Global mortality associated with 33 bacterial pathogens in 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Reducing the burden of death due to infection is an urgent global public health priority. Previous studies have estimated the number of deaths associated with drug-resistant infections and sepsis and found that infections remain a leading cause of death globally. Understanding the global burden of common bacterial pathogens (both susceptible and resistant to antimicrobials) is essential to identify the greatest threats to public health. To our knowledge, this is the first study to present global comprehensive estimates of deaths associated with 33 bacterial pathogens across 11 major infectious syndromes.

METHODS

We estimated deaths associated with 33 bacterial genera or species across 11 infectious syndromes in 2019 using methods from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, in addition to a subset of the input data described in the Global Burden of Antimicrobial Resistance 2019 study. This study included 343 million individual records or isolates covering 11 361 study-location-years. We used three modelling steps to estimate the number of deaths associated with each pathogen: deaths in which infection had a role, the fraction of deaths due to infection that are attributable to a given infectious syndrome, and the fraction of deaths due to an infectious syndrome that are attributable to a given pathogen. Estimates were produced for all ages and for males and females across 204 countries and territories in 2019. 95% uncertainty intervals (UIs) were calculated for final estimates of deaths and infections associated with the 33 bacterial pathogens following standard GBD methods by taking the 2·5th and 97·5th percentiles across 1000 posterior draws for each quantity of interest.

FINDINGS

From an estimated 13·7 million (95% UI 10·9-17·1) infection-related deaths in 2019, there were 7·7 million deaths (5·7-10·2) associated with the 33 bacterial pathogens (both resistant and susceptible to antimicrobials) across the 11 infectious syndromes estimated in this study. We estimated deaths associated with the 33 bacterial pathogens to comprise 13·6% (10·2-18·1) of all global deaths and 56·2% (52·1-60·1) of all sepsis-related deaths in 2019. Five leading pathogens-Staphylococcus aureus, Escherichia coli, Streptococcus pneumoniae, Klebsiella pneumoniae, and Pseudomonas aeruginosa-were responsible for 54·9% (52·9-56·9) of deaths among the investigated bacteria. The deadliest infectious syndromes and pathogens varied by location and age. The age-standardised mortality rate associated with these bacterial pathogens was highest in the sub-Saharan Africa super-region, with 230 deaths (185-285) per 100 000 population, and lowest in the high-income super-region, with 52·2 deaths (37·4-71·5) per 100 000 population. S aureus was the leading bacterial cause of death in 135 countries and was also associated with the most deaths in individuals older than 15 years, globally. Among children younger than 5 years, S pneumoniae was the pathogen associated with the most deaths. In 2019, more than 6 million deaths occurred as a result of three bacterial infectious syndromes, with lower respiratory infections and bloodstream infections each causing more than 2 million deaths and peritoneal and intra-abdominal infections causing more than 1 million deaths.

INTERPRETATION

The 33 bacterial pathogens that we investigated in this study are a substantial source of health loss globally, with considerable variation in their distribution across infectious syndromes and locations. Compared with GBD Level 3 underlying causes of death, deaths associated with these bacteria would rank as the second leading cause of death globally in 2019; hence, they should be considered an urgent priority for intervention within the global health community. Strategies to address the burden of bacterial infections include infection prevention, optimised use of antibiotics, improved capacity for microbiological analysis, vaccine development, and improved and more pervasive use of available vaccines. These estimates can be used to help set priorities for vaccine need, demand, and development.

FUNDING

Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care, using UK aid funding managed by the Fleming Fund.

The global burden of cancer attributable to risk factors, 2010-19: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally.

METHODS

The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented.

FINDINGS

Globally, in 2019, the risk factors included in this analysis accounted for 4·45 million (95% uncertainty interval 4·01-4·94) deaths and 105 million (95·0-116) DALYs for both sexes combined, representing 44·4% (41·3-48·4) of all cancer deaths and 42·0% (39·1-45·6) of all DALYs. There were 2·88 million (2·60-3·18) risk-attributable cancer deaths in males (50·6% [47·8-54·1] of all male cancer deaths) and 1·58 million (1·36-1·84) risk-attributable cancer deaths in females (36·3% [32·5-41·3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20·4% (12·6-28·4) and DALYs by 16·8% (8·8-25·0), with the greatest percentage increase in metabolic risks (34·7% [27·9-42·8] and 33·3% [25·8-42·0]).

INTERPRETATION

The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national burden of colorectal cancer and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Colorectal cancer is the third leading cause of cancer deaths worldwide. Given the recent increasing trends in colorectal cancer incidence globally, up-to-date information on the colorectal cancer burden could guide screening, early detection, and treatment strategies, and help effectively allocate resources. We examined the temporal patterns of the global, regional, and national burden of colorectal cancer and its risk factors in 204 countries and territories across the past three decades.

METHODS

Estimates of incidence, mortality, and disability-adjusted life years (DALYs) for colorectal cancer were generated as a part of the Global Burden of Diseases, Injuries and Risk Factors Study (GBD) 2019 by age, sex, and geographical location for the period 1990-2019. Mortality estimates were produced using the cause of death ensemble model. We also calculated DALYs attributable to risk factors that had evidence of causation with colorectal cancer.

FINDINGS

Globally, between 1990 and 2019, colorectal cancer incident cases more than doubled, from 842 098 (95% uncertainty interval [UI] 810 408-868 574) to 2·17 million (2·00-2·34), and deaths increased from 518 126 (493 682-537 877) to 1·09 million (1·02-1·15). The global age-standardised incidence rate increased from 22·2 (95% UI 21·3-23·0) per 100 000 to 26·7 (24·6-28·9) per 100 000, whereas the age-standardised mortality rate decreased from 14·3 (13·5-14·9) per 100 000 to 13·7 (12·6-14·5) per 100 000 and the age-standardised DALY rate decreased from 308·5 (294·7-320·7) per 100 000 to 295·5 (275·2-313·0) per 100 000 from 1990 through 2019. Taiwan (province of China; 62·0 [48·9-80·0] per 100 000), Monaco (60·7 [48·5-73·6] per 100 000), and Andorra (56·6 [42·8-71·9] per 100 000) had the highest age-standardised incidence rates, while Greenland (31·4 [26·0-37·1] per 100 000), Brunei (30·3 [26·6-34·1] per 100 000), and Hungary (28·6 [23·6-34·0] per 100 000) had the highest age-standardised mortality rates. From 1990 through 2019, a substantial rise in incidence rates was observed in younger adults (age <50 years), particularly in high Socio-demographic Index (SDI) countries. Globally, a diet low in milk (15·6%), smoking (13·3%), a diet low in calcium (12·9%), and alcohol use (9·9%) were the main contributors to colorectal cancer DALYs in 2019.

INTERPRETATION

The increase in incidence rates in people younger than 50 years requires vigilance from researchers, clinicians, and policy makers and a possible reconsideration of screening guidelines. The fast-rising burden in low SDI and middle SDI countries in Asia and Africa calls for colorectal cancer prevention approaches, greater awareness, and cost-effective screening and therapeutic options in these regions.

FUNDING

Bill & Melinda Gates Foundation.

The burden of bacterial antimicrobial resistance in the WHO European region in 2019: a cross-country systematic analysis

BACKGROUND

Antimicrobial resistance (AMR) represents one of the most crucial threats to public health and modern health care. Previous studies have identified challenges with estimating the magnitude of the problem and its downstream effect on human health and mortality. To our knowledge, this study presents the most comprehensive set of regional and country-level estimates of AMR burden in the WHO European region to date.

METHODS

We estimated deaths and disability-adjusted life-years attributable to and associated with AMR for 23 bacterial pathogens and 88 pathogen-drug combinations for the WHO European region and its countries in 2019. Our methodological approach consisted of five broad components: the number of deaths in which infection had a role, the proportion of infectious deaths attributable to a given infectious syndrome, the proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antimicrobial drug of interest, and the excess risk of mortality (or duration of an infection) associated with this resistance. These components were then used to estimate the disease burden by using two counterfactual scenarios: deaths attributable to AMR (considering an alternative scenario where infections with resistant pathogens are replaced with susceptible ones) and deaths associated with AMR (considering an alternative scenario where drug-resistant infections would not occur at all). Data were solicited from a wide array of international stakeholders; these included research hospitals, surveillance networks, and infection databases maintained by private laboratories and medical technology companies. We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity.

FINDINGS

We estimated 541 000 deaths (95% UI 370 000-763 000) associated with bacterial AMR and 133 000 deaths (90 100-188 000) attributable to bacterial AMR in the whole WHO European region in 2019. The largest fatal burden of AMR in the region came from bloodstream infections, with 195 000 deaths (104 000-333 000) associated with resistance, followed by intra-abdominal infections (127 000 deaths [81 900-185 000]) and respiratory infections (120 000 deaths [94 500-154 000]). Seven leading pathogens were responsible for about 457 000 deaths associated with resistance in 53 countries of this region; these pathogens were, in descending order of mortality, Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecium, Streptococcus pneumoniae, and Acinetobacter baumannii. Methicillin-resistant S aureus was shown to be the leading pathogen-drug combination in 27 countries for deaths attributable to AMR, while aminopenicillin-resistant E coli predominated in 47 countries for deaths associated with AMR.

INTERPRETATION

The high levels of resistance for several important bacterial pathogens and pathogen-drug combinations, together with the high mortality rates associated with these pathogens, show that AMR is a serious threat to public health in the WHO European region. Our regional and cross-country analyses open the door for strategies that can be tailored to leading pathogen-drug combinations and the available resources in a specific location. These results underscore that the most effective way to tackle AMR in this region will require targeted efforts and investments in conjunction with continuous outcome-based research endeavours.

FUNDING

Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.

Burnout syndrome in Romanian medical residents in time of the COVID-19 pandemic

Burnout is a state of physical or mental collapse caused by overwork or stress. Burnout during residency training has gained significant attention secondary to concerns regarding job performance and patient care. The new COVID-19 pandemic has raised public health problems around the world and required a reorganization of health services. In this context, burnout syndrome and physical exhaustion have become even more pronounced. Resident doctors, and especially those in certain specialties, seem even more exposed due to the higher workload, prolonged exposure and first contact with patients. This article is a short review of the literature and a presentation of some considerations regarding the activity of the medical residents in a non-Covid emergency hospital in Romania, based on the responses obtained via a questionnaire. Burnout prevalence is not equal in different specialties. We studied its impact and imagine the potential steps that can be taken in order to reduce the increasing rate of burnout syndrome in the pandemics.

The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990-2019: Findings from the Global Burden of Disease Study 2019

Background

Mental health is a public health issue for European young people, with great heterogeneity in resource allocation. Representative population-based studies are needed. The Global Burden of Disease (GBD) Study 2019 provides internationally comparable information on trends in the health status of populations and changes in the leading causes of disease burden over time.

Methods

Prevalence, incidence, Years Lived with Disability (YLDs) and Years of Life Lost (YLLs) from mental disorders (MDs), substance use disorders (SUDs) and self-harm were estimated for young people aged 10-24 years in 31 European countries. Rates per 100,000 population, percentage changes in 1990-2019, 95% Uncertainty Intervals (UIs), and correlations with Sociodemographic Index (SDI), were estimated.

Findings

In 2019, rates per 100,000 population were 16,983 (95% UI 12,823 - 21,630) for MDs, 3,891 (3,020 - 4,905) for SUDs, and 89·1 (63·8 - 123·1) for self-harm. In terms of disability, anxiety contributed to 647·3 (432-912·3) YLDs, while in terms of premature death, self-harm contributed to 319·6 (248·9-412·8) YLLs, per 100,000 population. Over the 30 years studied, YLDs increased in eating disorders (14·9%;9·4-20·1) and drug use disorders (16·9%;8·9-26·3), and decreased in idiopathic developmental intellectual disability (-29·1%;23·8-38·5). YLLs decreased in self-harm (-27·9%;38·3-18·7). Variations were found by sex, age-group and country. The burden of SUDs and self-harm was higher in countries with lower SDI, MDs were associated with SUDs.

Interpretation

Mental health conditions represent an important burden among young people living in Europe. National policies should strengthen mental health, with a specific focus on young people.

Funding

The Bill and Melinda Gates Foundation.

Global investments in pandemic preparedness and COVID-19: development assistance and domestic spending on health between 1990 and 2026

BACKGROUND

The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness.

METHODS

In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need.

FINDINGS

In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95% uncertainty interval [UI] 9·1-9·3) was spent on health worldwide. We found great disparities in the amount of resources devoted to health, with high-income countries spending $7·3 trillion (95% UI 7·2-7·4) in 2019; 293·7 times the $24·8 billion (95% UI 24·3-25·3) spent by low-income countries in 2019. That same year, $43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and $37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11-21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP.

INTERPRETATION

There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained.

FUNDING

Bill & Melinda Gates Foundation.

Burden of non-communicable diseases among adolescents aged 10-24 years in the EU, 1990-2019: a systematic analysis of the Global Burden of Diseases Study 2019

BACKGROUND

Disability and mortality burden of non-communicable diseases (NCDs) have risen worldwide; however, the NCD burden among adolescents remains poorly described in the EU.

METHODS

Estimates were retrieved from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Causes of NCDs were analysed at three different levels of the GBD 2019 hierarchy, for which mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) were extracted. Estimates, with the 95% uncertainty intervals (UI), were retrieved for EU Member States from 1990 to 2019, three age subgroups (10-14 years, 15-19 years, and 20-24 years), and by sex. Spearman's correlation was conducted between DALY rates for NCDs and the Socio-demographic Index (SDI) of each EU Member State.

FINDINGS

In 2019, NCDs accounted for 86·4% (95% uncertainty interval 83·5-88·8) of all YLDs and 38·8% (37·4-39·8) of total deaths in adolescents aged 10-24 years. For NCDs in this age group, neoplasms were the leading causes of both mortality (4·01 [95% uncertainty interval 3·62-4·25] per 100 000 population) and YLLs (281·78 [254·25-298·92] per 100 000 population), whereas mental disorders were the leading cause for YLDs (2039·36 [1432·56-2773·47] per 100 000 population) and DALYs (2040·59 [1433·96-2774·62] per 100 000 population) in all EU Member States, and in all studied age groups. In 2019, among adolescents aged 10-24 years, males had a higher mortality rate per 100 000 population due to NCDs than females (11·66 [11·04-12·28] vs 7·89 [7·53-8·23]), whereas females presented a higher DALY rate per 100 000 population due to NCDs (8003·25 [5812·78-10 701·59] vs 6083·91 [4576·63-7857·92]). From 1990 to 2019, mortality rate due to NCDs in adolescents aged 10-24 years substantially decreased (-40·41% [-43·00 to -37·61), and also the YLL rate considerably decreased (-40·56% [-43·16 to -37·74]), except for mental disorders (which increased by 32·18% [1·67 to 66·49]), whereas the YLD rate increased slightly (1·44% [0·09 to 2·79]). Positive correlations were observed between DALY rates and SDIs for substance use disorders (r_s=0·58, p=0·0012) and skin and subcutaneous diseases (r_s=0·45, p=0·017), whereas negative correlations were found between DALY rates and SDIs for cardiovascular diseases (r_s=-0·46, p=0·015), neoplasms (r_s=-0·57, p=0·0015), and sense organ diseases (r_s=-0·61, p=0·0005).

INTERPRETATION

NCD-related mortality has substantially declined among adolescents in the EU between 1990 and 2019, but the rising trend of YLL attributed to mental disorders and their YLD burden are concerning. Differences by sex, age group, and across EU Member States highlight the importance of preventive interventions and scaling up adolescent-responsive health-care systems, which should prioritise specific needs by sex, age, and location.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national burden of meningitis and its aetiologies, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Although meningitis is largely preventable, it still causes hundreds of thousands of deaths globally each year. WHO set ambitious goals to reduce meningitis cases by 2030, and assessing trends in the global meningitis burden can help track progress and identify gaps in achieving these goals. Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we aimed to assess incident cases and deaths due to acute infectious meningitis by aetiology and age from 1990 to 2019, for 204 countries and territories.

METHODS

We modelled meningitis mortality using vital registration, verbal autopsy, sample-based vital registration, and mortality surveillance data. Meningitis morbidity was modelled with a Bayesian compartmental model, using data from the published literature identified by a systematic review, as well as surveillance data, inpatient hospital admissions, health insurance claims, and cause-specific meningitis mortality estimates. For aetiology estimation, data from multiple causes of death, vital registration, hospital discharge, microbial laboratory, and literature studies were analysed by use of a network analysis model to estimate the proportion of meningitis deaths and cases attributable to the following aetiologies: Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, group B Streptococcus, Escherichia coli, Klebsiella pneumoniae, Listeria monocytogenes, Staphylococcus aureus, viruses, and a residual other pathogen category.

FINDINGS

In 2019, there were an estimated 236 000 deaths (95% uncertainty interval [UI] 204 000-277 000) and 2·51 million (2·11-2·99) incident cases due to meningitis globally. The burden was greatest in children younger than 5 years, with 112 000 deaths (87 400-145 000) and 1·28 million incident cases (0·947-1·71) in 2019. Age-standardised mortality rates decreased from 7·5 (6·6-8·4) per 100 000 population in 1990 to 3·3 (2·8-3·9) per 100 000 population in 2019. The highest proportion of total all-age meningitis deaths in 2019 was attributable to S pneumoniae (18·1% [17·1-19·2]), followed by N meningitidis (13·6% [12·7-14·4]) and K pneumoniae (12·2% [10·2-14·3]). Between 1990 and 2019, H influenzae showed the largest reduction in the number of deaths among children younger than 5 years (76·5% [69·5-81·8]), followed by N meningitidis (72·3% [64·4-78·5]) and viruses (58·2% [47·1-67·3]).

INTERPRETATION

Substantial progress has been made in reducing meningitis mortality over the past three decades. However, more meningitis-related deaths might be prevented by quickly scaling up immunisation and expanding access to health services. Further reduction in the global meningitis burden should be possible through low-cost multivalent vaccines, increased access to accurate and rapid diagnostic assays, enhanced surveillance, and early treatment.

FUNDING

Bill & Melinda Gates Foundation.

Adolescent transport and unintentional injuries: a systematic analysis using the Global Burden of Disease Study 2019

BACKGROUND

Globally, transport and unintentional injuries persist as leading preventable causes of mortality and morbidity for adolescents. We sought to report comprehensive trends in injury-related mortality and morbidity for adolescents aged 10-24 years during the past three decades.

METHODS

Using the Global Burden of Disease, Injuries, and Risk Factors 2019 Study, we analysed mortality and disability-adjusted life-years (DALYs) attributed to transport and unintentional injuries for adolescents in 204 countries. Burden is reported in absolute numbers and age-standardised rates per 100 000 population by sex, age group (10-14, 15-19, and 20-24 years), and sociodemographic index (SDI) with 95% uncertainty intervals (UIs). We report percentage changes in deaths and DALYs between 1990 and 2019.

FINDINGS

In 2019, 369 061 deaths (of which 214 337 [58%] were transport related) and 31·1 million DALYs (of which 16·2 million [52%] were transport related) among adolescents aged 10-24 years were caused by transport and unintentional injuries combined. If compared with other causes, transport and unintentional injuries combined accounted for 25% of deaths and 14% of DALYs in 2019, and showed little improvement from 1990 when such injuries accounted for 26% of adolescent deaths and 17% of adolescent DALYs. Throughout adolescence, transport and unintentional injury fatality rates increased by age group. The unintentional injury burden was higher among males than females for all injury types, except for injuries related to fire, heat, and hot substances, or to adverse effects of medical treatment. From 1990 to 2019, global mortality rates declined by 34·4% (from 17·5 to 11·5 per 100 000) for transport injuries, and by 47·7% (from 15·9 to 8·3 per 100 000) for unintentional injuries. However, in low-SDI nations the absolute number of deaths increased (by 80·5% to 42 774 for transport injuries and by 39·4% to 31 961 for unintentional injuries). In the high-SDI quintile in 2010-19, the rate per 100 000 of transport injury DALYs was reduced by 16·7%, from 838 in 2010 to 699 in 2019. This was a substantially slower pace of reduction compared with the 48·5% reduction between 1990 and 2010, from 1626 per 100 000 in 1990 to 838 per 100 000 in 2010. Between 2010 and 2019, the rate of unintentional injury DALYs per 100 000 also remained largely unchanged in high-SDI countries (555 in 2010 vs 554 in 2019; 0·2% reduction). The number and rate of adolescent deaths and DALYs owing to environmental heat and cold exposure increased for the high-SDI quintile during 2010-19.

INTERPRETATION

As other causes of mortality are addressed, inadequate progress in reducing transport and unintentional injury mortality as a proportion of adolescent deaths becomes apparent. The relative shift in the burden of injury from high-SDI countries to low and low-middle-SDI countries necessitates focused action, including global donor, government, and industry investment in injury prevention. The persisting burden of DALYs related to transport and unintentional injuries indicates a need to prioritise innovative measures for the primary prevention of adolescent injury.

FUNDING

Bill & Melinda Gates Foundation.

The erectile dysfunction as a marker of cardiovascular disease: a review

Cardiovascular disease (CVD) and erectile dysfunction (ED) are two conditions that often coexist. Both diseases are consequences of the systemic vascular disease, sharing common risk factors, like diabetes mellitus, arterial hypertension, smoking, obesity, dyslipidaemia. Furthermore, they share the same pathological basis, endothelial dysfunction. Symptoms of ED precede with three to five years the clinical manifestations of CVD. This period may be a window of opportunity for the early initiation of a prompt therapeutic action for cardiovascular risk factors. This article reviews the incidence and prevalence of CVD and ED, the common risk factors, the pathophysiological link between the two diseases, and the current diagnosis and management strategies of patients with CVD and ED, in order to prevent myocardial infarction, stroke or heart failure.

Insulin resistance is associated with all chronic complications in type 1 diabetes

BACKGROUND

Insulin resistance (IR) is present in type 1 diabetes mellitus (T1DM) and is suggested to be related to chronic diabetic complications. The primary aim of our study was to assess IR in T1DM patients with and without chronic complications. A secondary aim was to evaluate the possible association between IR and chronic diabetic complications.

METHODS

This cross-sectional study enrolled 272 patients with T1DM. Insulin resistance was quantified using the estimated glucose disposal rate (eGDR). Associations between eGDR and each diabetes complication were first evaluated using binary logistic regression, then multiparametric logistic regression with stepwise selection of covariates. The discriminative value of eGDR was assessed by receiver operating characteristic (ROC) curve analysis.

RESULTS

Estimated GDR was lower in patients with chronic diabetic complications (6.1 vs. 6.9 mg/kg per min [P = 0.02] for retinopathy; 6.3 vs. 7.3 mg/kg per min [P < 0.01] for nephropathy; 6.5 vs. 7.6 mg/kg per min [P < 0.01] for neuropathy; and 5.2 vs. 7.5 mg/kg per min [P < 0.01] for cardiovascular complications). In univariate analysis eGDR was associated all diabetic complications. These associations remained significant after adjustment for different variables in the final regression models. In addition, eGDR was a good discriminator for each diabetic complication, with an area under the curve between 0.609 and 0.759.

CONCLUSIONS

Patients with chronic diabetic complications are more insulin resistant than those without complications. Moreover, IR was independently associated with the presence of each chronic diabetic complication, and seems to be a good discriminator for them all.

Hypervirulent Klebsiella pneumoniae Endogenous Endophthalmitis-A Global Emerging Disease

The review aims to document the new emerging hypervirulent Klebsiella pneumoniae (Kp) endogenous endophthalmitis (EKE) in terms of incidence, microbiological characterization of the pathogenic agent, associated risk factors, management, and outcomes. Hypervirulent (hv) strains of KP (hvKp) induce invasive liver abscesses (LA) with specific clinical features. Up to 80–90% of cases have hepatic liver abscess as a primary focus of infection, followed by renal or lung hvKp infections. However, the incidence of EKE in patients with KPLA varied between 3.4% (19) and 12.6% (13), with a total of 95 cases of endophthalmitis in 1455 cases of KPLA (6.5%). Severe visual loss was encountered in 75% of cases, with 25% bilateral involvement. Intravitreal antibiotics are the mainstay therapeutic approach. Pars plana vitrectomy is a subject of controversy. HvKp strains present mostly natural “wild-type” antibiotic resistance profile suggestive for community-acquired infections, being highly susceptive to the third and fourth generation of cephalosporins and carbapenems. Antimicrobial resistance in hypervirulent strains was recently documented via plasmid transfer and may result in extremely difficult to treat cases. Global dissemination of these strains is a major epidemiologic shift that should be considered in the diagnostic and therapeutic management of patients with endogenous endophthalmitis. Ophthalmologic screening in patients with KPLA and other hvKp infections and a multidisciplinary therapeutic approach is extremely important for early diagnosis and preservation of the visual function.

Neutrophil/Lymphocyte Ratio as Predictor of Anastomotic Leak after Gastric Cancer Surgery

INTRODUCTION

Neutrophil/lymphocyte ratio (NLR) is known as a prognostic for the outcome of the patients with gastric cancer. As no definite risk marker for anastomotic leakage after gastric resection was identified, we investigated the possible role of NLR.

METHODS

Peripheral blood count for neutrophils and lymphocytes was done at the patient's admission. We retrospectively evaluated 204 gastric cancer patients, who underwent gastric resection, comparing the values of NLR between the group of patients with anastomotic leakage and those without complications.

RESULTS

Using the ROC curve, we found the cutoff value of NLR, which permitted the comparison of the group with low NLR, presenting increased NLR. The cutoff value for NLR was 3.54. Between the two groups, we could observe statistically significant differences in developing fistula (p < 0.01) and complications leading to death (p < 0.025). The odds ratio for patients with NLR greater than 3.54 to develop anastomotic leak was 17.62, compared to those with lower NLR.

CONCLUSION

Peripheral blood NLR proved to be a predictor for anastomotic leakage.

Venous thromboembolism in cancer patients: Still looking for answers

Patients with cancer-associated venous thromboembolism (VTE) represent a real challenge in clinical practice. Patients with cancer have a greater risk both of VTE and bleeding. There are only a few studies regarding the therapeutic approach of VTE in patients with cancer, especially after cancer surgery, and on thromboprophylaxis during chemotherapy. Many of the anticoagulation therapy recommendations for cancer patients are extrapolated from trials that are not conducted in cancer cohorts. It is essential to assess the efficacy and safety of VTE prophylaxis in this particular subgroup, which bears higher risks both of VTE recurrence and major hemorrhagic events. The introduction of direct oral anticoagulants in everyday practice represented a major evolution of the anticoagulant treatment. Direct anticoagulants could represent a more appealing alternative to low-molecular-weight heparin in paraneoplastic venous thrombosis, due to the patient comfort, easy administration of the drug and emerging studies that prove similar efficacy and safety as the standard treatment. However, there is limited data on the treatment with direct oral anticoagulants in patients with paraneoplastic venous thromboembolism.

Safety of Laparoscopic Cholecystectomy for Acute Cholecystitis in the Elderly: A Multivariate Analysis of Risk Factors for Intra and Postoperative Complications

Background and Objectives: This study investigates the impact of age upon the safety and outcomes of laparoscopic cholecystectomy performed for acute cholecystitis, by a multivariate approach. Materials and Methods: A 2-year retrospective study was performed on 333 patients admitted for acute cholecystitis who underwent emergency cholecystectomy. The patients included in the study group were divided into four age subgroups: A ≤49 years; B: 50-64 years; C: 65-79 years; D ≥80 years. Results: Surgery after 72 h from onset (p = 0.007), severe forms, and higher American Society of Anesthesiologists Physical Status Classification and Charlson comorbidity index scores (p < 0.001) are well correlated with older age. Both cardiovascular and surgical related complications were significantly higher in patients over 50 years (p = 0.045), which also proved to be a turning point for increasing the rate of conversion and open surgery. However, the comparative incidence did not differ significantly between patients aged from 50-64 years, 65-79 years and over 80 years (6.03%, 9.09% and 5.8%, respectively). Laparoscopic cholecystectomy (LC) was the most frequently used surgical approach in the treatment of acute cholecystitis in all age groups, with better outcomes than open cholecystectomy in terms of decreased overall and postoperative hospital stay, reduced surgery related complications, and the incidence of acute cardiovascular events in the early postoperative period (p < 0.001). Conclusions: The degree of systemic inflammation was the main factor that influenced the adverse outcome of LC in the elderly. Among comorbidities, diabetes was associated with increased surgical and systemic postoperative morbidity, while stroke and chronic renal insufficiency were correlated with a high risk of cardiovascular complications. With adequate perioperative care, the elderly has much to gain from the benefits of a minimally invasive approach, which allows a decreased rate of postoperative complications and a reduced hospital stay.

The Benefits and Risks of Antioxidant Treatment in Liver Diseases

Chronic liver diseases are a public health issue, because of their high incidence and prevalence, the important impact on the quality of life and high mortality rates. From a pathogenic point of view, in almost all liver diseases there is an increase in oxidative stress. Oxidative stress represents as an imbalance between the production of oxidizing agents and antioxidants. This imbalance contributes to the initiation and progression of hepatic injury. Among the most important risk factors for increased oxidative stress in chronic liver diseases are alcohol, drugs, environmental pollutants and irradiation. For the restoration of the oxidant-antioxidant balance and reduction of the oxidative stress in chronic liver diseases, a promising role may have the antioxidants. This hypothesis is now based on experimental evidence of their efficacy in animal models. In low concentrations, antioxidants improve liver function by preventing the oxidation of an oxidizable substrate, but in high doses, they may cause adverse reactions, such as the pro-oxidant effect, glutathione S transferase inhibition and thus the inhibition of detoxification and interference with coagulation. The objective of the article is to review the benefits of antioxidant treatment in chronic diseases of the liver, in order to put them in balance with their adverse reactions.

Association between vascular comorbidity and glaucoma progression: A four-year observational study

Glaucoma, one of the significant causes of blindness worldwide, is a chronic optic neuropathy, characterized by progressive loss of retinal ganglion cells and specific perimetric defects. This study aimed to assess the association between the risk of glaucoma progression and different systemic vascular abnormalities. A 4-year prospective study was carried out on 204 patients diagnosed with open-angle glaucoma. Associated systemic vascular pathology was documented in 102 cases. Progression was encountered in 57 (55.9%) patients with vascular comorbidities and only in 10 (9.8%) patients with no associated vascular diseases (OR 13.81, P<0.01). The vascular risk factors associated with glaucoma progression in the study group were diastolic hypotension (OR 5.444, P=0.027), ischemic cardiac disease (OR 5.826; P<0.01), peripheral vasospasm (OR 3.108, P=0.042) and arterial hypertension (OR 2.593, P=0.05). Diabetes was not significantly correlated with progression in the study group, but only patients without diabetic retinopathy were included. This study highlights that systemic comorbidities associated with endothelial lesions, atherosclerosis and hypoperfusion can lead to damage to the retinal nerve fiber layer and the underlying conjunctive tissue.

The burden of injury in Central, Eastern, and Western European sub-region: a systematic analysis from the Global Burden of Disease 2019 Study

BACKGROUND

Injury remains a major concern to public health in the European region. Previous iterations of the Global Burden of Disease (GBD) study showed wide variation in injury death and disability adjusted life year (DALY) rates across Europe, indicating injury inequality gaps between sub-regions and countries. The objectives of this study were to: 1) compare GBD 2019 estimates on injury mortality and DALYs across European sub-regions and countries by cause-of-injury category and sex; 2) examine changes in injury DALY rates over a 20 year-period by cause-of-injury category, sub-region and country; and 3) assess inequalities in injury mortality and DALY rates across the countries.

METHODS

We performed a secondary database descriptive study using the GBD 2019 results on injuries in 44 European countries from 2000 to 2019. Inequality in DALY rates between these countries was assessed by calculating the DALY rate ratio between the highest-ranking country and lowest-ranking country in each year.

RESULTS

In 2019, in Eastern Europe 80 [95% uncertainty interval (UI): 71 to 89] people per 100,000 died from injuries; twice as high compared to Central Europe (38 injury deaths per 100,000; 95% UI 34 to 42) and three times as high compared to Western Europe (27 injury deaths per 100,000; 95%UI 25 to 28). The injury DALY rates showed less pronounced differences between Eastern (5129 DALYs per 100,000; 95% UI: 4547 to 5864), Central (2940 DALYs per 100,000; 95% UI: 2452 to 3546) and Western Europe (1782 DALYs per 100,000; 95% UI: 1523 to 2115). Injury DALY rate was lowest in Italy (1489 DALYs per 100,000) and highest in Ukraine (5553 DALYs per 100,000). The difference in injury DALY rates by country was larger for males compared to females. The DALY rate ratio was highest in 2005, with DALY rate in the lowest-ranking country (Russian Federation) 6.0 times higher compared to the highest-ranking country (Malta). After 2005, the DALY rate ratio between the lowest- and the highest-ranking country gradually decreased to 3.7 in 2019.

CONCLUSIONS

Injury mortality and DALY rates were highest in Eastern Europe and lowest in Western Europe, although differences in injury DALY rates declined rapidly, particularly in the past decade. The injury DALY rate ratio of highest- and lowest-ranking country declined from 2005 onwards, indicating declining inequalities in injuries between European countries.

Esophageal diverticula: from diagnosis to therapeutic management-narrative review

Background and Objective

Esophageal diverticulum (ED) is a relatively rare condition, characterized by high etio- and pathophysiological versatility, with an uncommon clinical impact, consequently requiring a complete and complex diagnostic evaluation, so that the therapeutic decision is "appropriate" to a specific case. The aim of the paper is, therefore, a reassessment of the diagnostic possibilities underlying the establishment of the therapeutic protocol and the available therapeutic resources, making a review of the literature, and a non-statistical retrospective analysis of cases hospitalized and operated in a tertiary center.

Methods

Thus, classical investigations (upper digestive endoscopy, barium swallow) need to be correlated with complex, manometric, and imaging evaluations with direct implications in therapeutic management. Moreover, in the absence of a precise etiology, the operative indication needs to be established sparingly, with the imposition of the identification and interception of the pathophysiological mechanisms through the therapeutic gesture.

Key Content and Findings

The identification of the pathophysiological mechanisms is mandatory for the management of diverticular disease, the result obtained-restoring swallowing and comfort/good quality of life in the postoperative period-is directly related to the chosen therapeutic procedure. In addition, management appears to be a difficult goal in the context of the low incidence of ED but also of the results that emphasize important differences in the reports in the medical literature. Although ED is a benign condition, surgical techniques are demanding, impacted by significant morbidity and mortality. The causes of these results are multiple: possible localizations anywhere in the esophagus, diverticulum size/volume from a few millimeters to an impressive one, over 10-12 cm, metabolic impact in direct relation to the alteration swallowing, numerous diverticular complications but, perhaps most importantly, alteration of the quality of the diverticular wall by inflammatory phenomena, with an impact on the quality of the suture.

Conclusions

The accumulation of cases in a tertiary profile center, with volume/hospital, respectively volume/surgeon + gastroenterologist could be a solution in improving the results. One consequence would be the identification of alternative solutions to open surgical techniques, a series of minimally invasive or endoscopic variants can refine these results.

Acute surgical abdomen during the COVID-19 pandemic: Clinical and therapeutic challenges

The present study investigated the effects of the COVID-19 pandemic on the clinical presentation and therapeutic management of acute surgical abdomen. A retrospective study of emergency hospitalizations with a diagnosis of acute surgical abdomen between April and July 2020 vs. a similar period in 2019 was performed. The observation sheets and the operating protocols were analyzed. Between April and July 2020, 50 cases of acute surgical abdomen were hospitalized and treated, compared to 43 cases in the same period last year. The main types of pathology in both groups included: Occlusions (60%, respectively 44.2% in 2019) and peritonitis (32%, respectively 41.8% in 2019). There was an increased rate of patients with colorectal cancers neglected therapeutically or uninvestigated, who presented during the pandemic period with emergencies for complications such as occlusion or tumor perforation (32 vs. 6.97%, P=0.0039). One case, with gastric perforation, was COVID-positive, with no pulmonary symptoms at admission. The number of postoperative infectious complications was lower during the pandemic (2 vs. 13.95%, P=0.0461). As the COVID-19 pandemic appears to be still far from ending, we should learn to adapt our surgical protocols to the new evidence. Oncological patients are a vulnerable group, who were neglected in the first months of the pandemic. SARS-Cov-2 infection may be a cause of abdominal pain and should be taken into account in different diagnoses of acute abdomen in surgical wards. Correct wearing of adequate personal protective equipment (PPE) and respecting strict rules of asepsis and antisepsis are required for preventing in-hospital transmission of infection.

Evaluation of the SF-36 questionnaire for assessment of the quality of life of endometriosis patients undergoing treatment: A systematic review and meta-analysis

Endometriosis has a negative influence on the physical, psychological, and social aspects of a patient's life; therefore, it affects the health-related quality of life (HRQoL). The current review aimed to investigate the efficiency of a 36-item generic questionnaire survey (SF-36) for patients with endometriosis who were undergoing medical or surgical treatment. A search strategy including the key words ‘endometriosis’, ‘quality of life’ (QOL), and ‘questionnaire SF-36’ was applied using the PubMed/MEDLINE, EMBASE, and Cochrane databases in order to include articles that evaluated the QOL among women with endometriosis using the SF-36. Only articles that included interviews of patients both before and after surgical or medical endometriosis treatment or those articles that compared study groups were considered. The qualitative analysis was based on 37 articles, whereas the quantitative analysis utilized 14 articles. The research participants included 11,101 women, among whom 6,888 patients were diagnosed with endometriosis. The analysis recorded 17 studies dealing with all types of endometriosis, 9 studies dealing with deep infiltrative endometriosis (DIE), and 9 studies dealing with bowel endometriosis or DIE with bowel involvement. QOL was evaluated using only SF-36 in 12 studies that collectively included 1,912 women and using SF-36 in association with other questionnaires in 25 studies that collectively included 8,022 women. For patients with endometriosis, physical functioning [odds ratio (OR), 78.87; 95% confidence interval (CI), 68.97-88.77; I²=98.77%; P≤0.001] was the most affected life parameter. This parameter showed the highest improvement after surgical intervention (OR, 63.39; 95% CI, 48.71-78.07; I²=97.65%; P≤0.001) or hormonal treatment (OR, 38.65; 95% CI, 14.39-62.91; I²=38.65%; P≤0.001). The 36-item survey generic questionnaire seems to be an efficient tool for assessment of the QOL of life of women with endometriosis who are undergoing surgical or medical treatment. It can be applied before and after the procedure, and it can also be used for comparing study groups.

Incidence of thyroid carcinomas in an extended retrospective study of 526 autopsies

Thyroid cancer accounts for 1% of all malignancies, and is becoming increasingly common worldwide. The literature reports a prevalence of ~50% of thyroid nodules detected during autopsies in subjects with unknown thyroid pathology. An extended retrospective study of 526 autopsy cases was performed to identify the prevalence of thyroid carcinoma, among various types of thyroid nodules identified incidentally. Tissue samples were taken from thyroid nodules, for investigation of the presence of thyroid carcinoma, along with their macroscopic and microscopic features by means of histopathology and immunohistochemistry (IHC) methods. Histopathological diagnosis of malignancy was found in 51 cases of analyzed thyroid samples. Systematic detailed studies demonstrated that a thyroid gland, apparently normal on macroscopic examination, may be the site of pathological manifestations, sometimes presenting carcinomatous findings. Among thyroid carcinomas, the highest frequency was that of papillary microcarcinomas, which have a long evolution, and are incidentally detected during autopsies. Papillary microcarcinoma is an extremely common incidental finding and the vast majority of these tumors pursue a benign course. Furthermore, it is therefore necessary to create national screening programs for the early detection of thyroid carcinoma.

Minimally invasive biopsy in retroperitoneal tumors

Minimally invasive biopsy procedures have proven over the years to be essential for obtaining a correct diagnosis of retroperitoneal tumors, that allows proper therapeutical conduct. These procedures offer valuable tissue fragments for histopathological examination, that permits the distinction between benign and malignant tumors, identifying the tumors that can benefit from neo-adjuvant treatments, such as chemotherapy or radiotherapy and those that have a direct surgical indication. We have searched the existing data regarding minimally invasive biopsy in retroperitoneal tumors using the PubMed database, in order to evaluate the role of this procedure in establishing a correct diagnosis, as well as to find out the risks of tumor cell seeding and local recurrence after needle biopsy. The risk of tumor cell seeding is very low (<2%) and in some cases, it is considered negligible (<0.5%). Compared to open biopsy, needle biopsy seems to be associated with a significantly lower risk of tumor cell seeding. According to the existing data, the incidence of needle track tumor cell seeding also depends on the histological type of the tumors. Image-guided retroperitoneal biopsy has proven to be low cost, accessible, and a reliable procedure (in terms of diagnostic accuracy), usually associating with a low rate of complications and a low risk of tumor seeding. Several authors have underlined the importance of the retroperitoneal approach and the association with a co-axial imaging technique in order to avoid potentially deadly complications.