Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: Quantifying the epidemiological transition

Background The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age–sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. Methods We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. Findings Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6–6·6), from 65·3 years (65·0–65·6) in 1990 to 71·5 years (71·0–71·9) in 2013, HALE at birth rose by 5·4 years (4·9–5·8), from 56·9 years (54·5–59·1) to 62·3 years (59·7–64·8), total DALYs fell by 3·6% (0·3–7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6–29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non–communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. Interpretation Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition—in which increasing sociodemographic status brings structured change in disease burden—is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5–89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Bearing capacity of cold-formed unlipped channels with restrained flanges under EOF and IOF load cases

Bearing failure is a form of localized failure that occurs when thin-walled cold-formed steel sections are subjected to concentrated loads or support reactions. To determine the bearing capacity of cold-formed channel sections, a unified design equation with different bearing coefficients is given in the current North American specification AISI S100 and the Australian/New Zealand standard AS/NZS 4600. However, coefficients are not available for unlipped channel sections that are normally fastened to supports through their flanges. Eurocode 3 Part 1.3 includes bearing capacity equations for different load cases, but does not distinguish between fastened and unfastened support conditions. Therefore, an experimental study was conducted to determine the bearing capacities of these sections as used in floor systems. Twenty-eight web bearing tests on unlipped channel sections with restrained flanges were conducted under End One Flange (EOF) and Interior One Flange (IOF) load cases. Using the results from this study, a new equation was proposed within the AISI S100 and AS/NZS 4600 guidelines to determine the bearing capacities of cold-formed unlipped channels with flanges fastened to supports. A new design rule was also proposed based on the direct strength method.

Crystal and molecular structure of the quinoxaline antibiotic analog TANDEM (des-N-tetramethyltriostin A)

The crystal structure of TANDEM (des-N-tetramethyltriostin A), a synthetic analogue of the quinoxaline antibiotic triostin A, has been determined independently at -135 and 7 'C and refined to R values of 0.088 and 0.147, respectively. The molecule has approximate 2-fold symmetry, with the quinoxaline chromophores and the disulfide cross-bridge projecting from opposite sides of the peptide ring. The quinoxaline groups are nearly parallel to each other and separated by about 6.5 A. The peptide backbone resembles a distorted antiparallel 13 ribbon joined by intramolecular hydrogen bonds N-H(LVal)--O(L-Ala). At low temperatures, the TANDEM molecule is surrounded by a regular first- and second-order hydration sphere containing 14 independent water molecules. At room temperature, only the first-order hydration shell is maintained. Calculations of the interplanar separation of the quinoxaline groups as a function of their orientation with respect to the peptide ring support the viability of TANDEM to intercalate bifunctionally into DNA.

Guests at Sophie Oppenheimer's 70th birthday celebration Portraits Groups

Handwritten on verso: (top l-r) Heinz Marcus, Hilde Marcus, Heinz Ascher, Else Stern, Gerhard Ascher, Hattie Wallerstein, Kurt Stern, Paula Stern, Lula Ascher and Hilde Marcus; (second row l-r) Otto Oppenheimer, Heinrich Ascher, Julius Stern, David Wallerstein, Max Marcus, Alex Goldschmidt and Ernst Oppenheimer; (third row l-r) Rose, Hans Oppenheimer, Gertrud Ascher, Oma Oppenheimer, Emma, Martha, Lene, Lucy, Hans, Lore; (front row l-r) Margot Ascher, Heinz Ascher, Golda Ascher, Edith Goldschmidt, Irma Ascher, Lotti Goldschmidt, Gretl Oppenheimer and Ilse Oppenheimer

Portrait of Alice Bendix Portraits Women

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Portrait of Alice Bendix outdoors Portraits Women

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Portrait of Elizabeth Kitzinger Portraits Women

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Hedwig Jacobi, Alice Bendix, Anna Renner and Klara Mayer Portraits Groups Women

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Portrait of Caecilie Witkowski nee Seligsohn Portraits Women

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Portrait of Moritz and Helene Leffmann Portraits Couples

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Portrait of unidentified woman Portraits Women

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Portrait of unidentified man Portraits Men

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Wedding portrait of Adolf Wolff and Eva Nathan with guests; Berlin, Germany.

Back row against wall, left to right: Josef Molling, Margaret Molling nee Benjamin, Werner Wolff, Miss Hermann (called "Ferna", Peter Molling's governess), " Selma" (partially hidden, Anna Marianne/Berthold Nathan's cook), "Lisbeth" (Anna Marianne/Berthold's maid), Ilse Joachim, Ernst Joachim, Annemarie Nathan (3rd wife of Julius Nathan), Julius Nathan (brother of Berthold Nathan), Ernst Kallmes (son of Ceilchen nee Wolff, Helene's sister). Very tall against the wall: Max Benjamin (son of Helene). Third row, left to right: Mathilde Kaufmann nee Benjamin, Adolf Molling, Paul Nathan (son of Anna Marianne/Berthold), Marianne Rasmussen (daughter of Waldemar), Hildegard Weinberger (friend of bride), Herta Albrecht (friend of bride), Dr. Franz Gruenberg (friend of groom), Leonie Wolff nee Simon (wife of Werner Wolff), Lina Molling nee Marx (wife of Richard), Waldemar Benjamin-Rasmussen (son of Helene/David), Luzi's Husband, Minka Bernard nee Nathan (sister of Berthold Nathan), Richard Molling (brother of Claerchen), Albert Wolff (brothter of Moritz Wolff). Second row, seated, left to right: Helene Benjamin nee Wolff, Berthold Nathan, Anna Marianne Nathan nee Benjamin, bride Eva Wolff nee Nathan, groom Adolf Wolff, Claerchen Wolff nee Molling, Moritz Wolff, standing Luzi Rasmussen nee Gruen (wife of Waldemar). Front row, children on floor, left to right: Peter Molling, Elizabeth Benjamin-Rasmussen mar. Engel, Louis Peter Wolff, Helmut Benjamin Rasmussen (became Henry)

Family portrait taken in a garden on the 75th birthday of Henriette Gottschalk nee Rothschild.

Front row, from left to right: Fritz Gottschalk, Walter Gottschalk, Kurt Gottschalk, Ursula Gottschalk, Hans Ludwig (Hal) Gottschalk, Rudolf Gottschalk, Elizabeth Gottschalk; babies, from left to right: Ilse Gottschalk, Freddy Gottschalk; adults, from left to right: Karl Gottschalk, Elisabeth Gottschalk nee Steinfeld, Ernst Gottschalk, Henriette Gottschalk nee Rothschild, Therese Gottschalk nee Molling, Fritz Joseph Gottschalk