НАУЧНО-ПРАКТИЧЕСКИЕ И ОБРАЗОВАТЕЛЬНЫЕ АСПЕКТЫ КЛИНИЧЕСКОЙ ЭПИДЕМИОЛОГИИ

This article defines clinical epidemiology and describes its goal and objectives. The author claims that clinical epidemiology is a section of epidemiology which underlies the development of evidence-based standards for diagnostics, treatment and prevention and helps to select the appropriate algorithm for each clinical case. The study provides a comprehensive overview of the relationship between clinical epidemiology and evidence-based medicine. Epidemiological research is shown to be methodological basis of clinical epidemiology and evidence-based medicine with randomized controlled trials being the “gold standard” for obtaining reliable data. The key stages in the history of clinical epidemiology are discussed and further development of clinical epidemiology and the integration of courses on clinical epidemiology in education is outlined for progress in medical research and health care practice. Даны определение, цель и задачи клинической эпидемиологии. Показано, что клиническая эпидемиология является разделом эпидемиологии, который позволяет разрабатывать стандарты диагностики, лечения и профилактики, основанные на доказательствах, и подбирать соответствующий алгоритм действий для каждого конкретного клинического случая. Всесторонне рассмотрены взаимоотношения клинической эпидемиологии и доказательной медицины. Обосновано положение о том, что эпидемиологические исследования являются методической основой клинической эпидемиологии и доказательной медицины. «Золотым стандартом» получения доказательной информации являются рандомизированные контролируемые исследования. Представлены исторические этапы формирования клинической эпидемиологии. Показано, что развитие клинической эпидемиологии и расширение преподавания этого раздела будут способствовать прогрессу медицинской науки и практики здравоохранения.

Риск ― базовая концепция эпидемиологии

This article presents the analysis of current scientific understanding of the term «risk» along with theoretical justification of its use in epidemiological studies. Epidemiology commonly uses definitions such as «risk factor», «group of risk», «risk area», and «risk period». However, these definitions were useful only for specific groups or nosoligical infectious diseases. In Noninfectious Pathology the terms had been used exclusively in the applied studies. There is a lack of publications which compile theoretical basics of such fundamental term category. The authors suggest a definition of epidemiologic «risk» which can be used in the epidemiology of both infectious and noninfectious diseases. It is a probability of negative influence on illness (and/or its impact) of specific groups of general population which is defined by external and/or internal factors in specific times and territories. The authors differentiate types of risk and their evaluation measures into categories for used in applied studies of epidemiology. The relationships and the unity of the basic categories of the epidemiologic risk are discussed. The authors conclude that riskology is the main branch of epidemiology and the category of «risk» is the basic paradigm of this science.В медицинских исследованиях на популяционном уровне обобщений широко используются такие понятия, как «фактор риска», «группа риска», «территория риска» и «время риска». Тем не менее вплоть до настоящего времени эти категории находили свое применение и теоретическое обоснование в основном для отдельных групп или нозологических форм инфекционных заболеваний, а для неинфекционной патологии использовались лишь в прикладных исследованиях. Вместе с этим практически отсутствуют публикации обобщающего характера, касающиеся теоретических основ такой базисной эпидемиологической категории, как «риск». В представленном сообщении приведен анализ общенаучного понимания понятия «риск» и теоретическое обоснование использования этой категории в эпидемиологических исследованиях. В статье приведена систематизация различных видов риска и их оценочные характеристики для практического использования в эпидемиологических обобщениях, рассмотрены взаимосвязь и единство основных категорий эпидемиологического риска. В заключении авторами сделан обобщающий вывод о том, что учение о риске является ключевым, основополагающим направлением в эпидемиологии и становится основной парадигмой этой науки

ИНВАЗИВНАЯ СТРЕПТОКОККОВАЯ ИНФЕКЦИЯ (ГРУППЫ А) МЯГКИХ ТКАНЕЙ В ХИРУРГИЧЕСКОМ СТАЦИОНАРЕ Г. МОСКВЫ

Aim. To study features and risk factors  of soft tissue's invasive streptococcal infection in surgical unit's patients: a) emm-types of the most often recovered streptococcus; b) human immune response for streptococcal antigens (streptolysin-O and the group A carbohydrate antigen); c) main patient's conditions that complicate the course of soft tissue's streptococcal infection. Patients and methods. 101 surgical unit's patients with soft tissue's infection, which group A streptococcal (GAS) nature, were examined. Emm-types were determined by comparison of emm gene sequenced part with data of CDC Streptococcus Laboratory. ASO and specific anti-group-carbohydrate IgM were measured with photometry and ELISA accordingly.  Patient’s personal data were analyzed by standard statistical programs. Results. Among 34 emm-types of all streptococcal isolates emm28 and emm64 were registered only in invasive infection.  Emm-types 1, 49, 60, 66, 77, 84, 88 were most often. Among 23 sera from invasive GAS-infection's patients, 15 (65%) were ASO-negative, 6 (26%) were ASO-low-positive, and 2 (8%) were positive, but negative for the anti-group-A-carbohydrate IgM. Conclusion. Lower levels of the humoral immune response as well as risk factors such as trauma, alcoholism, diabetes, chronic venous insufficiency contributed to development of severe forms of GAS-infection. The main streptococcal emm-types for soft tissue's invasive GAS infection in one of Moscow surgical unit's patients in 2008-2011 were registered. Цель. Изучить особенности и факторы риска развития инвазивной стрептококковой инфекции мягких тканей у пациентов хирургического стационара, определив: а)emm-типы наиболее часто высеваемых стрептококков; б)уровень иммунного ответа макроорганизма  на антигены стрептококка (стрептолизин-О, полисахарид); в)состояния, осложняющие течение стрептококковой инфекции мягких тканей. Пациенты и методы. В исследование включали пациентов хирургического стационара (101чел.), у которых выделяли стрептококки группы А. Emm-типы стрептококков устанавливали сравнением секвенированной части гена emm с данными Международного банка данных emm-типов CDC. В сыворотках определяли антитела (IgM) к полисахариду (методом ИФА) и к стрептолизину-О (спектрофотометрически). Персональные данные о больных обработаны с помощью стандартных статистических программ. Результаты. Среди идентифицированных 34-х emm-типов стрептококков 28-ой и 64-ый встречались только при инвазивной инфекции.  Кроме того, наиболее часто определяли emm-типы 1, 49, 60, 66, 77, 84, 88. Из 23 сывороток больных инвазивной формой в 15-ти (65%) отмечали низкий уровень гуморального иммунного ответа на стрептолизин-О, в 6-ти (26%)  наблюдали незначительное превышение нормального уровня, в двух случаях (8%) показатели были высокие, но при низком уровне гуморального иммунного ответа  на полисахарид.  Заключение. К факторам риска отнесены травмы, алкоголизм, диабет, хроническая венозная недостаточность нижних конечностей и низкий уровень гуморального иммунного ответа на антигены стрептококка. Определен набор emm-типов стрептококка, вызывающих  развитие инвазивных форм стрептококковой (группы А) инфекции мягких тканей у пациентов хирургического стационара г.Москвы (2008-2011годы).

Клинико-эпидемиологические особенности проявлений папилломавирусной инфекции на примере рака шейки матки и аногенитальных (венерических) бородавок

Background: Cervical cancer and genital warts (GWs) are some of the most common manifestations of human papillomavirus infection (HPV). These lesions cause significant damage to the reproductive health of the population, which leads to increased attention to the prevention of HPV infection among various population groups. Aims: To determine the clinical and epidemiological features of the HPV manifestations by the example of cervical cancer and genital warts. Methods: A retrospective analysis of anamnestic information of 115 women with an established diagnosis of cervical cancer and 177 patients with an established diagnosis of GWs was performed. The clinical and epidemiological characteristics of patients with diagnoses of GWs and cervical cancer were based on the development of outpatient admission cards and inpatient histories, as well as test data for HPV. Results: HPV 16 was the most common HPV type among patients with GWs and cervical cancer ― it was detected in 37.6% of cases. Also the most frequently encountered: HPV 6/18/11/31/51/52. In 43.2% cases of HPV detection, two or more types were detected at once, the most common combinations: HPV16 and HPV18, HPV6 and HPV16, HPV6 and HPV11. Analysis of the frequency of screening for cervical cancer and visits to the gynecologist for 5 years before establishing the diagnosis showed that among those who did not screen for cervical cancer, the risk of diagnosing stage IIIV was 5.2 times higher than among individuals who underwent cervical screening 2 years ago, or once a year for the last five years. Among patients with GWs who had 2 or more sexual partners for 1 year, 13.5% of patients regularly used barrier contraception methods (condoms) during sexual contact, not regularly ― 61.5%, did not use them at all ― 25.0%. Conclusions: Identifying the clinical and epidemiological features of HPV infection should contribute to the development of new and optimize existing prevention programs for a wide range of HPV-associated diseases.Обоснование. Рак шейки матки (РШМ) и аногенитальные (венерические) бородавки являются наиболее распространенными проявлениями папилломавирусной инфекции. Данные поражения наносят существенный ущерб репродуктивному здоровью населения, что обусловливает повышенное внимание к вопросам профилактики папилломавирусной инфекции среди различных групп населения. Цель исследования ― определение отдельных клинико-эпидемиологических особенностей папилломавирусной инфекции на примере рака шейки матки и аногенитальных (венерических) бородавок. Методы. Выполнено ретроспективное исследование; объектом исследования были пациенты с диагнозами РШМ и аногенитальных (венерических) бородавок, обратившиеся за медицинской помощью в период с 2015 по 2018 г. Данные получены с помощью сбора информации из медицинских карт стационарного больного (форма 003/у) и медицинских карт пациента, получающего медицинскую помощь в амбулаторных условиях (форма 025/у). Методы анализа и обработки материала ― аналитический и статистический. Результаты. В рамках исследования были проанализированы 292 карты пациентов, обратившихся за медицинской помощью. Наиболее часто ― в 37,6% случаев ― у пациентов с аногенитальными бородавками и РШМ при лабораторном обследовании выявлялся вирус папилломы человека (ВПЧ) 16-го типа. Также часто встречались ВПЧ 6/18/11/31/51/52. В 43,2% случаев определялись одновременно два и более типов ВПЧ, при этом наиболее частыми сочетаниями были ВПЧ16 и ВПЧ18, ВПЧ6 и ВПЧ16, ВПЧ6 и ВПЧ11. Проведенный анализ частоты скрининга на РШМ и посещения врача-гинеколога в течение 5 лет до установления диагноза показал, что среди лиц, не проходивших скрининг на РШМ, или прошедших его при обнаружении заболевания, риск выявления диагноза на IIIV стадии был в 5,2 раза выше, чем среди лиц, которые проходили цервикальный скрининг 2 года назад или 1 раз в год в течение последних 5 лет. Среди всех пациентов с аногенитальными бородавками, имевших по два и более половых партнера в течение 1 года, о регулярном использовании методов барьерной контрацепции (презервативов) при половом контакте сообщили 13,5%, о нерегулярном использовании ― 61,5%; 25,0% пациентов вообще не задумывались о методах предохранения. Заключение. Выявление клинико-эпидемиологических особенностей папилломавирусной инфекции должно способствовать разработке новых и оптимизации существующих профилактических программ в отношении широкого спектра ВПЧ-ассоциированных заболеваний

The global, regional, and national burden of pancreatic cancer and its attributable risk factors in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

Background: Worldwide, both the incidence and death rates of pancreatic cancer are increasing. Evaluation of pancreatic cancer burden and its global, regional, and national patterns is crucial to policy making and better resource allocation for controlling pancreatic cancer risk factors, developing early detection methods, and providing faster and more effective treatments. Methods: Vital registration, vital registration sample, and cancer registry data were used to generate mortality, incidence, and disability-adjusted life-years (DALYs) estimates. We used the comparative risk assessment framework to estimate the proportion of deaths attributable to risk factors for pancreatic cancer: smoking, high fasting plasma glucose, and high body-mass index. All of the estimates were reported as counts and age-standardised rates per 100 000 person-years. 95% uncertainty intervals (UIs) were reported for all estimates. Findings: In 2017, there were 448 000 (95% UI 439 000\u2013456 000) incident cases of pancreatic cancer globally, of which 232 000 (210 000\u2013221 000; 51\ub79%) were in males. The age-standardised incidence rate was 5\ub70 (4\ub79\u20135\ub71) per 100 000 person-years in 1990 and increased to 5\ub77 (5\ub76\u20135\ub78) per 100 000 person-years in 2017. There was a 2\ub73 times increase in number of deaths for both sexes from 196 000 (193 000\u2013200 000) in 1990 to 441 000 (433 000\u2013449 000) in 2017. There was a 2\ub71 times increase in DALYs due to pancreatic cancer, increasing from 4\ub74 million (4\ub73\u20134\ub75) in 1990 to 9\ub71 million (8\ub79\u20139\ub73) in 2017. The age-standardised death rate of pancreatic cancer was highest in the high-income super-region across all years from 1990 to 2017. In 2017, the highest age-standardised death rates were observed in Greenland (17\ub74 [15\ub78\u201319\ub70] per 100 000 person-years) and Uruguay (12\ub71 [10\ub79\u201313\ub75] per 100 000 person-years). These countries also had the highest age-standardised death rates in 1990. Bangladesh (1\ub79 [1\ub75\u20132\ub73] per 100 000 person-years) had the lowest rate in 2017, and S\ue3o Tom\ue9 and Pr\uedncipe (1\ub73 [1\ub71\u20131\ub75] per 100 000 person-years) had the lowest rate in 1990. The numbers of incident cases and deaths peaked at the ages of 65\u201369 years for males and at 75\u201379 years for females. Age-standardised pancreatic cancer deaths worldwide were primarily attributable to smoking (21\ub71% [18\ub78\u201323\ub77]), high fasting plasma glucose (8\ub79% [2\ub71\u201319\ub74]), and high body-mass index (6\ub72% [2\ub75\u201311\ub74]) in 2017. Interpretation: Globally, the number of deaths, incident cases, and DALYs caused by pancreatic cancer has more than doubled from 1990 to 2017. The increase in incidence of pancreatic cancer is likely to continue as the population ages. Prevention strategies should focus on modifiable risk factors. Development of screening programmes for early detection and more effective treatment strategies for pancreatic cancer are needed. Funding: Bill & Melinda Gates Foundation

Global trends of hand and wrist trauma: A systematic analysis of fracture and digit amputation using the Global Burden of Disease 2017 Study

Background: As global rates of mortality decrease, rates of non-fatal injury have increased, particularly in low Socio-demographic Index (SDI) nations. We hypothesised this global pattern of non-fatal injury would be demonstrated in regard to bony hand and wrist trauma over the 27-year study period. Methods: The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 was used to estimate prevalence, age-standardised incidence and years lived with disability for hand trauma in 195 countries from 1990 to 2017. Individual injuries included hand and wrist fractures, thumb amputations and non-thumb digit amputations. Results: The global incidence of hand trauma has only modestly decreased since 1990. In 2017, t

Tracking development assistance for health and for COVID-19 : a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990-2050

Background The rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020. Methods We estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050. Findings In 2019, health spending globally reached$8. 8 trillion (95% uncertainty interval [UI] 8.7-8.8) or $1132 (1119-1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total,$40.4 billion (0.5%, 95% UI 0.5-0.5) was development assistance for health provided to low-income and middle-income countries, which made up 24.6% (UI 24.0-25.1) of total spending in low-income countries. We estimate that $54.8 billion in development assistance for health was disbursed in 2020. Of this,$13.7 billion was targeted toward the COVID-19 health response. $12.3 billion was newly committed and$1.4 billion was repurposed from existing health projects. $3.1 billion (22.4$2.4 billion (17.9%) was for supply chain and logistics. Only $714.4 million (7.7$1519 (1448-1591) per person in 2050, although spending across countries is expected to remain varied. Interpretation Global health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.Peer reviewe

Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000–17 : analysis for the Global Burden of Disease Study 2017

Background Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea. Methods We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates. Findings The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1–65·8), 17·4% (7·7–28·4), and 59·5% (34·2–86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage. Interpretation By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health