Global, regional, and national incidence and mortality burden of non-COVID-19 lower respiratory infections and aetiologies, 1990-2021: a systematic analysis from the Global Burden of Disease Study 2021

BACKGROUND

Lower respiratory infections (LRIs) are a major global contributor to morbidity and mortality. In 2020-21, non-pharmaceutical interventions associated with the COVID-19 pandemic reduced not only the transmission of SARS-CoV-2, but also the transmission of other LRI pathogens. Tracking LRI incidence and mortality, as well as the pathogens responsible, can guide health-system responses and funding priorities to reduce future burden. We present estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 of the burden of non-COVID-19 LRIs and corresponding aetiologies from 1990 to 2021, inclusive of pandemic effects on the incidence and mortality of select respiratory viruses, globally, regionally, and for 204 countries and territories.

METHODS

We estimated mortality, incidence, and aetiology attribution for LRI, defined by the GBD as pneumonia or bronchiolitis, not inclusive of COVID-19. We analysed 26 259 site-years of mortality data using the Cause of Death Ensemble model to estimate LRI mortality rates. We analysed all available age-specific and sex-specific data sources, including published literature identified by a systematic review, as well as household surveys, hospital admissions, health insurance claims, and LRI mortality estimates, to generate internally consistent estimates of incidence and prevalence using DisMod-MR 2.1. For aetiology estimation, we analysed multiple causes of death, vital registration, hospital discharge, microbial laboratory, and literature data using a network analysis model to produce the proportion of LRI deaths and episodes attributable to the following pathogens: Acinetobacter baumannii, Chlamydia spp, Enterobacter spp, Escherichia coli, fungi, group B streptococcus, Haemophilus influenzae, influenza viruses, Klebsiella pneumoniae, Legionella spp, Mycoplasma spp, polymicrobial infections, Pseudomonas aeruginosa, respiratory syncytial virus (RSV), Staphylococcus aureus, Streptococcus pneumoniae, and other viruses (ie, the aggregate of all viruses studied except influenza and RSV), as well as a residual category of other bacterial pathogens.

FINDINGS

Globally, in 2021, we estimated 344 million (95% uncertainty interval [UI] 325-364) incident episodes of LRI, or 4350 episodes (4120-4610) per 100 000 population, and 2·18 million deaths (1·98-2·36), or 27·7 deaths (25·1-29·9) per 100 000. 502 000 deaths (406 000-611 000) were in children younger than 5 years, among which 254 000 deaths (197 000-320 000) occurred in countries with a low Socio-demographic Index. Of the 18 modelled pathogen categories in 2021, S pneumoniae was responsible for the highest proportions of LRI episodes and deaths, with an estimated 97·9 million (92·1-104·0) episodes and 505 000 deaths (454 000-555 000) globally. The pathogens responsible for the second and third highest episode counts globally were other viral aetiologies (46·4 million [43·6-49·3] episodes) and Mycoplasma spp (25·3 million [23·5-27·2]), while those responsible for the second and third highest death counts were S aureus (424 000 [380 000-459 000]) and K pneumoniae (176 000 [158 000-194 000]). From 1990 to 2019, the global all-age non-COVID-19 LRI mortality rate declined by 41·7% (35·9-46·9), from 56·5 deaths (51·3-61·9) to 32·9 deaths (29·9-35·4) per 100 000. From 2019 to 2021, during the COVID-19 pandemic and implementation of associated non-pharmaceutical interventions, we estimated a 16·0% (13·1-18·6) decline in the global all-age non-COVID-19 LRI mortality rate, largely accounted for by a 71·8% (63·8-78·9) decline in the number of influenza deaths and a 66·7% (56·6-75·3) decline in the number of RSV deaths.

INTERPRETATION

Substantial progress has been made in reducing LRI mortality, but the burden remains high, especially in low-income and middle-income countries. During the COVID-19 pandemic, with its associated non-pharmaceutical interventions, global incident LRI cases and mortality attributable to influenza and RSV declined substantially. Expanding access to health-care services and vaccines, including S pneumoniae, H influenzae type B, and novel RSV vaccines, along with new low-cost interventions against S aureus, could mitigate the LRI burden and prevent transmission of LRI-causing pathogens.

FUNDING

Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care (UK).

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Enhanced attenuation of arsenic by Quaternary agricultural soils of Eastern Punjab, India upon anionic clays and gypsum amendment

Agricultural soil of the Sutlej River basin was evaluated for its natural attenuation efficacy for arsenic (As) under the field variables of pH, competitive anions, contact time and varied As contents. The role of layered double hydroxides (HTLDH) and gypsum on uptake efficiency and long-term stability of entrapped As demonstrates rapid As uptake by both geosorbents without mineral structure altering. Arsenic retention by gypsum is poorer than that by HTLDH and greater uptake (∼100% within 2 h) was achieved in the co-precipitation process than adsorption on HTLDH. Freundlich isotherm and pseudo-second-order kinetic model fits of the data demonstrate the multilayer rate-limiting sorption process. NO3- and PO43- hardly affected As retention capacity of HTLDH and gypsum with greater retention at pH 6 and high sorbate concentrations. Studied soil shows a strong potential for As (0.68 g kg-1) which enhanced upon adding HTLDH, while gypsum lowered As retention efficiency of soil except at pH 6.0. Gypsum exhibited relatively greater desorption than HTLDH where almost no As was desorbed in the latter case within seven days of exposure, but ∼30% sorbed As gets desorbed from gypsum which was further enhanced by NO3-+PO43- and soil mixing. Identical behaviour was observed from the soil and HTLDH/gypsum mixture at variable ratios as well. This study shows that MgFe-based HTLDH can efficiently retard arsenic mobilization from the soil with competitive anions and wide pH ultimately limiting As bioavailability in the environment and can be successfully used as a potential scavenger for As remediation purposes.

Global, regional, and national burden of disorders affecting the nervous system, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Disorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.

METHODS

We estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.

FINDINGS

Globally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378-521), affecting 3·40 billion (3·20-3·62) individuals (43·1%, 40·5-45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7-26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6-38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5-32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7-2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.

INTERPRETATION

As the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national age-specific progress towards the 2020 milestones of the WHO End TB Strategy: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Global evaluations of the progress towards the WHO End TB Strategy 2020 interim milestones on mortality (35% reduction) and incidence (20% reduction) have not been age specific. We aimed to assess global, regional, and national-level burdens of and trends in tuberculosis and its risk factors across five separate age groups, from 1990 to 2021, and to report on age-specific progress between 2015 and 2020.

METHODS

We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 (GBD 2021) analytical framework to compute age-specific tuberculosis mortality and incidence estimates for 204 countries and territories (1990-2021 inclusive). We quantified tuberculosis mortality among individuals without HIV co-infection using 22 603 site-years of vital registration data, 1718 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, 680 site-years of mortality surveillance data, and 9 site-years of minimally invasive tissue sample (MITS) diagnoses data as inputs into the Cause of Death Ensemble modelling platform. Age-specific HIV and tuberculosis deaths were established with a population attributable fraction approach. We analysed all available population-based data sources, including prevalence surveys, annual case notifications, tuberculin surveys, and tuberculosis mortality, in DisMod-MR 2.1 to produce internally consistent age-specific estimates of tuberculosis incidence, prevalence, and mortality. We also estimated age-specific tuberculosis mortality without HIV co-infection that is attributable to the independent and combined effects of three risk factors (smoking, alcohol use, and diabetes). As a secondary analysis, we examined the potential impact of the COVID-19 pandemic on tuberculosis mortality without HIV co-infection by comparing expected tuberculosis deaths, modelled with trends in tuberculosis deaths from 2015 to 2019 in vital registration data, with observed tuberculosis deaths in 2020 and 2021 for countries with available cause-specific mortality data.

FINDINGS

We estimated 9·40 million (95% uncertainty interval [UI] 8·36 to 10·5) tuberculosis incident cases and 1·35 million (1·23 to 1·52) deaths due to tuberculosis in 2021. At the global level, the all-age tuberculosis incidence rate declined by 6·26% (5·27 to 7·25) between 2015 and 2020 (the WHO End TB strategy evaluation period). 15 of 204 countries achieved a 20% decrease in all-age tuberculosis incidence between 2015 and 2020, eight of which were in western sub-Saharan Africa. When stratified by age, global tuberculosis incidence rates decreased by 16·5% (14·8 to 18·4) in children younger than 5 years, 16·2% (14·2 to 17·9) in those aged 5-14 years, 6·29% (5·05 to 7·70) in those aged 15-49 years, 5·72% (4·02 to 7·39) in those aged 50-69 years, and 8·48% (6·74 to 10·4) in those aged 70 years and older, from 2015 to 2020. Global tuberculosis deaths decreased by 11·9% (5·77 to 17·0) from 2015 to 2020. 17 countries attained a 35% reduction in deaths due to tuberculosis between 2015 and 2020, most of which were in eastern Europe (six countries) and central Europe (four countries). There was variable progress by age: a 35·3% (26·7 to 41·7) decrease in tuberculosis deaths in children younger than 5 years, a 29·5% (25·5 to 34·1) decrease in those aged 5-14 years, a 15·2% (10·0 to 20·2) decrease in those aged 15-49 years, a 7·97% (0·472 to 14·1) decrease in those aged 50-69 years, and a 3·29% (-5·56 to 9·07) decrease in those aged 70 years and older. Removing the combined effects of the three attributable risk factors would have reduced the number of all-age tuberculosis deaths from 1·39 million (1·28 to 1·54) to 1·00 million (0·703 to 1·23) in 2020, representing a 36·5% (21·5 to 54·8) reduction in tuberculosis deaths compared to those observed in 2015. 41 countries were included in our analysis of the impact of the COVID-19 pandemic on tuberculosis deaths without HIV co-infection in 2020, and 20 countries were included in the analysis for 2021. In 2020, 50 900 (95% CI 49 700 to 52 400) deaths were expected across all ages, compared to an observed 45 500 deaths, corresponding to 5340 (4070 to 6920) fewer deaths; in 2021, 39 600 (38 300 to 41 100) deaths were expected across all ages compared to an observed 39 000 deaths, corresponding to 657 (-713 to 2180) fewer deaths.

INTERPRETATION

Despite accelerated progress in reducing the global burden of tuberculosis in the past decade, the world did not attain the first interim milestones of the WHO End TB Strategy in 2020. The pace of decline has been unequal with respect to age, with older adults (ie, those aged >50 years) having the slowest progress. As countries refine their national tuberculosis programmes and recalibrate for achieving the 2035 targets, they could consider learning from the strategies of countries that achieved the 2020 milestones, as well as consider targeted interventions to improve outcomes in older age groups.

FUNDING

Bill & Melinda Gates Foundation.

Aggressive Alternaria brassicicola with reduced fungicide sensitivity can be associated with naturally infested broccoli seeds

Alternaria brassicicola is a part of Alternaria complex that causes leaf blight and head rot (ABHR) in brassica crops. Infested broccoli seeds can play an important role in introducing A. brassicicola in transplant houses and production fields. However, characterization of natural seed infestation and seed-to-seedling transmission of A. brassicicola in broccoli is yet to be demonstrated. In this research we characterized Alternaria spp. isolates from commercial broccoli seedlots for their species identity, pathogenicity and aggressiveness on broccoli and their sensitivity to Quinone-outside inhibitor (QoI) fungicide (azoxystrobin). Two hundred commercial seedlots from two broccoli cultivars; Cultivar 1 (EC; n=100 seedlots) and Cultivar 2 (ED; n=100 seedlots) were evaluated for the presence of A. brassicicola under in-vitro conditions using a seedling grow-out assay. Alternaria spp. was detected in 31 and 28% of the commercial seedlots of Cultivar 1 and Cultivar 2, respectively. The seed-to-seedling transmission (%) varied considerably within each positive infested seedlot, which ranged from 1.3 to 17.3%. Subsequent molecular identification of single spore cultures (n=138) was made by sequencing four housekeeping genes; actin, the major allergen (Alta1), plasma membrane ATPase and Glyceraldehyde-3-phosphate dehydrogenase (GPD), and later the sequences were concatenated and compared for the phylogenetic distance with diverse Alternaria species. Ninety-six percent (n=133) of the isolates formed a cluster with a known A. brassicicola based on multigene phylogeny, which were later confirmed as A. brassicicola using a species-specific PCR assay. One hundred percent of the A. brassicicola seed isolates (n=133) were either highly- or moderately- aggressive on broccoli (cv. Emerald Crown) based on a detached leaf assay. Sensitivity of representative A. brassicicola isolates (n=58) to azoxystrobin was evaluated using a spore germination assay and the EC50 values (effective fungicide concentration (ppm) at which germination of conidia of isolates were reduced by 50% compared to control) for each isolate was determined. A. brassicicola isolates from naturally infested commercial broccoli seeds were sensitive to azoxystrobin with considerably low EC50 values in the range of <0.0001 ppm to 0.33 ppm; however, there were a few isolates (14%), which showed 100-fold reduced sensitivity from the most sensitive isolate (EC50 =0.0001 ppm). Our results confirm that commercial broccoli seedlots can be naturally contaminated with pathogenic and aggressive A. brassicicola. We also provide evidence for potential presence of A. brassicicola isolates with reduced azoxystrobin-sensitivity in naturally infested commercial broccoli seedlots, which has never been reported before. Together, these findings may have implications in considerations for seed-health testing, seed treatments and greenhouse scouting to limit introduction of infested seedlots in commercial broccoli fields.

Dual production of human mesenchymal stromal cells and derived extracellular vesicles in a dissolvable microcarrier-based stirred culture system

BACKGROUND & AIMS

Cell therapies based on mesenchymal stromal cells (MSCs) have gained an increasing therapeutic interest in the context of multiple disorders. Nonetheless, this field still faces important challenges, particularly concerning suitable manufacturing platforms. Here, we aimed at establishing a scalable culture system to expand umbilical cord-derived Wharton's jelly MSC (MSC(WJ)) and their derived extracellular vesicles (EVs) by using dissolvable microcarriers combined with xeno(geneic)-free culture medium.

METHODS

MSC(WJ) isolated from three donors were cultured at a starting density of 1 × 106 cells per spinner flask, i.e., 2.8 × 103 cells per cm2 of dissolvable microcarrier surface area. After a 6-day expansion period of MSC(WJ), extracellular vesicles (EVs) were produced for 24 h.

RESULTS

Taking advantage of an intermittent agitation regimen, we observed high adhesion rates to the microcarriers (over 90% at 24 h) and achieved 15.8 ± 0.7-fold expansion after 6 days of culture. Notably, dissolution of the microcarriers was achieved through a pectinase-based solution to recover the cell product, reducing the hurdles of downstream processing. MSC identity was validated by detecting the characteristic MSC immunophenotype and by multilineage differentiation assays. Considering the growing interest in MSC-derived EVs, which are known to be mediators of the therapeutic features of MSC, this platform also was evaluated for EV production. Upon a 24-h period of conditioning, secreted EVs were isolated by ultrafiltration followed by anion-exchange chromatography and exhibited the typical cup-shaped morphology, small size distribution (162.6 ± 30.2 nm) and expressed EV markers (CD63, CD9 and syntenin-1).

CONCLUSIONS

Taken together, we established a time-effective and robust scalable platform that complies with clinical-grade standards for the dual production of MSC(WJ) and their derived EV.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Bill & Melinda Gates Foundation.

Impact of Just-in-Time TeamSTEPPS Training on Team Performance in a Pediatric Escape Room Interprofessional Experience

OBJECTIVE

To compare differences in observed and self-reported team dynamics between those who received versus those who did not receive TeamSTEPPS training prior to an interprofessional escape room scenario.

METHODS

Final-year pharmacy (N = 27) and physician assistant (N = 88) students participated in an escape room featuring pediatric dosing, asthma, otitis media, type 1 diabetes, and vaccine fundamentals. In total, 29 teams were randomized to control (14) or intervention arm (15). The control group went to the escape room and then returned to the classroom for a team-building module including TeamSTEPPS training. The intervention group started with the team-building module then went to the escape room. One faculty observer was assigned to each team and utilized the Performance Assessment Communication and Teamwork (PACT) expert-observer form to assess team performance. Post-event, students completed an abbreviated PACT post-assessment and a self-reflection on the prompt "What were the most important takeaways from today's interprofessional education experience?"

RESULTS

On the PACT expert-observer form, significantly higher global scores were noted for the intervention arm on all items except situation monitoring. On the aggregate observer data from all stations, leadership emerged as statistically different between the 2 groups. On the PACT post-assessment, the intervention arm reported significantly more leadership during the simulation. On the self-reflections, 70.9% versus 64% in the control arm recognized the importance of teamwork in managing patients.

CONCLUSIONS

Just-in-time TeamSTEPPS training improved observed and to a lesser extent, self-reported teamwork and communication skills. Incorporating TeamSTEPPS training immediately prior to an interprofessional education experience may enhance team performance.

Development of high-yielding white maize hybrids with better chapatti-making quality compared to traditionally used local landraces

Introduction

The present research focuses on the chapatti making quality of high-yielding white maize hybrids compared to available low-yielding local yellow and white landraces in India.

Materials and methods

In this study, the top nine superior hybrids were selected for testing the physical properties of the maize kernels, proximate composition of flours and chapattis, physical parameters of chapatti, textural properties, sensory evaluation of chapattis and pasting properties of maize flour.

Results and discussion

The results revealed the superiority of white maize hybrids (WMH), viz., WHM 1, WHM 2, and WHM 8 over the local yellow and white landraces for most of the parameters studied. In sensory analysis, though, the yellow landrace was considered superior by the panellists in terms of colour but the white maize hybrids outperformed in overall sensory analysis and were more acceptable than the yellow and white maize landraces. These high yielding white maize hybrids with good consumer acceptance may cater for the needs of rural and tribal populations in India who prefer white maize as a staple food.

Temporal patterns of cancer burden in Asia, 1990-2019: a systematic examination for the Global Burden of Disease 2019 study

Background

Cancers represent a challenging public health threat in Asia. This study examines the temporal patterns of incidence, mortality, disability and risk factors of 29 cancers in Asia in the last three decades.

Methods

The age, sex and year-wise estimates of incidence, mortality, and disability-adjusted life years (DALYs) of 29 cancers for 49 Asian countries from 1990 through 2019 were generated as a part of the Global Burden of Disease, Injuries and Risk Factors 2019 study. Besides incidence, mortality and DALYs, we also examined the cancer burden measured in terms of DALYs and deaths attributable to risk factors, which had evidence of causation with different cancers. The development status of countries was measured using the socio-demographic index. Decomposition analysis was performed to gauge the change in cancer incidence between 1990 and 2019 due to population growth, aging and age-specific incidence rates.

Findings

All cancers combined claimed an estimated 5.6 million [95% uncertainty interval, 5.1-6.0 million] lives in Asia with 9.4 million [8.6-10.2 million] incident cases and 144.7 million [132.7-156.5 million] DALYs in 2019. The age-standardized incidence rate (ASIR) of all cancers combined in Asia was 197.6/100,000 [181.0-214.4] in 2019, varying from 99.2/100,000 [76.1-126.0] in Bangladesh to 330.5/100,000 [298.5-365.8] in Cyprus. The age-standardized mortality rate (ASMR) was 120.6/100,000 [110.1-130.7] in 2019, varying 4-folds across countries from 71.0/100,000 [59.9-83.5] in Kuwait to 284.2/100,000 [229.2-352.3] in Mongolia. The age-standardized DALYs rate was 2970.5/100,000 [2722.6-3206.5] in 2019, varying from 1578.0/100,000 [1341.2-1847.0] in Kuwait to 6574.4/100,000 [5141.7-8333.0] in Mongolia. Between 1990 and 2019, deaths due to 17 of the 29 cancers either doubled or more, and 20 of the 29 cancers underwent an increase of 150% or more in terms of new cases. Tracheal, bronchus, and lung cancer (both sexes), breast cancer (among females), colon and rectum cancer (both sexes), stomach cancer (both sexes) and prostate cancer (among males) were among top-5 cancers in most Asian countries in terms of ASIR and ASMR in 2019 and cancers of liver, stomach, hodgkin lymphoma and esophageal cancer posted the most significant decreases in age-standardized rates between 1990 and 2019. Among the modifiable risk factors, smoking, alcohol use, ambient particulate matter (PM) pollution and unsafe sex remained the dominant risk factors between 1990 and 2019. Cancer DALYs due to ambient PM pollution, high body mass index and fasting plasma glucose has increased most notably between 1990 and 2019.

Interpretation

With growing incidence, cancer has become more significant public health threat in Asia, demanding urgent policy attention and guidance. Its heightened risk calls for increased cancer awareness, preventive measures, affordable early-stage detection, and cost-effective therapeutics in Asia. The current study can serve as a useful resource for policymakers and researchers in Asia for devising interventions for cancer management and control.

Funding

The GBD study is funded by the Bill and Melinda Gates Foundation.

Pathology, target discovery, and the evolution of XO inhibitors from the first discovery to recent advances (2020-2023)

Hyperuricemia, a disease characterized by elevation of serum uric acid level beyond 6 mg/dL. This elevation led to appearance of symptoms from joint pain to gout and from gout to difficulty in mobility of the patient. So, in this review, we have summarized the pathology of hyperuricemia, discovery of target and discovery of first XO inhibitor. At last, this review provides in-sights about the recently discovered as natural XO inhibitors, followed by design, structure activity relationship and biological activity of synthetic compounds as XO inhibitors discovered between 2020 and 2023 years. At last, the pharmacophores generated in this study will guide new researchers to design and modify the structure of novel XO inhibitors.

Aloe vera/Chitosan-Based Edible Film with Enhanced Antioxidant, Antimicrobial, Thermal, and Barrier Properties for Sustainable Food Preservation

Food bioactive packaging has received increasing attention from consumers and the food industry for its potential to reduce food waste and environmental issues. Several materials can be used to produce edible films/coats; however, bio-based, cost-effective, and sustainable coatings have gained a high reputation these days. For instance, Aloe vera gel (AV) is a promising bio-based material for edible coatings and films; therefore, the present study aimed to investigate the film-forming abilities of AV and Chitosan (CH) combination as a potential active food packaging material. The physicochemical and mechanical characteristics of formed films of various combinations were prepared at different concentrations, i.e., CH (0.5% w/v), AV (100%), CH:AV (75:25), and CH:AV (60:40). The results showed significant differences among all the prepared edible films wherein these differences were mainly on account of incorporating AV gel. The rheological and antioxidant properties of the formulations improved with the inclusion of AV gel. The films composed of CH:AV (60:40) positively affected the water solubility, thermal properties, and water vapour permeability of the edible films. The X-ray Diffraction (XRD) and Scanning electron microscopy (SEM) results showed that the films composed of CH:AV, (60:40) were amorphous and had smooth morphology. Further, the edible film solutions were applied to fresh figs (Ficus carica) to investigate their role in preserving fruits during storage. A significant reduction in microbial growth was found in coated fruits after 28 days of cold storage. The films composed of CH and AV showed overall improved results compared to the CH (0.5%, w/v). Therefore, the used formulations (CH:AV, 60:40) can form a sustainable film that has the potential to be utilized for fresh product preservation to maintain its quality and shelf life.

Evaluation of Stagonospora Nodorum Blotch Severity and Parastagonospora nodorum Population Structure and Genetic Diversity Across Multiple Locations and Wheat Varieties in Virginia

Parastagonospora nodorum is a necrotrophic pathogen that causes Stagonospora nodorum blotch (SNB) in wheat. Wheat varieties grown in Virginia vary in susceptibility to SNB, and the severity of SNB varies across locations and years. However, the impacts of wheat genetic backgrounds and environments on SNB severity and the structure of P. nodorum populations in the region have not been well studied. Thus, a population genetic study was conducted utilizing P. nodorum isolates collected from different wheat varieties and locations in Virginia. A total of 320 isolates were collected at seven locations over 2 years from five wheat varieties. Isolates were genotyped using multilocus simple sequence repeat markers, and necrotrophic effector (NE) and mating type genes were amplified using gene-specific primers. Wheat varieties varied in susceptibility to SNB, but site-specific environmental conditions were the primary drivers of disease severity. Fungal populations were genetically diverse, but no genetic subdivision was observed among locations or varieties. The ratio of the two mating type idiomorphs was not significantly different from 1:1, consistent with the P. nodorum population undergoing sexual reproduction. Three major NE genes were detected within the P. nodorum population, but not with equal frequency. However, NE gene profiles were similar for groups of isolates originating from different varieties, suggesting that wheat genetic backgrounds do not differentially select for NEs. There was no evidence of population structure among P. nodorum populations in Virginia and, thus, no support for wheat genetic backgrounds shaping these populations. Finally, although varieties only exhibited moderate resistance to SNB, current levels of resistance are likely to be durable over time and remain a useful tool for integrated management of SNB in the region. [Formula: see text] Copyright © 2024 The Author(s). This is an open access article distributed under the CC BY-NC-ND 4.0 International license.

Techno-functional attributes of oilseed proteins: influence of extraction and modification techniques

Plant-based protein isolates and concentrates are nowadays becoming popular due to their nutritional, functional as well as religious concerns. Among plant proteins, oilseeds, a vital source of valuable proteins, are continuously being explored for producing protein isolates/concentrates. This article delineates the overview of conventional as well as novel methods for the extraction of protein and their potential impact on its hydration, surface properties, and rheological characteristics. Moreover, proteins undergo several modifications using physical, chemical, and biological techniques to enhance their functionality by altering their microstructure and physical performance. The modified proteins hold a pronounced scope in novel food formulations. An overview of these protein modification approaches and their effects on the functional properties of proteins have also been presented in this review.

Links between socio-demographic characteristics and body mass index to colorectal cancer in North Borneo, Malaysia: A case-control study

INTRODUCTION

The fourth leading cause of cancer-related mortality and morbidity worldwide is colorectal cancer (CRC). Numerous reasons have contributed to the massive rise in CRC cases, for which Asian nations differ significantly in terms of risk incidence rates. The objectives of this study were to, first, identify the socio-demographic characteristics of those of North Borneo ethnicity and body mass index (BMI) and, second, determine the association of these factors with CRC. This research will contribute to preventing this form of cancer.

MATERIALS AND METHODS

This study is an analysis of a matched case-control study with a ratio of 1:2. The case group contained 206 respondents, and the control group contained 412. All CRC cases were confirmed with the histological results. The control group was matched for links between age, sex and ethnicity with CRC. The Statistical Package for Social Sciences Statistics (SPSS) IBM version 28.0 was used to conduct descriptive analysis using chi-squared testing and simple logistic regression. The statistical significance was P < 0.05.

RESULT

Overall, 618 respondents took part in this survey, of which 256 (41.4%) were female and 362 (58.6%) were male. The maximum age was 76, with a mean age ± SD of 53.17 ± 11.4. Those of Bajau ethnicity comprised 24.6% (152) of the population, followed by Dusun with 22.8% (141), Kadazan with 17.6% (109%), other North Borneo ethnic groups with 15.5% (96), Bugis with 9.7% (60), Brunei with 4.4% (27) and other predominant races with 5.3% (33). Regression analyses revealed that the incidence of CRC in North Borneo, Malaysia, was substantially correlated with income, occupation, other linked diseases and BMI.

CONCLUSION

Various risk factors are linked to CRC, based on the findings related to socio-demographic characteristics and BMI. Therefore, to lower the nationwide prevalence of CRC, national public health campaigns should include collaboration with the regional authorities to highlight the incidence and risk factors of CRC based on ethnicity.

Effectiveness of interventional package on body image perception and self-esteem among adolescents - A pilot study

Background of the Study

In adolescence various physical and psychological changes, impact their overall perception that leads to either satisfaction or dissatisfaction with body image. Adolescents can suffer from body image dissatisfaction. Counselling sessions, video and documentaries can be used to improve the body image concerns. So, this study aims to evaluate the impact of interventional package on the body image perception and self-esteem among adolescents.

Materials and Methods

The sampling technique used to enrol 65 adolescents was simple random. Body image was assessed in the form of affective and behavioural body image perception. Two different structured scales were used to assess affective and behavioural body image perception. Pre-test was conducted to assess the body image perception among adolescents; then, documentary was shown in the form of intervention 1 and the post-test 1 was taken, again booklet was distributed as intervention 2 and post-test -2 was taken.

Results

A statistically significant improvement in the satisfaction with weight, height, complexion, hair, teeth, buttocks, thigh and moustache, after the use of interventional package. In behavioural perception of body image, no significant association was found in pre-test, post-test 1 and 2, there is statistically significant improvement in self-esteem of adolescents, as P = 0.03.

Conclusion

Interventional package in the form of documentary and booklet is useful in improving body image perception among adolescents. Significant improvement was seen in perception related to certain body parts.

An emerging expanse: Novel and eco-friendly-biogenic synthesis of E. cardamomum-wrapped TiO2 nanoparticles for environmental and biological applications

The present research is targeted at E. cardamomum-derived TiO2-photocatalyst synthesis, reporting for the first time. The structural properties observed from the XRD pattern reveal that EC:TiO2 has an anatase phase and crystallite size is assessed by Debye-Scherrer's method (3.56 nm), WH-method (3.30 nm), and Modified-Debye-Scherrer's method (3.27 nm). An optical study by the UV-Vis spectrum shows strong absorption at 313 nm, and the corresponding band gap value is 3.28 eV. The topographical and morphological properties revealed by SEM and HRTEM images, elucidate the formation of multi-shaped particles of nano-size. Further, the phytochemicals on the EC:TiO2 NPs' surface are confirmed by the FTIR spectrum. The photocatalytic activity is well studied under UV light towards Congo Red dye, along with an effect of the dose of catalyst. EC:TiO2 (20 mg) has exhibited high photocatalytic efficiency up to 97% for 150 min of exposure due to the morphological, structural, and optical properties. CR degradation reaction exhibits pseudo-first-order kinetics, displaying a rate constant value of 0.01320 min-1. Reusability investigations reveal that after four photocatalysis cycles, EC:TiO2 has an effective efficiency of >85%. Additionally, EC:TiO2 NPs have been assessed for antibacterial activity and show potential against two bacterial species (S. aureus and P. aeruginosa). Therefore, these research outcomes from the eco-friendly and low-cost synthesis, are promising for the use of EC:TiO2 as a talented photocatalyst towards the removal of crystal violet dye as well as an antibacterial agent against bacterial pathogens.

Assessment of the Relation Between Asthma Severity and Serum Vitamin D Levels: A Cross-Sectional Study

Introduction Vitamin D3's importance for bone health in children and its potential role beyond musculocutaneous health is an ongoing area of research. This study assesses vitamin D3 deficiency prevalence in asthmatic children and its correlation with asthma cases and healthy controls.  Methods This cross-sectional study was conducted in a tertiary care hospital in Punjab, India among children between 5 and 15 years of age. Fifty children diagnosed with "bronchial asthma" who were under follow-up in the asthma clinic in outpatient and inpatient patients were enrolled as cases. Age-matched 50 healthy controls who presented for routine check-ups were enrolled in the control group. Demographic details were noted and clinical examination was done in all the cases. 25-(OH) vitamin D levels were estimated and compared in all cases and controls. The study also analyzed the relationship between 25-(OH) vitamin D levels with asthma control and severity. Results The study showed that serum vitamin D3 level was significantly decreased in asthmatic children (24.62 ± 14.95 ng/ml) as compared with the healthy control group (32.08 ± 12.22 ng/ml). Also, serum vitamin D3 level was significantly decreased in children with uncontrolled asthma (12.06 ± 4.68 ng/ml) as compared to children with well-controlled asthma (44.82 ± 10.48 ng/ml).  Conclusion The findings showed that low serum levels were observed more in asthmatic children as compared to healthy children. A correlation was also found between vitamin D3 levels and asthma severity, its control, and the number of acute exacerbations in the last year.

Specification, validation, and adherence of quality indicators to optimize the safe use of nonsteroidal anti-inflammatory drugs for knee osteoarthritis pain in the primary care setting

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) used for osteoarthritis (OA) in primary care may cause gastrointestinal or renal injury. This study estimated adherence to two quality indicators (QIs) to optimize NSAID safety: add proton pump inhibitors (PPI) to NSAIDs for patients with gastrointestinal (GI) risk (QI #1 NSAID-PPI) and avoid oral NSAIDs in chronic kidney disease (CKD) stage G4 or G5 (QI #2 NSAID-CKD).

METHODS

This retrospective study included index primary care clinic visits for knee OA at our health system in 2019. The validation cohort consisted of a random sample of 60 patients. The remainder were included in the expanded cohort. Analysis of structured data extracts was validated against chart review of clinic visit notes (validation cohort) and estimated QI adherence (expanded cohort).

RESULTS

Among 60 patients in the validation cohort, analysis of data extracts was validated against chart review for QI #1 NSAID-PPI (100% sensitivity and 91% specificity) and QI #2 NSAID-CKD (100% accuracy). Among 335 patients in the expanded cohort, 44% used NSAIDs, 27% used PPIs, 73% had elevated GI risk, and only 2% had CKD stage 4 or 5. Twenty-one percent used NSAIDs and had elevated GI risk but were not using PPIs. Therefore, adherence to QI #1 NSAID-PPI was 79% (95% CI, 74-83%). No patients with CKD stage 4 or 5 used NSAIDs. Therefore, adherence to QI #2 NSAID-CKD was 100%.

CONCLUSION

A substantial proportion of knee OA patients with GI risk factors did not receive PPI with NSAID therapy during primary care visits.

Gluten Intolerance and Its Association With Skin Disorders: A Narrative Review

Gluten sensitivity is defined as a chronic intolerance to gluten ingestion in genetically predisposed individuals. The etiology is thought to be immune-mediated and has a variable dermatologic presentation. Celiac disease (CD) is one of the most common forms of gluten intolerance and encompasses a wide range of extra-intestinal pathology, including cutaneous, endocrine, nervous, and hematologic systems. Psoriasis, another long-term inflammatory skin condition, has been linked to significant symptomatic improvement with a gluten-free diet (GFD). Palmoplantar pustulosis (PP), a variant of psoriasis, and aphthous stomatitis, which causes recurrent oral ulcers, have also exhibited beneficial results after the dietary elimination of gluten. In addition to this, dermatitis herpetiformis (DH), another immune-mediated skin disorder, is genetically similar to CD and has, therefore, shown tremendous improvement with a GFD. Another highly prevalent long-term skin condition called atopic dermatitis (AD), however, has revealed inconsistent results with gluten elimination and would require further research in the future to yield concrete results. Hereditary angioedema (HA) has shown an association with gluten intolerance in some patients who had symptomatic benefits with a GFD. Similarly, vitiligo and linear IgA bullous dermatosis have also shown some clinical evidence of reversal with a GFD. On the contrary, rosacea enhances the risk of developing CD. This narrative review emphasizes the potential impact of gluten intolerance on different cutaneous conditions and the potential therapeutic effect of a GFD on various symptomatic manifestations. There is a need for additional clinical and observational trials to further expand on the underlying pathophysiology and provide conclusive and comprehensive recommendations for possible dietary interventions.

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.

Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Diabetes is one of the leading causes of death and disability worldwide, and affects people regardless of country, age group, or sex. Using the most recent evidentiary and analytical framework from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), we produced location-specific, age-specific, and sex-specific estimates of diabetes prevalence and burden from 1990 to 2021, the proportion of type 1 and type 2 diabetes in 2021, the proportion of the type 2 diabetes burden attributable to selected risk factors, and projections of diabetes prevalence through 2050.

METHODS

Estimates of diabetes prevalence and burden were computed in 204 countries and territories, across 25 age groups, for males and females separately and combined; these estimates comprised lost years of healthy life, measured in disability-adjusted life-years (DALYs; defined as the sum of years of life lost [YLLs] and years lived with disability [YLDs]). We used the Cause of Death Ensemble model (CODEm) approach to estimate deaths due to diabetes, incorporating 25 666 location-years of data from vital registration and verbal autopsy reports in separate total (including both type 1 and type 2 diabetes) and type-specific models. Other forms of diabetes, including gestational and monogenic diabetes, were not explicitly modelled. Total and type 1 diabetes prevalence was estimated by use of a Bayesian meta-regression modelling tool, DisMod-MR 2.1, to analyse 1527 location-years of data from the scientific literature, survey microdata, and insurance claims; type 2 diabetes estimates were computed by subtracting type 1 diabetes from total estimates. Mortality and prevalence estimates, along with standard life expectancy and disability weights, were used to calculate YLLs, YLDs, and DALYs. When appropriate, we extrapolated estimates to a hypothetical population with a standardised age structure to allow comparison in populations with different age structures. We used the comparative risk assessment framework to estimate the risk-attributable type 2 diabetes burden for 16 risk factors falling under risk categories including environmental and occupational factors, tobacco use, high alcohol use, high body-mass index (BMI), dietary factors, and low physical activity. Using a regression framework, we forecast type 1 and type 2 diabetes prevalence through 2050 with Socio-demographic Index (SDI) and high BMI as predictors, respectively.

FINDINGS

In 2021, there were 529 million (95% uncertainty interval [UI] 500-564) people living with diabetes worldwide, and the global age-standardised total diabetes prevalence was 6·1% (5·8-6·5). At the super-region level, the highest age-standardised rates were observed in north Africa and the Middle East (9·3% [8·7-9·9]) and, at the regional level, in Oceania (12·3% [11·5-13·0]). Nationally, Qatar had the world's highest age-specific prevalence of diabetes, at 76·1% (73·1-79·5) in individuals aged 75-79 years. Total diabetes prevalence-especially among older adults-primarily reflects type 2 diabetes, which in 2021 accounted for 96·0% (95·1-96·8) of diabetes cases and 95·4% (94·9-95·9) of diabetes DALYs worldwide. In 2021, 52·2% (25·5-71·8) of global type 2 diabetes DALYs were attributable to high BMI. The contribution of high BMI to type 2 diabetes DALYs rose by 24·3% (18·5-30·4) worldwide between 1990 and 2021. By 2050, more than 1·31 billion (1·22-1·39) people are projected to have diabetes, with expected age-standardised total diabetes prevalence rates greater than 10% in two super-regions: 16·8% (16·1-17·6) in north Africa and the Middle East and 11·3% (10·8-11·9) in Latin America and Caribbean. By 2050, 89 (43·6%) of 204 countries and territories will have an age-standardised rate greater than 10%.

INTERPRETATION

Diabetes remains a substantial public health issue. Type 2 diabetes, which makes up the bulk of diabetes cases, is largely preventable and, in some cases, potentially reversible if identified and managed early in the disease course. However, all evidence indicates that diabetes prevalence is increasing worldwide, primarily due to a rise in obesity caused by multiple factors. Preventing and controlling type 2 diabetes remains an ongoing challenge. It is essential to better understand disparities in risk factor profiles and diabetes burden across populations, to inform strategies to successfully control diabetes risk factors within the context of multiple and complex drivers.

FUNDING

Bill & Melinda Gates Foundation.

Effect of more versus less intensive blood pressure control on cardiovascular, renal and mortality outcomes in people with type 2 diabetes: A systematic review and meta-analysis

BACKGROUND AND AIMS

Currently, there is uncertainty as to whether blood pressure control in patients with type 2 diabetes should be treated to standard recommended levels or more intensively.

METHODS

Medline, EMBASE, CENTRAL, and Clinicaltrials.gov were searched between January 1, 2000 and April 20th, 2023. Outcomes considered were all-cause mortality, stroke, heart failure, cardiovascular disease, albuminuria, coronary heart disease, and renal outcomes. Random-effects meta-analyses estimated pooled relative risks and mean differences.

RESULTS

Nine trials enrolling 11,005 participants with type 2 diabetes were included. The pooled mean difference between the intensive and standard treatment groups at follow-up were -7.98 mmHg (95% CI: 12.19 to -3.76) in systolic blood pressure, and -5.08 mmHg (-7.00 to -3.17) in diastolic blood pressure; although between study heterogeneity was high for both meta-analyses (I²>85%). Intensive blood pressure lowering resulted in a reduction in risk of stroke (risk ratio 0.64; 0.52 to 0.79), and macro-albuminuria (0.77; 0.63 to 0.93). More intensive blood pressure control did not result in a statistically significant reduction in risk of all-cause mortality, heart failure, cardiovascular death, cardiovascular events, renal outcomes, and micro-albuminuria; although the direction of estimated effect was beneficial for all outcomes.

CONCLUSIONS

The use of intensive compared with standard blood pressure targets resulted in a significant reduction in blood pressure, stroke, and macro-albuminuria in patients with type 2 diabetes. The post-treatment blood pressure level in the intensive group was 125/73 mmHg, suggesting the current recommendations of 130/80 mmHg blood pressure or lower if tolerated, could be reduced further.

Properties of Naked Silver Clusters with Up to 100 Atoms as Found with Embedded-Atom and Density-Functional Calculations

The structural and energetic properties of small silver clusters Agn with n = 2-100 atoms are reported. For n = 2-100 the embedded atom model for the calculation of the total energy of a given structure in combination with the basin-hopping search strategy for an unbiased structure optimization has been used to identify the energies and structures of the three energetically lowest-lying isomers. These optimized structures for n = 2-11 were subsequently studied further through density-functional-theory calculations. These calculations provide additional information on the electronic properties of the clusters that is lacking in the embedded-atom calculations. Thereby, also quantities related to the catalytic performance of the clusters are studied. The calculated properties in comparison to other available theoretical and experimental data show a good agreement. Previously unidentified magic (i.e., particularly stable) clusters have been found for n>80. In order to obtain a more detailed understanding of the structural properties of the clusters, various descriptors are used. Thereby, the silver clusters are compared to other noble metals and show some similarities to both copper and nickel systems, and also growth patterns have been identified. All vibrational frequencies of all the clusters have been calculated for the first time, and here we focus on the highest and lowest frequencies. Structural effects on the calculated frequencies were considered.

Terlipressin-Induced Skin Necrosis While Managing Hepatorenal Syndrome: A Rare Case Report From North India

Terlipressin is an analogue of vasopressin and is often used in the treatment of bleeding esophageal varices and also in the treatment of hepatorenal syndrome associated with liver cirrhosis. Although terlipressin is a safe drug, but it has been rarely associated with potentially serious adverse effects like ischemic necrosis of skin involving the abdominal skin, extremities, and scrotal skin. We present one such rare case where terlipressin-induced skin necrosis in bilateral lower extremities in a 48-year-old male while we were managing hepatorenal syndrome in the same.

Natural killer cells suppress human cutaneous squamous cell carcinoma cancer cell survival and tumor growth

Cutaneous squamous cell carcinoma (CSCC), which develops in response to ultraviolet irradiation exposure, is among the most common cancers. CSCC lesions can be removed by surgical excision, but 4.5% of these cancers reappear as aggressive and therapy-resistant tumors. CSCC tumors display a high mutation burden, and tumor frequency is dramatically increased in immune-suppressed patients, indicating a vital role for the immune system in controlling cancer development. Natural killer cells (NK cells) play a key role in cancer immune surveillance, and recent studies suggest that NK cells from healthy donors can be expanded from peripheral blood for use in therapy. In the present study, we test the ability of ex vivo expanded human NK cells to suppress the CSCC cell cancer phenotype and reduce tumor growth. We expanded human NK cells from multiple healthy donors, in the presence of IL-2, and tested their ability to suppress the CSCC cell cancer phenotype. NK cell treatment produced a dose-dependent reduction in SCC-13 and HaCaT cell spheroid growth and matrigel invasion and induced SCC-13 and HaCaT cell apoptosis as evidenced by increased procaspase 9, procaspase 3, and PARP cleavage. Moreover, two important CSCC cell pro-cancer signaling pathways, YAP1/TAZ/TEAD and MEK1/2-ERK1/2, were markedly reduced. Furthermore, tail-vein injection of NK cells markedly suppressed the growth of SCC-13 xenograft tumors in NSG mice, which was also associated with a reduction in YAP1 and MEK1/2-P levels and enhanced apoptosis. These findings show that NK cell treatment suppresses CSCC cell spheroid formation, invasion, viability, and tumor growth, suggesting NK cell treatment may be a candidate therapy for CSCC.

Survival Analysis of Oral Squamous Cell Carcinoma Patients Attending Tertiary Care Centre of North India

The cumulative survival for all stages in oral squamous cell cancers (OSCC) in the world remains poor despite the advances in management; hence, we conducted this study to evaluate the survival outcomes. This is a retrospective review and analysis of treatment, follow-up and survival records of 249 OSCC patients treated in our department from April 2010 to April 2014. Telephonic interviews were conducted for survival details for some patients who had not reported. Survival analysis was done using the Kaplan-Meier analysis, comparisons were done using log-rank test and multivariate analysis was conducted using the Cox proportional hazard model to find different variables (site, age, sex, stage and treatment) affecting overall survival (OS)/disease-free survival (DFS). Two-year and 5-year DFS for OSCC were observed to be 72.3% and 58.3% with mean survival of 63.17 months (95% CI: 58.342-68.002). Similarly, OS at 2 years and 5 years were 84.3% and 55.9% with mean survival of 65.143 months (95% CI: 60.143-69.601). Tumour site, patient age, stage of disease and treatment modality had a statistically significant hazardous effect on the overall and disease-free survival rates. The significant influence of age, site of tumour, stage of disease and modality of treatment required based on the clinic-pathologic risk factors on prognosis emphasizes the importance of early diagnosis through regular screening and early treatment which can be ensured with early referral, high clinical suspicion and awareness at the point of primary/secondary care.

Comparative study of the short-range structure of α-V2O5, α-TeO2 and xV2O5-(100 - x)TeO2 glasses using X-ray diffraction, Rietveld analysis and reverse Monte Carlo simulations

Vanadium-tellurite glasses, tetragonal TeO₂ and orthorhombic V₂O₅ crystalline samples were characterized for their atomic structure properties by synchrotron X-ray diffraction, pair distribution function analysis, reverse Monte Carlo simulations (RMC) and Rietveld analysis. The pair correlation function, G(r), of V₂O₅ shows the first peak at 1.61 Å. G(r) of TeO₂ shows three peaks at 1.57, 2.13 and 2.88 Å due to Te-O linkages of three different lengths, whereas the Te-Te atomic pair correlation shows a peak at 3.85 Å. The average coordination number of V with O in crystalline V₂O₅ is 4.39 while that of Te with O in crystalline TeO₂ is 3.71. G(r) of the vanadium tellurite glass shows the first peak at 1.90 Å due to overlapping Te-O and V-O atomic pair correlations. The RMC analysis on diffraction data of glasses found that the V-O coordination number is in the range 5.27-5.59 and the Te-O coordination number is 5.39-5.67. However, it is found that these coordination numbers cannot be clearly defined due to short-range disorder.

Education as a protective factor for mental health risks among youth living in highly dangerous regions in Afghanistan

BACKGROUND

Children in Afghanistan live in dangerous areas, and have been exposed to traumatic events and chaotic education. Progress has been made on access to education for girls who were the most affected by traditional attitudes against engagement in education.

OBJECTIVES

The objectives were to evaluate the mental health of Afghan children living in regions of conflict and the association of mental health with school attendance for girls and boys.

METHOD

The study included 2707 school aged children in eight regions of Afghanistan (16 provinces) residing in households recruited through a multi-stage stratified cluster sampling strategy in 2017. The level of terrorist threat was evaluated by the intensity of terrorist attacks recorded that year in each province. Child mental health was assessed with the parental report Strengths and Difficulties Questionnaire (SDQ) along with information on school attendance, sociodemographic characteristics and geographic location.

RESULTS

A total of 52.75% of children had scores above threshold for the SDQ total difficulties score, 39.19% for emotional difficulties, 51.98% for conduct challenges, and 15.37% for hyperactivity/inattention. Peer relationship problems were high (82.86%) and 12.38% reported that these problems impacted daily life. The level of terrorist threat was associated with SDQ total difficulties (Adjusted Odds Ratio [AOR] = 4.08, P < 0.0001), with youth in regions with high levels of terrorist threat more likely to have problems than youth in regions with low or medium levels of danger, independent of region and ethnicity. School attendance was negatively associated with emotional symptoms (AOR = 0.65, P < 0.0001) and mental health difficulties with impairment (AOR = 0.67, P = 0.007), but positively associated with peer relationships difficulties (AOR = 1.96, P > 0.0001). Conduct (AOR = 1.66, P < .0001) and SDQ total difficulties (AOR = 1.22, P = 0.019) were higher among boys. Overall, gender did not modify the relationship between school attendance and child mental health.

CONCLUSION

Attending school is essential for children's mental health, across gender, and should be supported as a priority in Afghanistan despite the return of the Taliban.

Tuberculosis Diagnosis Using Isothermal Nucleic Acid Amplification in a Paper-and-Plastic Device

Nucleic acid (DNA/RNA) amplification technologies are indispensable for applications like disease diagnostics, forensics, epidemiology, evolutionary biology, vaccine development, and therapeutics. While polymerase chain reaction (PCR) has deeply penetrated the abovementioned fields and has been commercially successful, two major common disadvantages are exorbitant costs of associated equipment, which create concerning roadblocks in terms of affordability and accessibility. This work describes development of an inexpensive, portable, easy-to-use and deliverable-to-end-users, nucleic acid amplification technology for infectious disease diagnosis. The device uses loop-mediated isothermal amplification (LAMP) and cell phone-based fluorescence imaging to enable nucleic acid amplification and detection. A regular lab incubator and a custom-made low-cost imaging box are the only two additional equipment required for testing. Material cost for a 12-test zone device was $0.88, and cost of reagents per reaction was $0.43. First successful application of the device was demonstrated for tuberculosis diagnosis with clinical sensitivity of 100% and clinical specificity of 68.75% for testing of 30 clinical patient samples.

Role of Tyrosine Kinases and their Inhibitors in Cancer Therapy: A Comprehensive Review

BACKGROUND

Cancer has been recognized as one of the non-communicable diseases with an increasing number of new cases, higher morbidity, and higher mortality rates at the global level. Thus, there is non-stop search for novel targets and small molecules to improve the chemotherapeutic outcomes concerning potency, selectivity, efficiency, affinity, ADMET, etc. Among anticancer therapeutic targets, tyrosine kinase has been documented well and approved as an important target with the development of various clinically used drugs. There are several structurally diverse small molecules in different preclinical and clinical stages of development that act by affecting tyrosine kinases in cancerous cells. Here, we have summarized different potent molecules acting against tyrosine kinases that can be considered as anticancer agents.

OBJECTIVE

The current review focused on structural aspects of different chemical agents for inhibition of tyrosine kinases as anticancer agents.

METHODS

The present study provides a summarized review of published information on tyrosine kinase inhibitors, their binding pattern, potencies, and structure-activity relationships. The review also highlighted the structural aspects of the interaction between inhibitors and amino acid residues of tyrosine kinases. Moreover, it also provided a summary of different types of cancers and the currently available options for treatment.

RESULTS

Several studies are being conducted for the inhibition of different tyrosine kinases using small molecules for the treatment of cancer. Tyrosine kinases have been reported involving in routine cellular functions, growth, and division of cells through different pathways which depend on phosphorylation. The overexpression and uncontrolled activity of tyrosine kinases have been identified as an important feature of cancerous cells. Thus, various small molecules have been reported which inhibit tyrosine kinases to block the growth and division of cancer cells. Here, more than 30 highly potent inhibitors of tyrosine kinases are summarised, which consist of pyrimidine, pyrazole, triazine, quinazoline, quinoline, pyrazine, chromene, etc. rings as a basic skeleton with different substituents.

CONCLUSION

Inhibition of tyrosine kinases by different small molecules is an approved strategy for the development of novel anticancer agents. Several published reports have mentioned the characteristics of the different binding sites and crucial residues in tyrosine kinases for the design of novel molecular inhibitors. However, selectivity is an important criterion for the development of chemotherapeutic agents due to the existence of approximately 30 families of tyrosine kinases.

Foreign Body Aspiration in Pediatric Airway: A Clinical Study

Immediate removal of foreign body (FB) can minimize the rate of complications. In the present study, we evaluated different types of foreign bodies, presenting clinical features amongst the children and their site of impaction. We also evaluated the anesthetic considerations during ventilation of pediatric airway in such Foreign body aspiration (FBA) patients. A retrospective study, for which prior Institutional Research Committee approval was taken, was conducted in 50 patients admitted in a tertiary care health centre. Relevant history regarding each patient's presenting symptoms or symptoms prior to hospitalization were recorded with special focus on interval between inhalation of foreign body and food intake. Each patient was examined for the nature and site of the foreign body. Appropriate method of ventilation for each case was discussed with the anesthesiologist before hand. Results of both therapeutic and diagnostic bronchoscopy were detailed. Majority of patients with foreign body aspiration (44%) were male children, between 1 and 3 years of age. The clinical features were mainly cough, respiratory distress and wheeze. Organic FB (73.9%) were the most common type of foreign body found. Right bronchus (64%) was the most common site of aspiration followed by left bronchus (24%). Jet ventilation was used in all the children, and duration of the rigid bronchoscopy was less than 15 min in majority of the cases. FBA are still dreaded as one of the leading causes of morbidity and mortality in infants and children that can be prevented by early diagnosis and management.

Enhanced functionality and shelf stability of burfi by incorporating kinnow (mandarin) fruit juice

Burfi, an Indian traditional dairy dessert is highly popular, however, its low nutritive value and poor shelf life limits commercial viability. Kinnow juice was utilized to improve the phytonutritional profile and shelf stability of burfi. To further improve the quality, pectin was added at different concentrations (1-4%). Compared to control, inclusion of kinnow juice significantly (p < 0.05) improved minerals and phytochemical constituents as confirmed using FTIR analysis. Developed burfi presented a softer texture which was consistent with SEM results. Increasing the pectin levels, increased textural properties of kinnow burfi while decreased moisture content and water activity, without affecting color and nutritional properties. Based on desirable sensory and textural properties, kinnow burfi prepared with pectin (4% of added sugar) was selected for product development and evaluation of shelf life under room (25 ± 2 °C) and refrigerated (4 ± 2 °C) conditions. Irrespective of storage temperatures, moisture content and bioactive constituents decreased while titratable acidity, total and reducing sugars, free fatty acids, hardness of texture, and yeast and mould count increased significantly. Except moisture, the extent of quality changes was rapid at room temperature. The product showed high sensory acceptability as well as microbial safety up to 21 days at room temperature and 28 days under refrigeration.

Management of Lambda-Cyhalothrin Poisoning in a North Indian Healthcare Setup: A Rare Case

Agricultural product (insecticides and pesticides) poisoning is common in the rural Indian setup, and in most cases, it occurs due to suicidal attempts rather than accidental intake. Furthermore, most cases of agrochemical poisoning are organophosphate poisoning rather than other less commonly used pesticides. Lambda-cyhalothrin is a less commonly used insecticide in India, and there have been a few instances in the literature where lambda-cyhalothrin poisoning and its subsequent management have been described. In this case report, we describe accidental lambda-cyhalothrin poisoning in a 26-year-old female and its management at our center.

Improvement in nutritional quality of traditional unleavened flat bread using Quality Protein Maize

Maize grains are consumed majorly in the form of unleavened flat bread (chapatti) in the South East Asian region. The landraces are better accepted for their chapatti-making attributes such as grain color and good organoleptic properties. However, these cultivars are low in essential amino acids, particularly lysine and tryptophan content. Hence, an investigation was performed to identify maize genotypes with high nutritional value coupled with good chapatti-making qualities. Seven genotypes, comprising two Quality Protein Maize (QPM) hybrids, two normal maize hybrids, and three normal white maize landraces were assessed for their physical characteristics, proximate composition, and chapatti-making quality. Landrace 593 showed the highest protein and ash content. Flours obtained from different genotypes were significantly different (p ≤ 0.001) in terms of protein content, color value, textural, as well as mineral content. PMH 10 and IQMH 203 exhibited the highest and lowest hydration index, respectively. Two QPM hybrids showed significantly higher lysine and tryptophan content as compared to other genotypes. QPM hybrids were identified as the promising material with improved nutritional quality with respect to chapatti making. In combination with mustard greens, maize chapatti constitutes an important traditional delicacy in north India. The enhanced nutritional quality of QPM chapattis is an added advantage. We show the differentiation of chapattis made from QPM and normal maize using a rapid protocol developed previously. This is expected to enable the development and quality control of commercial enterprises based on high protein quality QPM.

A Rare Case of Metastatic Extragonadal Yolk Sac Tumor – A Challenging Diagnosis on Cytomorphology

Introduction/Objective

Yolk sac tumors are characterized by variable histologic patterns and broad cytologic spectrum; thereby making the distinction from a poorly differentiated adenocarcinoma in a metastatic site extremely challenging. We present cytology and histology of a metastatic extragonadal germ cell tumor with predominant solid yolk sac component.

Methods/Case Report

36-year-old male presented with bilateral supraclavicular masses (right: 6 x 7 cm, left: 3 x 4 cm). CT chest and abdomen revealed large mediastinal and hilar nodal mass (11.6 cm), right hilar mass (8.5 cm), bilateral heterogeneous adrenal masses (right: 11.4 cm, left: 3.1 cm), and an enhancing retroperitoneal implant. Differential diagnoses of lymphoma, adrenocortical carcinoma, small cell lung carcinoma, and metastatic germ cell tumor were considered. Testicular ultrasound revealed no masses. Fine needle aspiration of supraclavicular lymph nodes showed highly cellular smears comprised of tumor cells, dispersed singly and in clusters, with irregular nuclear contours, increased nuclear to cytoplasmic ratio, coarse chromatin, occasional prominent nucleoli, and vacuolated cytoplasm. Tumor cells were positive for KRT7 and TTF-1, and negative for p40 and PAX8. A diagnosis of metastatic poorly differentiated carcinoma was rendered. Subsequent excisional biopsy of the lymph node showed a metastatic tumor with tumor cells similar to those seen in cytology, appearing in solid sheets with focal papillary architecture, replacing the entire lymph node. Additional immunohistochemistry showed expression of SALL4, Glypican 3, with lack of expression for OCT3/4, AFP, hCG, and CD30, supporting the diagnosis of metastatic yolk sac tumor, solid pattern.

Results (if a Case Study enter NA)

NA.

Conclusion

Aggressive clinical presentation, broad clinical differential diagnoses, rarity of a primary mediastinal yolk sac tumor, non-diagnostic cytomorphology along with expression of divergent differentiation markers (TTF-1 in our case) makes a definitive diagnosis of metastatic extragonadal yolk sac tumor extremely challenging. High index of clinical suspicion is required for a definitive diagnosis on cytomorphology.

Metastatic Common Bile Duct Melanoma Presenting as Obstructive Jaundice: A Case Report and Review

Introduction/Objective

Malignant melanomas (MM) account for 4-7% of all new cancer cases. The most common primary site is the skin, however, in 1.3% of cases, these tumors originate from the mucous membranes of the respiratory, genitourinary, and gastrointestinal tracts. The metastatic spread to the biliary system is extremely infrequent, with rare reports in the literature. Herein, we report a case of history of cutaneous MM with metastasis to the biliary tract.

Methods/Case Report

A 35-year-old Caucasian female presented with pruritis, dark urine, and jaundice. Laboratory results favored the cholestatic process (total bilirubin – 10 mg/dL, alkaline phosphatase – 500 U/L, AST- 400 U/L, ALT – 1000 U/L). She had a remote diagnosis of MM of the left chest with metastases to bilateral axillary and periclavicular lymph nodes 8 years ago. She underwent wide local excision of the skin lesion and lymph node dissection then. ERCP with direct cholangioscopy revealed a 3 x 2 cm obstructive mass in the common bile duct which was biopsied to reveal cohesive, pleomorphic, epithelioid cells containing black-brown pigment with enlarged, irregular, and hyperchromatic nuclei. These atypical cells stained strongly with SOX10 and Mart-1 immunohistochemical stains, confirming the diagnosis of metastatic malignant melanoma.

Results (if a Case Study enter NA)

NA.

Conclusion

MM is cancer that originates from melanocytes, derived from the neural crest during embryogenesis. The pathogenesis of metastatic spread to the biliary system is still unknown due to the paucity of literature describing this. Diagnosis is often difficult, with many patients completely asymptomatic or occasionally presenting with biliary symptoms. There should be a detailed history, and extensive clinical workup along with extensive histological and immunoprofile, esp. in cases with a history of cutaneous melanoma for early detection of a potential metastasis leading to adequate management.

Malignant Dural Solitary Fibrous Tumor; An Exceedingly Rare Entity

Introduction/Objective

A solitary fibrous tumor (SFT) is an extremely rare mesenchymal neoplasm, accounting for &lt;1% of all primary CNS tumors. Most SFT is dural-based and occurs predominantly in the fourth to sixth decade of life. Here, we present a case of a dural solitary fibrous tumor.

Methods/Case Report

A 28-year-old male presented with intermittent throbbing headache, nausea, and vomiting. Imaging revealed a large, well-circumscribed left parafalcine, dural-based multilobulated, solid, and cystic mass. The patient underwent craniotomy with mass resection. Preliminary intraoperative findings were of a spindle cell neoplasm. Histopathologic examination showed hypercellular neoplasm composed of the spindle to ovoid cells with a high nuclear to cytoplasmic ratio and limited intervening stroma arranged in a haphazard pattern with prominent branching staghorn vasculature. Focal areas of necrosis and mitotic counts of 8/10 high power field were also seen. The lesional cells showed focal cytoplasmic CD34 expression and strong STAT6 nuclear expression. Finally, a diagnosis of SFT, haemangiopericytoma phenotype classified as grade 3, was made.

Results (if a Case Study enter NA)

NA

Conclusion

Most SFTs are considered clinically benign (grade 1 tumors) with favorable outcomes after complete resection. However, haemangiopericytoma phenotype with hypercellularity, necrosis, and elevated mitotic count (&gt; 4/10 HPF) is known to have an increased risk of local recurrence and rare metastasis, requiring patients to receive adjuvant radiotherapy after resection for longer progression-free survival. Therefore, it is vital to be aware of this entity for optimal management and more active systemic surveillance in patients with high-grade SFT tumors. Our patient is currently doing well post-adjuvant radiotherapy and is under active annual surveillance.

Longitudinal Study to Find the Association of Serum Phosphorus Level with FGF23 in Three Different Hyperphosphatemia Management Groups of Stage 3 and 4 Chronic Kidney Disease (CKD) Patients

Background

There is paucity of clinical evidence on target serum phosphorus levels in early chronic kidney disease (CKD). Present longitudinal study was done to find target phosphorus level and its association with fibroblast growth factor (FGF23) in three different hyperphosphatemia management groups.

Methods

This 1-year, prospective, randomized controlled, open-labelled study was conducted among three equally allocated treatment groups that consisted of 120 screened early CKD patients totally. Group 1 patients were given dietary phosphorus modification (n = 40), group 2 patients were administered calcium-based phosphate binders (n = 40), and group 3 patients were given non-calcium-based phosphate binders (n = 40). Three-monthly dietary assessment, MDRD estimated glomerular filtration rate (eGFR), phosphorus, calcium, iPTH, alkaline phosphatase, and six-monthly FGF23, 2D echocardiography, and X-ray of chest and abdomen were performed. Association of three categories of phosphorus level up to 3.9, 4-5, and >5mg/dl, rate of progression of all parameters, and correlation with FGF23 were studied among all three groups.

Results

At baseline, all clinical and biochemical parameters were equally distributed with a controlled nutritional phosphate among all groups. There was no significant difference of FGF23 levels from all the three categories of phosphorus level among all groups. Serum phosphorus at the level of 5 mg/dl was associated with iPTH and eGFR at 1 year. Over 1 year, there was a significant decline in serum phosphorus levels in group 1 (P 0.02), group 2 (P 0.00), and group 3 (P 0.05). FGF23 declined significantly only in group 3 (P 0.00). There was no correlation of FGF23 with serum phosphorus levels (P 0.13). However, FGF23 correlated positively with iPTH (P 0.03, r = 0.19).

Conclusion

Serum phosphorus levels upto 5mg/dl had no effect on FGF23 at early CKD stages. Although different treatment groups showed significant phosphorus reduction, non-calcium phosphate binder had a major impact on FGF23 reduction.

Displacement Pattern, Stress Distribution, and Archwire Play Dimensions during En-masse Retraction of Anterior Teeth using Sliding Mechanics: A FEM Study

Aims

This finite element study was undertaken to evaluate the pattern of stress distribution around the implant and anterior teeth during en-masse retraction in the premolar extraction case. Displacement of the teeth and play of wire in the bracket slot were also evaluated to determine the most favorable height of the power arm attached to the arch-wire.

Materials and methods

A three-dimensional (3D) finite element model of the maxilla was constructed using computed tomography (CT) scan. A total of 12 models were fabricated with different heights of power arms placed distal to the canine. A retraction force of 1.5 N was applied from the implant placed between the roots of the second premolar and first molar, and the response was predicted using Analysis of Systems (ANSYS) software.

Results

When power-arm height was near the center of resistance of the anterior segment, stability in the stress distribution around the implant site and anterior teeth was observed. Displacement of the teeth varied along the three planes of space with the change in power-arm height.

Conclusion

For en-masse retraction, power-arm height should be kept at a level of the center of resistance. Play in the bracket slot and the archwire show a negative role in the bodily movement of anterior teeth.

Clinical significance

For efficient en-masse retraction of anterior teeth, it is imperative to study the most effective site of application of force. Therefore, our study recommends certain key points to keep in mind during the attachment of the power arm and engaging wire in the bracket slot, which could benefit the orthodontist immensely.

How to cite this article

Singh H, Khanna M, Walia C, et al. Displacement Pattern, Stress Distribution, and Archwire Play Dimensions during En-masse Retraction of Anterior Teeth using Sliding Mechanics: A FEM Study. Int J Clin Pediatr Dent 2022;15(6):739-744.