Lindsay N. Boyers

Global Burden of Skin Disease as Reflected in Cochrane Database of Systematic Reviews

IMPORTANCE Research prioritization should be guided by impact of disease. OBJECTIVE To determine whether systematic reviews and protocol topics in Cochrane Database of Systematic Reviews (CDSR) reflect disease burden, measured by disability-adjusted life years (DALYs) from the Global Burden of Disease (GBD) 2010 project. DESIGN, SETTING, AND PARTICIPANTS Two investigators independently assessed 15 skin conditions in the CDSR for systematic review and protocol representation from November 1, 2013, to December 6, 2013. The 15 skin diseases were matched to their respective DALYs from GBD 2010. An official publication report of all reviews and protocols published by the Cochrane Skin Group (CSG) was also obtained to ensure that no titles were missed. There were no study participants other than the researchers, who worked with databases evaluating CDSR and GBD 2010 skin condition disability data. MAIN OUTCOMES AND MEASURES Relationship of CDSR topic coverage (systematic reviews and protocols) with percentage of total 2010 DALYs, 2010 DALY rank, and DALY percentage change from 1990 to 2010 for 15 skin conditions. RESULTS All 15 skin conditions were represented by at least 1 systematic review in CDSR; 69% of systematic reviews and 67% of protocols by the CSG covered the 15 skin conditions. Comparing the number of reviews/protocols and disability, dermatitis, melanoma, nonmelanoma skin cancer, viral skin diseases, and fungal skin diseases were well matched. Decubitus ulcer, psoriasis, and leprosy demonstrated review/protocol overrepresentation when matched with corresponding DALYs. In comparison, acne vulgaris, bacterial skin diseases, urticaria, pruritus, scabies, cellulitis, and alopecia areata were underrepresented in CDSR when matched with corresponding DALYs. CONCLUSIONS AND RELEVANCE Degree of representation in CDSR is partly correlated with DALY metrics. The number of published reviews/protocols was well matched with disability metrics for 5 of the 15 studied skin diseases, while 3 skin diseases were overrepresented, and 7 were underrepresented. Our results provide high-quality and transparent data to inform future prioritization decisions.

The global burden of psoriatic skin disease

DEAR EDITOR, Psoriasis is a common chronic inflammatory disorder of the skin frequently characterized by relapsing thick scaling plaques, with or without nail and joint involvement. While not life-threatening, psoriasis may cause substantial disability subsequent to both physical discomfort (e.g. pruritus, arthralgias, etc.) and psychosocial harm. Although prior research has evaluated the prevalence of psoriasis in various regions and countries, adequate understanding of geographical variation in psoriasis epidemiology has been hindered by variability in study design, outcome measures, population sampling techniques and, importantly, lack of emphasis on psoriasis-associated disease burden. However, a recent enterprise has attempted to provide new insights into global disease burden resulting from psoriasis and other dermatological disorders. The Global Burden of Disease Study (GBD) 2010 is a comprehensive database of worldwide epidemiological information regarding diseasespecific burden stratified by age, sex, geography and time. GBD 2010 provides disability estimates for 291 diseases and injuries, along with 67 risk factors, from 1990 to 2010. Given this novel resource, we sought to evaluate temporal trends and geographical variation in psoriasis-associated disease burden in order to narrow an important knowledge gap concerning the consequences of this disorder across time, diverse world regions and sociodemographic populations. We used GBD 2010 to conduct a cross-sectional study of geographical regions with prevalent psoriasis (Table S1; see Supporting Information). A detailed description of GBD 2010 development, design and implementation has been described previously. The primary outcome was regional burden of disease associated with psoriasis, as measured by disabilityadjusted life years (DALYs). This metric combines years lost to disability (a morbidity component) with years of life lost (a mortality component), such that one DALY is equivalent to 1 year of healthy life lost. The DALY metric includes a constant value disability weight, which ranges from 0 to 1 and is derived from an analysis of the comparative impact of itch and disfigurement against other conditions by international volunteer panels. The disability weight for psoriasis was 0 054. The following metrics were obtained for psoriasis in 21 geographical regions (Table S1; see Supporting Information): age-adjusted DALY rates per 100 000 persons and associated 95% confidence intervals (CIs), median percentage change in psoriasis-associated DALY rates from 1990 to 2010 and percentage of total global DALYs (across all conditions and regions). These data are available for public access at GBD websites. Geographical differences in psoriasis-associated DALY rates were compared using standard Z-scores. The equality of psoriasis disease burden distribution across geographical regions was evaluated using the Lorenz curve and associated Gini coefficient (range 0–1, where values closer to 1 indicate greater inequality in disease burden distribution). All analyses were performed using Excel 2013 (Microsoft, Redmond, WA, U.S.A.) and Stata SE 13.1 (StataCorp, College Station, TX, U.S.A.), and all statistical tests were two-tailed with a = 0 05.

Global mortality from conditions with skin manifestations

BACKGROUND Global Burden of Disease Study is a research database containing systematically compiled information from vital statistics and epidemiologic literature to inform research, public policy, and resource allocation. OBJECTIVE We sought to compare mortality among conditions with skin manifestations in 50 developed and 137 developing countries from 1990 to 2010. METHODS This was a cross-sectional study to calculate mean age-standardized mortality (per 100,000 persons) across countries for 10 disease categories with skin manifestations. We compared differences in mortality from these disorders by time period (year 1990 vs year 2010) and by developing versus developed country status. RESULTS Melanoma death rates were 5.6 and 4.7 times greater in developed compared with developing countries in 1990 and 2010, respectively. Measles death rates in 1990 and 2010 were 345 and 197 times greater in developing countries, and corresponding syphilis death rates were 33 and 45 times greater. LIMITATIONS Inability to adjust for patient-, provider-, and geographic-level confounders may limit the accuracy and generalizability of these results. CONCLUSION The mortality burden from skin-related conditions differs between developing and developed countries, with the greatest differences observed for melanoma, measles, and syphilis. These results may help prioritize and optimize efforts to prevent and treat these disorders.

Comparing cutaneous research funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases with 2010 Global Burden of Disease results.

Importance Disease burden data helps guide research prioritization. Objective To determine the extent to which grants issued by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) reflect disease burden, measured by disability-adjusted life years (DALYs) from Global Burden of Disease (GBD) 2010 project. Design Two investigators independently assessed 15 skin conditions studied by GBD 2010 in the NIAMS database for grants issued in 2013. The 15 skin diseases were matched to their respective DALYs from GBD 2010. Setting The United States NIAMS database and GBD 2010 skin condition disability data. Main Outcome(s) and Measure(s) Relationship of NIAMS grant database topic funding with percent total GBD 2010 DALY and DALY rank for 15 skin conditions. Results During fiscal year 2013, 1,443 NIAMS grants were issued at a total value of

Global Burden of Eye and Vision Disease as Reflected in the Cochrane Database of Systematic Reviews

424 million. Of these grants, 17.7% covered skin topics. Of the total skin disease funding, 82% (91 grants) were categorized as “general cutaneous research.” Psoriasis, leprosy, and “other skin and subcutaneous diseases” (ie; immunobullous disorders, vitiligo, and hidradenitis suppurativa) were over-represented when funding was compared with disability. Conversely, cellulitis, decubitus ulcer, urticaria, acne vulgaris, viral skin diseases, fungal skin diseases, scabies, and melanoma were under-represented. Conditions for which disability and funding appeared well-matched were dermatitis, squamous and basal cell carcinoma, pruritus, bacterial skin diseases, and alopecia areata. Conclusions and Relevance Degree of representation in NIAMS is partly correlated with DALY metrics. Grant funding was well-matched with disability metrics for five of the 15 studied skin diseases, while two skin diseases were over-represented and seven were under-represented. Global burden estimates provide increasingly transparent and important information for investigating and prioritizing national research funding allocations.

Alignment of systematic reviews published in the Cochrane Database of Systematic Reviews and the Database of Abstracts and Reviews of Effectiveness with global burden-of-disease data: a bibliographic analysis

IMPORTANCE Eye and vision disease burden should help guide ophthalmologic research prioritization. The Global Burden of Disease (GBD) Study 2010 compiled data from 1990 to 2010 on 291 diseases and injuries, 1160 disease and injury sequelae, and 67 risk factors in 187 countries. The Cochrane Database of Systematic Reviews (CDSR) is a resource for systematic reviews in health care, with peer-reviewed systematic reviews that are published by Cochrane Review Groups. OBJECTIVE To determine whether systematic review and protocol topics in the CDSR reflect disease burden, measured by disability-adjusted life-years (DALYs), from the GBD 2010 project. This is one of a series of projects mapping GBD 2010 medical field disease burdens to corresponding systematic reviews in the CDSR. DESIGN AND SETTING Two investigators independently assessed 8 ophthalmologic conditions in the CDSR for systematic review and protocol representation according to subject content. The 8 diseases were matched to their respective DALYs from the GBD 2010 project. MAIN OUTCOMES AND MEASURES Cochrane Database of Systematic Reviews systematic review and protocol representation and percentage of total 2010 DALYs. RESULTS All 8 ophthalmologic conditions were represented by at least 1 systematic review in the CDSR. A total of 91.4% of systematic reviews and protocols focused on these conditions were from the Cochrane Eyes and Vision Group. Comparing the number of reviews and protocols with disability, only cataract was well matched; glaucoma, macular degeneration, and other vision loss were overrepresented. In comparison, trachoma, onchocerciasis, vitamin A deficiency, and refraction and accommodation disorders were underrepresented. CONCLUSIONS AND RELEVANCE These results prompt further investigation into why certain diseases are overrepresented or underrepresented in the CDSR relative to their DALY. With regard to ophthalmologic conditions, this study encourages that certain conditions get more focus to create a better representation of what is causing the most disability and mortality within this research database. These results provide high-quality and transparent data to inform future prioritization decisions.

The global burden of disease associated with alopecia areata

Background Systematic reviews of high-quality evidence are used to inform policy and practice. To improve community health, the production of such reviews should align with burden of disease. This study aims to assess if the volume of research output from systematic reviews proportionally aligns with burden of disease assessed using percentages of mortality and disability-adjusted life years (DALYs). Methods A cross-sectional audit of reviews published between January 2012 and August 2013 in the Cochrane Database of Systematic Reviews (CDSR) and Database of Abstracts of Reviews of Effects (DARE) was undertaken. Percentages of mortality and DALYs were obtained from the 2010 Global Burden of Disease study. Standardised residual differences (SRD) based on percentages of mortality and DALYs were calculated, where conditions with SRD of more than or less than three were considered overstudied or understudied, respectively. Results 1029 reviews from CDSR and 1928 reviews from DARE were examined. There was a significant correlation between percentage DALYs and systematic reviews published in CDSR and DARE databases (CDSR: r=0.68, p=0.001; DARE: r=0.60, p<0.001). There was no significant correlation between percentage mortality and number of systematic reviews published in either database (CDSR: r=0.34, p=0.14; DARE: r=0.22, p=0.34). Relative to percentage of mortality, mental and behavioural disorders, musculoskeletal conditions and other non-communicable diseases were overstudied. Maternal disorders were overstudied relative to percentages of mortality and DALYs in CDSR. Conclusions The focus of systematic reviews is moderately correlated with DALYs. A number of conditions may be overstudied relative to percentage of mortality particularly in the context of health and medical reviews.

The Surgeon General Should Say That Indoor Ultraviolet Radiation Tanning Causes Skin Cancer

DEAR EDITOR, Alopecia areata is characterized by episodes of nonscarring hair loss that vary in duration (from self-resolving to permanent) and distribution (focal to total body). These episodes may result in substantial psychological morbidity and negatively influence quality of life. Data regarding the epidemiology and global burden of disease due to alopecia areata are scarce. However, the Global Burden of Disease (GBD) Study has recently described the disability burden of skin disease worldwide. The GBD Study is an internationally comprehensive, epidemiological database comprised of information regarding the morbidity and mortality of diseases, injuries and associated risk factors stratified by age, sex, geography and time. Administered by the Institute for Health Metrics and Evaluation and funded by the Bill and Melinda Gates Foundation, the GBD Study provides access to transparent and disease-specific data to inform health-related research and public policy. The GBD Study 2010 estimated the disability of 291 diseases within 21 global regions and 187 countries from 1990 to 2010 (Table S1; see Supporting Information). Burden of disease is measured by disability-adjusted life year (DALYs), which combines a morbidity component – years lost to disability – with a mortality component – years of life lost – such that 1 DALY is equivalent to 1 year of healthy life lost. The DALY is a metric that allows for comparison of disease burden arising from both fatal and nonfatal conditions. Alopecia areata is among the diseases evaluated by GBD 2010. Given this unique, novel resource for understanding the global impact of this disorder, we used this database to conduct an exploratory cross-sectional study to identify the geographical regions with the greatest and least disease burden caused by alopecia areata. The methods used by GBD 2010 to generate DALY estimates have been published previously. In order to convert prevalence data to DALY estimates, alopecia areata (like all conditions studied by GBD) was assigned a disability weight. Disability weights range from 0 to 1 and are derived from an analysis of the comparative impact of itch and disfigurement against other conditions by international volunteer panels. The assigned disability weight for alopecia areata is 0 035. Age-standardized DALY rates (per 100 000 persons), percentage of total DALY, and median percentage change from 1990 to 2010 were obtained for alopecia areata in 21 geographical regions evaluated by GBD 2010. These data are available for public access at the GBD Compare and Arrow Diagram websites. Assuming that the regional differences in age-adjusted DALY rates associated with alopecia areata were normally distributed, we compared these rates across geographical regions using standard z-scores. All statistical tests were two tailed, and z-scores > 1 645 (critical value) were considered significant (Tables S2, S3; see Supporting Information). Globally, the mean age-adjusted DALY rate attributed to alopecia areata was 19 4, which remained essentially unchanged

Impact of Ultraviolet Photography on Sun Safety Practices of Snow Sport Industry Conference Attendees

Introduction The Surgeon General’s 1964 report states that smoking is causally related to lung cancer, an association that has been solidified and widely accepted by healthcare practitioners, policymakers, and the general public. In July 2014, the Acting Surgeon General, Dr. Lushniak, delivered “The Surgeon General’s Call to Action to Prevent Skin Cancer.” This important report calls upon members at all levels of government, health care, and the community to accomplish strategic goals for skin cancer prevention, including the promotion of sun protection and education; policy change; and increased research, surveillance, monitoring, and evaluation. However, the Call to Action lacks a simple causative statement that indoor ultraviolet radiation (UV) tanning causes skin cancer, analogous to smoking causing lung cancer. Additionally, during a stakeholder phone call discussing the Call to Action (July 29, 2014), Claudia Delude of the Jeff Dulude Melanoma Foundation asked the Acting Surgeon General, “Are you saying in this call to action that indoor UV tanning causes skin cancer?” The Surgeon General responded, “...We are saying that indoor UV tanning is strongly associated with increased skin cancer risk...” Skin cancer is the most common malignancy affecting the human population. Although basal and squamous cell carcinomas are readily detected and rarely metastasize, a diagnosis of melanoma carries substantial morbidity and mortality. Approximately 76,100 new cases of

Identifying gaps in research prioritization: The global burden of neglected tropical diseases as reflected in the Cochrane database of systematic reviews.

Studies have established ultraviolet (UV) exposure with increased melanoma skin cancer risk. The combination of UV exposure, high altitude, and reflection of UV rays on the snow may create a particularly relevant and high-risk population amongst those who participate in snow sports. The current study aims to determine the effectiveness of a UV-photography and personalized counseling-based intervention to improve sun protection awareness on the snow sport enthusiast population. Participants were recruited at the 2013 SnowSports Industries American (SIA) Snow Show in Denver to complete a 14 question pre-survey assessing sun-safety awareness followed by a Faraghan Medical Elise Digital UV Camera photograph of their face and counseling regarding individual results. Participants were contacted one to two months later by telephone to complete a ten question post-survey. Forty-one percent of participants (46/112) completed both pre- and post-surveys. The UV photography based intervention influenced the opinions and behaviors of sun protection in 78% of male and 62% of female participants with sunscreen use identified as the most frequently modified behavior (53%). While valid barriers to UV photography use include a current lack of reimbursement and lack of public knowledge of its utility, our study indicates the potential impact of UV photography-based interventions among high-risk populations who avidly participate in snow sports.