Cancer frequency detected by positron emission tomography-computed tomography in limbic encephalitis

OBJECTIVE

Paraneoplastic limbic encephalitis (LE) occurs frequently with considerable variability according to literature reports. We thus determined the cancer frequency in mixed LE subtypes sharing the diagnosis of temporal lobe epilepsy (TLE).

METHODS

All patients underwent magnetic resonance imaging (MRI) of the brain, electroencephalography (EEG) recordings, neuropsychological testing, immunohistochemistry, and clinical examination together with whole body 2-fluor-2-desoxy-d-glucose (FDG)-positron emission tomography (PET)/computed tomography (CT) to detect cancer in this observatory study.

RESULTS

Ninety-three patients (median: 52 years) with TLE due to autoimmune LE were investigated. Cancer was detected in the FDG-PET/CTs of 3 out of 93 (3.2%) patients with LE. Cancer was diagnosed upon, 5 years earlier and 5 years after FDG-PET/CT in 7 of 93 (7.5%) of all patients with LE. The cancer frequency in those patients was significantly lower than that reported in the largest series of patients with LE associated with and without different antibodies (7.5% vs. 23.5%, Bootstrap test, p < 0.05), but was indistinguishable from the estimated age-dependent cancer frequency in the German regional North-Rhine-Westfalian population without LE in 2014 (Chi-square test: p = 0.2).

CONCLUSIONS

Our findings reveal that the cancer frequency in patients with TLE with LE detected by FDG-PET/CT is low and not different from the age-dependent natural cancer occurrence in a regional population.

Hypoxia and tumor angiogenesis in the era of hepatocellular carcinoma transarterial loco-regional treatments

This review focuses upon interactions and potential therapeutic targets in the ‘vicious cycle’ between hypoxia and neoangiogenesis following treatment of hepatocellular carcinoma with transarterial loco-regional therapies. Biomarkers correlated with angiogenesis have been studied by many authors as prognostic determinants following transarterial intrahepatic therapy. According to these results future therapies directed toward specific factors related to angiogenesis could play a significant role in preventing local tumor recurrence and remote metastasis.

Epidemiology and determinants of type 2 diabetes in south Asia

Type 2 diabetes has rapidly developed into a major public health problem in south Asia (defined here as Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka) in recent decades. During this period, major lifestyle changes associated with economic transition, industrialisation, urbanisation, and globalisation have been key determinants in the increasing burden of non-communicable diseases. A decline in nutrition quality, reduced physical activity, and increased sedentary behaviours are reflected in the increasing prevalence of type 2 diabetes and related risk factors in the region. The International Diabetes Federation 2017 estimates of the prevalence of diabetes in adults in the region range from 4·0% in Nepal to 8·8% in India. The prevalence of overweight ranges from 16·7% in Nepal to 26·1% in Sri Lanka, and the prevalence of obesity ranges from 2·9% in Nepal to 6·8% in Sri Lanka. An increasing proportion of children, adolescents, and women are overweight or obese, leading to a heightened risk of type 2 diabetes. Ethnic south Asians present with greater metabolic risk at lower levels of BMI compared with other ethnic groups (referred to as the south Asian phenotype), with type 2 diabetes often developing at a younger age, and with rapid progression of diabetic complications. Because of the presence of multiple risk factors and a body composition conducive to the development of type 2 diabetes, south Asians should be aggressively targeted for prevention. In this Series paper, we detail trends in the prevalence of diabetes in the region and address major determinants of the disease in the context of nutrition and physical activity transitions and the south Asian phenotype.

The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Alcohol and drug use can have negative consequences on the health, economy, productivity, and social aspects of communities. We aimed to use data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 to calculate global and regional estimates of the prevalence of alcohol, amphetamine, cannabis, cocaine, and opioid dependence, and to estimate global disease burden attributable to alcohol and drug use between 1990 and 2016, and for 195 countries and territories within 21 regions, and within seven super-regions. We also aimed to examine the association between disease burden and Socio-demographic Index (SDI) quintiles.

METHODS

We searched PubMed, EMBASE, and PsycINFO databases for original epidemiological studies on alcohol and drug use published between Jan 1, 1980, and Sept 7, 2016, with out language restrictions, and used DisMod-MR 2.1, a Bayesian meta-regression tool, to estimate population-level prevalence of substance use disorders. We combined these estimates with disability weights to calculate years of life lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 1990-2016. We also used a comparative assessment approach to estimate burden attributable to alcohol and drug use as risk factors for other health outcomes.

FINDINGS

Globally, alcohol use disorders were the most prevalent of all substance use disorders, with 100·4 million estimated cases in 2016 (age-standardised prevalence 1320·8 cases per 100 000 people, 95% uncertainty interval [95% UI] 1181·2-1468·0). The most common drug use disorders were cannabis dependence (22·1 million cases; age-standardised prevalence 289·7 cases per 100 000 people, 95% UI 248·9-339·1) and opioid dependence (26·8 million cases; age-standardised prevalence 353·0 cases per 100 000 people, 309·9-405·9). Globally, in 2016, 99·2 million DALYs (95% UI 88·3-111·2) and 4·2% of all DALYs (3·7-4·6) were attributable to alcohol use, and 31·8 million DALYs (27·4-36·6) and 1·3% of all DALYs (1·2-1·5) were attributable to drug use as a risk factor. The burden of disease attributable to alcohol and drug use varied substantially across geographical locations, and much of this burden was due to the effect of substance use on other health outcomes. Contrasting patterns were observed for the association between total alcohol and drug-attributable burden and SDI: alcohol-attributable burden was highest in countries with a low SDI and middle-high middle SDI, whereas the burden due to drugs increased with higher S DI level.

INTERPRETATION

Alcohol and drug use are important contributors to global disease burden. Effective interventions should be scaled up to prevent and reduce substance use disease burden.

FUNDING

Bill & Melinda Gates Foundation and Australian National Health and Medical Research Council.

Baohuoside-I suppresses cell proliferation and migration by up-regulating miR-144 in melanoma

CONTEXT

Baohuoside-I was reported to induce apoptosis in non-small-cell lung cancer and inhibit the growth of multiple myeloma cells. The antitumour potential of baohuoside-I has not been demonstrated in melanoma yet.

OBJECTIVE

To investigate the potential antitumour activity of baohuoside-I against melanoma and elucidate its underlying molecular mechanism.

MATERIALS AND METHODS

Cell viability was evaluated by MTT assay. The malignant invasion capacity was measured with trans-well assay. The relative expression change of microRNAs was profiled with microarray. TargetScan was utilized for prediction of target gene of miR-144. Regulatory effect of miR-144 on SMAD1 was determined by dual luciferase reporter assay. Endogenous SMAD1 protein in response to ectopic expression of miR-144 was determined by immunoblotting. Xenograft mice were employed to evaluate antitumour potential of baohuoside-I (25 mg/kg by tail intravenous injection every two days) in vivo.

RESULTS

Baohuoside-I significantly inhibited proliferation (45 ± 4% reduction in M14 and 35 ± 3% reduction in MV3 at 24 h) and migration (70 ± 4% reduction in M14 and 72 ± 3% reduction in MV3) in melanoma cells. Mechanistically, baohuoside-I up-regulated miR-144 expression levels (3 ± 0.2-fold). Silence of miR-144 reversed the inhibition of baohuoside-I in melanoma. We have identified that SMAD1 was the novel target of miR-144. Moreover, baohuoside-I suppressed melanoma in vivo (52 ± 8% reduction in xenograft tumour size at day 20).

CONCLUSIONS

Our data suggested significant antitumour potential of baohuoside-I against melanoma both in vitro and in vivo, which warrants further laboratory investigation and clinical trial.

Deciphering the paradoxical incidence of cancer in schizophrenia

OBJECTIVES:

The incidence of cancer in schizophrenia has been an area of controversy. The current article aims to provide a commentary outlining the contradictory findings of incidence of cancer in schizophrenia as well as discuss the available theories linking cancer with schizophrenia and address the methodological issues of the studies which could lead to the discrepant findings.

METHOD:

A literature search was carried out primarily using the electronic database of MEDLINE through PubMed using the search terms 'cancer' and 'schizophrenia'. Google Scholar was used to supplement the search.

RESULTS:

The findings were inconclusive, with studies documenting increased, decreased as well as no risk of cancer in patients with schizophrenia, compared with the general population. Several methodological limitations exist with regard to measures of assessment, sample size and selection bias.

CONCLUSIONS:

The association between cancer and schizophrenia remains controversial. Genetic as well as environmental theories exist explaining the paradoxical incidence of cancer in schizophrenia. The methodological factors could contribute to the discrepant findings.

Mortality burden attributable to PM1 in Zhejiang province, China

BACKGROUND

Limited evidence is available on the health effects of particulate matter with an aerodynamic diameter of <1 μm (PM₁), mainly due to the lack of its ground measurement worldwide.

OBJECTIVES

To identify and examine the mortality risks and mortality burdens associated with PM₁, PM_2.5, and PM₁₀ in Zhejiang province, China.

METHODS

We collected daily data regarding all-cause (stratified by age and gender), cardiovascular, stroke, respiratory, and chronic obstructive pulmonary disease (COPD) mortality, and PM₁, PM_2.5, and PM₁₀, from 11 cities in Zhejiang province, China during 2013 and 2017. We used a quasi-Poisson regression model to estimate city-specific associations between mortality and PM concentrations. Then we used a random-effect meta-analysis to pool the provincial estimates. To show the mortality burdens of PM₁, PM_2.5, and PM₁₀, we calculated the mortality fractions and deaths attributable to these PMs.

RESULTS

Daily concentrations of PM₁, PM_2.5, and PM₁₀ ranged between 0-199 μg/m³, 0-218 μg/m³, and 0-254 μg/m³, respectively; Mortality effects were significant in lag 0-2 days. The relative risks for all-cause mortality were 1.0064 (95% CI: 1.0034, 1.0094), 1.0061 (95% CI: 1.0034, 1.0089), and 1.0060 (95% CI: 1.0038, 1.0083) associated with a 10 μg/m³ increase in PM₁, PM_2.5, and PM₁₀, respectively. Age- and gender-stratified analysis shows that elderly people (aged 65+) and females are more sensitive to PMs. The mortality fractions of all-cause mortality were estimated to be 2.39% (95% CI: 1.28, 3.48) attributable to PM₁, 2.53% (95% CI: 1.42, 3.63) attributable to PM_2.5, and 3.08% (95% CI: 1.95, 4.19) attributable to PM₁₀. The ratios of attributable cause-specific deaths for PM₁/PM_2.5, PM₁/PM₁₀, and PM_2.5/PM₁₀ were higher than the ratios of their respective concentrations.

CONCLUSIONS

PM₁, PM_2.5 and PM₁₀ are risk factors of all-cause, cardiovascular, stroke, respiratory, and COPD mortality. PM₁ accounts for the vast majority of short-term PM_2.5- and PM₁₀-induced mortality. Our analyses support the notion that smaller size fractions of PM have a more toxic mortality impacts, which suggests to develop strategies to prevent and control PM₁ in China, such as to foster strict regulations for automobile and industrial emissions.

Hearing Impairment and Type 1 Diabetes in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Cohort

OBJECTIVE

To evaluate the prevalence of hearing impairment in participants with type 1 diabetes enrolled in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study and compare with that of a spousal control group without diabetes. Among participants with type 1 diabetes, to evaluate the association of hearing impairment with prior DCCT therapy and overall glycemia.

RESEARCH DESIGN AND METHODS

DCCT/EDIC participants (n = 1,150) and 288 spouses without diabetes were recruited for the DCCT/EDIC Hearing Study. All subjects completed a self-administered questionnaire, medical history, and physical measurements. Audiometry was performed by study-certified personnel; audiograms were assessed centrally. Speech-frequency (pure-tone average [PTA] thresholds at 500, 1,000, 2,000, and 4,000 Hz) and high-frequency impairment (PTA thresholds at 3,000, 4,000, 6,000, and 8,000 Hz) were defined as PTA >25 dB hearing loss. Logistic regression models were adjusted for age and sex.

RESULTS

DCCT/EDIC participants and spousal control subjects were similar in age, race, education, smoking, and systolic blood pressure. There were no statistically significant differences between groups in the prevalence or adjusted odds of speech- or high-frequency impairment in either ear. Among participants with type 1 diabetes, for every 10% increase in the time-weighted mean HbA_1c, there was a 32% (95% CI 1.15-1.50) and 19% (95% CI 1.07-1.33) increase in speech- and high-frequency hearing impairment, respectively.

CONCLUSIONS

We found no significant difference in the prevalence of hearing impairment between the group with type 1 diabetes and the spousal control group. Among those with type 1 diabetes, higher mean HbA_1c over time was associated with hearing impairment.

Smoking cessation after engagement in HIV care in rural Uganda

People living with HIV (PLWH) are more likely to smoke compared to HIV-uninfected counterparts, but little is known about smoking behaviors in sub-Saharan Africa. To address this gap in knowledge, we characterized smoking cessation patterns among people living with HIV (PLWH) compared to HIV-uninfected individuals in rural Uganda. PLWH were at least 40 years of age and on antiretroviral therapy for at least three years, and HIV-uninfected individuals were recruited from the clinical catchment area. Our primary outcome of interest was smoking cessation, which was assessed using an adapted WHO STEPS smoking questionnaire. We fit Cox proportional hazards models to compare time to smoking cessation between PLWH pre-care, PLWH in care, and HIV-uninfected individuals. We found that, compared to HIV-uninfected individuals, PLWH in care were less likely to have ever smoked (40% vs. 49%, p = 0.04). The combined sample of 267 ever-smokers had a median age of 56 (IQR 49-68), 56% (n = 150) were male, and 26% (n = 70) were current smokers. In time-to-event analyses, HIV-uninfected individuals and PLWH prior to clinic enrollment ceased smoking at similar rates (HR 0.8, 95% CI 0.5-1.2). However, after enrolling in HIV care, PLWH had a hazard of smoking cessation over twice that of HIV-uninfected individuals and three times that of PLWH prior to enrollment (HR 2.4, 95% CI 1.3-4.6, p = 0.005 and HR 3.0, 95% CI 1.6-5.5, p = 0.001, respectively). In summary, we observed high rates of smoking cessation among PLWH after engagement in HIV care in rural Uganda. While we hypothesize that greater access to primary care services and health counseling might contribute, future studies should better investigate the mechanism of this association.

Dairy Consumption and Cardiometabolic Diseases: Systematic Review and Updated Meta-Analyses of Prospective Cohort Studies

PURPOSE OF REVIEW

Dairy products contain both beneficial and harmful nutrients in relation to cardiometabolic diseases. Here, we provide the latest scientific evidence regarding the relationship between dairy products and cardiometabolic diseases by reviewing the literature and updating meta-analyses of observational studies.

RECENT FINDINGS

We updated our previous meta-analyses of cohort studies on type 2 diabetes, coronary heart disease (CHD), and stroke with nine studies and confirmed previous results. Total dairy and low-fat dairy (per 200 g/d) were inversely associated with a 3-4% lower risk of diabetes. Yogurt was non-linearly inversely associated with diabetes (RR = 0.86, 95% CI: 0.83-0.90 at 80 g/d). Total dairy and milk were not associated with CHD (RR~1.0). An increment of 200 g of daily milk intake was associated with an 8% lower risk of stroke. The latest scientific evidence confirmed neutral or beneficial associations between dairy products and risk of cardiometabolic diseases.

Prevalence of the cardiovascular health status in adults: A systematic review and meta-analysis

BACKGROUND AND AIMS

The American Heart Association has outlined seven cardiovascular health (CVH) metrics, including smoking, body mass index, physical activity, dietary pattern, total cholesterol, and fasting plasma glucose, to define and monitor CVH status. Our study was to evaluate the global CVH in adults.

METHODS AND RESULTS

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and reference lists of relevant articles for studies published between 1 January 2010 and 30 June 2018. Included studies should report the proportions of ideal status for the seven CVH metrics and/or provide the prevalence of overall poor (having 0-2 ideal metrics) or ideal (having 5-7 ideal metrics) CVH status in adults. 88 articles were identified: 75 for the prevalence of ideal CVH metrics, 58 for the proportion of overall poor CVH status, and 55 for the proportion of overall ideal CVH status. Smoking had the highest prevalence of ideal status (69.1%) while dietary pattern has the lowest (12.1%). 32.2% and 19.6% of participants had overall poor and ideal CVH, respectively. Females and young adults had better CVH status when compared to males and older adults. There existed regional variations in ideal CVH metrics and overall CVH status. The overall CVH status had improved over study time.

CONCLUSION

The prevalence of ideal status was low for some metrics, such as dietary pattern, and the overall CVH status was still unsatisfactory. We should continue to measure the CVH status and carry out lifestyle interventions to improve the CVH status in the whole population.

Particulate matter air pollution and respiratory impact on humans and animals

Air pollution is now fully acknowledged to be a public health problem and a social issue. Particulate matter (PM) concentration has been linked with several clinical manifestations of pulmonary and cardiovascular diseases and is associated with morbidity and mortality induced by respiratory diseases both in human and animals. Current research on airborne particle-induced health effects investigates the critical characteristics of particulate matter that determine their biological effects. Scientific evidence assessed that the size of the airborne particles and their surface area determine the potential to elicit inflammatory injury, oxidative damage, and other biological effects. Thus, the present review paper aims to summarize the current evidences and findings on the effect of air pollution on lung function in both humans and animals.

The burden associated with ambient PM2.5 and meteorological factors in Guangzhou, China, 2012-2016: A generalized additive modeling of temporal years of life lost

BACKGROUND

Daily exposure to ambient particulate matter with aerodynamic diameter <2.5 μm (PM_2.5) increases deaths and is an important contributor to burden of disease in population. To better understand the disease burden associated with PM_2.5, we examined the effects of PM_2.5 on daily years of life lost (YLL) in Guangzhou, China.

METHODS

Using Guangzhou death registry, air pollution and meteorological database, we applied generalized additive models (GAM) to the relationships between YLL and PM_2.5. We then adjusted the models for age, gender, seasonality and meteorological variables. We also conducted within-data prediction of YLL while setting 2012-2014 as baseline.

RESULTS

Over 2 million YLLs (800,137 YLLs for females and 1,212,040 YLLs for males) were observed during 2012-2016. YLL was higher for the elderly people. Mean daily average PM_2.5 concentration was 47.3 μg/m³. In model comparisons, the GAM with six meteorological variables (sunshine hours, relative humidity, precipitation, atmospheric pressure, wind speed, evaporation) outperformed the others. The R² and total deviance were 0.542 and 53.0%, respectively. Non-linear trends were observed for PM_2.5 and meteorological variables. Fitted daily YLL increased to the highest level, when PM_2.5 concentration reached 134.3 μg/m³ and atmospheric pressure reached 99.4 kPa. Within-data prediction supported the fitted GAM, where low mean absolute percentage errors were observed.

CONCLUSIONS

Daily PM_2.5 exposure has a nonlinear effect on YLL and increased levels of PM_2.5 may lead to increased YLL. This study highlights the urge to reduce ambient PM_2.5 pollution in Guangzhou, in order to promote environmental health.

Is There a Neurologist in the House? A Summary of the Current State of Neurovascular Rotations for Emergency Medicine Residents

OBJECTIVES

Neurovascular and neurocritical care emergencies constitute a leading cause of morbidity/mortality. There has been great evolution in this field, including but not limited to extended time-window therapeutic interventions for acute ischemic stroke. The intent of this article is to evaluate the goals and future direction of clinical rotations in neurovascular and neurocritical care for emergency medicine (EM) residents.

METHODS

A panel of 13 board-certified emergency physicians from the Society for Academic Emergency Medicine (SAEM) neurologic emergencies interest group (IG) convened in response to a call for publications-three with fellowship training/board certification in stroke and/or neurocritical care; five with advanced research degrees; three who have been authors on national practice guidelines; and six who have held clinical duties within neurology, neurosurgery, or neurocritical care. A mixed-methods analysis was performed including a review of the literature, a survey of Council of Emergency Medicine Residency Directors (CORD) residency leaders/faculty and SAEM neuro-IG members, and a consensus review by this panel of select neurology rotations provided by IG faculty.

RESULTS

Thirteen articles for residency neurovascular education were identified: three studies on curriculum, three studies evaluating knowledge, and seven studies evaluating knowledge after an educational intervention. Intervention outcomes included the ability to recognize and manage acute strokes, manage intracerebral hemorrhage, calculate National Institutes of Health Stroke Scale (NIHSS), and interpret images. In the survey sent to CORD residency leaders and neuro-IG faculty, response was obtained from 48 programs. A total of 52.1% indicated having a required rotation (6.2% general neurology, 2% stroke service, 18.8% neurologic intensive care unit, 2% neurosurgery, 22.9% on a combination of services). The majority of programs with required rotations have a combination rotation (residents rotate through multiple services) and evaluations were positive.

CONCLUSIONS

Variability exists in the availability of neurovascular/neurocritical care rotations for EM trainees. Dedicated clinical time in neurologic education was beneficial to participants. Given recent advancements in the field, augmentation of EM residency training in this area merits strong consideration.

Effects of maternal body mass index on pregnancy outcome after 8570 artificial insemination cycles with donor's sperm

Increased body mass index (BMI) might have an adverse effect on pregnancy. However, the influence of BMI on the pregnancy outcomes after artificial insemination with donor's sperm (AID) had been rarely reported. This study aimed to investigate the correlation between BMI and AID. The pregnancy outcome of 8570 AID cycles was retrospectively analyzed. BMI was categorized as underweight (<18.5 kg/m²; group A), normal weight (18.5-23.9 kg/m²; group B), overweight (24-27.9 kg/m²; group C), and obese (≥28 kg/m²; group D). The results showed that cumulative pregnancy rate and cumulative live birth rate in groups A, B, C and D tended to decrease as BMI increased; however, abortion rate, and ectopic pregnancy rate in groups A, B, C, and D exhibited a gradual increase in the tendency. Cesarean delivery rate also increased as BMI increased. Birth defect rate in the group D were significantly higher than that in the group A. Interestingly, the pregnancy rate was gradually decreased with increasing age in groups A, B, and C, but this was not observed in the group D. The findings suggested that BMI can affect the pregnancy outcomes after AID; it is important to achieve a normal BMI prior to AID treatments.

Attitudes toward epilepsy among medical staffs in basic-level hospitals from southern China

OBJECTIVE

The objectives of the study were to assess attitudes toward epilepsy among medical staffs from basic-level hospitals in southern China and identify significant predictive factors for future stigma reduction interventions.

METHODS

The Public Attitudes Toward Epilepsy (PATE) scale, a two dimensional 14-item scale addressing two major domains: general domain and personal domain, was administered to 448 medical staffs from basic-level hospitals in southern China. Positively stated items in the PATE scale were reversely scored; in this case, a higher score would indicate a more negative attitude. Also, we compared the overall score and per-item scores of the medical staffs versus those of the general population reported in the previous studies using the same scale.

RESULTS

The cumulative score of the medical staffs was 41.65 ± 6.99, which is significantly lower as compared with 51.38 ± 6.80 of the general population (t (645) = -16.473, p < 0.001). The general average score (t (645) = -16.473, p < 0.001) and the mean score in the general domain (t (645) = -22.573, p < 0.001) of the PATE scale were both significantly lower in the medical staffs compared with the general population, whereas there was no significant difference between the two groups in the personal domain (t(645) = -0.180, p = 0.857). Age or years in clinical practice, specialty, and title had a significant impact on both the general domain and personal domain. Residence was the only factor found affecting the medical staffs' attitudes toward epilepsy in the personal domain but not in the general domain.

CONCLUSION

Medical staffs from basic-level hospitals in southern China demonstrate significant positive attitudes toward people with epilepsy in general aspects when compared with the general population. However, they still showed negative and conservative attitudes when it comes to the personal domain. Future strategies for stigma-reducing public interventions could focus on increasing better understanding of epilepsy among medical staffs in basic-level hospitals in China.

Low quality cardiovascular care is important coronary risk factor in India

Global Burden of Disease study has reported that cardiovascular and ischemic heart disease (IHD) mortality has increased by 34% in last 25 years in India. It has also been reported that despite having lower coronary risk factors compared to developed countries, incident cardiovascular mortality, cardiovascular events and case-fatality are greater in India. Reasons for the increasing trends and high mortality have not been studied. There is evidence that social determinants of IHD risk factors are widely prevalent and increasing. Epidemiological studies have reported low control rates of hypertension, hypercholesterolemia, diabetes and smoking/tobacco. Registries have reported greater mortality of acute coronary syndrome in India compared to developed countries. Secondary prevention therapies have significant gaps. Low quality cardiovascular care is an important risk factor in India. Package of interventions focusing on fiscal, intersectoral and public health measures, improvement of health services at community, primary and secondary healthcare levels and appropriate referral systems to specialized hospitals is urgently required.

Physical activity levels and associated cardiovascular disease risk factors among postmenopausal rural women of Bangladesh

OBJECTIVES

The role of physical inactivity in relation to cardiovascular disease (CVD) among postmenopausal women is understudied. The main objective of this study was to measure the physical activity levels (PALs) and evaluate its relation to other CVD risk factors among postmenopausal rural women of Bangladesh.

METHODS

A cross-sectional study was conducted among 265 postmenopausal women aged 40-70 years who visited the outpatient department of a primary health-care center situated in the village Karamtola of Gazipur district. A pretested modified questionnaire of STEP-wise approach to Surveillance (STEPS) of noncommunicable disease risk factors was used to collect data on sociodemographic and lifestyle factors. PAL was determined by the Estimated Energy Requirement (EER) equation of the Dietary Reference Intakes (DRIs) Committee, and association with CVD risk factors was examined by Spearman's rank correlation.

RESULTS

More than half (58.1%) of the postmenopausal women were identified as sedentary with high prevalence of central obesity (73.2%) among them. CVD risk factors including age (r = -0.228, p < 0.01), age at menopause (r = -0.129, p < 0.05), duration of menopause (r = -0.183, p < 0.05), 2-h plasma glucose (r = -0.148, p < 0.05), total cholesterol (r = -0.138, p < 0.05), low-density lipoprotein cholesterol (r = -0.122, p < 0.05), and triglyceride (r = -0.168, p < 0.01) showed a significant as well as inverse association with Metabolic Equivalent of Task (MET) of physical activity.

CONCLUSION

Low PAL and significant inverse correlation with various CVD risk factors demand interventions to maintain higher PAL among postmenopausal women of Bangladesh.

Cancer Tsunami: Emerging Trends, Economic Burden, and Perioperative Implications

PURPOSE OF REVIEW

This review discusses global trends in cancer mortality and survival, the socioeconomic drivers of those trends, and recent innovations in cancer surgery.

RECENT FINDINGS

Cancer is a leading cause of death worldwide. Cancer, previously a disease primarily of wealthy countries, is rapidly becoming a leading cause of death in low- and middle-income countries. Major economic forces driving global cancer trends include aging, frailty, and obesity. Alcohol consumption, poor diet, and lack of exercise also contribute to cancer types associated with modifiable causes. Surgery is responsible for 65% of cancer care globally, providing an opportunity for anesthesiologists to improve that care. Anesthesiologists can contribute to cancer remission through perioperative interventions that reduce risk of metastasis and speed return to intended oncologic therapy.

SUMMARY

Cancer surgery comprises a large proportion of anesthetic caseload. Good outcomes come from high volume cancer centers using a multidisciplinary approach.

Global, regional, and national burden of meningitis, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Acute meningitis has a high case-fatality rate and survivors can have severe lifelong disability. We aimed to provide a comprehensive assessment of the levels and trends of global meningitis burden that could help to guide introduction, continuation, and ongoing development of vaccines and treatment programmes.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2016 study estimated meningitis burden due to one of four types of cause: pneumococcal, meningococcal, Haemophilus influenzae type b, and a residual category of other causes. Cause-specific mortality estimates were generated via cause of death ensemble modelling of vital registration and verbal autopsy data that were subject to standardised data processing algorithms. Deaths were multiplied by the GBD standard life expectancy at age of death to estimate years of life lost, the mortality component of disability-adjusted life-years (DALYs). A systematic analysis of relevant publications and hospital and claims data was used to estimate meningitis incidence via a Bayesian meta-regression tool. Meningitis deaths and cases were split between causes with meta-regressions of aetiological proportions of mortality and incidence, respectively. Probabilities of long-term impairment by cause of meningitis were applied to survivors and used to estimate years of life lived with disability (YLDs). We assessed the relationship between burden metrics and Socio-demographic Index (SDI), a composite measure of development based on fertility, income, and education.

FINDINGS

Global meningitis deaths decreased by 21·0% from 1990 to 2016, from 403 012 (95% uncertainty interval [UI] 319 426-458 514) to 318 400 (265 218-408 705). Incident cases globally increased from 2·50 million (95% UI 2·19-2·91) in 1990 to 2·82 million (2·46-3·31) in 2016. Meningitis mortality and incidence were closely related to SDI. The highest mortality rates and incidence rates were found in the peri-Sahelian countries that comprise the African meningitis belt, with six of the ten countries with the largest number of cases and deaths being located within this region. Haemophilus influenzae type b was the most common cause of incident meningitis in 1990, at 780 070 cases (95% UI 613 585-978 219) globally, but decreased the most (-49·1%) to become the least common cause in 2016, with 397 297 cases (291 076-533 662). Meningococcus was the leading cause of meningitis mortality in 1990 (192 833 deaths [95% UI 153 358-221 503] globally), whereas other meningitis was the leading cause for both deaths (136 423 [112 682-178 022]) and incident cases (1·25 million [1·06-1·49]) in 2016. Pneumococcus caused the largest number of YLDs (634 458 [444 787-839 749]) in 2016, owing to its more severe long-term effects on survivors. Globally in 2016, 1·48 million (1·04-1·96) YLDs were due to meningitis compared with 21·87 million (18·20-28·28) DALYs, indicating that the contribution of mortality to meningitis burden is far greater than the contribution of disabling outcomes.

INTERPRETATION

Meningitis burden remains high and progress lags substantially behind that of other vaccine-preventable diseases. Particular attention should be given to developing vaccines with broader coverage against the causes of meningitis, making these vaccines affordable in the most affected countries, improving vaccine uptake, improving access to low-cost diagnostics and therapeutics, and improving support for disabled survivors. Substantial uncertainty remains around pathogenic causes and risk factors for meningitis. Ongoing, active cause-specific surveillance of meningitis is crucial to continue and to improve monitoring of meningitis burdens and trends throughout the world.

FUNDING

Bill & Melinda Gates Foundation.

Prevalence of cardiovascular risk factors in schoolchildren from a rural and urban area in Colombia

Introduction: Cardiovascular risk factors (CVRF) have their origin in childhood. Several studies have shown differences in the prevalence of CVRFs between rural and urban areas, probably related to lifestyle behaviors. Objective: To describe the CVRFs identified in children from a rural and urban population in Colombia. Materials and methods: A cross-sectional study was conducted between March and June 2013 in schoolchildren from an urban and a rural area in Colombia. Weight, height, blood pressure, triglycerides, fasting glucose, and total cholesterol were measured, and a survey covering nutrition, physical activity, and passive smoking was applied. The prevalence of CVRFs was calculated with a 95% CI. Results: A total of 1,055 schoolchildren (833 urban, 222 rural) participated; their mean age was 6.71 years. The prevalence of CVRFs in the rural and the urban study population, respectively, was 68.69%/90.16% for sedentary lifestyle, 97.18%/95.44% for unhealthy diet, 11.16%/14.52% for passive smoking, 0%/5.64% for obesity, 6.31%/11.28% for hypertension, 0%/0% for diabetes, and 18.28%/16.31% for total cholesterol. A total of 99.15% of the study population had at least one CVRF, with an average of 3.14 for the urban area (SD:1.12), and of 2.76 for the rural one (SD: 1.1). Overweight children had a higher prevalence of hypertension (15.21%; 95% CI:11.04%-20.59%) and sedentary lifestyle (90.69%), compared to those without this risk factor (8.98% and 84.32%, respectively). Conclusions: Our results showed a high prevalence of CVRFs in children, especially in the urban area. Public health strategies adapted to the rural and urban populations should be implemented.

Course of subthreshold depression into a depressive disorder and its risk factors

BACKGROUND

Information on the natural course of subthreshold depression and risk factors for the development of a full-blown depressive disorder in the general population is scarce. This information is crucial to understand the development of depression and to advance indicated depression prevention.

METHODS

Using longitudinal data from a representative population-based study (the Netherlands Mental Health Survey and Incidence Study-2) we assessed 3-year course of subthreshold depression (depressive symptoms causing clinically significant distress for at least 2 weeks, or for 3 days per month for a year; n = 120), compared to an asymptomatic group (n = 4111) and a depressive disorder group (major depression or dysthymia; n = 294). Next, risk factors for the development of a depressive disorder among adults with subthreshold depression were determined.

RESULTS

Twelve percent of the subthreshold cases developed a full-blown depressive disorder during 3-year follow-up. Risk factors were lower social support, having recurrent short episodes of depressive symptomatology, remitted and current anxiety disorder, remitted substance use disorder, lifetime suicide thoughts, a chronic physical disorder and diminished mental and physical functioning.

LIMITATIONS

The number of subjects with subthreshold depression that developed a depressive disorder was small. This limits the possibility to detect significant risk factors.

CONCLUSION

Only a minority of the subthreshold cases developed a full-blown depressive disorder over three years. This shows that subthreshold depression does not, by itself, carry an a priori risk to warrant focusing indicated prevention. The identified risk factors could help to detect those subthreshold cases in whom depression prevention is economically and practically viable.

Anthelmintic drug actions in resistant and susceptible C. elegans revealed by electrophysiological recordings in a multichannel microfluidic device

Many anthelmintic drugs used to treat parasitic nematode infections target proteins that regulate electrical activity of neurons and muscles: ion channels (ICs) and neurotransmitter receptors (NTRs). Perturbation of IC/NTR function disrupts worm behavior and can lead to paralysis, starvation, immune attack and expulsion. Limitations of current anthelmintics include a limited spectrum of activity across species and the threat of drug resistance, highlighting the need for new drugs for human and veterinary medicine. Although ICs/NTRs are valuable anthelmintic targets, electrophysiological recordings are not commonly included in drug development pipelines. We designed a medium-throughput platform for recording electropharyngeograms (EPGs)-the electrical signals emitted by muscles and neurons of the pharynx during pharyngeal pumping (feeding)-in Caenorhabditis elegans and parasitic nematodes. The current study in C. elegans expands previous work in several ways. Detecting anthelmintic bioactivity in drugs, compounds or natural products requires robust, sustained pharyngeal pumping under baseline conditions. We generated concentration-response curves for stimulating pumping by perfusing 8-channel microfluidic devices (chips) with the neuromodulator serotonin, or with E. coli bacteria (C. elegans' food in the laboratory). Worm orientation in the chip (head-first vs. tail-first) affected the response to E. coli but not to serotonin. Using a panel of anthelmintics-ivermectin, levamisole and piperazine-targeting different ICs/NTRs, we determined the effects of concentration and treatment duration on EPG activity, and successfully distinguished control (N2) and drug-resistant worms (avr-14; avr-15; glc-1, unc-38 and unc-49). EPG recordings detected anthelmintic activity of drugs that target ICs/NTRs located in the pharynx as well as at extra-pharyngeal sites. A bus-8 mutant with enhanced permeability was more sensitive than controls to drug treatment. These results provide a useful framework for investigators who would like to more easily incorporate electrophysiology as a routine component of their anthelmintic research workflow.

The effect of socioeconomic deprivation on the association between an extended measurement of unhealthy lifestyle factors and health outcomes: a prospective analysis of the UK Biobank cohort

BACKGROUND

Combinations of lifestyle factors interact to increase mortality. Combinations of traditional factors such as smoking and alcohol are well described, but the additional effects of emerging factors such as television viewing time are not. The effect of socioeconomic deprivation on these extended lifestyle risks also remains unclear. We aimed to examine whether deprivation modifies the association between an extended score of lifestyle-related risk factors and health outcomes.

METHODS

Data for this prospective analysis were sourced from the UK Biobank, a prospective population-based cohort study. We assigned all participants an extended lifestyle score, with 1 point for each unhealthy lifestyle factor (incorporating sleep duration and high television viewing time, in addition to smoking, excessive alcohol, poor diet [low intake of oily fish or fruits and vegetables, and high intake of red meat or processed meats], and low physical activity), categorised as most healthy (score 0-2), moderately healthy (score 3-5), or least healthy (score 6-9). Cox proportional hazards models were used to examine the association between lifestyle score and health outcomes (all-cause mortality and cardiovascular disease mortality and incidence), and whether this association was modified by deprivation. All analyses were landmark analyses, in which participants were excluded if they had an event (death or cardiovascular disease event) within 2 years of recruitment. Participants with non-communicable diseases (except hypertension) and missing covariate data were excluded from analyses. Participants were also excluded if they reported implausible values for physical activity, sleep duration, and total screen time. All analyses were adjusted for age, sex, ethnicity, month of assessment, history of hypertension, systolic blood pressure, medication for hypercholesterolaemia or hypertension, and body-mass index categories.

FINDINGS

328 594 participants aged 40-69 years were included in the study, with a mean follow-up period of 4·9 years (SD 0·83) after the landmark period for all-cause and cardiovascular disease mortality, and 4·1 years (0·81) for cardiovascular disease incidence. In the least deprived quintile, the adjusted hazard ratio (HR) in the least healthy lifestyle category, compared with the most healthy category, was 1·65 (95% CI 1·25-2·19) for all-cause mortality, 1·93 (1·16-3·20) for cardiovascular disease mortality, and 1·29 (1·10-1·52) for cardiovascular disease incidence. Equivalent HRs in the most deprived quintile were 2·47 (95% CI 2·04-3·00), 3·36 (2·36-4·76), and 1·41 (1·25-1·60), respectively. The HR for trend for one increment change towards least healthy in the least deprived quintile compared with that in the most deprived quintile was 1·25 (95% CI 1·12-1·39) versus 1·55 (1·40-1·70) for all-cause mortality, 1·30 (1·05-1·61) versus 1·83 (1·54-2·18) for cardiovascular disease mortality, and 1·10 (1·04-1·17) versus 1·16 (1·09-1·23) for cardiovascular disease incidence. A significant interaction was found between lifestyle and deprivation for all-cause and cardiovascular disease mortality (both p_interaction<0·0001), but not for cardiovascular disease incidence (p_interaction=0·11).

INTERPRETATION

Wide combinations of lifestyle factors are associated with disproportionate harm in deprived populations. Social and fiscal policies that reduce poverty are needed alongside public health and individual-level interventions that address a wider range of lifestyle factors in areas of deprivation.

FUNDING

None.

Wasting in Chronic Kidney Disease – a Complex Issue

Chronic kidney disease (CKD) has become a global health burden and is associated with increased morbidity and mortality. In particular, wasting is highly prevalent in later stages of the illness with muscle loss being a common problem. The aetiology and progression of this wasting is complex and multiple states have been identified linked to wasting in CKD. These include: ‘malnutrition’, ‘disease-related malnutrition’, ‘protein-energy wasting’, ‘cachexia’, ‘sarcopenia’, ‘frailty’ and ‘muscle wasting’. The purpose of this paper is to review these terms in the context of CKD. Common features include weight loss, loss of muscle mass and muscle function principally driven by CKD disease specific factors and inflammatory mediators. Disease-related malnutrition would appear to be a more appropriate term for CKD than malnutrition as it take in to consideration disease specific factors such as inflammation for example.  Frailty is commonly associated with age-related decline in physiological function. Development of novel screening tools measuring across multiple domains of nutritional status, muscle and physical function may be useful in CKD. Research into potential treatments are currently underway with focus on multi-modal therapies including nutrition, resistance training and anabolic drugs such as myostatin blockade and selective androgen receptor modulators. A better understanding of different states and terms may help guide assessment and treatment opportunities for patients.

Clinical presentation, risk factors and outcome of central nervous system metastasis vs stroke in cancer patients

BACKGROUND AND PURPOSE

Cancer and stroke are the second and third causes of death worldwide; brain metastases (BM) occur in one third of patients with cancer, any neurologic deficit in these population always prompts the clinician to discard metastases for their presence carries a bad outcome. Both might share clinical presentation and differences in their outcome are not entirely known. The aim was to compare risk factors, clinical presentation, and outcome of cancer patients with BM vs stroke.

METHODS

A descriptive study with prospectively acquired data from a cancer referral center included patients seen at the neuro-oncologic unit from March 2011 to February 2018 with confirmed cancer who had BM or stroke.

RESULTS

Six hundred and thirteen BM patients were compared with 268 with stroke and cancer. Demographic factors, cancer type, risk factors, clinical presentation, and outcome are presented. Median overall survival in months for those with any stroke was 15 (95%confidence interval [CI] 8.6-21.4)-5 (95%CI 0.12.4) for hemorrhagic stroke and 22 (95%CI 13.4-30.6) in the ischemic group-and for those with BM 12 (95%CI 10.4-13.6). Hemorrhagic stroke commonly found in stroke patients as well as focal motor weakness, aphasia, and altered mental status. BM was more common in breast and lung cancer with headache, visual complaint, and/or vertigo.

CONCLUSION

Survival in cancer patients with BM is not that different than those with stroke, but clinical presentation and risk factors were found different.

The future of disc surgery and regeneration

Low back and neck pain are among the top contributors for years lived with disability, causing patients to seek substantial non-operative and operative care. Intervertebral disc herniation is one of the most common spinal pathologies leading to low back pain. Patient comorbidities and other risk factors contribute to the onset and magnitude of disc herniation. Spine fusions have been the treatment of choice for disc herniation, due to the conflicting evidence on conservative treatments. However, re-operation and costs have been among the main challenges. Novel technologies including cage surface modifications, biologics, and 3D printing hold a great promise. Artificial disc replacement has demonstrated reduced rates of adjacent segment degeneration, need for additional surgery, and better outcomes. Non-invasive biological approaches are focused on cell-based therapies, with data primarily from preclinical settings. High-quality comparative studies are needed to evaluate the efficacy and safety of novel technologies and biological therapies.

Integrated LAMP and immunoassay platform for diarrheal disease detection

The challenges of diagnosing infectious disease, especially in the developing world, and the shortcomings of available instrumentation have exposed the need for portable, easy-to-use diagnostic tools capable of detecting the wide range of causative microbes while operating in low resource settings. We present a centrifugal microfluidic platform that combines ultrasensitive immunoassay and isothermal amplification-based screening for the orthogonal detection of both protein and nucleic acid targets at the point-of-care. A disposable disc with automatic aliquoting inlets is paired with a non-contact heating system and precise rotary control system to yield an easy-to-use, field-deployable platform with versatile screening capabilities. The detection of three enterotoxins (cholera toxin, Staphylococcal enterotoxin B, and Shiga-like toxin 1) and three enteric bacteria (C. jejuni, E. coli, and S. typhimurium) were performed independently and shown to be highly sensitive (limit of detection = 1.35-5.50 ng/mL for immunoassays and 1-30 cells for isothermal amplification), highly exclusive in the presence of non-specific targets, and capable of handling a complex sample matrix like stool. The full panel of toxins and bacteria were reliably detected simultaneously on a single disc at clinically relevant sample concentrations in less than an hour. The ability of our technology to detect multiple analyte types in parallel at the point-of-care can serve a variety of needs, from routine patient care to outbreak triage, in a variety of settings to reduce disease impact and expedite effective treatment.

Pelvic Organ Prolapse Symptoms in American Samoan Women

OBJECTIVES

American Samoa has one of the highest rates of obesity worldwide, making it a population at high risk for pelvic organ prolapse (POP). The primary objective of this study was to describe the presence of POP symptoms and associated degree of bother in American Samoan women. The secondary objective was to determine which characteristics are associated with POP symptoms in this cohort.

METHODS

We performed a cross-sectional survey of women presenting to the waiting room of the emergency department of the Lyndon B. Johnson Tropical Medical Center in Faga'alu, American Samoa from February to March 2017. Questions included self-described characteristics and the Pelvic Organ Prolapse Distress Inventory 6. Univariate distributions were described and comparisons of social and health characteristics were made between women without POP symptoms and those with at least 1 POP symptom.

RESULTS

Two hundred eighty-four women were approached and 225 women completed the survey (79% response rate). The mean (SD) age was 40.5 (14.7), the mean (SD) body mass index was 36.4 (8.7), and the median (range) number of vaginal births was 2 (0-14). A total of 44.2% endorsed at least 1 POP symptom, most commonly pelvic pressure (29.9%) and feeling of incomplete bladder emptying (26.7%). The number of vaginal births was associated with lower abdominal pressure (P = 0.04) and hysterectomy was associated with pelvic heaviness (P = 0.05).

CONCLUSIONS

This is the first study investigating POP in American Samoa. Almost half of women reported at least 1 pelvic floor symptom, demonstrating the need for further research on pelvic floor disorders within this high-risk population.

Effects of Nursing Quality Improvement on Thrombolytic Therapy for Acute Ischemic Stroke

Background and purpose: Intravenous thrombolytic therapy significantly improves the outcomes of acute ischemic stroke patients in a time-dependent manner. The aim of this study was to investigate whether continuous nursing quality improvement in stroke nurses has a positive effect on reducing the time to thrombolysis in acute ischemic stroke.

Methods: The implementation of nursing quality improvement measures includes establishing full-time stroke nurses, pre-notification by emergency medical services (EMS), stroke team notification protocols, rapid triage, publicity and education, etc. Using a history-controlled approach, we analyzed acute ischemic stroke patients with intravenous thrombolysis during a pre-intervention period (April 1, 2015-July 31, 2016), trial period (August 1, 2016-October 31, 2016), and post-intervention period (November 1, 2016-September 30, 2017). This was done in accordance with the implementation of nursing quality improvement measures, including the general characteristics of the three groups, the time of each step in the process of thrombolysis, and the prognosis.

Results: After the implementation of nursing quality improvement measures, the median door-to-needle time (DNT) was shortened from 73 min (interquartile range [IQR] 62–92 min) to 49 min (IQR 40-54 min; p < 0.001) in the post-intervention period. The median onset-to-needle time (ONT) was reduced from 193 min (IQR 155–240 min) to 167 min (IQR 125-227 min; p < 0.001). The proportion of patients with DNT ≤ 60 min increased from 23.94% (51/213) to 86.36% (190/220; p < 0.001) while the proportion of patients with DNT ≤ 40 min increased from 3.29% (7/213) to 25.00% (55/220; p < 0.001). The median time for door-to-laboratory results was decreased from 68 min to 56 min (p < 0.001). There was no significant difference in the fatality rate, 90-day modified Rankin score, length of stay or hospitalization expenses between the three groups of patients (p> 0.05).

Conclusions: Implementation of nursing quality improvement measures in stroke nurses is an important factor in shortening the time of medication in patients with thrombolytic therapy, reducing the delay of intravenous thrombolysis in the hospital and helping to expedite presenting patients' arrival to the hospital post-stroke.

The Global Burden of Musculoskeletal Pain-Where to From Here?

To summarize the current understanding of the global burden of musculoskeletal pain-related conditions, consider the process of evidence generation and the steps to generate global pain estimates, identify key gaps in our understanding, and propose an agenda to address these gaps, we performed a narrative review. In the 2010 Global Burden of Disease Study (GBD), which broadened the scope of musculoskeletal conditions that were included over previous rounds, low back pain imposed the highest disability burden of all specific conditions assessed, and subsequent GBD reports further reinforce the size of this burden. Over the past decade, the GBD has produced compelling evidence of the leading contribution of musculoskeletal pain conditions to the global burden of disability, but this has not translated into global health policy initiatives. However, system- and service-level responses to the disease burden persist across high-, middle-, and low-income settings. There is a mismatch between the burden of musculoskeletal pain conditions and appropriate health policy response and planning internationally that can be addressed with an integrated research and policy agenda.

Potential benefits of triage for the trauma patient in a Kenyan emergency department

BACKGROUND

Improved trauma management can reduce the time between injury and medical interventions, thus decreasing morbidity and mortality. Triage at the emergency department is essential to ensure prioritization and timely assessment of injured patients. The aim of the present study was to investigate how a lack of formal triage system impacts timely intervention and mortality in a sub-Saharan referral hospital. Further, the study attempts to assess potential benefits of triage towards efficient management of trauma patients in one middle income country.

METHODS

A prospective descriptive study was conducted. Adult trauma patients admitted to the emergency department during an 8-month period at Moi Teaching and Referral Hospital in Eldoret, Kenya, were included. Mode of arrival and vital parameters were registered. Variables included in the analysis were Injury Severity Score, time before physician's assessment, length of hospital stay, and mortality. The patients were retrospectively categorized according to the Rapid Emergency Triage and Treatment System (RETTS) from patient records.

RESULTS

A total of 571 patients were analyzed, with a mean Injury Severity Score of 12.2 (SD 7.7) with a mean length of stay of 11.6 (SD 18.3) days. The mortality rate was 1.8%. The results obtained in this study illustrate that trauma patients admitted to the emergency department at Eldoret are not assessed in a timely fashion, and the time frame recommendations postulated by RETTS are not adhered to. Assessment of patients according to the triage algorithm used revealed a significantly higher average Injury Severity Score in the red category than in the other color categories.

CONCLUSION

The results from this study clearly illustrate a lack of correct prioritization of patients in relation to the need for timely assessment. This is further demonstrated by the retrospective triage classification of patients, which identified patients with high ISS as in urgent need of care. Since no significant difference in to time to assessment regardless of injury severity was observed, the need for a well-functioning triage system is apparent.

In vivo multiplex molecular imaging of vascular inflammation using surface-enhanced Raman spectroscopy

Vascular immune-inflammatory responses play a crucial role in the progression and outcome of atherosclerosis. The ability to assess localized inflammation through detection of specific vascular inflammatory biomarkers would significantly improve cardiovascular risk assessment and management; however, no multi-parameter molecular imaging technologies have been established to date. Here, we report the targeted in vivo imaging of multiple vascular biomarkers using antibody-functionalized nanoparticles and surface-enhanced Raman scattering (SERS).

Methods: A series of antibody-functionalized gold nanoprobes (BFNP) were designed containing unique Raman signals in order to detect intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1) and P-selectin using SERS.

Results: SERS and BFNP were utilized to detect, discriminate and quantify ICAM-1, VCAM-1 and P-selectin in vitro on human endothelial cells and ex vivo in human coronary arteries. Ultimately, non-invasive multiplex imaging of adhesion molecules in a humanized mouse model was demonstrated in vivo following intravenous injection of the nanoprobes.

Conclusion: This study demonstrates that multiplexed SERS-based molecular imaging can indicate the status of vascular inflammation in vivo and gives promise for SERS as a clinical imaging technique for cardiovascular disease in the future.

Availability and affordability of priority life-saving medicines for under-five children in health facilities of Tigray region, northern Ethiopia

Background

In developing countries, child health outcomes are influenced by the non-availability of priority life-saving medicines at public sector health facilities and non-affordability of medicines at private medicine outlets. This study aimed to assess availability, price components and affordability of priority life-saving medicines for under-five children in Tigray region, Northern Ethiopia.

Methods

A cross-sectional study was conducted in Tigray region from December 2015 to July 2016 using a standard method developed by the World Health Organization and Health Action International (WHO/HAI). Data on the availability and price of 27 priority life-saving medicines were collected from 31 public and 10 private sectors. Availability and prices were expressed in percent and median price ratios (MPRs), respectively. Affordability was reported in terms of the daily wage of the lowest-paid unskilled government worker.

Results

The overall availability of priority life-saving drugs in this study was low (34.1%). The average availabilities of all surveyed medicines in public and private sectors were 41.9 and 31.5%, respectively. The overall availability of medicines for malaria was found to be poor with average values of 29.3% for artemisinin combination therapy tablet, 19.5% for artesunate injection and 0% for rectal artesunate. Whereas, the availability of oral rehydration salt (ORS) and zinc sulphate dispersible tablets for the treatment of diarrhea was moderately high (90% for ORS and 82% for zinc sulphate). Medicines for pneumonia showed an overall percent availability in the range of 0% (ampicillin 250 mg and 1 g powder for injection and oxygen medicinal gas) to 100% (amoxicillin 500 mg capsule). The MPRs of 12 lowest price generic medicines were 1.5 and 2.7 times higher than the international reference prices (IRPs) for the private and public sectors, respectively. About 30% of priority life-saving medicines in the public sector and 50% of them in the private sector demanded above a single daily wages to purchase the standard treatment of the prevalent diseases of children.

Conclusions

The lower availability, high price and low affordability of lowest price generic priority life-saving medicines in public and private sectors reflect a failure to implement the health policy on priority life-saving medicines in the region.

Oral Cancer Screening among Smokers and Nonsmokers

Aims and Objectives:

The aim of visual systematic screening is early identification of oral cancer (OC) precursor lesion. OC mortality improves when cancer is identified at early stages. This is important in patients whose lifestyle choices render them at higher risk of developing OC. This study described the prevalence of OC screening among smokers and nonsmokers in Kuwait and ascertained demographic predictors.

Materials and Methods:

This cross-sectional study utilized a self-administered online survey in English and Arabic through Survey Monkey^® and disseminated using the social networking app “WhatsApp.” The survey included 21 questions on demographics, smoking status, and knowledge of OC. Screening questions were adopted from the Maryland Cancer Screening and Risk Behavior Survey. Data were analyzed using the computer software “Statistical Package for Social Sciences, SPSS version 24.0” (IBM Corp, Armonk, NY, USA).

Results:

The study included 404 Kuwaiti respondents, 311 (77%) nonsmokers and 93 (23%) smokers. Prevalence of OC screening was 7.2, 7.7% among nonsmokers and 5.4% in smokers. Only 36.6% were aware of OC, with more nonsmokers (38.9%) than smokers (29%). Logistic regression revealed twice more males likely to go for screening than females and with the likelihood of those being in the age group of 25–44 years four times more (P < 0.012) than other age groups.

Conclusion:

There was low prevalence of screening and poor awareness of OC among sampled. Increased efforts are needed by health professionals to spread awareness and improve knowledge on OC and demand the inclusion of screening during their routine and opportunistic oral examinations.

Availability of healthier vs. less healthy food and food choice: an online experiment

BACKGROUND

Our environments shape our behaviour, but little research has addressed whether healthier cues have a similar impact to less healthy ones. This online study examined the impact on food choices of the number of (i) healthier and (ii) less healthy snack foods available, and possible moderation by cognitive load and socioeconomic status.

METHODS

UK adults (n = 1509) were randomly allocated to one of six groups (two cognitive load x three availability conditions). Participants memorised a 7-digit number (7777777: low cognitive load; 8529713: high cognitive load). While remembering this number, participants chose the food they would most like to eat from: (a) two healthier and two less healthy foods, (b) six healthier and two less healthy foods, or (c) two healthier and six less healthy foods.

RESULTS

Compared to being offered two healthier and two less healthy options, the odds of choosing a healthier option were twice as high (Odds Ratio (OR): 2.0, 95%CI: 1.6, 2.6) with four additional healthier options, while the odds of choosing a less healthy option were four times higher (OR: 4.3, 95%CI: 3.1, 6.0) with four additional less healthy options. There were no significant main effects or interactions with cognitive load or socioeconomic status.

CONCLUSIONS

This study provides a novel test of the impact of healthier vs. less healthy food cues on food choice, suggesting that less healthy food cues have a larger effect than healthier ones. Consequently, removing less healthy as opposed to adding healthier food options could have greater impact on healthier choices. Studies are now needed in which choices are made between physically-present foods.

Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health-An integrative review

Scientific advances in health care have been disproportionately distributed across social strata. Disease burden is also disproportionately distributed, with marginalized groups having the highest risk of poor health outcomes. Social determinants are thought to influence health care delivery and the management of chronic diseases among marginalized groups, but the current conceptualization of social determinants lacks a critical focus on the experiences of people within their environment. The purpose of this article was to integrate the literature on marginalization and situate the concept in the framework of social determinants of health. We demonstrate that social position links marginalization and social determinants of health. This perspective provides a critical lens to assess the societal power dynamics that influence the construction of the socio-environmental factors affecting health. Linking marginalization with social determinants of health can improve our understanding of the inequities in health care delivery and the disparities in chronic disease burden among vulnerable groups.

Has carotid intima-media thickness prognostic impact in patients with high cardiovascular risk? A long-term cohort study

BACKGROUND

Carotid intima-media thickness (CIMT) is an established surrogate marker for cardiovascular events in patients with intermediate risk. In patients with high cardiovascular risk or established cardiovascular disease, the impact of CMIT measurement on risk stratification for future events is less clear. Our objective was to evaluate the impact of CIMT on the occurrence of cardiovascular events in a cohort of individuals with high cardiovascular risk, in long-term follow-up.

METHODS

We analyzed 296 individuals, mean follow-up of 6.9 ± 2.2 years. Individuals were divided into tertiles according to CIMT. Tertiles were compared in terms of baseline characteristics and outcomes during follow-up-all-cause mortality and composite outcome (mortality, acute coronary syndromes, coronary revascularization, stroke/transient ischemic attack, heart failure, or cardiovascular admission).

RESULTS

Our population had a mean age of 65 ± 9 years at the beginning of the study, 55% males. Patients with higher CIMT showed a trend for higher cardiovascular mortality (P = 0.084) and for the composite outcome (P = 0.049). A CIMT ≥ 0.85 mm was also associated with higher rate of events; however, CIMT was not an independent predictor of outcome after adjustment for age and gender. CIMT assessment was useful in patients with hypertension, hyperlipidemia, and metabolic syndrome and in nondiabetic patients. For the composite outcome, it was also useful in females, smokers, and in patients without coronary artery disease.

CONCLUSIONS

Patients with higher CIMT have worst outcome, but this was mainly driven by age and gender. CIMT is useful as a prognostic marker in specific subsets of patients.

Preclinical development of a microRNA-based therapy for intervertebral disc degeneration

Understanding the molecular mechanisms regulating the maintenance and destruction of intervertebral disc may lead to the development of new therapies for intervertebral disc degeneration (IDD). Here we present evidence from miRNA microarray analyses of clinical data sets along with in vitro and in vivo experiments that miR-141 is a key regulator of IDD. Gain- and loss-of-function studies show that miR-141 drives IDD by inducing nucleus pulposus (NP) apoptosis. Furthermore, miR-141 KO in mice attenuated spontaneous and surgically induced IDD. Mechanistically, miR-141 promotes IDD development by targeting and depleting SIRT1, a negative regulator of NF-κB pathway. Therapeutically, upregulation or downregulation of miR-141 by nanoparticle delivery in IDD model aggravated or alleviated experimental IDD, respectively. Our findings reveal a novel mechanism by which miR-141, in part, promotes IDD progression by interacting with SIRT1/NF-κB pathway. Blockade of miR-141 in vivo may serve as a potential therapeutic approach in the treatment of IDD.

Intervertebral disk degeneration (IDD) is characterized by changes in the nucleus pulposus (NP) extra cellular matrix that compromise disk structural integrity. In a miRNA screen of human IDD patient NP tissue, the authors identify deregulated miR-141 and show that direct injection of nanoparticle-coupled miR-141 into the NP alleviates IDD in mice.

PRISMA-compliant meta-analysis: association of metabolic syndrome and its components with the risk of chronic obstructive pulmonary disease

A preferred reporting items for systematic reviews and meta-analyses-compliant meta-analysis was conducted to test the association of metabolic syndrome and its components with the risk of chronic obstructive pulmonary disease (COPD) based on observational studies. Literature retrieval, article selection and data extraction were done by two researchers independently. Total 16 articles (20 independent studies) were analyzed with 3915 COPD patients and 25,790 control participants. Overall analysis indicated that metabolic syndrome was significantly associated with 1.53-fold (95% confidence interval [CI]: 1.23–1.9, P<0.001) increased risk of COPD, with moderate heterogeneity (I² = 74.3%). Of four metabolic components, hypertension was significantly associated with 1.55-fold (95% CI: 1.14–2.11, P=0.005) increased risk, and averaged levels of systolic blood pressure (weighted mean difference [WMD] = 3.626 mmHg, 95% CI: 1.537–5.714, P<0.001) and glucose (WMD = 2.976 mmol/l, 95% CI: 0.141–5.812; P=0.04) were significantly higher in COPD patients than in control participants, yet that of body mass index (WMD = −1.463 kg/m², 95% CI: −2.716 to −0.211, P=0.022) were significantly lower. Gender, race, source of control participants, matched status and sample size were identified as accountable factors for significant heterogeneity. Altogether, the presence of metabolic syndrome, especially its component hypertension, was associated with significantly increased risk of COPD.

Clinical Impact of the Polypill for Cardiovascular Prevention in Latin America: A Consensus Statement of the Inter-American Society of Cardiology

The burden of cardiovascular diseases (CVD) is increasing, particularly in low-middle-income countries such as most of Latin America. This region presents specific socioeconomic characteristics, generating a high incidence of CVD despite efforts to control the problem. A consensus statement has been developed by Inter-American Society of Cardiology with the aim of answering some important questions related to CVD in this region and the role of the polypill in cardiovascular (CV) prevention as an intervention to address these issues. A multidisciplinary team composed of Latin American experts in the prevention of CVD was convened by the Inter-American Society of Cardiology and participated in the process and the formulation of statements. To characterize the prevailing situation in Latin American countries, we describe the most significant CV risk factors in the region. The barriers that impair the use of CV essential medications are also reviewed. The role of therapeutic adherence in CV prevention and how the polypill emerges as an effective strategy for optimizing adherence, accessibility, and affordability in the treatment of CVDs are discussed in detail. Clinical scenarios in which the polypill could represent an effective intervention in primary and secondary CV prevention are described. This initiative is expected to help professionals involved in the management of CVD and public health policymakers develop optimal strategies for the management of CVDs.

Sex differences and risk factors for diabetes mellitus - an international study from 193 countries

Background

Increases in overweight and obesity among youths have resulted in the diagnosis of Type 2 diabetes mellitus (T2DM) at earlier ages. The impact of lifestyle-related factors has been implicated; however, its relation to morbidity and mortality and sex differences remain unclear. We aimed to document the changes in risk factors and sex differences associated with T2DM-related morbidity and mortality during 1995–2015.

Method

We used mortality rates and morbidity estimates from the Global Burden of Diseases Study 2016 using Disability-Adjusted Life Years (DALY). Multiple linear regression analyses were used to determine associations between T2DM-related mortality and related risk factors. DALYs were grouped by country income level, and were stratified by sex.

Results

Increases in mortality were observed for both sexes, and females tended to have higher mortality rates per 100,000 persons. Body mass index (BMI) continued to be the leading risk factor for T2DM-related mortality, and increases in BMI were more common in low- and middle-income countries (LIC and MIC). Low physical activity was strongly associated with mortality rates, followed by dietary risks and smoking (2.4; 1.4; 0.8 per 100,000 persons, respectively). Similar patterns were observed after adjustments for income level, sex, and age. DALYs continued to show increasing trends across all income levels during 1995–2015 (high-income (HIC):16%; MIC: 36%; LIC: 12%). Stratification by sex showed similar results; males had fewer T2DM DALYs than females, though a greater increase was observed among males.

Conclusion

Overall, T2DM related mortality was higher among females. Compared to in HIC, there appeared to be a considerable increase in the burden of T2DM in MIC and LIC, where BMI is the leading risk factor for T2DM-related mortality. Prevention programs should emphasize related risk factors according to the existing standard of care.

Health-care utilization for headache disorders in Nepal: a population-based door-to-door survey

BACKGROUND

Headache disorders are an important global public-health problem, but under-diagnosed, undertreated and under-prioritized. Deficiencies in health care for headache, present everywhere, are likely to be greater in poorly-resourced countries. This study reports on health-care utilization for headache in Nepal, a low-income country with high headache burden.

METHODS

We took data from a cross-sectional, nationwide population-based door-to-door survey, with multistage cluster random sampling. Face-to-face structured interviews included enquiry into consultations with professional health-care providers (HCPs), and investigations and treatments for headache. Analysis included associations with sociodemographic variables and indices of symptom severity.

RESULTS

Of 2100 participants, 1794 reported headache during the preceding year (mean age 36.1 ± 12.6 years; male/female ratio 1:1.6). Of these, 58.4% (95% CI: 56.1-60.7%) had consulted at least once in the year with HCPs at any level, most commonly (25.0%) paramedical; 15.0% had consulted pharmacists, 10.8% general physicians and 7.6% specialists (of any type). Participants with probable medication-overuse headache consulted most (87.0%), followed by those with migraine (67.2%) and those with tension-type headache (48.6%; p < 0.001). A minority (11.9%) were investigated, mostly (8.9%) by eye tests. Half (50.8%) had used conventional medications for headache in the preceding month, paracetamol being by far the most common (38.0%), and 10.3% had used herbal therapies. Consultation was positively associated with rural habitation (AOR = 1.5; p < 0.001). Proportions consulting increased in line with all indices of symptom severity.

CONCLUSIONS

Although over half of participants with headache had consulted professional HCPs, this reflects demand, not quality of care. Although 7.6% had seen specialists, very few would have been headache specialists in any sense of this term. High persistent burden, with only half of participants with headache using conventional medications, and these not best chosen, suggests these consultations fell far short of meeting need. Health policy in Nepal should recognise this, since the consequences otherwise are costly: lost health, diminished productivity and damaged national economy. On a positive note, the proportions consulting suggest that capacity exists at multiple levels within the Nepalese health system. With this to build upon, structured headache services in line with international recommendations appear achievable in Nepal. Educational programmes are the essential requirement.