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.

Early single-center experience with middle meningeal artery embolization using Zoom™ 45 Catheter

BACKGROUND

Middle meningeal artery (MMA) embolization for subdural hematomas (SDH) and dural arteriovenous fistulas (dAVFs) has gained momentum in the neuroendovascular space. However, there is variability in the technique for safe and effective embolization. The aim of this report is to describe the technical feasibility and clinical performance of using Zoom™ 45 catheter for MMA access to facilitate embolization.

METHODS

We analyzed all cases of MMA embolization in which the Zoom™ 45 catheter was used and performed in our institution from February 2021 to March 2023 for SDH and dAVFs.

RESULTS

A total of 32 patients were included. Mean age was 64.0 ± 18.0 years, 75.0% (4/32) were male, and 56.7% (17/30), were black. The technical success was achieved in 93.8% (30/32) of cases, with selective embolization utilizing microcatheter directly into frontal and parietal branches for most patients (96.9%, 31/32). Identification of dangerous collaterals, such as lacrimal and petrous branches, prior to embolization, was achieved in most patients (96.9%, 31/32). Bilateral MMA embolization was done in 50.0% (16/32) of patients. The transradial approach and transfemoral approach were used in 53.1% (17/32) and 46.9% (15/32) of patients, respectively. The most common embolization material was n-butyl cyanoacrylate (84.4%, 27/32). There were no access site complications or complications related to the MMA embolization procedures and used devices.

CONCLUSIONS

The use of Zoom™ 45 Catheter seems to be technically feasible, safe, and effective for facilitating MMA access for embolization in the context of SDH and dAVFs.

Implementation of a Real-Time Documentation Assistance Tool: Automated Diagnosis (AutoDx)

BACKGROUND

Clinical documentation improvement programs are utilized by most healthcare systems to enhance provider documentation. Suggestions are sent to providers in a variety of ways, and are commonly referred to as coding queries. Responding to these coding queries can require significant provider time and do not often align with workflows. To enhance provider documentation in a more consistent manner without creating undue burden, alternative strategies are required.

OBJECTIVE

The aim of this study is to evaluate the impact of a real-time documentation assistance tool, named AutoDx, on the volume of coding queries and encounter level outcome metrics, including case-mix index (CMI).

METHODS

The AutoDx tool was developed utilizing tools existing within the electronic health record, and is based on the generation of messages when clinical conditions are met. These messages appear within provider notes and required little to no interaction. Initial diagnoses included in the tool were electrolyte deficiencies, obesity, and malnutrition. The tool was piloted in a cohort of Hospital Medicine providers, then expanded to the Neuro Intensive Care Unit (NICU), with addition diagnoses being added.

RESULTS

The initial Hospital Medicine implementation evaluation 590 encounters pre and 531 post-implementation. The volume of coding queries decreased 57% (p < 0.0001) for the targeted diagnoses compared to 6% (p = 0.77) in other high volume diagnoses. In the NICU cohort 829 encounters pre-implementation were compared to 680 post. The proportion of AutoDx coding queries compared to all other coding queries decreased from 54.9% to 37.1% (p<0.0001). During the same period, CMI demonstrated a significant increase post-implementation (4.00 vs 4.55, p = 0.02).

CONCLUSIONS

The real-time documentation assistance tool led to a significant decrease in coding queries for targeted diagnoses in two unique provider cohorts. This improvement was also associated with a significant increase in CMI during the implementation time period.

Comparative Analysis of Clinical Severity and Outcomes in Penetrating Versus Blunt Traumatic Brain Injury Propensity Matched Cohorts

Traumatic brain injury (TBI) is a global health challenge; however, penetrating brain injury (PBI) remains under-represented in evidence-based knowledge and research efforts. This study utilized data from the Trauma Quality Improvement Program (TQIP) of the National Trauma Data Bank (NTDB) to investigate outcomes of PBI as compared with clinical-severity-matched non-penetrating or blunt TBI. A total of 1765 patients with PBI were 1:1 propensity score-matched for clinical severity with blunt TBI patients. The intent of PBI was self-inflicted in 34.1% of the cases, and the mechanism was firearm-inflicted in 89.1%. Mortality was found to be significantly more common in PBI than in the severity- matched TBI cohort (33.9% vs. 14.3 %, p < 0.001) as was unfavorable outcome. Mortality was mediated by withdrawal of life-sustaining therapies (WOLST) 30% of the time, and WOLST occurred earlier (median 3 days vs. 6 days, p < 0.001) in PBI. Increased rate of mortality was observed with a Glasgow Coma Scale (GCS) of <11 in PBI as compared with <7 in blunt TBI. In conclusion, PBI patients exhibited higher mortality rates and unfavorable outcomes; one third of excess mortality was mediated by WOLST. The study also brings into question the applicability of the conventional TBI classification, based on GCS, in PBI. We emphasize the need to address the observed disparities and better understand the distinctive characteristics and mechanisms underlying PBI outcomes to improve patient care and reduce mortality.

Checklist of monogeneans from Egyptian marine fishes, including some newly collected species

A checklist of 113 monogenean species parasitizing marine fishes (60 species) from different localities in Egypt is provided. The list is supplemented by eight newly collected monogenean species from Red Sea fishes, off Safaga and El-Quseir. Five of these species are new Egyptian records: Calydiscoides euzeti Justine, 2007, Calydiscoides rohdei Oliver, 1984, Lethrinitrema austrosinense (Li & Chen, 2005) Sun, Li & Yang, 2014, Pseudohaliotrema sphincteroporus Yamaguti, 1953, and Pentatres sphyraenae Euzet & Razarihelisoa, 1959. Furthermore, Lutjanus ehrenbergii (Peters), Lethrinus nebulosus (Forsskål), Lethrinus mahsena (Forsskål), Siganus stellatus (Forsskål), and Sphyraena flavicauda Rüppell represent new host records. The current study also lists nine monogenean species from the Gulf of Aqaba for which the coordinates of the sampling localities were not clearly defined, but which could also belong to the Egyptian fauna as the gulf is part of the Red Sea basin. Dactylogyrus aegyptiacus Ramadan, 1983 is transferred to Ecnomotrema Kritsky, 2023 as E. aegyptiacum (Ramadan, 1983) n. comb. Entobdella aegyptiacus Amer, 1990, Polylabroides aegyptiacus Mahmoud & Shaheed 1998, Gotocotyla sigani Abdel Aal, Ghattas & Badawy, 2001, Neohexostoma epinepheli Abdel Aal, Ghattas & Badawy, 2001, Neothoracocotyle commersoni Abdel Aal, Ghattas & Badawy, 2001, Acleotrema maculatum Morsy, El Fayoumi & Fahmy, 2014, Diplectanum harid Morsy, El Fayoumi, Al Shahawy & Fahmy, 2014, and Pseudorhabdosynochus chlorostigma Morsy, El Fayoumi, Al Shahawy & Fahmy, 2014, are considered species inquirendae. Paranaella diplodae Bayoumy, Abd El-Hady & Hassanain, 2007 is considered incertae sedis. Allencotyla lutini El-Dien, 1995 and Lamellodiscus diplodicus Bayoumy, 2003 are regarded as nomina nuda.

Endovascular Embolization of Traumatic Vessel Injury Using N-butyl Cyanoacrylate: A Case Series

There is limited evidence of N-butyl cyanoacrylate (n-BCA) use in endovascular embolization of traumatic face and neck vessel injuries. We investigated the safety and effectiveness of n-BCA for this purpose. We retrospectively analyzed consecutive patients presenting to a Level 1 trauma center between April 2021 and July 2022. We included patients aged ≥ 18 years old with any vessel injury in the face and neck circulation requiring n-BCA embolization. The primary endpoint was n-BCA effectiveness defined as immediate control of active bleeding post-embolization. In total, 13 patients met the inclusion criteria. The median decade of life was 3 (IQR 3 - 5) with a male predominance (n = 11, 84.6%). Median Glasgow Coma Scale score on presentation was 15 (IQR 3-15). Eleven patients suffered gunshot wound injuries; two patients suffered blunt injuries. Injured vessels included facial artery (n = 6, 46.2%), buccal branch artery (n = 3, 23.1%), internal maxillary (n = 5, 38.5%), cervical internal carotid artery (n = 1, 7.7%), and vertebral artery (n = 1, 7.7%). All patients were treated with 1:2 n-BCA to ethiodol mixture with immediate extravasation control. No bleeding recurrence or need for retreatment occurred. One patient died in-hospital (7.7%). Patients were discharged to home (n = 8, 61.5%), day rehabilitation (n = 1, 7.7%), or acute rehabilitation (n = 3, 23.1%). One patient developed a right posterior cerebral artery infarct with hemorrhagic transformation. To our knowledge, this is the first study demonstrating the safety and effectiveness of n-BCA liquid embolism in traumatic vessel injuries, especially penetrating gunshot wounds.

Comparative Effectiveness of Early Neurosurgical Intervention in Civilian Penetrating Brain Injury Management

BACKGROUND AND OBJECTIVES

To compare the outcomes of early vs no-neurosurgical intervention in civilians with penetrating brain injury (PBI).

METHODS

We collected data from the National Trauma Data Bank for PBI between 2017 and 2019. A total of 10 607 cases were identified; 1276 cases met the following criteria: age 16-60 years, an intensive care unit (ICU) length of stay (LOS) of >2 days, a Glasgow Coma Scale of 3-12, and at least one reactive pupil on presentation. Patients with withdrawal of life-sustaining treatments within 72 hours were excluded, leaving 1231 patients for analysis. Neurosurgical intervention was defined as an open-approach cranial procedure involving release, drainage, or extirpation of brain matter performed within 24 hours. Outcomes of interest were mortality, withdrawal of life-sustaining treatments, ICU LOS, and dispositional outcome.

RESULTS

The target population was 1231 patients (84.4% male; median [IQR] age, 29 [18] years); 267 (21.7%) died, and 364 (29.6%) had a neurosurgical intervention within the first 24 hours. 1:1 matching yielded 704 patients (352 in each arm). In the matched cohort (mortality 22.6%), 64 patients who received surgery (18.2%) died compared with 95 (27%) in the nonsurgical group. Survival was more likely in the surgical group (odds ratio [OR] 1.66, CI 1.16-2.38, P < .01; number needed to treat 11). Dispositional outcome was not different. Overlap propensity score-weighted analysis (1231 patients) resulted in higher odds of survival in the surgical group (OR 1.8, CI 1.16-2.80, P < .01). The E-value for the OR calculated from the matched data set was 2.83. Early neurosurgical intervention was associated with longer ICU LOS (median 12 days [7.0, 19.0 IQR] vs 8 days [4.0, 15.0 IQR], P < .05).

CONCLUSION

Management including early neurosurgical intervention is associated with decreased mortality and increased ICU LOS in matched cohorts of PBI.

The Zoom RDL radial access system for neurointervention: An early single-center experience

BACKGROUND

The transradial approach (TRA) for neurointerventional procedures is increasingly being used given its technical feasibility and safety. However, catheter trackability and device deliverability are reported barriers to TRA adoption.

METHODS

This is the first report describing the technical feasibility and performance of using the Zoom RDL Radial Access System (Imperative Care, Inc., Campbell, CA) in 29 patients who underwent neurointerventional procedures from October 2022 to January 2023 in a single-center institution.

RESULTS

Mean age of the study population was 61.9±17.2 years, 79.3% were male (23/29), and 62.1% were black (18/29). The most common procedures were stroke thrombectomy (31.0%, 9/29) and aneurysm embolization (27.6%, 8/29). All the stroke thrombectomy procedures were successfully performed; first-pass effect rate (mTICI≥2 c in one pass) was achieved in 66.7% (6/9) of cases. We used TRA in 86.2% of cases (25/29), including distal radial/snuffbox access in 31.0% (9/29) of cases. The radial diameter was >2 mm for all cases. An intermediate/aspiration catheter was used in 89.7% (26/29) of cases. Access success was achieved in 89.7% of cases (26/29); two cases required conversion from TRA to transfemoral approach (6.9%) and one case required conversion to a different guide catheter (3.4%). There were no access site complications or other Zoom RDL-related complications. One intracerebral hemorrhage, and one procedure-related thrombus were observed.

CONCLUSIONS

The use of Zoom RDL Radial Access System is technically feasible and effective for complex neurointerventional procedures with low complication rates.

The use of PK Papyrus covered coronary stent for carotid reconstruction: an initial institutional experience

BACKGROUND

The use of covered stent grafts for the treatment of carotid rupture is increasingly being used given their ability to preserve the parent artery while simultaneously occluding the fistula or rupture point.

METHODS

This case series describes the technical feasibility of using, and the performance of, the PK Papyrus covered coronary stent (Biotronik, Inc., Lake Oswego, Oregon, USA) in six patients with carotid rupture, including carotid cavernous fistulas, between July 2021 and October 2023 in a single-center institution in the USA.

RESULTS

The median decade of life was 5 (IQR 3) with a 1:1 male-to-female ratio. The majority were black patients (n=5/6, 83.3%). The most common disease pathology was carotid cavernous fistula (n=4/6, 66.7%), followed by traumatic carotid rupture (n=2/6, 33.3%). All the stent embolization procedures were successfully treated with the PK Papyrus covered coronary stent. None of the patients had any recurrence or re-treatment. The number of stents required ranged from 1 to 3. A balloon guide catheter was used in 66.7% of cases (n=4/6). In-hospital mortality was 0.0% (n=0/6). No in-stent thrombosis was observed, but there was one case of cangrelor-associated hemorrhagic stroke conversion. Transfemoral access was used in all cases with one access site complication. Median follow-up time was 1.8 months (IQR 3.5).

CONCLUSIONS

To our knowledge, this is the largest case series in the USA demonstrating the feasibility and safety of using the PK Papyrus covered coronary stent for the treatment of carotid rupture, including carotid cavernous fistulas.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Endovascular Thrombectomy With or Without Thrombolysis for Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

To this date, whether to administer intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT) for stroke patients still stirs some debate. We aimed to systematically update the evidence from randomized trials comparing EVT alone vs EVT with bridging IVT.

Methods

We searched MEDLINE, EMBASE, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT with or without IVT in patients presenting with stroke secondary to a large vessel occlusion. We conducted meta-analyses using random-effects models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH), between EVT and EVT with IVT. We assessed risk of bias using the Cochrane risk-of-bias tool and certainty of evidence for each outcome using the GRADE approach.

Results

Of 11,111 citations, we included 6 studies with a total of 2336 participants. We found low-certainty evidence of possibly a small decrease in the proportion of patients with functional independence (risk difference [RD] -2.0%, 95% CI -5.9% to 2.0%), low-certainty evidence that there is possibly a small increase in mortality (RD 1.0%, 95% CI -2.2% to 4.7%), and moderate-certainty evidence that there is probably a decrease in sICH (RD -1.0%, 95% CI -1.6% to .7%) for patients with EVT alone compared to EVT plus IVT, respectively.

Conclusion

Low-certainty evidence shows that there is possibly a small decrease in functional independence, low-certainty evidence shows that there is possibly a small increase in mortality, and moderate-certainty evidence that there is probably a decrease in sICH for patients with EVT alone compared to EVT plus IVT.

Endovascular Thrombectomy with or without Bridging Thrombolysis in Acute Ischemic Stroke: A Cost-Effectiveness Analysis

BACKGROUND

There is unclear added benefit of intravenous thrombolysis (IVT) with endovascular thrombectomy (EVT). We performed a cost-effectiveness analysis to assess the cost-effectiveness of comparing EVT with IVT versus EVT alone.

METHODS

We used a decision tree to examine the short-term costs and outcomes at 90 days after the occurrence of index stroke to compare the cost-effectiveness of EVT alone with EVT plus IVT for patients with stroke. Subsequently, we developed a Markov state transition model to assess the costs and outcomes over 1-year, 5-year, and 20-year time horizons. We estimated total and incremental cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio.

RESULTS

The average costs per patient were estimated to be $47,304, $49,510, $59,770, and $76,561 for EVT-only strategy and $55,482, $57,751, $68,314, and $85,611 for EVT with IVT over 90 days, 1 year, 5 years, and 20 years, respectively. The cost saving of EVT-only strategy was driven by the avoided medication costs of IVT (ranging from $8,178 to $9,050). The additional IVT led to a slight decrease in QALY estimate during the 90-day time horizon (loss of 0.002 QALY), but a small gain over 1-year and 5-year time horizons (0.011 and 0.0636 QALY). At a willingness-to-pay threshold of $50,000 per QALY gained, the probabilities of EVT only being cost-effective were 100%, 100%, and 99.3% over 90-day, 1-year, and 5-year time horizons.

CONCLUSION

Our cost-effectiveness model suggested that EVT only may be cost-effective for patients with acute ischemic stroke secondary to large vessel occlusion.

Intravenous cangrelor use for neuroendovascular procedures: a two-center experience and updated systematic review

Background

The optimal antiplatelet therapy regimen for certain neuroendovascular procedures remains unclear. This study investigates the safety and feasibility of intravenous dose-adjusted cangrelor in patients undergoing acute neuroendovascular interventions.

Methods

We conducted a retrospective chart review of all consecutive patients on intravenous cangrelor for neuroendovascular procedures between September 1, 2020, and March 13, 2022. We also conducted an updated systematic review and meta-analysis using PubMed, Scopus, Web of Science, Embase and the Cochrane Library up to February 22, 2023.

Results

In our cohort, a total of 76 patients were included [mean age (years): 57.2 ± 18.2, males: 39 (51.3), Black: 49 (64.5)]. Cangrelor was most used for embolization and intracranial stent placement (n = 24, 32%). Approximately 44% of our patients had a favorable outcome with a modified Rankin Scale (mRS) score of 0 to 2 at 90 days (n = 25/57); within 1 year, 8% of patients had recurrent or new strokes (n = 5/59), 6% had symptomatic intracranial hemorrhage [sICH] (4/64), 3% had major extracranial bleeding events (2/64), and 3% had a gastrointestinal bleed (2/64). In our meta-analysis, 11 studies with 298 patients were included. The pooled proportion of sICH and intraprocedural thromboembolic complication events were 0.07 [95% CI 0.04 to 1.13] and 0.08 [95% CI 0.05 to 0.15], respectively.

Conclusion

Our study found that intravenous cangrelor appears to be safe and effective in neuroendovascular procedures, with low rates of bleeding and ischemic events. However, further research is needed to compare different dosing and titration protocols of cangrelor and other intravenous agents.

Predictive Value of CT Biomarkers in Lung Transplantation Survival: Preliminary Investigation in a Diverse, Underserved, Urban Population

INTRODUCTION

Survival following lung transplant is low. With limited donor lung availability, predicting post-transplant survival is key. We investigated the predictive value of pre-transplant CT biomarkers on survival.

METHODS

In this single-center retrospective cohort study of adults in a diverse, underserved, urban lung transplant program (11/8/2017-5/20/2022), chest CTs were analyzed using TeraRecon to assess musculature, fat, and bone. Erector spinae and pectoralis muscle area and attenuation were analyzed. Sarcopenia thresholds were 34.3 (women) and 38.5 (men) Hounsfield Units (HU). Visceral and subcutaneous fat area and HU, and vertebral body HU were measured. Demographics and pre-transplant metrics were recorded. Survival analyses included Kaplan-Meier and Cox proportional hazard.

RESULTS

The study cohort comprised 131 patients, 50 women, mean age 60.82 (SD 10.15) years, and mean follow-up 1.78 (SD 1.23) years. Twenty-nine percent were White. Mortality was 32.1%. Kaplan-Meier curves did not follow the proportional hazard assumption for sex, so analysis was stratified. Pre-transplant EMR metrics did not predict survival. Women without sarcopenia at erector spinae or pectoralis had 100% survival (p = 0.007). Sarcopenia did not predict survival in men and muscle area did not predict survival in either sex. Men with higher visceral fat area and HU had decreased survival (p = 0.02). Higher vertebral body density predicted improved survival in men (p = 0.026) and women (p = 0.045).

CONCLUSION

Pre-transplantation CT biomarkers had predictive value in lung transplant survival and varied by sex. The absence of sarcopenia in women, lower visceral fat attenuation and area in men, and higher vertebral body density in both sexes predicted survival in our diverse, urban population.

Novel EEG Metric Correlates with Intracranial Pressure in an Animal Model

BACKGROUND

Intracranial pressure (ICP) can be continuously and reliably measured using invasive monitoring through an external ventricular catheter or an intraparenchymal probe. We explore electroencephalography (EEG) to identify a reliable real-time noninvasive ICP correlate.

METHODS

Using a previously described porcine model of intracranial hypertension, we examined the cross correlation between ICP time series and the slope of the EEG power spectral density as described by ϕ. We calculated ϕ as tan-1 (slope of power spectral density) and normalized it by π, where slope is that of the power-law fit (log frequency vs. log power) to the power spectral density of the EEG signal. Additionally, we explored the relationship between the ϕ time series and cerebral perfusion pressure. A total of 11 intracranial hypertension episodes across three different animals were studied.

RESULTS

The mean correlation between ϕ angle and ICP was - 0.85 (0.15); the mean correlation with cerebral perfusion pressure was 0.92 (0.02). Significant correlation occurred at zero lag. In the absence of intracranial hypertension, the absolute value of the ϕ angle was greater than 0.9 (mean 0.936 radians). However, during extreme intracranial hypertension causing cerebral circulatory arrest, the ϕ angle is on average below 0.9 radians (mean 0.855 radians).

CONCLUSIONS

EEG ϕ angle is a promising real-time noninvasive measure of ICP/cerebral perfusion using surface electroencephalography.

Machine and Deep Learning Approaches Applied to Classify Gougerot-Sjögren Syndrome and Jointly Segment Salivary Glands

To diagnose Gougerot-Sjögren syndrome (GSS), ultrasound imaging (US) is a promising tool for helping physicians and experts. Our project focuses on the automatic detection of the presence of GSS using US. Ultrasound imaging suffers from a weak signal-to-noise ratio. Therefore, any classification or segmentation task based on these images becomes a difficult challenge. To address these two tasks, we evaluate different approaches: a classification using a machine learning method along with feature extraction based on a set of measurements following the radiomics guidance and a deep-learning-based classification. We propose, therefore, an innovative method to enhance the training of a deep neural network with a two phases: multiple supervision using joint classification and a segmentation implemented as pretraining. We highlight the fact that our learning methods provide segmentation results similar to those performed by human experts. We obtain proficient segmentation results for salivary glands and promising detection results for Gougerot-Sjögren syndrome; we observe maximal accuracy with the model trained in two phases. Our experimental results corroborate the fact that deep learning and radiomics combined with ultrasound imaging can be a promising tool for the above-mentioned problems.

Tranexamic Acid, Mortality, and Intracranial Hemorrhage Type in Moderate or Severe Traumatic Brain Injury

This cohort study examines the association of tranexamic acid administration with intracranial hemorrhage type, neurologic outcomes, and mortality in patients with traumatic brain injury.

vNOTEsHC : Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopic for large uteri: study protocol for a multicentre randomised controlled trial

Background

In France, 62,000 hysterectomies are performed per year, 70% of which are benign. The choice of approach (laparotomy, laparoscopy or vaginal route) is particularly important in the case of large uterus (> 280g) which are associated with a higher risk of complications. The current data are not sufficient to favour one or other approach. A new medical device, the vNOTES (Natural Vaginal Orifice Transluminal Endoscopy System), offers the advantage of both laparoscopic and vaginal route for pelvic surgery.

Objectives

To demonstrate the superiority in terms of intraoperative and postoperative complications of the use of a natural orifice transluminal endoscopic hysterectomy system (vNOTES) versus laparoscopic hysterectomy for benign pathologies on estimated large volume uteri (>280g).

Materials and Methods

A randomised, double-blind, superiority trial will be performed at five hospital centres. Women with benign uterine pathology requiring hysterectomy and with a large uterus (> 280g) will be randomised to receive either laparoscopic or vNOTES hysterectomy.

Main outcome measures

The primary outcome will be the occurrence of intraoperative and postoperative complications within 6 weeks of surgery. Secondary outcomes will be conversion during surgery, duration of surgery and hospitalisation, postoperative pain, postoperative complications, resumption of sexual life and satisfaction with the surgical team.

Results

248 women will be randomised.

Conclusion

This trial will provide a better understanding of the approach to large uteri optimise the care of these thousands of women undergoing hysterectomy.

What’s new?

This trial will evaluate the vNotes for large uteri.

Advanced Topics and Smart Systems for Wireless Communications and Networks

Telecommunication has shaped our civilization and fueled economic growth significantly throughout human history [...].

Underlying intracranial atherosclerotic disease is associated with worse outcomes in acute large vessel occlusion undergoing endovascular thrombectomy

BACKGROUND

Data on large vessel occlusion (LVO) management due to intracranial atherosclerotic disease (ICAD) are scarce.

OBJECTIVE

To compare clinical outcomes between patients with ICAD and those without ICAD following mechanical thrombectomy (MT).

METHODS

We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center, and compared in-hospital mortality, 90-day mortality, favorable functional outcome at 90 days, and symptomatic intracranial hemorrhage (ICH) using chi-squared tests and multivariate logistic regression analyses. We defined ICAD as observable plaque at occlusion site post-thrombectomy.

RESULTS

Among 215 patients (mean age 67.1 ± 16.0 years; 60.5% female; 83.6% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p = 0.027 and 29.0% vs. 14.7%, p = 0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p = 0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p = 0.081). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p = 0.003 and 52.6% vs. 26.6%, p = 0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p = 0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4).

CONCLUSION

Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT.

Dirofilariasis mouse models for heartworm preclinical research

Introduction

Dirofilariasis, including heartworm disease, is a major emergent veterinary parasitic infection and a human zoonosis. Currently, experimental infections of cats and dogs are used in veterinary heartworm preclinical drug research.

Methods

As a refined alternative in vivo heartworm preventative drug screen, we assessed lymphopenic mouse strains with ablation of the interleukin-2/7 common gamma chain (γc) as susceptible to the larval development phase of Dirofilaria immitis.

Results

Non-obese diabetic (NOD) severe combined immunodeficiency (SCID)γc^-/- (NSG and NXG) and recombination-activating gene (RAG)2^-/-γc^-/- mouse strains yielded viable D. immitis larvae at 2-4 weeks post-infection, including the use of different batches of D. immitis infectious larvae, different D. immitis isolates, and at different laboratories. Mice did not display any clinical signs associated with infection for up to 4 weeks. Developing larvae were found in subcutaneous and muscle fascia tissues, which is the natural site of this stage of heartworm in dogs. Compared with in vitro-propagated larvae at day 14, in vivo-derived larvae had completed the L4 molt, were significantly larger, and contained expanded Wolbachia endobacteria titres. We established an ex vivo L4 paralytic screening system whereby assays with moxidectin or levamisole highlighted discrepancies in relative drug sensitivities in comparison with in vitro-reared L4 D. immitis. We demonstrated effective depletion of Wolbachia by 70%-90% in D. immitis L4 following 2- to 7-day oral in vivo exposures of NSG- or NXG-infected mice with doxycycline or the rapid-acting investigational drug, AWZ1066S. We validated NSG and NXG D. immitis mouse models as a filaricide screen by in vivo treatments with single injections of moxidectin, which mediated a 60%-88% reduction in L4 larvae at 14-28 days.

Discussion

Future adoption of these mouse models will benefit end-user laboratories conducting research and development of novel heartworm preventatives via increased access, rapid turnaround, and reduced costs and may simultaneously decrease the need for experimental cat or dog use.

Endovascular thrombectomy with or without thrombolysis bridging in patients with acute ischaemic stroke: protocol for a systematic review, meta-analysis of randomised trials and cost-effectiveness analysis

INTRODUCTION

Current published guidelines and meta-analyses comparing endovascular thrombectomy (EVT) alone versus EVT with bridging intravenous thrombolysis (IVT) suggest that EVT alone is non-inferior to EVT with bridging thrombolysis in achieving favourable functional outcome. Because of this controversy, we aimed to systematically update the evidence and meta-analyse data from randomised trials comparing EVT alone versus EVT with bridging thrombolysis, and performed an economic evaluation comparing both strategies.

METHODS AND ANALYSIS

We will conduct a systematic review of randomised controlled trials comparing EVT with or without bridging thrombolysis in patients presenting with large vessel occlusions. We will identify eligible studies by systematically searching the following databases from inception without any language restrictions: MEDLINE (through Ovid), Embase and the Cochrane Library. The following criteria will be used to assess eligibility for inclusion: (1) adult patients ≥18 years old; (2) randomised patients to EVT alone or to EVT with IVT; and (3) measured outcomes, including functional outcomes, at least 90 days after randomisation. Pairs of reviewers will independently screen the identified articles, extract information and assess the risk of bias of eligible studies. We will use the Cochrane Risk-of-Bias tool to evaluate risk of bias. We will also use the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty in evidence for each outcome. We will then perform an economic evaluation based on the extracted data.

ETHICS AND DISSEMINATION

This systematic review will not require a research ethics approval because no confidential patient data will be used. We will disseminate our findings by publishing the results in a peer-reviewed journal and via presentation at conferences.

PROSPERO REGISTRATION NUMBER

CRD42022315608.

Socioeconomic risk factors for low birth weight newborns: A population-based study

Low birth weight (LBW) is an important indicator of maternal health and poverty. This study explored the socioeconomic factors associated with LBW.

METHODS

Data was collected from a 4-year maternal-newborn registry.

RESULTS

There were 5,316 LBW and 54,029 normal birth weight (NBW). The prevalence of LBW was 9%. The Native women in the LBW group compared to non-native women were 10.4% (1784/5316) vs. 8.4% (3532/5316) with a P-value of 0.001. There were more illiterate mothers in the LBW compared to the NBW, respectively: 8.1% (1597/19497) vs. 7.5% (1763/23230) with a P-value of 0.001. Working mothers tend to have more LBW infants compared to mothers with NBW, 8.4% (1588/17217) vs. 7.9% (2532/31891) and P-value 0.001. Young mothers (<20 years old) with early childbearing had more LBW compared to older mothers, respectively 12.7% (180/1414) vs. 8.9% (5149/52919) P-value <0.001. Women with no antenatal care reported a high rate of LBW compared to women with regular antenatal care: 14.2% (516/3696) vs. 8.6% (4741/55691) P-value <0.001. LBW babies were born more from assisted conception pregnancies (38% compared to 8.4% of normal pregnancies) P-value <0.001. Smoking mothers scored higher with LBW at 13.6% vs. 8.3% and a P-value of 0.001. There were no differences between the two groups regarding religion, consanguinity, marital status, or family income.

CONCLUSION

Risk factors for low birth weight can be improved by providing antenatal care, smoking cessation, optimizing high-risk pregnancy care, and governing assisted reproduction regulations.

Establishment of an Electro-Optical Mixing Design on a Photonic SOA-MZI Using a Differential Modulation Arrangement

We design and evaluate two experimental systems for a single and simultaneous electro-optical semiconductor optical amplifier Mach-Zehnder interferometer (SOA-MZI) mixing system based on the differential modulation mode. These systems and the optimization of their optical and electrical performance largely depend on characteristics of an optical pulse source (OPS), operating at a frequency of f= 39 GHz and a pulse width of 1 ps. The passive power stability of the electro-optical mixing output over one hour is better than 0.3% RMS (root mean square), which is excellent. Additionally, we generate up to 22 dBm of the total average output power with an optical conversion gain of 32 dB, while achieving a record output optical signal to noise ratio (OSNR) up to 77 dB. On the other hand, at the SOA-MZI output, the 128 quadratic amplitude modulation (128-QAM) signal at an intermediate frequency (IF), f1, is up-mixed to higher output frequencies nf ± f1. The advantages of the resulting 128-QAM mixed signal during electrical conversion gains (ECGs) and error vector magnitudes (EVMs) are also evaluated. The performed empirical SOA-MZI mixing can operate up to 118.5 GHz in its high-frequency range. The positive and almost constant conversion gains are achieved. Indeed, the obtained conversion gain values are very close across the entire range of output frequencies. The largest frequency range achieved during experimental work is 118.5 GHz, where the EVM achieves 6% at a symbol rate of 10 GSymb/s. Moreover, the peak data rate of the 128-QAM up mixed signal can reach 70 GBit/s. Finally, the study of the simultaneous electro-optical mixing system is accepted with unmatched performance improvement.

Comparative Effectiveness of Intracranial Pressure Monitoring vs No Monitoring in Severe Penetrating Brain Injury Management

Importance

Civilian penetrating brain injury (PBI) is associated with high mortality. However, scant literature is available to guide neurocritical care monitoring and management of PBI.

Objective

To examine the association of intracranial pressure (ICP) monitoring with mortality, intensive care unit (ICU) length of stay (LOS), and dispositional outcomes in patients with severe PBI.

Design, Setting, and Participants

This comparative effectiveness research study analyzed data from the Trauma Quality Improvement Program of the National Trauma Data Bank in the US from January 1, 2017, to December 31, 2019. Patients with PBI were identified, and those aged 16 and 60 years who met these inclusion criteria were included: ICU LOS of more than 2 days, Glasgow Coma Scale (GCS) score lower than 9 on arrival and at 24 hours, and Abbreviated Injury Scale score of 3 to 5 for the head region and lower than 3 for other body regions. Patients with bilaterally fixed pupils or incomplete data were excluded. A 1:1 propensity score (PS) matching was used to create a subgroup of patients. Patients were divided into 2 groups: with vs without ICP monitoring. Data analysis was conducted between September and December 2022.

Exposures

Intracranial pressure monitoring vs no monitoring.

Main Outcomes and Measures

Outcomes were mortality, rate of withdrawal, ICU LOS, and dispositional outcome. Measures were age, initial systolic blood pressure, initial oxygen saturation level on a pulse oximeter, first-recorded GCS score, GCS score at 24 hours, Abbreviated Injury Scale score, midline shift, and pupillary reactivity.

Results

A total of 596 patients (505 males [84.7%]; mean [SD] age, 32.2 [12.3] years) were included, among whom 220 (36.9%) died and 288 (48.3%) had ICP monitoring. The PS matching yielded 466 patients (233 in each group with vs without ICP monitoring). Overall mortality was 35.8%; 72 patients with ICP monitoring (30.9%) died compared with 95 patients (40.8%) without ICP monitoring . Patients with ICP monitoring were more likely to survive (odds ratio [OR], 1.54; 95% CI, 1.05-2.25; P = .03; number needed to treat, 10). No difference in favorable discharge disposition was observed. The PS-weighted analysis included all 596 patients and found that patients with ICP monitoring were more likely to survive than those without (OR, 1.40; 95% CI, 1.10-1.78; P = .005). The E-value for the OR calculated from the PS-matched data set was 1.79. In addition, ICP monitoring vs no monitoring was associated with an increase in median (IQR) ICU LOS (15.0 [8.0-21.0] days vs 7.0 [4.0-12.0] days; P < .001).

Conclusions and Relevance

In this comparative effectiveness research study, PBI management guided by ICP monitoring was associated with decreased mortality and increased ICU LOS, challenging the notion of universally poor outcomes after civilian PBI. Randomized clinical trials that evaluate the efficacy of ICP monitoring in PBI are warranted.

Abstract TP135: Underlying Intracranial Atherosclerotic Disease Is Associated With Worse Outcomes In Acute Large Vessel Occlusion Undergoing Endovascular Thrombectomy

Introduction: Acute large vessel occlusion (LVO) can be secondary to thromboembolism or intracranial atherosclerotic disease (ICAD). Data on LVO management due to underlying ICAD are scarce. We hypothesized that patients with ICAD have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD.

Methods: We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between January 14, 2018 and October 24, 2021. Presence of ICAD at LVO site was determined by the interventionalist. We compared in-hospital mortality, 90-day mortality, and 90-day modified Rankin Scale (mRS) scores between those with and without ICAD, in unadjusted and adjusting logistic regression models.

Results: Among 215 patients (mean age 67.1±16.0 years; 60.5% female; 80.5% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p=0.027 and 29.0% vs. 14.7%, p=0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p=0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p=0.054). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p=0.003 and 52.6% vs. 26.6%, p=0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p=0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4).

Conclusions: Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT. Further research is warranted to understand factors associated with worse outcomes and investigate alternative interventional approaches and medical management in this high-risk population.

Abstract WP160: Intravenous Dose-adjusted Cangrelor Use For Neuroendovascular Procedures: An Institutional Experience

Introduction: The optimal antiplatelet therapy regimen for neuroendovascular procedures remains unclear. This study investigates the safety and feasibility of intravenous dose-adjusted cangrelor for neurovascular interventions.

Methods: We conducted a retrospective review of consecutive patients who underwent neuroendovascular procedures and were placed on intravenous cangrelor between September 1, 2020 and March 13, 2022. Demographic characteristics, interventional variables, and clinical outcomes were collected.

Results: Fifty patients were included. The mean age (years) was 56.0 ± 18.6, and 26 (52.0%) were males. Most patients were African American (n=39/48, 81.3%). The most common comorbidities were hypertension (n=25/49, 51.0%), active smoking status (n=14/40, 35.0%), and prior ischemic stroke (n=13/49, 26.5%). Intravenous thrombolysis was used in 4 patients (8.0%). Cangrelor infusion was used for the following procedures: embolization (n=10/50, 20.0%), embolization and stent placement (n=9/50, 18.0%), thrombectomy alone (n=5/50, 10.0%), thrombectomy and stent placement (n=10/50, 20.0%), and stent placement only (n=14/50, 28.0%). Stent placement occurred intracranially, remainder of carotid, and both intracranial and carotid arteries in 18, 12, and 3 patients, respectively. PRU levels were measured in 48 patients (96.0%), with 26 patients (54.2%) achieving a PRU level of 50-150 greater than or equal to 50% of the time. Approximately 51.5% of the patients had a favorable functional outcome with modified Rankin Scale (mRS) score of 0 to 2 at 90 days (n=17/33). During 1-year follow up, approximately 4 patients had recurrent or new strokes (9.5%), 1 patient had in-stent thrombosis (2.9%) and 1 patient with symptomatic sICH (2.4%), both while not on antiplatelet therapy, and 2 patients with asymptomatic ICH (4.8%). When stratified by PRU level, there were no significant differences in sICH (p=0.841) or asymptomatic ICH (p=0.853).

Conclusions: To our knowledge, this is the first report in the largest cohort to date to demonstrate the safety and effectiveness of intravenous dose-adjusted cangrelor use for neuroendovascular procedures. Comparative studies to standard dose maintenance cangrelor are necessary.

Abstract WP71: Endovascular Thrombectomy With Or Without Bridging Thrombolysis In Patients With Acute Ischemic Stroke: A Cost-utility Analysis

Introduction: There is clinical equipoise behind bridging intravenous thrombolysis (BT) with endovascular thrombectomy (EVT). We performed a cost-effectiveness analysis comparing BT versus EVT alone.

Methods: We conducted a model-based cost-utility analysis comparing the cost-effectiveness of BT vs EVT only for patients with acute ischemic stroke. We used a decision tree to examine the short-term costs and outcomes at 90 days after the index stroke, and developed a Markov state transition model to assess the costs and outcomes over 1-year, 5-year, and 20-year time horizons. Clinical outcome inputs were derived from our systematic review. We considered the impact of disability and recurrent stroke on mortality risk, health-related quality of life, and costs. We estimated total and incremental cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Probabilistic analysis was used to calculate the reference case estimates.

Results: The average costs per patient were estimated to be $55,503, $57,814, $68,183, and $84,946 for EVT only strategy, and $47,311, $49,556, $59,625, and $75,898 for BT over 90-day, 1-year, 5-year, and 20-year, respectively. The cost saving of EVT only strategy was driven by the avoided medication costs of IVT (ranging from $8,193 to $9,048). The additional thrombolytics led to slight decrease in QALY estimate during the 90-day time horizon (loss of 0.0016 QALY), but a small gain over 1-year, 5-year, and 20-year time horizons (0.0108, 0.0638, and 0.1481 QALY). With similar outcomes and less cost, the EVT only strategy was cost-effective compared with BT. Analyses with longer time horizon show lower probabilities of EVT only strategy being cost-effective. At a fixed willingness to pay threshold of $50,000, the probabilities of EVT only to be cost-effective were 100%, 100%, 99.0%, and 65.9% over 90-day, 1-year, 5-year, and 20-year time horizons. At the willingness to pay thresholds of $100,000 per QALY, the probabilities of EVT only strategy being cost-effective was 22.8% over the 20-year time horizon.

Conclusions: Our cost-effectiveness model suggested that bridging with thrombolytics may not be cost-effective for patients with acute ischemic stroke secondary to large vessel occlusion.

Endovascular thrombectomy for cerebral venous sinus thrombosis using the Penumbra Indigo® Aspiration System

We present a 35-year-old male with ulcerative colitis initially admitted for a flare-up who then presented with altered mental status and was found to have extensive cerebral venous sinus thrombosis on computed tomography imaging. The patient underwent successful partial recanalization of the superior sagittal sinus and bilateral transverse sinuses using the Penumbra Indigo® Aspiration System with improved outcomes. To our knowledge, this is the first reported use of this device in the treatment of cerebral venous sinus thrombosis.

Steric, Electronic and Conformational Synergistic Effects in the Gold(I)-catalyzed α-C-H Bond Functionalization of Tertiary Amines

Direct C-H bond functionalization is a useful strategy for the straightforward formation of C-C and C-Heteroatom bonds. In the present work, a unique approach for the challenging electrophilic Au-catalyzed α-C-H bond functionalization of tertiary amines is presented. Electronic, steric and conformational synergistic effects exerted by the use of a malonate unit in the substrate were key to the success of this transformation. This new reactivity was applied to the synthesis of tetrahydro-γ-carboline products which, under oxidative conditions, could be converted into valuable structural motifs found in bioactive alkaloid natural products.

Early intramedullary nailing of bilateral femur fractures: who might benefit most?

INTRODUCTION

Identifying which patients can receive immediate intramedullary nailing (IMN) after bilateral femoral shaft fracture may improve health-related quality of life outcomes and decrease healthcare costs. This retrospective study evaluated the perioperative factors that guided emergency department transfer of patients to the operating room (OR) where IMN or temporizing external fixation (TEF) was performed, to the intensive care unit (ICU), or to the orthopedic ward. The hypothesis was that patients referred initially to the OR or to the ICU had more serious co-morbidities, complications, or orthopedic polytrauma, increasing the likelihood that they would benefit from "damage control orthopedics" and TEF use.

METHODS

A Level I Trauma Center database (2010-2020) review identified the records of 23 patients that met study inclusion and exclusion criteria. Most sustained their injury in a motor vehicle accident (87%) and were not wearing a seatbelt.

RESULTS

Patients transferred to the operating room had a greater body mass index and shorter times between admission and surgery. Those transferred to the OR or ICU had higher injury severity scores (ISS), higher arterial blood O₂ partial pressure (paO₂) values on the first post-surgical day, and had more red blood cell unit (RBCU) transfusions during hospitalization. Patients transferred to the ICU more often underwent TEF and had shorter initial surgical procedure duration. Those with pneumothorax, rib fractures, or with other orthopedic comorbidities were more often transferred to the OR or ICU and those with acute complications requiring exploratory laparotomy were transferred to the OR.

CONCLUSIONS

Patients with higher BMI, ISS, greater RBCU transfusion needs, with pneumothorax, rib fractures, or acute complications requiring exploratory laparotomy were more likely to be initially transferred to the OR or ICU. Patients transferred to the orthopedic ward represented a more heterogenous group with greater possibility for benefitting from earlier definitive IMN.

Highly Mesoporous MoO3 Catalysts for Electrophilic Aromatic Substitution

Herein, a straightforward synthesis method for highly mesoporous molybdenum oxide has been demonstrated via use of inverse micelles and molybdenum-oxo cluster formation. The synthesized catalyst is stable, crystalline, and MoO₃ phase pure, as confirmed through thermogravimetric analysis, X-ray diffraction, and X-ray photoelectron spectroscopy. Further results from electron paramagnetic resonance, Raman spectroscopy, and UV-vis spectroscopy confirm the MoO₃ phase purity. Chemisorption studies reveal that the synthesized material is 65 times more active than its commercial parts. The quantitative value of ammonia chemisorption for the synthesized catalyst is 1270 μmol/g, whereas the commercial catalyst only gives 22 μmol/g. These materials were tested for electrophilic substitution reactions since they are excellent solid acid. Electrophilic substitution of benzyl alcohol with toluene gives a >99% conversion with ∼80% of selectivity toward the methyl diphenylmethane product. The turnover number and turnover frequency values were calculated to be as high as 115 and 38, respectively. A substrate scope study shows that the reaction has preference toward electron-donating groups, whereas electron-withdrawing groups block the reaction. Based on the obtained results, a mechanism has been proposed.

Prediction of Intracranial Hypertension and Brain Tissue Hypoxia Utilizing High-Resolution Data from the BOOST-II Clinical Trial

The current approach to intracranial hypertension and brain tissue hypoxia is reactive, based on fixed thresholds. We used statistical machine learning on high-frequency intracranial pressure (ICP) and partial brain tissue oxygen tension (PbtO₂) data obtained from the BOOST-II trial with the goal of constructing robust quantitative models to predict ICP/PbtO₂ crises. We derived the following machine learning models: logistic regression (LR), elastic net, and random forest. We split the data set into 70–30% for training and testing and utilized a discrete-time survival analysis framework and 5-fold hyperparameter optimization strategy for all models. We compared model performances on discrimination between events and non-events of increased ICP or low PbtO₂ with the area under the receiver operating characteristic (AUROC) curve. We further analyzed clinical utility through a decision curve analysis (DCA). When considering discrimination, the number of features, and interpretability, we identified the RF model that combined the most recent ICP reading, episode number, and longitudinal trends over the preceding 30 min as the best performing for predicting ICP crisis events within the next 30 min (AUC 0.78). For PbtO₂, the LR model utilizing the most recent reading, episode number, and longitudinal trends over the preceding 30 min was the best performing (AUC, 0.84). The DCA showed clinical usefulness for wide risk of thresholds for both ICP and PbtO₂ predictions. Acceptable alerting thresholds could range from 20% to 80% depending on a patient-specific assessment of the benefit-risk ratio of a given intervention in response to the alert.

Expedited Total Synthesis of (±)-Brevianamide A via the Strategic Use of Gold(I) Catalysis

Two concise and complementary routes to the polycyclic alkaloid (±)-brevianamide A from readily available amino acid building blocks are presented. Key to the synthesis is the strategic use of a gold(I)-catalyzed cascade process that quickly assembles the characteristic pseudoindoxyl motif of the natural product along with the two adjacent quaternary centers in a single step. This sequence, which exemplifies the structural complexity that can be achieved with gold catalysis, allowed for the shortest and highest-yield synthesis of (±)-brevianamide A to date (four steps LLS, 14% overall yield).

COVID-19 Vaccine Triggered Rejection in Lung Transplant Recipients: A Case Series

Purpose

Methods

Results

Conclusion