Effect of fire onthe structure and floristic composition of a cerrado sensu stricto area in fazenda Água Limpa - DF

O objetivo desta pesquisa foi avaliar o efeito do fogo na estrutura e composição florística de uma área de 10 ha de cerrado sensu stricto, localizada na fazenda Água Limpa da Universidade de Brasília. Foram realizados dois inventários, sendo o primeiro em 1999, logo após a área ter sido totalmente queimada, devido a um incêndio criminoso, e o segundo em novembro de 2002. Quatro parcelas de 0,1 ha (20 x 50 m) foram tomadas, aleatoriamente, na área queimada. Todos os indivíduos lenhosos arbóreos vivos, com Db (diâmetro tomado a 0,30 m do solo) igualou superior a 3 cm, foram identificados botanicamente, e seus diâmetros e alturas foram registrados. Valores de densidade, dominância, freqüência e índice de valor de cobertura foram obtidos para os dois levantamentos. A avaliação da similaridade florística entre os dois inventários foi realizada para dados qualitativos (presença e ausênciade espécies), a partir do índice de Sφrensen. Os resultados mostraram que houve pouca mudança na composição florística da comunidade durante o período estudado. Entre os dois inventários houve um aumento de aproximadamente 125% na densidade por hectare. A similaridade entre os dois levantamentos foi alta (índice de Sφrensen igual a0,68). A densidade florística, obtida a partir do índice de Shannon, foi baixa (cerca de 2,5) nas duas épocas monitoradas, quando comparada com pesquisas a longo prazo no cerrado sensu stricto da FAL (cerca de 3,5). Contudo, este valor é comum em áreas de cerrado que sofreram distúrbios. No segundo inventário, realizado três anos após o fogo, surgiram 13 espécies novas na área, o que comprova a sua recuperação e recolonização.This research aimed to evaluate the effect of fire on the structure and floristic composition of a 10 hacerrado sensu stricto area located at the Ecological and Experimental Reserve of the University of Brasilia, Fazenda Água Limpa FAL. Two assessments were conducted in the area: the first, after the area had suffered a criminal firein 1999, and the second in 2002. A sample of four 20 x 50 m permanent plots was assessed. All individuals withstems 5 cm diameter at 0,30 m (Db) from the ground level were registered, and had their Db and total height measured. Density, basal area, frequency and value of covering index were calculated for the two assessments. The floristic similarity between the two surveys was evaluated for qualitative data (presence and absence of species)based on the Sφrensen Index. Few changes were observed in the floristic composition of the community during the studied period. There was an increase of 125% in density by hectare from 1999 to 2002. A high similarity (SφrensenIndex equal to 0.68)was found between the two assessments while diversity (Shannon Index) was small (about 2.5).This value is smaller than those found in natural areas of the Cerrado sensu stricto at Fazenda Água Limpa,although it is common in areas with disturbances. Three years after fire 13 new species were verified in the area

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Regeneration and establishment de Copaifera langsdorffii (Desf.) e Emmotum nitens (Benth.) Miers in natural conditions

Dissertação (mestrado)—Universidade de Brasília, Faculdade de Tecnologia, Departamento de Engenharia Florestal, 2006.Fatores como tipo de fitofisionomia, a remoção e predação de sementes por animais e a sazonalidade climática podem limitar o estabelecimento de diversas espécies arbóreas. Copaifera langsdorffii e Emmotum nitens são duas espécies típicas do Cerrado que são encontradas desde formações florestais como os cerradões até savânicas como campo sujo e cerrado sensu stricto no Centro-Oeste brasileiro. O presente trabalho teve como objetivo geral analisar a capacidade de regeneração, a remoção e predação das sementes de Copaifera langsdorffii e Emmotum nitens, no cerradão e no cerrado sensu stricto circundante na Estação Ecológica do Jardim Botânico de Brasília – EEJBB. Alem disso, determinar a influência do tipo de fitofisionomia no estabelecimento das duas espécies e se os efeitos da predação variam entre uma formação florestal em que as espécies já estão bem estabelecidas e, uma formação savânica adjacente, em que está ocorrendo (ou potencialmente possa ocorrer) o processo de colonização, após a dispersão das sementes. E também, determinar a capacidade de estabelecimento, os padrões fenológicos e de crescimento de C. langsdorffii nos primeiros 6 anos de vida, cujas sementes foram plantadas em um fragmento de cerradão e numa formação de campo sujo adjacente na Fazenda Água Limpa – FAL. Em um inventário do componente arbóreo do cerradão do EEJBB, E. nitens foi a espécie de maior densidade e de maior valor de importância (IVI), enquanto C. langsdorffii apresentou uma menor densidade de indivíduos e valores menores de IVI. No inventário, realizado no cerrado sensu stricto circundante ao fragmento de cerradão para a observação da existência de indivíduos adultos das duas espécies foram encontrados poucos indivíduos de E. nitens, a maioria localizados próximos ao cerradão. Não foi encontrado nenhum indivíduo de C. langsdorffii. Na análise da regeneração na área amostrada no cerradão do EEJBB foram encontrados 392 indivíduos de E. nitens o que representa uma densidade absoluta (DA) de 10.453 indivíduos por hectare, já para a C. langsdorffii foram encontrados apenas 46 indivíduos obtendo uma densidade absoluta de 1.253 indivíduos por hectare. A regeneração de E. nitens e C. langsdorffii no cerradão agrupada em classes de diâmetro apresentou uma distribuição em forma de J invertido, com a maioria dos indivíduos distribuídos nas primeiras classes, o que também pode ser observado para E. nitens no cerrado sensu stricto circundante. Essa distribuição não ficou tão evidente para C. langsdorffii nessa mesma fitofisionomia devido à pequena quantidade de indivíduos jovens encontrados. Em termos de remoção e predação, as sementes de C. langsdorffii apresentaram taxas maiores de remoção que as de E. nitens, nas duas fitofisionomias. Das 400 sementes de C. langsdorffii dispersas artificialmente em cada fitofisionomia houve remoção em torno de 78% nas duas fitofisionomias após 100 dias, alcançando remoção total das sementes que não germinaram aos 210 dias no cerradão e aos 330 dias no cerrado sensu stricto circundante. No cerradão 16,5% das sementes C. langsdorffii germinaram e houve mortalidade de 44%, sendo que 37 plantas permaneciam vivas 510 dias após o início do experimento. Para E. nitens não houve germinação em nenhuma das duas fitofisionomias e a remoção foi de 41,8% e 59% no cerradão e cerrado sensu stricto, respectivamente após os 510 dias. O experimento na FAL, as sementes de C. langsdorffii foram plantadas no cerradão e no campo sujo. A emergência foi baixa 21% no campo sujo e 28% no cerradão. Das plântulas que emergiram 59,3% e 27,8% respectivamente permaneciam vivas após 6 anos. A maior parte da mortalidade ocorreu logo após a emergência durante a época de chuva. As plantas apresentam no campo sujo um comprimento médio de 27,44 cm e no cerradão de 17,45 cm ao final de 75 meses, o número de folíolos/planta foi maior no campo sujo, onde apresentou um número médio, aos 75 meses, de 40 e no cerradão de 20 folíolos. Ao longo dos 75 meses, o número de folíolos/planta foi sempre crescente, apesar de uma diminuição sazonal no período de estiagem. A porcentagem de remoção do limbo das folhas presentes nas plantas teve nos primeiros meses seus índices mais altos, sempre caindo com o passar do tempo, atingindo 4,5 e 1%, respectivamente, aos 75 meses. Em termos de plantios de reflorestamento e de enriquecimento florestal a simples dispersão das sementes na superfície do solo não é a melhor maneira para se garantir a regeneração e estabelecimento das espécies estudadas, no entanto, o plantio em pequenas covas, aumenta consideravelmente o tempo médio para a germinação e a emergência das plântulas, sendo a fase mais limitante para o estabelecimento, os primeiros meses após a emergência. Superado esta fase inicial, estas terão grandes chances de se estabelecerem no local e colonizar a área. _______________________________________________________________________________ ABSTRACTFactors such as type of plant formation, seed removal and predation by animals and the seasonality of the climate can limit tree establishment and growth. Copaifera langsdorffii and Emmotum nitens are typical trees of the forests of Central Brazil, especially in the cerradão, a type of dry forest, they are also found in the savanna type of vegetation, The aim of this study was to examine the regeneration potential of both species, seed predation and removal in a cerradão formation and in the surroundign open savanna vegetation at the Ecological Station of the Botanical Garden of Brasilia – EEJBB in order to determine the influence of the type of vegetation on seed predation and removal and on the regeneration potential of both species. Moreover, we followed plant establishment, seasonal patterns of stem growth, leaf phenology and leaf damage by leaf area removal due to herbivory in C. langsdorffii during the first the 6 years of life. In this are seeds were planted in a cerradão and adjacent campo sujo (open savanna with scattered trees) at Fazenda Água Limpa, the experimental farm of the University of Brasilia - FAL. In the tree inventory of the cerradão vegetation at EEJBB, E. nitens was the most abundant tree and the one with the highest importance value (IVI), while C. langsdorffii was much less abundant and with lower IVI. In the inventory of the surrounding savanna vegetation, very few trees of E. nitens were found, most located close to the cerradão, while no adult individuals of C. langsdorffii were found. In the analysis of the regeneration of both species at the cerradão site 392 individuals of E nitens were found, which represents an absolute density of about 10453 individuals/ha, while only 47 individuals of C. langsdorffii were found, which gives an absolute density of about 1253 individuals in one hectare. The regeneration of E.nitens in the cerradão grouped in diameter classes presented a distribution in the form of inverted J, with the majority of the individuals distributed in the first classes of diameter C langsdorffii showed a similar pattern. For the surrounding open savanna vegetation, this J distribution of E. nitens regeneration was also evident. For the regeneration of C. langsdorffii this format was not possible to be observed, because only two individuals were found. In the removal and predation experiment, a larger number of seeds of C. langsdorffii were removed than of E nitens in the two types of vegetation. Of the 400 artificially dispersed seeds in both vegetation types, around 78% of the C. langsdorffii were removed after 100 days and all non-germinated seeds have been removed 210 days after seed dispersal in the cerradão and in 330 days in the surrounding open savanna vegetation. In the cerradão, 16.5% of the C langsdorffii seeds germinated and mortality was 44%. The remaining 37 plants were still 510 days after the beginning of the experiment. No seeds of E. nitens germinated in both types of vegetation. For the experiment at FAL, the seeds of C langsdorffii had been planted in the cerradão and in the campo sujo site. The emergency was low 21% in the campo sujo and 28% in the cerradão. Of the emerged seedlings, 59.3% and 27.8% remained alive after 6 years. Most of the mortality occurred soon after the emergency during the rainy season. The plants presented in the campo sujo an average length of 27,44cm and in the cerradão of 17,45cm at the end of 75 months. The number of leaflets/plant was larger in the campo sujo where it presented an average number of 40 leaflets/plant, and of 20 in the cerradão at 75 months, those numbers always increasing, although occurred a seasonal reduction in the dry period. The percentage of leaf area loss due to herbivory was higher in the the first months after emergence, but it decreased afterwards, being 4,47 and 1% respectively at 75 months. In terms of projects of reforestation and forest enrichment the simple dispersion of the seeds on the surface of the soil is not the best way to guarantee the regeneration and establishment of the species. However, seed burial in small hollows increased seed germination considerably and decreased the average emergence time, being the first months after seedling emergency the most critical for plant survival. Surpassed this initial phase, C. langsdorffii seedlings will have great possibility of establishing in the place and colonizing the area

Conservação ex situ de Cactaceae no Jardim Botânico de Brasí­lia, DF.

O Jardim Botânico de Brasí­lia recebeu, recentemente, a doação de uma coleção viva de Cactaceae e outras suculentas, que estão sendo cadastradas e identificadas. Estima-se que a coleção contenha 172 espécies de Cactaceae e 200 espécimes de outras suculentas. A coleção é a primeira registrada para o Centro-Oeste e a mais diversa do paí­s. Com os primeiros estudos realizados na coleção foram identificadas   quatro espécies de Cactaceae que estão na lista das ameaçadas de extinção. Propõe-se aqui, um projeto para a manutenção da coleção e a conservação ex situ das espécies de Cactaceae e outras suculentas. Como produto final, além da conservação da coleção e disponibilização da mesma para a visita do público e para estudos cientí­ficos, será publicado o catálogo ilustrado das espécies da coleção de Cactaceae e outras suculentas do Jardim Botânico de Brasí­lia

Conservação ex situ de Cactaceae no Jardim Botânico de Brasí­lia, DF.

O Jardim Botânico de Brasí­lia recebeu, recentemente, a doação de uma coleção viva de Cactaceae e outras suculentas, que estão sendo cadastradas e identificadas. Estima-se que a coleção contenha 172 espécies de Cactaceae e 200 espécimes de outras suculentas. A coleção é a primeira registrada para o Centro-Oeste e a mais diversa do paí­s. Com os primeiros estudos realizados na coleção foram identificadas   quatro espécies de Cactaceae que estão na lista das ameaçadas de extinção. Propõe-se aqui, um projeto para a manutenção da coleção e a conservação ex situ das espécies de Cactaceae e outras suculentas. Como produto final, além da conservação da coleção e disponibilização da mesma para a visita do público e para estudos cientí­ficos, será publicado o catálogo ilustrado das espécies da coleção de Cactaceae e outras suculentas do Jardim Botânico de Brasí­lia

Efeito de incêndios florestais na estrutura e composição florística de uma área de cerrado sensu stricto na fazenda Água Limpa-DF<a name=tx></a> Effect of fire on the structure and floristic composition of a cerrado sensu stricto area in fazenda Água Limpa-DF

O objetivo desta pesquisa foi avaliar o efeito do fogo na estrutura e composição florística de uma área de 10 ha de cerrado sensu stricto, localizada na fazenda Água Limpa da Universidade de Brasília. Foram realizados dois inventários, sendo o primeiro em 1999, logo após a área ter sido totalmente queimada, devido a um incêndio criminoso, e o segundo em novembro de 2002. Quatro parcelas de 0,1 ha (20 x 50 m) foram tomadas, aleatoriamente, na área queimada. Todos os indivíduos lenhosos arbóreos vivos, com Db (diâmetro tomado a 0,30 m do solo) igual ou superior a 3 cm, foram identificados botanicamente, e seus diâmetros e alturas foram registrados. Valores de densidade, dominância, freqüência e índice de valor de cobertura foram obtidos para os dois levantamentos. A avaliação da similaridade florística entre os dois inventários foi realizada para dados qualitativos (presença e ausência de espécies), a partir do índice de Sfrensen. Os resultados mostraram que houve pouca mudança na composição florística da comunidade durante o período estudado. Entre os dois inventários houve um aumento de aproximadamente 125% na densidade por hectare. A similaridade entre os dois levantamentos foi alta (índice de Sfrensen igual a 0,68). A densidade florística, obtida a partir do índice de Shannon, foi baixa (cerca de 2,5) nas duas épocas monitoradas, quando comparada com pesquisas a longo prazo no cerrado sensu stricto da FAL (cerca de 3,5). Contudo, este valor é comum em áreas de cerrado que sofreram distúrbios. No segundo inventário, realizado três anos após o fogo, surgiram 13 espécies novas na área, o que comprova a sua recuperação e recolonização.<br>This research aimed to evaluate the effect of fire on the structure and floristic composition of a 10 ha cerrado sensu stricto area located at the Ecological and Experimental Reserve of the University of Brasilia, Fazenda Água Limpa-FAL. Two assessments were conducted in the area: the first, after the area had suffered a criminal fire in 1999, and the second in 2002. A sample of four 20 x 50 m permanent plots was assessed. All individuals with stems 5 cm diameter at 0,30 m (Db) from the ground level were registered, and had their Db and total height measured. Density, basal area, frequency and value of covering index were calculated for the two assessments. The floristic similarity between the two surveys was evaluated for qualitative data (presence and absence of species) based on the Sfrensen Index. Few changes were observed in the floristic composition of the community during the studied period. There was an increase of 125% in density by hectare from 1999 to 2002. A high similarity (Sfrensen Index equal to 0.68)was found between the two assessments while diversity (Shannon Index) was small (about 2.5). This value is smaller than those found in natural areas of the Cerrado sensu stricto at Fazenda Água Limpa, although it is common in areas with disturbances. Three years after fire 13 new species were verified in the area

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BackgroundRegular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.MethodsThe Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model—a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates—with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality—which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.FindingsThe leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2–100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1–290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1–211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4–48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3–37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7–9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.InterpretationLong-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere

Global fertility in 204 countries and territories, 1950–2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BackgroundAccurate assessments of current and future fertility—including overall trends and changing population age structures across countries and regions—are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios. MethodsTo estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10–54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression—Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values—a metric assessing gain in forecasting accuracy—by comparing predicted versus observed ASFRs from the past 15 years (2007–21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline. FindingsDuring the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63–5·06) to 2·23 (2·09–2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137–147), declining to 129 million (121–138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1—canonically considered replacement-level fertility—in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7–29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59–2·08) in 2050 and 1·59 (1·25–1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6–43·1) in 2050 and 54·3% (47·1–59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions—decreasing, for example, in south Asia from 24·8% (23·7–25·8) in 2021 to 16·7% (14·3–19·1) in 2050 and 7·1% (4·4–10·1) in 2100—but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40–1·92) in 2050 and 1·62 (1·35–1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction. InterpretationFertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world. FundingBill & Melinda Gates Foundation