Background Alcohol consumption is known to be a significant risk factor for cancer. In 2025, the US Surgeon General recommended adding cancer risk warning labels to alcoholic beverages, emphasizing the need for increased awareness. However, national-level data describing long-term trends in alcohol-attributable cancer mortality, including variation by age, sex, and geographic region, remain limited. This study aims to evaluate trends in alcohol-attributable cancer mortality in the USA. Methods This was a population-based observational trend analysis using data from the Global Burden of Disease database. We analyzed age-standardized mortality rates (ASMRs) and the percentage of ASMR attributable to heavy alcohol use–defined as consumption exceeding the theoretical minimum risk exposure level, in the USA from 1990 to 2023. We evaluated ASMR for all cancers combined, followed by ten specific cancers. Results (per 100,000 population) were stratified by sex, location (50 states and Washington DC), and age-groups (20–54, 55 years and older). Joinpoint regression was performed using Monte Carlo permutation testing to select the optimal model; EAPCs were reported with 95% confidence intervals and two-sided p values. All rates are reported per 100,000 population. Findings Alcohol-attributable cancer deaths in the USA doubled from 1990 (11,361) to 2023 (23,126). Mortality rates were higher in the 55 years and older age-group (19.2; 95% CI, 12.8–28.7) versus 20–54 years (2.4; 1.4–3.4), and in males (6.4; 3.8–9.7) versus females (2.1; 1.4–3.0). The percentage of mortality attributable to alcohol increased across most cancer types, age groups, and sexes, with liver cancer demonstrating the greatest increase in alcohol-attributable (113.9%). In 2023, liver (12.7; 11.2–14.4) and breast (2.4; 0.9–5.9) cancers had the highest alcohol-related mortality rates in 55 years and older males and females, respectively; in ages 20–54, colorectal (0.9; 0.4–1.4) in males and breast (0.9; 0.5–1.4) in females were highest. State-wise, the District of Columbia recorded the highest (M: 9.8; 6.0–14.1; F: 3.5; 2.2–5.2), while Utah had the lowest (M: 3.9; 2.4–5.9; F: 1.4; 0.9–2.0) ASMR. Interpretation Alcohol-attributable cancer mortality has increased in the USA, with a disproportionate burden observed in males and 55 years and older individuals. Our findings highlight the critical need for targeted prevention efforts and increased awareness to address the rising impact of alcohol consumption on cancer-related mortality. Funding No funding received for this study.
In a diverse and developing country, higher education is often viewed as a critical pathway to social mobility and national development. Although universities worldwide are facing a student mental health crisis, Brazil and other countries from the Global South present unique structural and cultural features that add layers of complexity to this growing concern. In this Personal View, we examine the landscape of undergraduate student mental health in Brazil by tracing its roots in the country's higher education history and its contemporary consequences. We focus on the opposing dynamics of sector expansion and democratization of access since the 2000s, followed by intensified underfunding from the mid-2010s. We discuss how academic migration, growing ethnic/racial and socioeconomic diversity, financial and human resource constraints, and generational shifts have created demands that exceed institutional capacities. We identify key research gaps and conclude with a call to strengthen research, address structural determinants, and promote student mental health.
Background Population-based data on the epidemiology of primary biliary cholangitis (PBC) in Latin America are lacking. We aimed to characterise incidence, prevalence, and geographic patterns of PBC within Brazil's public healthcare system. Methods We performed a nationwide population-based retrospective study using de-identified administrative data from the Unified Health System (DATASUS), curated through an artificial intelligence platform. Adults (≥16 years) with ICD-10 code K74.3 and public dispensation of ursodeoxycholic acid between 1 January 2021 and 31 December 2024 were included. Annual World Health Organization (WHO) age-standardised incidence and prevalence were estimated by sex, age group, and macroregion. Temporal trends were modelled with log-linear regression to obtain average annual percent change (AAPC). Correlation with macroregional Human Development Index (HDI) was explored. Findings We identified 10,125 PBC patients [77.75% (7872) women; mean age 54.95 ± 20 years], within a nationwide dataset comprising approximately 230 million records. Age-standardised prevalence increased from 10.5 to 17.8 per 100,000 people (AAPC +18.2%; 95% CI: 12.5; 24.3%); while age-standardised incidence modestly declined from 4.00 to 3.42 per 100,000 person-years (AAPC −5.0%; 95% CI: −6.3; −3.7%). The female-to-male prevalence ratio in 2024 was 3.67:1, with peak rates at ages 66–70 years. A marked south–north gradient was observed, with highest rates in the South and Southeast and lowest in the North and Northeast; macroregional HDI showed a positive correlation with both incidence and prevalence. Interpretation In Brazil, PBC is characterised by rising prevalence, relatively stable incidence, a narrower female predominance than historically reported, and marked geographic inequalities. These findings suggest possible under-recognition in less developed regions and provide a foundation for targeted public health strategies. The observed south–north gradient warrants further investigation in relation to environmental, socioeconomic, and healthcare-access factors. Funding This study is supported by a research grant from IPSEN.
Summary: Background: Visceral adipose tissue (VAT) may causally contribute to cardiovascular disease (CVD); however, evidence in Latin America is limited. Here, we evaluated the association between estimated VAT (eVAT) and incident CVD among individuals without diabetes and estimated its population-attributable fraction (PAF) using data from the Cohorts Consortium of Latin America and the Caribbean (CC-LAC). Methods: We pooled data from 15 prospective cohorts across 7 countries (n = 23,097; 62% women [n = 14,383], median age 51 years). Baseline eVAT (in grams [g]) was estimated using the Metabolic Score for Visceral Fat (METS-VF) index, incorporating age, sex, an insulin resistance index, and waist-to-height ratio. The primary outcome was incident CVD events, including fatal and non-fatal outcomes. Cause-specific Cox proportional hazards models estimated adjusted hazard ratios (aHR). PAF estimates used scenario-based eVAT quartile reductions. Findings: Over a median follow-up of 4 years (113,622 person-years), 436 participants (1.9%) experienced an incident CVD event (174 fatal; 262 non-fatal). Uniformly age- and sex-standardized incidence rates were 3.8 (95% CI: 3.5–4.2) per 1000 person-years. Each 100 g increase in eVAT was associated with a 4% higher CVD hazard (aHR 1.04, 1.03–1.06). Compared with Q1 (<735 g), those in Q3 (1069–1441 g) and Q4 (≥1441 g) had a higher CVD hazard (Q3 aHR: 1.78 [1.28–2.49]; Q4 aHR: 2.03 [1.48–2.79]; p-for-trend <0.001). Associations were stronger for non-fatal events. In PAF estimates, shifting individuals from Q4 to lower quartiles could prevent 8.8% (2.8%–14.7%) of CVD events over 10 years. Interpretation: Higher eVAT was associated with increased CVD risk in Latin America, supporting the view that modest VAT reductions could decrease regional CVD burden. Funding: CC-LAC was funded by the Wellcome Trust.
Rheumatic heart disease (RHD) remains a significant public health challenge in Latin America, disproportionately affecting vulnerable populations despite global declines in disease prevalence and mortality. It is known that RHD affects over 55 million individuals worldwide, accounting for more than 390,000 deaths annually. However, region-specific RHD epidemiologic data are scarce, and most clinical studies on RHD epidemiology date back to the 1990s. On the other hand, the emergence of echocardiographic screening initiatives in the last decade reinforced the burden of the disease, revealing alarming rates of subclinical RHD in Latin American schoolchildren and young adults. This comprehensive review focused on epidemiologic data on RHD from Latin America and highlighted subgroups at highest risk for the disease.
Rheumatic heart disease (RHD) is a lifelong chronic condition with complex pathogenesis and major management challenges in regions where it is endemic. Therapeutic difficulties stem from the need for prolonged medical treatment and lifelong surgical planning in a predominantly young population. Gaps in our understanding of optimal medical and surgical treatment strategies persist, in part because clinically apparent RHD has become uncommon in high-income countries, where most therapeutic innovations historically originate, limiting research investment in this population. This review summarizes established and emerging aspects of the medical management of RHD, its major complications, and available surgical and transcatheter interventions with a focus on the mitral valve. Ongoing research continues to expand the evidence base for RHD care, but parallel efforts to strengthen health systems are essential to ensure effective delivery of available therapies. Sustained global collaboration, research partnerships, and policy initiatives are critical to improving outcomes for individuals living with RHD worldwide.
Rheumatic heart disease (RHD) remains a major cause of cardiovascular morbidity and premature mortality in low- and middle-income countries. This review examines RHD from an echocardiographic perspective, emphasizing how valve-specific phenotypes, hemodynamic burden, and disease progression shape clinical presentation, prognosis, and management. The evolution of echocardiography, from M-mode and two-dimensional imaging to Doppler, strain, and three-dimensional techniques, has transformed understanding of rheumatic valve disease and established imaging as central to diagnosis, risk stratification, and therapeutic guidance. Rheumatic mitral stenosis, in particular, served as a model for the development of key echocardiographic principles in valve morphology, hemodynamics, and intervention planning. Beyond anatomical severity, physiological variables such as exercise-induced pulmonary pressure changes and net atrioventricular compliance provide important prognostic information and better reflect functional impairment. Across the spectrum of disease, echocardiography remains fundamental for early detection, phenotypic characterization, longitudinal surveillance, and individualized management of RHD.
Background In low- and middle-income countries, reimbursement decisions often rely on projected incremental budget impact (IBI) analyses. We assessed whether drug incorporations into the Brazilian public health system (SUS) between 2012 and 2024 were consistent with affordability considerations within the health technology assessment (HTA) framework. Methods A retrospective documentary analysis was conducted using technical recommendation reports issued by the Brazilian National Committee for Health Technology Incorporation (Conitec). The primary variable was the total projected IBI of incorporated drugs. Subgroup analyses were performed by year of incorporation, health condition, and budget impact output. The proportion of total projected IBI relative to the Specialized Component of Pharmaceutical Care (CEAF) budget was assessed. Findings A total of 199 incorporated drugs were analyzed, 64 of which were projected to be cost-saving (Int$ 6·67 billion). These savings exceeded the total positive projected IBI generated by the remaining drugs (Int$ 4·05 billion). When COVID-19 vaccines were excluded, the cumulative projected IBI became positive, totaling Int$ 2·80 billion over the period analyzed, with sensitivity analyses yield estimates ranging from Int$ 2·36 billion to Int$ 2·88 billion. Preventable diseases exhibited the lowest median per capita IBI (Int$ 28; IQR Int$ 15; IQR Int$ 132), and oncological diseases the highest (Int$ 23,550; IQR Int$ 6789; IQR Int$ 57,154). Among drugs reimbursed exclusively by the Ministry of Health, the cumulative projected IBI represented 29% of the CEAF budget in 2024, exceeding 45% from 2019 to 2022. Interpretation The findings suggest that Conitec's decisions were consistent with HTA principles related to affordability. This interpretation is based on the evidence available at the time of the HTA decision rather than on observed real-world data following incorporation into the SUS. Funding None.
Background:In early 2025, the United States (U.S.) federal government issued several executive orders restricting healthcare access and non-discrimination protections for transgender and nonbinary (trans) populations. The current study investigated correlates of HIV prevention service disruptions among trans adults across five U.S. states. Methods:We analysed cross-sectional survey data of trans adults (Feb-April 2025) from the Priority Assessment in Trans Health Across States (PATHS2). This multi-state survey was conducted in five varying policy environments (Connecticut, Georgia, New York, Utah, and Washington). Analyses were restricted to participants currently using HIV prevention services, including PrEP (oral or long-acting) or HIV testing in the prior 12 months (N = 693). Main outcomes were (a) any HIV prevention service disruption (delayed or denied HIV prevention medications (PrEP: oral or long-acting), lost insurance or financial assistance coverage, reduced service availability, increased healthcare stigma) and (b) disruption breadth, modelled as ordinal (none/some [1-2 types]/significant [≥3 types]). Multivariable and ordinal logistic regressions assessed correlates across sociodemographic, psychosocial, and policy-related factors. Findings:Nearly two-thirds (64·5%, n = 447/693) of participants reported having experienced HIV prevention disruption; among this group. Among those reporting any disruption (n = 447), the most common disruption types included delayed/denied medications (53·2%, n = 238), reduced HIV service availability (50·3%, n = 225), lost coverage (40·9%, n = 183), and increased healthcare stigma (29·3%, n = 131). Compared with trans men, trans women had significantly higher odds of any disruption (aOR = 2·69, 95% CI 1·50-4·81) and greater disruption breadth (aOR = 1·85, 95% CI 1·16-2·93). Nonbinary individuals had elevated odds across all disruption types (aORs range = 2·99-6·58). Past-year discrimination was the strongest correlate of any disruption (aOR = 16·5, 95% CI 9·08-30·07) and breadth (aOR = 9·68, 95% CI 6·26-14·99). Black/African American participants had higher odds of any disruption compared with White participants (aOR = 2·17, 95% CI 1·06-4·46). State policy environment was not significantly associated with disruption in adjusted models. Interpretation:Past-year discrimination was the dominant correlate of disruption. State-level protective policies did not independently buffer against disruption in this short post-issuance window, suggesting that a federal policy shock of this magnitude may have exceeded the buffering capacity of state-level protections. Targeted, actionable responses, such as sustained funding for Black-trans-led community health organisations as trusted PrEP access points, anti-discrimination enforcement in healthcare, navigation services to maintain continuity of PrEP and prescription assistance during coverage instability, and insurance marketplace protections (e.g., Affordable Care Act) and programs (e.g., Medicaid, Ryan White) that explicitly prohibit gender-identity-based denials of HIV prevention coverage, are urgently needed. Funding:The Royalty Research Fund at the University of Washington.
Background:Appendicitis is a common surgical emergency and a leading cause of gastrointestinal hospital admission in Ecuador. However, its long-term national patterns have not been comprehensively characterized. We aimed to describe appendicitis-related hospital discharge rates, temporal and geographic variation, and in-hospital case-fatality in Ecuador during 2004-2024. Methods:We conducted a nationwide descriptive ecological study using publicly available, anonymized hospital discharge records from the Ecuadorian National Institute of Statistics and Censuses. The unit of temporal and geographic analysis was the canton-year. Discharges with a primary ICD-10 diagnosis of K35-K37 were included. Annual population denominators were used to calculate crude and age- and sex-specific hospital discharge rates per 100,000 population. In-hospital case-fatality was calculated as deaths among appendicitis-related discharges. Comparisons were descriptive and unadjusted. Findings:We identified 717,639 appendicitis-related discharges, including 378,080 (52.7%) among males and 339,559 (47.3%) among females, and 1179 in-hospital deaths (case-fatality 0.164%). Recorded ethnicity was Mestizo in 602,817 (84.0%), Indigenous in 12,918 (1.8%), other in 9329 (1.3%), White in 3588 (0.5%), and Afro-Ecuadorian in 2153 (0.3%); 23,682 (3.3%) were recorded in additional categories, including Montubio, and 63,152 (8.8%) were unknown or unrecorded. Discharge rates increased until 2018-19, declined in 2020, and only partially recovered by 2024. Rates were highest mainly among adolescents and young adults, and crude case-fatality varied across health-system characteristics. Interpretation:Appendicitis represents a substantial surgical burden in Ecuador. The observed temporal, geographic, and health-system variation supports strengthening timely diagnosis, referral pathways, and equitable surgical access. Findings are ecological and should not be interpreted causally. Funding:No funding.
Background:Cancer registries in Latin America continue to face challenges related to coverage, under-registration, and data quality. We evaluated childhood cancer epidemiology in Chile from 2007 to 2023, assessed the quality of the National Childhood Cancer Registry (RENCI) according to International Agency for Research on Cancer (IARC) standards, and described the childhood cancer control policy context. Methods:We analysed 8821 incident cases in children aged 0-14 years registered in RENCI and classified according to ICD-O-3.2 and ICCC-3. Incidence and mortality rates were age-standardised using the Segi world standard population. Mortality and years of potential life lost (YPLL) were estimated using national mortality data (2002-2021). Trends were assessed using Joinpoint regression and five-year observed survival using the Kaplan-Meier method. Registry quality was evaluated according to IARC criteria. Findings:Incidence increased from 137.4 to 143.0 per million (AAPC 1.36, 95% CI 0.5-2.4), with leukaemias remaining the most common cancer type (58.6 per million), followed by central nervous system tumours (24.8) and lymphomas (12.7). Five-year survival improved from 71.4% (95% CI 69.6-73.8) in 2007-2011 to 80.5% (95% CI 76.4-83.9) in 2020-2023. Mortality declined from 36.3 to 25.7 per million between 2002 and 2021 (AAPC -0.57, 95% CI -1.5 to 0.4). RENCI achieved 100% national coverage, an MV% of 93.5%, and a DCO% of 0.7%. Interpretation:This study describes the implementation and operation of a national population-based childhood cancer registry in a middle-income country and reports its epidemiological findings. Key findings include increasing incidence, improved survival in recent cohorts, and a non-significant downward trend in mortality. These results offer practical insights for other low- and middle-income countries seeking to strengthen childhood cancer surveillance systems. The descriptive nature of the study and the temporal (non-causal) associations observed should be considered when interpreting the findings. Funding:National Childhood Cancer Registry (RENCI) of the Ministry of Health of Chile.
Evidence on how health is incorporated into climate adaptation planning in Central America and the Caribbean remains limited. We conducted a scoping review following PRISMA-ScR guidelines to characterise how climate-health adaptation is reflected across planning documents from 20 countries in this region and the extent to which key dimensions are addressed. Official documents published between 2000 and 2025 were retrieved from the UNFCCC repository and government websites. A total of 147 national and seven cross-border planning documents were reviewed using a structured framework covering six dimensions: objectives, actions, disproportionately affected populations, costing and funding, monitoring and evaluation, and cross-border collaboration. Climate-health objectives and actions are widely included, followed by references to disproportionately affected populations, whereas only four countries reached the highest level of detail in costing and funding information, suggesting an area where future planning could support implementation and policy translation.
Messenger RNA (mRNA) technology helped prevent millions of deaths during the COVID-19 pandemic and is emerging as a promising cancer treatment modality. Early-phase trials suggest mRNA immunotherapies can improve overall and recurrence-free survival. However, the U.S. Department of Health and Human Services has terminated investment in this transformative platform. Although the funding cuts target infectious-disease vaccines, they could also slow broader research across the platform, with implications for cancer applications. To assess the potential public health and economic value of mRNA immunotherapies as cancer treatments, we combined early clinical trial evidence with incidence- and demographic-adjusted survival estimates from the National Cancer Institute's SEER program to project outcomes for non-small cell lung cancer, pancreatic cancer, renal cell carcinoma, and metastatic melanoma. We then applied the U.S. Department of Health and Human Services' Value of a Statistical Life Year ($604,246; 3% discount rate) to quantify the economic value associated with survival gains. Among U.S. patients diagnosed with these cancers in a single year, mRNA immunotherapies could avert an estimated 49,415 (95% CrI: 28,233-71,085) deaths. The corresponding economic value is estimated at $75.55 (95% CrI: $44.20-$103.43) billion, substantially exceeding the funding cut and highlighting the long-term value of continued innovation in mRNA-based therapeutics.
Background:While job loss is associated with adverse mental health, it is unclear if the relationship between job loss and mental health differs across pre-existing financial circumstances (objective financial status or subjective financial strain). Methods:We analyzed data from the nationally representative, longitudinal Cumulative Life Stressors Impact on Mental Health and Well-being study (2023-2024) conducted across the United States. We assessed associations between past-year job loss and probable depression (Patient Health Questionnaire-9, PHQ-9 ≥ 10), balancing on pre-job loss characteristics including objective financial status (USD, household savings ≥$5000) and subjective financial strain (difficulty meeting monthly bills). Propensity score weights were generated using a survey-weighted gradient boosted model. Generalized linear models estimated the odds ratio of probable depression by job loss group, overall and stratified by objective financial status and subjective financial strain. Findings:Among 1023 working-age adults, 79 (8.6%) experienced past-year job loss during the study period. Job loss was associated with higher odds of probable depression among adults with pre-existing subjective financial strain [Conditional Odds Ratio, cOR = 1.62 (95% Confidence Interval (CI): 1.01, 2.59)] but not in the group without subjective financial strain, although the formal test comparing estimates between strain groups was not statistically significant [3.72 (95% CI: 0.39, 35.43)]. Estimates were non-significant across objective financial status groups [<$5000 cOR = 1.56 (95% CI: 0.81, 3.02); ≥$5000 cOR = 1.43 (95% CI: 0.88, 2.32)]. Interpretation:Among working-age adults with pre-existing financial strain, job loss was associated with later probable depression. The presence or absence of $5000 or more in objective savings was not associated with differences in the association between job loss and probable depression. These findings suggest that subjective financial strain prior to job loss may be associated with differential mental health following job loss. Funding:The CLIMB study was supported in part by the de Beaumont Foundation, JHU Nexus Award, InHealth, Hopkins Business of Health Initiative Pilot Award, and Hopkins Center for Health Disparities Solutions Pilot Project Award.
