Tomi Akinyemiju

Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015

Importance Elevated systolic blood (SBP) pressure is a leading global health risk. Quantifying the levels of SBP is important to guide prevention policies and interventions. Objective To estimate the association between SBP of at least 110 to 115 mm Hg and SBP of 140 mm Hg or higher and the burden of different causes of death and disability by age and sex for 195 countries and territories, 1990-2015. Design A comparative risk assessment of health loss related to SBP. Estimated distribution of SBP was based on 844 studies from 154 countries (published 1980-2015) of 8.69 million participants. Spatiotemporal Gaussian process regression was used to generate estimates of mean SBP and adjusted variance for each age, sex, country, and year. Diseases with sufficient evidence for a causal relationship with high SBP (eg, ischemic heart disease, ischemic stroke, and hemorrhagic stroke) were included in the primary analysis. Main Outcomes and Measures Mean SBP level, cause-specific deaths, and health burden related to SBP (≥110-115 mm Hg and also ≥140 mm Hg) by age, sex, country, and year. Results Between 1990-2015, the rate of SBP of at least 110 to 115 mm Hg increased from 73 119 (95% uncertainty interval [UI], 67 949-78 241) to 81 373 (95% UI, 76 814-85 770) per 100 000, and SBP of 140 mm Hg or higher increased from 17 307 (95% UI, 17 117-17 492) to 20 526 (95% UI, 20 283-20 746) per 100 000. The estimated annual death rate per 100 000 associated with SBP of at least 110 to 115 mm Hg increased from 135.6 (95% UI, 122.4-148.1) to 145.2 (95% UI 130.3-159.9) and the rate for SBP of 140 mm Hg or higher increased from 97.9 (95% UI, 87.5-108.1) to 106.3 (95% UI, 94.6-118.1). Loss of disability-adjusted life-years (DALYs) associated with SBP of at least 110 to 115 mm Hg increased from 148 million (95% UI, 134-162 million) to 211 million (95% UI, 193-231 million), and for SBP of 140 mm Hg or higher, the loss increased from 5.2 million (95% UI, 4.6-5.7 million) to 7.8 million (95% UI, 7.0-8.7 million). The largest numbers of SBP-related deaths were caused by ischemic heart disease (4.9 million [95% UI, 4.0-5.7 million]; 54.5%), hemorrhagic stroke (2.0 million [95% UI, 1.6-2.3 million]; 58.3%), and ischemic stroke (1.5 million [95% UI, 1.2-1.8 million]; 50.0%). In 2015, China, India, Russia, Indonesia, and the United States accounted for more than half of the global DALYs related to SBP of at least 110 to 115 mm Hg. Conclusions and Relevance In international surveys, although there is uncertainty in some estimates, the rate of elevated SBP (≥110-115 and ≥140 mm Hg) increased substantially between 1990 and 2015, and DALYs and deaths associated with elevated SBP also increased. Projections based on this sample suggest that in 2015, an estimated 3.5 billion adults had SBP of at least 110 to 115 mm Hg and 874 million adults had SBP of 140 mm Hg or higher.

The Burden of Primary Liver Cancer and Underlying Etiologies From 1990 to 2015 at the Global, Regional, and National Level: Results From the Global Burden of Disease Study 2015

Importance Liver cancer is among the leading causes of cancer deaths globally. The most common causes for liver cancer include hepatitis B virus (HBV) and hepatitis C virus (HCV) infection and alcohol use. Objective To report results of the Global Burden of Disease (GBD) 2015 study on primary liver cancer incidence, mortality, and disability-adjusted life-years (DALYs) for 195 countries or territories from 1990 to 2015, and present global, regional, and national estimates on the burden of liver cancer attributable to HBV, HCV, alcohol, and an “other” group that encompasses residual causes. Design, Settings, and Participants Mortality was estimated using vital registration and cancer registry data in an ensemble modeling approach. Single-cause mortality estimates were adjusted for all-cause mortality. Incidence was derived from mortality estimates and the mortality-to-incidence ratio. Through a systematic literature review, data on the proportions of liver cancer due to HBV, HCV, alcohol, and other causes were identified. Years of life lost were calculated by multiplying each death by a standard life expectancy. Prevalence was estimated using mortality-to-incidence ratio as surrogate for survival. Total prevalence was divided into 4 sequelae that were multiplied by disability weights to derive years lived with disability (YLDs). DALYs were the sum of years of life lost and YLDs. Main Outcomes and Measures Liver cancer mortality, incidence, YLDs, years of life lost, DALYs by etiology, age, sex, country, and year. Results There were 854 000 incident cases of liver cancer and 810 000 deaths globally in 2015, contributing to 20 578 000 DALYs. Cases of incident liver cancer increased by 75% between 1990 and 2015, of which 47% can be explained by changing population age structures, 35% by population growth, and −8% to changing age-specific incidence rates. The male-to-female ratio for age-standardized liver cancer mortality was 2.8. Globally, HBV accounted for 265 000 liver cancer deaths (33%), alcohol for 245 000 (30%), HCV for 167 000 (21%), and other causes for 133 000 (16%) deaths, with substantial variation between countries in the underlying etiologies. Conclusions and Relevance Liver cancer is among the leading causes of cancer deaths in many countries. Causes of liver cancer differ widely among populations. Our results show that most cases of liver cancer can be prevented through vaccination, antiviral treatment, safe blood transfusion and injection practices, as well as interventions to reduce excessive alcohol use. In line with the Sustainable Development Goals, the identification and elimination of risk factors for liver cancer will be required to achieve a sustained reduction in liver cancer burden. The GBD study can be used to guide these prevention efforts.

Race/ethnicity and socio-economic differences in breast cancer surgery outcomes

BACKGROUND The purpose of this study is to evaluate racial and socio-economic differences in breast cancer surgery treatment, post-surgical complications, hospital length of stay and mortality among hospitalized breast cancer patients. METHODS We examined the association between race/ethnicity and socio-economic status with treatment and outcomes after surgery among 71,156 women hospitalized with a primary diagnosis of breast cancer using the Nationwide Inpatient Sample database from 2007 to 2011. Multivariable regression models were used to compute estimates, odds ratios and 95% confidence intervals adjusting for age, comorbidities, stage at diagnosis, insurance, and residential region. RESULTS Black women were more likely to receive breast conserving surgery but less likely to receive mastectomies compared with white women. They also experienced significantly longer hospital stays (β=0.31, 95% CI: 0.24, 0.39), post-surgical complications (OR=1.21, 95% CI: 1.04-1.42) and in-hospital mortality (OR=1.26, 95% CI: 1.07-1.50) compared with Whites, after adjusting for other factors including the number of comorbidities and treatment type. CONCLUSION Among patients hospitalized for breast cancer, there were racial differences observed in treatment and outcomes. Further studies are needed to fully characterize whether these differences are due to individual, provider level or hospital level factors, and to highlight areas for targeted approaches to eliminate these disparities.

Depression and Anxiety Disorders among Hospitalized Women with Breast Cancer.

Purpose To document the prevalence of depression and anxiety disorders, and their associations with mortality among hospitalized breast cancer patients. Methods We examined the associations between breast cancer diagnosis and the diagnoses of anxiety or depression among 4,164 hospitalized breast cancer cases matched with 4,164 non-breast cancer controls using 2006-2009 inpatient data obtained from the Nationwide Inpatient Sample database. Conditional logistic regression models were used to compute odds ratios (ORs) and 95% confidence intervals (CI) for the associations between breast cancer diagnosis and diagnoses of anxiety or depression. We also used binary logistic regression models to examine the association between diagnoses of depression or anxiety, and in-hospital mortality among breast cancer patients. Results We observed that breast cancer cases were less likely to have a diagnosis of depression (OR=0.63, 95% CI: 0.52-0.77), and less likely to have a diagnosis of anxiety (OR=0.68, 95% CI: 0.52-0.90) compared with controls. This association remained after controlling for race/ethnicity, residential income, insurance and residential region. Breast cancer patients with a depression diagnosis also had lower mortality (OR=0.69, 95% CI: 0.52-0.89) compared with those without a depression diagnosis, but there was no significant difference in mortality among those with and without anxiety diagnoses. Conclusion Diagnoses of depression and anxiety in breast cancer patients were less prevalent than expected based on our analysis of hospitalized breast cancer patients and matched non-breast cancer controls identified in the NIS dataset using ICD-9 diagnostic codes. Results suggest that under-diagnosis of mental health problems may be common among hospitalized women with a primary diagnosis of breast cancer. Future work may fruitfully explore reasons for, and consequences of, inappropriate identification of the mental health needs of breast cancer patients.

Pathway-Structured Predictive Model for Cancer Survival Prediction: A Two-Stage Approach

Heterogeneity in terms of tumor characteristics, prognosis, and survival among cancer patients has been a persistent problem for many decades. Currently, prognosis and outcome predictions are made based on clinical factors and/or by incorporating molecular profiling data. However, inaccurate prognosis and prediction may result by using only clinical or molecular information directly. One of the main shortcomings of past studies is the failure to incorporate prior biological information into the predictive model, given strong evidence of the pathway-based genetic nature of cancer, i.e., the potential for oncogenes to be grouped into pathways based on biological functions such as cell survival, proliferation, and metastatic dissemination. To address this problem, we propose a two-stage approach to incorporate pathway information into the prognostic modeling using large-scale gene expression data. In the first stage, we fit all predictors within each pathway using the penalized Cox model and Bayesian hierarchical Cox model. In the second stage, we combine the cross-validated prognostic scores of all pathways obtained in the first stage as new predictors to build an integrated prognostic model for prediction. We apply the proposed method to analyze two independent breast and ovarian cancer datasets from The Cancer Genome Atlas (TCGA), predicting overall survival using large-scale gene expression profiling data. The results from both datasets show that the proposed approach not only improves survival prediction compared with the alternative analyses that ignore the pathway information, but also identifies significant biological pathways.

Racial and socio-economic disparities in breast cancer hospitalization outcomes by insurance status.

BACKGROUND Breast cancer remains a major cause of morbidity and mortality among women in the US, and despite numerous studies documenting racial disparities in outcomes, the survival difference between Black and White women diagnosed with breast cancer continues to widen. Few studies have assessed whether observed racial disparities in outcomes vary by insurance type e.g. Medicare/Medicaid versus private insurance. Differences in coverage, availability of networked physicians, or cost-sharing policies may influence choice of treatment and treatment outcomes, even after patients have been hospitalized, effects of which may be differential by race. PURPOSE The aim of this analysis was to examine hospitalization outcomes among patients with a primary diagnosis of breast cancer and assess whether differences in outcome exist by insurance status after adjusting for age, race/ethnicity and socio-economic status. METHODS We obtained data on over 67,000 breast cancer patients with a primary diagnosis of breast cancer for this cross-sectional study from the 2007-2011 Healthcare Cost and Utilization project Nationwide Inpatient Sample (HCUP-NIS), and examined breast cancer surgery type (mastectomy vs. breast conserving surgery or BCS), post-surgical complications and in-hospital mortality. Multivariable regression models were used to compute estimates, odds ratios and 95% confidence intervals. RESULTS Black patients were less likely to receive mastectomies compared with White women (OR: 0.80, 95% CI: 0.71-0.90), regardless of whether they had Medicare/Medicaid or Private insurance. Black patients were also more likely to experience post-surgical complications (OR: 1.41, 95% CI: 1.12-1.78) and higher in-hospital mortality (OR: 1.57, 95%: 1.21-2.03) compared with White patients, associations that were strongest among women with Private insurance. Women residing outside of large metropolitan areas were significantly more likely to receive mastectomies (OR: 1.89, 95% CI: 1.54-2.31) and experience higher in-hospital mortality (OR: 1.74, 95% CI: 1.40-2.16) compared with those in metropolitan areas, regardless of insurance type. CONCLUSION Among hospitalized patients with breast cancer, racial differences in hospitalization outcomes existed and worse outcomes were observed among Black women with private insurance. Future studies are needed to determine factors associated with poor outcomes in this group of women, as well as to examine contributors to low BCS adoption in non-metropolitan areas.

Meta‐analysis of the association between dietary inflammatory index (DII) and cancer outcomes

Proinflammatory dietary patterns have been associated with increased cancer risk and mortality. We present a systematic review and meta‐analysis of the current published literature on a dietary inflammatory index (DII) score and its association with cancer risk and mortality outcomes. Published articles from online databases (PubMed, Scopus, and Embase) examining the association between DII and any cancer risk, incidence, or mortality between 1980 and November 2016 were selected for review. Results of studies meeting inclusion criteria were summarized and meta‐analyzed using STATA to generate summary measures of association across studies. Sixty‐three published articles were identified from the search, and following title, abstract and full‐text review, twenty‐four studies met inclusion criteria. All articles calculated DII scores based on study‐specific food‐frequency questionnaires using methodology from the same article. Of the 24 included studies, 13 were case–control, 6 were prospective cohort, 1 was a retrospective cohort, 3 were RCTs, and 1 did not specify study design. The most common cancers examined were colorectal, breast, lung, and prostate. Individuals in the highest versus lowest DII categories had 25% increased risk of overall cancer incidence (RR: 1.25, 95% CI: 1.16–1.35), 75% higher odds of cancer (OR: 1.75, 95% CI: 1.43–2.16) and 67% increased risk of cancer mortality (RR: 1.67, 95% CI: 1.13–2.48). Upon stratification for cancer type, positive associations remained (RRbreast: RR: 1.12, 95% CI: 1.03–1.22) (RRcolorectal: 1.33, 95% CI: 1.22–1.46) (RRlung: 1.30, 95% CI: 1.13–1.50). There were consistent and significant positive associations between higher DII and cancer incidence and mortality across cancer types, study populations, and study design.

Disparities in the prevalence of comorbidities among US adults by state Medicaid expansion status.

INTRODUCTION About 92% of US older adults have at least one chronic disease or medical condition and 77% have at least two. Low-income and uninsured adults in particular experience a higher burden of comorbidities, and the Medicaid expansion provision of the Affordable Care Act was designed to improve access to healthcare in this population group. However, a significant number of US states have declined expansion. The purpose of this study is to determine the distribution of low-income and uninsured adults in expanded versus non-expanded states, and evaluate the prevalence of comorbidities in both groups. METHODS Data from the 2013 Behavioral Risk Factor Surveillance System (BRFSS) dataset was analyzed, and Medicaid expansion status was assessed from the Center for Medicare and Medicaid Services report on State Medicaid and CHIP Income Eligibility Standards. Next, age adjusted mean number of comorbidities between expanded and non-expanded states was compared, with adjustment for socio-demographic differences. RESULTS Expanded states had a higher proportion of adults with income of at least

Association between body mass index and in-hospital outcomes: Analysis of the nationwide inpatient database.

50,000 per year (39.6% vs. 35.5%, p<0.01) and a lower proportion of individuals with no health insurance coverage (15.2% vs. 20.3%, p<0.01) compared with non-expanded states. Among the uninsured, there was a higher proportion of obese (31.6% vs. 26.9%, p<001), and higher average number of comorbidities (1.62 vs. 1.52, p<0.01) in non-expanded states compared to expanded states. Overall, the prevalence of comorbidities was higher among BRFSS participants in states that did not expand Medicaid compared with those in expanded states. CONCLUSION States without Medicaid expansion have a greater proportion of poor, uninsured adults with more chronic diseases and conditions.

Trends in smoking and obesity among US adults before, during, and after the great recession and Affordable Care Act roll-out

Importance: Over one-third of American adults (36%) are obese and more than two-thirds (69%) are overweight. The impact of obesity on hospitalization outcomes is not well understood. Objective: To examine the association between body mass index (BMI) and overall, cancer, chronic obstructive pulmonary disease (COPD), asthma, and cardiovascular disease (CVD)-specific in-hospital mortality; postsurgical complications; and hospital length of stay (LOS). Design: Cross-sectional study. Setting: Representative sample of US hospitals included in the Health Cost and Utilization Project Nationwide Inpatient Sample database. Participants: We obtained data for patients admitted with a primary diagnosis of cancer, COPD, asthma, and CVD. Main Outcome: In-hospital mortality, postsurgical complications, and hospital LOS. Results: A total of 800,417 patients were included in this analysis. A higher proportion of Blacks (26.8%; 12.5%) and Whites (23.3%; 8.7%) had BMI of 40 to 49.9 and ≥50, respectively, compared with Hispanics (20.4%; 7.3%). Compared with normal BMI patients, the odds of in-hospital mortality increased 3.6-fold (odds ratio [OR] 3.62, 95% confidence interval [CI]: 3.37–3.89) for preobese patients, 6.5-fold (OR: 6.52, 95% CI: 5.79–7.34) for patients with BMI: 30 to 31.9, 7.5-fold (OR: 7.57, 95% CI: 6.67–8.59) for patients with BMI: 34 to 35.9, and 1.6- fold (OR: 1.77, 95% CI: 1.56–1.79) for patients with BMI ≥ 50. Compared with normal BMI patients, preobese and overweight patients had shorter hospital stays (&bgr; preobese: −1.58, 95% CI: −1.63, −1.52); however, no clear trends were observed for postsurgical complications. Conclusions: The majority of hospitalized patients in this analysis had a BMI > 30, and higher BMI was associated with increased risk of mortality and longer hospital stay.