Impact of improved cookstoves on women's and child health in low and middle income countries: a systematic review and meta-analysis

OBJECTIVES

Improved biomass cookstoves may help reduce the substantial global burden of morbidity and mortality due to household air pollution (HAP) that disproportionately affects women and children in low and middle income countries (LMICs).

DESIGN

Systematic review and meta-analysis of (quasi-)experimental studies identified from 13 electronic databases (last update: 6 April 2018), reference and citation searches and via expert consultation.

SETTING

LMICs PARTICIPANTS: Women and children INTERVENTIONS: Improved biomass cookstoves MAIN OUTCOME MEASURES: Low birth weight (LBW), preterm birth, perinatal mortality, paediatric acute respiratory infections (ARIs) and COPD among women.

RESULTS

We identified 53 eligible studies, including 24 that met prespecified design criteria. Improved cookstoves had no demonstrable impact on paediatric lower ARIs (three studies; 11 560 children; incidence rate ratio (IRR)=1.02 (95% CI 0.84 to 1.24)), severe pneumonia (two studies; 11 061 children; IRR=0.88 (95% CI 0.39 to 2.01)), LBW (one study; 174 babies; OR=0.74 (95% CI 0.33 to 1.66)) or miscarriages, stillbirths and infant mortality (one study; 1176 babies; risk ratio (RR) change=15% (95% CI -13 to 43)). No (quasi-)experimental studies assessed preterm birth or COPD. In observational studies, improved cookstoves were associated with a significant reduction in COPD among women: two studies, 9757 participants; RR=0.74 (95% CI 0.61 to 0.90). Reductions in cough (four studies, 1779 participants; RR=0.72 (95% CI 0.60 to 0.87)), phlegm (four studies, 1779 participants; RR=0.65 (95% CI 0.52 to 0.80)), wheezing/breathing difficulty (four studies; 1779 participants; RR=0.41 (95% CI 0.29 to 0.59)) and conjunctivitis (three studies, 892 participants; RR=0.58 (95% CI 0.43 to 0.78)) were observed among women.

CONCLUSION

Improved cookstoves provide respiratory and ocular symptom reduction and may reduce COPD risk among women, but had no demonstrable child health impact.

REGISTRATION

PROSPERO: CRD42016033075.

Cardiovascular disease (CVD) and associated risk factors among older adults in six low-and middle-income countries: results from SAGE Wave 1

BACKGROUND

Cardiovascular disease (CVD) is one of the leading causes of death worldwide. Our study aimed to investigate the prevalence of two conditions, angina and stroke, and relevant risk factors among older adults in six low- and middle- income countries(LMICs).

METHODS

The data was from World Health Organization (WHO) Study on global AGEing and adult Health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russian Federation and South Africa. Presence of CVD was based on self-report of angina and stroke. Multivariate logistic regression was performed to examine the relationship between CVD and selected variables, including age, sex, urban/rural setting, household wealth, and risk factors such as smoking, alcohol drinking, fruit/vegetable intake, physical activity and BMI.

RESULTS

The age standardized prevalence of angina ranged from 9.5 % (South Africa) to 47.5 % (Russian Federation), and for stoke from 2.0% (India) to 6.1 % (Russia). Hypertension was associated with angina in China, India and Russian Federation after adjustment for age, sex, urban/rural setting, education and marital status (OR ranging from 1.3 [1.1-1.6] in India to 3.8 [2.9-5.0] in Russian Federation), furthermore it was a risk factor of stroke in five countries except Mexico. Low or moderate physical activity were also associated with angina in China, and were also strongly associated with stroke in all countries except Ghana and India. Obesity had a stronger association with angina in Russian Federation and China(ORs were 1.5[1.1-2.0] and 1.2 [1.0-1.5] respectively), and increased the risk of stroke in China. Smoking was associated with angina in India and South Africa(ORs were 1.6[1.0-2.4] and 2.1 [1.2-3.6] respectively ), and was also a risk factor of stroke in South Africa. We observed a stronger association between frequent heavy drinking and stroke in India. Household income was associated with reduced odds of angina in China, India and Russian Federation, however higher household income was a risk factor of angina in South Africa.

CONCLUSION

While the specific mix of risk factors contribute to disease prevalence in different ways in these six countries - they should all be targeted in multi-sectoral efforts to reduce the high burden of CVD in today's society.

Integration of care for hypertension and diabetes: a scoping review assessing the evidence from systematic reviews and evaluating reporting

BACKGROUND

With the rise in pre-mature mortality rate from non-communicable disease (NCD), there is a need for evidence-based interventions. We evaluated existing systematic reviews on effectiveness of integration of healthcare services, in particular with focus on delivery of care designed to improve health and process outcomes in people with multi-morbidity, where at least one of the conditions was diabetes or hypertension.

METHODS

We searched MEDLINE, EMBASE, Cochrane Library, and Health Evidence to November 8, 2016 and consulted experts. One review author screened titles, abstracts and two review authors independently screened short listed full-texts and selected reviews for inclusion. We considered systematic reviews evaluating integration of care, compared to usual care, for people with multi-morbidity. One review author extracted data and another author verified it. Two review authors independently evaluated risk of bias using ROBIS and AMSTAR. Inter-rater reliability was analysed for ROBIS and AMSTAR using Cohen's kappa and percent agreement. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used to assess reporting.

RESULTS

We identified five systematic reviews on integration of care. Four reviews focused on comorbid diabetes and depression and two covered hypertension and comorbidities of cardiovascular disease, depression, or diabetes. Interventions were poorly described. The health outcomes evaluated included risk of all-cause mortality, measures of depression, cholesterol levels, HbA1c levels, effect of depression on HbA1c levels, symptom improvement, systolic blood pressure, and hypertension control. Process outcomes included access and utilisation of healthcare services, costs, and quality of care. Overall, three reviews had a low and medium risk of bias according to ROBIS and AMSTAR respectively, while two reviews had high risk of bias as judged by both ROBIS and AMSTAR. Findings have demonstrated that collaborative care in general resulted in better health and process outcomes when compared to usual care for both depression and diabetes and hypertension and diabetes.

CONCLUSIONS

Several knowledge gaps were identified on integration of care for comorbidities with diabetes and/or hypertension: limited research on this topic for hypertension, limited reviews that included primary studies based in low-middle income countries, and limited reviews on collaborative care for communicable and NCDs.

Tβ4 Increases Neovascularization and Cardiac Function in Chronic Myocardial Ischemia of Normo- and Hypercholesterolemic Pigs

Translations of new therapeutic options for cardiovascular disease from animal studies into a clinical setting have been hampered, in part by an improper reflection of a relevant patient population in animal models. In this study, we investigated the impact of thymosin β4 (Tβ4), which promotes collateralization and capillarization, during hypercholesterolemia, a known risk factor of coronary artery disease. Initial in vitro results highlighted an improved endothelial cell function upon Tβ4 treatment under control conditions and during hypercholesterolemic stress (scratch area [pixels]: oxidized low-density lipoprotein [oxLDL], 191,924 ± 7,717; and oxLDL + Tβ4, 105,621 ± 11,245). To mimic the common risk factor of hypercholesterolemia in vivo, pigs on regular (NC) or high-fat (HC) diet underwent chronic myocardial ischemia followed by recombinant adeno-associated virus (rAAV)-mediated transduction of Tβ4 or LacZ as a control. We show that Tβ4 overexpression improves capillarization and collateralization (collaterals: NC + rAAV.LacZ, 2.1 ± 0.5; NC + rAAV.Tβ4, 6.7 ± 0.5; HC + rAAV.LacZ, 3.0 ± 0.3; and HC + rAAV.Tβ4, 6.0 ± 0.4), ultimately leading to an improved myocardial function in both diet groups (ejection fraction [EF] at day 56 [%]: NC + rAAV.LacZ, 26 ± 1.1; NC + rAAV.Tβ4, 45 ± 1.5; HC + rAAV.LacZ, 26 ± 2.5; and HC + rAAV.Tβ4, 41 ± 2.6). These results demonstrate the potency of Tβ4 in a patient-relevant large animal model of chronic myocardial ischemia.

Cilia-localized LKB1 regulates chemokine signaling, macrophage recruitment, and tissue homeostasis in the kidney

Polycystic kidney disease (PKD) and other renal ciliopathies are characterized by cysts, inflammation, and fibrosis. Cilia function as signaling centers, but a molecular link to inflammation in the kidney has not been established. Here, we show that cilia in renal epithelia activate chemokine signaling to recruit inflammatory cells. We identify a complex of the ciliary kinase LKB1 and several ciliopathy‐related proteins including NPHP1 and PKD1. At homeostasis, this ciliary module suppresses expression of the chemokine CCL2 in tubular epithelial cells. Deletion of LKB1 or PKD1 in mouse renal tubules elevates CCL2 expression in a cell‐autonomous manner and results in peritubular accumulation of CCR2⁺ mononuclear phagocytes, promoting a ciliopathy phenotype. Our findings establish an epithelial organelle, the cilium, as a gatekeeper of tissue immune cell numbers. This represents an unexpected disease mechanism for renal ciliopathies and establishes a new model for how epithelial cells regulate immune cells to affect tissue homeostasis.

Factors associated with non-participation in and dropout from cardiac rehabilitation programmes: a systematic review of prospective cohort studies

BACKGROUND

Although evidence exists for the efficacy of cardiac rehabilitation programmes to reduce morbidity and mortality among patients with cardiovascular disease, cardiac rehabilitation programmes are underused. We aimed systematically to review the evidence from prospective cohort studies on factors associated with non-participation in and/or dropping out from cardiac rehabilitation programmes.

METHODS

MedLine, Embase, Scopus, Open Grey and Cochrane Database were searched for relevant publications from inception to February 2018. Search terms included (a) coronary heart disease and other cardiac conditions; (b) cardiac rehabilitation and secondary prevention; and (c) non-participation in and/or dropout. Databases were searched following the PRISMA statement. Study selection, data extraction and the assessment of study quality were performed in duplicate.

RESULTS

We selected 43 studies with a total of 63,425 patients from 10 different countries that met the inclusion criteria. Factors associated with non-participation in and dropout from cardiac rehabilitation were grouped into six broad categories: intrapersonal factors, clinical factors, interpersonal factors, logistical factors, cardiac rehabilitation programme factors and health system factors. We found that clinical factors, logistical factors and health system factors were the main factors assessed for non-participation in cardiac rehabilitation. We also found differences between the factors associated with non-participation and dropout.

CONCLUSIONS

Several factors were determinant for non-participation in and dropout from cardiac rehabilitation. These findings could be useful to clinicians and policymakers for developing interventions aimed at improving participation and completion of cardiac rehabilitation, such as E-health or home-based delivery programmes. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) identifier: CRD42016032973.

Laboratory-Confirmed Respiratory Infections as Predictors of Hospital Admission for Myocardial Infarction and Stroke: Time-Series Analysis of English Data for 2004-2015

Background

Acute respiratory infections are associated with increased risk of myocardial infarction (MI) and stroke; however, the role of different organisms is poorly characterized.

Methods

Time-series analysis of English hospital admissions for MI and stroke (age-stratified: 45-64, 65-74, ≥75 years), laboratory-confirmed viral respiratory infections, and environmental data for 2004-2015. Weekly counts of admissions were modeled using multivariable Poisson regression with weekly counts of respiratory viruses (influenza, parainfluenza, rhinovirus, respiratory syncytial virus [RSV], adenovirus, or human metapneumovirus [HMPV]) investigated as predictors. We controlled for seasonality, long-term trends, and environmental factors.

Results

Weekly hospital admissions in adults aged ≥45 years averaged 1347 (interquartile range [IQR], 1217-1541) for MI and 1175 (IQR, 1023-1395) for stroke. Respiratory infections ranged from 11 cases per week (IQR, 5-53) for influenza to 55 (IQR, 7-127) for rhinovirus. In the adjusted models, all viruses except parainfluenza were significantly associated with MI and ischemic stroke admissions in those aged ≥75. Among 65- to 74-year-olds, adenovirus, rhinovirus, and RSV were associated with MI but not ischemic stroke admissions. Respiratory infections were not associated with MI or ischemic stroke in people aged 45-64 years, nor with hemorrhagic stroke in any age group. An estimated 0.4%-5.7% of MI and ischemic stroke admissions may be attributable to respiratory infection.

Conclusions

We identified small but strongly significant associations in the timing of respiratory infection (with HMPV, RSV, influenza, rhinovirus, and adenovirus) and MI or ischemic stroke hospitalizations in the elderly.

Clinical Trials Registration

NCT02984280.

Production and efficacy of a low-cost recombinant pneumococcal protein polysaccharide conjugate vaccine

Streptococcus pneumoniae is the leading cause of bacterial pneumonia. Although this is a vaccine preventable disease, S. pneumoniae still causes over 1 million deaths per year, mainly in children under the age of five. The biggest disease burden is in the developing world, which is mainly due to unavailability of vaccines due to their high costs. Protein polysaccharide conjugate vaccines are given routinely in the developed world to children to induce a protective antibody response against S. pneumoniae. One of these vaccines is Prevnar13, which targets 13 of the 95 known capsular types. Current vaccine production requires growth of large amounts of the 13 serotypes, and isolation of the capsular polysaccharide that is then chemically coupled to a protein, such as the diphtheria toxoid CRM197, in a multistep expensive procedure. In this study, we design, purify and produce novel recombinant pneumococcal protein polysaccharide conjugate vaccines in Escherichia coli, which act as mini factories for the low-cost production of conjugate vaccines. Recombinant vaccine efficacy was tested in a murine model of pneumococcal pneumonia; ability to protect against invasive disease was compared to that of Prevnar13. This study provides the first proof of principle that protein polysaccharide conjugate vaccines produced in E. coli can be used to prevent pneumococcal infection. Vaccines produced in this manner may provide a low-cost alternative to the current vaccine production methodology.

Slaying little dragons: the impact of the Guinea Worm Eradication Program on dracunculiasis disability averted from 1990 to 2016

Background: The objective of this study was to document the worldwide decline of dracunculiasis (Guinea worm disease, GWD) burden, expressed as disability-adjusted life years (DALYs), from 1990 to 2016, as estimated in the Global Burden of Disease study 2016 (GBD 2016). While the annual number of cases of GWD have been consistently reported by WHO since the 1990s, the burden of disability due to GWD has not previously been quantified in GBD. Methods: The incidence of GWD was modeled for each endemic country using annual national case reports. A literature search was conducted to characterize the presentation of GWD, translate the clinical symptoms into health sequelae, and then assign an average duration to the infection. Prevalence measures by sequelae were multiplied by disability weights to estimate DALYs. Results: The total DALYs attributed to GWD across all endemic countries (n=21) in 1990 was 50,725 (95% UI: 35,265-69,197) and decreased to 0.9 (95% UI: 0.5-1.4) in 2016. A cumulative total of 12,900 DALYs were attributable to GWD from 1990 to 2016. Conclusions: Using 1990 estimates of burden propagated forward, this analysis suggests that between 990,000 to 1.9 million DALYs have been averted as a result of the eradication program over the past 27 years.

Long-term albumin administration in decompensated cirrhosis (ANSWER): an open-label randomised trial

BACKGROUND

Evidence is scarce on the efficacy of long-term human albumin (HA) administration in patients with decompensated cirrhosis. The human Albumin for the treatmeNt of aScites in patients With hEpatic ciRrhosis (ANSWER) study was designed to clarify this issue.

METHODS

We did an investigator-initiated multicentre randomised, parallel, open-label, pragmatic trial in 33 academic and non-academic Italian hospitals. We randomly assigned patients with cirrhosis and uncomplicated ascites who were treated with anti-aldosteronic drugs (≥200 mg/day) and furosemide (≥25 mg/day) to receive either standard medical treatment (SMT) or SMT plus HA (40 g twice weekly for 2 weeks, and then 40 g weekly) for up to 18 months. The primary endpoint was 18-month mortality, evaluated as difference of events and analysis of survival time in patients included in the modified intention-to-treat and per-protocol populations. This study is registered with EudraCT, number 2008-000625-19, and ClinicalTrials.gov, number NCT01288794.

FINDINGS

From April 2, 2011, to May 27, 2015, 440 patients were randomly assigned and 431 were included in the modified intention-to-treat analysis. 38 of 218 patients died in the SMT plus HA group and 46 of 213 in the SMT group. Overall 18-month survival was significantly higher in the SMT plus HA than in the SMT group (Kaplan-Meier estimates 77% vs 66%; p=0·028), resulting in a 38% reduction in the mortality hazard ratio (0·62 [95% CI 0·40-0·95]). 46 (22%) patients in the SMT group and 49 (22%) in the SMT plus HA group had grade 3-4 non-liver related adverse events.

INTERPRETATION

In this trial, long-term HA administration prolongs overall survival and might act as a disease modifying treatment in patients with decompensated cirrhosis.

FUNDING

Italian Medicine Agency.

The Role of n-3 Long Chain Polyunsaturated Fatty Acids in Cardiovascular Disease Prevention, and Interactions with Statins

Decreases in global cardiovascular disease (CVD) mortality and morbidity in recent decades can be partly attributed to cholesterol reduction through statin use. n-3 long chain polyunsaturated fatty acids are recommended by some authorities for primary and secondary CVD prevention, and for triglyceride reduction. The residual risk of CVD that remains after statin therapy may potentially be reduced by n-3 long chain polyunsaturated fatty acids. However, the effects of concomitant use of statins and n-3 long chain polyunsaturated fatty acids are not well understood. Pleiotropic effects of statins and n-3 long chain polyunsaturated fatty acids overlap. For example, cytochrome P450 enzymes that metabolize statins may affect n-3 long chain polyunsaturated fatty acid metabolism and vice versa. Clinical and mechanistic study results show both synergistic and antagonistic effects of statins and n-3 long chain polyunsaturated fatty acids when used in combination.

Acute gastroenteritis in a pediatric population from Cali, Colombia in the post rotavirus vaccine era

BACKGROUND

Epidemiological data from Latin America on acute gastroenteritis (AGE) in the post rotavirus vaccine era obtained using highly sensitive molecular techniques are scarce.

METHODS

This prospective surveillance study was performed between March 15, 2015 and March 19, 2016 in two municipal health networks (MHNs) in Cali, Colombia to detect AGE in children <5 years of age. Consecutive sampling was performed simultaneously in all health facilities belonging to both MHNs until completion of the required sample size. Stool samples from AGE patients were tested with a nucleic acid assay for 16 pathogens. Detection frequency and incidence rates were obtained for specific pathogens according to age-group in children with AGE leading to hospitalization or outpatient care.

RESULTS

Overall incidence rates of AGE-related hospitalization and outpatient care were 20 and 237 per 1000 children <5 years of age, respectively. Despite almost complete rotavirus vaccine uptake, rotavirus was the most common etiology overall, including hospitalization and outpatient treatment of 0-23-month-olds, with incidence rates of 12 and 108 per 1000 children, respectively. Norovirus incidence rates were similar to rotavirus rates in this age group and associated with high Vesikari scores. Shigella predominated in 24-59-month-olds.

CONCLUSIONS

AGE remains an important cause of morbidity in children under 5 years of age, especially in those under 2 years. Rotavirus remains the leading AGE-associated pathogen, followed closely by norovirus in younger children. Preventive measures, including novel vaccination strategies, are necessary in this population to further reduce AGE-related morbidity.

Manipulating extracellular tumour pH: an effective target for cancer therapy

The pH in tumour cells and the tumour microenvironment has played important roles in cancer development and treatment. It was thought that both the extracellular and intracellular pH values in tumours are acidic and lower than in normal cells. However, recent progress in the measurement of pH in tumour tissue has disclosed that the intracellular pH (pHi) of cancer cells is neutral or even mildly alkaline compared to normal tissue cells. This review article has summarized the recent advancement in the measurement pHi and extracellular pH (pHe) in cancer cells, and the effect of pHi and pHe on proliferation, migration and biological functions of cancer cells. This paper has also elaborated recent treatment strategies to manipulate pHi and pHe for cancer treatment. Based on the recent progress in pHi and pHe manipulation in cancer treatment, we have proposed potential nanoparticle-based strategies to manipulate pHi and pHe to effectively treat cancer.

Global disability-adjusted life-year estimates of long-term health burden and undernutrition attributable to diarrhoeal diseases in children younger than 5 years

Background

Diarrhoea is a leading cause of death and illness globally among children younger than 5 years. Mortality and short-term morbidity cause substantial burden of disease but probably underestimate the true effect of diarrhoea on population health. This underestimation is because diarrhoeal diseases can negatively affect early childhood growth, probably through enteric dysfunction and impaired uptake of macronutrients and micronutrients. We attempt to quantify the long-term sequelae associated with childhood growth impairment due to diarrhoea.

Methods

We used the Global Burden of Diseases, Injuries, and Risk Factors Study framework and leveraged existing estimates of diarrhoea incidence, childhood undernutrition, and infectious disease burden to estimate the effect of diarrhoeal diseases on physical growth, including weight and height, and subsequent disease among children younger than 5 years. The burden of diarrhoea was measured in disability-adjusted life-years (DALYs), a composite metric of mortality and morbidity. We hypothesised that diarrhoea is negatively associated with three common markers of growth: weight-for-age, weight-for-height, and height-for-age Z-scores. On the basis of these undernutrition exposures, we applied a counterfactual approach to quantify the relative risk of infectious disease (subsequent diarrhoea, lower respiratory infection, and measles) and protein energy malnutrition morbidity and mortality per day of diarrhoea and quantified the burden of diarrhoeal disease due to these outcomes caused by undernutrition.

Findings

Diarrhoea episodes are significantly associated with childhood growth faltering. We found that each day of diarrhoea was associated with height-for-age Z-score (–0·0033 [95% CI −0·0024 to −0·0041]; p=4·43 × 10⁻¹⁴), weight-for-age Z-score (–0·0077 [–0·0058 to −0·0097]; p=3·19 × 10⁻¹⁵), and weight-for-height Z-score (–0·0096 [–0·0067 to −0·0125]; p=7·78 × 10⁻¹¹). After addition of the DALYs due to the long-term sequelae as a consequence of undernutrition, the burden of diarrhoeal diseases increased by 39·0% (95% uncertainty interval [UI] 33·0–46·6) and was responsible for 55 778 000 DALYs (95% UI 49 125 400–62 396 200) among children younger than 5 years in 2016. Among the 15 652 300 DALYs (95% UI 12 951 300–18 806 100) associated with undernutrition due to diarrhoeal episodes, more than 84·7% are due to increased risk of infectious disease, whereas the remaining 15·3% of long-term DALYs are due to increased prevalence of protein energy malnutrition. The burden of diarrhoea has decreased substantially since 1990, but progress has been greater in long-term (78·7% reduction [95% UI 69·3–85·5]) than in acute (70·4% reduction [95% UI 61·7–76·5]) DALYs.

Interpretation

Diarrhoea represents an even larger burden of disease than was estimated in the Global Burden of Disease Study. In order to adequately address the burden of its long-term sequelae, a renewed emphasis on controlling the risk of diarrhoea incidence may be required. This renewed effort can help further prevent the potential lifelong cost on child health, growth, and overall potential.

Funding

Bill & Melinda Gates Foundation.

Prognostic value of carotid intima-media in the short- and long-term mortality in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study

BACKGROUND AND AIMS

Atherosclerotic in carotids can determinate a poor prognosis in individuals after acute coronary syndrome (ACS). Thus, we aimed to evaluate mortality associated to carotid intima media thickness (CIMT) in the participants from the Strategy of Registry of Acute Coronary Syndrome (ERICO) study.

METHODS

Carotid intima media thickness was evaluated by B-mode ultrasound for mortality risk assessment in 180 days, 1-3 years. We performed Kaplan-Meier survival curves and Cox logistic regression models to evaluate all-cause, cardiovascular (CVD) and coronary heart disease (CHD) mortality by CIMT tertiles in crude, age and sex- and multivariate models.

RESULTS

Among 644 ACS individuals (median age 61-year old), we observed a median CIMT of 0.74 mm. Besides aging, low education, hypertension, diabetes, and dyslipidemia were associated with the 3rd tertile of CIMT values. During 3 years of follow-up, we observed 65 deaths (10.1%), crude case-fatality rates were progressively higher across the CIMT tertiles in all periods, being the highest rates observed in participants with the highest CIMT (3rd tertile) (180-day: 6.6% vs 1-year: 9.0% vs 2-year:12.3% vs 3-year:16.0%, P < .05). In crude analyses, lowest survival rates (all-cause, CVD and CHD, p log-rank values <0.005) and higher hazard ratios of dying for all-cause and CVD (from 1 to 3 years) and for CHD (2 and 3 years) were observed. However, we kept no significant results after adjusting for age.

CONCLUSION

Carotid intima media thickness was mainly influenced by aging. CIMT was not a good predictor of all-cause, CVD or CHD mortality in the ERICO study.

Beneficial Role of Mg2+ in Prevention and Treatment of Hypertension

Hypertension constitutes one of the most widespread pathological conditions in developed and developing countries. Currently, more than 1 billion people worldwide are affected by the condition, either as frank hypertension or as prehypertension, raising the risk for major long-term complications and life-threatening pathologies. The costs in terms of health care services, medications for the treatment of hypertension and its complications, and associated loss in productivity represent a major economic burden for the various countries. The necessity of developing treatments that are economically more sustainable and with better compliance has been increasing alongside the incidence of the pathology. Along these lines, attention has been paid to the implementation of affordable but nutritious diets that deliver appropriate levels of macro- and micronutrients as integral part of the diets themselves or as supplements. In particular, experimental and clinical evidence suggests that an appropriate intake of dietary magnesium can be beneficial in controlling blood pressure. Additional advantages of a more diffuse therapeutic and/or preventive utilization of magnesium supplements are the virtual absence of side-effects and their affordable costs. The present review will attempt to frame our knowledge of how magnesium exerts its beneficial effects on blood pressure maintenance, which may lead to the development of more effective treatments of hypertension and its main complications.

Respiratory Complications Before and After Liver Transplant

Respiratory complications before and after liver transplant are common, diverse, and potentially have a negative impact on patient outcomes. In this review, we discuss the most frequent respiratory conditions that patients may develop in the perioperative period. Their prevention and/or treatment may help to maximize the benefit these patients may derive from liver transplant. This review examines diagnostic and therapeutic approaches to these complications for hepatologists, surgeons, and critical care physicians.

Risk factors for acquiring HCV at a healthcare center in Hidalgo, Mexico

INTRODUCTION AND AIMS

The approach to HCV infection begins with the directed search for risk factors linked to its acquisition. Therefore, our primary aim was to identify the prevalence of risk factors associated with HCV infections in insured individuals seen at the Hidalgo delegation of the IMSS.

MATERIALS AND METHODS

An observational, descriptive, cross-sectional study was conducted through validated surveys that identified major and minor risk factors. In cases of major risk factors, the Advanced Quality™ RAPID-ANTI-HCV TEST Accutrack^® tests were applied to detect anti-HCV. Patients with positive tests were referred to the Hepatology service for the diagnostic-therapeutic approach. Statistical analysis was performed through measures of central tendency and percentages.

RESULTS

A total of 528 insured individuals were surveyed (95%CI with a 5% margin of error). Two hundred eighty-two rapid tests were performed. Five of them were positive (0.94%) and belonged to the patients in the dialysis/hemodialysis group. A total of 71.2% persons had positive risk factors. The association of 2 or more factors varied from 2 to 8 factors present at the same time. Of the entire study population, 6.25% presented with 4 risk factors and 4.35% presented with 5 risk factors at the same time.

CONCLUSIONS

Nearly three quarters of the individuals surveyed were exposed to HCV acquisition. The association of 2 or more risk factors in patients demonstrated their collective potentiality for acquiring HCV. We identified persons receiving treatment with dialysis/hemodialysis and those with high-risk sexual practices as vulnerable groups for HCV infection and suggest that they receive promotion and prevention activities, as well as public policy management.

Cost-effectiveness of health care service delivery interventions in low and middle income countries: a systematic review

Background

Low and middle income countries (LMICs) face severe resource limitations but the highest burden of disease. There is a growing evidence base on effective and cost-effective interventions for these diseases. However, questions remain about the most cost-effective method of delivery for these interventions. We aimed to review the scope, quality, and findings of economic evaluations of service delivery interventions in LMICs.

Methods

We searched PUBMED, MEDLINE, EconLit, and NHS EED for studies published between 1st January 2000 and 30th October 2016 with no language restrictions. We included all economic evaluations that reported incremental costs and benefits or summary measures of the two such as an incremental cost effectiveness ratio. Studies were grouped by both disease area and outcome measure and permutation plots were completed for similar interventions. Quality was judged by the Drummond checklist.

Results

Overall, 3818 potentially relevant abstracts were identified of which 101 studies were selected for full text review. Thirty-seven studies were included in the final review. Twenty-three studies reported on interventions we classed as “changing by whom and where care was provided”, specifically interventions that entailed task-shifting from doctors to nurses or community health workers or from facilities into the community. Evidence suggests this type of intervention is likely to be cost-effective or cost-saving. Nine studies reported on quality improvement initiatives, which were generally found to be cost-effective. Quality and methods differed widely limiting comparability of the studies and findings.

Conclusions

There is significant heterogeneity in the literature, both methodologically and in quality. This renders further comparisons difficult and limits the utility of the available evidence to decision makers.

Introduction: Overview of Fungal Genomics

Genome sequences and postgenomic tools have had a major impact on fungal research. When the first fungal genome sequences became available it became clear how much more complex fungal biology was than had been previously assumed. Since then an increasing number of genomes have become available enabling detailed comparative studies, especially when combined with postgenomic tools such as transcriptomics and proteomics. This chapter provides an overview and current state of fungal genomics.

Hepatitis B virus infection

Hepatitis B virus (HBV) is a hepatotropic virus that can establish a persistent and chronic infection in humans through immune anergy. Currently, 3.5% of the global population is chronically infected with HBV, although the incidence of HBV infections is decreasing owing to vaccination and, to a lesser extent, the use of antiviral therapy to reduce the viral load of chronically infected individuals. The course of chronic HBV infection typically comprises different clinical phases, each of which potentially lasts for decades. Well-defined and verified serum and liver biopsy diagnostic markers enable the assessment of disease severity, viral replication status, patient risk stratification and treatment decisions. Current therapy includes antiviral agents that directly act on viral replication and immunomodulators, such as interferon therapy. Antiviral agents for HBV include reverse transcriptase inhibitors, which are nucleoside or nucleotide analogues that can profoundly suppress HBV replication but require long-term maintenance therapy. Novel compounds are being actively investigated to achieve the goal of HBV surface antigen seroclearance (functional cure), a serological state that is associated with a higher remission rate (thus, no viral rebound) after treatment cessation and a lower rate of cirrhosis and hepatocellular carcinoma. This Primer addresses several aspects of HBV infection, including epidemiology, immune pathophysiology, diagnosis, prevention and management.

Matrix methods in health demography: a new approach to the stochastic analysis of healthy longevity and DALYs

BACKGROUND

Increases in human longevity have made it critical to distinguish healthy longevity from longevity without regard to health. Current methods focus on expectations of healthy longevity, and are often limited to binary health outcomes (e.g., disabled vs. not disabled). We present a new matrix formulation for the statistics of healthy longevity, based on health prevalence data and Markov chain theory, applicable to any kind of health outcome and which provides variances and higher moments as well as expectations of healthy life.

METHOD

The model is based on a Markov chain description of the life course coupled with the moments of health outcomes ("rewards") at each age or stage. As an example, we apply the method to nine European countries using the SHARE survey data on the binary outcome of disability as measured by activities of daily living, and the continuous health outcome of hand grip strength.

RESULTS

We provide analytical formulas for the mean, variance, coefficient of variation, skewness and other statistical properties of healthy longevity. The analysis is applicable to binary, categorical, ordinal, or interval scale health outcomes. The results are easily evaluated in any matrix-oriented software. The SHARE results reveal familiar patterns for the expectation of life and of healthy life: women live longer than men but spend less time in a healthy condition. New results on the variance shows that the standard deviation of remaining healthy life declines with age, but the coefficient of variation is nearly constant. Remaining grip strength years decrease with age more dramatically than healthy years but their variability pattern is similar to the pattern of healthy years. Patterns are similar across nine European countries.

CONCLUSIONS

The method extends, in several directions, current calculations of health expectancy (HE) and disability-adjusted life years (DALYs). It applies to both categorical and continuous health outcomes, to combinations of multiple outcomes (e.g., death and disability in the formulation of DALYs) and to age- or stage-classified models. It reveals previously unreported patterns of variation among individuals in the outcomes of healthy longevity.

Skin microbiota-host interactions

The skin is a complex and dynamic ecosystem that is inhabited by bacteria, archaea, fungi and viruses. These microbes-collectively referred to as the skin microbiota-are fundamental to skin physiology and immunity. Interactions between skin microbes and the host can fall anywhere along the continuum between mutualism and pathogenicity. In this Review, we highlight how host-microbe interactions depend heavily on context, including the state of immune activation, host genetic predisposition, barrier status, microbe localization, and microbe-microbe interactions. We focus on how context shapes the complex dialogue between skin microbes and the host, and the consequences of this dialogue for health and disease.

Long-Term Prognosis of Patients With Transient Ischemic Attack or Stroke and Symptomatic Vascular Disease in Multiple Arterial Beds

Supplemental Digital Content is available in the text.

Background and Purpose—

Cerebrovascular, coronary, and peripheral vascular disease have common underlying arterial pathology and risk factors, but the clinical significance of multiple-territory disease in patients with transient ischemic attack (TIA)/ischemic stroke is unclear, particularly whether the number of clinically affected territories still predicts long-term outcome on current standard secondary prevention therapies.

Methods—

In a population-based study of 92 728 individuals in Oxfordshire, United Kingdom (Oxford Vascular Study), we studied patients presenting with TIA/ischemic stroke (2002–2014) in relation to the number of other vascular beds (coronary, peripheral) affected by symptomatic (current or previous) disease. We compared the risk factor profile and long-term prognosis in patients with single- versus multiple-territory disease.

Results—

Among 2554 patients with 10 679 patient-years of follow-up, 1842 (72.1%) had single- (TIA/stroke only), 608 (23.8%) double-, and 104 (4.1%) triple-territory symptomatic vascular disease. The number of affected vascular beds increased with the number of atherosclerotic risk factors (P_trend<0.0001). Compared with patients with TIA/stroke only, those with multiple-territory disease had more hypertension (age/sex-adjusted odds ratio [OR], 3.43; 95% confidence interval [CI], 2.76–4.27; P<0.0001), diabetes mellitus (OR, 2.89; 95% CI, 2.27–3.66; P<0.0001), hypercholesterolemia (OR, 4.67; 95% CI, 3.85–5.66; P<0.0001), and current or previous smoking (OR, 1.52; 95% CI, 1.26–1.84; P<0.0001). Triple-territory disease was particularly strongly associated with hypercholesterolemia (OR, 6.80; 95% CI, 4.39–10.53; P<0.0001). Despite more intensive secondary prevention in patients with multiple-territory disease, the 5-year risk of vascular death increased steeply with the number of territories affected (17.2% versus 30.0% versus 42.9%; P<0.0001). Compared with patients with single-territory, patients with multiple-territory disease also had higher postacute long-term risks (90 days to 10 years) of recurrent ischemic stroke (age/sex-adjusted hazard ratio, 1.38; 95% CI, 1.04–1.81; P=0.02) and nonstroke acute vascular events (hazard ratio, 3.06; 95% CI, 2.23–4.20; P<0.0001).

Conclusions—

Number of affected vascular beds appeared to be a simple clinical rule in identifying TIA/ischemic stroke patients who are at high long-term risk of nonstroke vascular events and vascular death.

Statin use and all-cause mortality in people living with HIV: a systematic review and meta-analysis

Background

It is unknown whether statin use among people living with HIV results in a reduction in all-cause mortality. We aimed to evaluate the effect of statin use on all-cause mortality among people living with HIV.

Methods

We conducted comprehensive literature searches of Medline, Embase, CINAHL, the Cochrane Library, and cross-references up to April 2018. We included randomised, quasi-randomised trials and prospective cohort studies that examined the association between statin use and cardio-protective and mortality outcomes among people living with HIV. Two reviewers independently abstracted the data. Hazard ratios (HRs) were pooled using empirical Bayesian random-effect meta-analysis. A number of sensitivity analyses were conducted.

Results

We included seven studies with a total of 35,708 participants. The percentage of participants on statins across the studies ranged from 8 to 35%. Where reported, the percentage of participants with hypertension ranged from 14 to 35% and 7 to 10% had been diagnosed with diabetes mellitus. Statin use was associated with a 33% reduction in all-cause mortality (pooled HR = 0.67, 95% Credible Interval 0.39 to 0.96). The probability that statin use conferred a moderate mortality benefit (i.e. decreased risk of mortality of at least 25%, HR ≤ 0.75) was 71.5%. Down-weighting and excluding the lower quality studies resulted in a more conservative estimate of the pooled HR.

Conclusion

Statin use appears to confer moderate mortality benefits in people living with HIV.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3162-1) contains supplementary material, which is available to authorized users.

Effective approaches to address the global cardiovascular disease burden

PURPOSE OF REVIEW

Describe the global burden of cardiovascular disease (CVD), highlight barriers to evidence-based care and propose effective interventions based on identified barriers.

RECENT FINDINGS

The global burden of CVD is increasing worldwide. This trend is steeper in lower income countries, where CVD incidence and fatality remains high. Risk factor control, around the world, remains poor, especially in lower and middle-income countries. Barriers at the patient, healthcare provider and health system have been identified. The use of multifaceted interventions that target identified contextual barriers to care, including increasing awareness of CVD and related risk, improving health policy (i.e. taxation of tobacco), improving the availability and affordability of fixed-dose combined medications and task-shifting of healthcare responsibilities are potential solutions to improve the global burden of CVD.

SUMMARY

There is a need to address identified barriers using evidence-based and multifaceted interventions. Global initiatives, led by the World Heart Federation and the WHO, to facilitate the implementation of such interventions are underway.

How to apply SHA 2011 at a subnational level in China's practical situation: take children health expenditure as an example

Background

System of Health Accounts 2011 (SHA 2011) is a new health care accounts system, revised from SHA 1.0 by the Organisation for Economic Co-operation and Development (OECD), the World Health Organization (WHO) and Eurostat. It keeps the former tri-axial relationship and develops three analytical interfaces, in order to fix the existing shortcomings and make it more convenient for analysis and comparison across countries. SHA 2011 was introduced in China in 2014, and little about its application in China has been reported. This study takes children as an example to study how to apply SHA 2011 at the subnational level in the practical situation of China’s health system.

Methods

Multistage random sampling method was applied and 3 532 517 samples from 252 institutions were included in the study. Official yearbooks and account reports helped the estimation of provincial data. The formula to calculate Current Health Expenditure (CHE) was introduced step-by-step. STATA 10.0 was used for statistics.

Results

Under the frame of SHA 2011, the CHE for children in Liaoning was calculated as US$ 0.74 billion in 2014; 98.56% of the expenditure was spent in hospital and the allocation to primary health care institutions was insufficient. Infection, maternal and prenatal diseases cost the most in terms of Global Burden of Disease (GBD), and respiratory system diseases took the leading place in terms of International Classification of Disease Tenth Revision (ICD-10). In addition, medical income contributed most to the health financing.

Conclusions

The method to apply SHA 2011 at the subnational level is feasible in China. It makes health accounts more adaptable to rapidly developing health systems and makes the financing data more readily available for analytical use. SHA 2011 is a better health expenditure accounts system to reveal the actual burden on residents and deserves further promotion in China as well as around the world.

Measuring and mapping the global burden of antimicrobial resistance

The increasing number and global distribution of pathogens resistant to antimicrobial drugs is potentially one of the greatest threats to global health, leading to health crises arising from infections that were once easy to treat. Infections resistant to antimicrobial treatment frequently result in longer hospital stays, higher medical costs, and increased mortality. Despite the long-standing recognition of antimicrobial resistance (AMR) across many settings, there is surprisingly poor information about its geographical distribution over time and trends in its population prevalence and incidence. This makes reliable assessments of the health burden attributable to AMR difficult, weakening the evidence base to drive forward research and policy agendas to combat AMR. The inclusion of mortality and morbidity data related to drug-resistant infections into the annual Global Burden of Disease Study should help fill this policy void.

Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016

BACKGROUND

A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016.

METHODS

Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita.

FINDINGS

In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries.

INTERPRETATION

GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations.

FUNDING

Bill & Melinda Gates Foundation.

Serum metabolites are associated with all-cause mortality in chronic kidney disease

Chronic kidney disease (CKD) involves significant metabolic abnormalities and has a high mortality rate. Because the levels of serum metabolites in patients with CKD might provide insight into subclinical disease states and risk for future mortality, we determined which serum metabolites reproducibly associate with mortality in CKD using a discovery and replication design. Metabolite levels were quantified via untargeted liquid chromatography and mass spectroscopy from serum samples of 299 patients with CKD in the Modification of Diet in Renal Disease (MDRD) study as a discovery cohort. Six among 622 metabolites were significantly associated with mortality over a median follow-up of 17 years after adjustment for demographic and clinical covariates, including urine protein and measured glomerular filtration rate. We then replicated associations with mortality in 963 patients with CKD from the African American Study of Kidney Disease and Hypertension (AASK) cohort over a median follow-up of ten years. Three of the six metabolites identified in the MDRD cohort replicated in the AASK cohort: fumarate, allantoin, and ribonate, belonging to energy, nucleotide, and carbohydrate pathways, respectively. Point estimates were similar in both studies and in meta-analysis (adjusted hazard ratios 1.63, 1.59, and 1.61, respectively, per doubling of the metabolite). Thus, selected serum metabolites were reproducibly associated with long-term mortality in CKD beyond markers of kidney function in two well characterized cohorts, providing targets for investigation.

Canadian trends in opioid-related mortality and disability from opioid use disorder from 1990 to 2014 through the lens of the Global Burden of Disease Study

Introduction:

Several regions in Canada have recently experienced sharp increases in opioid overdoses and related hospitalizations and deaths. This paper describes opioidrelated mortality and disability from opioid use disorder in Canada from 1990 to 2014 using data from the Global Burden of Disease (GBD) study.

Methods:

We used data from the GBD study to describe temporal trends (1990–2014) in opioid-related mortality and disability from opioid use disorder using common metrics: disability-adjusted life years (DALY), deaths, years of life lost (YLL) and years lived with disability (YLD). We also compared age-standardized YLL and DALY rates per 100 000 population between Canada, the USA and other regions.

Results:

The age-standardized opioid-related DALY rate in Canada was 355.5 per 100 000 population in 2014, which was higher than the global rate of 193.2, but lower than the rate of 767.9 in the United States. Between 1990 and 2014, the age-standardized opioid-related YLL rate in Canada increased by 142.2%, while globally this rate decreased by 10.1%. In comparison with YLL, YLD accounted for a larger proportion of the overall opioid-related burden across all age groups. Health loss was greater for males than females, and highest among those aged 25 to 29 years.

Conclusion:

The health burden associated with opioid-related mortality and disability from opioid use disorder in Canada is significant and has increased dramatically from 1990 to 2014. These data point to a need for public health action including enhanced monitoring of a range of opioid-related harms.

The global burden of kidney disease and the sustainable development goals

Kidney disease has been described as the most neglected chronic disease. Reliable estimates of the global burden of kidney disease require more population-based studies, but specific risks occur across the socioeconomic spectrum from poverty to affluence, from malnutrition to obesity, in agrarian to post-industrial settings, and along the life course from newborns to older people. A range of communicable and noncommunicable diseases result in renal complications and many people who have kidney disease lack access to care. The causes, consequences and costs of kidney diseases have implications for public health policy in all countries. The risks of kidney disease are also influenced by ethnicity, gender, location and lifestyle.  Increasing economic and health disparities, migration, demographic transition, unsafe working conditions and environmental threats, natural disasters and pollution may thwart attempts to reduce the morbidity and mortality from kidney disease. A multisectoral approach is needed to tackle the global burden of kidney disease. The sustainable development goals (SDGs) emphasize the importance of a multisectoral approach to health. We map the actions towards achieving all of the SDGs that have the potential to improve understanding, measurement, prevention and treatment of kidney disease in all age groups. These actions can also foster treatment innovations and reduce the burden of such disease in future generations.

Transparent cap-assisted endoscopic sclerotherapy in esophageal varices: a randomized-controlled trial

BACKGROUND AND AIM

Endoscopic treatment is widely accepted as the first-line therapy selection for esophageal variceal bleeding. Nevertheless, endoscopic injection sclerotherapy requires experienced endoscopists and is associated with a high risk of bleeding. Our study evaluates the feasibility and efficacy of transparent cap-assisted endoscopic sclerotherapy in the management of esophageal varices.

PATIENTS AND METHODS

A randomized-controlled trial was conducted in a tertiary referral center from April 2015 to May 2016. Patients who received endoscopic sclerotherapy were randomized in a blinded manner into two groups: the transparent cap-assisted group (n=59) and the control group (n=61).

RESULTS

The average injection sites were reduced in the transparent cap-assisted group compared with the control group (1.2±0.4 vs. 1.4±0.05, P=0.000), whereas no difference was observed in the dosage of lauromacrogol (16.97±4.91 vs. 16.85±4.57, P=0.662) and the hemorrhage that occurred during injection made no difference (50.8 vs. 61.0%, P=0.276); yet, salvage hemostasis methods were used in only nine patients in the transparent cap-assisted group compared with 17 patients in the control group (25.0 vs. 38.7%, P=0.0936). The cost of each procedure in the cap-assisted group was ¥2578 (1878-4202), whereas it was ¥3691 for the control group (2506-5791) (P=0.023). Moreover, in both groups, no esophageal constriction was observed during the 6-month follow-up period, whereas the rebleeding rate between two groups showed no statistical significance in 6 months (89.8 vs. 93.4%, P=0.563).

CONCLUSION

Transparent cap-assisted sclerotherapy provided a clear field of vision and helped to fix the targeted veins, thus significantly reducing the use of the salvage hemostasis method during sclerotherapy injection hemorrhage. It is also associated with reduced injection sites and endoscopic therapy cost.

Bismuth improves efficacy of proton-pump inhibitor clarithromycin, metronidazole triple Helicobacter pylori therapy despite a high prevalence of antimicrobial resistance

BACKGROUND

Helicobacter pylori (H. pylori) eradication has become increasingly difficult especially for penicillin allergy patients.

AIMS

To evaluate the efficacy of adding bismuth or high-dose metronidazole to an H. pylori eradication regimen containing a proton-pump inhibitor, clarithromycin, and metronidazole in patients allergic to penicillin.

METHODS

Pilot study in which penicillin-allergic, treatment-naive subjects were randomized (1:1) to 14-day esomeprazole (20 mg q12h), clarithromycin (500 mg q12h), and high dose of metronidazole (400 mg q6h) with (BECM group) or without (ECM group) bismuth (600 mg q12h). Eradication was confirmed by ¹³ C-urea breath test 6 weeks after therapy. Antimicrobial susceptibility was assessed by the agar dilution method. Adverse events were recorded.

RESULTS

Sixty-six subjects were randomized, four were lost to follow-up and eight violated the protocol. The eradication rates were 63.6% (95% CI: 47.2%-80.0%) for ECM vs 84.8% (95% CI 72.6%-97.1%) (p = .049) for BECM by intention-to-treat, 67.7% (95% CI 51.3%-84.2%) vs 90.3% (95% CI 79.9%-100%) (p = .029) by modified ITT, and 70% (95% CI 53.6%-86.4%) vs 96% (95% CI 88.3%-100%) (P = .033) by per-protocol. Metronidazole, clarithromycin, and dual-resistant rates were 74.2%, 24.2%, and 18.2%, respectively. The cure rates were significantly improved by the addition of bismuth for both clarithromycin-resistant isolates (100% vs 25%, P = .024) and metronidazole-resistant isolates (94.7% vs 63.6%, P = .043). Adverse events were reported by 45.5% of subjects in ECM group and 48.5% in the BECM group (P = .805).

CONCLUSIONS

This prospective trial demonstrated that while high-dose metronidazole could not completely overcome metronidazole resistance, bismuth was additive and improved the overall cure rates by 21%-26%.

The burden of Neglected Tropical Diseases in Brazil, 1990-2016: A subnational analysis from the Global Burden of Disease Study 2016

BACKGROUND

Neglected Tropical Diseases (NTDs) are important causes of morbidity, disability, and mortality among poor and vulnerable populations in several countries worldwide, including Brazil. We present the burden of NTDs in Brazil from 1990 to 2016 based on findings from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016).

METHODOLOGY

We extracted data from GBD 2016 to assess years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) for NTDs by sex, age group, causes, and Brazilian states, from 1990 to 2016. We included all NTDs that were part of the priority list of the World Health Organization (WHO) in 2016 and that are endemic/autochthonous in Brazil. YLDs were calculated by multiplying the prevalence of sequelae multiplied by its disability weight. YLLs were estimated by multiplying each death by the reference life expectancy at each age. DALYs were computed as the sum of YLDs and YLLs.

PRINCIPAL FINDINGS

In 2016, there were 475,410 DALYs (95% uncertainty interval [UI]: 337,334-679,482; age-standardized rate of 232.0 DALYs/100,000 population) from the 12 selected NTDs, accounting for 0.8% of national all-cause DALYs. Chagas disease was the leading cause of DALYs among all NTDs, followed by schistosomiasis and dengue. The sex-age-specific NTD burden was higher among males and in the youngest and eldest (children <1 year and those aged ≥70 years). The highest age-standardized DALY rates due to all NTDs combined at the state level were observed in Goiás (614.4 DALYs/100,000), Minas Gerais (433.7 DALYs/100,000), and Distrito Federal (430.0 DALYs/100,000). Between 1990 and 2016, the national age-standardized DALY rates from all NTDs decreased by 45.7%, with different patterns among NTD causes and Brazilian states. Most NTDs decreased in the period, with more pronounced reduction in DALY rates for onchocerciasis, lymphatic filariasis, and rabies. By contrast, age-standardized DALY rates due to dengue, visceral leishmaniasis, and trichuriasis increased substantially. Age-standardized DALY rates decreased for most Brazilian states, increasing only in the states of Amapá, Ceará, Rio Grande do Norte, and Sergipe.

CONCLUSIONS/SIGNIFICANCE

GBD 2016 findings show that, despite the reduction in disease burden, NTDs are still important and preventable causes of disability and premature death in Brazil. The data call for renewed and comprehensive efforts to control and prevent the NTD burden in Brazil through evidence-informed and efficient and affordable interventions. Multi-sectoral and integrated control and surveillance measures should be prioritized, considering the population groups and geographic areas with the greatest morbidity, disability, and most premature deaths due to NTDs in the country.

Chronic obstructive pulmonary disease in China: a nationwide prevalence study

BACKGROUND

Because of the rapid change in economic development and lifestyle in China, and the ageing population, concerns have grown that chronic obstructive pulmonary disease (COPD) could become epidemic. An up-to-date nationwide estimation of COPD prevalence in China is needed.

METHODS

We did a cross-sectional survey of a nationally representative sample of individuals from mainland China aged 40 years or older. The primary outcome was COPD, defined according to the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) lung function criteria.

FINDINGS

Between Dec 29, 2014, and Dec 31, 2015, 66 752 adults were recruited to the study population. The estimated standardised prevalence of COPD was 13·6% (95% CI 12·0-15·2). The prevalence of COPD differed significantly between men and women (19·0%, 95% CI 16·9-21·2 vs 8·1%, 6·8-9·3; p<0·0001), mainly because of a significant difference in smoking status between men and women (current smokers 58·2% vs 4·0%). The prevalence of COPD differed by geographic region, with the highest prevalence in southwest China (20·2%, 95% CI 14·7-25·8) and the lowest in central China (10·2%, 8·2-12·2). Among adults with COPD, 56·4% (95% CI 53·7-59·2) had mild disease (GOLD stage I), 36·3% (34·3-38·3) had moderate disease (GOLD stage II), 6·5% (5·5-7·4) had severe disease (GOLD stage III), and 0·9% (0·6-1·1) had very severe disease (GOLD stage IV).

INTERPRETATION

In a large, nationally representative sample of adults aged 40 years or older, the estimated overall prevalence of COPD in China in 2014-15 was 13·6%, indicating that this disease has become a major public-health problem. Strategies aimed at prevention and treatment of COPD are needed urgently.

FUNDING

Chinese Central Government, the Ministry of Science and Technology of The People's Republic of China, and the National Natural Science Foundation of China.

Geographic and sociodemographic variation of cardiovascular disease risk in India: A cross-sectional study of 797,540 adults

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality in India. Yet, evidence on the CVD risk of India's population is limited. To inform health system planning and effective targeting of interventions, this study aimed to determine how CVD risk-and the factors that determine risk-varies among states in India, by rural-urban location, and by individual-level sociodemographic characteristics.

METHODS AND FINDINGS

We used 2 large household surveys carried out between 2012 and 2014, which included a sample of 797,540 adults aged 30 to 74 years across India. The main outcome variable was the predicted 10-year risk of a CVD event as calculated with the Framingham risk score. The Harvard-NHANES, Globorisk, and WHO-ISH scores were used in secondary analyses. CVD risk and the prevalence of CVD risk factors were examined by state, rural-urban residence, age, sex, household wealth, and education. Mean CVD risk varied from 13.2% (95% CI: 12.7%-13.6%) in Jharkhand to 19.5% (95% CI: 19.1%-19.9%) in Kerala. CVD risk tended to be highest in North, Northeast, and South India. District-level wealth quintile (based on median household wealth in a district) and urbanization were both positively associated with CVD risk. Similarly, household wealth quintile and living in an urban area were positively associated with CVD risk among both sexes, but the associations were stronger among women than men. Smoking was more prevalent in poorer household wealth quintiles and in rural areas, whereas body mass index, high blood glucose, and systolic blood pressure were positively associated with household wealth and urban location. Men had a substantially higher (age-standardized) smoking prevalence (26.2% [95% CI: 25.7%-26.7%] versus 1.8% [95% CI: 1.7%-1.9%]) and mean systolic blood pressure (126.9 mm Hg [95% CI: 126.7-127.1] versus 124.3 mm Hg [95% CI: 124.1-124.5]) than women. Important limitations of this analysis are the high proportion of missing values (27.1%) in the main outcome variable, assessment of diabetes through a 1-time capillary blood glucose measurement, and the inability to exclude participants with a current or previous CVD event.

CONCLUSIONS

This study identified substantial variation in CVD risk among states and sociodemographic groups in India-findings that can facilitate effective targeting of CVD programs to those most at risk and most in need. While the CVD risk scores used have not been validated in South Asian populations, the patterns of variation in CVD risk among the Indian population were similar across all 4 risk scoring systems.

Time-series analysis of tuberculosis from 2005 to 2017 in China

Seasonal autoregressive integrated moving average (SARIMA) has been used to model nationwide tuberculosis (TB) incidence in other countries. This study aimed to characterise monthly TB notification rate in China. Monthly TB notification rate from 2005 to 2017 was used. Time-series analysis was based on a SARIMA model and a hybrid model of SARIMA-generalised regression neural network (GRNN) model. A decreasing trend (3.17% per years, P < 0.01) and seasonal variation of TB notification rate were found from 2005 to 2016 in China, with a predominant peak in spring. A SARIMA model of ARIMA (0,1,1) (0,1,1)12 was identified. The mean error rate of the single SARIMA model and the SARIMA-GRNN combination model was 6.07% and 2.56%, and the determination coefficient was 0.73 and 0.94, respectively. The better performance of the SARIMA-GRNN combination model was further confirmed with the forecasting dataset (2017). TB is a seasonal disease in China, with a predominant peak in spring, and the trend of TB decreased by 3.17% per year. The SARIMA-GRNN model was more effective than the widely used SARIMA model at predicting TB incidence.

Indoor black carbon of outdoor origin and oxidative stress biomarkers in patients with chronic obstructive pulmonary disease

OBJECTIVES

We assessed relationships between indoor black carbon (BC) exposure and urinary oxidative stress biomarkers, 8-hydroxy-2'-deoxyguanosine (8-OHdG) and malondialdehyde (MDA), in participants with chronic obstructive pulmonary disease (COPD).

METHODS

Eighty-two participants completed in-home air sampling for one week prior to providing urine samples up to four times in a year. Weekly indoor and daily outdoor concentrations were used to estimate indoor daily lags and moving averages. There were no reported in-home BC sources, thus indoor levels closely represented outdoor BC infiltration. Mixed effects regression models with a random intercept for each participant were used to assess relationships between indoor BC and 8-OHdG and MDA, adjusting for age, race, BMI, diabetes, heart disease, season, time of urine collection, urine creatinine, and outdoor humidity and temperature.

RESULTS

There were positive effects of BC on 8-OHdG and MDA, with the greatest effect the day before urine collection (6.9% increase; 95% CI 0.9-13.3%, per interquartile range: 0.22 μg/m³) for 8-OHdG and 1 to 4 days before collection (8.3% increase; 95% CI 0.03-17.3% per IQR) for MDA. Results were similar in models adjusting for PM_2.5 not associated with BC and NO₂ (10.4% increase, 95% CI: 3.5-17.9 for 8-OHdG; 8.1% increase, 95% CI: -1.1-18.1 for MDA). Effects on 8-OHdG were greater in obese participants.

CONCLUSIONS

We found positive associations between BC exposure and 8-OHdG and MDA, in which associations with 8-OHdG were stronger in obese participants. These results suggest that exposure to low levels of traffic-related pollution results in lipid peroxidation and oxidative DNA damage in individuals with COPD.

A lipid A-based TLR4 mimetic effectively adjuvants a Yersinia pestis rF-V1 subunit vaccine in a murine challenge model

Vaccination can significantly reduce worldwide morbidity and mortality to infectious diseases, thereby reducing the health burden as a result of microbial infections. Effective vaccines contain three components: a delivery system, an antigenic component of the pathogen, and an adjuvant. With the growing use of purely recombinant or synthetic antigens, there is a need to develop novel adjuvants that enhance the protective efficacy of a vaccine against infection. Using a structure-activity relationship (SAR) model, we describe here the synthesis of a novel TLR4 ligand adjuvant compound, BECC438, by bacterial enzymatic combinatorial chemistry (BECC). This compound was identified using an in vitro screening pipeline consisting of (i) NFκB activation and cytokine production by immortalized cell lines, (ii) cytokine production by primary human PBMCs, and (iii) upregulation of surface costimulatory markers by primary human monocyte-derived dendritic cells. Using this SAR screening regimen, BECC438 was shown to produce an innate immune activation profile comparable to the well-characterized TLR4 agonist adjuvant compound, phosphorylated hexa-acyl disaccharide (PHAD). To evaluate the in vivo adjuvant activity of BECC438, we used the known protective Yersinia pestis (Yp) antigen, rF1-V, in a murine prime-boost vaccination schedule followed by lethal challenge. In addition to providing protection from lethal challenge, BECC438 stimulated production of higher levels of rF1-V-specific total IgG as compared to PHAD after both prime and boost vaccinations. Similar to PHAD, BECC438 elicited a balanced IgG1/IgG2c response, indicative of active T_H2/T_H1-driven immunity. These data demonstrate that the novel BECC-derived TLR4L adjuvant, BECC438, elicits cytokine profiles in vitro similar to PHAD, induces high antigen-specific immune titers and a T_H1-associated IgG2c immune titer skew, and protects mice against a lethal Yp challenge.

Estimating the completeness of death registration: An empirical method

Introduction

Many national and subnational governments need to routinely measure the completeness of death registration for monitoring and statistical purposes. Existing methods, such as death distribution and capture-recapture methods, have a number of limitations such as inaccuracy and complexity that prevent widespread application. This paper presents a novel empirical method to estimate completeness of death registration at the national and subnational level.

Methods

Random-effects models to predict the logit of death registration completeness were developed from 2,451 country-years in 110 countries from 1970–2015 using the Global Burden of Disease 2015 database. Predictors include the registered crude death rate, under-five mortality rate, population age structure and under-five death registration completeness. Models were developed separately for males, females and both sexes.

Findings

All variables are highly significant and reliably predict completeness of registration across a wide range of registered crude death rates (R-squared 0.85). Mean error is highest at medium levels of observed completeness. The models show quite close agreement between predicted and observed completeness for populations outside the dataset. There is high concordance with the Hybrid death distribution method in Brazilian states. Uncertainty in the under-five mortality rate, assessed using the dataset and in Colombian departmentos, has minimal impact on national level predicted completeness, but a larger effect at the subnational level.

Conclusions

The method demonstrates sufficient flexibility to predict a wide range of completeness levels at a given registered crude death rate. The method can be applied utilising data readily available at the subnational level, and can be used to assess completeness of deaths reported from health facilities, censuses and surveys. Its utility is diminished where the adult mortality rate is unusually high for a given under-five mortality rate. The method overcomes the considerable limitations of existing methods and has considerable potential for widespread application by national and subnational governments.

Impact of Obesity and Ozone on the Association Between Particulate Air Pollution and Cardiovascular Disease and Stroke Mortality Among US Adults

Background

Cardiovascular diseases (CVDs) and stroke are the highest and third highest causes of death, respectively, in the whole United States. It is well established that both long‐ and short‐term exposure to particulate air pollution (particulate matter with diameters <2.5 μm [PM_2.5]) increases the risks of both CVD and stroke mortality.

Methods and Results

We combined county‐level data for CVD and stroke mortality, and prevalence of hypertension and obesity, with spatial patterns of PM_2.5 and ozone in a cross‐sectional ecological study. We found significant positive associations between both CVD (β=15.4, P<0.001) and stroke (β=2.7, P<0.001) mortality with PM_2.5. Ozone had significant link with just CVD (β=1372.1, P<0.001). Once poverty, ethnicity, and education were taken into account, there were still significant positive associations between PM_2.5 and both CVD (β=1.2, P<0.001) and stroke (β=1.1, P<0.001) mortality. Moreover, the association between CVD and ozone remained after adjustment for these factors (β=21.8, P<0.001). PM_2.5 and ozone were independent risk factors. The impact of PM_2.5 on CVD and stroke mortality was strongly dependent on the prevalence of obesity. Hypertension partially mediated the associations of PM_2.5 and mortality from CVD and stroke.

Conclusions

There was a spatial association between PM_2.5 exposure and the leading causes of death and disability in United States. The effect of PM_2.5 was considerably greater in areas where obesity is more prevalent. Hypertension is a possible mediator of the association of PM_2.5 and both CVD and stroke.

Regulatory polymorphism of CXCL10 rs1439490 in seronegative occult hepatitis C virus infection

AIM

To examine the relationship between the single nucleotide polymorphism CXCL10 rs1439490 and seronegative occult hepatitis C virus (HCV) infection (OCI).

METHODS

One hundred and three cases of seronegative OCI and 155 cases of seropositive chronic HCV infection (CHC) were diagnosed at five Liver Centers in Northeastern China, from 2012 to 2016. CXCL10 rs1439490, rs1440802, and IL-28B rs12979860 were analyzed by sequencing. Serum CXCL10 was measured by ELISA. Intrahepatic CXCL10 was determined by quantitative PCR and immunohistochemical semi-quantitative scoring. Liver necroinflammation and fibrosis were scored according to the METAVIR system.

RESULTS

CXCL10 rs1439490 G/G was more prevalent in OCI patients (n = 93/103; 90.3%) than in CHC patients (n = 116/155; 74.8%; P = 0.008). OCI patients had lower serum CXCL10 levels than CHC patients (192.91 ± 46.50 pg/mL vs 354.78 ± 102.91 pg/mL, P < 0.0001). Of IL-28B rs12979860 C/C patients, OCI patients with rs1439490 G/G had lower serum and liver levels of CXCL10 and lower levels of liver necroinflammation and fibrosis than non-G/G patients. OCI patients had higher alanine aminotransferase normalization rates after Peg-interferon treatment than CHC patients (P < 0.05) and serum CXCL10 decreased significantly (P < 0.0001). Liver necroinflammation and fibrosis were alleviated in 8 OCI patients after treatment. Multivariate analysis indicated that rs1439490 G/G significantly influenced the occurrence of OCI in HCV infection (OR = 0.31, 95%CI: 0.15-0.66, P = 0.002).

CONCLUSION

CXCL10 rs1439490 G/G is positively associated with OCI in HCV infection and antiviral outcome.

Prevalence and risk factors for HBV and HCV in prisoners in Iran: a national bio-behavioural surveillance survey in 2015

OBJECTIVES

To provide more accurate estimates of the prevalence of Hepatitis B (HBV) and Hepatitis C (HCV) and their contributing factors among prisoners in Iran.

METHODS

Cross-sectional study of 6200 Iranian prisoners in 2015. Data were collected through questionnaires and interviews. HBV infection and HCV exposure status of the participants was determined by HBsAg and HCV antibodies blood tests using enzyme-linked immunosorbent assay (ELISA). Data were analysed in STATA-12.

RESULT

Prevalence of HCV exposure was 9.48% (95% CI: 8.73-10.27), and prevalence of HBV was 2.48% (95% CI: 2.07-2.89) in the general prison population. In multivariate analysis, the most important risk factor for HBV was a history of drug use in lifetime (adjusted odds ratio, AOR: 1.8, 95% CI: 1.17-3.02). The main risk factors for HCV exposure were a history of drug use in lifetime (AOR: 4.08, CI: 2.56-6.27), age over 30 (AOR: 2.68, CI: 2.01-3.56), and having tattoos (AOR = 1.67, CI: 1.35-2.07).

CONCLUSION

Although vaccination is used to control HBV among prisoners, prevalence of HCV exposure is alarming in the prison population of Iran, especially among people who inject drugs. Eliminating viral hepatitis in Iran by 2030 requires a national commitment and rapid measures for targeting this high-risk group. Given the increased efficiency of HCV treatment in recent years, prisons provide an opportunity to access patients for treatment.

Task shifting between physicians and nurses in acute care hospitals: cross-sectional study in nine countries

BACKGROUND

Countries vary in the extent to which reforms have been implemented expanding nurses' Scopes-of-Practice (SoP). There is limited cross-country research if and how reforms affect clinical practice, particularly in hospitals. This study analyses health professionals' perceptions of role change and of task shifting between the medical and nursing professions in nine European countries.

METHODS

Cross-sectional design with surveys completed by 1716 health professionals treating patients with breast cancer (BC) and acute myocardial infarction (AMI) in 161 hospitals across nine countries. Descriptive and bivariate analysis on self-reported staff role changes and levels of independence (with/without physician oversight) by two country groups, with major SoP reforms implemented between 2010 and 2015 (Netherlands, England, Scotland) and without (Czech Republic, Germany, Italy, Norway, Poland, Turkey). Participation in 'medical tasks' was identified using two methods, a data-driven and a conceptual approach. Individual task-related analyses were performed for the medical and nursing professions, and Advanced Practice Nurses/Specialist Nurses (APN/SN).

RESULTS

Health professionals from the Netherlands, England and Scotland more frequently reported changes to staff roles over this time period vs. the other six countries (BC 74.0% vs. 38.7%, p < .001; AMI 61.7% vs. 37.3%, p < .001), and higher independence in new roles (BC 58.6% vs. 24.0%, p < .001; AMI 48.9% vs. 29.2%, p < .001). A higher proportion of nurses and APN/SN from these three countries reported to undertake tasks related to BC diagnosis, therapy, prescribing of medicines and information to patients compared to the six countries. Similar cross-country differences existed for AMI on prescribing medications and follow-up care. Tasks related to diagnosis and therapy, however, remained largely within the medical profession's domain. Most tasks were reported to be performed by both professions rather than carried out by one profession only.

CONCLUSIONS

Higher levels of changes to staff roles and task shifting were reported in the Netherlands, England and Scotland, suggesting that professional boundaries have shifted, for instance on chemotherapy or prescribing medicines. For most tasks, however, a partial instead of full task shifting is practice.

Association of Fast-Food and Full-Service Restaurant Densities With Mortality From Cardiovascular Disease and Stroke, and the Prevalence of Diabetes Mellitus

BACKGROUND

We explored whether higher densities of fast-food restaurants (FFRs) and full-service restaurants are associated with mortality from cardiovascular disease (CVD) and stroke and the prevalence of type 2 diabetes mellitus (T2D) across the mainland United States.

METHODS AND RESULTS

In this cross-sectional study county-level data for CVD and stroke mortality, and prevalence of T2D, were combined with per capita densities of FFRs and full-service restaurants and analyzed using regression. Mortality and diabetes mellitus prevalence were corrected for poverty, ethnicity, education, physical inactivity, and smoking. After adjustment, FFR density was positively associated with CVD (β=1.104, R²=2.3%), stroke (β=0.841, R²=1.4%), and T2D (β=0.578, R²=0.6%) and full-service restaurant density was positively associated with CVD mortality (β=0.19, R²=0.1%) and negatively related to T2D prevalence (β=-0.25, R²=0.3%). In a multiple regression analysis (FFRs and full-service restaurants together in same model), only the densities of FFRs were significant (and positive). If we assume these relationships are causal, an impact analysis suggested that opening 10 new FFRs in a county would lead to 1 extra death from CVD every 42 years and 1 extra death from stroke every 55 years. Repeated nationally across all counties, that would be an extra 748 CVD deaths and 567 stroke deaths (and 390 new cases of T2D) over the next 10 years.

CONCLUSIONS

These results suggest that an increased density of FFRs is associated with increased risk of death from CVD and stroke and increased T2D prevalence, but the maximal impact (assuming the correlations reflect causality) of each individual FFR is small.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT03243253.

Carnitine palmitoyltransferase gene upregulation by linoleic acid induces CD4+ T cell apoptosis promoting HCC development

Hepatocellular carcinoma (HCC) is a common cause of cancer-related death worldwide. As obesity and diabetes become more prevalent, the contribution of non-alcoholic fatty liver disease (NAFLD) to HCC is rising. Recently, we reported intrahepatic CD4⁺ T cells are critical for anti-tumor surveillance in NAFLD. Lipid accumulation in the liver is the hallmark of NAFLD, which may perturb T cell function. We sought to investigate how the lipid-rich liver environment influences CD4⁺ T cells by focusing on carnitine palmitoyltransferase (CPT) family members, which control the mitochondrial β-oxidation of fatty acids and act as key molecules in lipid catabolism. Linoleic acid (C18:2) co-localized within the mitochondria along with a corresponding increase in CPT gene upregulation. This CPT upregulation can be recapitulated by feeding mice with a high-C18:2 diet or the NAFLD promoting methionine-choline-deficient (MCD) diet. Using an agonist and antagonist, the induction of CPT genes was found to be mediated by peroxisome proliferator-activated receptor alpha (PPAR-α). CPT gene upregulation increased mitochondrial reactive oxygen species (ROS) and led to cell apoptosis. In vivo, using liver-specific inducible MYC transgenic mice fed MCD diet, blocking CPT with the pharmacological inhibitor perhexiline decreased apoptosis of intrahepatic CD4⁺ T cells and inhibited HCC tumor formation. These results provide useful information for potentially targeting the CPT family to rescue intrahepatic CD4⁺ T cells and to aid immunotherapy for NAFLD-promoted HCC.