RevCore thrombectomy system for treatment of chronic left external and common iliac vein stent occlusion

In recent years, deep venous stenting has increasingly become a treatment strategy for post-thrombotic syndrome. Stent thrombosis can occur, resulting in symptom recurrence despite medical therapy, and there are few options available for durable stent patency restoration. We present a case of a 50-year-old male with prior iliocaval reconstruction that experienced recurrent left lower extremity swelling secondary to occlusion of left external iliac and common iliac vein stents during follow-up. Mechanical thrombectomy with the RevCore System and angioplasty was performed. One month later, the patient demonstrated widely patent bilateral iliac vein stents and complete symptomatic resolution. The RevCore System is a feasible alternative for treatment of chronic in-stent thrombosis.

Extensive iliofemoral and femoropopliteal venous thrombosis in a young patient with iliocaval atresia

Inferior vena cava (IVC) atresia is a rare congenital anomaly. Standardized treatment is not well defined due to its uncommon presentation, with this pathology associated with an increased risk of unprovoked lower extremity deep vein thrombosis (DVT). We present a case of a 32-year-old man who was admitted for bilateral lower extremity edema and pain and was found to have bilateral extensive iliofemoral and femoropopliteal DVT, absence of IVC filling, and extensive tortuous collateralization arising from the pelvic veins to the azygos vein. Bilateral mechanical thrombectomy and endovascular iliocaval reconstruction was performed. Three months later, the patient demonstrated widely patent iliocaval stents and the absence of DVT. Endovascular treatment of IVC atresia is feasible and optimizes the reduction of thrombus burden.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Bill & Melinda Gates Foundation.

Global, 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.

Does the format of result presentation and type of conclusion in Cochrane plain language summaries matter? A randomised controlled trial

OBJECTIVES

This study aimed to investigate whether the format and type of conclusion in Cochrane plain language summaries (PLSs) influence readers' perception of treatment benefit and decision-making.

DESIGN

An online parallel group, three-arm randomised controlled trial was conducted.

SETTING

The study was conducted online.

PARTICIPANTS

The participants were physiotherapy students.

INTERVENTIONS

The participants read two Cochrane PLSs, one with a positive conclusion (strong evidence of benefit) and another with a negative conclusion (strong evidence of non-benefit). Each participant read the results of both reviews presented in one of three formats: (1) numerical, (2) textual or (3) numerical and textual.

MAIN OUTCOME MEASURES

The primary outcome measure was the participants' perception of treatment benefit.

RESULTS

All three groups of participants perceived the treatment to have positive effects when the Cochrane PLS had a positive conclusion, regardless of the format of presentation (mean perception of treatment benefit score: textual 7.7 (SD 2.3), numerical 7.9 (SD 1.8), numerical and textual 7.7 (SD 1.7), p=0.362). However, when the Cochrane PLS had a negative conclusion, all three groups of participants failed to perceive a negative effect (mean perception of treatment benefit score: textual 5.5 (SD 3.3), numerical 5.6 (SD 2.7), numerical and textual 5.9 (SD 2.8), p=0.019).

CONCLUSIONS

The format of Cochrane PLSs does not appear to significantly impact physiotherapy students' perception of treatment benefit, understanding of evidence, persuasiveness or confidence in their decision. However, participants' perception of treatment benefit does not align with the conclusion when the Cochrane PLS indicates strong evidence of non-benefit from the intervention.

TRIAL REGISTRATION NUMBER

CTRI/2022/10/046476.

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.

Contribution of infection and vaccination to population-level seroprevalence through two COVID waves in Tamil Nadu, India

This study employs repeated, large panels of serological surveys to document rapid and substantial waning of SARS-CoV-2 antibodies at the population level and to calculate the extent to which infection and vaccination separately contribute to seroprevalence estimates. Four rounds of serological surveys were conducted, spanning two COVID waves (October 2020 and April-May 2021), in Tamil Nadu (population 72 million) state in India. Each round included representative populations in each district of the state, totaling ≥ 20,000 persons per round. State-level seroprevalence was 31.5% in round 1 (October-November 2020), after India's first COVID wave. Seroprevalence fell to 22.9% in round 2 (April 2021), a roughly one-third decline in 6 months, consistent with dramatic waning of SARS-Cov-2 antibodies from natural infection. Seroprevalence rose to 67.1% by round 3 (June-July 2021), with infections from the Delta-variant induced second COVID wave accounting for 74% of the increase. Seroprevalence rose to 93.1% by round 4 (December 2021-January 2022), with vaccinations accounting for 63% of the increase. Antibodies also appear to wane after vaccination. Seroprevalence in urban areas was higher than in rural areas, but the gap shrunk over time (35.7 v. 25.7% in round 1, 89.8% v. 91.4% in round 4) as the epidemic spread even in low-density rural areas.

Unleashing the binding interaction of chrysin-Cu(II) complex with the biomacromolecular targets: further studies of cell cytotoxicity and radical scavenging properties

Flavonoids are significant dietary components and have ability to coordinate with metal ions to produce novel drug discovery leads that are superior to those of the parent flavonoids. Here, in this report, we have synthesized chrysin-Cu(II) complex (as per reported article) and characterized it further with different analytical techniques. The synthesized complex was evaluated for radical scavenging and cell cytotoxicity studies where it exhibited enhanced activity as compared to bare chrysin. The interaction studies of the complex with ct-DNA (Kb ⁓ 105 M-1), human serum albumin (HSA) and ovalbumin (Kb ⁓ 104 M-1) were evaluated using multi-spectroscopic and molecular docking studies. Groove binding mode with ct-DNA was observed as confirmed from competitive displacement studies, viscosity measurement, melting temperature estimation and docking analyses. The complex exhibited comparatively higher affinity towards ct-DNA which indicated it efficient transportation by the carrier proteins and controlled release in the target DNA.Communicated by Ramaswamy H. Sarma.

Kommerell's Diverticulum in a Right-Sided Aortic Arch With an Aberrant Left Subclavian Artery Hybrid Repair

BACKGROUND

Kommerell's diverticulum (KD) with a right aortic arch (RAA) and aberrant left subclavian artery (aLSCA) is a rare congenital anomaly of the aortic arch. Treatment is not well defined due to its uncommon presentation, with rupture and dissection risk rates of up to 53%.

CASE SUMMARY

A 54-year-old male with a history of chronic obstructive pulmonary disease (COPD) and hypertension presented with difficulty breathing during exercise without dysphagia. Follow-up computerized tomography angiogram (CTA) revealed the presence of a RAA and aLSCA arising from the descending thoracic aorta with an adjacent 58 × 41-mm KD and tracheal and esophageal displacement. Due to the size of the KD, risk of rupture, unsuitable anatomy for total endovascular aortic repair (EVAR), and high COPD burden, the patient was planned to undergo a hybrid surgical repair. Left common carotid (LCCA) artery to LSCA bypass, full aortic debranching, LSCA embolization and percutaneous thoracic endovascular aortic repair (TEVAR) were performed. Successful device position and exclusion of the diverticulum and aneurysmal aorta were observed after completion thoracic aortogram. 18-month follow-up CTA demonstrated patency of the LSCA to LCCA bypass graft and arch vessel branches, as well as stable exclusion of the KD. Persistence of a type II endoleak originated at the right first posterior intercostal artery has been noted and is being followed conservatively since no sac growth has occurred.

CONCLUSION

We highlight the presence of a KD with RAA and aberrant subclavian artery, a rare congenital anatomic variation of the aortic arch with complex anatomy. Surgical planning must be individualized according to comorbidities and anatomical variations identified on imaging and 3D reconstructions.

Factors influencing physiotherapists implementation of high value care in the management of nonspecific low back pain in Indian healthcare settings: A qualitative study

BACKGROUND

Non-specific low back pain is a common musculoskeletal condition that often requires the involvement of physiotherapists for effective management. However, there is limited understanding of the factors influencing physiotherapists' implementation of high-value care in the management of non-specific low back pain (NSLBP), particularly in Indian healthcare settings.

OBJECTIVE

The aim of this study was to explore the barriers and facilitators of implementation of high-value care in managing NSLBP from the perspective of physiotherapists practicing in Indian healthcare settings.

DESIGN

Descriptive qualitative design.

METHODS

We adopted a descriptive phenomenological approach and purposefully selected physiotherapists (N = 15) from diverse healthcare settings, encompassing varying years of clinical experience, to capture a broad range of perspectives. Semi-structured face-to-face interviews were conducted via the Zoom video conferencing platform. Each interview lasted on average for 30-45 min, and no follow-up interviews were conducted. Data were analyzed using thematic analysis with an inductive approach.

RESULTS

Our analysis revealed three major themes and seven sub-themes uncovering barriers and facilitators of implementation of high-value care. These themes include misconceptions about low back pain and its management among physiotherapists, their perceived lack of autonomy in clinical decision-making due to external influences, and the significance of aligning treatment plans with patient goals while considering evidence-based care.

CONCLUSION

The study results provide insights into the unique challenges associated with implementation of high-value care for non-specific low back pain in Indian healthcare settings.

Transport use limitations and its association with social participation among patients with stroke living in rural India

PURPOSE

This study aimed to investigate the limitations in transport use among stroke survivors in rural India and examine its impact on their social participation.

MATERIALS AND METHODS

A cross-sectional survey assessed transport patterns, post-stroke changes, and limitations among patients with stroke (N = 77). Social participation was measured with the Stroke Impact Scale (SIS 3.0).

RESULTS

Following stroke, there was a significant decrease (28-41%) in the proportion of participants who could use various modes of transport unassisted, particularly in driving a motorbike or scooter and using a bus or train. Post-stroke changes in transport use showed that many participants ceased or decreased their use of different modes of transport. Independent users consistently had higher social participation scores than dependent users across all transport modes, indicating better social participation. The mean differences in various transport modes ranged from 6 to 11 points (p < 0.01).

CONCLUSIONS

Independent use of different modes of transport, particularly public transportation, reduced among rural Indian stroke survivors. These transport limitations are significantly associated with reduced social participation, highlighting the need for interventions to improve accessibility and fostering greater community engagement for stroke survivors in this population.IMPLICATIONS FOR REHABILITATIONLimited transportation access limits social participation for stroke survivors in rural India.Study results show a significant decrease in independent transport use among stroke survivors, affecting their social participation.Rehabilitation interventions should focus on improving transportation accessibility to enhance social engagement for rural stroke survivors.

Superior mesenteric artery aneurysm endovascular repair

Superior mesenteric artery aneurysms are rare and associated with high mortality rates in cases of rupture. Current Society for Vascular Surgery guidelines recommend treatment of all superior mesenteric artery aneurysms regardless of size. A 53-year-old woman who was admitted for abdominal pain was found with a 14-cm, ruptured superior mesenteric artery branch aneurysm. Endovascular approach was performed with microvascular plug embolization of a feeding branch and aneurysm sac exclusion with a stent graft. Four months later, the patient demonstrated a 21% regression of the aneurysm and stent patency. Thus, timely diagnosis and treatment of superior mesenteric artery aneurysms with endovascular techniques can reduce potential complications.

Acute limb ischemia secondary to bullet embolism following a cardiac gunshot wound in a pediatric patient

Bullet embolism following a gunshot wound to the heart is a very unusual cause of acute limb ischemia. We report the case of a 3-year-old boy who sustained a penetrating cardiac trauma secondary to an accidental self-inflicted gunshot wound with a BB (ball bearing) gun. The BB pellet entered the left ventricle and embolized into the peripheral circulation, lodging at the bifurcation of the left common femoral artery. This resulted in acute left lower extremity ischemia. The patient was successfully treated by open common femoral artery exploration and foreign body removal.

Efficient Biosorption of Hexavalent Chromium from Water with Human Hair

The triphenyl group (trityl radical) possessing three-phenyl rings, self-assembled through aromatic π-π stacking interactions, can form interesting crystalline organic nano-flowers. In this work, we have synthesized a hybrid material of 1,2-bis(tritylthio)ethane and magnetite, which reduces toxic Cr(VI) to non-toxic Cr(III). We validated the efficacy of the hybrid in reducing toxic Cr(VI) along with three other adsorbent systems. Among the five adsorbent systems tested, we observed that human hair has higher Cr removal efficiency, which prompted us to explore further using different mechanical forms of human hair. Pulverized hair (PH), hair powder (HP), and raw hair (RH) were evaluated by employing different reaction factors such as the adsorbent dose, pH, initial Cr(VI) concentration, and contact time. The comparative evaluation showed that PH has greater adsorption capacity (15.14 mg/g), followed by RH (13.27 mg/g) and HP (10.5 mg/g). While investigating the adsorption mechanism, we observed that it follows pseudo-second-order kinetics suggesting chemisorption. The Freundlich isotherm model fitted well for Cr(VI) adsorption by human hair, suggesting a multi-layered adsorption process. Overall, this study promises a cost-effective and eco-friendly bio-adsorbent for Cr(VI), which may be scaled up to design automated industrial waste disposal systems.

A Rare Case of Amyloid Light Chain Amyloidosis with Extensive Hepatic Involvement

Introduction/Objective

Amyloid light chain (AL) amyloidosis is a life-threatening disease entity, with an incidence of 10–15 per million per year in the USA. Amyloidosis is caused by the extracellular deposition of insoluble fibrillary amyloid protein resulting in multiorgan damage. Though amyloidosis is primarily a systemic disease, 10%-20% of cases can be localized.

Methods/Case Report

We present a case of a 37-year-old male admitted with predominant hepatic manifestations, whose liver biopsy led to the diagnosis of amyloidosis. The patient presented with intermittent abdominal pain, weight loss, persistent hypoglycemia, hepatomegaly, and raised liver enzymes. Imaging studies showed hepatomegaly with a heterogeneous lace like appearance of the liver parenchyma. Liver biopsy revealed an extensive deposition of amyloid protein in peri-sinusoidal spaces. The amyloid protein is highlighted by crystal violet stain and revealed apple- green birefringence on polarized microscopy after Congo red staining. On further evaluation, elevated kappa and lambda free light chains with increased kappa-lambda ratio were identified by serum protein electrophoresis. Subsequent bone marrow aspirate and biopsy identified a monoclonal kappa positive plasma cell neoplasm with an amorphous eosinophilic infiltrate. Liquid chromatography-tandem mass spectrometry on bone marrow biopsy detected a peptide profile consistent with AL (kappa) type amyloid deposition.

Results (if a Case Study enter NA)

NA.

Conclusion

AL amyloidosis patients with predominant hepatic involvement have a worse prognosis. Rapid diagnosis and prompt clinical intervention prevents further organ damage. This case study aims to promote awareness of the unusual presentations of amyloidosis.

CVID Colopathy: An Important Clinical Diagnosis with a Broad Differential

Introduction/Objective

Colonic injury with increased epithelial cell apoptosis can be sometimes seen in colonic biopsies; raising a broad differential diagnosis. The possible etiologies include graft-versus-host disease and, drug- induced injury (including but not limited to mycophenolate mofetil, checkpoint inhibitors, antimetabolites, and tumor necrosis alpha inhibitors), infections (particularly cytomegalovirus and adenovirus), and immune disorders (common variable immune deficiency and autoimmune enterocolopathy). Hence, the umbrella term “apoptotic colopathy” was coined as a broad-spectrum diagnosis for further workup.

Methods/Case Report

Herein, we report a case of a 36-year-old Caucasian male who presented for follow-up of ulcerative pancolitis with additional history of decompensated liver cirrhosis. The patient has a past history of Common variable immunodeficiency (CVID) with CVID enteropathy and CMV gastritis. The patient’s long-term medications included Entyvio, IVIG, and Valcyte. Surveillance colonoscopy was performed and revealed portal colopathy, otherwise was unremarkable. Both right and left colon were biopsied. Microscopic examination showed marked epithelial cell apoptosis with no granulomas, dysplasia, or malignancy. No history of mycophenolate or stem cell transplant was noted. No viral cytopathic effect was seen, supported by CMV stain. Apoptotic colopathy with the possible differential diagnosis was rendered as the final diagnosis; mentioning the given clinical history of the patient for CVID, the histological picture is compatible with CVID colopathy.

Results (if a Case Study enter NA)

NA.

Conclusion

It is pertinent to be aware of all above mentioned possible etiologies in such cases. Correlation with detailed clinical history, medications, laboratory findings, and other histopathological findings (including judicial use of immunohistostains) is warranted to reach a definitive diagnosis that would drive patient management accordingly and help provide optimal patient care.

Antibacterial hydrogels of aromatic tripeptides

Self-assembled peptide hydrogels have emerged as alternatives to the conventional approaches employed in controlled drug release, wound-healing, and drug delivery, and as anti-infective agents. However, peptide hydrogels possessing antibacterial properties are less explored. In this work, we have designed three ultrashort antibacterial peptide hydrogels: Fmoc-FFH-CONH₂, Fmoc-FHF-CONH₂, and Fmoc-HFF-CONH₂. The rheological study showed the higher storage modulus of Fmoc-FFH-CONH₂ (30.43 kPa) compared to Fmoc-FHF-CONH₂ and Fmoc-HFF-CONH₂, which may be attributed to the enhanced aromatic interaction in Fmoc-FFH-CONH₂ compared to the other two variants, resulting in more mechanical rigidity. Further, the prepared hydrogels were evaluated for their inherent antibacterial potency against Gram-positive (Staphylococcus aureus, strain MTCC 96) and Gram-negative (Pseudomonas aeruginosa, strain PA01) bacteria. Antibacterial experiments demonstrated the potency of the hydrogels in the order of Fmoc-FFH-CONH₂ > Fmoc-FHF-CONH₂ > Fmoc-HFF-CONH₂. The antibacterial effect of the hydrogels was predominantly due to the osmotic stress and membrane disruption, which was verified by reactive oxygen species (ROS) generation and outer membrane permeabilization assays. Our findings point to the scope of using the synthesized peptide hydrogels as agents for topical applications.

Influence of Obesity on Blood Pressure Responses to Antihypertensive Drug Therapy in an Urban Hypertension Specialty Clinic

BACKGROUND

Previous studies have reported that lean hypertensives have worse clinical outcomes than obese hypertensives as obesity confers pharmacological resistance to antihypertensive therapy. We explored whether the higher prescribed doses of antihypertensives in obese hypertensives were adequate for the attainment of similar on-treatment blood pressure (BP) versus leaner hypertensives.

METHODS

A retrospective chart review of predominantly African American females from a deidentified urban referral clinic was conducted (N = 851; median follow-up = 11.3 months). Body mass index (BMI, kg/m2) was categorized as either below or above or equal to 30. Antihypertensive therapeutic intensity score (TIS) was calculated as the total daily antihypertensive dose/maximum United States Food and Drug Administration (USFDA) approved daily dose, summed across all hypertensive drugs. General linear models were used to estimate the significance of continuous variables across BMI categories.

RESULTS

At baseline, systolic blood pressure (SBP) was similar between groups (P = 0.14), though 2.7 mm Hg higher in the highest BMI group. Antihypertensive TIS was greater in the highest BMI category at both baseline and end of follow-up (both P < 0.001). After covariate adjustment end of follow-up SBP and diastolic blood pressure was higher in the obese group by 3.4 (0.6-6.1) and 1.8 (0.1-3.53) mm Hg, respectively (P = 0.02, P = 0.04).

CONCLUSIONS

Attained on-treatment BP is higher in obese than non-obese hypertensives despite greater prescription of antihypertensive medications. Whether even more prescription of medications or other interventions will equalize BP responses relative to non obese hypertensives merits further study.

Effect of spin in the abstract of a randomised controlled trial on physiotherapists' perception of treatment benefit: a randomised controlled trial

OBJECTIVE

To assess the effect of spin in the abstract of a randomised controlled trial (RCT) on physiotherapists' perception of treatment benefit evaluated in the trial.

DESIGN

Parallel-group RCT.

SETTING

Physiotherapy departments in hospitals and clinics in India.

PARTICIPANTS

Physiotherapists working in clinical settings.

INTERVENTIONS

We selected one abstract with high level of spin published in one of the core journals of physiotherapy and created two versions of the abstract, that is, with and without spin. We randomly assigned physiotherapists working in clinical settings (N=128) to read one version of the selected abstract, with or without spin. Participants were blinded to the study design, objectives and randomisation.

MAIN OUTCOME MEASURES

Physiotherapists' interpretation of beneficial effect of the experimental treatment (0-10 scale) reported in the abstract. The secondary outcomes were clinicians' perception of methodological rigour and the study importance, their interest in reading the full text, and their interest in running another trial evaluating this treatment.

RESULTS

We found a medium reduction in confidence of beneficial effect of the experimental treatment among physiotherapists who read the abstract without spin (mean score 4.3±2.8) compared with those who read the abstract with spin (mean score 6.14±2.6). The mean difference in scores between abstracts with and without spin was 1.8 (95% CI 0.8 to 2.8; p<0.001). For other outcomes measures studied there was no statistically significant effect.

CONCLUSIONS

Removal of spin in the abstract of RCT reporting statistically non-significant results have medium effect in improving physiotherapists' accuracy of interpretation of study results. Spin contributes to clinicians' positive perception about the benefit of experimental intervention tested in the trial despite the evidence showing no superiority of experimental intervention.

TRIAL REGISTRATION NUMBER

CTRI/2020/02/023557.

Limited evidence exists on determinants of physiotherapists' adherence to high value interventions in nonspecific low back pain management: A scoping review

BACKGROUND

Examining the emerging body of evidence investigating what drives physiotherapist's clinical decisions in the management of low back pain can guide future research into identifying barriers and facilitators of their adherence to evidence recommended interventions.

OBJECTIVE

To establish the body of evidence regarding factors that improve or hinder physiotherapists' adherence to high-value interventions on the management of non-specific low back pain.

DESIGN

Scoping review.

METHODS

We conducted a Scoping review by searching MEDLINE, CINAHL, and SPORTDiscus databases on 13 February 2021. Two reviewers independently screened the retrieved literature and selected articles for inclusion. We included quantitative research that investigated an association between physiotherapists' personal characteristics or setting related characteristics with their clinical management of patients with non-specific low back pain.

RESULTS

Twelve studies reported in 13 publications were included. The majority of the studies were conducted in high-income countries including, the United States, Canada and UK. Twenty-six factors were investigated as potentially influencing physiotherapists' adherence to high value interventions in low back pain management. The most commonly examined physiotherapists' attributes were educational qualification that is postgraduate or certification course (58%, N = 7 studies), years of experience (41%, N = 5 studies), and beliefs and attitude about low back pain (41%, N = 5 studies). Work setting (N = 4) and workload (N = 3) were frequently investigated setting related factors.

CONCLUSION

Currently, there is limited evidence available to understand determinants controlling practice behaviours of physiotherapists' management of nonspecific low back pain. Future researches conceptualized within contemporary theories of clinician behaviour change and models of knowledge translation are needed.

Placental Mesenchymal Dysplasia, An Exceedingly Rare Entity and Challenging Diagnosis

Introduction/Objective

Placental mesenchymal dysplasia (PMD) is an extremely rare entity with an incidence of only 0.02/1000 deliveries.

Methods/Case Report

We present a case of a 26 year-old female Gravida 3, Para 1 with intrauterine pregnancy at 37 weeks of gestation. Fetal ultrasound showed mildly cystic upper portion of the placenta. The noninvasive prenatal testing was negative for triploidy. A viable healthy female infant was delivered with no maternal complications.

On gross examination, placenta was heavy with approximately 25% incomplete cotyledons. Placental maternal surface showed, spongiform cut surfaces admixed with multiple cystic structures ranging in size from 0.5 to 1.5 cm and markedly dilated blood vessels.

Histopathologic examination revealed markedly enlarged villi, mesenchymal hyperplasia, and hyper vascularity of small vessels. No trophoblast proliferation was identified. Subsequently, the diagnosis of PMD was made.

Results (if a Case Study enter NA)

NA

Conclusion

PMD is a rare anomaly which is characterized by placentomegaly and grape like vesicles resembling molar pregnancy. Etiologies include imbalance of paternal and maternal alleles, androgenetic and bi-parental mosaicism, and Beckwith Weidman Syndrome (BWS). Differential diagnosis includes partial molar pregnancy, complete mole with co-existing normal fetus, hemangioma, subchorionic hematoma, confined placental mosaicism and hydropic complications. Histologic features, ancillary studies including immunohistochemistry and genetic testing are helpful in differentiating PMD. PMD is an underdiagnosed entity with increased risk of premature delivery and intrauterine fetal death. It is pertinent for the clinicians to be aware of this entity for optimal patient management.

A Rare Case of Cavernous Angiomatosis of the Uterus

Introduction/Objective

Angiomatosis is a rare, non-neoplastic vascular malformation characterized by the proliferation of blood vessels which involve skin, soft tissue, and bone. Angiomatosis of the female genital tract is extremely rare with very few cases described in the English literature.

Methods/Case Report

We present a case of an unexpected finding of angiomatosis of the uterus and cervix in a 34- year-old nulliparous female with a history of abnormal uterine bleeding and dysmenorrhea of one year duration. Imaging studies showed an anteverted uterus measuring 9 cm × 6 cm × 5 cm with thickened irregular endometrium, blood clots within the endometrial cavity, and subserosal uterine fibroids. A subsequent endometrial curettage showed benign superficial endometrium. Hysterectomy was performed and histopathological examination revealed diffuse haphazardly arranged large vascular channels within the uterine wall and cervical stroma. A diagnosis of cavernous angiomatosis of the uterus and cervix was made.

Results (if a Case Study enter NA)

NA

Conclusion

Angiomatosis of the female genital tract is a rare vascular proliferation that tends to grow at a slow rate and cause heavy menstrual bleeding in otherwise healthy patients. Differential diagnoses of angiomatosis include other vascular tumors such as hemangiomas, lymphangioma, arteriovenous malformation and papillary endothelial hyperplasia. Clinical examination and investigations like hysteroscopy, endometrial curettage and ultrasonography may not help in accurate diagnosis. Definitive diagnosis relies heavily on histopathological examination. Treatment of symptomatic angiomatosis is purely surgical and in our case, was curative. Following treatment, recurrences can occur and appropriate surveillance is recommended. Malignant transformation have not been reported. It is important to be aware of this rare entity to make an accurate diagnosis.

A tribute to Dr. Serge N. Timasheff, our mentor

Dr. Serge N. Timasheff, our mentor and friend, passed away in 2019. This article is a collection of tributes from his postdoctoral fellows, friends, and daughter, who all have been associated with or influenced by him or his research. Dr. Timasheff is a pioneer of research on thermodynamic linkage between ligand interaction and macromolecular reaction. We all learned a great deal from Dr. Timasheff, not only about science but also about life.

Nitric oxide (NO) and salicylic acid (SA): A framework for their relationship in plant development under abiotic stress

The free radical nitric oxide (NO) and the phenolic phytohormone salicylic acid (SA) are signal molecules which exert key functions at biochemical and physiological levels. Abiotic stresses, especially in early plant development, impose the biggest threats to agricultural systems and crop yield. These stresses impair plant growth and subsequently cause a reduction in root development, affecting nutrient uptake and crop productivity. The molecules NO and SA have been identified as robust tools for efficiently mitigating the negative effects of abiotic stress in plants. SA is engaged in an array of tasks under adverse environmental situations. The function of NO depends on its cellular concentration; at a low level, it acts as a signal molecule, while at a high level, it triggers nitro-oxidative stress. The crosstalk between NO and SA involving different signalling molecules and regulatory factors modulate plant function during stressful situations. Crosstalk between these two signalling molecules induces plant tolerance to abiotic stress and needs further investigation. This review aims to highlight signalling aspects of NO and SA in higher plants and critically discusses the roles of these two molecules in alleviating abiotic stress.

Gastric lipoma: a rare cause of massive haematemesis

Gastric lipomas are rare benign neoplasms of the stomach. These submucosal lesions and located mostly in the antral region of the stomach. Small lipomas are usually asymptomatic and are detected incidentally. When large, they may present with abdominal pain, gastrointestinal (GI) bleeding or gastric outlet obstruction. We hereby present a case of gastric lipoma in a 54-year-old man presenting with massive upper GI bleed and haemodynamic instability. The diagnosis was established with endoscopy and contrast-enhanced computed tomography of the abdomen. After resuscitation, the patient underwent laparoscopic resection of the antral lipoma.

What is known about factors improving physiotherapists' adherence to high value interventions in nonspecific low back pain? A scoping review protocol

INTRODUCTION

Despite multiple guidelines providing best practice treatment recommendations for managing low back pain (LBP), current evidence suggests that physiotherapists across the world often provide costly, ineffective, unnecessary, even harmful care. The purpose of this scoping review is to establish the body of evidence regarding factors that improve or hinder physiotherapist's adherence to high-value interventions in the management of non-specific LBP.

METHODS

This scoping review will be conducted based on the methodological framework for scoping review recommended by Arksey & O'Malley's and Levac. Three electronic databases will be searched: MEDLINE, CINAHL and SPORTDiscus. A search of grey literature will also be performed. The search will cover studies published in English from the inception of each database to the present date. The reference lists of all included reports and articles will be hand-searched for additional results. Two independent reviewers will screen titles and abstracts for assessment against the eligibility criteria. Data will be extracted and presented in tabular form and a narrative summary that aligns with the review's aim.

ETHICS AND DISSEMINATION

This scoping review does not require ethics approval. Results of this scoping review will be disseminated via conference presentation and/or publication in a scientific journal. We will also disseminate the results as part of stakeholder meetings with physiotherapists including clinicians, academicians, researchers and administrators managing non-specific LBP. A summary of the key results will be shared across social networking sites in the form of infographics.

The Effect of COVID-19 on Training and Case Volume of Vascular Surgery Trainees

Background:

In many facilities, the coronavirus disease (COVID-19) pandemic caused suspension of elective surgery. We therefore sought to determine the impact of this on the surgical experience of vascular trainees.

Methods:

Surgical case volume, breadth, and the participating trainee post-graduate level from 3 large New York City Hospitals with integrated residency and fellowship programs (Mount Sinai, Montefiore Medical Center/Albert Einstein College of Medicine, and New York University) were reviewed. Procedures performed between February 26 to March 25, 2020 (pre-pandemic month) and March 26 to April 25, 2020 (peak pandemic period) were compared to those performed during the same time period in 2019. The trainees from these programs were also sent surveys to evaluate their subjective experience during this time.

Results:

The total number of cases during the month leading into the peak pandemic period was 635 cases in 2019 and 560 cases in 2020 (12% decrease). During the peak pandemic period, case volume decreased from 445 in 2019 to 114 in 2020 (74% reduction). The highest volume procedures during the peak pandemic month in 2020 were amputations and peripheral cases for acute limb ischemia; during the 2019 period, the most common cases were therapeutic endovascular procedures. There was a decrease in case volume for vascular senior residents of 77% and vascular junior and midlevel residents of 75%. There was a 77% survey response rate with 50% of respondents in the senior years of training. Overall, 20% of respondents expressed concern about completing ACGME requirements due to the COVID-19 pandemic.

Conclusions:

Vascular surgery-specific clinical educational and operative experiences during redeployment efforts have been limited. Further efforts should be directed to quantify the impact on training and to evaluate the efficacy of training supplements such as teleconferences and simulation.

The Indian Stroke Scale: Development and validation of a scale to measure participation in daily activities among patients with stroke in India

BACKGROUND

Prospects of a participation measure to be valid across cultures are debatable. Existing stroke outcome measures had been shown to have limited validity when used within Indian sociocultural contexts.

AIM

To develop and validate a patient-reported outcome measure of participation in daily activities appropriate for patients with stroke living in an Indian sociocultural context.

METHODS

The scale was developed in two phases: scale development and psychometric testing. Items were derived from a conceptual framework of participation in daily activities of patients who had experienced stroke within an Indian context. The final version of the scale consisted of 25 items. A total of 377 patients diagnosed with stroke were recruited from two tertiary care hospitals and five physiotherapy outpatient rehabilitation centers in India. Psychometric testing of the scale included investigation of internal consistency, unidimensionality, construct validity (known group and convergent validity), and test-retest reliability.

RESULTS

The scale items demonstrated good internal consistency (Cronbach's alpha = .94). Confirmatory factor analysis results showed acceptable goodness of fit. The scale has shown good construct validity and test-retest reliability (intraclass correlation coefficient = 0.80). The scale differentiated patients with low and high disability severity (mean difference = 34, 95% CI = 27 to 39) and moderately associated with physical and instrumental activities of daily living (r = 0.64, p < .001) and social participation domains of stroke impact scale (r = 0.44, p < .001) and Barthel index (r = 0.59, p < .001).

CONCLUSION

The Indian Stroke Scale has shown preliminary evidence of validity to support its use as a patient-reported outcome measure for evaluating poststroke participation in daily activities among patients with stroke in India.

Adverse Health Outcomes Associated With Refractory and Treatment-Resistant Hypertension in the Chronic Renal Insufficiency Cohort

Refractory hypertension (RfH) is a severe phenotype of antihypertension treatment failure. Treatment-resistant hypertension (TRH), a less severe form of difficult-to-treat hypertension, has been associated with significantly worse health outcomes. However, no studies currently show how health outcomes may worsen upon progression to RfH. RfH and TRH were studied in 3147 hypertensive participants in the CRIC (Chronic Renal Insufficiency Cohort study). The hypertensive phenotype (ie, no TRH or RfH, TRH, or RfH) was identified at the baseline visit, and health outcomes were monitored at subsequent visits. Outcome risk was compared using Cox proportional hazards models with time-varying covariates. A total of 136 (4.3%) individuals were identified with RfH at baseline. After adjusting for participant characteristics, individuals with RfH had increased risk for the composite renal outcome across all study years (50% decline in estimated glomerular filtration rate or end-stage renal disease; hazard ratio for study years 0-10=1.73 [95% CI, 1.42-2.11]) and the composite cardiovascular disease outcome during later study years (stroke, myocardial infarction, or congestive heart failure; hazard ratio for study years 0-3=1.25 [0.91-1.73], for study years 3-6=1.50 [0.97-2.32]), and for study years 6-10=2.72 [1.47-5.01]) when compared with individuals with TRH. There was no significant difference in all-cause mortality between those with refractory versus TRH. We provide the first evidence that RfH is associated with worse long-term health outcomes compared with TRH.

De Novo Designed Heterochiral Blue Fluorescent Protein

Diversification of chain stereochemistry offers a tremendous increase in protein design space. We have designed a minimal fluorescent protein, pregnant with β-(1-azulenyl)-l-alanine in the hydrophobic core of a heterotactic protein scaffold, employing automated design tools such as automated repetitive simulated annealing molecular dynamics and IDeAS. The de novo designed heterochiral protein can be selectively excited at 342 nm, quite distant from the intrinsic fluorophore, and emits in the blue region. The structure and stability of the designed proteins were evaluated by established spectroscopic and calorimetric methods.

Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries.

METHODS

GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution.

FINDINGS

Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990-2010 time period, with the greatest annualised rate of decline occurring in the 0-9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10-24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10-24 years were also in the top ten in the 25-49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50-74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI.

INTERPRETATION

As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and development investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve.

FUNDING

Bill & Melinda Gates Foundation.

Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease.

METHODS

GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk-outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk-outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk-outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden.

FINDINGS

The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10·8 million (95% uncertainty interval [UI] 9·51-12·1) deaths (19·2% [16·9-21·3] of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8·71 million (8·12-9·31) deaths (15·4% [14·6-16·2] of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253-350) DALYs (11·6% [10·3-13·1] of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0-9 years, the three leading detailed risk factors for attributable DALYs were all related to malnutrition. Iron deficiency was the leading risk factor for those aged 10-24 years, alcohol use for those aged 25-49 years, and high systolic blood pressure for those aged 50-74 years and 75 years and older.

INTERPRETATION

Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public.

FUNDING

Bill & Melinda Gates Foundation.

RADON, THORON AND THEIR PROGENY DISTRIBUTION AND ESTIMATION OF ANNUAL EFFECTIVE DOSE AND EXCESS LIFETIME CANCER RISK IN PANATHADY, KASARAGOD DISTRICT, KERALA

Radon and thoron are natural radioactive gases that tend to accumulate in the indoor environment and one of their major health implications is the ability to cause lung cancer. Present study comprises the quantification of radon and thoron activity concentrations and measurement of gamma exposure rates in different types of dwellings from the endosulfan-affected area, Panathady, Kasaragod district, Kerala. It is observed that, residents of this area were more prone to various diseases and health problems including cancer. The LR-115 type II solid state nuclear track detectors with single entry pin-hole based dosemeters have been used for the measurement of 222Radon and 220Rn activity concentrations. The assessment of radiological parameters such as annual effective doses and excess lifetime cancer risk has also been done in order to understand the dose level and the associated risk. The estimated values have been compared with the limit recommended by the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) and International Commission on Radiological Protection (ICRP). The average indoor radon and thoron activity concentrations observed in these dwellings were 134 ± 30 and 111 ± 28 Bq m-3, respectively. The estimated activity concentrations, effective doses, etc. are found to be within the recommended level by the UNSCEAR or ICRP.

Serious Adverse Events Cluster in Participants Experiencing the Primary Composite Cardiovascular Endpoint: A Post Hoc Analysis of the SPRINT Trial

BACKGROUND

Intensively treated participants in the SPRINT study experienced fewer primary cardiovascular composite study endpoints (CVD events) and lower mortality, although 38% of participants experienced a serious adverse event (SAE). The relationship of SAEs with CVD events is unknown.

METHODS

CVD events were defined as either myocardial infarction, acute coronary syndrome, decompensated heart failure, stroke, or death from cardiovascular causes. Cox models were utilized to understand the occurrence of SAEs with CVD events according to baseline atherosclerotic cardiovascular disease (ASCVD) risk.

RESULTS

SAEs occurred in 96% of those experiencing a CVD event but only in 34% (P < 0.001) of those not experiencing a CVD event. Occurrence of SAEs monotonically increased across the range of baseline ASCVD risk being approximately twice as great in the highest compared with the lowest risk category. SAE occurrence was strongly associated with ASCVD risk but was similar within risk groups across treatment arms. In adjusted Cox models, experiencing a CVD event was the strongest predictor of SAEs in all risk groups. By the end of year 1, the hazard ratios for the low, middle, and high ASCVD risk tertiles, and baseline clinical CVD group were 2.56 (95% CI = 1.39-4.71); 2.52 (1.63-3.89); 3.61 (2.79-4.68); 1.86 (1.37-2.54), respectively-a trend observed in subsequent years until study end. Intensive treatment independently predicted SAEs only in the second ASVCD risk tertile.

CONCLUSIONS

The occurrence of SAEs is multifactorial and mostly related to prerandomization patient characteristics, most prominently ASCVD risk, which, in turn, relates to in-study CVD events.