Characteristics of discharged patients from hospitals - Georgian descriptive study

COVID-19, the disease caused by the novel coronavirus, started spreading rapidly across the world. Although, many aspects of disease is still under the observation. Therefore, in this study retrospectively was investigated the data on patients discharged from Georgian hospitals between February and June.

According to Georgian regulation, all patients with confirmed COVID-19 should be hospitalized. The data sources were hospitalization registry and the standardized case report forms. In this descriptive study, epidemiological characteristics of 500 COVID-19 cases confirmed with PCR tests were analyzed. Among variables were: gender, age and geographic distribution, disease characteristics, underlying health conditions, test-related features, etc.

Majority of patients (72.0%) were admitted to hospitals by the ambulance. The mean age of the patients was 43 years. The sex distribution was merely the same for both genders (49.4% male and 50.6% female). The most common symptoms were fever (82.4%, 95% CI 78.4-85.9), fatigue (49.6%, 95% CI 44.7-54.5), and cough (38.3%, 95% CI 33.6-43.1). The proportion of asymptomatic cases during the PCR testing were 16.6%. More than one symptom was observed in 57.6% of patients. Most common underlying health conditions were cardiovascular diseases (21.8%), diabetes (7.6%), kidney disease (3.6%), chronic lung disease (2.4%), cancer (2.2%), and chronic hepatitis (1.8%). Disease severity significantly differ among cases. Of those without comorbidity conditions, 94% had mild severity. However, among those with comorbidity conditions 35% were sever or critical. 50% of patients were reported as obese. The proportion of severe or critical patients was higher with BMI-18.5-24.9 and BMI ≥30. The case-fatality rate was 2.6%, with majority of deaths among aged ≥70.

The severity of illness was strongly associated with comorbidity conditions and BMI. These findings are important to contribute and improve evidence-based knowledge for the novel coronavirus.

Global, regional, and national age-sex-specific mortality and life expectancy, 1950-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Assessments of age-specific mortality and life expectancy have been done by the UN Population Division, Department of Economics and Social Affairs (UNPOP), the United States Census Bureau, WHO, and as part of previous iterations of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD). Previous iterations of the GBD used population estimates from UNPOP, which were not derived in a way that was internally consistent with the estimates of the numbers of deaths in the GBD. The present iteration of the GBD, GBD 2017, improves on previous assessments and provides timely estimates of the mortality experience of populations globally.

METHODS

The GBD uses all available data to produce estimates of mortality rates between 1950 and 2017 for 23 age groups, both sexes, and 918 locations, including 195 countries and territories and subnational locations for 16 countries. Data used include vital registration systems, sample registration systems, household surveys (complete birth histories, summary birth histories, sibling histories), censuses (summary birth histories, household deaths), and Demographic Surveillance Sites. In total, this analysis used 8259 data sources. Estimates of the probability of death between birth and the age of 5 years and between ages 15 and 60 years are generated and then input into a model life table system to produce complete life tables for all locations and years. Fatal discontinuities and mortality due to HIV/AIDS are analysed separately and then incorporated into the estimation. We analyse the relationship between age-specific mortality and development status using the Socio-demographic Index, a composite measure based on fertility under the age of 25 years, education, and income. There are four main methodological improvements in GBD 2017 compared with GBD 2016: 622 additional data sources have been incorporated; new estimates of population, generated by the GBD study, are used; statistical methods used in different components of the analysis have been further standardised and improved; and the analysis has been extended backwards in time by two decades to start in 1950.

FINDINGS

Globally, 18·7% (95% uncertainty interval 18·4-19·0) of deaths were registered in 1950 and that proportion has been steadily increasing since, with 58·8% (58·2-59·3) of all deaths being registered in 2015. At the global level, between 1950 and 2017, life expectancy increased from 48·1 years (46·5-49·6) to 70·5 years (70·1-70·8) for men and from 52·9 years (51·7-54·0) to 75·6 years (75·3-75·9) for women. Despite this overall progress, there remains substantial variation in life expectancy at birth in 2017, which ranges from 49·1 years (46·5-51·7) for men in the Central African Republic to 87·6 years (86·9-88·1) among women in Singapore. The greatest progress across age groups was for children younger than 5 years; under-5 mortality dropped from 216·0 deaths (196·3-238·1) per 1000 livebirths in 1950 to 38·9 deaths (35·6-42·83) per 1000 livebirths in 2017, with huge reductions across countries. Nevertheless, there were still 5·4 million (5·2-5·6) deaths among children younger than 5 years in the world in 2017. Progress has been less pronounced and more variable for adults, especially for adult males, who had stagnant or increasing mortality rates in several countries. The gap between male and female life expectancy between 1950 and 2017, while relatively stable at the global level, shows distinctive patterns across super-regions and has consistently been the largest in central Europe, eastern Europe, and central Asia, and smallest in south Asia. Performance was also variable across countries and time in observed mortality rates compared with those expected on the basis of development.

INTERPRETATION

This analysis of age-sex-specific mortality shows that there are remarkably complex patterns in population mortality across countries. The findings of this study highlight global successes, such as the large decline in under-5 mortality, which reflects significant local, national, and global commitment and investment over several decades. However, they also bring attention to mortality patterns that are a cause for concern, particularly among adult men and, to a lesser extent, women, whose mortality rates have stagnated in many countries over the time period of this study, and in some cases are increasing.

FUNDING

Bill & Melinda Gates Foundation.

Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016

BACKGROUND

A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016.

METHODS

Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita.

FINDINGS

In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries.

INTERPRETATION

GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Detailed assessments of mortality patterns, particularly age-specific mortality, represent a crucial input that enables health systems to target interventions to specific populations. Understanding how all-cause mortality has changed with respect to development status can identify exemplars for best practice. To accomplish this, the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) estimated age-specific and sex-specific all-cause mortality between 1970 and 2016 for 195 countries and territories and at the subnational level for the five countries with a population greater than 200 million in 2016.

METHODS

We have evaluated how well civil registration systems captured deaths using a set of demographic methods called death distribution methods for adults and from consideration of survey and census data for children younger than 5 years. We generated an overall assessment of completeness of registration of deaths by dividing registered deaths in each location-year by our estimate of all-age deaths generated from our overall estimation process. For 163 locations, including subnational units in countries with a population greater than 200 million with complete vital registration (VR) systems, our estimates were largely driven by the observed data, with corrections for small fluctuations in numbers and estimation for recent years where there were lags in data reporting (lags were variable by location, generally between 1 year and 6 years). For other locations, we took advantage of different data sources available to measure under-5 mortality rates (U5MR) using complete birth histories, summary birth histories, and incomplete VR with adjustments; we measured adult mortality rate (the probability of death in individuals aged 15-60 years) using adjusted incomplete VR, sibling histories, and household death recall. We used the U5MR and adult mortality rate, together with crude death rate due to HIV in the GBD model life table system, to estimate age-specific and sex-specific death rates for each location-year. Using various international databases, we identified fatal discontinuities, which we defined as increases in the death rate of more than one death per million, resulting from conflict and terrorism, natural disasters, major transport or technological accidents, and a subset of epidemic infectious diseases; these were added to estimates in the relevant years. In 47 countries with an identified peak adult prevalence for HIV/AIDS of more than 0·5% and where VR systems were less than 65% complete, we informed our estimates of age-sex-specific mortality using the Estimation and Projection Package (EPP)-Spectrum model fitted to national HIV/AIDS prevalence surveys and antenatal clinic serosurveillance systems. We estimated stillbirths, early neonatal, late neonatal, and childhood mortality using both survey and VR data in spatiotemporal Gaussian process regression models. We estimated abridged life tables for all location-years using age-specific death rates. We grouped locations into development quintiles based on the Socio-demographic Index (SDI) and analysed mortality trends by quintile. Using spline regression, we estimated the expected mortality rate for each age-sex group as a function of SDI. We identified countries with higher life expectancy than expected by comparing observed life expectancy to anticipated life expectancy on the basis of development status alone.

FINDINGS

Completeness in the registration of deaths increased from 28% in 1970 to a peak of 45% in 2013; completeness was lower after 2013 because of lags in reporting. Total deaths in children younger than 5 years decreased from 1970 to 2016, and slower decreases occurred at ages 5-24 years. By contrast, numbers of adult deaths increased in each 5-year age bracket above the age of 25 years. The distribution of annualised rates of change in age-specific mortality rate differed over the period 2000 to 2016 compared with earlier decades: increasing annualised rates of change were less frequent, although rising annualised rates of change still occurred in some locations, particularly for adolescent and younger adult age groups. Rates of stillbirths and under-5 mortality both decreased globally from 1970. Evidence for global convergence of death rates was mixed; although the absolute difference between age-standardised death rates narrowed between countries at the lowest and highest levels of SDI, the ratio of these death rates-a measure of relative inequality-increased slightly. There was a strong shift between 1970 and 2016 toward higher life expectancy, most noticeably at higher levels of SDI. Among countries with populations greater than 1 million in 2016, life expectancy at birth was highest for women in Japan, at 86·9 years (95% UI 86·7-87·2), and for men in Singapore, at 81·3 years (78·8-83·7) in 2016. Male life expectancy was generally lower than female life expectancy between 1970 and 2016, and the gap between male and female life expectancy increased with progression to higher levels of SDI. Some countries with exceptional health performance in 1990 in terms of the difference in observed to expected life expectancy at birth had slower progress on the same measure in 2016.

INTERPRETATION

Globally, mortality rates have decreased across all age groups over the past five decades, with the largest improvements occurring among children younger than 5 years. However, at the national level, considerable heterogeneity remains in terms of both level and rate of changes in age-specific mortality; increases in mortality for certain age groups occurred in some locations. We found evidence that the absolute gap between countries in age-specific death rates has declined, although the relative gap for some age-sex groups increased. Countries that now lead in terms of having higher observed life expectancy than that expected on the basis of development alone, or locations that have either increased this advantage or rapidly decreased the deficit from expected levels, could provide insight into the means to accelerate progress in nations where progress has stalled.

FUNDING

Bill & Melinda Gates Foundation, and the National Institute on Aging and the National Institute of Mental Health of the National Institutes of Health.

Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015: a novel analysis from the Global Burden of Disease Study 2015

BACKGROUND

National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015.

METHODS

We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure-the Healthcare Quality and Access (HAQ) Index-on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time.

FINDINGS

Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0-42·8) in 1990 to 53·7 (52·2-55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015.

INTERPRETATION

This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015

BACKGROUND

Improving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures.

METHODS

We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD 2013 and GBD 2010. Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing. We also expanded the database of vital registration, survey, and census data to 14 294 geography-year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

FINDINGS

Globally, life expectancy from birth increased from 61·7 years (95% uncertainty interval 61·4-61·9) in 1980 to 71·8 years (71·5-72·2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11·3 years (3·7-17·4), to 62·6 years (56·5-70·2). Total deaths increased by 4·1% (2·6-5·6) from 2005 to 2015, rising to 55·8 million (54·9 million to 56·6 million) in 2015, but age-standardised death rates fell by 17·0% (15·8-18·1) during this time, underscoring changes in population growth and shifts in global age structures. The result was similar for non-communicable diseases (NCDs), with total deaths from these causes increasing by 14·1% (12·6-16·0) to 39·8 million (39·2 million to 40·5 million) in 2015, whereas age-standardised rates decreased by 13·1% (11·9-14·3). Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42·1%, 39·1-44·6), malaria (43·1%, 34·7-51·8), neonatal preterm birth complications (29·8%, 24·8-34·9), and maternal disorders (29·1%, 19·3-37·1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000-183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000-532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death.

INTERPRETATION

At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.

METHODS

We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.

FINDINGS

292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland.

INTERPRETATION

Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.

FUNDING

Bill & Melinda Gates Foundation.

Carcinogenesis--a new point of view

Presented article suggests the novel hypothesis of carcinogenesis, where the key moment for all types (biological, physical, chemical) of carcinogenesis has been discussed. For confirmation of the hypothesis thorough theoretical analysis of the mechanisms of malignant transformation of cells after influence of any type of carcinogens and results of experiments have been presented. Hypothesis highlights are formulated as follows: 1) Covalent bond disorders between S+-methionine and Fe3+ atoms in cytochrome; 2) Electron transport chain blockade with certain ligand after its penetration in cytochrome pocket with further formation of 6th coordination bond between ligand and Fe atom (in one case increase in mitochondrial pH precede-, and in other, it follows electron transport chain blockade in cytochromes); 3) Fe3+ reduction up to Fe2+ leading to blockade of aerobic glycolysis; 4) Decrease in enzyme (Е1-TDP, oxidases etc.) activity due to mitochondrial pH alterations; 5) Production of S-adenosylmethionine owing to lipoic acid amide leading to accumulation of homocysteine in cytoplasm with further penetration in cell nucleus producing DNA mutations; 6) Fe2+ wash-out from cytochrome and its deposition in ferritin.

Anticancer efficacy of hydroxyethylthiamine diphosphate in vivo

AIM

The aim of the presented article was investigation of anticancer efficacy of hydroxyethylthiamine diphosphate (HTD) in vivo.

MATERIALS AND METHODS

The study was carried out on 30 C57BL/6J mice subcutaneously transplanted with Ehrlich carcinoma. Animals were treated with intraperitoneal injections of the solution composed from pyruvic acid and thiamine bromide every other day during 10 days and thereafter, every day during 2 weeks. Treatment efficacy was evaluated by tumor growth inhibition.

RESULTS

In experimental animals treated with HTD, significant tumor growth inhibition has been registered: 73% at day 45(th) compared to the control group (p < 0.001).

CONCLUSION

Treatment with HTD demonstrated high anticancer efficacy in vivo.

[Bacterial phagelysates and malignant tumor growth]

Anti-tumor preventive efficacy of E.coli phagelysate has been studied. Investigations were conducted on 2-3 months 48 male mice. Regimen of preventive vaccinations were: single - 0,25 ml phagelysate intraperitoneal injection, 3 days before Ehrlich carcinoma inoculation (1x10(6) tumor cells); 3 times vaccinations (0,25 ml, with 3 day intervals) 3, 6, and 9 days before inoculation of carcinoma; and 10 times (during 10 days, before inoculation of carcinoma). Treatment efficacy was evaluated according to the indices of cancer growth (development of cancer tissue, cancer growth inhibition percent, lifespan and survival percent). Experiments have shown that single and 3 times preventive vaccinations inhibited tumor development and delayed malignant growth, while, 10 times permanent vaccinations had no effects on cancer growth. Cancer growth inhibition percent in single and 3 times vaccinated animals were 58% on the average. Maximal lifespan in control group mice consisted 59 days. By the 125th day of cancer growth, at single vaccination 17% of mice were alive, while in 3 times vaccinated mice the survival percent was 25%. Anti-tumor potential of E.coli pagelysate supposedly could be explained by immunoregulatory properties of the preparation.

The novel hypothesis of carcinogenesis and anti-cancer treatment perspectives - Hydroxyethylthiamine diphosphate

In presented article, the novel hypothesis of carcinogenesis, and thorough discussion of some essential biochemical mechanisms which might be responsible for the malignant transformation of cells (bond disorders between Fe(3+) and S(+)-methionine in cytochrome; blockage of the last 3-d orbital of Fe by the certain ligand and formation of 6th coordinated bond leading to Fe(3+) reduction up to Fe(2+) and cessation of tissue respiration; increase in mitochondrial pH and further in cell, leading to decreased activity of most of enzymes (thiamine diphosphate, oxidases); formation of S-adenosyl-methionine with its further dissociation and production of adenosine and homocysteine; effects of homocysteine on DNA structures, homocysteine-induced dimethylation of certain nitrogen basis and their extrusion from strands of DNA leading to mutations and cellular atypism) has been suggested. Along with theoretical discussions, article provides results of preliminary investigations carried out on C57Bl/6J mice with Ehrlich carcinoma aimed to capture lipoic acid amide with Hydroxyethylthiamine diphosphate, and study effects of Hydroxyethylthiamine diphosphate against malignant transformation of cells. Experiments have shown inhibition of cancer growth in treated animals. Morphological investigations of cancer tissue revealed necrotic zones, inflammatory infiltrations, central necrosis with adjacent inflammatory mono- and polymorph infiltrations, must cells, segmento-nuclear leukocytes, lymphadenoid follicular hyperplasia. According to the novel hypothesis of carcinogenesis and results of experiments the new approaches and perspectives of anti-cancer treatment with the use of Hydroxiethyl-thiamine diphosphate has been suggested.

Antitumor and adjuvant effects of phagelysates of E.coli in mice with Ehrlich carcinoma

AIM

To augment anti-tumor host response and overcome the tumor-induced immunosuppression is of paramount importance especially when patient is subjected to radio-/chemotherapy and immune system suffers significantly. Various immunological methods have been employed as supplemental antitumor therapies. We were aimed to investigate the antitumor potential of phagelysates of gram-negative bacteria and their adjuvant effects for conventional chemotherapy in experiment.

METHODS

Bacterial phagelysates of E.coli and purified suspensions of corresponding Un bacteriophage were obtained by standard methods of phage research. Experiments were carried out on BL57C/6J mice bearing transplanted Ehrlich carcinoma. Different regimens of phagelysate administration (0,5 ml E. coli phagelysate, 3/8 times with 5 day intervals) and conventional chemotherapy (combination of Doxorubicin 60 mg/m2, Cyclophosphan 800 mg/m(2), Ftoruracil 600 mg/m(2), 3 times with 21 day intervals) were tested. Treatment efficacy was evaluated by tumor growth inhibition percent, index of malignant growth, lifespan and survival percent.

RESULTS

Experiments have shown that application of optimal doses of E. coli phagelysate can be well tolerated in mice. No stimulation or support of malignant growth was observed. E. coli phagelysate exhibited significant anticancer effect and adjuvant efficacy. Cancer development was delayed in 65% of inoculated animals in the test group. E. coli phagelysate inhibited tumor growth by 80-90% without apparent side effects. The mice survival was prolonged twice and more. On 65th-69th days of tumor growth in 13% animals complete regression of neoplasms was registered. Application of phagelysates in combination with chemotherapy significantly increased antitumor efficacy of conventional chemotherapeutic drugs.

CONCLUSION

Application of bacterial phagelysates can be considered as promising novel strategy in cancer therapeutics.

Addictive potential of Tianeptine - the threatening reality

A total of 24 patients (male volunteers), consumers of opiates in the past and suffering from Tianeptine abuse, were under clinical observation. The age range of patients was from 21 to 33 years. Tianeptine consumption history was 5 months duration on the average. The daily dose of preparation was 40 tablets (500 mg intravenous injections on the average). Patients used Tianeptine in combination with antihistamines (Promethazine, Suprastin). Research was carried out with the use of clinical, psychological and laboratory methods. Has been used Ch. Spilberger's scale of anxiety and T. Balashov's scale of depression. Comparison of withdrawal syndrome developed after cessation of Tianeptine and opiates consumption has shown that in case of Tianeptine, in the dynamic of withdrawal syndrome predominates well expressed high-level of anxiety and depression, while at opiates consumption - withdrawal syndrome is characterized by algesic events and vegetodysfunctions. Supposedly, Tianeptine, in contrast to other anti-depressants, stimulates release of neurotransmitter dopamine in nucleus Accumbens, that probably determine addictive potential of this drug. High level of anxiety, excitability and vegetodysfunctions, presumably could be explained by activation of the NMDA (glutamate receptors) receptor system in Locus coeruleus, and in vegetative ganglion. In the present article potential threat that may develop at Tianeptine consumption, especially in former opiate consumers, without medical purposes has been emphasized.

Effects of carvedilol, losartan and trimetazidin on functional parameters of isolated heart of rats at oxidative stress

Effects of carvedilol, lozartan and trimetazidin on functional parameters of isolated heart (heart rate and volume speed of coronary blood flow) of rats at oxidative stress have been studied with the use of Langendorf's method. Experiments have been carried out on 32 pubertal white rats (with body mass 220-250 g). Oxidative stress was induced through perfusion of hydrogen peroxide (with concentration - 4.10 -5 M). Obtained results were analyzed statistically according to the Student's t criterion. Studies have shown that carvedilol and trimetazidin have well expressed antioxidant and cardio protective effects at oxidative stress provoked by hydrogen peroxide compared to lozartan. Moreover, effect of carvedilol on HR and VsCBf was especially obvious than effects of Trimetazidin. Antioxidant and positive treatment effects of carvedilol could be explained by its wide range of pharmacological ability: as nonselective beta-adrenoblocker (via inhibition of adenylatecyclase and decreasing cyclic adenosinemonophosphate), alpha 1-adrenoblocker (decreasing activation of phospholipase C and concentration of inositoltriphosphate, diacylglicerole and Ca(++)) and antioxidant. It is suggested that positive effects of carvedilol on HR and VsCBf at oxidative stress are related with wide range of pharmacological mechanisms of preparation. Cardio protective effects of carvedilol at oxidative stress (revealed in our experiments) along with other positive cardio - hemodynamic peculiarities perhaps is very important and could be used successfully at treatment of cardio-vascular system diseases.

Anti-tumor preventative effect of mono-therapy with the use of proteus vaccine, Staphylococcus antitoxin and divaccine of Staphylococcus-proteus

Anti-tumor preventative effect of mono-therapy with the use of Proteus vaccine, Staphylococcus antitoxin and divaccine of Staphylococcus-Proteus has been studied. Experiments were carried out on 80 non-purebred laboratory white mice (age--3-3,5 months, body mass--18-20 g) and 60 rats (body mass--100-120 g) using intraperitoneal inoculation of Ehrlich's adenocarcinoma (ascitic form--EAT, in mice, cancer cells--3 x 10(6)), and subcutaneous inoculation of Sarcoma S-45 (in rats). Anti-tumor preventative effect of bacterial vaccines and immunization was evaluated according to the following parameters: Frequency of cancer development, Inhibition of cancer growth, Body mass index of experimental animals, Volume of ascitic fluid. Results of experiments have shown that use of bacterial polysaccharides with preventative purposes has better effect at S-45 growth than at EAT growth; Vaccination with Proteus prolongs lifespan mach more than vaccination with antitoxin of Staphylococcus; Vaccination with complex divaccine of Staphylococcus-Proteus causes complete resorption of tumors from 32 to 60 days; Development of experimental malignant tumors depends on type of anti-microbial vaccines and starting date of inoculation after completion of vaccination.

[Correlated changes and value of redox-status, nitric oxide and blood supply in experimental malignant tumor growth]

With the use of methods of electronic paramagnetic resonance (EPR) and polarography EPR specter of tumor tissue, content of free nitric oxide and intensity of local hemo circulation in dynamics of sarcoma S-45 growth has been studied. It was stated that the intensity of local hemo circulation (especially in center of tumor tissue) progressively decreases. Sharp decrease of hemo circulation in the central part of the tumor tissue could be explained by drastically reduced concentration of NO, which in turn is related to disorders in electron transport in mitochondrial respiratory chain and probably to conversion of NO into toxic peroxinitrite. The relatively less expressed decrease of local hemo circulation in periphery, despite impaired reheological features of the blood, is explained by increased concentration of NO. It is suggest, that tumor tissue blood supply enhancement increases chemotherapeutic effects via affecting energetic metabolism in mitochondria, redox-status and concentration of free NO.