Health trends in Canada 1990-2019: An analysis for the Global Burden of Disease Study

OBJECTIVE

Monitoring trends in key population health indicators is important for informing health policies. The aim of this study was to examine population health trends in Canada over the past 30 years in relation to other countries.

METHODS

We used data on disability-adjusted life years (DALYs), years of life lost (YLL), years lived with disability, life expectancy (LE), and child mortality for Canada and other countries between 1990 and 2019 provided by the Global Burden of Disease Study.

RESULTS

Life expectancy, age-standardized YLL, and age-standardized DALYs all improved in Canada between 1990 and 2019, although the rate of improvement has leveled off since 2011. The top five causes of all-age DALYs in Canada in 2019 were neoplasms, cardiovascular diseases, musculoskeletal disorders, neurological disorders, and mental disorders. The greatest increases in all-age DALYs since 1990 were observed for substance use, diabetes and chronic kidney disease, and sense organ disorders. Age-standardized DALYs declined for most conditions, except for substance use, diabetes and chronic kidney disease, and musculoskeletal disorders, which increased by 94.6%, 14.6%, and 7.3% respectively since 1990. Canada's world ranking for age-standardized DALYs declined from 9th place in 1990 to 24th in 2019.

CONCLUSION

Canadians are healthier today than in 1990, but progress has slowed in Canada in recent years in comparison with other high-income countries. The growing burden of substance abuse, diabetes/chronic kidney disease, and musculoskeletal diseases will require continued action to improve population health.

Temporal evolution of electron cloud in a cylindrical Penning trap at room temperature

The temporal evolution of the electron cloud at room temperature has been recorded through a resonance circuit by observing the axial oscillation frequency of its center of mass. The electron cloud undergoes radial expansion by interacting with the residual gas molecules, and it is finally lost upon hitting the Penning trap electrodes. It has been confirmed through detailed experimental investigations that the unique temporal pattern of frequency variation is a consequence of the cloud's radial expansion. Consequently, this approach offers a non-destructive means for single-shot detection, enabling continuous monitoring of the electron cloud's radial expansion during the confinement time. This technique offers a significant advantage over its destructive alternatives.

Status of Serum Calcium in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) remains a major public health problem with relatively high prevalence rates worldwide (5-13%). COPD is a major cause of morbidity and mortality worldwide and results in an economic and social burden that is both substantial and increasing. The purpose of the study was to explore the alteration of serum calcium in patients with COPD. This cross-sectional study was carried out in the Department of Biochemistry, Mymensingh Medical College, Bangladesh from January 2021 to December 2021. Data was collected from Medicine Department of Mymensingh Medical College Hospital, Mymensingh. A total number of 120 subjects participated in this study. Out of them, 60 apparently normal healthy individuals were selected as Group I and another 60 diagnosed COPD patients were selected as Group II. Serum calcium was measured by colorimetric method using the test kit. The results were calculated and analyzed by using statistical package for social science (SPSS), windows package version 21.0. Data were expressed in mean ±SD and statistical significance was done by Student's unpaired 't' test. In this study, the mean ±SD values of serum calcium were 9.21±1.06mg/dl and 8.26±0.95mg/dl in Group I and Group II respectively. The results were highly significant (p<0.001). The result suggested that there was significant relation between COPD and alteration of serum calcium. So, by this study we recommended that routine evaluation of serum calcium is important for prevention of exacerbations, reduction of morbidity and mortality in patients with COPD.

A 3D Deep Convolutional Neural Network for Dose Distribution Prediction of Intracavitary HDR Brachytherapy of Cervical Cancer

PURPOSE/OBJECTIVE(S)

The purpose of this work is to develop a voxel-wise dose prediction model using convolutional neural network (CNN) for cervical cancer high-dose-rate (HDR) intracavitary brachytherapy treatment planning with tandem-and-ovoid (T&O) or tandem-and-ring (T&R) applicators.

MATERIALS/METHODS

A 3D U-NET CNN was implemented to generate voxel-wise dose predictions based on high-risk clinical target volume (HRCTV) and organs at risk (OAR) contour information. A multi-institutional cohort of 77 retrospective clinical HDR brachytherapy plans treated to a prescription dose in the range of 4.8-7.0 Gy/fx was used in this study. Those plans were randomly divided into 60%/20%/20% as training, validating, and testing cohorts. Data augmentation techniques were implemented in the training and validation cohort data to increase the number of plans to 252. The model was trained using the mean-squared loss function, Adam optimization algorithm, a learning rate of 0.001, 250 epochs, and a batch size of 8. The model performance was evaluated on the testing dataset by analyzing the outcomes in terms of mean dose values and derived dose-volume-histogram (DVH) indices from 3D dose distributions and comparing the generated dose distributions against the ground-truth dose distributions using dose statistics and clinically meaningful dosimetric indices.

RESULTS

The proposed 3D U-Net model showed competitive accuracy in predicting 3D dose distributions that closely resemble the ground truth dose distributions. The average value of mean absolute error was 0.108±3.617 Gy for HRCTV, 0.074±1.315 Gy for bladder, 0.093±0.981 Gy for rectum, and 0.035±2.789 Gy for sigmoid. The median absolute error was 1.264 Gy for HRCTV, 0. 441 Gy for the bladder, 0.018 Gy for rectum, and 0.019 Gy for sigmoid. Our results showed that the predicted mean D2cc OAR doses in the bladder, rectum, and sigmoid were 4.02±0.93, 3.77±0.57 and 3.36±0.82 Gy in comparison to 4.35±0.98, 3.99±0.53, 3.75±0.83 Gy in clinical plans, respectively, and the mean individual differences (ΔD2cc) were 0.33±0.41, 0.22±0.16 and 0.39±0.45 Gy, respectively. The predicted D90 of the HRCTV was 6.72±0.99 Gy in comparison with 6.83±1.72 Gy in clinical plans. Results indicate a good potential to predict useful dosimetric indices and thus would facilitate an improvement in brachytherapy treatment planning workflow. The proposed model needs less than 5 seconds to predict a full 3D dose distribution of 64 × 64 × 64 voxels for any new patient plan, thus making it sufficient for near real-time applications and aid in decision-making in clinic.

CONCLUSION

The proposed model can be used to predict 3D dose distributions for near real-time decision-making, before planning, for planning quality assurance, and for guiding future automated planning for improved plan consistency, quality, and planning efficiency.

Direction Modulated Brachytherapy Tandem Model Applicators for Treatment Planning of Multi-Institutional Cervical Cancer Cases

PURPOSE/OBJECTIVE(S)

Direction Modulated Brachytherapy (DMBT) offers a means of utilizing an anisotropic source to create more conformal dose distributions when integrated with image-guided adaptive brachytherapy (IGABT). Authors sought to validate the implementation of nine unique six-channeled, MRI-compatible, novel DMBT tandem applicators of varying physical dimensions within Varian's BrachyVision® (v16.1) treatment planning system (BV-TPS).

MATERIALS/METHODS

A total of 110 retrospective clinically delivered high-dose-rate (HDR) cervical cancer brachytherapy plans, from three institutions, were re-planned for each of the nine DMBT tandem models within the BV-TPS, using the latest VEGO® inverse optimization algorithm, with dose heterogeneity accounted for through AcurosBV®. Plans consisted of both intracavitary (77 plans) and interstitial (33 plans) cases with an average prescription dose and high-risk clinical target volumes (CTVHR) of 607±113 cGy and 26.96±14.95 [range 6.70-69.58] cm3, respectively. During re-planning, the conventional tandems were replaced by one of the nine DMBT tandem models while leaving ovoids or rings, and needles (if present), in place. A two-step inverse optimization process was performed such that the lowest possible organs at risk (OAR) D2cc doses could be achieved while 1) keeping equivalent target coverage (ΔCTVHR-D90 to within ±0.5%) and, at the same time, 2) maintaining the general pear-shape dose distribution of the original plans.

RESULTS

Noteworthy improvements in plan quality were achieved by all nine DMBT tandem models, which are presented in Table 1. Irrespective of the model, about ∼50 cGy reduction in D2cc across all OARs appear feasible. There is also a general trend of D2cc reductions' magnitude becoming smaller as the CTVHR volume increased due to loss in modulation at distance. Additionally, D2cc reductions in terms of EQD2 [Gy] were calculated assuming each re-plan was delivered throughout the course of treatment, which includes the external beam radiotherapy dose of 45 Gy and showed significant reductions of -6.29±4.38 Gy, -3.80±2.06 Gy, and -4.86±3.02 Gy for the bladder, rectum, and sigmoid, respectively, for DMBT model #9 for example.

CONCLUSION

We have successfully incorporated nine DMBT tandem models into a commercial TPS and re-planned 110 cases, to a total of 990 plans. All nine DMBT tandem models were each able to generate notable D2cc reductions to OARs (∼50 cGy), without compromising target coverage, across plans from multiple institutions with various clinical/optimization practices. The results indicate both a promising impact and smooth integration of DMBT tandem technology into modern clinical IGABT workflow.

Direction Modulated Brachytherapy Tandem Model Applicators for Treatment Planning of Multi-Institutional Cervical Cancer Cases: Removing Needles in Intracavitary-Interstitial Techniques

PURPOSE/OBJECTIVE(S)

To evaluate the potential of nine direction modulated brachytherapy (DMBT) tandem applicator models of various designs to obviate the need for needles during intracavitary-interstitial (IC-IS) cervical cancer brachytherapy.

MATERIALS/METHODS

A cohort of 33 retrospective clinical high dose-rate (HDR) brachytherapy plans, from three institutions, were re-planned with Varian's BrachyVision® (v16.1) treatment planning system (BV-TPS), using the latest VEGO® inverse optimization algorithm, with dose heterogeneity accounted for through the AcurosBV® model-based dose calculation algorithm. All plans consisted of IC-IS cases, with a range of 2-4 freehand-loaded needles, with an average prescription dose of 706±54 cGy and average high-risk clinical target volume (HRCTV) of 36.0±17.4 [range 9.8-69.6] cm3. Nine novel DMBT tandem models of varying physical dimensions were integrated for the first time into the BV-TPS, with thicknesses (4-8 mm). During re-planning, the conventional tandems and all of the needles were replaced by one of the nine DMBT tandem models while leaving the ovoids/rings in place. An optimization process was performed such that the lowest possible organs at risk (OAR) D2cc doses could be achieved while keeping equivalent target coverage (ΔHRCTV-D90 to within ±0.5%) and maintaining a pear-shape dose distribution. The process was repeated for each of the nine DMBT tandem models resulting in (33 × 9 =) 297 plans.

RESULTS

Average ΔHRCTV-D90 was +0.35±0.39% (+2.8±3.1 cGy). OAR D2cc reductions were achieved by all models for all plans. The performance of the thickest DMBT model (8 mm) was the best in terms of achieving the lowest D2cc for all OARs, with 31 out of 33 plans (94%) achieving lower D2cc doses for all three OARs. The two cases in which the D2cc doses could not be reduced had HRCTV volumes ranging between 50 cm3 and 60 cm3. Additionally, D2cc reductions in terms of EQD2 [Gy] were calculated assuming each re-plan was delivered throughout the entire course of a patient's treatment, which included the external beam radiotherapy dose of 45 Gy, showed significant reductions of -2.64±2.67 Gy, -1.65±1.97 Gy, and -2.80±2.20 Gy for bladder, rectum, and sigmoid, respectively.

CONCLUSION

According to the results, it is clinically feasible to replace the conventional IC-IS cases, with 2-4 freehand-loaded needles, with the DMBT tandem technology, effectively avoiding the need for needle involvement.

Combining Novel Direction Modulated Brachytherapy Tandem-and-Ovoids Applicators for Treatment Planning of Multi-Institutional Cervical Cancer Cases: Removing Needles in Intracavitary-Interstitial Techniques

PURPOSE/OBJECTIVE(S)

Lack of standard guidelines for optimal needle insertion during high-dose-rate (HDR) intracavitary-interstitial (IC-IS) brachytherapy of the cervix means a sophisticated and technical skillset of inserting needles next to IC applicators must be developed to enhance plan quality. This study sought to evaluate the performance of two separate direction modulated brachytherapy (DMBT) tandem applicators used in conjunction with one set of novel DMBT ovoids, uniquely designed to effectively obviate the need for IS needles.

MATERIALS/METHODS

A cohort of 32 retrospective clinical HDR brachytherapy plans, from three institutions, were re-planned with Varian's BrachyVision® (v16.1) treatment planning system (BV-TPS), using the latest VEGO® inverse optimization algorithm, with dose heterogeneity accounted for through the AcurosBV®. All plans consisted of IC-IS cases, with a range of 2-4 freehand-loaded needles, with an average prescription dose of 709±53 cGy, and with an average high-risk clinical target volume (HRCTV) of 36.73±17.15 [range 9.8-69.6] cm3. Two DMBT tandem models of 5.4-mm and 8.0-mm thicknesses along with a novel DMBT ovoids design, introduced for the first time, with 9 equi-angled grooves and 10-mm-diameter thickness. During re-planning, the conventional tandems, ovoids/rings, and all of the needles were replaced by one of the two DMBT tandem models and a set of DMBT ovoids. A two-step inverse optimization process was performed to achieve the lowest possible OAR D2cc doses while 1) keeping equivalent target coverage (ΔHRCTV-D90 to within ±0.5%) and 2) maintaining the general pear-shape dose distribution used by the original plans. For all plans, this process was repeated using each of the two DMBT tandem-and-ovoids combinations for a total re-planning of (32×2 =) 64 cases.

RESULTS

On average, -47.15±29.61 (-40.40±34.90) cGy, -42.98±26.58 (-41.70±27.40) cGy, and -40.47±25.05 (-32.55±25.30) cGy reductions in D2cc across bladder, rectum, and sigmoid, respectively, were achieved for the 8-mm (5.4-mm) DMBT tandem-and-ovoids combinations while the average ΔHRCTV-D90 was +4.3±2.9 cGy (+0.5%±0.4%). Additionally, D2cc reductions in terms of EQD2 [Gy] were calculated and showed significant reductions of -4.05±2.47 (-3.37±2.83) Gy, -2.71±1.79 (-2.59±1.74) Gy, and -3.27±1.96 (-2.65±2.06) Gy for bladder, rectum, and sigmoid, respectively with an average net increase in total dwell times of 241.0±87.6 seconds at the luxury of avoiding IS needle insertions.

CONCLUSION

It is clinically feasible to obviate the need for IS needles by incorporating the DMBT tandem-and-ovoids while producing lower OAR D2cc doses and maintaining equivalent target coverage.

Comparative study between GRA and MEREC technique on an agricultural-based MCGDM problem in pentagonal neutrosophic environment

In this research article, an improved Multi-criteria group decision-making (MCGDM) strategy has been developed in pentagonal neutrosophic environment incorporating grey relational analysis and method on the removal effects of criteria (MEREC) techniques to address the relative advantages and disadvantages of these aspects in MCGDM. The aim of the study is to improve MCGDM technique which can capture the underlying uncertainties in robust way and can produce consistent results in a more rigorous way. Here, the conception of Hamming distance between two pentagonal neutrosophic number (PNN)s is introduced and the weighted arithmetic and geometric averaging operators in PNN arena are deployed to craft our computational technique more progressive and robust. An agriculture-based numerical problem is illustrated to demonstrate the ranking results of the alternatives by both of the techniques. After evaluating the problem by two aggregation operators, it is found that "plantation crop" is the best alternative under certain circumstances. Lastly, the sensitivity investigation is performed which reveals that with the appliance of arithmetic and geometric aggregation operators the best ranked alternative preserves its position by both of the ranking methods, which definitely exhibit the consistency and robustness of our executed methodology.

Study of Serum Calcium and Magnesium Levels in Type 2 Diabetes Mellitus Patients

The prevalence of diabetes mellitus is a significant global public health concern, particularly in emerging nations like Bangladesh. Bangladesh is already overrun with non-communicable diseases while still battling communicable diseases. About 90.0% of all cases of diabetes that have been diagnosed are type 2 diabetes. High calorie diet, age, sedentary lifestyle and obesity are the main risk factors for type 2 diabetes. Different micronutrients have been linked to an increased incidence of diabetes in addition to existing risk factors. The goal of the study was to assess the serum levels of calcium and magnesium in people with type 2 diabetes mellitus and compare them to those in healthy controls. This cross-sectional study was conducted from July 2018 to June 2019 at the Mymensingh Medical College, Mymensingh, Department of Biochemistry in cooperation with the Department of Endocrinology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh. Purposive (non-random) sampling was used to pick the subjects based on inclusion and exclusion criteria. This study had 100 individuals in total. Out of them, 50 people with type 2 diabetes mellitus who had been diagnosed were chosen as cases, and another 50 people who appeared to be in generally good health were chosen as controls. Serum calcium and magnesium levels were measured for this study's analytical purposes. The mean±SD was used to express all values. The statistical package for social science (SPSS), a Windows application, was used to conduct the statistical analyses. Using the Student's unpaired 't' test, the statistical significance of the difference between the case and control groups was assessed. Following comprehensive analysis, it was discovered that type 2 diabetes mellitus patients had considerably lower mean serum calcium (in case group was 8.46±0.63 and control group 8.86±0.64mg/dl) and magnesium levels (in case group was 2.09±0.42 and control group 2.24±0.16mg/dl) than healthy controls. According to the results of the current investigation, patients with type 2 diabetes mellitus had significantly altered serum calcium and magnesium levels. As a result, the study's hypothesis was accepted.

Study of Changes in Serum Copper Level in Patients with Acute Myocardial Infarction

Acute myocardial infarction (AMI) commonly known as heart attack is defined pathologically as the irreversible death of myocardial cells caused by ischemia. Risk factors include high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol and excessive alcohol intake. The major cause of acute MI is coronary atherosclerosis with superimposed luminal thrombus, which accounts for more than 80% of all infarcts. Micronutrients and trace elements are very essential for normal functioning of the body. Even though they are required in very small amount, an alteration in the level of this element may lead to serious diseases like CAD and its consequences. The injury induced by reperfusion of the ischemic myocardium could result partially from the cytotoxic effects of oxygen free radicals. Copper is involved in several of the reactions in the protection from free radical damage. So, this study was designed to evaluate serum cupper level in AMI patients. This case-control study was conducted in the Department of Biochemistry, Mymensingh Medical College, Mymensingh, Bangladesh from July 2016 to June 2017. Total number of subjects was 120 in number. Among them 60 were diagnosed case of acute myocardial infarction and 60 were apparently healthy volunteers. Data were collected using pre-designed data collection sheets. After proper counseling informed written consent was taken from the study population. The study revealed that mean serum copper level was higher in case group as compared to control group. The mean±SD values of copper were 105.44±24.15μg/dl and 146.49±23.52μg/dl in control and case group respectively. The level of significance was 0.001 (p<0.05). After analyzing the results of the study it is concluded that serum copper level was significantly higher in Acute Myocardial Infarction patients than normal individuals. Therefore, estimation of serum copper level in AMI patients might be useful to take appropriate measure to prevent free radical induced reperfusion injury.

Evaluation of Liver Function Tests in β-Thalassemia Major Children

Thalassemia is the most prevalent single gene defect in human beings worldwide. Repeated blood transfusions along with chelation therapy are mainstay of treatment in thalassemia patients. However these recurrent blood transfusions result in iron overload which along with chelation therapy causes deterioration of liver function. Aim of the study was to evaluate the liver function tests in β-thalassemia major patients. This cross sectional study was conducted in the Department of Biochemistry, Dhaka Medical College, Dhaka, Bangladesh from January 2017 to December 2017. In this study, 50 diagnosed patients of β Thalassemia major (Group A) and 50 apparently healthy children (Group B) of both sexes were selected from the department of Paediatrics, Dhaka medical college. The study parameters were serum ferritin, bilirubin, AST, ALT, ALP. The results were compared statistically between groups. Serum ferritin level (mean±SD) in thalassemic major patients in Group A (890±446.38 microgram/L) which is significantly higher above normal level. Serum bilirubin in Group A (3.27±2.62 mg/dl) and in Group B (0.48±0.24 mg/dl), Serum ALT in Group A (53.06±34.0 U/L) and in Group B (16.70±4.81 U/L), AST in Group A (84.56±33.54 U/L) and in Group B (11.60±2.72 U/L) and ALP levels in Group A (422.42±226.99 IU/L) and in Group B (221.86±80.54 IU/L). All the values were significantly higher (p<0.001) in β-thalassemia patient than that of normal children. This study concludes that liver function parameters are significantly higher in β thalassemia major patients. So routine evaluation of liver function tests may be advocated for thalassemic patients to predict early onset of hepatic dysfunction.

Human Bone Marrow Stromal Cell Exosomes Ameliorate Periodontitis

Human bone marrow stromal cell (hBMSC)-derived exosomes are promising therapeutics for inflammatory diseases due to their unique microRNA (miRNA) and protein cargos. Periodontal diseases often present with chronicity and corresponding exuberant inflammation, which leads to loss of tooth support. In this study, we explored whether hBMSC exosomes can affect periodontitis progression. hBMSC exosomes were isolated from cell culture medium through sequential ultracentrifugation. miRNAs and proteins that were enriched in hBMSC exosomes were characterized by RNA sequencing and protein array, respectively. hBMSC exosomes significantly suppressed periodontal keystone pathogen Porphyromonas gingivalis-triggered inflammatory response in macrophages in vitro. Transcriptomic analysis suggested that exosomes exerted their effects through regulating cell metabolism, differentiation, and inflammation resolution. In vivo, weekly exosome injection into the gingival tissues reduced the tissue destruction and immune cell infiltration in rat ligature-induced periodontitis model. Collectively, these findings suggest that hBMSC-derived exosomes can potentially be used as a host modulation agent in the management of periodontitis.

745 PROACTIVE INPUT FROM GERIATRICIAN LED SURGICAL LIAISON SERVICE FOR OLDER SURGICAL PATIENTS AT ROYAL BERKSHIRE HOSPITAL, READING

Introduction

Need for a geriatrician in the peri operative care of older surgical patients is evident by the NCEPOD reports in 2010 and 2011. Funding for Consultant Geriatrician led surgical liaison service for RBH was approved in 2014.We present a comparative review of the service during 2019/2020.

Methods

A retrospective audit of elective and emergency surgical patients over 65 years of age from January to March 2019 and June to September 2020 was done. Geriatrician input was provided on weekdays by Less than full time (80%) equivalent Consultant, 1 full time equivalent physician associate and a Gerontology Registrar on pro rota basis.

Results

We reviewed 76 patients in 2019 (Emergency 74/76 = 95% Vs Elective 2/76 = 3%) and 161patients in 2020 (Emergency134/161 = 83% Vs Elecetive27/161 = 17%). Majority of emergency presentations were small bowel obstruction, acute cholecystitis, and pancreatitis while laparoscopic right hemi colectomy was the commonest elective surgical admission. The average age of patients was 72 years (2019) and 79 years (2020). Length of stay up to 5 days reduced from 75% (51/76) in 2019 to 43% (70/161) in 2020. The overall length of stay reduced from 12 days to 8.5 days in 2019 and 2020, respectively 30 days readmission rate increased from 21% (16/76) in 2019 to 25.5% (41/161) in 2020. 75% (2019) and 96% (2020) of patients were discharged back to their usual residence and death rates reduced from 14% to 1% between the 2 audits.

Conclusion

There is an increase in patient number, age, and complexity. Number of elective surgical admissions after the 1st Covid wave has risen. Even with less than full time Consultant Geriatrician cover the service has helped to reduce the overall length of hospital, mortality rate and added to cost saving. There is need for senior cover for service to work efficiently and to meet its ever-increasing demand.

142 Amyand’s Hernia: An Extensive Review of History, Aetiopathogenesis, Symptomatology, and Management – Should We Scan, Scope & Snip?

Background

Amyand’s hernia, first described by Claudius Amyand in 1735, continues to remain a diagnostic & therapeutic challenge. By definition includes inguinal herniae that contain the vermiform appendix.

Aim

This up-to-date review aims to define and classify Amyand’s hernia and suggest appropriate management options in the current era. Aim to shed light on the value of pre-operative cross-sectional imaging and the use of laparoscopic surgery to provide a one stop solution.

Method

Published English literature was reviewed (1735–2021), using PubMed and Embase, combining the MeSH terms “hernia”, “inguinal”, “appendix”, “Amyand”, “low dose CT” and “laparoscopic herniotomy”. Most cited open access reviews, case series and case reports were chosen to provide a framework. A recent case is described with selected images (radiological, histology and intra operative).

Results

Since the original publication, by Claudius Amyand in 1735, there exists a gulf on this condition in the available British medical literature. Nearly 100,000 hernia repairs are performed in the UK annually. If Amyand’s hernia account for 1% of these (according to the most stated estimate), there should be a thousand Amyand’s herniae repaired annually in the UK alone. Unfortunately, the management options remain nonstandard.

Conclusions

Computerized tomography (CT) allows for pre-operative diagnosis and should be considered more often, even in children. Laparoscopic appendicectomy combined with a laparoscopic herniotomy is a safe one stop solution, in experienced hands, for paediatric patients.

Antioxidant potential and α-glucosidase inhibitory activity of onion (Allium cepa L.) peel and bulb extracts

Allium cepa L. is a commonly consumed vegetable that belongs to the Amaryllidaceae family and contains nutrients and antioxidants in ample amounts. In spite of the valuable food applications of onion bulb, its peel and outer fleshy layers are generally regarded as waste and exploration of their nutritional and therapeutic potential is still in progress with a very slow progression rate. The present study was designed with the purpose of doing a comparative analysis of the antioxidant potential of two parts of Allium cepa, i.g., bulb (edible part) and outer fleshy layers and dry peels (inedible part). Moreover, the inhibitory effect of the onion bulb and peel extracts on rat intestinal α-glucosidase and pancreatic α-amylase of porcine was also evaluated. The antioxidant potential of onion peel and bulb extracts were evaluated using 2,2-diphenyl- 1-picryl hydrazyl (DPPH), ferric-reducing antioxidant power assay (FRAP), 2,2'-azino-bis- 3-ethylbenzothiazoline-6-sulfonic acid (ABTS) radical scavenging assay, H2O2 radical scavenging activity and Fe2+ chelating activity. Total flavonoids and phenolic content of ethanolic extract of onion peel were significantly greater as compared to that of onion bulb. Ethanolic extract of onion peel also presented better antioxidant and free-radical scavenging activity as compared to the ethanolic extract of bulb, while the aqueous extract of bulb presented weakest antioxidative potential. Onion peel extract's α-glucosidase inhibition potential was also correlated with their phenolic and flavonoid contents. The current findings presented onion peel as a possible source of antioxidative agents and phenolic compounds that might be beneficial against development of various common chronic diseases that might have an association with oxidative stress. Besides, outer dry layers and fleshy peels of onion exhibited higher phenolic content and antioxidant activities, compared to the inner bulb. The information obtained by the present study can be useful in promoting the use of vegetable parts other than the edible mesocarp for several future food applications, rather than these being wasted.

Molecular Epidemiology of Plasmodium species in Conflicted Federally Administered Tribal Area (FATA) Pakistan

Military conflicts have been significant obstacles in detecting and treating infectious disease diseases due to the diminished public health infrastructure, resulting in malaria endemicity. A variety of violent and destructive incidents were experienced by FATA (Federally Administered Tribal Areas). It was a struggle to pursue an epidemiological analysis due to continuing conflict and Talibanization. Clinical isolates were collected from Bajaur, Mohmand, Khyber, Orakzai agencies from May 2017 to May 2018. For Giemsa staining, full blood EDTA blood samples have been collected from symptomatic participants. Malaria-positive microscopy isolates were spotted on filter papers for future Plasmodial molecular detection by nested polymerase chain reaction (nPCR) of small subunit ribosomal ribonucleic acid (ssrRNA) genes specific primers. Since reconfirming the nPCR, a malariometric study of 762 patients found 679 positive malaria cases. Plasmodium vivax was 523 (77%), Plasmodium falciparum 121 (18%), 35 (5%) were with mixed-species infection (P. vivax plus P. falciparum), and 83 were declared negative by PCR. Among the five agencies of FATA, Khyber agency has the highest malaria incidence (19%) with followed by P. vivax (19%) and P. falciparum (4.1%). In contrast, Kurram has about (14%), including (10.8%) P. vivax and (2.7%) P. falciparum cases, the lowest malaria epidemiology. Surprisingly, no significant differences in the distribution of mixed-species infection among all five agencies. P. falciparum and P. vivax were two prevalent FATA malaria species in Pakistan's war-torn area. To overcome this rising incidence of malaria, this study recommends that initiating malaria awareness campaigns in school should be supported by public health agencies and malaria-related education locally, targeting children and parents alike.

Payment for ecosystem services (PES): a holistic tool for sustainable forest management-a case study from Pakistan

Economic valuation of ecosystem services is a new concept in forest management. Economic valuation provides basis for payment for ecosystem services (PES). Therefore, objective of this study was to evaluate eco-tourism and carbon stock services of the Maindam valley, District Swat, Pakistan. For the carbon stock calculation, a sample size of 155 plots of 0.1 hectare (Ha) was taken using preliminary survey at 95% confidence interval and 10% allowable error. The data for tourism services was collected from owners of all the hotels, 100 tourists and key informants of the area at 10% sampling intensity on pretested questionnaire for twenty years period (1997-2017). Results showed that Miandam valley has carbon stock worth US$ 16,306,000 while the value of eco-tourism was US$ 1,578,458 on annual basis. The results also showed that trend of tourism has drastically declined after the 9/11 incident for foreigners and locals and the situation was further deteriorated during the era of Talibanization or militancy from 2008-2011. This study recommends implementation of PES strategy at the rate of 5%, thus a total of US$ 78,922 can be earned from eco-tourism and carbon crediting in the study area annually, which could play important role in sustainable forest management.

Major threats and habitat use status of Demoiselle crane (Anthropoides virgo), in district Bannu, Pakistan

Cranes are the large and attractive Creatures of nature with long necks, legs, and life-span. Adults of both sexes are the same with similar color patterns. Demoiselle cranes spend most of their lifespan on dry grasses. They are also found around the stream, rivers, shallow lakes, natural wetlands, and depressions. To evaluate the current status of habitat use and major threats a study was conducted in tehsil Domel district Bannu. Line transect method and water quality tests (temperature, PH, contamination of E-coli bacteria) were used. To determine the major threats questionnaire method was used. The whole data was analyzed by using SPSS 21 version. Based on the distribution four study sites were selected and four water samples from each study site were taken. Most sites were moderate to highly degraded except Kashoo and kurram river mixing point which was low degraded with livestock grazing and human activities. Water quality tests showed PH ranges from 7-9, temperature 6.5-8.5, and contamination of E-coli in all samples. The social survey revealed that hunting, habitat degradation, and pollution as major threats. Effective long-term conservation and management in the study area are needed to focus on the protection of disturbance-free habitat.

An ethno-botanical study of indigenous medicinal plants and their usage in rural valleys of Swabi and Hazara region of Pakistan

An ethnobotanical study was conducted to document indigenous medicinal plants and their usage from knowledgeable and elderly persons in Razzar and Gadoon valley of Swabi and Allai and Tanawal valley of Hazara region of Pakistan during 2016-2019. Several systematic field visits and questionnaire surveys were carried out in selected sites of the study area to gather relevant information from the local community. Rapid assessment method was adopted for data collection by interviewing the local people having enough knowledge of medicinal plants use for treatment of different ailments. UV (UV) formula was applied to calculate the relative importance of medicinal plant species in each site of the study area. In the present study, 221 medicinal plants belonging to 105 families have been reported through 580 respondents (385 males, 138 females and 57 local health healer) from the Swabi and Hazara region. The main sources of herbal medicines were leaves (21%) followed by fruits (21%), seeds (17%), whole plants (14%), roots (9%), bark (9%), flowers (7%) and gum (2%). Mentha spicata L. and Berberis lycium Royle were reported with highest UV (UV) i.e. 0.92 and 0.68 in Razzar tehsil and Gadoon valley of Swabi, whereas Mentha longifolia L and Geranium wallichianum D were reported with highest UV i.e. (0.65) and (0.88) in Allai and Tanawal valley of Hazara region, respectively. It was concluded that Swabi and Hazara region is rich in medicinal plants species and associated traditional knowledge. Moreover, ethno-medicines have played significant role in the indigenous healthcare system of the study area. However, uprooting the entire plant for ethno-medicine is a big threat to conservation of medicinal plants diversity in the study area.

Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries.

METHODS

GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution.

FINDINGS

Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990-2010 time period, with the greatest annualised rate of decline occurring in the 0-9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10-24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10-24 years were also in the top ten in the 25-49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50-74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI.

INTERPRETATION

As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and development investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve.

FUNDING

Bill & Melinda Gates Foundation.

Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease.

METHODS

GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk-outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk-outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk-outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden.

FINDINGS

The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10·8 million (95% uncertainty interval [UI] 9·51-12·1) deaths (19·2% [16·9-21·3] of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8·71 million (8·12-9·31) deaths (15·4% [14·6-16·2] of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253-350) DALYs (11·6% [10·3-13·1] of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0-9 years, the three leading detailed risk factors for attributable DALYs were all related to malnutrition. Iron deficiency was the leading risk factor for those aged 10-24 years, alcohol use for those aged 25-49 years, and high systolic blood pressure for those aged 50-74 years and 75 years and older.

INTERPRETATION

Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public.

FUNDING

Bill & Melinda Gates Foundation.

Ethanol and isopropanol inactivation of human coronavirus on hard surfaces

BACKGROUND

The coronavirus disease 2019 pandemic has greatly increased the frequency of disinfecting surfaces in public places, causing a strain on the ability to obtain disinfectant solutions. An alternative is to use plain alcohols (EtOH and IPA) or sodium hypochlorite (SH).

AIM

To determine the efficacy of various concentrations of EtOH, IPA and SH on a human coronavirus (HCoV) dried on to surfaces using short contact times.

METHODS

High concentrations of infectious HCoV were dried on to porcelain and ceramic tiles, then treated with various concentrations of the alcohols for contact times of 15 s, 30 s and 1 min. Three concentrations of SH were also tested. Reductions in titres were measured using the tissue culture infectious dose 50 assay.

FINDINGS

Concentrations of EtOH and IPA from 62% to 80% were very efficient at inactivating high concentrations of HCoV dried on to tile surfaces, even with a 15-s contact time. Concentrations of 95% dehydrated the virus, allowing infectious virus to survive. The dilutions of SH recommended by the Centers for Disease Control and Prevention (1/10 and 1/50) were efficient at inactivating high concentrations of HCoV dried on to tile surfaces, whereas a 1/100 dilution had substantially lower activity.

CONCLUSIONS

Multiple concentrations of EtOH, IPA and SH efficiently inactivated infectious HCoV on hard surfaces, typical of those found in public places. Often no remaining infectious HCoV could be detected.

Mapping geographical inequalities in access to drinking water and sanitation facilities in low-income and middle-income countries, 2000-17

BACKGROUND

Universal access to safe drinking water and sanitation facilities is an essential human right, recognised in the Sustainable Development Goals as crucial for preventing disease and improving human wellbeing. Comprehensive, high-resolution estimates are important to inform progress towards achieving this goal. We aimed to produce high-resolution geospatial estimates of access to drinking water and sanitation facilities.

METHODS

We used a Bayesian geostatistical model and data from 600 sources across more than 88 low-income and middle-income countries (LMICs) to estimate access to drinking water and sanitation facilities on continuous continent-wide surfaces from 2000 to 2017, and aggregated results to policy-relevant administrative units. We estimated mutually exclusive and collectively exhaustive subcategories of facilities for drinking water (piped water on or off premises, other improved facilities, unimproved, and surface water) and sanitation facilities (septic or sewer sanitation, other improved, unimproved, and open defecation) with use of ordinal regression. We also estimated the number of diarrhoeal deaths in children younger than 5 years attributed to unsafe facilities and estimated deaths that were averted by increased access to safe facilities in 2017, and analysed geographical inequality in access within LMICs.

FINDINGS

Across LMICs, access to both piped water and improved water overall increased between 2000 and 2017, with progress varying spatially. For piped water, the safest water facility type, access increased from 40·0% (95% uncertainty interval [UI] 39·4-40·7) to 50·3% (50·0-50·5), but was lowest in sub-Saharan Africa, where access to piped water was mostly concentrated in urban centres. Access to both sewer or septic sanitation and improved sanitation overall also increased across all LMICs during the study period. For sewer or septic sanitation, access was 46·3% (95% UI 46·1-46·5) in 2017, compared with 28·7% (28·5-29·0) in 2000. Although some units improved access to the safest drinking water or sanitation facilities since 2000, a large absolute number of people continued to not have access in several units with high access to such facilities (>80%) in 2017. More than 253 000 people did not have access to sewer or septic sanitation facilities in the city of Harare, Zimbabwe, despite 88·6% (95% UI 87·2-89·7) access overall. Many units were able to transition from the least safe facilities in 2000 to safe facilities by 2017; for units in which populations primarily practised open defecation in 2000, 686 (95% UI 664-711) of the 1830 (1797-1863) units transitioned to the use of improved sanitation. Geographical disparities in access to improved water across units decreased in 76·1% (95% UI 71·6-80·7) of countries from 2000 to 2017, and in 53·9% (50·6-59·6) of countries for access to improved sanitation, but remained evident subnationally in most countries in 2017.

INTERPRETATION

Our estimates, combined with geospatial trends in diarrhoeal burden, identify where efforts to increase access to safe drinking water and sanitation facilities are most needed. By highlighting areas with successful approaches or in need of targeted interventions, our estimates can enable precision public health to effectively progress towards universal access to safe water and sanitation.

FUNDING

Bill & Melinda Gates Foundation.

National Clinical Guidance for the Management of Cardiovascular Intervention in the COVID-19 Pandemic: From Bangladesh Society of Cardiovascular Interventions (BSCI)

Since the first recorded case of SARS-CoV-2 in Bangladesh on 8th March 2020, COVID-19 has spread widely through different regions of the country, resulting in a necessity to re-evaluate the delivery of cardiovascular services, particularly procedures pertaining to interventional cardiology in resource-limited settings. Given its robust capacity for human-to-human transmission and potential of being a nosocomial source of infection, the disease has specific implications on healthcare systems and health care professionals faced with performing essential cardiac procedures in patients with a suspected or confirmed diagnosis of COVID-19. The limited resources in terms of cardiac catheterization laboratories that can be designated to treat only COVID positive patients are further compounded by the additional challenges of unavailability of widespread rapid testing on-site at tertiary cardiac hospitals in Bangladesh. This document prepared for our nation by the Bangladesh Society of Cardiovascular Interventions (BSCI) is intended to serve as a clinical practice guideline for cardiovascular health care professionals, with a focus on modifying standard practice of care during the COVID-19 pandemic, in order to ensure continuation of adequate and timely treatment of cardiovascular emergencies avoiding hospital-based transmission of SARS-COV-2 among healthcare professionals and the patients. This is an evolving document based on currently available global data and is tailored to healthcare systems in Bangladesh with particular focus on, but not limited to, invasive cardiology facilities (cardiac catheterization, electrophysiology & pacing labs). This guideline is limited to the provision of cardiovascular care, and it is expected that specific targeted pharmaco-therapeutics against SARS-CoV-2 be prescribed as stipulated by the National Guidelines on Clinical Management of Corona virus Disease 2019 (COVID-19) published by the Director General of Health Services, Ministry of Health and Family Welfare of Bangladesh.

Sulphur doses and application times on yield and oil quality of canola grown in calcareous soil

Pakistan has been constantly deficient in its oil seed production and it is very difficult to meet the edible oil requirement of its ever-increasing population. A field experiment was conducted at the Agronomy Research Farm, The University of Agriculture Peshawar, Northern Pakistan during winter (2013–14). Five sulphur levels (15, 30, 45, 60 and 75 kg·ha-1) and times of application (at seedling, bolting and flowering stages) were used for the canola variety Abasin-95. The experiment was laid out in a randomized complete block design replicated four times on a 5 m × 3.2 m plot size. The results showed that the sulphur-applied plots gave the highest seed yield, biological yield, glucosinolate, erucic acid, oil content, protein content, oleic acid and linoleic acid compared to the control plots. Sulphur applied at the rate of 60 kg·ha-1 and applied at the bolting stage increased seed yield, biological yield, oil content, and protein content.

Incidence of central diabetes insipid us among the patients undergoing pituitary tumor surgery 06 through trans-sphenoidal approach

Background: Diabetes insipidus (DI) is a common complication following pituitary surgery. Thiscondition can be transient or permanent and the signs and symptoms of this disorder can bemimicked by the normal postoperative course. Objective: This study was carried out to find out the incidence of central diabetes insipidus (DI)among the patients undergoing pituitary tumor surgery through trans-sphenoidal approach eitherendoscopic or microsurgical for the first time.Study Design: Cross sectional observational study Methods: Patients with central (Neurogenic) diabetes insipidus prior to surgery, co-morbiditieslike diabetes mellitus, kidney diseases, electrolyte imbalance, recurrent cases were excludedfrom this study. Patients were followed up to 7th postoperative day by recording and analyzingfindings of postoperative serum electrolytes, urinary specific gravity, hourly urinary volume forestablishing diabetes insipid us. Results: 76.9% of patients developed diabetes insipidus and 70.0% of patients did not developdiabetes insipid us those who underwent pituitary tumour surgery by trans-sphenoidal endoscopicapproach; 23.1% of patients developed diabetes insipid us and 30.0% of patients did not developdiabetes insipid us those who underwent pituitary tumour surgery by trans-sphenoidal mlcrosurgicalapproach. Conclusion: Prediction of DI help us in pre-operative counseling and post-operative managementof the patients as well as to reduce complications related morbidity after pituitary tumor surgery. Journal of Surgical Sciences (2017) Vol. 21 (1) :6-10

Corrigendum to "Dietary administration of Nexrutine inhibits rat liver tumorigenesis and induces apoptotic cell death in human hepatocellular carcinoma cells". [Toxicol. Rep. 2 (2014) (November) 1-11]

[This corrects the article DOI: 10.1016/j.toxrep.2014.11.006.].

Regioselective synthesis of 7-acetyl-11c-methyl-4b,5,7,11c-tetrahydro[1]benzofuro[2′,3′:4,5]thiopyrano[2,3-b]indoles by sequential Claisen rearrangement of 2-(4′-aryloxybut-2′-ynylthio)-1-acetylindoles

Hitherto unreported indole-annulated pentacyclic heterocycles containing oxygen, nitrogen and sulfur have been synthesised by thermal Claisen rearrangement followed by Lewis acid catalysed Claisen rearrangement. 9-Acetyl-4-aryloxymethyl-2,9-dihydrothiopyrano[2,3- b]indoles are regioselectively synthesised in 80–85 % yield by thermal rearrangement of 2-(4′-aryloxybut-2′-ynylthio)-1-acetylindoles. A second, Lewis acid catalysed, rearrangement gave 7-acetyl-11c-methyl-4b,5,7,11c-tetrahydro[1]benzofuro[2′,3′: 4,5]thiopyrano[2,3- b]indoles in yields of 85–90 %. The thermal Claisen rearrangement in refluxing N,N-diethylaniline for 3 h gave the same products in lower yield (50–54 %).

Assessment of the burden of diseases and injuries attributable to risk factors in Canada from 1990 to 2016: an analysis of the Global Burden of Disease Study

BACKGROUND

An understanding of the risk factors contributing to disease burden is critical for determining research priorities and informing national health policy. We aimed to identify the risk factor trends in Canada.

METHODS

As part of the Global Burden of Disease (GBD) study (1990-2016), we conducted an analysis of country-level estimates for Canada to assess the burden of diseases and injuries attributable to risk factors. For both 1990 and 2016, metabolic, environmental and behavioural risk factors were ranked according to their contribution to disability-adjusted life years (healthy years of life lost), total deaths and years lived with disability.

RESULTS

In 2016, the risk factors accounting for the largest percentage of disability-adjusted life years in Canada were (1) tobacco, (2) diet, (3) high body mass index, (4) high fasting plasma glucose, (5) high systolic blood pressure, (6) alcohol and drug use, (7) occupational risks, (8) high total cholesterol, (9) impaired kidney function and (10) air pollution. Risk factor rankings remained similar from 1990 to 2016 despite some substantial declines in burden, including a 47% (± 3%) decline in the age-standardized disability-adjusted life years rate attributable to tobacco since 1990. Risk factors with an increasing contribution to disability-adjusted life years rates from 1990 to 2016 included high body mass index, high fasting plasma glucose and alcohol and drug use.

INTERPRETATION

Metabolic and behavioural risk factors, including modifiable factors such as tobacco use and diet, remain the leading risk factors contributing to the burden of diseases and injuries in Canada. This work identifies priorities and targets for reducing premature death and disability burden in Canada.

Evaluation of Fixation for Distal Humeral Diaphyseal Fracture by Locking Compression Plate

Treatment of extra-articular distal humeral shaft fractures with plating techniques is often difficult. The recent development of LCP has improved the surgical treatment of fractures by overcoming the few drawbacks of older fixators. The aim of this prospective observational study was to assess the effectiveness of osteosynthesis of extra-articular diaphyseal fractures of the distal third of the humerus using a single locking compression plate (LCP) and was conducted from July 2016 to June 2018 at the National Institute of Traumatology and Orthopedic Rehabilitation (NITOR), Dhaka, Bangladesh. Thirty (30) patients with closed fracture distal 3rd extra-articular humeral shaft fractures were treated by open reduction and internal fixation by locking compression plate. Two cases were excluded from the evaluation of final outcome due to their discontinued follow up. Detailed clinical conditions of all patients, technical difficulty with the implant, postoperative hospital stay period were recorded. Patients were followed up at 2nd week, 4th week, then 4 weekly upto 6 months. The patients were evaluated clinically and radiologically for outcomes. The progresses of healing as well as occurrence of complications were recorded. The range of motion of the shoulder and elbow were evaluated according to the criteria by Rommens grading. Functional evaluation was made according to the criteria by Modified Constant and Murley Scoring System. Union was achieved in all the patients after a mean of 15 weeks (range 12-20 weeks). There were no complications like deep infection, nonunion, malunion, implant failure, or nerve injury occurs in any of the patients. Two patients had transient radial nerve palsy. Two patients developed superficial infection. All patients were relieved pain postoperatively. Functional outcome were excellent in 10 patients, good in 15 patients which constituted 89% satisfactory results. The study has shown that the LCP is an effective, dependable solution for the management of distal third diaphyseal fractures of the humerus.

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk-outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk-outcome pairs, and new data on risk exposure levels and risk-outcome associations.

METHODS

We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017.

FINDINGS

In 2017, 34·1 million (95% uncertainty interval [UI] 33·3-35·0) deaths and 1·21 billion (1·14-1·28) DALYs were attributable to GBD risk factors. Globally, 61·0% (59·6-62·4) of deaths and 48·3% (46·3-50·2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10·4 million (9·39-11·5) deaths and 218 million (198-237) DALYs, followed by smoking (7·10 million [6·83-7·37] deaths and 182 million [173-193] DALYs), high fasting plasma glucose (6·53 million [5·23-8·23] deaths and 171 million [144-201] DALYs), high body-mass index (BMI; 4·72 million [2·99-6·70] deaths and 148 million [98·6-202] DALYs), and short gestation for birthweight (1·43 million [1·36-1·51] deaths and 139 million [131-147] DALYs). In total, risk-attributable DALYs declined by 4·9% (3·3-6·5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23·5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18·6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low.

INTERPRETATION

By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning.

FUNDING

Bill & Melinda Gates Foundation.

Global Burden of Disease Study trends for Canada from 1990 to 2016

BACKGROUND

The Global Burden of Disease Study represents a large and systematic effort to describe the burden of diseases and injuries over the past 3 decades. We aimed to summarize the Canadian data on burden of diseases and injuries.

METHODS

We summarized data from the 2016 iteration of the Global Burden of Disease Study to provide current (2016) and historical estimates for all-cause and cause-specific diseases and injuries using mortality, years of life lost, years lived with disability and disability-adjusted life years in Canada. We also compared changes in life expectancy and health-adjusted life expectancy between Canada and 21 countries with a high sociodemographic index.

RESULTS

In 2016, leading causes of all-age disability-adjusted life years were neoplasms, cardiovascular diseases, musculoskeletal diseases, and mental and substance use disorders, which together accounted for about 56% of disability-adjusted life years. Between 2006 and 2016, the rate of all-cause age-standardized years of life lost declined by 12%, while the rate of all-cause age-standardized years lived with disability remained relatively stable (+1%), and the rate of all-cause age-standardized disability-adjusted life year declined by 5%. In 2016, Canada aligned with countries that have a similar high sociodemographic index in terms of life expectancy (82 yr) and health-adjusted life expectancy (71 yr).

INTERPRETATION

The patterns of mortality and morbidity in Canada reflect an aging population and improving patterns of population health. If current trends continue, Canada will continue to face challenges of increasing population morbidity and disability alongside decreasing premature mortality.

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.

'At the end of the day, it is more important that he stays happy': an interpretative phenomenological analysis of people who have a sibling with 22q11.2 deletion syndrome

BACKGROUND

22q11.2 deletion syndrome (22q11.2DS) is the most common microdeletion syndrome. However, there is little research examining the effect of this multisystem disorder on the family, particularly siblings. The current study was a phenomenological exploration of sense-making in siblings of a person with 22q11.2DS.

METHOD

Interpretative phenomenological analysis informed a detailed and open examination of being a sibling of a person with 22q11.2DS. Using in-depth semistructured interviews, five typically developing siblings (two men, three women) of people with 22q11.2DS were individually interviewed, providing the data set for transcription and thematic analysis.

RESULTS

The theme 'They are the priority' overarched two subordinate themes that emerged from participants' descriptions of the struggle with acceptance and finding positive meaning. Participants oscillated between conflicting feelings about their sibling with 22q11.2DS always taking centre stage. For example, they felt anger, guilt and resentment; yet, they also embraced patience, empathy and gratitude.

CONCLUSIONS

This phenomenological study provides a foundation for future research relating to 22q11.2DS and fostering family wellbeing, particularly around acceptance and psychological growth. The siblings in this study actively withdrew from their family to allow prioritisation of their affected sibling. However, this does not mean that their needs should be overlooked. There are easily accessible resources to support siblings of individuals with disabilities, and it is important for health professionals and parents to consider these options.

A rare case of Theileria annulata induced corneal opacity in a calf

A 10 months old male cross-bred calf was presented in OPD Medicine, Referral Veterinary Polyclinic, ICAR-Indian Veterinary Research Institute, Izatnagar with the history of anorexia, impaired vision, heavy tick infestation and diarrhoea for the last 1 week. The clinical examination revealed enlarged pre-scapular lymph nodes, prominent cloudiness in eyes and exophthalmos. The presence of Koch blue bodies in biopsied lymph nodes and a PCR assay confirmed it to be bovine tropical theileriosis associated with unique corneal opacity. Treatment with buparvaquone at a dose of 2.5 mg/kg i.m. two doses 48 h apart was successful and typical ocular manifestations completely subsided after 2 weeks of therapy.

Raman-shifted wavelength-selectable pulsed fiber laser with high repetition rate and high pulse energy in the visible

A high-pulse-energy, diffraction-limited, wavelength-selectable, visible source, based on Raman frequency shifting of a frequency-doubled Yb-doped fiber laser, has been studied. The relative length-scaling laws of Raman gain and self-phase modulation push the design towards short fiber lengths with large core size. It is experimentally demonstrated that the Raman clean-up effect in a graded-index multi-mode fiber is not sufficient to obtain diffraction-limited beam quality in the short fiber length. Thus, a large-core photonic crystal fiber is used to maintain diffraction-limited performance and output pulse energies of ~1 μJ, at a 1-MHz repetition rate and 1.3-ns pulse-width are successfully achieved. This step-tunable visible source should find applications in photoacoustic microscopy.