Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND: Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI). METHODS: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate. FINDINGS: The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9-78·6) for females and 72·0 years (68·8-75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0-49·5]) and for males was in Lesotho (41·5 years [39·0-44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97-6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74-6·27) for males and 6·49 years (6·08-6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61-1·93) for males and 1·96 years (1·69-2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (-2·3% [-5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally. INTERPRETATION: At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support. FUNDING: Bill & Melinda Gates Foundation

Characterizing Recurrence Following Hybrid Ablation in Patients With Persistent Atrial Fibrillation

Purpose: It is It is widely accepted that atrial fibrillation (AF) accounts for half of arrhythmia recurrences following endocardial catheter ablation of AF. An epicardial-endocardial approach (hybrid) has emerged as an alternative to endocardial ablation alone for the treatment of AF, yet recurrence after a hybrid procedure has not been well characterized. This retrospective study is aimed at characterizing recurrence following hybrid ablation for patients with persistent AF. Methods: Patients with persistent AF (N = 108) received both endocardial and epicardial ablation of the posterior left atrial wall using catheter ablation and a small midline surgical approach (hybrid). Presence of atrial flutter or AF was determined with ambulatory monitoring (n = 22) or electrocardiogram analysis (n = 86) at each follow-up visit. Recurrence mode was confirmed by electrophysiology study for those patients undergoing subsequent catheter ablation after hybrid ablation. Results: Patients were followed for a mean ± standard deviation of 25 ± 14 months. Of patients who had a recurrence, 53% (n = 33) were in atrial flutter and 47% (n = 29) were in AF. Of those who had a recurrence with atrial flutter, 14 received repeat ablation for either left (n = 11) or left/right (n = 3) atrial flutter and 3 received AF ablation. Half of ablations for atrial flutter recurrence following the hybrid procedure involved the mitral isthmus. Conclusions: Atrial flutter accounts for about half of arrhythmia recurrences post-hybrid ablation. If catheter ablation of the mitral isthmus is considered during the hybrid procedure to prevent subsequent occurrence of perimitral flutter, bidirectional block must be performed to ensure a complete line of block

Benefit of implantable cardioverter-defibrillator in patients with improved left ventricular systolic function

Conclusions: In the Aurora cohort of patients with transient LV dysfunction recovered to EF≥40%, characteristics of ICD recipients were similar to prior primary prevention ICD trials. ICD recipients were more likely to have diabetes, and EF improved to a lesser degree and over a longer period. An associated between presence of ICD and better all-cause survival was observed. This difference was driven by a benefit in patients with EF 40-49%. Our findings suggest: in patients who develop significant LV dysfunction, recovery of LV function to EF\u3e35% does not afford adequate SCD protection, and that ICD therapy may be appropriate and protective in patients with EF improved up to 49%

Risk assessment for infected endocarditis in Staphylococcus aureus bacteremia patients: when is transesophageal echocardiography needed?

AIMS: Echocardiography is the main technique for the diagnosis of endocarditis in patients with METHODS AND RESULTS: Data from SAB patients admitted from 2012 to 2014 were collected. We tested the Palraj scores to stratify patients\u27 risk for endocarditis. Moreover, we analyzed our population to identify any other possible clinical predictors of endocarditis not included in the score. Endocarditis was diagnosed in 38 of 205 patients (18.5%). Palraj\u27s score was effective in the detection of patients at high risk of endocarditis. In addition, we identified the presence of cardiac devices, prolonged bacteremia and intravenous drug abuse (IVDA) as elements strongly correlated with endocarditis. Two scoring systems (Day-1 and Day-5) were derived including IVDA as a variable. Using a Day-1 cut-off value ≥5 and a Day-5 cut-off value ≥2, the \u27modified Palraj\u27s score\u27 showed sensitivities of 42.1% and 97.0% and specificities of 88.6% and 32.0% for Day-1 and Day-5 scores, respectively. CONCLUSION: We modify and expand upon an effective scoring system to identify SAB patients at high risk for endocarditis in order to guide use of TEE. The inclusion of IVDA in the criteria for the calculation of the scores improves its effectiveness

Comparative effectiveness of hybrid ablation versus endocardial ablation alone in patients with persistent atrial fibrillation: A retrospective analysis

Background: Variable outcomes exist following endocardial ablation (endo) in medically refractory persistent atrial fibrillation (AF) patients. A hybrid epicardial-endocardial approach (hybrid) has emerged as an alternative to endocardial ablation. This retrospective feasibility study aimed to assess outcomes. Methods: In 133 consecutive patients, 69 received endocardial ablation alone (pulmonary vein isolation and radiofrequency [RF] ablation), and 64 received both endo and epicardial ablation of the posterior left atrial wall using a subxyphoid approach with irrigated RF. Recurrence was defined as any arrhythmia following the 3-month blanking period. Results:Patients were followed for a median (Q1,Q3) of 16 (12,24) months. Hybrid and endo groups were similar in mean (±SD) age (61±10 vs 62±8) years, body mass index (35±6 vs 35±7), CHA2D2-VASc (2±1 vs 2±1) and ejection fraction (54±11 vs 53±8, %). Hybrids had a longer AF duration (months) [12 (8,28) vs 7 (5,12), p Conclusions: Among persistent AF patients, hybrid ablation is associated with less AF recurrence. Further prospective randomized trials are needed to validate these results