Background Antimicrobial resistance (AMR) poses a major threat to human health around the world. Previous publications have estimated the effect of AMR on incidence, deaths, hospital length of stay, and health-care costs for specific pathogen-drug combinations in select locations. To our knowledge, this study presents the most comprehensive estimates of AMR burden to date. MethodsWe estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with bacterial AMR for 23 pathogens and 88 pathogen-drug combinations in 204 countries and territories in 2019. We obtained data from systematic literature reviews, hospital systems, surveillance systems, and other sources, covering 471 million individual records or isolates and 7585 study-location-years. We used predictive statistical modelling to produce estimates of AMR burden for all locations, including for locations with no data. Our approach can be divided into five broad components: number of deaths where infection played a role, proportion of infectious deaths attributable to a given infectious syndrome, proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antibiotic of interest, and the excess risk of death or duration of an infection associated with this resistance. Using these components, we estimated disease burden based on two counterfactuals: deaths attributable to AMR (based on an alternative scenario in which all drugresistant infections were replaced by drug-susceptible infections), and deaths associated with AMR (based on an alternative scenario in which all drug-resistant infections were replaced by no infection). We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. We present final estimates aggregated to the global and regional level. FindingsOn the basis of our predictive statistical models, there were an estimated 4•95 million (3•62-6•57) deaths associated with bacterial AMR in 2019, including 1•27 million (95% UI 0•911-1•71) deaths attributable to bacterial AMR. At the regional level, we estimated the all-age death rate attributable to resistance to be highest in western sub-Saharan Africa, at 27•3 deaths per 100 000 (20•9-35•3), and lowest in Australasia, at 6•5 deaths (4•3-9•4) per 100 000. Lower respiratory infections accounted for more than 1•5 million deaths associated with resistance in 2019, making it the most burdensome infectious syndrome. The six leading pathogens for deaths associated with resistance (Escherichia coli, followed by Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa) were responsible for 929 000 (660 000-1 270 000) deaths attributable to AMR and 3•57 million (2•62-4•78) deaths associated with AMR in 2019. One pathogen-drug combination, meticillinresistant S aureus, caused more than 100 000 deaths attributa...

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Stomach content analyses were conducted on Atlantic salmon Salmo salar post-smolt (average size, 119-154 mm fork length, L F ) caught in eight large Norwegian fjord systems along a north-south geographical axis during 1998-2001. In general, post-smolts from southern Norway showed low feeding intensity in the fjords, whereas extensive feeding was observed in fjords in the northern and middle parts of Norway. The marine diet mainly included different crustaceans and in particular marine pelagic fish larvae (sand-eels Ammodytes spp., herring Clupea harengus and gadoids), but with a substantial spatial and annual variation in prey diversity and feeding intensity. Insects were most frequently taken in the estuary, although fishes often made a large contribution in mass. In contrast, fishes, and to some extent various crustaceans (particularly Hyperiidae, Gammaridae, Euphausiacea and Copepoda) dominated the diet in the middle and outer parts of the fjords, where post-smolts also fed more extensively than in the inner part. The results indicate that extensive feeding immediately after sea entrance may be more common for post-smolts in the northern and middle parts of Norway, than in the southern fjords. The observed differences in post-smolt feeding may be due to spatial and temporal differences in prey availability within and between the different types of fjord systems, and this might influence post-smolt growth and survival. # 2004 The Fisheries Society of the British Isles

Stomach samples from 1384 Atlantic salmon, collected from 1991 to 2003 in the Northeast Atlantic, were analysed to fill the gap between studies on post-smolt diet in fjords and coastal areas of the Northeast Atlantic and studies on the diet of pre-adults and adults in the Norwegian Sea. The post-smolts fed largely on 0-group fish. Blue whiting was an important prey only in the slope current transporting the larvae from the spawning areas west of the United Kingdom into the North and Norwegian Seas. Sandeel and herring were important or present in the stomachs throughout most of the area studied. Unusually large quantities of 0-group herring in the Norwegian Sea in summer 2002 coincided with a high condition factor of post-smolts that year. The forage ratio of the post-smolts was positively related to the proportion of herring in the stomachs and the abundance of herring recruits. Despite these findings, the most productive period for Atlantic salmon on record, the 1970s, coincided with the collapse of the Norwegian spring-spawning herring, which raises the question as to whether herring is more important as a competitor than as a food source. Hyperiid amphipods were more important prey than krill, in contrast to the situation for other pelagic fish species.

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Background Earlier age at menopause has been associated with increased risk of coronary heart disease (CHD), but the shape of association and role of established cardiovascular risk factors remain unclear. Therefore, we examined the associations between menopausal characteristics and CHD risk; the shape of the association between age at menopause and CHD risk; and the extent to which these associations are explained by established cardiovascular risk factors. Methods We used data from EPIC-CVD, a case–cohort study, which includes data from 23 centres from 10 European countries. We included only women, of whom 10 880 comprise the randomly selected sub-cohort, supplemented with 4522 cases outside the sub-cohort. We conducted Prentice-weighted Cox proportional hazards regressions with age as the underlying time scale, stratified by country and adjusted for relevant confounders. Results After confounder and intermediate adjustment, post-menopausal women were not at higher CHD risk compared with pre-menopausal women. Among post-menopausal women, earlier menopause was linearly associated with higher CHD risk [HRconfounder and intermediate adjusted per-year decrease = 1.02, 95% confidence interval (CI) = 1.01–1.03, p = 0.001]. Women with a surgical menopause were at higher risk of CHD compared with those with natural menopause (HRconfounder-adjusted = 1.25, 95% CI = 1.10–1.42, p < 0.001), but this attenuated after additional adjustment for age at menopause and intermediates (HR = 1.12, 95% CI = 0.96–1.29, p = 0.15). A proportion of the association was explained by cardiovascular risk factors. Conclusions Earlier and surgical menopause were associated with higher CHD risk. These associations could partially be explained by differences in conventional cardiovascular risk factors. These women might benefit from close monitoring of cardiovascular risk factors and disease.

Currently, no consistent evidence-based guidelines for the management of synchronous bilateral breast cancer (SBBC) exist and it is uncertain how presenting with SBBC affects patients' prognosis. We conducted a review of studies analyzing the association between SBBC and prognosis. The studies that reported adjusted effect measures were included in meta-analyses of effect of bilaterality on breast cancer mortality. From 57 initially identified records 17 studies from 11 different countries including 8,050 SBBC patients were included. The quality of the studies varied but was generally low with small sample sizes, and lack of consistent, detailed histo-pathological information. When doing meta-analysis on the subgroup of studies that provided adjusted effect estimates on breast cancer mortality (nine studies including 3,631 SBBC cases), we found that bilaterality in itself had a negative impact on prognosis after adjustment for known prognostic factors (pooled HR 1.37, 95 % CI 1.24-1.50, p < 0.0001). Multiple sensitivity analyses indicated robustness of the overall estimate. This review summarizes the current evidence of the association between SBBC and prognosis. The previously accepted convention that appropriate adjuvant treatment can be determined by considering the higher risk cancer was not confirmed in this review; rather it seems that being diagnosed with two tumors simultaneously entails a worse prognosis above and beyond that of the unilateral cancers of the same stage. To determine the true association between SBBC and breast cancer prognosis, studies of large and updated samples of SBBC should be done and include thorough histo-pathologic information.