Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950–2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

Background: Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020–21 COVID-19 pandemic period. Methods: 22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution. Findings: Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5–65·1] decline), and increased during the COVID-19 pandemic period (2020–21; 5·1% [0·9–9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98–5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50–6·01) in 2019. An estimated 131 million (126–137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7–17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8–24·8), from 49·0 years (46·7–51·3) to 71·7 years (70·9–72·5). Global life expectancy at birth declined by 1·6 years (1·0–2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67–8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4–52·7]) and south Asia (26·3% [9·0–44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations. Interpretation: Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions

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

Ocupación precolonial en la cuenca hidrográfica del río Araguaia, estados de Goiás y Mato Grosso, Brasil: síntesis aproximada y dos estudios de casos

O artigo traz um quadro aproximado da ocupação pré-colonial na planície aluvial e nos terraços do rio Araguaia utilizando informações de projetos de pesquisa preventiva e acadêmica, trabalhos científicos, dois estudos de casos e dados de sítios fora desse ambiente, para ampliar o contexto ocupacional, especialmente no que se refere a sítios lito-cerâmicos. Ao longo dos tempos, o rio Araguaia foi um elemento significativo da paisagem para a ocupação humana no Planalto Central brasileiro. Relatos históricos mencionam aldeias indígenas junto às suas margens. Em relação a ocupação pré-colonial esse rio localiza-se estrategicamente entre o norte e o sul do País e da América do Sul, sendo uma via de deslocamento favorável entre as bacias amazônica e platina. A planície aluvial e os terraços apresentam uma série de sítios arqueológicos lito-cerâmicos de grupos agricultores e ceramistas, predominantemente da Tradição Uru. Na bacia hidrográfica do rio Araguaia, também ocorrem sítios pré-cerâmicos e de agricultores e ceramistas de outras tradições arqueológicas, de superfície e em abrigos rochosos com reocupações, havendo alguns com pinturas e gravuras rupestres. Nessa abordagem, mostra-se a estruturação da bacia do rio Araguaia como tema fundamental para a Arqueologia, visualizando a relação com os sistemas fluviais, análise espacial dos sítios, processos de formação do registro arqueológico, e apropriação e construção da paisagem.The article presents a proximate picture of the pre-colonial occupation in the Araguaia river alluvial plain and terraces, using information from preventive and academic research projects, scientific works, two case studies and data from sites external to this environment, to expand the occupational context, especially with respect to lithic-ceramic sites. Throughout the ages, the Araguaia River has been a significant element of the landscape for human occupation in the Brazilian Central Plateau. Historical reports mention indigenous villages along its banks. This river is located strategically between the north and south regions of the country and of South America and provides an advantageous travel route between the Amazonian and Plate basins. The alluvial plain and the terraces present a series of ceramist and farmer group litho-ceramic archaeological sites predominantly from of the Uru Tradition. In the Araguaia river basin, there are also other farmer and potter lithics from other archaeological traditions, surface and rock shelters with reoccupations, some of them with cave paintings and engravings. This work approaches the structure of the Araguaia river basin as a fundamental theme for Archaeology, visualizing the relationship between river systems, spatial analysis of sites, processes of archaeological record formation, appropriation and construction of the landscape.El artículo trae un cuadro aproximado de la ocupación precolonial en la llanura aluvial y en las terrazas del río Araguaia, utilizando informaciones de proyectos de investigación preventiva y académica, trabajos científicos, dos estudios de casos y datos de sitios fuera de ese ambiente, para ampliar el contexto ocupacional, especialmente en lo que se refiere a los sitios litocerámicos. A lo largo de los tiempos, el río Araguaia fue un elemento significativo del paisaje para la ocupación humana en el Planalto Central brasileño. Los relatos históricos mencionan aldeas indígenas junto a sus márgenes. En relación a la ocupcción precolonial, el río se encuentra estratégicamente entre el norte y el sur del país y de América del Sur, siendo una vía de desplazamiento favorable entre las cuencas Amazónica y Platina. La llanura aluvial y las terrazas presentan una serie de sitios arqueológicos lito-cerámicos de grupos agricultores y ceramistas, predominantemente de la Tradición Uru. En la cuenca hidrográfica del río Araguaia, también ocurren sitios precerámicos y de agricultores y ceramistas de otras tradiciones arqueológicas, de superficie y en abrigos rocosos con reocupaciones, habiendo algunos con pinturas y grabados rupestres. En este abordaje, se muestra la estructuración de la cuenca del río Araguaia como tema fundamental para la arqueología, visualizando la relación con los sistemas fluviales, el análisis espacial de los sitios, de los procesos de formación del registro arqueológico, y de la apropriacíón y construcción del paisaje.Dossier: Arqueología y ríos de las Tierras Bajas de América del Sur.Facultad de Ciencias Naturales y Muse

Ocupación precolonial en la cuenca hidrográfica del río Araguaia, estados de Goiás y Mato Grosso, Brasil: síntesis aproximada y dos estudios de casos

O artigo traz um quadro aproximado da ocupação pré-colonial na planície aluvial e nos terraços do rio Araguaia utilizando informações de projetos de pesquisa preventiva e acadêmica, trabalhos científicos, dois estudos de casos e dados de sítios fora desse ambiente, para ampliar o contexto ocupacional, especialmente no que se refere a sítios lito-cerâmicos. Ao longo dos tempos, o rio Araguaia foi um elemento significativo da paisagem para a ocupação humana no Planalto Central brasileiro. Relatos históricos mencionam aldeias indígenas junto às suas margens. Em relação a ocupação pré-colonial esse rio localiza-se estrategicamente entre o norte e o sul do País e da América do Sul, sendo uma via de deslocamento favorável entre as bacias amazônica e platina. A planície aluvial e os terraços apresentam uma série de sítios arqueológicos lito-cerâmicos de grupos agricultores e ceramistas, predominantemente da Tradição Uru. Na bacia hidrográfica do rio Araguaia, também ocorrem sítios pré-cerâmicos e de agricultores e ceramistas de outras tradições arqueológicas, de superfície e em abrigos rochosos com reocupações, havendo alguns com pinturas e gravuras rupestres. Nessa abordagem, mostra-se a estruturação da bacia do rio Araguaia como tema fundamental para a Arqueologia, visualizando a relação com os sistemas fluviais, análise espacial dos sítios, processos de formação do registro arqueológico, e apropriação e construção da paisagem.The article presents a proximate picture of the pre-colonial occupation in the Araguaia river alluvial plain and terraces, using information from preventive and academic research projects, scientific works, two case studies and data from sites external to this environment, to expand the occupational context, especially with respect to lithic-ceramic sites. Throughout the ages, the Araguaia River has been a significant element of the landscape for human occupation in the Brazilian Central Plateau. Historical reports mention indigenous villages along its banks. This river is located strategically between the north and south regions of the country and of South America and provides an advantageous travel route between the Amazonian and Plate basins. The alluvial plain and the terraces present a series of ceramist and farmer group litho-ceramic archaeological sites predominantly from of the Uru Tradition. In the Araguaia river basin, there are also other farmer and potter lithics from other archaeological traditions, surface and rock shelters with reoccupations, some of them with cave paintings and engravings. This work approaches the structure of the Araguaia river basin as a fundamental theme for Archaeology, visualizing the relationship between river systems, spatial analysis of sites, processes of archaeological record formation, appropriation and construction of the landscape.El artículo trae un cuadro aproximado de la ocupación precolonial en la llanura aluvial y en las terrazas del río Araguaia, utilizando informaciones de proyectos de investigación preventiva y académica, trabajos científicos, dos estudios de casos y datos de sitios fuera de ese ambiente, para ampliar el contexto ocupacional, especialmente en lo que se refiere a los sitios litocerámicos. A lo largo de los tiempos, el río Araguaia fue un elemento significativo del paisaje para la ocupación humana en el Planalto Central brasileño. Los relatos históricos mencionan aldeas indígenas junto a sus márgenes. En relación a la ocupcción precolonial, el río se encuentra estratégicamente entre el norte y el sur del país y de América del Sur, siendo una vía de desplazamiento favorable entre las cuencas Amazónica y Platina. La llanura aluvial y las terrazas presentan una serie de sitios arqueológicos lito-cerámicos de grupos agricultores y ceramistas, predominantemente de la Tradición Uru. En la cuenca hidrográfica del río Araguaia, también ocurren sitios precerámicos y de agricultores y ceramistas de otras tradiciones arqueológicas, de superficie y en abrigos rocosos con reocupaciones, habiendo algunos con pinturas y grabados rupestres. En este abordaje, se muestra la estructuración de la cuenca del río Araguaia como tema fundamental para la arqueología, visualizando la relación con los sistemas fluviales, el análisis espacial de los sitios, de los procesos de formación del registro arqueológico, y de la apropriacíón y construcción del paisaje.Dossier: Arqueología y ríos de las Tierras Bajas de América del Sur.Facultad de Ciencias Naturales y Muse

Ocupação pré-colonial na bacia hidrográfica do rio Araguaia, estados de Goiás e Mato Grosso, Brasil: síntese aproximada e dois estudos de casos

The article presents a proximate picture of the pre-colonial occupation in the Araguaia river alluvial plain and terraces, using information from preventive and academic research projects, scientific works, two case studies and data from sites external to this environment, to expand the occupational context, especially with respect to lithic-ceramic sites. Throughout the ages, the Araguaia River has been a significant element of the landscape for human occupation in the Brazilian Central Plateau. Historical reports mention indigenous villages along its banks. This river is located strategically between the north and south regions of the country and of South America and provides an advantageous travel route between the Amazonian and Plate basins. The alluvial plain and the terraces present a series of ceramist and farmer group litho-ceramic archaeological sites predominantly from of the Uru Tradition. In the Araguaia river basin, there are also other farmer and potter lithics from other archaeological traditions, surface and rock shelters with reoccupations, some of them with cave paintings and engravings. This work approaches the structure of the Araguaia river basin as a fundamental theme for Archaeology, visualizing the relationship between river systems, spatial analysis of sites, processes of archaeological record formation, appropriation and construction of the landscape.El artículo trae un cuadro aproximado de la ocupación precolonial en la llanura aluvial y en las terrazas del río Araguaia, utilizando informaciones de proyectos de investigación preventiva y académica, trabajos científicos, dos estudios de casos y datos de sitios fuera de ese ambiente, para ampliar el contexto ocupacional, especialmente en lo que se refiere a los sitios lito-cerámicos. A lo largo de los tiempos, el río Araguaia fue un elemento significativo del paisaje para la ocupación humana en el Planalto Central brasileño. Los relatos históricos mencionan aldeas indígenas junto a sus márgenes. En relación a la ocupcción precolonial, el río se encuentra estratégicamente entre el norte y el sur del país y de América del Sur, siendo una vía de desplazamiento favorable entre las cuencas Amazónica y Platina. La llanura aluvial y las terrazas presentan una serie de sitios arqueológicos lito-cerámicos de grupos agricultores y ceramistas, predominantemente de la Tradición Uru. En la cuenca hidrográfica del río Araguaia, también ocurren sitios precerámicos y de agricultores y ceramistas de otras tradiciones arqueológicas, de superficie y en abrigos rocosos con reocupaciones, habiendo algunos con pinturas y grabados rupestres. En este abordaje, se muestra la estructuración de la cuenca del río Araguaia como tema fundamental para la arqueología, visualizando la relación con los sistemas fluviales, el análisis espacial de los sitios, de los procesos de formación del registro arqueológico,  y de la apropriacíón y construcción del paisaje.O artigo traz um quadro aproximado da ocupação pré-colonial na planície aluvial e nos terraços do rio Araguaia utilizando informações de projetos de pesquisa preventiva e acadêmica, trabalhos científicos, dois estudos de casos e dados de sítios fora desse ambiente, para ampliar o contexto ocupacional, especialmente no que se refere a sítios lito-cerâmicos. Ao longo dos tempos, o rio Araguaia foi um elemento significativo da paisagem para a ocupação humana no Planalto Central brasileiro. Relatos históricos mencionam aldeias indígenas junto às suas margens. Em relação a ocupação pré-colonial esse rio localiza-se estrategicamente entre o norte e o sul do País e da América do Sul, sendo uma via de deslocamento favorável entre as bacias amazônica e platina. A planície aluvial e os terraços apresentam uma série de sítios arqueológicos lito-cerâmicos de grupos agricultores e ceramistas, predominantemente da Tradição Uru. Na bacia hidrográfica do rio Araguaia, também ocorrem sítios pré-cerâmicos e de agricultores e ceramistas de outras tradições arqueológicas, de superfície e em abrigos rochosos com reocupações, havendo alguns com pinturas e gravuras rupestres. Nessa abordagem, mostra-se a estruturação da bacia do rio Araguaia como tema fundamental para a Arqueologia, visualizando a relação com os sistemas fluviais, análise espacial dos sítios,  processos de formação do registro arqueológico, e apropriação e construção da paisagem

Ocupación precolonial en la cuenca hidrográfica del río Araguaia, estados de Goiás y Mato Grosso, Brasil: síntesis aproximada y dos estudios de casos

O artigo traz um quadro aproximado da ocupação pré-colonial na planície aluvial e nos terraços do rio Araguaia utilizando informações de projetos de pesquisa preventiva e acadêmica, trabalhos científicos, dois estudos de casos e dados de sítios fora desse ambiente, para ampliar o contexto ocupacional, especialmente no que se refere a sítios lito-cerâmicos. Ao longo dos tempos, o rio Araguaia foi um elemento significativo da paisagem para a ocupação humana no Planalto Central brasileiro. Relatos históricos mencionam aldeias indígenas junto às suas margens. Em relação a ocupação pré-colonial esse rio localiza-se estrategicamente entre o norte e o sul do País e da América do Sul, sendo uma via de deslocamento favorável entre as bacias amazônica e platina. A planície aluvial e os terraços apresentam uma série de sítios arqueológicos lito-cerâmicos de grupos agricultores e ceramistas, predominantemente da Tradição Uru. Na bacia hidrográfica do rio Araguaia, também ocorrem sítios pré-cerâmicos e de agricultores e ceramistas de outras tradições arqueológicas, de superfície e em abrigos rochosos com reocupações, havendo alguns com pinturas e gravuras rupestres. Nessa abordagem, mostra-se a estruturação da bacia do rio Araguaia como tema fundamental para a Arqueologia, visualizando a relação com os sistemas fluviais, análise espacial dos sítios, processos de formação do registro arqueológico, e apropriação e construção da paisagem.The article presents a proximate picture of the pre-colonial occupation in the Araguaia river alluvial plain and terraces, using information from preventive and academic research projects, scientific works, two case studies and data from sites external to this environment, to expand the occupational context, especially with respect to lithic-ceramic sites. Throughout the ages, the Araguaia River has been a significant element of the landscape for human occupation in the Brazilian Central Plateau. Historical reports mention indigenous villages along its banks. This river is located strategically between the north and south regions of the country and of South America and provides an advantageous travel route between the Amazonian and Plate basins. The alluvial plain and the terraces present a series of ceramist and farmer group litho-ceramic archaeological sites predominantly from of the Uru Tradition. In the Araguaia river basin, there are also other farmer and potter lithics from other archaeological traditions, surface and rock shelters with reoccupations, some of them with cave paintings and engravings. This work approaches the structure of the Araguaia river basin as a fundamental theme for Archaeology, visualizing the relationship between river systems, spatial analysis of sites, processes of archaeological record formation, appropriation and construction of the landscape.El artículo trae un cuadro aproximado de la ocupación precolonial en la llanura aluvial y en las terrazas del río Araguaia, utilizando informaciones de proyectos de investigación preventiva y académica, trabajos científicos, dos estudios de casos y datos de sitios fuera de ese ambiente, para ampliar el contexto ocupacional, especialmente en lo que se refiere a los sitios litocerámicos. A lo largo de los tiempos, el río Araguaia fue un elemento significativo del paisaje para la ocupación humana en el Planalto Central brasileño. Los relatos históricos mencionan aldeas indígenas junto a sus márgenes. En relación a la ocupcción precolonial, el río se encuentra estratégicamente entre el norte y el sur del país y de América del Sur, siendo una vía de desplazamiento favorable entre las cuencas Amazónica y Platina. La llanura aluvial y las terrazas presentan una serie de sitios arqueológicos lito-cerámicos de grupos agricultores y ceramistas, predominantemente de la Tradición Uru. En la cuenca hidrográfica del río Araguaia, también ocurren sitios precerámicos y de agricultores y ceramistas de otras tradiciones arqueológicas, de superficie y en abrigos rocosos con reocupaciones, habiendo algunos con pinturas y grabados rupestres. En este abordaje, se muestra la estructuración de la cuenca del río Araguaia como tema fundamental para la arqueología, visualizando la relación con los sistemas fluviales, el análisis espacial de los sitios, de los procesos de formación del registro arqueológico, y de la apropriacíón y construcción del paisaje.Dossier: Arqueología y ríos de las Tierras Bajas de América del Sur.Facultad de Ciencias Naturales y Muse

CT or Invasive Coronary Angiography in Stable Chest Pain.

Background: In the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain. Methods: We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris. Results: Among 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P = 0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48). Conclusions: Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy. (Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number, NCT02400229.)

Guidance on mucositis assessment from the MASCC Mucositis Study Group and ISOO: an international Delphi studyResearch in context

Summary: Background: Mucositis is a common and highly impactful side effect of conventional and emerging cancer therapy and thus the subject of intense investigation. Although common practice, mucositis assessment is heterogeneously adopted and poorly guided, impacting evidence synthesis and translation. The Multinational Association of Supportive Care in Cancer (MASCC) Mucositis Study Group (MSG) therefore aimed to establish expert recommendations for how existing mucositis assessment tools should be used, in clinical care and trials contexts, to improve the consistency of mucositis assessment. Methods: This study was conducted over two stages (January 2022–July 2023). The first phase involved a survey to MASCC-MSG members (January 2022–May 2022), capturing current practices, challenges and preferences. These then informed the second phase, in which a set of initial recommendations were prepared and refined using the Delphi method (February 2023–May 2023). Consensus was defined as agreement on a parameter by >80% of respondents. Findings: Seventy-two MASCC-MSG members completed the first phase of the study (37 females, 34 males, mainly oral care specialists). High variability was noted in the use of mucositis assessment tools, with a high reliance on clinician assessment compared to patient reported outcome measures (PROMs, 47% vs 3%, 37% used a combination). The World Health Organization (WHO) and Common Terminology Criteria for Adverse Events (CTCAE) scales were most commonly used to assess mucositis across multiple settings. Initial recommendations were reviewed by experienced MSG members and following two rounds of Delphi survey consensus was achieved in 91 of 100 recommendations. For example, in patients receiving chemotherapy, the recommended tool for clinician assessment in clinical practice is WHO for oral mucositis (89.5% consensus), and WHO or CTCAE for gastrointestinal mucositis (85.7% consensus). The recommended PROM in clinical trials is OMD/WQ for oral mucositis (93.3% consensus), and PRO-CTCAE for gastrointestinal mucositis (83.3% consensus). Interpretation: These new recommendations provide much needed guidance on mucositis assessment and may be applied in both clinical practice and research to streamline comparison and synthesis of global data sets, thus accelerating translation of new knowledge into clinical practice. Funding: No funding was received