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Thyroid hormones and mortality risk in euthyroid individuals: the Kangbuk Samsung health study

Zhang Y, Chang Y, Ryu S, Cho J, Lee WY, Rhee EJ, et al.

J Clin Endocrinol Metab, 2014 Jul;99(7):2467-76.
PMID: 24708095 DOI: 10.1210/jc.2013-3832

CONTEXT: Hyperthyroidism and hypothyroidism, both overt and subclinical, are associated with all-cause and cardiovascular mortality. The association between thyroid hormones and mortality in euthyroid individuals, however, is unclear.
OBJECTIVE: To examine the prospective association between thyroid hormones levels within normal ranges and mortality endpoints.
SETTING AND DESIGN: A prospective cohort study of 212 456 middle-aged South Korean men and women who had normal thyroid hormone levels and no history of thyroid disease at baseline from January 1, 2002 to December 31, 2009. Free T4 (FT4), free T3 (FT3), and TSH levels were measured by RIA. Vital status and cause of death ascertainment were based on linkage to the National Death Index death certificate records.
RESULTS: After a median follow-up of 4.3 years, 730 participants died (335 deaths from cancer and 112 cardiovascular-related deaths). FT4 was inversely associated with all-cause mortality (HR = 0.77, 95% confidence interval 0.63-0.95, comparing the highest vs lowest quartile of FT4; P for linear trend = .01), and FT3 was inversely associated cancer mortality (HR = 0.62, 95% confidence interval 0.45-0.85; P for linear trend = .001). TSH was not associated with mortality endpoints.
CONCLUSIONS: In a large cohort of euthyroid men and women, FT4 and FT3 levels within the normal range were inversely associated with the risk of all-cause mortality and cancer mortality, particularly liver cancer mortality.

Matched MeSH terms: Cause of Death
Prevalence of diatom frustules in non-vegetarian foodstuffs and its implications in interpreting identification of diatom frustules in drowning cases

Yen LY, Jayaprakash PT

Forensic Sci Int, 2007 Jul 20;170(1):1-7.
PMID: 17023133

Detection of diatom frustules in bone marrow (diatom test) is used for diagnosing ante-mortem drowning where the usual signs of drowning are not present in dead bodies recovered from water. However, controversies over the reliability of diatom test results are continuing. There have been indications on the possibilities of diatoms entering into systemic circulation from atmospheric air, food and drink. While diatoms have been demonstrated in the gut content of edible marine forms such as shrimps and clams, the present study, for the first time, provides empirical evidence on the prevalence as well as abundance of diatom frustules in the samples of cooked non-vegetarian foodstuffs that impend human consumption in Kelantan, Malaysia. It is found that 50 g each of cleaned and cooked prawns and of clams impending human consumption contain about 8360 and 29,054 diatom frustules, respectively. A person accustomed to prawn and clam food would be ingesting an estimated 2 million diatoms in a single year. Considering the suggestion that detection of five diatom frustules in 10 g of bone marrow would suffice for concluding drowning as mode of death, and the fact that there is yet no proof that diatom frustules do not enter into the human systemic circulation through the digestive tract, the estimated number of diatom frustules routinely ingested acquires significance since entry of a few of such ingested frustules into the systemic circulation can lead to false positive test results. The findings of this research raise two important issues: first, population based routine food related diatom ingestion requires to be estimated, and, second, studies have to be initiated to categorically prove or disprove the possibility of entry of diatom frustules into the systemic circulation via the digestive tract.

Matched MeSH terms: Cause of Death
Glucagon-Like Peptide-1 Formulation--the Present and Future Development in Diabetes Treatment

Lee CY

Basic Clin Pharmacol Toxicol, 2016 Mar;118(3):173-80.
PMID: 26551045 DOI: 10.1111/bcpt.12524

Type 2 diabetes mellitus is a chronic metabolic disorder that has become the fourth leading cause of death in the developed countries. The disorder is characterized by pancreatic β-cells dysfunction, which causes hyperglycaemia leading to several other complications. Treatment by far, which focuses on insulin administration and glycaemic control, has not been satisfactory. Glucagon-like peptide-1 (GLP1) is an endogenous peptide that stimulates post-prandial insulin secretion. Despite being able to mimic the effect of insulin, GLP1 has not been the target drug in diabetes treatment due to the peptide's metabolic instability. After a decade-long effort to improve the pharmacokinetics of GLP1, a number of GLP1 analogues are currently available on the market. The current Minireview does not discuss these drugs but presents strategies that were undertaken to address the weaknesses of the native GLP1, particularly drug delivery techniques used in developing GLP1 nanoparticles and modified GLP1 molecule. The article highlights how each of the selected preparations has improved the efficacy of GLP1, and more importantly, through an overview of these studies, it will provide an insight into strategies that may be adopted in the future in the development of a more effective oral GLP1 formulation.

Matched MeSH terms: Cause of Death
Fulltext A strategy for reducing maternal mortality

Suleiman AB, Mathews A, Jegasothy R, Ali R, Kandiah N

Bull World Health Organ, 1999;77(2):190-3.
PMID: 10083722

A confidential system of enquiry into maternal mortality was introduced in Malaysia in 1991. The methods used and the findings obtained up to 1994 are reported below and an outline is given of the resulting recommendations and actions.
PIP: This is a report on the methods, findings, resulting recommendations and actions of a study on maternal mortality in Malaysia during the period 1991-94. Maternal death was defined as the death of a woman while pregnant or within 42 days following termination of pregnancy from any cause related to the pregnancy or its management but not from accidental causes. Between 1991 and 1994 there were 1066 reported maternal deaths, and the maternal mortality ratios for the successive years were respectively 44, 48, 46 and 39 per 100,000 live births. The primary causes of maternal death were postpartum hemorrhage (24%), hypertensive disorders of pregnancy (16%), obstetric pulmonary embolism (13%), and associated medical conditions (7%). Analysis of the 375 deaths from 1992 - 1993 showed that the maternal mortality ratio was 53/100,000 live births for deliveries performed at home, 36/100,000 in government hospitals, and 21/100,000 in private institutions. Shortcomings among health personnel were detected in several cases; these involved failure to diagnose, failure to appreciate the severity of a patient's condition, inadequate therapy, and inappropriate, delayed or failed adherence to protocols. The high proportion of maternal mortality associated with substandard care demonstrates that it is important to make the standard of care more widely available. Reports have been circulated to institutions and organizations providing maternal care and to medical schools. Articles and case histories have been published, and many new protocols and procedures have been developed. Furthermore, seminars have been organized and training modules have been distributed to all involved in the provision of maternity care.

Matched MeSH terms: Cause of Death
Withdrawal and limitation of life support in paediatric intensive care

Goh AY, Lum LC, Chan PW, Bakar F, Chong BO

Arch Dis Child, 1999 May;80(5):424-8.
PMID: 10208946

OBJECTIVES: To compare the modes of death and factors leading to withdrawal or limitation of life support in a paediatric intensive care unit (PICU) in a developing country.
METHODS: Retrospective analysis of all children (< 12 years) dying in the PICU from January 1995 to December 1995 and January 1997 to June 1998 (n = 148).
RESULTS: The main mode of death was by limitation of treatment in 68 of 148 patients, failure of active treatment including cardiopulmonary resuscitation in 61, brain death in 12, and withdrawal of life support with removal of endotracheal tube in seven. There was no significant variation in the proportion of limitation of treatment, failure of active treatment, and brain death between the two periods; however, there was an increase in withdrawal of life support from 0% in 1995 to 8% in 1997-98. Justification for limitation was based predominantly on expectation of imminent death (71 of 75). Ethnic variability was noted among the 14 of 21 patients who refused withdrawal. Discussions for care restrictions were initiated almost exclusively by paediatricians (70 of 75). Diagnostic uncertainty (36% v 4.6%) and presentation as an acute illness were associated with the use of active treatment.
CONCLUSIONS: Limitation of treatment is the most common mode of death in a developing country's PICU and active withdrawal is still not widely practised. Paediatricians in developing countries are becoming more proactive in managing death and dying but have to consider sociocultural and religious factors when making such decisions.

Matched MeSH terms: Cause of Death
Fulltext Mortality patterns in Malaysian systemic lupus erythematosus patients

Yeap SS, Chow SK, Manivasagar M, Veerapen K, Wang F

Med J Malaysia, 2001 Sep;56(3):308-12.
PMID: 11732075

A retrospective analysis of the case records of 494 systemic lupus erythematosus (SLE) patients under follow-up at University Hospital, Kuala Lumpur during 1976-1990 was performed. Overall mortality was 20.2% (100 patients). The causes of death were infection (30%), renal (15%), respiratory (14%), neurological (5%), cardiovascular (7%), other causes (2%) and unknown (27%). Active SLE was a contributing factor in 19% of the deaths. The patients who died had significantly more renal disease, neurological disease, serositis or thrombocytopenia by the end of the first year of disease compared to the survivors. As in other series, infection and active SLE remain important causes of death.

Matched MeSH terms: Cause of Death
The effect of being overweight on cancer incidence and all-cause mortality in Asians: a prospective study in Singapore

Lee J, Wang H, Chia KS, Koh D, Hughes K

Int J Epidemiol, 2002 Aug;31(4):875-6.
PMID: 12177037
Matched MeSH terms: Cause of Death
Fulltext Maternal deaths due to liver disease in Malaysia

Ravindran J, Jayadev R, Lachmanan SR, Merican I

Med J Malaysia, 2000 Jun;55(2):209-19.
PMID: 19839149

Liver disease is an important and serious condition in pregnancy. The Confidential Enquiries Into Maternal Deaths in Malaysia showed that there were 23 maternal deaths attributed to liver disease between 1991-1994. Over the same period, there were 1066 reported maternal deaths with 929 of them being due to direct and indirect causes. Thus 2.15% of such deaths were due to liver disease in Malaysia. The three main causes of maternal deaths due to liver disease in pregnancy were hepatitis (6 cases), acute fatty liver in pregnancy (6 cases) and septicaemia (4 cases). Liver disease is common at a mean of thirty weeks of gestation with a preponderance to women of low parity. Only two patients in this series had no antenatal care. The majority of cases (45.8%) presented between 28-37 weeks of gestation. All cases delivered by spontaneous vaginal delivery. Remediable factors that were identified included failure to appreciate the severity of disease. Case summaries of all the cases of maternal deaths due to liver disease are discussed and a guideline to management of liver disease in pregnancy presented.

Matched MeSH terms: Cause of Death
A national study of risk factors associated with mortality in very low birthweight infants in the Malaysian neonatal intensive care units. Malaysian Very Low Birth Weight Study Group

J Paediatr Child Health, 1997 Feb;33(1):18-25.
PMID: 9069039

OBJECTIVE: To determine the risk factors associated with mortality in very low birthweight (VLBW) infants admitted to the neonatal intensive care units (NIUC) in Malaysia.
METHOD: A prospective observational study of outcome of all VLBW infants born between 1 January 1993 and 30 June 1993 and admitted to the NICU.
RESULTS: Data of 868 VLBW neonates from 18 centres in Malaysia were collected. Their mean birthweight was 1223 g (95% confidence intervals: 1208-1238 g). Thirty-seven point four per cent (325/868) of these infants died before discharge. After exclusion of all infants with congenital anomalies (n = 66, and nine of them also had incomplete records) and incomplete records (n = 82), stepwise logistic regression analysis of the remaining 720 infants showed that the risk factors that were significantly associated with increased mortality before discharge were: delivery in district hospitals, Chinese race, lower birthweight, lower gestation age, persistent pulmonary hypertension of the newborn, pulmonary airleak, necrotizing enterocolitis of stage 2 or 3, confirmed sepsis, hypotension, hypothermia, acute renal failure, intermittent positive pressure ventilation, and umbilical arterial catheterization. Factors that were significantly associated with lower risk of mortality were: use of antenatal steroid, oxygen therapy, surfactant therapy and blood transfusion.
CONCLUSION: The mortality of VLBW infants admitted to the Malaysian NICU was high and was also associated with a number of preventable risk factors.

Matched MeSH terms: Cause of Death
Research to prevent injuries

Krishnan R, Karim H

World Health Forum, 1998;19(2):159-60.
PMID: 9652215
Matched MeSH terms: Cause of Death
Fulltext Nutrition and cardiovascular disease: an Asia Pacific perspective

Khor GL

Asia Pac J Clin Nutr, 1997 Jun;6(2):122-42.
PMID: 24394715

Changes in the dietary intake patterns of countries in the Asia Pacific region are considered in relation to trends of cardiovascular disease mortality. Cardiovascular disease now constitutes the major cause of mortality in many of the countries of the region. The mortality rate for coronary heart disease (CHD) has been on the decline since the mid-1960s in countries such as Australia, New Zealand and Japan, while a decline in other countries, including Singapore and Hong Kong, appears to be occurring about two decades later after a delayed increase. In contrast, countries like Malaysia and China have had and continue an upward trend for CHD mortality. Nonetheless, the mortality rates due to CHD in New Zealand, Australia, Singapore followed by Hong Kong rank among the highest in the region. In China, Taiwan and Japan, death due to cerebrovascular disease remains a major cause of death, although the latter two countries have undergone a significant decline in stroke death rates since 1970. The intakes of fat from land animal products, fish and vegetable oils, depending on fatty acid patterns and, possibly other constituents, are candidate contributors to the different atherogenic and thrombotic effects. Countries which have a higher mortality from CHD tend to have a higher intake of energy from fat and proportion of fat from animal products. These fat intakes may operate to increase hypercholesterolemia and overweight in various countries. Again, intakes of other food items and constituents used in the region such as soybeans, dietary antioxidants in fruits, vegetables, seeds, cereals, nuts and tea and alcohol consumption are candidate cardio-protectants. The wide dietary scope of Asia Pacific populations, from diverse socio-cultural backgrounds, and at different levels of economic and technological development poses several analytic challenges and opportunities. Future research should improve the datasets and think laterally about pathogenesis and intervention.

Matched MeSH terms: Cause of Death
SLE mortality in an oriental population

Koh ET, Seow A, Leong KH, Chng HH

Lupus, 1997;6(1):27-31.
PMID: 9116715 DOI: 10.1177/096120339700600104

We analysed the causes of 67 deaths, over a 4 y period, in our oriental population with systemic lupus erythematosus (SLE). The median disease duration was 48 +/- 60.5 months (range 1-250 months). The mean age at diagnosis and death were 30 and 35.1 y respectively. SLE alone accounted for death in 30 patients (44.8%), infection in 27 (40.3%), pulmonary embolism in 5 (7.5%), malignancy in 4 (5.9%) and rheumatic heart disease in 1 (1.5%). The major organ involvement in those with active disease at death were SLE related thrombocytopenia (n = 23/44, 52.3%), nephritis (n = 21/44), 47.7%), cerebral lupus (n = 16/44, 36.4%), and pulmonary haemorrhage (n = 12/44, 27.3%). As in other series, SLE and infection were the principal causes of death in our population. During this 4 y period, there was no late death due to atherosclerosis.
Study site: Tan Tock Seng Hospital (TTSH), Singapore

Matched MeSH terms: Cause of Death
The pattern of chronic renal failure in Kelantan, northeastern state of Malaysia

Zainal D, Monniaty M, Nazmi N

Southeast Asian J. Trop. Med. Public Health, 1995 Dec;26(4):781-4.
PMID: 9139394

The pattern and outcome of patients with chronic renal failure (CRF) in Kelantan, the northeastern state of Malaysia was determined. A total of 60 patients with CRF managed at the Hospital Universiti Sains Malaysia between January 1991 and June 1993 were reviewed retrospectively. The prevalence of CRF was 24.8 patients per year. The ratio of male to female patients was 1.5 : 1.0. Their mean age at presentation was 51.4 +/- 13.7 years. The cause of CRF in majority of our patients was unknown. Their mean blood urea and serum creatinine were 38.9 +/- 9.8 mmol/l and 1,154.9 +/- 458.7 mumol/l respectively. Sixty-five percent of our patients were already in end-stage renal failure (ESRF) at the time of presentation and only 53.8% of them could afford a definitive renal replacement therapy. Their mortality rate was 21.7% and majority of the death occurred in patients who were not receiving definitive renal replacement therapy. This debilitating course will continue unless the cost of renal replacement therapy is subsidised or a renal transplantation program is activated. Hence public education to encourage organ donation in this part of Malysia is necessary.

Matched MeSH terms: Cause of Death
An outbreak of acute hepatic encephalopathy due to severe aflatoxicosis in Malaysia

Lye MS, Ghazali AA, Mohan J, Alwin N, Nair RC

Am J Trop Med Hyg, 1995 Jul;53(1):68-72.
PMID: 7625536

In October 1988, 13 Chinese children died of acute hepatic encephalopathy in the northwestern state of Perak in peninsular Malaysia. The acuteness of the illness differed from previously reported outbreaks described in Kenya, India, and Thailand. Epidemiologic investigations determined that the children had eaten a Chinese noodle, loh see fun, hours before they died. The attack rates among those who had eaten the noodles were significantly higher than those who had not (P < 0.0001). The cases were geographically scattered in six towns in two districts along the route of distribution of the noodle supplied by one factory in Kampar town. Aflatoxins were confirmed in postmortem samples from patients. This outbreak has important public health implications for many developing countries.

Matched MeSH terms: Cause of Death
Environmental problems of the tropical city: a brief overview

Badri MA

Southeast Asian J. Trop. Med. Public Health, 1992;23 Suppl 3:94-109.
PMID: 1342764
Matched MeSH terms: Cause of Death
Fulltext Cardiovascular mortality in Peninsular Malaysia: 1950-1989

Khoo KL, Tan H, Khoo TH

Med J Malaysia, 1991 Mar;46(1):7-20.
PMID: 1836041

Mortality statistics of Peninsular Malaysia for the period 1950-1989 have been studied in relation to cardiovascular diseases, with particular emphasis on coronary heart disease as an important cause of death. It was observed that among six major disease groups reviewed, cardiovascular diseases which occupied third place as a cause of death in 1950 emerged as the number one killer during the 1970s and has remained so since (with exception in 1980). In contrast, infectious diseases which ranked first in 1950 dropped to fourth position in 1980. Between 1960 and 1980, mortality due to cardiovascular diseases was higher in males than in females. This tendency became less apparent during 1985-1989. With reference to race, the incidence of cardiovascular deaths was highest in Indians followed by Chinese and Malays. Among the specific cardiovascular diseases, coronary heart and cerebrovascular diseases accounted for the main causes of mortality. Mortality due to coronary heart disease has increased by more than three fold over the last 40 years and is still rising. However, mortality incidence due to rheumatic heart disease and hypertension decreased during the same period. In 1965, mortality due to coronary heart disease was highest in the 55-59 age group. In recent years (1985 to 1989), it shifted to the older age group (i.e. 65-69). There was a tendency for higher mortality due to coronary heart disease in males compared to females. Indians had a higher mortality due to coronary heart disease than Chinese and Malays.

Matched MeSH terms: Cause of Death
Fulltext Identifying causes of Under Five mortality for better planning

Nur Syakirah Awai, Aminah Bee Mohd Kassim

Malaysian Journal of Medicine and Health Sciences, 2019;15(104):20-20.
MyJurnal

Introduction: Under 5 mortality is a leading indicator of the level of child health and overall development of a coun-try. In Malaysia, progressive reduction has been observed from 1990 however since 2000 progress has been static. Further understanding about this trend is crucial. The objective of this study was to identify causes of mortality for better policy development in order to further reduce this rate. Methods: Analysis of mortality trends was done using data from Department of Statistics and causes of mortality using data collected through the Stillbirth and Under 5 Mortality Reporting System (SU5MR) in 2016. Results: The trend for Under 5 mortality rate between 2006 till 2016 is still plateaued and hovered between 8 to 9 per 1000 live births at the national level. High percentage of death is seen among the neonatal group (51%), followed by children 28 days to 1year (31%) and toddlers 1-4 years (18%). Percentage of preventable deaths increased with age i.e. 21% among neonates, 41% among children 28 days to 1year and 48% among toddlers. The leading causes of death are conditions from perinatal period (34.4%), congen-ital malformation (30%), injuries and external causes (6.4%), respiratory (5.6%) and certain infectious and parasitic disease (5.1%). Conclusion: To further reduce under -5 mortality focus needs to be on preventable deaths; to reduce neonatal deaths will require political commitment to ensure adequate resources; interagency collaboration is needed to reduce toddler mortality and family and community awareness on prevention of injury and infection.

Matched MeSH terms: Cause of Death
Fulltext The use of collagen biomaterial in oral cancer: a systematic review

Muhammad Lutfi Mohamed Halim, Nora Azirah Mohd Zayi, Mohd Yusof Mohamad, Mohd Hafiz Arzmi

Malaysian Journal of Medicine and Health Sciences, 2019;15(108):33-33.
MyJurnal

Introduction: Oral cancer is the sixth most common malignancy in the world. It is a major concern in Southeast Asia primarily due to betel quid chewing, smoking, and alcohol consumption. In Malaysia, oral cancer related cases accounts for 1.55% of the cause of deaths. Despite recent advances in cancer diagnoses and therapies, the survival rate of oral cancer patients only reached 50% in the last few decades. Tissue engineering (TE) principles may pro-vide new technology platforms to study mechanisms of angiogenesis and tumour cell growth as well as potentially tumour cell spreading in cancer research. The use of biomaterial, appropriate cell source and proper signalling mol-ecules are vital components of TE. Collagen biomaterial are widely used scaffold or membrane in oral application. Nevertheless, no review has been performed on the its usage for the study of oral cancer. This study aimed to sys-tematically review the use of collagen scaffold in oral cancer application. Methods: Research articles were searched using Scopus, Pubmed and Web of Science (WOS) databases. The keywords were limited to “collagen membrane OR collagen scaffold” AND “oral cancer”. Results: Initial search yielded 61 papers (Scopus:37, Pubmed: 12, WOS: 12). Further scrutinization of the papers based on the inclusion criteria resulted total of 3 papers. Two of the papers used collagen membrane for regeneration of oral mucosal defect and increment of alveolar ridge height post-surgery. The remaining paper utilize collagen biomaterial as scaffold for the culture of adenoid cystic carcinoma (ACC) cells. All papers reported significant role of collagen biomaterial in terms of tissue formation, healing scaffold and cellular proliferation. Conclusion: Collagen utilization as biomaterial offers potential use for regeneration of oral related structures as well providing useful model for therapeutics anti-cancer research.

Matched MeSH terms: Cause of Death
Fulltext Induction of apoptosis and role of paclitaxel-loaded hyaluronic acid-crosslinked nanoparticles in the regulation of AKT and RhoA

Chaudhry GE, Akim A, Zafar MN, Abdullah MA, Sung YY, Muhammad TST

J Adv Pharm Technol Res, 2020 07 14;11(3):101-106.
PMID: 33102192 DOI: 10.4103/japtr.JAPTR_26_20

Cancer is a complex multifactorial disease and leading causes of death worldwide. Despite the development of many anticancer drugs, there is a reduced survival rate due to severe side effects. The nontargeted approach of convention drugs is one of the leading players in context to toxicity. Hyaluronan is a versatile bio-polymer and ligand of the receptor (CD44) on cancer cells. The MCF-7 and HT-29 cancer cell lines treated with hyaluronic acid-paclitaxel (HA-PTX) showed the distinguishing morphological features of apoptosis. Flow cytometric analysis showed that HA-PTX induces apoptosis as a significant mode of cell death. The activation level of tumor suppressor protein (p53) increased after PTX treatment in MCF-7, but no changes observed in HT-29 might be due to hereditary mutations. The lack of suppression in AKT and Rho A protein suggest the use of possible inhibitors in future studies which might could play a role in increasing the sensitivity of drug towards mutated cells line and reducing the possibilities for cancer cell survival, migration, and metastasis.

Matched MeSH terms: Cause of Death
Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a prospective cohort study

Dagenais GR, Leong DP, Rangarajan S, Lanas F, Lopez-Jaramillo P, Gupta R, et al.

Lancet, 2020 03 07;395(10226):785-794.
PMID: 31492501 DOI: 10.1016/S0140-6736(19)32007-0

BACKGROUND: To our knowledge, no previous study has prospectively documented the incidence of common diseases and related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) with standardised approaches. Such information is key to developing global and context-specific health strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate differences in the incidence of common diseases, related hospital admissions, and related mortality in a large contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised approaches.
METHODS: The PURE study is a prospective, population-based cohort study of individuals aged 35-70 years who have been enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the age-standardised and sex-standardised incidence of these events per 1000 person-years.
FINDINGS: This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years (IQR 8·5-10·9). During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease, 5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911 (1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease (COPD). Cardiovascular disease occurred more often in LICs (7·1 cases per 1000 person-years) and in MICs (6·8 cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries, COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3 deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest in HICs was observed for all causes of death except cancer, where mortality was similar across country income levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of deaths in HICs (vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile, Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular disease medication use were lowest in LICs and highest in HICs.
INTERPRETATION: Among adults aged 35-70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease, indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in many countries, mortality from cancer will probably become the leading cause of death. The high mortality in poorer countries is not related to risk factors, but it might be related to poorer access to health care.
FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).

Matched MeSH terms: Cause of Death

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