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

Implement BPR and CPI to optimize the process of getting medicine in pharmacy : a comparison between Sweden and China

This report generally focuses on the process of getting medicine from the pharmacy in the hospital. The processes are different in Sweden and in China due to the different concrete conditions. Compared with the Swedish process the Chinese flow lags fairly far behind. To optimize the Chinese process by taking advantage of the Swedish process is the intention of this report; it also gives the advice on how to improve the performance for the Swedish process. By comparing the multiple theories for process improvement, I used Business Process Reengineering (BPR) theory to reengineer the Chinese process and used Continues Process Improvement (CPI) theory to ameliorate the Swedish process. The differences between BPR and CPI are also revealed in this report

PVAT: an important guardian of the cardiovascular system

Perivascular adipose tissue (PVAT) had long been considered to serve only structural, vessel- supporting purposes, but today PVAT is recognized to be an endocrine organ with important physiological and pathological effects. The expansion of PVAT in vascular homeostasis and vascular disease has attracted much interest. PVAT has been shown to release a wide spectrum of molecules, such as PVAT-derived relaxing factors (PVATRFs) and PVAT-derived contracting factors (PVATCFs). PVAT dysfunction may lead to obesity, atherosclerosis, and other cardiovascular diseases. This review describes recent advances in our understanding of PVAT’s important effects on the cardiovascular syste

The built environment, purpose-specific walking behaviour and overweight: evidence from Wuhan metropolis in central China

AbstractThe impact of objective and subjective environmental factors on health outcomes has been a topic of significant debate, with a growing body of research acknowledging the role of a physically active lifestyle in promoting health. However, consensus regarding their precise influence remains elusive. This study contributes to these discussions by exploring how individual health outcomes correlate with transport and leisure walking behaviours, set against both the objective and subjective aspects of environmental influences in the context of Wuhan, an inland Chinese megacity. Street view images, multi-source geospatial data and a questionnaire survey were employed to characterise the “5D + Greenery” objective and perceived characteristics of the neighbourhood environment. Multi-group structural equation modelling was utilised to unravel the complex relationship and gender heterogeneity among environmental factors, purpose-specific walking, and overweight. Our results suggest that both objective land use diversity and perceived convenience are significantly associated with overweight. The accessibility of local service facilities and visible greenery promote both transport and leisure walking. While perceived neighbourhood safety encourages transport walking, perceived walkability is positively correlated with leisure walking. Notably, leisure walking, usually considered beneficial, presents a positive association with overweight conditions, acting as a mediation. Gender disparities exist in pathways between the environment and purpose-specific walking, as well as weight. The findings lend support to the planning of an activity-supporting built environment as a crucial strategy for obesity prevention.</jats:p

The built environment, purpose-specific walking behaviour and overweight: evidence from Wuhan metropolis in central China

Abstract The impact of objective and subjective environmental factors on health outcomes has been a topic of significant debate, with a growing body of research acknowledging the role of a physically active lifestyle in promoting health. However, consensus regarding their precise influence remains elusive. This study contributes to these discussions by exploring how individual health outcomes correlate with transport and leisure walking behaviours, set against both the objective and subjective aspects of environmental influences in the context of Wuhan, an inland Chinese megacity. Street view images, multi-source geospatial data and a questionnaire survey were employed to characterise the “5D + Greenery” objective and perceived characteristics of the neighbourhood environment. Multi-group structural equation modelling was utilised to unravel the complex relationship and gender heterogeneity among environmental factors, purpose-specific walking, and overweight. Our results suggest that both objective land use diversity and perceived convenience are significantly associated with overweight. The accessibility of local service facilities and visible greenery promote both transport and leisure walking. While perceived neighbourhood safety encourages transport walking, perceived walkability is positively correlated with leisure walking. Notably, leisure walking, usually considered beneficial, presents a positive association with overweight conditions, acting as a mediation. Gender disparities exist in pathways between the environment and purpose-specific walking, as well as weight. The findings lend support to the planning of an activity-supporting built environment as a crucial strategy for obesity prevention

Experimental study on dynamic behavior of CFRP-to-Concrete Interface

arbon fiber-reinforced polymer (CFRP) sheets/plates are widely used to strengthen deficient RC structures. Existing studies show that the effectiveness of externally bonded CFRP materials generally depends on the bond between the CFRP element and concrete. Most of the research studies developed so far have focused on the bond behavior of the CFRP sheet-concrete interface under static loading. In this work, the bond behavior was experimentally investigated from the dynamic standpoint, through the drop-mass impact test method, with the aim of highlighting the effect of the loading rate on the bond strength. The test results show that the strain distribution gradient of the CFRP sheets under impact loading was larger than under static loading, and that the loading rate significantly influences the bond strength, while only moderately affecting the effective bond length. A practical bond-slip model is proposed to simulate the CFRP-to-concrete interface bond behavior under dynamic conditions, which considers the strain-rate effect based on the recommendations for the strength of concrete under impact loading. Furthermore, starting from the equations given in some existing guidelines, a design proposal is developed to accurately predict the effective bond length and the bond strength of the CFRP-to-concrete interface under impact loading

Confined Synthesis of Organometallic Chains and Macrocycles by Cu–O Surface Templating

The bottom-up construction of low-dimensional macromolecular nanostructures directly on a surface is a promising approach for future application in molecular electronics and integrated circuit production. However, challenges still remain in controlling the formation of these nanostructures with predetermined patterns (such as linear or cyclic) or dimensions (such as the length of one-dimensional (1D) chains). Here, we demonstrate that a high degree of structural control can be achieved by employing a Cu(110)-(2×1)O nanotemplate for the confined synthesis of organometallic chains and macrocycles. This template contains ordered arrays of alternating stripes of Cu–O chains and bare Cu, the widths of which are controllable. Using scanning tunneling microscopy and low-energy electron diffraction, we show that well-defined, ordered 1D zigzag organometallic oligomeric chains with uniform lengths can be fabricated on the Cu stripes (width >5.6 nm) of the Cu(110)-(2×1)O surface. In addition, the lengths of the <i>meta</i>-terphenyl (MTP)-based chains can be adjusted by controlling the widths of the Cu stripes within a certain range. When reducing the widths of Cu stripes to a range of 2.6 to 5.6 nm, organometallic macrocycles including tetramer (MTP-Cu)₄, hexamer (MTP-Cu)₆, and octamer (MTP-Cu)₈ species are formed due to the spatial confinement effect and attraction to the Cu–O chains. An overview of all formed organometallic macrocycles on the Cu stripes with different widths reveals that the origin of the formation of these macrocycles is the <i>cis</i>-configured organometallic dimer (MTP)₂Cu₃, which was observed on the extremely narrow Cu stripe with a width of 1.5 nm