities in health utility scores among cancer patients receiving systemic and/or radiation therapy. METHODS: This cross-sectional study included 607 patients with a confirmed cancer diagnosis who were receiving systemic and/or radiation therapy treatment in two tertiary hospitals in Bangladesh. Patients were grouped into income quintiles, and health utility scores were assessed using EQ-5D-5L instrument. Socioeconomic inequalities were assessed using relative (rich-poor ratio) and absolute (rich-poor difference) measures, the concentration index, and regression-based decomposition analysis. Associations between health utility scores and key factors such as cancer stage, type, treatment facility, and physical activity, were examined using a generalise linear model with a Gamma distribution and log link function. RESULTS: Patients in the highest income quintile had significantly higher health utility scores compared with those in the lowest income quintile (relative inequality = 1.10; absolute difference = 0.07). The concentration index indicated a pro-rich distribution of health utility scores (CI = 0.025, SE = 0.019). Subgroup analyses demonstrated pronounced disparities by cancer stage, cancer type, and treatment facility. Advanced-stage disease, cancers of the female reproductive organs, and lung cancer were associated with larger income-related gaps. Inequalities were most evident self-care and usual activities dimensions of the EQ-5D-5L instrument, where the poorest patients had substantially higher risks of severe/extreme problems. Decomposition analysis identified advanced cancer stage, treatment in public hospitals, and physical inactivity as major contributors to lower utility scores, underscoring the compounded disadvantage among low-income patients. CONCLUSION: Socioeconomic disparities, measured by income quintiles, were associated with significant differences in HRQoL (i.e. health utility scores) among Bangladeshi cancer patients. Inequalities were most pronounced in specific subgroups, particularly those with advanced disease, certain cancer types, and limited physical activity. Targeted, equity-focused interventions or strategies such as enhanced supportive and palliative care, rehabilitation and physical activity programs and improved access to quality services in public facilities, may help reduce income-related gaps in quality of life.
We aimed to determine the prevalence of anxiety and to identify associated factors among multi-professional residents in Brazil during the early days of the COVID-19 pandemic. A cross-sectional study included a sample of 752 multi-professional residents selected by snowball technique. Symptoms of anxiety were measured by the Beck anxiety inventory scale (≥ 16 cut-off). We used WHOQOL-BREF to access the health-related quality of life and the Maslach Burnout Inventory to measure the burnout syndrome. PR and respective 95% confidence intervals (CI) were calculated using the Poisson regression model. The prevalence of anxiety was 41.2% (310/752). Some variables were strongly associated with anxiety: afraid of getting COVID-19; extra work demand during COVID-19 pandemic; sweating/wheezing/increased heart rate during work; feeling safe when using personal protective equipment at work, and psychological support from residence preceptors. Residents with symptoms of anxiety showed high emotional exhaustion at work (36.6 ± 9.6 vs. 24.7 ± 10.7, P = 0.001) and depersonalization (8.9 ± 6.0 vs. 5.6 ± 4.9, P = 0.001). Correlations coefficients between emotional exhaustion versus Physical WHOQOL-BREF and between emotional exhaustion versus Psychological WHOQOL-BREF were significantly lower among residents without anxiety (P = 0.027 and P = 0,03, respectively). The prevalence of anxiety was high and strongly associated with several variables, particularly with being afraid of getting COVID-19, the perception of workload, somatization (sweating, wheezing and increased heart rate during work), feeling unsafe when using personal protective equipment, and lack of psychological support from residence preceptors. Anxiety was associated with increased emotional exhaustion and depersonalization and low health-related quality of life during the COVID-19 pandemic in Brazil. Low WHOQOL-BREF environment domain, and high emotional exhaustion MBI domain increased the chances of presenting symptoms of anxiety.
Focal laser ablation (FLA) serves as a targeted therapy for prostate cancer (PCa). Clinical studies have demonstrated significant variations in ablation volumes with consistent fiber configurations. Consequently, a prediction model is needed for the safe application of FLA in treating PCa. This study aimed to evaluate the reproducibility of FLA-induced temperature profiles in controlled ex vivo experiments using clinical laser treatment protocols. Additionally, it sought to examine the effectiveness of the CEM43 model in predicting the zone of irreversible damage (ZID) and to compare these findings with outcomes derived from the Arrhenius model. Freshly excised postmortem human prostate and porcine liver specimens were used for controlled ex vivo ablation. Tissues were secured in a Perspex sample holder for precise placement of the laser fiber and thermocouples. FLA was conducted with a 1064-nm Nd:YAG laser at 3 W in continuous-wave mode for 10 min. Pre- and post-FLA 3D T1-weighted 7 T MRI scans were obtained to assess the treatment area. Whole-mount hematoxylin and eosin histological slides were prepared and digitized. On histology, the ZID was defined as the total of vaporized, carbonized, and coagulated tissue. A 2D thermal development map was created from temperature data, using bi-cubic interpolation. The cumulative equivalent thermal isoeffect dose at 43°C in minutes (CEM43) model was applied to predict the ZID, with 240 equivalent minutes (240-CEM43) used as the damage threshold. Additionally, the Arrhenius thermal model was used for comparison of CEM43 results. Predicted ZIDs were compared to MRI and histology. FLA treatment was performed on ex vivo human prostate samples (n = 2) and porcine liver specimens (n = 5). For human prostate tissue, FLA did not result in an identifiable ZID upon histological macroscopic examination or a lesion on MRI. Ex vivo porcine liver samples showed a clearly demarcated oval-shaped hyperintense lesion surrounding the laser fiber tip on post-FLA MRI. The MRI lesion (range 1.6-2.1 cm2) corresponded with the shape and location of the ZID on histology, but was smaller (median 1.7 vs. 3.2, p = 0.02). Histological examination of porcine liver samples revealed ZIDs ranging from 2.1 to 4.1 cm2, whereas 240-CEM43-predicted ZIDs ranged from 3.3 to 3.8 cm2. Although the median 240-CEM43-predicted ZID was not significantly larger than the histology ZID (3.8 vs. 3.2 cm2, p = 0.22), it tended to overpredict the histological results in most experiments. The median Arrhenius-predicted ZID was similar to the histological ZID (3.2 vs. 3.2 cm2, p = 0.56), but varied in size when comparing individual experiments (range 2.5-3.2 cm2). FLA on ex vivo human prostate showed no thermal damage on histopathology or MRI. Ex vivo porcine liver FLA resulted in identifiable ZID on histology and lesions on MRI. 240-CEM43 generally overestimated the ZID and had less variability compared to histology. Results from the Arrhenius model were in better agreement with the histology findings, but still did not predict the individual FLA-induced histological thermal damage. Inter-experiment ZID variability underlines the need for developing a more comprehensive predictive dosimetry model for FLA in PCa treatment.
The COVID-19 pandemic has led to a generally high level of state anxiety resulting from the high contagiousness of the disease and strict prevention and control policies. The present study mainly focused on the relationship between the individual intolerance of uncertainty and state anxiety in the regular epidemic prevention and control phase in China, and aimed to investigate the mediating role of information overload and rumination, as well as the moderating role of self-compassion. A total of 992 Chinese residents from 31 provinces participated in this study, and completed questionnaires regarding intolerance of uncertainty, information overload, self-compassion, rumination, and state anxiety. Descriptive statistics and correlation analyses, as well as tests for mediating effects and moderated chain mediating effects, were performed on the data using SPSS 26.0 and Process 3.5 macro program. The findings indicated that intolerance of uncertainty significantly predicted individual state anxiety. Information overload mediates the effects of intolerance of uncertainty and state anxiety. Rumination also mediates the effect of uncertainty intolerance on state anxiety. Information overload and rumination have a chain mediation effect on the link between intolerance of uncertainty and state anxiety. Self-compassion mediates the effect of information overload on rumination. The results illuminate theoretical and practical implications in the regular epidemic prevention and control phases and reveal the protective role of self-compassion.
In an increasingly urbanized world, understanding the determinants of urban well-being will continue to grow in importance. Although the effects of different indicators of living conditions on well-being have been widely studied individually, little is known about their relative impact when examined jointly. In this study, we use a unique multi-source dataset that allows us to investigate the effect and relative importance of a variety of subjectively and objectively assessed aspects of urban living conditions on the subjective well-being (SWB) of German Foreign Service expatriates. The study captures living conditions in metropolises around the world at different stages of development, and assesses living conditions in a culturally comparably homogeneous set of participants, thus being potentially less confounded with cultural differences. Using linear regression and dominance analysis, we find that 'quality of and access to nature' (i.e., green space), 'quality of housing', and 'quality of public goods' (i.e., water, air, and sewage systems) have the strongest associations with SWB. Subjectively rated characteristics show stronger associations with SWB than externally assessed characteristics. Additionally, we examine whether the size of a city or the level of development of a country has an effect on SWB. Both living in a megacity (≥ 10 million inhabitants) and a lower development status have negative effects on SWB. However, these effects disappear when the various indicators of living conditions are controlled for. Our findings can inform organisations sending employees abroad as well as urban planners seeking to improve their policies and decision-making. The online version contains supplementary material available at 10.1007/s11482-023-10169-w.
Enabling older people to live comfortably in their own neighbourhoods for longer, known as ageing-in-place, has become a policy priority to reduce pressures on health and social care systems amid global population ageing. However, research on place and health remains predominantly deficit-focused, emphasising illness and decline (e.g. frailty, depression, and anxiety). This review adopts a positive psychology perspective and a life-course framework to synthesise evidence on how neighbourhood environments support flourishing in later life, a multidimensional state encompassing happiness, life satisfaction, and meaning in life. Searches were conducted across nine databases. Content analysis was used to synthesise findings, guided by an adapted version of Wahl, Iwarsson and Oswald's person-environment framework of ageing well. Risk of bias was assessed using the NHLBI Quality Assessment Tool. From 3375 records, 52 studies met the inclusion criteria. Consistent positive associations were identified between neighbourhood physical characteristics (e.g. green space, littering) and social characteristics (e.g. ageism, social cohesion) and older adults' flourishing. Findings on the functional characteristics (e.g. service accessibility and transport) varied by service type and measurement approach. Compositional characteristics (e.g. age mix, socioeconomic status) significantly moderated person-environment interactions but remain underexplored. The evidence base overall is limited by reliance on cross-sectional data. Emerging evidence suggests that neighbourhood effects differ across young-old (50-64), old-old (65-79) and oldest-old (80 +) groups, highlighting the need for more life-course research to disentangle cumulative and temporal dynamics in person-environment interactions in later life. Neighbourhoods play a crucial role in supporting older adults' flourishing, but evidence on causal pathways and life-course dynamics remains limited. The proposed integrative framework enhances conceptual clarity and provides a foundation for longitudinal research to guide place-based interventions for positive ageing.
PURPOSE: Infertility is associated with considerable psychosocial distress, yet many affected individuals lack formal diagnosis or treatment. The Fertility Quality of Life (FertiQoL) tool is widely used to assess quality of life in infertile populations, while the Patient Health Questionnaire-4 (PHQ-4) is a validated screening tool for anxiety and depression. This study investigated whether FertiQoL could be applied as a screening measure to identify high-risk individuals during in vitro fertilization–embryo transfer (IVF-ET). METHODS: This study enrolled participants (320 patients with 444 valid responses) between February and July 2023 across 11 assisted reproductive technology institutions in Taiwan. FertiQoL was used to evaluate quality of life, and PHQ-4 was used to screen for anxiety and depression. Associations between the two measures were analyzed, and a decision tree model was applied to identify an optimal FertiQoL cutoff score for risk classification. RESULTS: FertiQoL total scores were significantly and negatively correlated with PHQ-4 outcomes (–0.531 for PHQ-2; − 0.525 for GAD-2). A cutoff FertiQoL score of 63.6 provided satisfactory performance in identifying high-risk individuals, demonstrating sensitivities and specificities of 72% and 76% for anxiety (GAD-2), and 81% and 73% for depression (PHQ-2). CONCLUSIONS: The findings support the clinical utility of FertiQoL as a standardized tool not only for quality of life assessment but also for identifying mental health risks in infertile patients.
Cardiac rehabilitation improves recovery after cardiovascular events, but changes in health-related quality of life (HRQoL) may differ by socio-economic subgroups. This study investigated whether changes in HRQoL differed by country of birth, employment status, socio-economic status of area of residence, and remoteness. Data were analysed from individuals who completed pre- and post-program assessments at a publicly funded cardiac rehabilitation program in Western Sydney, Australia. Changes in domain scores of the 36-Item Short Form Health Survey (SF-36) were assessed using multivariable linear regression with robust standard errors. False discovery rate (FDR) correction was applied across nine models for each socio-economic characteristic. Of 11,695 individuals referred (mean age, 61 years; standard deviation [SD], 12; 78% male), 6,461 (55%) completed the program and 4,918 (42%) completed both HRQoL assessments (mean age, 61 years; SD, 11; 80% male). Being born overseas (vs Australia) was associated with more modest improvement in Health Transition. Being retired or unemployed (vs employed) was associated with more modest improvement across Physical Functioning, Role Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role Emotional, and Mental Health. Socio-economic status of area was not associated with differences in change. Residing in inner or outer regional areas (vs major cities) was associated with more modest improvement in Role Physical, while residing in remote or very remote areas was associated with more modest improvement in Role Physical and Role Emotional. HRQoL improved across all domains, but improvements were more modest among individuals who were born overseas, unemployed, or retired, and those residing in regional or remote areas. Programs may need to strengthen culturally adapted resources and extend flexible delivery to support more equitable recovery.
Relationships between activity engagement and health related quality of life (HRQOL) can differ based on the level of analyses. For instance, greater exercise on average may be linked with lower fatigue across individuals (between-person level), whereas the momentary experience of exercise may be associated with increased fatigue within an individual (within-person level). Disentangling the between- and within-person associations between everyday activities and HRQOL outcomes may provide insights for personalized lifestyle-oriented health promotion efforts for individuals with chronic conditions. The purpose of this paper was to examine the between- and within-person relationships between activity engagement and HRQOL relevant measures in a sample of 92 workers with type 1 diabetes (T1D), from whom we collected ecological momentary assessment (EMA) data 5-6 times daily over 14 days. At each EMA prompt, information was collected on the activity participants just engaged in, and HRQOL relevant metrics (e.g. mental health, blood glucose, fatigue, functioning). Momentary reports of "caring for others", and more frequently "caring for others", were both associated with decreased HRQOL. Reporting napping 10% or more of the time during a person's waking hours, but not the momentary experience of napping, was associated with decreased HRQOL. Momentary reports of sleeping were associated with low activity satisfaction relative to other activities, but higher activity importance. Study results provided a quantitative representation of the lived experience of T1D covering multiple types of activity engagement, which potentially has health promotion implications for workers with T1D. The online version contains supplementary material available at 10.1007/s11482-023-10171-2.
BACKGROUND: Maternal hypertensive Disorders (MHD), including gestational hypertension, preeclampsia, and eclampsia, remain a major contributor to maternal and neonatal morbidity and mortality worldwide. While global healthcare advancements have improved maternal survival, the incidence of MHD continues to rise, particularly in low- and middle-income countries (LMICs). OBJECTIVE: This study aimed to comprehensively assess the global and regional trends in the burden of MHD among women aged 15–49 years from 1990 to 2021 using data from the Global Burden of Disease (GBD) 2021 study. We examined disparities across countries and Socio-Demographic Index (SDI) regions, analyzed the influence of demographic and epidemiological factors through decomposition analysis, and projected future trends in MHD burden through 2050 using a Bayesian age-period-cohort (BAPC) model. METHODS: We extracted incidence, mortality, and disability-adjusted life years (DALYs) of women aged 15–49 years from the GBD 2021 database across 204 countries. Temporal trends were analyzed using Joinpoint regression and the estimated annual percentage change (EAPC). Socioeconomic disparities were evaluated using the SDI, and future projections were conducted using a BAPC model with sensitivity analysis. RESULTS: The global MHD mortality (AAPC: -2.16%; 95% CI: -2.1 to -2.21) and incidence (AAPC: -0.5%, 95% CI: -0.45% to -0.56%) rate has declined. Decomposition analysis revealed that population growth and epidemiological changes were the main drivers of the increasing incidence, while aging had a less pronounced effect. Health inequality analysis demonstrated a clear negative correlation between MHD burden and socioeconomic development, highlighting the disproportionate impact on disadvantaged populations. CONCLUSION: The global burden of MHD exhibits significant regional disparities, with an declined trend in incidence. To address this persistent challenge, targeted interventions focusing on strengthening healthcare systems, improving access to quality obstetric care, and addressing socioeconomic inequities are urgently needed.
Tears secreted from the lacrimal gland are essential for preserving the ocular surface. Thus, dysfunction of the lacrimal gland in Sjögren's syndrome (SS) can lead to dry eye, resulting in a reduced quality of life. We previously reported that blueberry 'leaf' water extract prevents lacrimal hyposecretion in male non-obese diabetic (NOD) mice in a SS-like model. In this study, we investigated the effect of blueberry 'stem' water extract (BStEx) on lacrimal hyposecretion in NOD mice. Male NOD mice were fed 1% BStEx or control (AIN-93G) for 2, 4, or 6 weeks from 4 weeks of age. Pilocarpine-induced tear secretion was measured using a phenol red-impregnated thread. The lacrimal glands were histologically evaluated by HE staining. Inflammatory cytokine levels in the lacrimal glands were measured using ELISA. Immunostaining was performed to examine aquaporin 5 (AQP5) localization. The expression levels of autophagy-related proteins, AQP5, and phosphorylated AMPK were measured using western blotting. After feeding BStEx to mice for 4 or 6 weeks, tear volume was observed to have increased in the BStEx group compared with that in the control group. There were no significant differences in inflammatory cell infiltration, autophagy-related protein expression, or the localization and expression of AQP5 in the lacrimal glands between the two groups. In contrast, AMPK phosphorylation increased in the BStEx group. BStEx prevented lacrimal hyposecretion in the SS-like model of male NOD mice, probably by opening tight junctions via the activation of AMPK in lacrimal acinar cells.