Neoadjuvant Chemotherapy in Locally Advanced Sinonasal Teratocarcinosarcoma a Rare Malignancy: An Audit From an Academic Tertiary Care Centre in India

AIMS

Sinonasal teratocarcinosarcomas (SNTCS) are rare sinonasal malignancies, the incidence of which is less than 1% of all tumors. There is limited data available on SNTCS's, often as case reports and small case series. The management of SNTCS is complicated because of its location, locally aggressive biology, difficulty in achieving complete resection, and limited data on chemotherapy in these malignancies. This audit was performed to understand the role of neoadjuvant chemotherapy (NACT) in SNTCS's, its ability to downstage the disease, achieve complete resection, and impact on long-term survival outcomes.

METHODS

This was a retrospective analysis of a prospectively maintained database approved by the Institutional Ethics Committee (IEC). The baseline characteristics, the extent of tumor, Kadish stage, NACT regimen, and adverse events were extracted from the Electronic Medical Records and the patient's case file. Patients with baseline extensive/inoperable disease were referred for NACT from the multidisciplinary joint clinic followed by response assessment (RECIST v1.1). Patients underwent skull-base surgery if respectable post-completion of NACT, however, if deemed unresectable were treated with non-surgical modalities or palliative therapies.

RESULTS

The data of 27 patients were evaluated from the year 2015-2022. The median age was 42 years (IQR:30-56) and 85.2% (n = 23) were males. The ECOG-PS was 0-1 in 88.8% (n = 24) patients. All 27 patients received NACT in view of extensive disease at presentation. 74.1% (n = 20) patients received Cisplatin-Etoposide and 25.9% (n = 7) received other chemotherapy regimens. The median number of chemotherapy cycles was 2(IQR:2-3). 96.3% patients (n = 26) completed the planned NACT cycles. 70.4% (n = 19) patients achieved a partial response in post-NACT imaging. 77.8% (n = 18) underwent surgery, 18.5% (n = 5) received CTRT, and 7.4% (n = 2) received definitive-RT alone. The median PFS and OS of the cohort was 19months (95%CI:12.0-25.6) and 23months (95%CI:5.94-40.06) respectively.

CONCLUSION

NACT is safe, feasible, and effective with significant response rates, leading to effective downstaging, resectability and improved survival in patients with locally advanced SNTCS's.

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.

Burden of disease scenarios for 204 countries and territories, 2022-2050: a forecasting analysis for the Global Burden of Disease Study 2021

BACKGROUND

Future trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050.

METHODS

Using forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline.

FINDINGS

In the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8-63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0-45·0] in 2050) and south Asia (31·7% [29·2-34·1] to 15·5% [13·7-17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4-40·3) to 41·1% (33·9-48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6-25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5-43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5-17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7-11·3) in the high-income super-region to 23·9% (20·7-27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5-6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2-26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [-0·6 to 3·6]).

INTERPRETATION

Globally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions.

FUNDING

Bill & Melinda Gates Foundation.

Global fertility in 204 countries and territories, 1950-2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Accurate assessments of current and future fertility-including overall trends and changing population age structures across countries and regions-are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios.

METHODS

To estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10-54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression-Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values-a metric assessing gain in forecasting accuracy-by comparing predicted versus observed ASFRs from the past 15 years (2007-21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline.

FINDINGS

During the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63-5·06) to 2·23 (2·09-2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137-147), declining to 129 million (121-138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1-canonically considered replacement-level fertility-in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7-29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59-2·08) in 2050 and 1·59 (1·25-1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6-43·1) in 2050 and 54·3% (47·1-59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions-decreasing, for example, in south Asia from 24·8% (23·7-25·8) in 2021 to 16·7% (14·3-19·1) in 2050 and 7·1% (4·4-10·1) in 2100-but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40-1·92) in 2050 and 1·62 (1·35-1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction.

INTERPRETATION

Fertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world.

FUNDING

Bill & Melinda Gates Foundation.

Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic.

METHODS

The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic.

FINDINGS

Global DALYs increased from 2·63 billion (95% UI 2·44-2·85) in 2010 to 2·88 billion (2·64-3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7-17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8-6·3) in 2020 and 7·2% (4·7-10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0-234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7-198·3]), neonatal disorders (186·3 million [162·3-214·9]), and stroke (160·4 million [148·0-171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3-51·7) and for diarrhoeal diseases decreased by 47·0% (39·9-52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54-1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5-9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0-19·8]), depressive disorders (16·4% [11·9-21·3]), and diabetes (14·0% [10·0-17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7-27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6-63·6) in 2010 to 62·2 years (59·4-64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6-2·9) between 2019 and 2021.

INTERPRETATION

Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades.

FUNDING

Bill & Melinda Gates Foundation.

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

METHODS

The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

FINDINGS

Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

INTERPRETATION

Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

FUNDING

Bill & Melinda Gates Foundation.

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.

METHODS

22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.

FINDINGS

Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.

INTERPRETATION

Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.

FUNDING

Bill & Melinda Gates Foundation.

Does This Infant Have a Dislocated Hip?: The Rational Clinical Examination Systematic Review

Importance

Delayed diagnosis of a dislocated hip in infants can lead to complex childhood surgery, interruption to family life, and premature osteoarthritis.

Objective

To evaluate the diagnostic accuracy of clinical examination in identifying dislocated hips in infants.

Data Sources

Systematic search of CINAHL, Embase, MEDLINE, and the Cochrane Library from the inception of each database until October 31, 2023.

Study Selection

The 9 included studies reported the diagnostic accuracy of the clinical examination (index test) in infants aged 3 months or younger and a diagnostic hip ultrasound (reference test). The Graf method of ultrasound assessment was used to classify hip abnormalities.

Data Extraction and Synthesis

The Rational Clinical Examination scale was used to assign levels of evidence and the Quality Assessment of Diagnostic Accuracy Studies tool was used to assess bias. Data were extracted using the individual hip as the unit of analysis; the data were pooled when the clinical examinations were evaluated by 3 or more of the included studies.

Main Outcomes and Measures

Sensitivity, specificity, and likelihood ratios (LRs) of identifying a dislocated hip were calculated.

Results

Among infants screened with a clinical examination and a diagnostic ultrasound in 5 studies, the prevalence of a dislocated hip (n = 37 859 hips) was 0.94% (95% CI, 0.28%-2.0%). There were 8 studies (n = 44 827 hips) that evaluated use of the Barlow maneuver and the Ortolani maneuver (dislocate and relocate an unstable hip); the maneuvers had a sensitivity of 46% (95% CI, 26%-67%), a specificity of 99.1% (95% CI, 97.9%-99.6%), a positive LR of 52 (95% CI, 21-127), and a negative LR of 0.55 (95% CI, 0.37-0.82). There were 3 studies (n = 22 472 hips) that evaluated limited hip abduction and had a sensitivity of 13% (95% CI, 3.3%-37%), a specificity of 97% (95% CI, 87%-99%), a positive LR of 3.6 (95% CI, 0.72-18), and a negative LR of 0.91 (95% CI, 0.76-1.1). One study (n = 13 096 hips) evaluated a clicking sound and had a sensitivity of 13% (95% CI, 6.4%-21%), a specificity of 92% (95% CI, 92%-93%), a positive LR of 1.6 (95% CI, 0.91-2.8), and a negative LR of 0.95 (95% CI, 0.88-1.0).

Conclusions and Relevance

In studies in which all infant hips were screened for developmental dysplasia of the hip, the prevalence of a dislocated hip was 0.94%. A positive LR for the Barlow and Ortolani maneuvers was the finding most associated with an increased likelihood of a dislocated hip. Limited hip abduction or a clicking sound had no clear diagnostic utility.

Lead optimization based design, synthesis, and pharmacological evaluation of quinazoline derivatives as multi-targeting agents for Alzheimer's disease treatment

The complexity and multifaceted nature of Alzheimer's disease (AD) have driven us to further explore quinazoline scaffolds as multi-targeting agents for AD treatment. The lead optimization strategy was utilized in designing of new series of derivatives (AK-1 to AK-14) followed by synthesis, characterization, and pharmacological evaluation against human cholinesterase's (hChE) and β-secretase (hBACE-1) enzymes. Amongst them, compounds AK-1, AK-2, and AK-3 showed good and significant inhibitory activity against both hAChE and hBACE-1 enzymes with favorable permeation across the blood-brain barrier. The most active compound AK-2 revealed significant propidium iodide (PI) displacement from the AChE-PAS region and was non-neurotoxic against SH-SY5Y cell lines. The lead molecule (AK-2) also showed Aβ aggregation inhibition in a self- and AChE-induced Aβ aggregation, Thioflavin-T assay. Further, compound AK-2 significantly ameliorated Aβ-induced cognitive deficits in the Aβ-induced Morris water maze rat model and demonstrated a significant rescue in eye phenotype in the Aꞵ-phenotypic drosophila model of AD. Ex-vivo immunohistochemistry (IHC) analysis on hippocampal rat brains showed reduced Aβ and BACE-1 protein levels. Compound AK-2 suggested good oral absorption via pharmacokinetic studies and displayed a good and stable ligand-protein interaction in in-silico molecular modeling analysis. Thus, the compound AK-2 can be regarded as a lead molecule and should be investigated further for the treatment of AD.

Low Temperature Dynamic Polaron Liquid in a Manganite Exhibiting Colossal Magnetoresistance

Polarons-fermionic charge carriers bearing a strong companion lattice deformation-exhibit a natural tendency for self-localization due to the recursive interaction between electrons and the lattice. While polarons are ubiquitous in insulators, how they evolve in transitions to metallic and superconducting states in quantum materials remains an open question. Here, we use resonant inelastic x-ray scattering to track the electron-lattice coupling in the colossal magneto-resistive bi-layer manganite La_{1.2}Sr_{1.8}Mn_{2}O_{7} across its metal-to-insulator transition. The response in the insulating high-temperature state features harmonic emissions of a dispersionless oxygen phonon at small energy transfer. Upon cooling into the metallic state, we observe a drastic redistribution of spectral weight from the region of these harmonic emissions to a broad high energy continuum. In concert with theoretical calculations, we show that this evolution implies a shift in electron-lattice coupling from static to dynamic lattice distortions that leads to a distinct polaronic ground state in the low temperature metallic phase-a dynamic polaron liquid.

Social Disadvantage and Multimorbidity Including Oral Conditions in the United States

Existing studies on multimorbidity have largely excluded oral diseases in multimorbidity prevalence estimates. The reason behind this is somewhat unclear, as chronic oral conditions are highly prevalent, affecting over half the global population. To address this gap, we examined the relationship between social disadvantage and multimorbidity, stratifying by the inclusion and exclusion of oral conditions. For participants aged 30 y and over (n = 3,693), cross-sectional analysis was carried out using the US National Health and Nutrition Survey (2013-2014). Multimorbidity was defined as having 2 or more chronic conditions. Five medical conditions were examined: diabetes, asthma, arthritis, cardiovascular disease, and depression, as well as 4 oral health conditions: caries, periodontal disease, number of teeth, and edentulousness. Education and income poverty ratio were selected as measures of social disadvantage. Multimorbidity prevalence estimates according to social disadvantage were analyzed on an absolute and relative scale using inverse probability treatment weighting (IPTW), adjusting for age, sex, and ethnicity. The inclusion of oral health conditions in the assessment of multimorbidity increased the overall prevalence of multimorbidity from 20.8% to 53.4%. Findings from IPTW analysis demonstrated clear social gradients for multimorbidity estimates stratified by the exclusion of oral conditions. Upon inclusion of oral conditions, the prevalence of multimorbidity was higher across all social groups for both education and income. Stratifying by the inclusion of oral conditions, the mean probability of multimorbidity was 27% (95% confidence interval [CI], 23%-30%) higher in the low-education group compared to the high-education group. Similarly, the mean probability of multimorbidity was 44% (95% CI, 40%-48%) higher in the low-income group. On a relative scale, low education was associated with a 1.52 times (95% CI, 1.44-1.61) higher prevalence of multimorbidity compared to high education. Low income was associated with a 2.18 (95% CI, 1.99-2.39) higher prevalence of multimorbidity. This novel study strongly supports the impact of chronic oral conditions on multimorbidity prevalence estimates.

School-based physical activity interventions: which intervention characteristics are associated with participation and retention? A meta-analysis

OBJECTIVE

Many school-based intervention studies are conducted to increase students' physical activity (PA). Recruitment and retention problems potentially impact the robustness of RCT findings. We conducted a meta-analysis to summarize recruitment and retention rates in long-term secondary school-based PA intervention studies and examined associated participant and intervention characteristics.

METHODS

Web of Science, Pubmed, Medline, and PsychInfo were searched until March 20th 2023. We included studies on secondary school-based PA interventions ≥12 weeks, aimed at typically developing adolescents. We abstracted number of schools and students invited, randomized, and participating at follow-up to calculate pooled recruitment and retention rates; participant and intervention characteristics were abstracted to execute subgroup or meta-regression analyses.

RESULTS

Recruitment rates were 51% for invited schools and 80% for invited students, the retention for schools was almost 100% and for students 91%. Interventions with fixed and flexible components, executed in Asia and South America, and from later publication years had higher student recruitment rates. Students' retention rates were lower for interventions which had flexible components, were theory/model-based, used an accelerometer, had a longer intervention duration, and included more females.

CONCLUSION

Recruitment and retention rates in school-based PA interventions are high. Some participant and intervention characteristics influence these rates: flexibility of the intervention, theory/model-based intervention, accelerometer use, intervention duration, continent, and number of females. Researchers should consider these characteristics in intervention development to achieve optimal balance between intervention effectiveness, recruitment, and retention.

Structure-Guided Design, Synthesis, and Biological Evaluation of Peripheral Anionic Site Selective and Brain Permeable Novel Oxadiazole-Piperazine Conjugates against Alzheimer's Disease with Antioxidant Potential

Alzheimer's disease (AD) is a multifactorial and emerging neurological disorder, which has invoked researchers to develop multitargeted ligands. Herein, hybrid conjugates of 5-phenyl-1,3,4-oxadiazole and piperazines were rationally designed, synthesized, and pharmacologically evaluated against hAChE, hBChE, and hBACE-1 enzymes for the management of AD. Among the series, compound 5AD comprising pyridyl substitution at terminal nitrogen of piperazine contemplated as a paramount lead compound (hAChE, IC50 = 0.103 ± 0.0172 μM, hBChE, IC50 ≥ 10 μM, and hBACE-1, IC50 = 1.342 ± 0.078 μM). Compound 5AD showed mixed-type enzyme inhibition in enzyme kinetic studies against the hAChE enzyme. In addition, compound 5AD revealed a significant displacement of propidium iodide from the peripheral anionic site (PAS) of hAChE and excellent blood-brain barrier (BBB) permeability in a parallel artificial membrane permeation assay (PAMPA). Besides, 5AD also exhibited anti-Aβ aggregation activity in self- and AChE-induced thioflavin T assay. Further, compound 5AD has shown significant improvement in learning and memory (p < 0.001) against the in vivo scopolamine-induced cognitive dysfunction mice model. The ex vivo study implied that after treatment with compound 5AD, there was a decrease in AChE and malonaldehyde (MDA) levels with an increase in catalase (CAT, oxidative biomarkers) in the hippocampal brain homogenate. Hence, compound 5AD could be regarded as a lead compound and further be explored in the treatment of AD.

The effect of flow-responsive pulsation on teat tissue condition and milking performance in Holstein dairy cows

The objectives of this study were to assess the effect of a reduced liner-open phase applied through flow-responsive pulsation (FRP), as a method to provide supplemental stimulation, on teat tissue conditions and milking characteristics in dairy cows. In 2 switch-back trials, 156 Holstein cows milked 3 times daily were assigned to the FRP or conventional (CON) group in alternating sequences. Trial I lasted for 35 d and was split into 5 alternating 1-week periods of FRP and CON. The duration of Trial II was 84 d, consisting of 4 alternating 3-week periods of FRP and CON. Premilking udder preparation for both groups consisted of predipping, forestripping and wiping the teats. Upon milking unit attachment, the FRP cows were milked at a pulsation rate of 50 cycles/min and a pulsation ratio of 30:70 until the preset milk flow threshold of 0.5 kg/min was reached. When the threshold value of 0.5 kg/min was reached, the pulsation was automatically switched to milking mode, which consisted of a pulsation rate of 60 cycles/min and a pulsation ratio of 70:30. Cows in the CON group were milked by milking mode (pulsation rate, 60 cycles/min; pulsation ratio, 70:30) immediately after attachment of the milking unit. We assessed machine milking-induced short-term changes to the teat tissue by palpation and visual inspection during Trial I, and we assessed teat-end hyperkeratosis in Trial II. Electronic on-farm milk meters were used to assess milking characteristics [milk yield (kg/milking session), milking unit-on time (s), 2-min milk yield (kg), peak milk flow rate (kg/min), and duration of low milk flow rate (s)]. Generalized linear mixed models were used to analyze the effect of treatment on the outcome variables. The odds of machine milking-induced short-term changes to the teat tissue were lower for cows in the FRP group than for those in the CON group [odds ratio (95% confidence interval; 95% CI) = 0.41 (0.31-0.55)]. There were no meaningful differences in the odds of teat-end hyperkeratosis between the FRP and CON groups [odds ratio (95% CI) = 1.05 (0.38-2.89)]. The least squares means (95% CI) of milking characteristics in the FRP and CON groups were 14.3 (13.8-14.7) and 14.3 (13.8-14.7) kg for milk yield, respectively; 272 (264-281) and 270 (262-278) s for milking unit-on time, respectively; and 5.0 (4.8-5.1) and 4.9 (4.7-5.1) kg/min for peak milk flow rate, respectively. The FRP group had lower odds of bimodality than the CON group [odds ratio (95% CI) = 0.67 (0.61-0.74)]. In reference to CON, the odds ratios (95% CI) in FRP were 1.05 (0.76-1.46) for kick-off, and 1.02 (0.85-1.23) for milking unit reattachment. In this study, cows that were milked using FRP had lower odds of postmilking short-term changes to the teat tissue and lower odds of bimodal milk flow. We conclude that FRP may foster adequate teat stimulation in cows before the initiation of milk harvest and has the potential to improve teat tissue conditions.

An objective way to predict remission and relapse in Cushing disease using Bayes' theorem of probability

OBJECTIVE

In this study on patients with Cushing disease, post-transsphenoidal surgery (TSS), we attempt to predict the probability of remaining in remission, at least for a year and relapse after that, using Bayes' theorem and the equation of conditional probability. The number of parameters, as well as the weightage of each, is incorporated in this equation.

DESIGN AND METHODS

The study design was a single-centre ambispective study. Ten clinical, biochemical, radiological and histopathological parameters capable of predicting Cushing disease remission were identified. The presence or absence of each parameter was entered as binary numbers. Bayes' theorem was applied, and each patient's probability of remission and relapse was calculated.

RESULTS

A total of 145 patients were included in the study. ROC plot showed a cut-off value of the probability of 0.68, with a sensitivity of 82% (range 73-89%) and a specificity of 94% (range 83-99%) to predict the probability of remission. Eighty-one patients who were in remission at 1 year were followed up for relapse and 23 patients developed relapse of the disease. The Bayes' equation was able to predict relapse in only 3 out of 23 patients.

CONCLUSIONS

Using various parameters, remission of Cushing disease can be predicted by applying Bayes' theorem of conditional probability with a sensitivity and a specificity of 82% and 94%, respectively. This study provided an objective way of predicting remission after TSS and relapse in patients with Cushing disease giving a weightage advantage to every parameter.

Search for a Neutron Dark Decay in ^{6}He

Neutron dark decays have been suggested as a solution to the discrepancy between bottle and beam experiments, providing a dark matter candidate that can be searched for in halo nuclei. The free neutron in the final state following the decay of ^{6}He into ^{4}He+n+χ provides an exceptionally clean detection signature when combined with a high efficiency neutron detector. Using a high-intensity ^{6}He^{+} beam at Grand Accélérateur National d'Ions Lourds, a search for a coincident neutron signal resulted in an upper limit on a dark decay branching ratio of Br_{χ}≤4.0×10^{-10} (95% C.L.). Using the dark neutron decay model proposed originally by Fornal and Grinstein, we translate this into an upper bound on a dark neutron branching ratio of O(10^{-5}), improving over global constraints by one to several orders of magnitude depending on m_{χ}.

The association between teat shape and bimodal milk ejection in Holstein dairy cows

Our objectives were to investigate the association of teat shape with (1) bimodality (2) incremental milk flow rates (average flow rates during the first 15 s, 15-30 s, 30-60 s, and 60-120 s of milking), and (3) peak milk flow rate in Holstein dairy cows milked 3 times per day. In this prospective cohort study, we analyzed 220,928 milking observations that were collected from 2,520 cows from a single dairy herd over a period of 31 d. Teat shape was visually assessed and classified into 1 of 4 categories as follows: (1) triangular barrel and pointed teat end (TP), (2) square barrel and round teat end (SR), (3) square barrel, round teat end, and flat in the area of the teat orifice (SRF), and (4) square barrel and flat teat end (SF). Individual cow-level milk flow rates were obtained using electronic on-farm milk meters. We considered bimodality to be present if any of the incremental milk flow rates (flow rates during 15-30 s, 30-60 s, or 60-120 s) were lower than any of the previous rates (flow rates during the first 15 s, 15-30 s, or 30-60 s). The frequency distribution of cows with different teat shapes was as follows: TP, 96 (3.8%); SR, 1,751 (69.5%); SRF, 617 (24.5%); and SF, 56 (2.2%). A generalized linear mixed model revealed differences in the odds of bimodality among cows with different teat shapes. Compared with cows in category SR, the odds (95% confidence interval) of bimodality of cows in other categories were as follows: TP, 0.68 (0.48-0.97); SF, 1.96 (1.21-3.19); and SRF, 1.46 (1.23-1.72). General linear mixed models indicated an association between teat shape and all incremental milk flow rates, with higher milk flow rates being present for cows with teat shapes in the SRF and SF categories. The general linear mixed model for the dependent variable peak milk flow rate indicated an association between teat shape and peak milk flow rate. Least squares means and 95% confidence intervals were 5.1 (4.9-5.3) kg/min for TP, 5.8 (5.5-6.1) kg/min for SF, 5.6 (5.5-5.7) for SRF, and 5.3 (5.3-5.4) for SR, respectively. We conclude that in this study cohort, bimodality is more likely to occur in cows with flat teat ends compared with those with a round teat ends. We attribute this relationship to the difference in milking speed across cows with different teat shapes. Teat shape may serve as a useful phenotype to identify cows that are more likely to exhibit bimodality. Because our study population was unique, future studies considering different circumstances such as breed, milking system, and milking routine are needed before results can be extrapolated.

Cultural factors and family influences on adolescent oral health: qualitative research in a socially disadvantaged population

AIM

This qualitative study sought to assess the influence of cultural factors and family on oral health behaviour of 12- to 15-year-old adolescents from the socially disadvantaged population.

DESIGN

A qualitative design was developed with focus group discussions (FGDs) among 12- to 15-year-old adolescents. Four focus groups (n = 32 participants) were created from a selected sample to capture oral health beliefs and practices, oral health-seeking behaviour along with other relevant information. Focus group discussions were audio-recorded, transcribed verbatim and translated. Data were analysed thematically and structural coding was applied.

RESULTS

Three key themes that emerged from FGDs were importance of oral health; role of family in oral health behaviour; and beliefs influencing access, prevention and treatment of oral diseases. Cultural background, family values and beliefs were imperative in moulding the behaviour of adolescents towards oral health. The use of traditional oral hygiene aides was a norm in this population.

CONCLUSIONS

Findings of the study provide greater insights into the authoritative role of family and cultural barriers in the uptake of dental services. The study also highlights the potential value of qualitative research and emphasizes the need to integrate oral health-associated cultural beliefs and attitudes of the adolescents towards a wider evidence base.

The effect of 2 different premilking stimulation regimens, with and without a latency period, on teat tissue condition and milking performance in Holstein dairy cows

The objectives of this study were to assess the effect of 2 different premilking stimulation regimens, with and without a latency period between tactile stimulation and the attachment of the milking unit, on the teat tissue condition and milking performance of dairy cows. In a randomized controlled crossover study, 145 Holstein cows milked 3 times daily were assigned to treatment (TRT) or control (CON) groups. Premilking udder preparation for the TRT group consisted of the application of a latency period resulting in a preparation lag time of 90 s. The only difference in the premilking udder preparation of the CON group was the absence of latency period; the milking unit was attached immediately after completion of the tactile stimulation. The average duration of total tactile stimulation in TRT and CON group was 8 ± 2 and 9 ± 2 s, respectively. The study lasted for 14 d and was split into 2 periods, each consisting of a 2-d adjustment period followed by 5 d of data collection. We assessed machine milking-induced short-term changes to the teat tissue by palpation and visual inspection postmilking. Electronic on-farm milk meters were used to assess milking characteristics (milk yield [kg/milking session], machine-on time [s], 2-min milk yield [kg], and duration of low milk flow rate [s]). Generalized linear mixed models were used to analyze the effect of treatment on the outcome variables. The odds of machine milking-induced short-term changes to the teat tissue were lower for cows that received a 90-s preparation lag time (TRT cows) compared with cows in the CON group (odds ratio [95% confidence interval; 95% CI] = 0.13 [0.08-0.20]). The least squares means (95% CI) values of cows in the TRT and CON groups were 15.4 (14.9-15.9) and 15.3 (14.8-15.8) kg, respectively, for milk yield, and 246 (239-253) and 253 (247-260) s for machine-on time. The 2-min milk yield was higher for the TRT compared with CON group cows at all the parity levels. The 2-min milk yields of animals in lactation 1, 2, and ≥3 were 5.7, 5.7, and 6.5 kg, respectively, in the TRT group and 4.6, 5.0, and 5.9 kg in the CON group. The TRT cows spent less time in low milk flow rate compared with CON cows at all parity levels. The durations of low milk flow rate of cows in lactation 1, 2, and ≥3 in the TRT group were 19, 17 and 13 s, respectively, and those in the CON group were 31, 22, and 15 s. In this study, cows that received a latency period, and thus were subjected to a 90-s preparation lag time had lower odds of exhibiting short-term changes to the teat tissue after machine milking, shorter machine-on time, higher 2-min milk yields, and lower durations of low milk flow rates. We conclude that consideration of latency period leading to a 90-s preparation lag time in the premilking stimulation regimen facilitated cows' milk-ejection reflex. This latency period can alleviate the adverse effects of vacuum-induced forces on teat tissue during machine milking, improve udder health, and promote animal well-being.

Outcomes of mechanical thrombectomy in acute stroke patients with atrial fibrillation detected after stroke versus known atrial fibrillation

We aim to compare the outcomes in patients with atrial fibrillation detected after stroke (AFDAS) and their counterparts with known AF (KAF) presenting with large vessel occlusion (LVO) treated with mechanical thrombectomy (MT). This observational, prospective study included consecutive patients with acute LVO ischemic stroke of the anterior circulation with AFDAS, KAF and without AF. The primary study outcome was functional independence at 90 days after stroke. The secondary study outcomes were variation of the NIHSS score at 24 h, rate of successful reperfusion, death at 90 days and rate of immediate complications post-procedure. Overall, our cohort included 518 patients with acute ischemic stroke and LVO treated with MT, with 289 (56.8%) without a diagnosis of AF; 107 (21%) with AFDAS; 122 (22.2%) with KAF. There was no significant difference in terms of functional independence at 90 days after stroke between the three groups. Regarding the secondary study outcome, the rate of symptomatic intracranial haemorrhage (sICH) and/or parenchymal hematoma (PH) were significantly higher in the group of patients without AF (respectively, P = 0.030 and  < 0.010). Logistic regression analysis showed that the subtypes of AF were not statistically significantly associated with functional independence at 90 days after stroke and with the likelihood of any ICH. Our results suggest that the subtypes of AF are not associated with clinical and safety outcomes of MT in patients with acute stroke and LVO. Further studies are needed to confirm our findings.

Safety and outcomes of different endovascular treatment techniques for anterior circulation ischaemic stroke in the elderly: data from the Imperial College Thrombectomy Registry

BACKGROUND

Although previous studies investigated the main predictors of outcomes after endovascular thrombectomy (EVT) in patients aged 80 years and older, less is known about the impact of the procedural features on outcomes in elderly patients. The aim of this study was to investigate the influence of EVT technical procedures on the main 3-month outcomes in a population of patients aged 80 years and older.

METHODS

This observational, prospective, single-centre study included consecutive patients with acute LVO ischaemic stroke of the anterior circulation. The study outcomes were functional independence at 3 months after EVT (defined as a mRS score of 0-2), successful reperfusion (mTICI ≥ 2b), incidence of haeamorrhagic transformation, and 90-day all cause of mortality.

RESULTS

Our cohort included 497 patients with acute ischaemic stroke due to LVO treated with EVT. Among them, 105 (21.1%) patients were aged ≥ 80 years. In the elderly group, multivariable regression analysis showed that thromboaspiration technique vs stent-retriever was the single independent predictor of favourable post-procedural TICI score (OR = 7.65, 95%CI = 2.22-26.32, p = 0.001).

CONCLUSIONS

Our study suggests that EVT for LVO stroke in the elderly could be safe. The use of thromboaspiration was associated with positive reperfusion outcome in this population. Further studies in larger series are warranted to confirm the present results and to evaluate the safety and efficacy of EVT in the elderly and oldest adults.

Global perspective on child and adolescent oral health: a systematic review and meta-analysis of oral impacts on daily performance

OBJECTIVE

Several prevalence studies have estimated the region-specific impact of oral diseases on oral health-related quality of life. However, none of them reported and compared the same from a global perspective. This meta-analysis aims to evaluate pooled epidemiologic data about child-oral impacts on daily performance (C-OIDP) globally.

METHODS

A search was conducted in PubMed, Science Direct, SciELO, Semantic scholar, and Cochrane databases up to January 2023. Studies evaluating OIDP among 11-18-year-olds were included in the review. Quality of the included studies was evaluated using the health states quality index for cross-sectional studies. The meta-analysis used R package software version 4.3.0. A common effect model was used to calculate the pooled prevalence. The protocol was registered in the PROSPERO (CRD-NIHR) database with Reference ID CRD42023393798.

RESULTS

The systematic literature search yielded 257 unique citations. After screening titles and abstracts, 214 irrelevant citations were excluded, leaving 55 for full-text review. Overall, 43 studies from 23 countries were included. The meta-analysis reported a pooled prevalence impact C-OIDP of 53.36% (CI: 52.78-53.95, 43 studies, 16,622 participants). The prevalence of C-OIDP scores among South America, Asia, Europe, Africa and Oceania was 83%, 63%, 58%, 33% and 47%, respectively. The maximum prevalence was reported in South America while the least prevalence was noted in the African population.

CONCLUSION

Oral diseases affect the oral health-related quality of life of more than half of children and adolescents globally. Huge variations were noted in the prevalence of oral impacts across different regions. These findings can be utilized by policymakers to draft measures required for reducing impacts of oral diseases and improving the health-related quality of life.

Risk factors and associated pathway for rural and urban unmet dental prosthetic needs among older adults in Central India

AIM

This study was undertaken to evaluate the risk factors and associated pathways for unmet dental prosthetic needs among older adult population in Central India.

METHODS

A total of 11,145 randomly selected older adults participated in the study; 4613 from urban region and 6532 form rural region. Oral examinations were conducted at individual households for recording dental caries, periodontal disease, prosthetic status and needs. Structural Equation Modelling (SEM) was used to examine relationship between a set of exogenous variables and unmet dental prosthetic needs with variables that remained significant in the adjusted multilevel logistic model. Path coefficients were calculated for all variables with 95% confidence interval. Goodness of fit of the model was assessed by several indices.

RESULTS

A total of 8433 (75.7%) participants had never visited a dentist and 9139 (82%) had unmet dental prosthetic needs. Dental caries was observed among 3207 (69.5%) and 4644 (71.1%) study participants from urban and rural regions respectively (p < .05). Low utilization of dental services was associated with high dental prosthetic needs in upper arch and lower arch (PC = -0.05, 0.001) and DMFT was associated with lower utilization of dental services (PC = -0.09, 0.001). DMFT was also associated with age, annual income, level of education, paternal education, type of family, tobacco consumption and CPI score in the hypothesized model. The fit indices used indicated that the model was adequate.

CONCLUSIONS

Dental prosthetic needs in the proposed pathway model was associated with low utilization of dental services, dental caries, periodontal disease and other socio-demographic factors.

Health care access, psychosocial outcomes and mental health in adults living with epilepsy during the COVID-19 pandemic

PURPOSE

People living with epilepsy (PLWE) have a higher prevalence of mental health comorbidities and poorer psychosocial outcomes compared to the general population. The aim of this study was to examine psychosocial outcomes, mental health, healthcare accessibility, and seizure burden in PLWE during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional study of adults with epilepsy treated in an urban multicenter health system from 2021 to 2022. A standardized questionnaire assessed for COVID-19 history, comorbidities, access to antiseizure medications (ASMs) and neurological care, seizure burden, and psychosocial outcomes (e.g., employment, social and financial support). The Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) were administered to evaluate for depression and anxiety. Frequency and proportions for categorical variables and median and interquartile ranges for continuous variables were calculated.

RESULTS

Fifty-five PLWE participated (95 % response rate). Median age was 40 years (IQR 31.5-66.5), 61.8 % were women, 47.3 % had a bachelor's degree or higher and 29.1 % each had Medicaid and Medicare insurance. Race (from highest to lowest %) was: 32.7 % White, 20 % Black, 20 % Latinx, 14.5 % Asian, and 12.7 % selected "other" or "prefer not to say." COVID-19 had been diagnosed in 21.8 % of participants. Symptoms of anxiety and depression were self-reported by 43.6 % and 34.5 % of patients, respectively, with many describing this symptom as new post-pandemic (37.5 % and 31.6 %, respectively). Using validated scales, 52.7 % had depression (PHQ-9 score ≥ 5) with 30.9 % having moderate/severe depression (PHQ-9 score ≥ 10), while 29.1 % had probable generalized anxiety disorder (GAD-7 score ≥ 8). Seizure burden increased in 21.8 % of participants, while 20 % reported fewer seizures and 29.1 % were seizure free since the COVID-19 pandemic. Economic impacts of the pandemic included job loss (25 % amongst those employed at onset of pandemic), new or worsened financial difficulties (40 %), and new or worsened social support issues (30.9 %). Of all participants, 18.2 % reported difficulties accessing ASMs and 25.5 % cancelled visits, but of those with cancelled visits, 78.6 % had their appointments rescheduled as a telehealth visit.

CONCLUSION

Our cohort of PLWE experienced some challenges during the COVID-19 pandemic including poorer mental health and financial and employment-related stressors. Encouragingly, healthcare access was relatively spared during the COVID-19 crisis, with some patients even reporting a reduction in seizure burden. However, PLWE require ongoing psychosocial support with particular attention to decompensation of mental health and social stressors that may be exacerbated by the COVID-19 pandemic.

Novel high throughput screen reports that benzo(a)pyrene overrides mouse trophoblast stem cell multipotency, inducing SAPK activity, HAND1 and differentiated trophoblast giant cells

INTRODUCTION

Cultured mouse trophoblast stem cells (mTSC) maintain proliferation/normal stemness (NS) under FGF4, which when removed, causes normal differentiation (ND). Hypoxic, or hyperosmotic stress forces trophoblast giant cells (TGC) differentiate. Hypoxic, hyperosmotic, and genotoxic benzo(a)pyrene (BaP), which is found in tobacco smoke, force down-regulation of inhibitor of differentiation (Id)2, enabling TGC differentiation. Hypoxic and hyperosmotic stress induce TGC by SAPK-dependent HAND1 increase. Here we test whether BaP forces mTSC-to-TGC while inducing SAPK and HAND1.

METHODS

Hand1 and SAPK activity were assayed by immunoblot, mTSC-to-TGC growth and differentiation were assayed at Tfinal after 72hr exposure of BaP, NS, ND, Retinoic acid (RA), or sorbitol. Nuclear-stained cells were micrographed automatically by a live imager, and assayed by ImageJ/FIJI, Biotek Gen 5, AIVIA proprietary artificial intelligence (AI) software or open source, CellPose artificial intelligence/AI software.

RESULTS

BaP (0.05-1μM) activated SAPK and HAND1 without diminishing growth. TSC-to-TGC differentiation was assayed with increasingly accuracy for 2-4 N cycling nuclei and >4 N differentiating TGC nuclei, using ImageJ/FIJI, Gen 5, AIVIA, or CellPose AI software. The AIVIA and Cellpose AI software matches human accuracy. The lowest BaP effects on SAPK activation/HAND1 increase are >10-fold more sensitive than similar effects for mESC. RA induces 44-47% 1st lineage TGC differentiation, but the same RA dose induces only 1% 1st lineage mESC differentiation.

DISCUSSION

First, these pilot data suggest that mTSC can be used in high throughput screens (HTS) to predict toxicant exposures that force TGC differentiation. Second, mTSC differentiated more cells than mESC for similar stress exposures, Third, open source AI can replace human micrograph quantitation and enable a miscarriage-predicting HTS.

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

BACKGROUND

Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.

METHODS

This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.

RESULTS

The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.

CONCLUSION

Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.

Rapid nongenomic estrogen signaling controls alcohol drinking behavior

The sex steroid hormone estrogen is a key modulator of numerous physiological processes and adaptive behaviors, but it may also be co-opted to drive maladaptive behaviors. While many behavioral roles for estrogen signaling have been shown to occur through canonical genomic signaling mechanisms via nuclear receptors, estrogen can also act in a neurotransmitter-like fashion at membrane-associated estrogen receptors to rapidly regulate neuronal function. Early alcohol drinking confers greater risk for alcohol use disorder in women than men, and binge alcohol drinking is correlated with high circulating estrogen but a causal role for estrogen in alcohol drinking has not been established. Here, we demonstrate that gonadally intact female mice consume more alcohol and display an anxiolytic phenotype when they have elevated levels of ovarian-derived estrogen across the estrous cycle. We found that rapid, nongenomic estrogen signaling at membrane-associated estrogen receptor alpha in the bed nucleus of the stria terminalis (BNST) is necessary and sufficient for the pro-alcohol drinking effects of ovarian estrogen signaling, regardless of the transcriptional program of a high ovarian estrogen state. We further show that a population of corticotropin-releasing factor (CRF) BNST neurons (BNSTCRF) is a critical mediator of these effects, as high estrogen rapidly enhances synaptic excitation of BNSTCRF neurons and promotes their role in driving binge alcohol drinking. These findings show a causal role for endogenous, ovarian-derived estrogen in hormonal modulation of risky alcohol consumption and provide the first demonstration of a purely rapid, nongenomic signaling mechanism of ovarian estrogen in the brain controlling behavior in gonadally intact females.

Novel Approaches to Sleep Apnea in Heart Failure

Sleep apnea is a serious comorbid condition affecting patients with heart failure. Present in 50% to 75% of heart failure patients, it is often underrecognized, underdiagnosed, and undertreated. Patients with sleep apnea and heart failure are at increased risk of adverse cardiovascular events and sudden death. Treatment of sleep apnea has shown mixed results in reduction of adverse outcomes by sleep apnea type and intervention strategy. Evolving home-based technologies and device therapies present an exciting frontier for patients with sleep apnea and heart failure and an opportunity to improve outcomes. This article reviews novel approaches to sleep apnea in heart failure.

Plummeting toxic contaminates from water through phycoremediation: Mechanism, influencing factors and future outlook to enhance the capacity of living and non-living algae

Freshwater habitats hold a unique role in the survival of all living organisms and supply water for drinking, irrigation, and life support activities. In recent decades, due to anthropogenic activities, deterioration in the water quality has been a long-lasting problem and challenge to the scientific fraternity. Although, these freshwater bodies have a bearable intrinsic capacity for pollution load however alarming increase in pollution limits the intrinsic capacities and requires additional technological interventions. The release of secondary pollutants from conventional interventions further needs revisiting the existing methodologies and asking for green interventions. Green interventions such as phycoremediation are natural, eco-friendly, economic, and energy-efficient alternatives and provide additional benefits such as nutrient recovery, biofuel production, and valuable secondary metabolites from polluted freshwater bodies. This systemic review in a nut-shell comprises the recent research insights on phycoremediation, technological implications, and influencing factors, and further discusses the associated mechanisms of metal ions biosorption by living and non-living algae, its advantages, and limitations. Besides, the article explores the possibility of future research prospects for applicability at a field scale that will help in the efficient utilization of resources, and improved ecological and health risks.

Effect of premature loss of primary teeth on prevalence of malocclusion in permanent dentition: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to assess the effect of premature loss of primary teeth in children of mixed dentition age on the prevalence of malocclusion in permanent dentition.

MATERIAL AND METHODS

A search was conducted in Medline through PubMed, Cochrane databases, Google Scholar, and Directory of Open Access Journals (DOAJ) through March 2023. All observational studies that evaluated the association between premature loss of primary teeth and malocclusion in permanent dentition were included for analysis. Quality of studies was evaluated using the Newcastle-Ottawa tool. Meta-analysis was conducted using Cochrane Review Manager (RevMan) Version 5.3. The association between different categories of malocclusion and premature loss of primary teeth was assessed using a random-effects model. Heterogeneity was explored through sensitivity analysis. Certainty of evidence was evaluated using GRADE analysis.

RESULTS

This meta-analysis showed that the premature loss of primary teeth significantly increases the prevalence of overall malocclusion in permanent dentition (OR=2.54, P=0.003; I2: 83%). Subgroup analysis showed an insignificant relationship of premature loss of primary teeth with Class I malocclusion (OR=1.14, P=0.45; I2: 63%) and Class II malocclusion (OR=1.63, P=0.18; I2: 87%) but statistically significant relationship with Class III malocclusion (OR=3.73, P=0.006; I2: 71%). Sensitivity analysis reflected a significant reduction in I2 values.

CONCLUSION

This meta-analysis provides substantial evidence supporting the relationship between premature loss of primary teeth and malocclusion in permanent dentition. Notably, Class III malocclusions exhibited a significant association with premature loss of primary teeth.

IMPACT OF MOTHER'S HYPOTHYROIDISM ON FETAL DEVELOPMENT AND OUTCOMES: A SYSTEMATIC REVIEW

The thyroid, a gland with a butterfly-like shape in the base of the human neck, plays an important role in metabolism. Body heat, energy levels, weight, hair, fingernail, and regular menstruation cycles are controlled by three hormones produced by the thyroid. A system of feedback regulates the release of those hormones. Overproduction as well as underproduction of thyroid hormones can result from shifts in the stimulation and regulation of those hormones. These factors can have physiological or pathological origins. Pregnancy is a physiological factor. There is a plethora of physiological and psychological shifts that occur during pregnancy. A thyroid alteration in the mother is one example. Thyroid irregularities result from a failure to adjust to new circumstances. Thyroid hormone levels can drop, or manufacturing could be slowed during pregnancy due to variations in hormone concentration. Hypothyroidism describes this disorder. Hypothyroidism in women who are pregnant is either gestational or could be a disorder that is present before pregnancy. Gestational hypothyroidism cures itself throughout postpartum times, though it can stay as subclinical hyperthyroidism for some time after delivery. They pose a serious risk to development, stunt the growth of the unborn child and lead to defects in subsequent generations. Enhanced thyroid binding globulin levels, enhanced iodine clearance by the kidneys, modified effects of the human reproductive hormone and reduced dietary consumption of iodine lead to these alterations in the gland. Cretinism and mental disorders are among the serious health problems related to an iodine imbalance in maternal hypothyroidism. The growth of the brain, nervous system and Intelligence of an unborn child depends on thyroid hormones. As a result, normal early stages of development suffer due to changes in maternal hormone levels.

A LONGITUDINAL STUDY OF CHILDHOOD SEPARATION ANXIETY DISORDER AND ITS IMPLICATIONS FOR ADOLESCENT PSYCHOPATHOLOGY

A prevalent psychiatric disorder called Child Separation Anxiety Disorder (SAD) is characterized by extreme discomfort when a child gets separated from their primary carers. While SAD's quick consequences on kids are well-researched, its long-term implications for teenage psychopathology have received less attention. This longitudinal study aims to ascertain the connection between child SAD and future psychopathological consequences in adolescents. 500 adolescents were chosen as part of the adolescent depression project, and at the age of 17, we retrospectively evaluated past and present mental disorders. At ages 25 and 32, they conducted diagnostic evaluations of these people during adolescence while they continued to monitor them. Based on childhood/adolescent assessments, the participants were split into different groups: SAD (n=34), other forms of Anxiety (n=76), a control group with combined psychiatric conditions (n=205), and mentally sound control group (n=185). Statistics were evaluated by hierarchical multiple logistic regression after various illnesses and pertinent demographic variables were considered. It implies that SAD has a high risk (80.2%) of being a significant risk indicator for the emergence of mental illnesses in young adults. This study highlights the importance of early SAD management and therapy and the possible advantages of treating SAD in lowering the likelihood of developing other mental health problems in adolescence. It also emphasizes the value of continuous studies to comprehend these connections and enhance the effects on SAD sufferers' psychological well-being.

DENTAL CAVITIES IN PEOPLE WITH TYPE 2 DIABETES MELLITUS: AN ANALYSIS OF RISK INDICATORS

Diabetes is associated with a greater number of dental cavities. It is unclear, therefore, how potential risk factors such as salivary glucose, glycemic control and blood sugar could impact the onset of dental caries between people that have type 2 diabetes (T2D). Aim of the study - analyzing the risk factors for oral cavity disease in T2D patients. We analyzed the patient data including their dietary habits, dental hygiene practices, age and control of glycemic. The Indian dataset was used. Individual patient observations include the patient's diabetes classification as a range of medical attributes such as age, pregnancy, pedigree, glucose, body mass index, skin, blood pressure and insulin. The research discovered a significant correlation between poorly managed glycemic levels and dental caries are more prevalent in people with T2DM. High sugar consumption and poor oral hygiene habits have been identified as risk factors. These results highlight the need for integrating diabetes treatment measures with dental care to reduce dental caries in this susceptible group. Utilizing dental cavities into account improves oral health and has a positive impact on health outcomes for those with type 2 diabetes.

EMERGING NATIONS' LEARNING SYSTEMS AND THE COVID-19 PANDEMIC: AN ANALYSIS

National learning systems improve training and proficiency. In order to support education during the COVID-19 epidemic, the rate of online and remote learning accelerated. Since there were some available technologies, strong, flexible educational infrastructures were required to accommodate a range of student demands. Digital resources and inclusive education need government investment. This study highlights the vital role that adaptable educational frameworks play in lessening the effects of the crisis and fostering resilience in the face of uncertainty by examining the complex relationship between the COVID-19 pandemic and the creation of national education methodologies. This study offers a detailed analysis of the intricacy, challenges, and opportunities that have emerged in this significant field by investigating the ways in which the COVID-19 pandemic has affected educational institutions in developing countries. Twenty selected, peer-reviewed scientific journal articles from 2019 to 2023 were included in the research after a comprehensive search of relevant literature. Taking into consideration the viewpoints of parents, children, teachers, and administrators, this extensive and professionally handled research study provides a critical and nuanced examination of many consequences of the COVID-19 epidemic on the educational system. By using a comprehensive analysis of 25 academic articles, it achieves this. A broad number of useful tools and tactics are highlighted in this research, which offers an in-depth analysis of the intricate area of information and computational model deployment. Employing analysis of variance (ANOVA) as a robust statistical method, this analysis uncovers and scrutinizes the complex dynamics at play with the educational systems of developing nations amidst the unprecedented challenges brought by the global COVID-19 crisis. The COVID-19 epidemic has spurred rising countries to rethink and improve their education institutions, accelerating technology-driven education. The epidemic has underlined the need for inclusive and resilient learning infrastructures that respond to emergencies despite the digital device and access inequities.

Outcomes of mechanical thrombectomy in orally anticoagulated patients with anterior circulation large vessel occlusion: a propensity-matched analysis of the Imperial College Thrombectomy Registry

BACKGROUND

Mechanical thrombectomy (MT) remains an effective treatment for patients with acute ischemic stroke receiving oral anticoagulation (OAC) and large vessel occlusion (LVO). However, to date, it remains unclear whether MT is safe in patients on treatment with OAC.

AIMS

In our study, we performed a propensity-matched analysis to investigate the safety and efficacy of MT in patients with acute ischemic stroke receiving anticoagulants. A propensity score method was used to target the causal inference of the observational study design.

METHODS

This observational, prospective, single-centre study included consecutive patients with acute LVO ischemic stroke of the anterior circulation. Demographic, neuro-imaging and clinical data were collected and compared according to the anticoagulation status at baseline, patients on OAC vs those not on OAC. The primary study outcomes were the occurrence of any intracerebral haemorrhage (ICH) and symptomatic ICH. The secondary study outcomes were functional independence at 90 days after stroke (defined as modified Rankin Scale (mRS) scores of 0 through 2), mortality at 3 months and successful reperfusion rate according to the modified treatment in cerebral infarction (mTICI) score.

RESULTS

Overall, our cohort included 573 patients with acute ischemic stroke and LVO treated with MT. After propensity score matching, 495 patients were matched (99 OAC group vs 396 no OAC group). There were no differences in terms of clinical characteristics between the two groups, except for the rate of intravenous thrombolysis less frequently given in the OAC group. There was no significant difference in terms of the rate of any ICH and symptomatic ICH between the two groups. With regards to the secondary study outcome, there was no significant difference in terms of the rate of successful recanalization post-procedure and functional independence at 3 months between the two groups. Patients in the OAC group showed a reduced mortality rate at 90 days compared to the patients with no previous use of anticoagulation (20.2% vs 21.2%, p = 0.031). Logistic regression analysis did not reveal a statistically significant influence of the anticoagulation status on the likelihood of any ICH (OR = 0.95, 95% CI = 0.46-1.97, p = 0.900) and symptomatic ICH (OR = 4.87, 95% CI = 0.64-37.1, p = 0.127). Our analysis showed also that pre-admission anticoagulant use was not associated with functional independence at 90 days after stroke (OR = 0.76, 95% CI = 0.39-1.48, p = 0.422) and rate of successful reperfusion (OR = 0.81, 95% CI = 0.38-1.72, p = 0.582).

CONCLUSION

According to our findings anticoagulation status at baseline did not raise any suggestion of safety and efficacy concerns when MT treatment is provided according to the standard guidelines. Confirmation of these results in larger controlled prospective cohorts is necessary.

RELEVANCE FOR DIAGNOSIS, THERAPY, AND STRATEGIES OF GUT MICROBES DYSBIOSIS IN CHRONIC KIDNEY DISEASE: A SYSTEMATIC REVIEW

Dysbiosis and weakened gastrointestinal barrier function have been identified as potential regulators of Chronic Kidney Disease (CKD). The complex connection among gut micro biota and CKD is provided in this study, with particular attention to how inflammation contributes to the CKD path physiology. It establishes the inverse association between CKD and gut microbial dysbiosis by exploring the collision of CKD about the organization and capabilities of the gut micro biota. The possibility of new diagnostic tools in measuring the dynamic changes within the gut microbial ecology illustrates the importance of accurately diagnosing gut micro biota abnormalities in CKD. Additionally, the study explores the targeted medicines that focus on gut micro biota in CKD. Using data from both human clinical trials and rat models, the study demonstrates the variety of therapeutic approaches and their ability to limit the rate of development of CKD and its accompanying problems. The study we performed was based on the Preferred Reporting Items for Systematic reviews and Meta Analyses (PRISMA) approach. The findings show the significance of investigating the relationship between gut micro biota and CKD, paving up the possibility for new therapeutic strategies to improve the patient outcomes and quality of life. The present understanding of CKD-induced modifications to the gut micro biota and the ensuing effects on gastrointestinal health, emphasizing studies, will be highlighted in this review.

AN IN-DEPTH ASSESSMENT OF THE TUMOR'S IMPACT ON SARCOPENIA

Loss of muscle mass is a typical symptom of cancer and it is strongly correlated with poor prognosis. Cancer-related Sarcopenia is unresponsive to conventional dietary changes and exercise, in contrast to age-associated muscle atrophy. This particular type of weakness differs from different kinds of muscle loss in that it is triggered by a number of interrelated mechanisms, notably inflammatory processes, abnormal metabolic processes, proteolysis, and autophagy. This research is to examine evidence supporting the theory that tumors have a causal role in causing muscular atrophy. It seeks to investigate the precise regulators that the tumour generates and how they affect the processes that result in muscle waste. The evaluation looks for new directions for further studies and medical treatments. The analysis is based on a thorough examination of the scientific literature and research that shows how tumor and muscle atrophy are related. It concentrates on studies that clarify the numerous strategies by which malignancies cause the loss of muscle. This article highlights particular mechanisms by which these tumor-derived substances affect the development of muscle loss, including inflammatory processes, metabolic disturbance, proteolysis, and autophagy. The discovery of such targets offers hope for the creation of efficient treatment strategies that can enhance the long-term outlook and quality of life of cancer sufferers who are experiencing muscle loss.

Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the pediatric population: A systematic review and meta-analysis of the adverse outcomes

Purpose

Fractures of the femoral diaphysis are associated with a risk of morbidity in children. Various fixation methods have been developed, but with only limited evidence to support their use. This systematic review assesses the evidence regarding clinical outcomes of closed femoral diaphyseal fractures in children treated with plate fixation or flexible intramedullary nails.

Methods

A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis were conducted. MEDLINE, Embase, and Web of Science (WoS) databases were searched from inception to February 2023. Inclusion criteria included clinical studies reporting adverse outcomes following surgical treatment of pediatric closed femoral diaphyseal fractures using plate fixation and flexible intramedullary nails. The ROBINS-I and RoB 2 tools evaluated the risk of bias.

Results

Thirteen papers (2 prospective randomized controlled trials and 11 retrospective cohorts) reported 805 closed diaphyseal femoral fractures in 801 children (559 males, 242 females). There were 360 plate fixations and 445 flexible intramedullary nails. Two cases of osteomyelitis and one nonunion were reported. Meta-analysis showed that plate fixation had a lower risk of soft tissue infection (relative risk 0.26 (95% confidence interval 0.07-0.92)). There was no difference in the following outcomes: malunion (relative risk 0.68 (95% confidence interval 0.32-1.44)); unplanned reoperation (relative risk 0.59 (95% confidence interval 0.31-1.14)), and leg-length difference (relative risk 1.58 (95% confidence interval 0.66-3.77)). The risk of bias was high in all studies.

Conclusions

An analysis of 805 fractures with minimal differences in meta-analyses is considered high quality even when the quality of the evidence is low. The findings are limited by important flaws in the methodology in the published literature. Well-designed multicentre prospective studies using standardized core outcomes are required to advise treatment recommendations.

Level of evidence

III.

Design and development of benzyl piperazine linked 5-phenyl-1,2,4-triazole-3-thione conjugates as potential agents to combat Alzheimer's disease

Our present work demonstrates the molecular hybridization-assisted design, synthesis, and biological evaluation of 22 benzylpiperazine-linked 1,2,4-triazole compounds (PD1-22) as AD modifying agents. All the compounds were tested for their in vitro hChEs, hBACE-1, and Aβ-aggregation inhibition properties. Among them, compound PD-08 and PD-22 demonstrated good hChE and hBACE-1 inhibition as compared to standards donepezil and rivastigmine. Both compounds displaced PI from PAS at 50 µM concentration which was comparable to donepezil and also demonstrated anti-Aβ aggregation properties in self- and AChE-induced thioflavin T assay. Both compounds have shown excellent BBB permeation via PAMPA-BBB assay and were found to be non-neurotoxic at 80 µM concentration against differentiated SH-SY5Y cell lines. Compound PD-22 demonstrated an increase in rescued eye phenotype in Aβ-phenotypic drosophila AD model and amelioration of behavioral deficits in the Aβ-induced rat model of AD. The in-silico docking studies of compound PD-22 revealed a good binding profile towards CAS and PAS residues of AChE and the catalytic dyad of the BACE-1. The 100 ns molecular dynamics simulation studies of compound PD-22 complexed with AChE and BACE-1 enzymes suggested stable ligand-protein complex throughout the simulation run. Based on our findings compound PD-22 could further be utilized as a lead to design a promising candidate for AD therapy.

EXPLORING MEDICAL STUDENTS' COMPETENCY IN UNDERSTANDING PRIMARY IMMUNODEFICIENCY DISEASES IN INDIA

Primary Immunodeficiency Disease (PID) represents a class of diverse illnesses marked by compromised immune system performance. For better patient outcomes, PIDs must be diagnosed and treated quickly. Medical graduates are essential to the detection and treatment of these illnesses. The purpose of this study was to evaluate medical students' knowledge about PIDs in different Indian medical colleges. To perform this analytical investigation, college students from Maharashtra-area universities were enlisted between March and April of 2023. The participants received a questionnaire from mediators from every institution. Of the 500 students in the study, 66% were between the ages of 22 and 24 and 52% were female. Their understanding ratings had an average of 16.3±6.2 and varied between 4 and 32. A set of students classified as below average (86%) and a mean/above average (14%), were separated among the students. The largest percentage of above-average knowledge was demonstrated by VI-year participants (p<0.05). This investigation emphasizes how critical it is to provide focused educational activities to improve medical students' comprehension of PIDs in India.

COVID-19 SAFETY MEASURES AND THEIR EFFECTS ON GAMBLING HABITS: AN INVESTIGATIVE STUDY

This study looked at the way COVID-19 was starting to affect gambling during first six weeks of emergency actions. The following factors were evaluated: the economic effect of COVID-19 on internet gambling, according to COVID-19, psychological issues, addiction to drugs, and risky gambling habits and intentions. Online survey with cross-sectional data of 2015 gamblers was conducted, with a subsample of 1048 people who gambled online (age 18 and older). Numerous metrics of correlation and probability ratio analyses were performed. The Issue of Gambling Intensity Index's extremely dangerous gamblers and those who have gambled online are more likely to engage in gambling online, according to the outcomes, even though there was an obvious transition toward physical gaming. The most predicted indicators for high-risk gamblers on the internet were moderate to severe depression and anxiety, reduced work weeks, convincing themselves to gamble by COVID-19, gambling under the effects of alcohol or cannabis, and dangerous gambling motivations related to psychological disorders, such as gambling to relieve anxiety and depressive disorders, chasing gambling damages, and trying to make money from gambling. This research has validated numerous risk connections associated with gambling risk, psychological issues, and substance use reported in previous studies on the worldwide recession and upcoming COVID-19-related investigations. In contrast to many other inquiries, the current research considers each component comprehensively. It offers more information on the risk factors associated with online gambling throughout the epidemic.

Critical Evaluation of Lateral Calcaneal Artery Fascio-Cutaneous Flap in Re-Surfacing Posterior Heel Defects: A Review of 24 Cases

Purpose and background

To assess feasibility and functional acceptability of lateral calcaneal artery fascio-cutaneous flap (LCAFCF) in providing cover to posterior heel defects in single stage.

Aims and objectives

To provide stable and sensate cover to small and moderate posterior heel defects.

Materials and methods

This review was conducted in department of Burns & Plastic Surgery of Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana between October 2021 and September 2022 to analyse the clinical outcome of LCAFCF in 24 patients (18 males, 6 females) aged between 20 and 35 years who had chronic dry wounds n = 9, failed primary reconstruction by reverse sural flap n = 1, granulated wounds n = 8, exposed achilles tendons n = 4 and scarred tissue restricting ankle joint movements n = 2 in region of posterior heel following trauma, while riding motor-cycle. Course of lateral calcaneal artery was marked with hand-held doppler. Flap size ranged from 3 to 3.5 cm in width and 5.5-7.5 cm length. The donor sites were split skin grafted. Sutures were removed on 22nd day of surgery. Mean follow up was 13 months.

Results

All flaps survived. Two had partial loss of skin graft and two developed hyperkeratosis on grafted site. Sensations in flap, regain of movements of ankle joint, comfort of walking and driving were acceptable.

Conclusions

LCAFCF is handy, safe and reliable flap for re-surfacing difficult wounds of posterior heel, therefore should be included in surgical armamentarium.

Hepatic lobectomy in dogs using a stapling device with a vascular cartridge: a retrospective study of 13 cases

CASE HISTORY

Medical records of two veterinary hospitals in Canada were reviewed to identify cases of dogs that underwent liver lobectomy via open laparotomy using the Endo GIA surgical stapling device with a vascular cartridge (height of open and closed staples: 2.5 and 1.0 mm, respectively) between January 2016 and June 2018. Mean age at the time of surgery of the dogs (n = 13) included in the study was 10.4 (SD 1.5; min 7.9, max 12.8) years and mean body weight was 14 (min 3.9, max 37.8) kg.

CLINICAL FINDINGS

Liver masses requiring hepatic lobectomy were identified in 12 dogs by abdominal ultrasound examination. The remaining dog required a lobectomy of the right medial liver lobe to address leakage from the right medial lobe hepatic duct that occurred as a complication of cholecystectomy to treat a ruptured gallbladder mucocoele.

TREATMENT AND OUTCOME

Complete liver lobectomy of 14 lobes (11 from the left hepatic division) in 12 dogs and partial lobectomy of one lobe in one dog was performed via open laparotomy using the Endo GIA device. The mean surgical time, including concurrent procedures, was 50 (SD 17; median 45, min 28, max 91) minutes. The most common intra-operative complication was oozing from the transected liver parenchyma in 6/13 dogs, which was mild in all cases. Five dogs experienced minor post-operative complications. No major peri- or post-operative complications occurred, and no patients required surgical re-exploration. All patients survived until discharge and were alive at the 2-week follow-up for suture removal.

CLINICAL RELEVANCE

Use of the Endo GIA stapling device with a vascular cartridge is feasible for liver lobectomy of the left hepatic division and in this study had low rates of intra-operative and post-operative complications. The Endo GIA stapling device is a viable option for this type of liver lobectomy in dogs. Though successful, the small number of central (two lobes) and right (one lobe) hepatic division lobectomies in this study precludes us from drawing definitive conclusions about the feasibility of this technique on these divisions.

Azimuthal Correlations within Exclusive Dijets with Large Momentum Transfer in Photon-Lead Collisions

The structure of nucleons is multidimensional and depends on the transverse momenta, spatial geometry, and polarization of the constituent partons. Such a structure can be studied using high-energy photons produced in ultraperipheral heavy-ion collisions. The first measurement of the azimuthal angular correlations of exclusively produced events with two jets in photon-lead interactions at large momentum transfer is presented, a process that is considered to be sensitive to the underlying nuclear gluon polarization. This study uses a data sample of ultraperipheral lead-lead collisions at sqrt[s_{NN}]=5.02  TeV, corresponding to an integrated luminosity of 0.38  nb^{-1}, collected with the CMS experiment at the LHC. The measured second harmonic of the correlation between the sum and difference of the two jet transverse momentum vectors is found to be positive, and rising, as the dijet transverse momentum increases. A well-tuned model that has been successful at describing a wide range of proton scattering data from the HERA experiments fails to describe the observed correlations, suggesting the presence of gluon polarization effects.

Measurement of the mass dependence of the transverse momentum of lepton pairs in Drell-Yan production in proton-proton collisions at s=13TeV

The double differential cross sections of the Drell-Yan lepton pair (ℓ + ℓ - , dielectron or dimuon) production are measured as functions of the invariant mass m ℓ ℓ , transverse momentum p T ( ℓ ℓ ) , and φ η ∗ . The φ η ∗ observable, derived from angular measurements of the leptons and highly correlated with p T ( ℓ ℓ ) , is used to probe the low-p T ( ℓ ℓ ) region in a complementary way. Dilepton masses up to 1Te V are investigated. Additionally, a measurement is performed requiring at least one jet in the final state. To benefit from partial cancellation of the systematic uncertainty, the ratios of the differential cross sections for various m ℓ ℓ ranges to those in the Z mass peak interval are presented. The collected data correspond to an integrated luminosity of 36.3fb - 1 of proton-proton collisions recorded with the CMS detector at the LHC at a centre-of-mass energy of 13Te V . Measurements are compared with predictions based on perturbative quantum chromodynamics, including soft-gluon resummation.

The role of dexmedetomidine in post cranioplasty refractory status epilepticus

Cranioplasty, specifically a repair of the skull defect resulting from a previous decompressive craniectomy, is a relatively simple procedure associated with a minimal rate of complications. Even though seizures are seen in up to 30% of the patients postoperatively, status epilepticus is not commonly described. Cerebral oedema, ischaemia and neuro-inflammation have been reported as putative causes of seizures in this population. Here, we report a case of refractory status epilepticus unresponsive to standard anti-epileptic and anaesthetic agents. The use of dexmedetomidine helped terminate the episode and led to a favourable outcome. Most of the standard anti-epileptic and anaesthetic agents act through potentiation of GABAergic transmission or sodium channel blockade and postsynaptic adrenoceptor activation by dexmedetomidine may help potentiate their effect. Further studies are needed to investigate its anticonvulsant effect on post-traumatic brain injury and elaborate on optimal dosage.