Global, regional, and national incidence and mortality burden of non-COVID-19 lower respiratory infections and aetiologies, 1990-2021: a systematic analysis from the Global Burden of Disease Study 2021

BACKGROUND

Lower respiratory infections (LRIs) are a major global contributor to morbidity and mortality. In 2020-21, non-pharmaceutical interventions associated with the COVID-19 pandemic reduced not only the transmission of SARS-CoV-2, but also the transmission of other LRI pathogens. Tracking LRI incidence and mortality, as well as the pathogens responsible, can guide health-system responses and funding priorities to reduce future burden. We present estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 of the burden of non-COVID-19 LRIs and corresponding aetiologies from 1990 to 2021, inclusive of pandemic effects on the incidence and mortality of select respiratory viruses, globally, regionally, and for 204 countries and territories.

METHODS

We estimated mortality, incidence, and aetiology attribution for LRI, defined by the GBD as pneumonia or bronchiolitis, not inclusive of COVID-19. We analysed 26 259 site-years of mortality data using the Cause of Death Ensemble model to estimate LRI mortality rates. We analysed all available age-specific and sex-specific data sources, including published literature identified by a systematic review, as well as household surveys, hospital admissions, health insurance claims, and LRI mortality estimates, to generate internally consistent estimates of incidence and prevalence using DisMod-MR 2.1. For aetiology estimation, we analysed multiple causes of death, vital registration, hospital discharge, microbial laboratory, and literature data using a network analysis model to produce the proportion of LRI deaths and episodes attributable to the following pathogens: Acinetobacter baumannii, Chlamydia spp, Enterobacter spp, Escherichia coli, fungi, group B streptococcus, Haemophilus influenzae, influenza viruses, Klebsiella pneumoniae, Legionella spp, Mycoplasma spp, polymicrobial infections, Pseudomonas aeruginosa, respiratory syncytial virus (RSV), Staphylococcus aureus, Streptococcus pneumoniae, and other viruses (ie, the aggregate of all viruses studied except influenza and RSV), as well as a residual category of other bacterial pathogens.

FINDINGS

Globally, in 2021, we estimated 344 million (95% uncertainty interval [UI] 325-364) incident episodes of LRI, or 4350 episodes (4120-4610) per 100 000 population, and 2·18 million deaths (1·98-2·36), or 27·7 deaths (25·1-29·9) per 100 000. 502 000 deaths (406 000-611 000) were in children younger than 5 years, among which 254 000 deaths (197 000-320 000) occurred in countries with a low Socio-demographic Index. Of the 18 modelled pathogen categories in 2021, S pneumoniae was responsible for the highest proportions of LRI episodes and deaths, with an estimated 97·9 million (92·1-104·0) episodes and 505 000 deaths (454 000-555 000) globally. The pathogens responsible for the second and third highest episode counts globally were other viral aetiologies (46·4 million [43·6-49·3] episodes) and Mycoplasma spp (25·3 million [23·5-27·2]), while those responsible for the second and third highest death counts were S aureus (424 000 [380 000-459 000]) and K pneumoniae (176 000 [158 000-194 000]). From 1990 to 2019, the global all-age non-COVID-19 LRI mortality rate declined by 41·7% (35·9-46·9), from 56·5 deaths (51·3-61·9) to 32·9 deaths (29·9-35·4) per 100 000. From 2019 to 2021, during the COVID-19 pandemic and implementation of associated non-pharmaceutical interventions, we estimated a 16·0% (13·1-18·6) decline in the global all-age non-COVID-19 LRI mortality rate, largely accounted for by a 71·8% (63·8-78·9) decline in the number of influenza deaths and a 66·7% (56·6-75·3) decline in the number of RSV deaths.

INTERPRETATION

Substantial progress has been made in reducing LRI mortality, but the burden remains high, especially in low-income and middle-income countries. During the COVID-19 pandemic, with its associated non-pharmaceutical interventions, global incident LRI cases and mortality attributable to influenza and RSV declined substantially. Expanding access to health-care services and vaccines, including S pneumoniae, H influenzae type B, and novel RSV vaccines, along with new low-cost interventions against S aureus, could mitigate the LRI burden and prevent transmission of LRI-causing pathogens.

FUNDING

Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care (UK).

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Effectiveness of Vitamin D supplementation in combination with calcium on risk of maternal and neonatal outcomes: A quasi-experimental clinical trial

Objectives

We examined the effectiveness of combining Vitamin D supplementation with calcium on maternal and neonatal outcomes, as opposed to using Vitamin D supplements alone.

Materials and Methods

Pregnant women in their third trimester were divided into two groups. The control group received a daily dose of 1000 IU of Vitamin D, but, the experimental group received a combined daily dosage of 1000 IU of Vitamin D and 500 mg of calcium, until delivery.

Results

The women in the Vitamin D + calcium group were less likely to develop gestational diabetes (2.78%; vs. 19.51%; P = 0.0318), preeclampsia (2.78% vs. 26.83%; P = 0.004), newly onset gestational hypertension (11.11% vs. 46.34%; P = 0.001), proteinuria (5.56% vs. 39.02%; P = 0.0004), and impaired glucose tolerance (2.78% vs. 21.95%; P = 0.0163) and had lower blood pressure at 20th and 39th weeks of gestation. The newborns in the Vitamin D + calcium group were less likely to experience low birth weight (5.71% vs. 31.58%; P = 0.0066), low birth length (5.71% vs. 44.74%; P = 0.0007), were less likely to be admitted to the neonatal intensive care unit (14.29% vs. 42.11%; P = 0.0105), have a larger head circumference (35.00 vs. 33.63; P < 0.0001), longer gestational age at birth (40.0 vs. 37.56 weeks; P < 0.0001), and higher APGAR scores (9.58 vs. 6.31; P < 0.0001.) compared to Vitamin D group, respectively.

Conclusions

Taking Vitamin D and calcium by pregnant women in the third trimester is an effective treatment to decrease maternal, fetal, and neonatal outcomes.

Global, regional, and national burden of disorders affecting the nervous system, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Disorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.

METHODS

We estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.

FINDINGS

Globally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378-521), affecting 3·40 billion (3·20-3·62) individuals (43·1%, 40·5-45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7-26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6-38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5-32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7-2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.

INTERPRETATION

As the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed.

FUNDING

Bill & Melinda Gates Foundation.

Effect of probiotics plus zinc supplementation on clinical outcomes of infants and children with acute infectious diarrhea: a randomized controlled trial

BACKGROUND

Findings are conflicting regarding the effect of zinc supplementation on disease severity in children with acute gastroenteritis.

PURPOSE

To examine the effects of probiotics and zinc on the clinical outcomes of infants and children with acute infectious diarrhea.

METHODS

In this randomized controlled trial, children with mild or moderate to severe acute gastroenteritis in the Kurdistan Region from November 2021 to June 2022 were diagnosed clinically and randomly assigned to the experimental or control group. The experimental group (n=50) received probiotics and zinc, whereas the control group (n=51) received probiotics alone for 1 week. The product contained live Bifidobacterium infantis, Lactobacillus paracasei, and Lactobacillus rhamnosus (10×106 colony-forming units/day for 7 days). Zinc syrup was administered to the probiotic plus zinc group. Each 5 mL of syrup contained 15 mg of zinc sulfate. Dehydration and disease severity in both groups were measured using the Clinical Dehydration Scale and the Modified Vesikari Scale, respectively. An illness episode was defined as an episode of gastroenteritis with a total score of ≥9 on the Modified Vesikari Scale (range, 0-20).

RESULTS

The probiotic and probiotic plus zinc groups were similar in age (1.79 years vs. 1.69 years, respectively; P= 0.645), sex (male/female ratio: 1.43 and 1.0, respectively; P=0.373), and medical characteristics. The groups had similar mean dehydration and disease severity scores and a similar incidence of dehydration recovery (some dehydration, 3.92% and 4.00%, respectively; P=1.000), and recovery from mild gastroenteritis (0.0% and 2.0%, respectively; P=0.495) at 2 weeks. Significant decreases in mean dehydration severity and disease severity score (1.80 to 0 and 6.66 to 0, respectively; P<0.001) and the development of dehydration (some dehydration, from 94.0% to 4.0%; P<0.001) from baseline to 2 weeks were noted in the probiotics plus zinc group. The probiotics group responded similarly. The development of mild gastroenteritis was significantly reduced from baseline to 2 weeks (90.2% to 0% and 78.0% to 2.0% in the probiotics and probiotics plus zinc groups, respectively; P<0.0001). The probiotics plus zinc group had a shorter mean recovery time (1.34 days vs. 2.00 days, respectively; P<0.001).

CONCLUSION

Taking probiotics plus zinc did not significantly affect disease severity in children with gastroenteritis at 2 weeks. However, the probiotics plus zinc group recovered more quickly than the probiotics group.

Global, regional, and national age-specific progress towards the 2020 milestones of the WHO End TB Strategy: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Global evaluations of the progress towards the WHO End TB Strategy 2020 interim milestones on mortality (35% reduction) and incidence (20% reduction) have not been age specific. We aimed to assess global, regional, and national-level burdens of and trends in tuberculosis and its risk factors across five separate age groups, from 1990 to 2021, and to report on age-specific progress between 2015 and 2020.

METHODS

We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 (GBD 2021) analytical framework to compute age-specific tuberculosis mortality and incidence estimates for 204 countries and territories (1990-2021 inclusive). We quantified tuberculosis mortality among individuals without HIV co-infection using 22 603 site-years of vital registration data, 1718 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, 680 site-years of mortality surveillance data, and 9 site-years of minimally invasive tissue sample (MITS) diagnoses data as inputs into the Cause of Death Ensemble modelling platform. Age-specific HIV and tuberculosis deaths were established with a population attributable fraction approach. We analysed all available population-based data sources, including prevalence surveys, annual case notifications, tuberculin surveys, and tuberculosis mortality, in DisMod-MR 2.1 to produce internally consistent age-specific estimates of tuberculosis incidence, prevalence, and mortality. We also estimated age-specific tuberculosis mortality without HIV co-infection that is attributable to the independent and combined effects of three risk factors (smoking, alcohol use, and diabetes). As a secondary analysis, we examined the potential impact of the COVID-19 pandemic on tuberculosis mortality without HIV co-infection by comparing expected tuberculosis deaths, modelled with trends in tuberculosis deaths from 2015 to 2019 in vital registration data, with observed tuberculosis deaths in 2020 and 2021 for countries with available cause-specific mortality data.

FINDINGS

We estimated 9·40 million (95% uncertainty interval [UI] 8·36 to 10·5) tuberculosis incident cases and 1·35 million (1·23 to 1·52) deaths due to tuberculosis in 2021. At the global level, the all-age tuberculosis incidence rate declined by 6·26% (5·27 to 7·25) between 2015 and 2020 (the WHO End TB strategy evaluation period). 15 of 204 countries achieved a 20% decrease in all-age tuberculosis incidence between 2015 and 2020, eight of which were in western sub-Saharan Africa. When stratified by age, global tuberculosis incidence rates decreased by 16·5% (14·8 to 18·4) in children younger than 5 years, 16·2% (14·2 to 17·9) in those aged 5-14 years, 6·29% (5·05 to 7·70) in those aged 15-49 years, 5·72% (4·02 to 7·39) in those aged 50-69 years, and 8·48% (6·74 to 10·4) in those aged 70 years and older, from 2015 to 2020. Global tuberculosis deaths decreased by 11·9% (5·77 to 17·0) from 2015 to 2020. 17 countries attained a 35% reduction in deaths due to tuberculosis between 2015 and 2020, most of which were in eastern Europe (six countries) and central Europe (four countries). There was variable progress by age: a 35·3% (26·7 to 41·7) decrease in tuberculosis deaths in children younger than 5 years, a 29·5% (25·5 to 34·1) decrease in those aged 5-14 years, a 15·2% (10·0 to 20·2) decrease in those aged 15-49 years, a 7·97% (0·472 to 14·1) decrease in those aged 50-69 years, and a 3·29% (-5·56 to 9·07) decrease in those aged 70 years and older. Removing the combined effects of the three attributable risk factors would have reduced the number of all-age tuberculosis deaths from 1·39 million (1·28 to 1·54) to 1·00 million (0·703 to 1·23) in 2020, representing a 36·5% (21·5 to 54·8) reduction in tuberculosis deaths compared to those observed in 2015. 41 countries were included in our analysis of the impact of the COVID-19 pandemic on tuberculosis deaths without HIV co-infection in 2020, and 20 countries were included in the analysis for 2021. In 2020, 50 900 (95% CI 49 700 to 52 400) deaths were expected across all ages, compared to an observed 45 500 deaths, corresponding to 5340 (4070 to 6920) fewer deaths; in 2021, 39 600 (38 300 to 41 100) deaths were expected across all ages compared to an observed 39 000 deaths, corresponding to 657 (-713 to 2180) fewer deaths.

INTERPRETATION

Despite accelerated progress in reducing the global burden of tuberculosis in the past decade, the world did not attain the first interim milestones of the WHO End TB Strategy in 2020. The pace of decline has been unequal with respect to age, with older adults (ie, those aged >50 years) having the slowest progress. As countries refine their national tuberculosis programmes and recalibrate for achieving the 2035 targets, they could consider learning from the strategies of countries that achieved the 2020 milestones, as well as consider targeted interventions to improve outcomes in older age groups.

FUNDING

Bill & Melinda Gates Foundation.

Role of wet-cupping therapy in physiological and mental pains in patients with migraine: A quasi-clinical trial

BACKGROUND

There is growing evidence of the potential benefits of wet-cupping therapy in reducing physiological pain severity in migraine; however, the role of this therapy on mental pain is unclear in this process. Therefore, this study aimed to examine the effectiveness of wet-cupping therapy on physiological and mental pains in patients with migraine. In this study, 72 migraine patients were treated with wet-cupping therapy and followed up after 1 month.

METHODS

The severity of physiological and mental pain was measured before therapy, 10 minutes and 1 month following therapy.

RESULTS

The study showed that patients in the wet-cupping therapy had a significantly lower mean value of physiological (0.42 vs 3.39; P < .001) and mental pain (1.60 vs 3.06; P < .001) compared to the patients in the control group, respectively. The mean value of the physiological was significantly decreased from 6.97 (baseline) to 0.73 (10 minutes) and 0.63 (1 month; P < .001) in the wet-cupping therapy patients, and the mean value of mental pain from 3.76 (baseline) to 0.71 (10 minutes) and 1.71 (1 month; P < .001). The mean values of physiological and mental pains were significantly reduced (from 7.80-3.39; P < .001) and (from 3.48-3.06; P = .0044), respectively. The level of physiological pain severity was significantly decreased with a decreasing level of mental pain severity at the posttest within the control (r = 0.5471; P = .0002) and the wet-cupping therapy (r = 0.3814; P .0412).

CONCLUSION

This study showed that the physiological pain was controlled by the mental pain in the wet-cupping therapy.

Temporal patterns of cancer burden in Asia, 1990-2019: a systematic examination for the Global Burden of Disease 2019 study

Background

Cancers represent a challenging public health threat in Asia. This study examines the temporal patterns of incidence, mortality, disability and risk factors of 29 cancers in Asia in the last three decades.

Methods

The age, sex and year-wise estimates of incidence, mortality, and disability-adjusted life years (DALYs) of 29 cancers for 49 Asian countries from 1990 through 2019 were generated as a part of the Global Burden of Disease, Injuries and Risk Factors 2019 study. Besides incidence, mortality and DALYs, we also examined the cancer burden measured in terms of DALYs and deaths attributable to risk factors, which had evidence of causation with different cancers. The development status of countries was measured using the socio-demographic index. Decomposition analysis was performed to gauge the change in cancer incidence between 1990 and 2019 due to population growth, aging and age-specific incidence rates.

Findings

All cancers combined claimed an estimated 5.6 million [95% uncertainty interval, 5.1-6.0 million] lives in Asia with 9.4 million [8.6-10.2 million] incident cases and 144.7 million [132.7-156.5 million] DALYs in 2019. The age-standardized incidence rate (ASIR) of all cancers combined in Asia was 197.6/100,000 [181.0-214.4] in 2019, varying from 99.2/100,000 [76.1-126.0] in Bangladesh to 330.5/100,000 [298.5-365.8] in Cyprus. The age-standardized mortality rate (ASMR) was 120.6/100,000 [110.1-130.7] in 2019, varying 4-folds across countries from 71.0/100,000 [59.9-83.5] in Kuwait to 284.2/100,000 [229.2-352.3] in Mongolia. The age-standardized DALYs rate was 2970.5/100,000 [2722.6-3206.5] in 2019, varying from 1578.0/100,000 [1341.2-1847.0] in Kuwait to 6574.4/100,000 [5141.7-8333.0] in Mongolia. Between 1990 and 2019, deaths due to 17 of the 29 cancers either doubled or more, and 20 of the 29 cancers underwent an increase of 150% or more in terms of new cases. Tracheal, bronchus, and lung cancer (both sexes), breast cancer (among females), colon and rectum cancer (both sexes), stomach cancer (both sexes) and prostate cancer (among males) were among top-5 cancers in most Asian countries in terms of ASIR and ASMR in 2019 and cancers of liver, stomach, hodgkin lymphoma and esophageal cancer posted the most significant decreases in age-standardized rates between 1990 and 2019. Among the modifiable risk factors, smoking, alcohol use, ambient particulate matter (PM) pollution and unsafe sex remained the dominant risk factors between 1990 and 2019. Cancer DALYs due to ambient PM pollution, high body mass index and fasting plasma glucose has increased most notably between 1990 and 2019.

Interpretation

With growing incidence, cancer has become more significant public health threat in Asia, demanding urgent policy attention and guidance. Its heightened risk calls for increased cancer awareness, preventive measures, affordable early-stage detection, and cost-effective therapeutics in Asia. The current study can serve as a useful resource for policymakers and researchers in Asia for devising interventions for cancer management and control.

Funding

The GBD study is funded by the Bill and Melinda Gates Foundation.

Global, regional, and national incidence of six major immune-mediated inflammatory diseases: findings from the global burden of disease study 2019

Background

The causes for immune-mediated inflammatory diseases (IMIDs) are diverse and the incidence trends of IMIDs from specific causes are rarely studied. The study aims to investigate the pattern and trend of IMIDs from 1990 to 2019.

Methods

We collected detailed information on six major causes of IMIDs, including asthma, inflammatory bowel disease, multiple sclerosis, rheumatoid arthritis, psoriasis, and atopic dermatitis, between 1990 and 2019, derived from the Global Burden of Disease study in 2019. The average annual percent change (AAPC) in number of incidents and age standardized incidence rate (ASR) on IMIDs, by sex, age, region, and causes, were calculated to quantify the temporal trends.

Findings

In 2019, rheumatoid arthritis, atopic dermatitis, asthma, multiple sclerosis, psoriasis, inflammatory bowel disease accounted 1.59%, 36.17%, 54.71%, 0.09%, 6.84%, 0.60% of overall new IMIDs cases, respectively. The ASR of IMIDs showed substantial regional and global variation with the highest in High SDI region, High-income North America, and United States of America. Throughout human lifespan, the age distribution of incident cases from six IMIDs was quite different. Globally, incident cases of IMIDs increased with an AAPC of 0.68 and the ASR decreased with an AAPC of -0.34 from 1990 to 2019. The incident cases increased across six IMIDs, the ASR of rheumatoid arthritis increased (0.21, 95% CI 0.18, 0.25), while the ASR of asthma (AAPC = -0.41), inflammatory bowel disease (AAPC = -0.72), multiple sclerosis (AAPC = -0.26), psoriasis (AAPC = -0.77), and atopic dermatitis (AAPC = -0.15) decreased. The ASR of overall and six individual IMID increased with SDI at regional and global level. Countries with higher ASR in 1990 experienced a more rapid decrease in ASR.

Interpretation

The incidence patterns of IMIDs varied considerably across the world. Innovative prevention and integrative management strategy are urgently needed to mitigate the increasing ASR of rheumatoid arthritis and upsurging new cases of other five IMIDs, respectively.

Funding

The Global Burden of Disease Study is funded by the Bill and Melinda Gates Foundation. The project funded by Scientific Research Fund of Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital (2022QN38).

Impact of short and intensive art-based intervention on symptomatology and social interactions among children with autism spectrum disorder

BACKGROUND

Consensus on the effectiveness of art therapy in children with autism spectrum disorders (ASDs) is lacking in the literature.

PURPOSE

Here, we examined the effectiveness of a short and intensive art-based intervention on autistic symptomatology and social skills among children with ASD levels 2 and 3.

METHODS

This pre- and postexperimental investigation included 13 children previously diagnosed with ASD levels 2 and 3 in Kurdistan Region in 2019. They completed the art-based intervention 2 hours/day for 3 days/week for 1 month. The activities included cutting and pasting squares and triangles, coloring black-and-white images, and recognizing and coloring shapes. Children used wooden and aquatic pens and scissors under guidance. Symptom severity was measured using the Social Responsiveness Scale (SRS-2), a validated tool for measuring the severity of autistic traits and symptoms that features subscales of social awareness, social cognition, social communication, social motivation, and autistic mannerisms. Children with ASD level 2 require significant support and experience notable difficulties in verbal and social communication, while those with ASD level 3 require extensive support and have the most severe form of autism. The outcome was measured one day before the course commenced and one week after completion.

RESULTS

The mean patient age (n=13) was 8.15 years (standard deviation, 1.95; range, 5-11 years). Most patients were male (n=11, 84.62%). The mean SRS-2 score did not change significantly pre- to postexperiment (159 vs. 157, P=0.601). Similarly, we found no significant changes in social awareness (19 vs. 19, P=0.779); social cognition (28 vs. 27, P=0.199); social communication (56 vs. 54, P=0.600); social motivation (26 vs. 24, P=0.684); and autistic mannerisms (33 vs. 32; P= 0.780), respectively.

CONCLUSION

The art-based intervention did not improve autism symptoms or social interactions among children with ASD levels 2 and 3.

Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Diabetes is one of the leading causes of death and disability worldwide, and affects people regardless of country, age group, or sex. Using the most recent evidentiary and analytical framework from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), we produced location-specific, age-specific, and sex-specific estimates of diabetes prevalence and burden from 1990 to 2021, the proportion of type 1 and type 2 diabetes in 2021, the proportion of the type 2 diabetes burden attributable to selected risk factors, and projections of diabetes prevalence through 2050.

METHODS

Estimates of diabetes prevalence and burden were computed in 204 countries and territories, across 25 age groups, for males and females separately and combined; these estimates comprised lost years of healthy life, measured in disability-adjusted life-years (DALYs; defined as the sum of years of life lost [YLLs] and years lived with disability [YLDs]). We used the Cause of Death Ensemble model (CODEm) approach to estimate deaths due to diabetes, incorporating 25 666 location-years of data from vital registration and verbal autopsy reports in separate total (including both type 1 and type 2 diabetes) and type-specific models. Other forms of diabetes, including gestational and monogenic diabetes, were not explicitly modelled. Total and type 1 diabetes prevalence was estimated by use of a Bayesian meta-regression modelling tool, DisMod-MR 2.1, to analyse 1527 location-years of data from the scientific literature, survey microdata, and insurance claims; type 2 diabetes estimates were computed by subtracting type 1 diabetes from total estimates. Mortality and prevalence estimates, along with standard life expectancy and disability weights, were used to calculate YLLs, YLDs, and DALYs. When appropriate, we extrapolated estimates to a hypothetical population with a standardised age structure to allow comparison in populations with different age structures. We used the comparative risk assessment framework to estimate the risk-attributable type 2 diabetes burden for 16 risk factors falling under risk categories including environmental and occupational factors, tobacco use, high alcohol use, high body-mass index (BMI), dietary factors, and low physical activity. Using a regression framework, we forecast type 1 and type 2 diabetes prevalence through 2050 with Socio-demographic Index (SDI) and high BMI as predictors, respectively.

FINDINGS

In 2021, there were 529 million (95% uncertainty interval [UI] 500-564) people living with diabetes worldwide, and the global age-standardised total diabetes prevalence was 6·1% (5·8-6·5). At the super-region level, the highest age-standardised rates were observed in north Africa and the Middle East (9·3% [8·7-9·9]) and, at the regional level, in Oceania (12·3% [11·5-13·0]). Nationally, Qatar had the world's highest age-specific prevalence of diabetes, at 76·1% (73·1-79·5) in individuals aged 75-79 years. Total diabetes prevalence-especially among older adults-primarily reflects type 2 diabetes, which in 2021 accounted for 96·0% (95·1-96·8) of diabetes cases and 95·4% (94·9-95·9) of diabetes DALYs worldwide. In 2021, 52·2% (25·5-71·8) of global type 2 diabetes DALYs were attributable to high BMI. The contribution of high BMI to type 2 diabetes DALYs rose by 24·3% (18·5-30·4) worldwide between 1990 and 2021. By 2050, more than 1·31 billion (1·22-1·39) people are projected to have diabetes, with expected age-standardised total diabetes prevalence rates greater than 10% in two super-regions: 16·8% (16·1-17·6) in north Africa and the Middle East and 11·3% (10·8-11·9) in Latin America and Caribbean. By 2050, 89 (43·6%) of 204 countries and territories will have an age-standardised rate greater than 10%.

INTERPRETATION

Diabetes remains a substantial public health issue. Type 2 diabetes, which makes up the bulk of diabetes cases, is largely preventable and, in some cases, potentially reversible if identified and managed early in the disease course. However, all evidence indicates that diabetes prevalence is increasing worldwide, primarily due to a rise in obesity caused by multiple factors. Preventing and controlling type 2 diabetes remains an ongoing challenge. It is essential to better understand disparities in risk factor profiles and diabetes burden across populations, to inform strategies to successfully control diabetes risk factors within the context of multiple and complex drivers.

FUNDING

Bill & Melinda Gates Foundation.

Attitudes of Islamic Clerics to Receiving COVID-19 Vaccine in Iraqi Kurdistan: A Focus Group Study

OBJECTIVES

Religious beliefs may play a role in the rejection and acceptance of coronavirus disease (COVID-19) vaccines. We aimed to explore attitudes of Islamic clerics toward receiving the COVID-19 vaccines in a semi-structured qualitative focus group study.

METHODS

The clerics of members of the Union of Muslim Scholars of the Erbil branch were included through their representative in Iraqi Kurdistan in 2021.

RESULTS

This study found that both acceptance and non-acceptance focus groups approved of the existence and importance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The acceptance group intended to receive COVID-19 to protect themselves and tried to convince people to receive the vaccine. However, the non-acceptance focus group did not believe in the COVID-19 vaccine due to different reasons: (1) COVID-19 vaccines have been commercialized and politicized by the governments; (2) the government makes limitations for the people due to COVID-19; (3) making fake vaccine cards; and (4) several serious side effects of COVID-19 (death, etc.) and not receiving by health care workers. The acceptance group reported that some rumors are spread in our community and impact the public to not receive COVID-19 vaccines.

CONCLUSIONS

This study showed that some Islamic clerics have serious concerns about the side effects of COVID-19 vaccines.

The Impact of COVID-19 on Individuals and Communities Through the Lens of a Kurdish Artist: A Narrative Inquiry Study

The COVID-19 pandemic affects individuals and society at different levels. For a brief period during the pandemic, the Kurdish government closed all governmental organizations and interconnected routes, except for medical and security settings, and announced a curfew. In this article, we portray the effects of the pandemic on individuals and communities from an artist's view through an art-based narrative inquiry. Narrative analysis is used for analyzing texts or visual data in story form. It describes the life experiences of individuals and the environment in which they reside. Data came from the observations and experiences of the first author during the time he conducted research regarding the impacts of COVID-19 on different aspects of the Kurdish community in the Kurdistan Region through our previous research. The images and stories show that individuals feared COVID-19 and struggled to protect themselves from infection. They faced prolonged social distancing, quarantine, and complete lockdown and lost their family members and loved ones-their relationships with family members and others were disrupted during the pandemic. Additionally, vulnerable groups, such as children and older adults, have been especially affected psychologically during the COVID-19 pandemic. We suggest that the pandemic has affected different groups of people and impacted the health security of Iraqi Kurdistan society. Our findings add a conceptual understanding of the health threat of the pandemic that can be used to implement health services and health policy for individuals and communities in Iraqi Kurdistan.

The lived experience of surviving from the Islamic State attack and capture in Iraq and Syria: An arts-based qualitative study with Yazidi young women

BACKGROUND

In August 2014, the Islamic State in Iraq and Syria (ISIS) attacked the Sinjar district and destroyed several villages and towns and killed several individuals.

AIM

In this study, the Yazidi young women who survived the ISIS attack were encouraged to express their lived experiences through paintings following participation in a 6-month art-based intervention program.

METHODS

A total of 13 Yazidi Kurdish females aged 18 to 25 years (Mean: 21.7 years) were invited to participate in an art-based (drawing and painting) course for 6 months in 2018. They were invited to draw or paint images that portrayed their lived experiences of attack and capture by the ISIS. Qualitative research situated within feminist methodology was used with the young women in this study. The interviews were analyzed using the descriptive content analysis method.

RESULTS

The paintings and narratives of the participants were constructed into three main themes: fear and traumatic experiences; feeling of hopelessness; and freedom and hope. During the attack and capture, due to the escape, rape, and horrific treatments by the ISIS fighters, the young women were traumatized severely. They were sold as a sex slave by the ISIS fighters. The participants still had severe anxiety and psychological challenges after being free from the capture. However, despite their traumatic experiences and feeling of hopelessness, most of them were hoping for freedom and a better future.

CONCLUSIONS

This study showed that the Yazidi young females still experienced psychological challenges burdens even 3 years after the traumatic day. However, the participants showed their resilience through feeling hopeful for freedom and a better future.

The lived experience of hospitalized and non-hospitalized health care providers of COVID-19 pandemic: a qualitative study

This paper explores the lived experience and any mental health issues of COVID-19 survivors throughout the disease crisis using a qualitative method. The semi-structured interviewing method was conducted with COVID-19 patients who were admitted and non-admitted to hospitals in Kurdistan, Iraq. The patients had positive and negative perceptions of the COVID-19 pandemic and disease, including beliefs and thoughts about COVID-19, conspiracy thinking, and concerns toward the family and their children. The patients were affected by the disease in different ways including physical consequences of COVID-19 infection, social isolation, life changes, and mental wellbeing. But they had some coping strategies to overcome the disease, such as seeking help, preventive measures, and coping techniques. The patients had some concerns about health settings and therapeutic procedures, including lack of sufficient care, receptiveness, hospital environment, and infection guidelines. This study showed that the COVID-19 disease had devastating effects on patients either physically or psychologically.

Receiving COVID-19 vaccine, hospitalization, and outcomes of patients with COVID-19: A prospective study

Despite Iraq having started the COVID-19 vaccine in January 2020, there is no official data on vaccination and hospitalization across the country. We aimed to explore the role of the COVID-19 vaccine on the hospitalization and outcomes of patients with COVID-19 in Iraqi Kurdistan. In this prospective study, patients who were admitted to two COVID-19 hospitals in Iraqi Kurdistan in 2021 were followed-up by the discharge time between August and November 2021. The mean age of the patients was 57.6 (27-98 years) of both genders. Most of the patients were illiterate (69.3%) or had a lower level of education (20.5%). A small percentage of patients had previous thrombotic disorders (4.7%) and close to half of the patients had chronic diseases (44.9%). The patients had mild to moderate (44.9%), moderate-severe (36.2%), and critical (18.9%) status. The median hospitalization day was 9 days (1-45 days). The study found that 91.3% of the COVID-19 hospitalized patients did not receive the vaccine and 26.8% of patients died. We did not find a significant association between receiving vaccination and patients' outcomes or disease severity. No patients with previous thrombotic disorders received the COVID-19 vaccine. The male patients were more likely to receive the COVID-19 vaccine compared to female patients; 14.55% vs. 4.17%, p=0.0394.  This study showed that most patients with COVID-19 who were admitted to the hospitals have not received the COVID-19 vaccine. A high percentage of the COVID-19 hospitalized patients died of the disease in this region.

Hepcidin-to-ferritin ratio: A potential novel index to predict iron overload-liver fibrosis in ß-thalassemia major

OBJECTIVES

We aimed to determine a threshold cutoff for hepcidin, ferritin, and the hepcidin-to-ferritin ratio in the diagnosis of liver fibrosis caused by iron overload in chronic hepatitis C virus (HCV)-free ß-thalassemia major patients .

METHODS

This 1:1-matched case-control study included 102 individuals (3-30 yr.); 51 ß-thalassemia major patients with iron overload , and 51 apparently healthy individuals.

RESULTS

The highest areas under the receiver operating characteristic curves (AUC-ROCs) for the diagnosis of patients vs. controls had overlapping 95% confidence intervals (CIs): serum hepcidin (0.758; 0.64-0.87; P ˂ 0.001), serum ferritin (1.000; 1.00-1.00; P˂0.001), and the hepcidin/ferritin ratio (1.000; 1.00-1.00; P˂0.001). For differentiation of patients with liver fibrosis stages of F0-F1 vs. F2-F4 and F0-F1 vs. F3-F4, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) with P-values˂0.001 were the only statistically significant parameters, while the AUC-ROCs of the hepcidin/ferritin ratio (0.631, P=0.188 and 0.684, P=0.098) exhibited 90% and 89.5% sensitivity, respectively, in staging liver fibrosis.

CONCLUSION

Our results showed that the hepcidin/ferritin ratio is as effective as the APRI and maybe a better predictor for the diagnosis of liver fibrosis and discriminating its stages, with excellent sensitivity and specificity compared to its components.

Response of the Public to Preventive Measures of COVID-19 in Iraqi Kurdistan

OBJECTIVES

On March 1, 2020, the Kurdistan Region Government (KRG) announced 4 confirmed cases of coronavirus disease (COVID-19). We aimed to explore the response of the public toward the prevention principles against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

METHODS

The investigators invited individuals from different geographic areas of Duhok Governorate of Iraqi Kurdistan in March 2020.

RESULTS

The mean age of the participants was 25.74 (16-95 years). The mean score and prevalence of fear toward SARS-CoV-2 infection was 4.40 of 10 and 81.9%, respectively. A small percentage of participants did not minimize their exposures by reducing close contacts and transmission of respiratory droplets (14.5%) and visited public areas during the epidemic (28.7%). The study revealed that 30.8% of the participants do not use face masks or tissues when they sneeze in public areas. Most of the participants wash their hands when they suspect a possible transmission of the SARS-CoV-2 pathogen (94.6%) and clean or disinfect pathogen contamination-suspected areas at home (84.6%). The study also revealed that some participants (11.2%), due to a lower education, did not visit a medical clinic when they experienced possible symptoms of SARS-CoV-2 infection. Participants agreed with the health policies of KRG against the COVID-19 outbreak (90.8%).

CONCLUSIONS

Some individuals do not adhere to preventive measures against SARS-CoV-2 infection.

Psychological response of children to home confinement during COVID-19: A qualitative arts-based research

BACKGROUND

The evidence has shown that children are more susceptible to the emotional effects of traumatic events such as outbreaks with the possible disruption in their daily lives.

AIM

In this paper, we discussed the psychological wellbeing of children during the COVID-19 outbreak through the art-based qualitative study using the drawing method among children in Iraqi Kurdistan.

METHODS

In this qualitative arts-based research study, 15 children aged 6 to 13 years old who were confined at home during the COVID-19 outbreak for at least 1 month were included following obtaining the consent from their parents. The children were asked to draw his/her feelings, reflections, and responses during the COVID-19 on a paper. The children were guided to paint their reflections during the COVID-19 based on the following criteria: if they experienced loneliness, tiredness, insomnia, depression, worry or anxiety, or have behavior changes and their relationship with their parents and other siblings.

RESULTS

This study showed that children have a high level of stress at home during the COVID-19 outbreak. The children had great fear about the coronavirus. They experienced loneliness and stress, and felt sad, depressed due to home confinement and social distancing. The possibility of infection by coronavirus has occupied their entire mind. Mental health care providers must take the experiences of children who are caught in this global pandemic seriously and ensure that appropriate care is offered to the children and their parents.

CONCLUSIONS

The children exhibited a strong feeling of distress, loneliness, and fear during the COVID-19 outbreak. This has implications for mental health care.

Prevalence and correlates of COVID-19 vaccine hesitancy in the general public in Iraqi Kurdistan: A cross-sectional study

Low vaccine acceptance is a major barrier to vaccination coverage in every health system. This study aimed to explore the prevalence and associated factors of the COVID‐19 vaccine hesitancy in a sample of the general population in Iraqi Kurdistan. The general population with both genders with different educational levels and sociodemographic characteristics from the Duhok governorate was eligible to participate in this cross‐sectional study in 2021. Therefore, an online Google form was sent to main pages and social groups through two main social media platforms. To obtain a representative sample of individuals with different educational levels, the author visited the main shopping center in Duhok city to collect the information from illiterate and low‐level education individuals. The study found that 83.5% (n = 773) of the participants have not received and 51.4% (n = 476) did not intend to receive the COVID‐19 vaccine. A small percentage has not decided to receive a COVID‐19 vaccine yet (n = 17, 1.8%). The intention to receive a COVID‐19 vaccine was increased with increasing level of education; 25.9%, 26.7%, 39.8%, and 53.6% in illiterate, under high school, high school, and college and higher, respectively (p < 0.0001). Healthcare workers were more likely to intend to receive a COVID‐19, 57.5% vs 40.1%, p < 0.0001. Individuals who had concerns about the side effects of a COVID‐19 vaccine were more likely to not receive and not intend to receive the COVID‐19 vaccine. Prevalence of COVID‐19 vaccine hesitancy was high in this region and was correlated with lower education and concerns about side effects.

Experiences of nurses amidst giving care to COVID-19 patients in clinical settings in Iraqi Kurdistan: A qualitative descriptive study

Aim and objective

We explored the experiences of nurses who cared for coronavirus disease 2019 patients in Iraqi Kurdistan.

Background

Nurses play a major role in response to pandemics and epidemics in delivering patient care. The experiences of nurses who provided care have significant short and long‐term consequences for individuals, communities, and the nursing profession.

Methods

Descriptive qualitative research approach was adopted in this study. We interviewed 12 nurses (22–50 years) who cared for the coronavirus disease 2019 patients in one of the clinical units of two coronavirus disease 2019 hospitals in Iraqi Kurdistan in 2020. Interviews were conducted via phone calls and were analysed using the thematic analysis method. The Consolidated criteria for reporting qualitative research checklist was applied when constructing this paper.

Results

The nurses had to care for a number of situations during the outbreak of coronavirus disease 2019 in Kurdistan. As people in the public did not believe that there was such a virus, nurses often had to deal with this lack of knowledge and aggression from some patients and their family members. Most nurses changed their preventive behaviours since the coronavirus disease 2019 outbreak at hospital or in public. This was mainly to protect not only themselves but their patients, colleagues, family members and friends. They were cautious about the use of a mask at the hospital and in public. Most nurses experienced fear, stress, anxiety and isolation during this period.

Conclusions

The patients had some concerns about their health and staying at hospitals, and some of them had aggressive behaviours towards nurses at corona hospitals. The public, close friends and relatives of the nurses had a fear of getting the infection by the virus through the nurses. However, the nurses attempted to protect themselves, colleagues and family members, and provide the best care to coronavirus disease 2019 patients. The nurses had a high obligation towards care giving at hospitals.

Relevance to clinical practice

The negative experiences of the nurses regarding the care of coronavirus disease 2019 patients must be considered in clinical settings. Sensitive policy programs must be established to protect nurses from the ostracization and stigmatization of the coronavirus disease 2019 pandemic and to allow them to be able to achieve their professional practices safely.

Effectiveness of wet cupping therapy on relieving pain in patients with chronic migraine: an observational study

BACKGROUND

Chronic migraine is a disabling condition that negatively affects many aspects of migraineurs' lives. Patients who use pharmacological agents experience various side effects. Some studies have reported clinical improvement following wet cupping therapy in migraine patients. This study examined the effectiveness of wet cupping therapy on headache severity and its complications in patients with migraine.

METHODS

In this study, a total of 29 patients previously diagnosed with migraine were treated with wet cupping therapy and followed up for headache severity. The severity of pain was measured before therapy, 1 h after therapy, and one month after therapy. The wet cupping therapy was performed by an experienced nurse who was not part of the research team.

RESULTS

The mean age of the patients was 36.17 (Sta. Deviation: 10.74 years; range: 22-68 years), and on average, patients had experienced migraine for 11.14 years. The severity of headache pain was decreased significantly from 6.66 (very intense pain) before cupping therapy to 2.48 (discomforting pain) 1 h after cupping therapy and 0.72 (very mild pain) one month after cupping therapy (p<0.001). The observed complications were skin pigmentation (6.9%), skin scarring (24.1%), and itching in the cupping region (31.0%).

CONCLUSIONS

The present study suggests a significant improvement in the severity of headache in migraine patients 1 h and one month after wet cupping therapy.

Clinical and epidemiological characteristics and outcomes of Coronavirus disease-19 patients in a large longitudinal study

OBJECTIVE

This study aimed to determine the clinical and epidemiological characteristics and outcomes of Coronavirus disease (COVID)-19 patients.

METHODS

In this large cohort study, 15,409 confirmed patients with the COVID-19 of different severities were followed-up from three specialized COVID-19 hospitals between March 18 and October 11, 2020 in Iraqi Kurdistan. The predictors of mortality and severity were examined in binary logistic regression analysis.

RESULTS

The incidence rate of severe/critical status was 12.3% with a median age of 36.0 and case fatality rate (CFR) of 1.98%. The incidence rate of severe/critical conditions and CFR rose with increased age groups; except for 0-14 years (11.9%). The incidence rate of severe/critical patients and CFR was 8.3% and 0.5%, 21.1% and 4.0%, and 23.7% and 8.7% in 15-49 years, 50-64 years, and 65 and older age groups, respectively. The severity of the disease and CFR was associated with coexisting chronic diseases such as cardiovascular diseases (18.2% and 3.1%) and diabetes mellitus (19.8% and 3.4%). The asymptomatic patients (8400 and 54.5%) had statistically higher CFR; 2.3% versus 1.6% (P = 0.006). The most common symptoms on diagnosis were fever (31.9%), cough (23.5%), loss of smell/taste (16.3%), sore throat (15.7%), shortness of breath (9.8%), and headache (9.5%). The results showed that being older was the only predictor of mortality and severity in COVID-19 patients.

CONCLUSIONS

This region has a low incidence of severe-critic status and CFR. The patients with coexisting medical conditions are more likely to have severe conditions and die of COVID-19. The older age predicts severe/critic status and higher CFR.

Relation of Dietary Factors with Infection and Mortality Rates of COVID-19 across the World

Objective

Poor dietary habits are considered to be the second-leading risk factors for mortality and disability-adjusted life-years (DALYs) in the world. Dietary patterns are different based on cultural, environmental, technological, and economic factors. Nutritional deficiencies of energy, protein, and specific micronutrients have been shown to contribute to depressed immune function and increased susceptibility to infections. We aimed to explore the relation of dietary factors with global infection and mortality rates of COVID-19 in this study.

Design

In the current ecological study, the countries that had national dietary data from the Global Dietary Databases of the United Nations and Coronavirus disease statistics from the World Health Organization (WHO) were included. The countries that had Coronavirus disease statistics from the WHO were consecutively checked for the recent data of the dietary factors.

Setting

World.

Participants

158 countries across the world.

Measurements

infection and mortality rates of COVID-19; dietary factors.

Results

The median crude infection and mortality rates by COVID-19 were 87.78 (IQR: 468.03) and 0.0015 (IQR: 0.0059), respectively. The two highest percentage of the crude infection rate were between 0 and 500 (75.9%) and 500–1000 (8.9%) per one million persons. The regression analysis showed that the crude infection rate has been increased by raising consuming fruits (Beta: 0.237; P=0.006) and calcium (Beta: 0.286; P=0.007) and was decreased with rising consuming beans and legumes (Beta: −0.145; P=0.038). The analysis showed that the crude mortality rate was increased by raising consuming sugar-sweetened beverages (Beta: 0.340; P<0.001). Whereas, the crude mortality rate by COVID-19 has been decreased by increasing fruits consuming (Beta: −0.226; P=0.047) and beans and legumes (Beta: −0.176; P=0.046).

Conclusion

The present study showed the higher intake of fruits and sugar-sweetened beverages had a positive effect on infection and mortally rates by COVID-19, respectively. In contrast, the higher intake of beans and legumes had a negative effect on both increasing infection and mortality rates.

Circulating human anti nucleolus antibody (ANCAb) and biochemical parameters in type 2 diabetic patients with and without complications

Introduction

There is no evidence on the role of Human Anti Nucleolus Antibody (ANCAb) in type 2 diabetes mellitus (T2DM). We compared prevalence and concentration of ANCAb between age and a gender-matched sample of T2DM with and without diabetes-related complications.

Methods

In this study, the reaction to ANCAb was compared quantitatively between 38 T2DM patients complicated with microvascular conditions and 43 T2DM without complications as controls.

Results

The patients in complicated and non-complicated groups were comparable in diabetes duration (9.0 vs. 5.0 years; P = 0.065), respectively. The study found that 27 cases (71.1%) of the complicated group reacted to ANCAb test compared to 25 (58.1%) in non-complicated patients (P = 0.226; 3.53 vs. 2.72 ng/mL; P = 0.413). The reaction response to ANCAb in patients with neuropathy and cardiovascular complications was 80.0%, 76.2% in patients with neuropathy compared to 58.1% in the control group (P = 0.398). The reaction response to ANCAb in patients with mono-complication was 72.7% compared 68.8% in patients with multi-complication (P = 0.466). Similarly, 76.2% of patients with T2DM and complicated with neuropathy (n = 21 patients) reacted to ANCAb compared to 58.1% in control patients with (P = 0.158).

Conclusions

Reaction to ANCAb was not statistically different between the T2DM patients with and without complications.

COVID-19 outbreak in Iraqi Kurdistan: The first report characterizing epidemiological, clinical, laboratory, and radiological findings of the disease

INTRODUCTION

On March 11, 2020, the novel coronavirus was declared a global pandemic. The disease was named COVID-19 standing for coronavirus disease 2019. The objectives were to determine the epidemiological, clinical, laboratory, and radiological characteristics of COVID-19 patients.

METHODS

In this prospective descriptive study, 15 confirmed hospitalized cases of COVID-19 between 18th March and April 7, 2020 were followed-up till discharge.

RESULTS

There were 15 reported patients infected by 3 imported index cases from Europe. The mean age of the patients was 28.06 (SD: 16.42 years). The patients' age stratification was as follows: 0-5 (2, 13.3%); 6-18 (2, 13.3); 19-50 (10, 66.7%), and 51-64 years (1, 6.7%). The patients were male (9, 60.0%) and female (6, 40.0%). Most of the patients had mild disease severity (13, 86.7%), followed by mild-moderate (1, 6.7%) and moderate-severe (1, 6.7%). The study revealed that 6 patients were asymptomatic, and 9 patients were symptomatic. The most common symptoms were: fever (n = 8; 53.3%), cough (n = 7; 46.7%), shortness of breath (n = 3; 20.0%), fatigue (n = 3; 20.0%), and taste and smell disorders (n = 4; 26.7%). All patients were recovered and discharged over a median of 8 between 8 and 21 days. The mean and Std. deviation values of the hematological were: WBC: 6.57 (1.86); neutrophil count: 3.75 (1.26); lymphocyte count: 1.87 (0.41); Hb: 13.89 (1.26); platelet count: 207.67 (52.21).

CONCLUSION

All COVID-19 cases were linked to foreign visits with few local transmissions to close contacts without community transmission. The majority of cases were mild illnesses with full recovery.

Insomnia and stress of physicians during COVID-19 outbreak

Background

Healthcare workers are at high risk of developing sleep disorders during an outbreak. This study aimed to measure severity of sleep difficulty and its correlation with duration of deal with suspected/confirmed cases of novel coronavirus (COVID-19) in physicians.

Methods

In this cross-sectional study, 268 physicians from different medical settings were included during the COVID-19 outbreak.

Results

The mean age and experience of physicians were 35.06 (33-70 years) and 10.13 years. The median duration of dealing with suspected/confirmed cases of COVID-19 was 1.0 (0-30 days). The mean sleep score and stress of physicians were 8.43 of 24.0 and 4.20 of 10, respectively. More than two-thirds of the physicians were sleepless (68.3%) and majority had stress (93.7%). The study did not find a significant difference in sleep score of physicians with different specialties (P = 0.059). However, most physicians were sleepless; including anesthesia and intensive care (77.8%); general physicians (80.8%), and obstetrics and gynecology (80.0%). They were sleepless in morning (58.7%); evening (77.8%); night (100%); and multi-shift (70.9%). The physicians who dealt with suspected or confirmed cases of COVID-19 or with stress had more escalated sleep compared to those who did not deal with patients or without stress (9.39 vs. 7.17 and 8.78 vs. 2.69 P < 0.001). The sleep of physicians was escalated with increasing stress (r = 0.558; P < 0.001) and a number of days that physicians dealt with suspected/confirmed cases of COVID-19 (r = 0.210; P = 0.001), respectively.

Conclusion

The study confirmed that working with COVID-19 patients has a negative effect on the sleep of physicians.

The effectiveness of military physical exercise on irisin concentrations and oxidative stress among male healthy volunteers

Background Irisin, a newly discovered hormone, is secreted into the circulation from skeletal muscles in response to physical exercise. The biochemical parameters related to irisin secretion have not been sufficiently investigated yet. The aim of this study was to examine the effectiveness of exercise on the level of irisin and its correlation with biochemical and oxidative stress parameters. Materials and methods In this pre- and post-test observational study, 39 healthy male volunteers from a military training setting were followed up on between September and November 2015. The individuals who were included in this study were between 22 and 27 years old with an average age of 24. Those with inflammatory disorders or chronic diseases such as diabetes mellitus were excluded from the study. The parameters were measured at the baseline, at 4 weeks, and at 8 weeks of intervention. Results The study found that the systolic and diastolic blood pressures substantially decreased after 8 weeks of intervention. The cholesterol-to-HDL ratio and glucose levels were significantly higher at the baseline compared to 8 weeks. Total protein and albumin were significantly higher following 4 weeks (0.25 and 0.21 g/dL) and 8 weeks (0.32 and 0.16 g/dL), respectively. Meanwhile, total globulin and irisin increased following 8 weeks of the intervention by only 0.16 g/dL and 0.41 μg/mL, respectively. The high sensitivity C-reactive protein (hs-CRP) decreased following 8 weeks (-0.81 μg/mL). The protein carbonyl (PC) decreased following 4 weeks by only 0.34 nmol/L. Conclusions This study demonstrated that military training enhanced irisin hormone secretion following 8 weeks of military exercise.

Lead and zinc exposure in the blood of workers in municipal waste management

Improper treating, sorting, storing, transporting, or disposing of wastes poses a potential risk to the health of humans and the environment. The workers of waste management plants are at risk of exposure to heavy metals and their toxic and hazardous effects through respiratory or cutaneous routes. Accordingly, concentrations of two heavy metals in the biological samples of workers of a municipal waste management (MSW) plant in Iraqi Kurdistan were measured in 139 persons who worked for at least 6 months. Blood and plasma samples were collected to measure lead and zinc concentrations, respectively. Their working units, occupational history, smoking habits, and the distance living from the landfill site were recorded in a predesigned questionnaire. A blood lead level (BLL) of less than 40 μg/dL was considered a safe cutoff. The lower limit of normal fasting plasma zinc was set at 70-120 μg/dL. The study showed that the mean age of the workers was 33.43, ranging from 16 to 67 years old, and they worked for the last 4.93 years. Further, 22.3% of the staff had previous experience in a job with suspected exposure to heavy metals. The mean BLL concentrations and the plasma zinc level were 31 μg/dl and 5.77 μg/dl, respectively. The study did not find a substantial difference in lead and zinc among workers with different characteristics. We did not find any predictor for lead and zinc concentrations in our sample. The study showed that the mean levels of lead and zinc were lower than the permitted ranges.

Emotional intelligence dimensions as predictors of coping reactions to stress in nursing practitioners

Stress is an inevitable part of nursing life. Nurses need to respond to their stressful environment contents to reduce negative consequences. We examined the role of dimensions of emotional intelligence in predicting coping reactions to stress in 201 college nursing practitioners in this cross-sectional study between November 2017 and January 2018. The nurses appraised their own emotions, but they were not sure that appraised others' emotions, regulated their and others' emotions. They could cope with new ideas and faced obstacles. Most of the nurses were moderately stressed. Those nurses were not able to regulate their own emotions were determined to have a higher level of perceived stress. Active coping, positive reframing and acceptance were the most prevalent coping mechanisms. The investigation showed that others' emotion appraisal was a predictor for self-blame reaction, and emotion utilization was the predictor for positive reframing and self-blame.

Relation of Dietary Factors with Infection and Mortality Rates of COVID-19 across the World

OBJECTIVE

Poor dietary habits are considered to be the second-leading risk factors for mortality and disability-adjusted life-years (DALYs) in the world. Dietary patterns are different based on cultural, environmental, technological, and economic factors. Nutritional deficiencies of energy, protein, and specific micronutrients have been shown to contribute to depressed immune function and increased susceptibility to infections. We aimed to explore the relation of dietary factors with global infection and mortality rates of COVID-19 in this study.

DESIGN

In the current ecological study, the countries that had national dietary data from the Global Dietary Databases of the United Nations and coronavirus disease statistics from the World Health Organization (WHO) were included. The countries that had coronavirus disease statistics from the WHO were consecutively checked for the recent data of the dietary factors.

SETTING

World.

PARTICIPANTS

158 countries across the world.

MEASUREMENTS

infection and mortality rates of COVID-19; dietary factors.

RESULTS

The median crude infection and mortality rates by COVID-19 were 87.78 (IQR: 468.03) and 0.0015 (IQR: 0.0059), respectively. The two highest percentage of the crude infection rate were between 0 and 500 (75.9%) and 500-1000 (8.9%) per one million persons. The regression analysis showed that the crude infection rate has been increased by raising consuming fruits (Beta: 0.237; P=0.006) and calcium (Beta: 0.286; P=0.007) and was decreased with rising consuming beans and legumes (Beta: -0.145; P=0.038). The analysis showed that the crude mortality rate was increased by raising consuming sugar-sweetened beverages (Beta: 0.340; P<0.001). Whereas, the crude mortality rate by COVID-19 has been decreased by increasing fruits consuming (Beta: -0.226; P=0.047) and beans and legumes (Beta: -0.176; P=0.046).

CONCLUSION

The present study showed the higher intake of fruits and sugar-sweetened beverages had a positive effect on infection and mortally rates by COVID-19, respectively. In contrast, the higher intake of beans and legumes had a negative effect on both increasing infection and mortality rates.

Fatigue as a primary and secondary factor in relation to shift-rotating and patient safety in nurses

Objective: The role of nurses’ shift-rotations in predicting adverse patient events has received little attention. The effect of fatigue on patient safety as a primary factor and the impact of shift-working on fatigue as a secondary factor in hospital-based nurses was investigated in the present study.Methods: In this cross-sectional study set in Iraqi Kurdistan in 2018, 71 nurses (Range: 20-44 years) were recruited purposively who worked in rotating shifts, in four multi-specialty hospitals.Results: The mean age of the nurses was 30.24 years (SD: 4.81; range: 20-44 years). The majority of nurses worked in the public sector (63.4%). The nurses worked in morning shift (26.8%) and shift-rotations (39.4%) for between 7.75 and 9.13 hours. In addition, 59.4% and 18.3% of nurses reported that they injured “sometimes” and “frequently” (respectively) patients in their care either directly or indirectly. Similarly, 19.7% of them reported that these were medication errors “sometimes” and “frequently.” Patient information was recorded incompletely or incorrectly sometimes by 18.3% and frequently by 35.2%. Also, 36.6% and 31.0% of them reported that they delayed care to patients frequently and sometimes, respectively. The mean values of physical and psychological fatigue were 8.77 of 21 and 3.42 of 12, respectively. The physical and psychological fatigue were escalated in case of lower total psychological well-being (p = .009 and p = .018, respectively). The study showed that single-shift working is a predictor of delayed patients care; 95.3% vs. 60.7%; p < .001).Conclusions: Hospital administrators must be aware that nurses are not able to work effectively on short roosters or extended shifts. Protocols for better nurse health surveillance and social support in respect to 24 hours shift work must be prioritized in order to avoid mental and physical significant impairment on nurses and adverse outcomes for their clients.

Factors Influencing Prescribing Perceived Utility of Drugs: Experiences from Iraqi Kurdistan

Introduction:

Pharmaceutical expenditures have increased dramatically in most developed and developing countries in recent decades. Healthcare system policymakers have expressed concerns about the inappropriate, irrational, or harmful prescribing of drugs.

Objectives:

The attitudes of physicians towards prescribing generic drugs and predictors of perceived utility of drugs were investigated in the present study.

Methods:

In this cross-sectional research, 77 physicians at different levels of job hierarchies, working in various public sector shifts, were recruited to participate in a survey of their attitudes toward prescribing generic drugs in Iraqi Kurdistan in 2018. The doctors were located in a general, an emergency, and a pediatric hospital. A self-administered structured questionnaire was designed based on the extended technology acceptance model for product use (TETPU).

Results:

The doctors agreed that drugs should be prescribed according to their utility for patients (median [M] = 5.0; interquartile range [IQR] = 2.9). Most of the physicians mentioned that they prescribed drugs according to the patients’ needs (75.0%), evaluation of the availability of alternatives (69.0%) and consumer perceptions of a price (69.0%). The analysis showed that (1) the importance of physicians’ perceptions and their recognition of patients’ need achievement (P=.012), (2) the physicians' recognition of the actual use of drugs by consumers (P=.030) and (3) being male (p=.009) were associated with perceptions of drug utility.

Conclusions:

The study’s results suggest that perceived drug utility in prescription writing is associated with physicians’ perceptions of need achievement and attitudes toward how patients actually use medicines.

The impact of health education on attitudes of parents and religious leaders towards female genital mutilation

BACKGROUND

Previous studies conducted in Iraqi Kurdistan have reported that parent's decisions to circumcise their daughters are based on religious or cultural beliefs. Despite the widespread practice of female genital mutilation (FGM), the effectiveness of educational strategies to change attitudes towards FGM has not been examined in this region. The present investigation examined the effectiveness of a short-term educational intervention to change the attitudes of parents and religious leaders towards FGM.

METHODS

192 Mullahs (religious leaders), 212 Mokhtars (traditional leaders) and 523 parents in rural areas in Iraqi Kurdistan were invited to participate in a pre- and post-test community-based interventional study in 2017. The Health Belief Model informed the intervention, and participants' attitudes were compared across two stages of the study.

RESULTS

The attitudes of Mullahs, Mokhtars and parents substantially changed from a position of supporting female circumcision to expressing a wish to abandon the practice and not cut their future daughters (OR 1.57, 95% CI 1.02 to 2.42; OR 1.99, 95% CI 1.3 to 3.04 and OR 0.13, 95% CI 0.09 to 0.18, respectively).

CONCLUSIONS

The present study suggests that brief educational interventions can be an effective strategy for changing the attitudes of parents and public leaders towards FGM. Health education is a useful strategy for changing attitudes. However, such interventions must be delivered alongside other strategies to ensure a multifaceted approach to addressing complex social dynamics. A comprehensive public health approach is, therefore, necessary that includes legal measures, community-based action and an appropriate health system approach.

Association of irisin and oxidative stress with biochemical parameters in patients with metabolic syndrome

Background Irisin, a hormone-like myokine, is suspected to have a role in metabolic syndrome (MetS) through regulating energy homeostasis and mediating physical activity. In this regard, the role of irisin and malondialdehyde (MDA) along with some other biochemical parameters in the prediction of MetS was examined in the present investigation. Materials and methods In the present case-control study, 36 subjects diagnosed with MetS according to International Diabetes Federation were considered as cases and were matched in age and gender with 31 healthy participants. The difference of biochemical indicators between cases and controls were determined whether by independent t-test or the Mann-Whitney U-test. The predictors of MetS and insulin resistance (IR) were examined through logistic and linear regressions analysis models, respectively. Results Irisin and MDA were not found to be predictors for MetS in logistic regression; p = 0.258 and p = 0.694, respectively. The IR was found to be the only direct predictor of MetS (p = 0.010). Similarly, in linear regression, irisin and MDA were not identified to be predictors for IR; p = 0.801 and p = 0.781, respectively. Conclusions The study did not show that irisin and MDA, directly and indirectly, were predictors of MetS disorder. The IR was only predictor of MetS.

Female Genital Mutilation in Rural Regions of Iraqi Kurdistan: A Cross-Sectional Study

OBJECTIVES

Although female genital mutilation (FGM) is illegal in Iraqi Kurdistan, FGM continues to be performed frequently in Muslim communities in the region. The objectives of this study were to (1) determine the prevalence of FGM among females living in rural areas of Iraqi Kurdistan; (2) assess the attitudes toward FGM of mothers, village community leaders, and religious leaders; and (3) compare the prevalence of FGM by maternal education.

METHODS

In a cross-sectional, double-randomized study of rural areas in Iraqi Kurdistan, we used a semi-structured questionnaire to interview 1657 mothers of 5048 daughters, 192 mullahs (religious leaders), and 386 mokhtars (community leaders). We examined data on maternal education level, daughters' ages, whether daughters had experienced FGM, and attitudes about FGM.

RESULTS

A total of 2361 of 5048 (46.8%) daughters had experienced FGM. Of 1643 mothers, 565 (34.4%) supported FGM for their daughters in the future, although 825 of 1652 (49.9%) mothers were aware that it was illegal. Eighty-six of 192 (44.8%) mullahs and 339 of 382 (88.7%) mokhtars supported abandoning the practice of FGM. Support for FGM was significantly higher among uneducated mothers than among educated mothers (prevalence ratio [PR] = 1.45; 95% confidence interval [CI], 1.22-1.72; P < .001) and significantly higher among mothers with ≤9 years of education than among mothers with >9 years of education (PR = 1.66; 95% CI, 1.17-2.35; P = .003).

CONCLUSIONS

FGM continues to be prevalent in rural areas of Iraqi Kurdistan. Public health interventions in this region are needed to improve knowledge about the harmful effects of FGM, its illegality, and the importance of prevention, particularly targeting leaders and households with low education levels.

Sleep severity and fatigue manifestations in relation to the doctor-patient relationship

OBJECTIVES

The doctor-patient relationship has an important role in the delivery of high-quality healthcare. The aim of the present study was to explore and evaluate the impact of sleep severity and fatigue manifestations on doctor-patient relationships.

METHODS

The present study was an analysis of a cross-sectional sample of a total of 123 physicians with different specialties and work in various shifts in Iraq. Sleep severity difficulty was measured by Athens Insomnia Scale (AIS) in accordance with the International Classification of Diseases (ICD-10) and the multidimensional nature of fatigue was assessed by the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF). Moreover, the doctor-patient relationship was measured by Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10).

RESULTS

In this study, nearly half of the physicians (45.5%) were insomniacs. The total fatigue score was 9.46; general fatigue (Mean (M): 5.84 of 24); physical fatigue (M: 5.15 of 24); emotional fatigue (M: 6.04 of 24); mental fatigue (M: 5.45 of 24); and vigor (M: 12.98 of 24). The doctors felt slight irritation in their communications with patients (M: 2.33); had moderate dysphoria (M: 3.37); had slight compliance in their communications (M: 1.71), and slightly considered patients to be self-destructive (M: 1.97). In addition, the study showed that general and physical fatigue, night shift-work, and increased working hours in the public sector were predictors for doctors finding their patient irritating. Similarly, increased working hours by clinicians in the public sector was a predictor for having less compliance in their relationships with patients.

CONCLUSION

The present investigation suggests that insomnia has an indirect association with negative categories of the doctor-patient relationship.

Circulating betatrophin in relation to metabolic, inflammatory parameters, and oxidative stress in patients with type 2 diabetes mellitus

AIMS

Recently, it was suggested that betatrophin has a role in controlling pancreatic β cell proliferation and lipid metabolism, however, its role in human subjects has not been established yet. The predicting role of betatrophin and MDA along with other biochemical indicators in type 2 diabetes mellitus (T2DM) in a sample of the Iraqi population was examined in the present investigation.

METHODS

A total of 31 patients diagnosed with T2DM and 30 adult subjects without diabetes were matched in age and gender in a case-control study. Logistic and linear regression models were performed to examine the role of MDA and betatrophin in T2DM and triglyceride, respectively.

RESULTS

The study confirmed a higher concentration of LDL (124.45 vs. 102.70 mg/dL; P = .001) and TG (191.13 vs. 103.83 mg/dL; P < .0001), insulin (18.40 vs. 10.97 μU/mL; P < .0001), and Hs. CRP (5.39 vs. 2.80 mg/L; P = .033) in diabetic patients compared to the controls. No significant difference in betatrophin and MDA was found between diabetic patients and non-diabetic healthy subjects. The study showed triglyceride as the only predictor of T2DM (P = .028). Similarly, total cholesterol (P < .0001), HDL (P = .001), LDL (P < .0003), and MDA (P = .010) were shown as predictors of triglyceride in diabetic patients.

CONCLUSION

The present study that triglyceride is a direct and MDA is an indirect predictor for T2DM.

Impacts of self-management education on glycaemic control in patients with type 2 diabetes mellitus

OBJECTIVES

Dietary and physical activity advice have been considered to be seminal ingredients in prevention and management of type 2 diabetes mellitus. In this regard, the impacts of a three-month self-management intervention on glycemic control in patients with type 2 diabetes were examined in the present study.

STUDY DESIGN

A Double-arm post-test intervention study.

METHODS

In the current post-test intervention study, three two-hour educational sessions on dietary habits and physical activity designed according to Health Belief Model were presented to 16 non-complicated type 2 diabetic patients and their dietary, physical activities, and biochemical outcomes were compared to a 23 patient-control arm in Iraq in 2017. The level of physical activity was measured through International Physical Activity Questionnaire (IPAQ), dietary habits through UK Diabetes and Diet Questionnaire (UKDDQ), and biochemical indicators including HbA1c were measured after three months of program completion.

RESULTS

The study showed that walking, taking vegetable, fruit, and bread were higher and taking full-fat cheese and full-fat spread was lower among experimental group significantly compared to control arm. In addition, the experimental group had a substantial higher albumin and lower urea, ALP-Phosphatase, and glucose levels in comparison with control patients. No substantial change was seen in HbA1C and no change in milk and fish products.

CONCLUSIONS

The substantial positive changes in physical activity, dietary habits, and some biochemical indicators were seen following intervention completion in the experimental arm.

Sleep disorders as primary and secondary factors in relation with daily functioning in medical students

BACKGROUND

College students experience various types of sleep disorders that impact daily functioning. Previous studies have focused on the effect of one sleep disorder.

OBJECTIVE

Examine factors that might relate to several sleep disorders and the impacts of sleep disorders on the daily functioning in medical students.

DESIGN

Cross-sectional study.

SETTING

Medical college.

SUBJECTS AND METHODS

A random sample of medical students from a public university was invited to participate in a cross-sectional study using the structured SLEEP-50 self-reported questionnaire. The sleep disorders covered by the questionnaire were insomnia, sleep apnea, restless legs syndrome, sleep walking, circadian rhythm sleep disorder, nightmares, narcolepsy, and factors impacting sleep, effects of sleep complaints on daily functioning, and sleeping duration.

MAIN OUTCOME MEASURE

Sleep duration, sleep disorders.

RESULTS

Of 317 participants, 165 (50.2%) reported having less than 7 hours sleep and apart from hyper-somnia, had various kinds of sleep disorders. Various factors such as having no pleasure and entertainment, feeling sadness, alcohol drinking, amount of sleeping hours, smoking, age, a noisy or light bedroom, and substance abuse were related to different sleep disorders. Moreover, students with sleep disorders felt tired arising, felt sleepy during the day, were easily irritated, had difficulty in concentration, had concerns about amount of sleep, and slept badly at college.

CONCLUSIONS

Insufficient sleep is a common issue in medical students and a number of sleep disorders were found. The results suggest that sleep disorders could have negative impacts on the daily functioning of students.

LIMITATIONS

The study findings may not be generalizable because sociocultural characteristics of the sample may differ from the general population.

Sleep disorders as primary and secondary factors in relation with daily functioning in medical students

BACKGROUND

College students experience various types of sleep disorders that impact daily functioning. Previous studies have focused on the effect of one sleep disorder.

OBJECTIVE

Examine factors that might relate to several sleep disorders and the impacts of sleep disorders on the daily functioning in medical students.

DESIGN

Cross-sectional study.

SETTING

Medical college.

SUBJECTS AND METHODS

A random sample of medical students from a public university was invited to participate in a cross-sectional study using the structured SLEEP-50 self-reported questionnaire. The sleep disorders covered by the questionnaire were insomnia, sleep apnea, restless legs syndrome, sleep walking, circadian rhythm sleep disorder, nightmares, narcolepsy, and factors impacting sleep, effects of sleep complaints on daily functioning, and sleeping duration.

MAIN OUTCOME MEASURE

Sleep duration, sleep disorders.

RESULTS

Of 317 participants, 165 (50.2%) reported having less than 7 hours sleep and apart from hyper-somnia, had various kinds of sleep disorders. Various factors such as having no pleasure and entertainment, feeling sadness, alcohol drinking, amount of sleeping hours, smoking, age, a noisy or light bedroom, and substance abuse were related to different sleep disorders. Moreover, students with sleep disorders felt tired arising, felt sleepy during the day, were easily irritated, had difficulty in concentration, had concerns about amount of sleep, and slept badly at college.

CONCLUSIONS

Insufficient sleep is a common issue in medical students and a number of sleep disorders were found. The results suggest that sleep disorders could have negative impacts on the daily functioning of students.

LIMITATIONS

The study findings may not be generalizable because sociocultural characteristics of the sample may differ from the general population.