Effect of WeChat-based intervention on food safety knowledge, attitudes and practices among university students in Chongqing, China: a quasi-experimental study

BACKGROUND

Food safety is of global importance and has been of concern in university settings in recent years. However, effective methods to conduct food safety education are limited. This study aims to evaluate the effects of an intervention on food safety knowledge, attitudes and practices (KAP) by social media, WeChat, among university students.

METHODS

A quasi-experimental study was conducted in Chongqing, China. Two departments were recruited randomly from a normal university and a medical university. One department from each university was randomly selected as the intervention group and the other as the control group. All freshmen students in each selected department were chosen to participate in this study. One thousand and twenty-three students were included at baseline, and 444 students completed the study. This intervention was conducted through food safety-related popular science articles with an average of three articles per week released by WeChat official accounts called "Yingyangren" for two months to the intervention group. No intervention was conducted in the control group. An independent t-test was used to test statistical differences in the food safety KAP scores between the two groups. A paired t-test was used to test statistical differences in the food safety KAP scores between before and after the intervention. And quantile regression analysis was conducted to explore the difference between the two groups across the quantile levels of KAP change.

RESULTS

After the intervention, compared with control group, participants in the intervention group did not score significant higher on knowledge (p = 0.98), attitude (p = 0.13), and practice (p = 0.21). And the scores of food safety knowledge and practices slightly improved after the intervention both in the intervention group (p = 0.01 and p = 0.01, respectively) and in the control group (p = 0.0003 and p = 0.0001, respectively). Additionally, the quantile regression analysis showed that the intervention had no effect on improving the food safety KAP scores.

CONCLUSIONS

The intervention using the WeChat official account had limited effects on improving the food safety KAP among the university students. This study was an exploration of food safety intervention using the WeChat official account; valuable experience can be provided for social media intervention in future study.

TRIAL REGISTRATION

ChiCTR-OCH-14004861.

The development of inflammatory arthritis following SARS-CoV-2 infection: a systematic review of the literature

BACKGROUND

Given the widespread impact of COVID-19, it is important to explore any atypical presentations and long-term sequelae associated with this viral infection, including the precipitation of inflammatory arthritis.

OBJECTIVE

To identify and summarize clinical reports of acute inflammatory arthritis associated with COVID-19.

METHODS

A systematic review of the PubMed (MEDLINE), Google Scholar, and Cochrane Central databases through January 31, 2022 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The inclusion criteria were: human subjects and English language. Data extraction and qualitative synthesis of the demographics, clinical presentations, treatments, and outcomes were performed. Quality assessment was performed using the Joanna-Briggs Institute critical appraisal tools.

RESULTS

A total of 37 articles collectively describing the cases of 54 patients were included. The mean age was 48.2 years (6-78 years). 53.7% of patients were male and 46.3% were female. The onset of articular symptoms varied considerably, and the majority of cases were described as polyarticular (29). The classification of inflammatory arthritis in the included studies was as follows: reactive (19), post-viral (13), new-onset rheumatoid arthritis (RA) (8), crystal-proven arthropathy flare (4), acute viral (2), new-onset psoriatic arthritis (2), flare of preexisting RA (2), and other (4). Arthritis treatment regimens varied but consisted largely of NSAIDs and corticosteroids with most patients experiencing improvement or resolution of their joint symptoms.

CONCLUSION

There is limited low-level evidence suggesting that patients may develop acute arthritis during or after SARS-CoV-2 infection. This review highlights the need for further research to elucidate the relationship between COVID-19 and the development of inflammatory arthritis.

Prognostic significance of peak atrial longitudinal strain in patients with functional mitral regurgitation

Funding Acknowledgements

Type of funding sources: None.

Background

Chronic mitral regurgitation has been shown to promote left atrial (LA) dysfunction and remodeling. However, the significance of LA dysfunction in this setting has not been fully investigated. The aim of our study was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in a cohort of patients with LV systolic dysfunction and functional mitral regurgitation (FMR).

Methods

Patients with at least mild FMR and reduced LVEF (< 50%) under optimized medical therapy who underwent transthoracic echocardiography between 2010 and 2018 were retrospectively identified at a single-centre. FMR grading was undertaken according to the new 2021 valvular guidelines. PALS was assessed by 2D speckle tracking in apical 4-chamber view (as per EACVI current recommendations). Cox proportional hazards regression was applied for univariable and multivariable analysis to investigate the association between clinical and echocardiographic parameters, namely PALS, and all-cause mortality.

Results

A total of 307 patients (median age 70 years, 77% male) were included. Median LVEF was 35% (IQR: 27 – 40%) and median mitral regurgitant volume was 25mL (IQR: 14 – 34mL). According to the new ESC 2021 valvular guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 – 6.6), 148 patients died. Median PALS was 14% (IQR 8 – 20%). The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS (figure 1). On ROC curve analysis, the best PALS cut-off value associated with mortality was < 15%. Kaplan-Meier survival curves according to FMR severity and PALS > or < 15% are depicted in figure 2. PALS remained independently associated with all-cause mortality on multivariable analysis (adjusted hazard ratio [aHR]: 0.94; 95%CI: 0.90 – 0.98; p = 0.004) even after adjustment for several (n = 14) clinical and echocardiographic confounders.

Conclusion

In a cohort of patients with reduced LVEF and functional mitral regurgitation, peak atrial longitudinal strain was associated with all-cause mortality. Abstract Figure 1  Abstract Figure 2

Practical Strategies and Tools for Use by Occupational and Environmental Medicine Departments During COVID-19 Pandemic Surges

OBJECTIVES

Occupational and environmental medicine (OEM) departments in healthcare institutions can be quickly overwhelmed when COVID-19 infection rates rapidly and simultaneously increase in the workforce and the patients served. Our goal is to present a detailed toolkit of practical approaches for use by front-line OEM specialists to address workforce management tasks during pandemic surges.

METHODS

Specific focus is on tasks related to employee symptom triage, exposure risk assessment, workplace contact tracing, and work restrictions.

RESULTS

Tools include strategies used by customer call centers, two decision support algorithms (exposure due to cohabitation or non-cohabitation), a color-coded employee case tracking tool, a contact tracing protocol, and documentation templates that serve as memory aids for encounters.

CONCLUSIONS

These tools are created with commonly used software. Implementation is feasible in most front-line OEM settings, including those with limited resources.

Prevalence and determinants of right ventricular dysfunction in patients with severe symptomatic high gradient aortic stenosis

Background

Right ventricular (RV) function in aortic stenosis (AS) has been largely neglected. Recently it was demonstrated that right ventricular impairment may be influenced by left ventricular (LV) function and afterload, well before overt pulmonary hypertension development.

Aim

To describe the prevalence of RV dysfunction in a group of patients with severe symptomatic aortic stenosis (AS) and its relation to LV function parameters and afterload.

Methods

We prospectively studied 93 consecutive patients (age: 73 years [IQR 68–77] years, 55% women) with pure severe symptomatic high gradient aortic stenosis: mean transaortic pressure gradient: 57.0mmHg [IQR 46.9–71.1]; aortic valve area: 0.72cm2 [IQR 0.61–0.88]; indexed stroke volume: 48.8±1.5 mL/m2 (11 patients with low-flow AS), preserved LV ejection fraction (EV) (LVEF: 56.0% [51.0–61.3]; GLS: −14.5% [IQR −16.1 to −10.6]), with no previous coronary artery disease and no history of cardiomyopathy. Beyond complete transthoracic echocardiography, all patients underwent cardiac magnetic resonance (CMR) for LV myocardium tissue characterization (late gadolinium enhancement and extracellular volume). Normal RV function was defined according to TAPSE ≥17mm, tricuspid annular systolic velocity ≥12cm/s, mean free wall longitudinal strain ≤−20%. Patients were divided into four groups: (0) – all three RV parameters below normal (1.1%), (1) – 1 normal parameter (12.9%), (2) – 2 normal parameters (44.1%), (3) – 3 normal parameters (41.9%). Indexes of LV systolic and diastolic function, CMR derived LV geometric remodeling, hypertrophy and tissue characterization, aortic valve disease severity and afterload were compared across the 4 groups of patients. We tried to identify predictors of RV dysfunction (group 0, 1, 2 vs. group 3) at multivariate regression analysis.

Results

Left ventricular performance parameters, diastolic and myocardial work indexes were significantly different across the groups (Figure). Neither AV severity indexes nor LV tissue characterization were distinct. At multivariate analysis only global constructive work was an independent predictor of RV dysfunction.

Conclusion

RV dysfunction is common in this group of patients with severe high gradient aortic stenosis and preserved ejection fraction. RV impairment is significantly related to several LV systolic and diastolic parameters and also to LV afterload, probably accounting for RV-LV interdependence.

Funding Acknowledgement

Type of funding sources: None.

Thalamic deep brain stimulation for post-traumatic neuropathic limb pain: Efficacy at five years' follow-up and effective volume of activated brain tissue

Chronic neuropathic pain affects 7%-10% of the population. Deep brain stimulation (DBS) has shown variable but promising results in its treatment. This study prospectively assessed the long-term effectiveness of DBS in a series of patients with chronic neuropathic pain, correlating clinical results with neuroimaging. Sixteen patients received 5 years' post-surgical follow-up in a single center. Six had phantom limb pain after amputation and 10 had deafferentation pain after traumatic brachial plexus injury. Patient-reported outcome measures were completed before and after surgery, using VAS, UWNPS, BPI and SF-36 scores. Neuroimaging evaluated electrode location and effective volumes of activated tissue (VAT). Two subgroups were created based on the percentage of VAT superimposed upon the ventroposterolateral thalamic nucleus (eVAT), and clinical outcomes were compared. Analgesic effect was assessed at 5 years and compared to preoperative pain, with an improvement on VAS of 76.4% (p=0.0001), on UW-NPS of 35.2% (p=0.3582), on BPI of 65.1% (p=0.0505) and on SF-36 of 5% (p=0.7406). Eight patients with higher eVAT showed improvement on VAS of 67.5% (p=0.0017) while the remaining patients, with lower eVAT, improved by 50.6% (p=0.03607). DBS remained effective in improving chronic neuropathic pain after 5 years. While VPL-targeting contributes to success, analgesia is also obtained by stimulating surrounding posterior ventrobasal thalamic structures and related spinothalamocortical tracts.

Mitophagy in Cerebral Ischemia and Ischemia/Reperfusion Injury

Ischemic stroke is a severe cerebrovascular disease with high mortality and morbidity. In recent years, reperfusion treatments based on thrombolytic and thrombectomy are major managements for ischemic stroke patients, and the recanalization time window has been extended to over 24 h. However, with the extension of the time window, the risk of ischemia/reperfusion (I/R) injury following reperfusion therapy becomes a big challenge for patient outcomes. I/R injury leads to neuronal death due to the imbalance in metabolic supply and demand, which is usually related to mitochondrial dysfunction. Mitophagy is a type of selective autophagy referring to the process of specific autophagic elimination of damaged or dysfunctional mitochondria to prevent the generation of excessive reactive oxygen species (ROS) and the subsequent cell death. Recent advances have implicated the protective role of mitophagy in cerebral ischemia is mainly associated with its neuroprotective effects in I/R injury. This review discusses the involvement of mitochondria dynamics and mitophagy in the pathophysiology of ischemic stroke and I/R injury in particular, focusing on the therapeutic potential of mitophagy regulation and the possibility of using mitophagy-related interventions as an adjunctive approach for neuroprotective time window extension after ischemic stroke.

Circadian misalignment is associated with a high cardiovascular risk among shift workers: is this an opportunity for prevention in occupational settings?

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Fundação para a Ciência e Tecnologia (FCT) and Fundo Social Europeu (FSE)

Introduction

Atypical work schedules encompass more than 20% of the European workforce. The link between shift work and cardiovascular disease (CVD) has been extensively studied being lifestyle behaviours, sleep disruption and circadian misalignment the key mechanisms involved. Social Jetlag (SJL) has been proposed as a proxy for circadian misalignment in epidemiological studies, once it takes into account  individual’s chronotype and working schedules. Therefore we hypothesize that, among  workers under fixed atypical work schedules, those with a greater SJL have a higher CVD risk.

Methods

A cross-sectional observational study was conducted among blue-collar workers of one retail company. Fixed working schedules were early morning, late evening, and night work. Sociodemographic, occupational, lifestyle and sleep data were collected through questionnaire. SJL was quantified by the difference for mid-sleep points on work- and free-days. Even though SJL is a continuous variable, 3 categories have been used (≤2h; 2-4h; ≥4h). Blood pressure (BP) and the total cholesterol (TC) were assessed. The CVD risk was estimated according to the relative risk SCORE chart. A relative risk≥3 was considered "high CVD risk". Descriptive statistics and bivariate analysis according to the CVD risk (high vs other) was performed. The relationship between SJL and high CVD risk was analysed through logistic binary regression using generalized linear models adjusted for age, sex, education, Body Mass Index, consumptions, sleep duration and quality plus work schedule and seniority.

Results

Of the 301 workers, 56.1% were male with a mean age of 33.0 ± 9.4years. Average SJL was 1:57 ± 1:38hours with the majority of workers experiencing ≤2h (59.4%) and 8% (n = 24) more than 4h. Less than a half had hypercholesterolemia (48.8%), overweight (37.9%)or hypertensive values (10.6%), however 50.5% were currently smokers. We found a significant trend for hypertension (p = 0.006) and smoking prevalence (p = 0.043) among ordinal SJL categories. A relative "high CVD risk" was found in 20.3% of the sample (n = 61). These workers were significantly older (p < 0.001), less educated (p = 0.003) and slept less hours on workdays (p = 0.021). In the multiple regression analysis, SJL was an independent risk factor for a "high CVD risk" (p = 0.029).The odds of having a "high CVD risk" increased almost thirty per cent  per each additional hour of SJL (OR = 1.29; 95% CI:1.03-1.63), even after adjusting for sociodemographic, lifestyle, sleep and working features.

Conclusions

We found compelling evidence that a greater SJL was associated with a bigger chance of high CVD risk. From this innovative perspective, the focus is not just on the working schedule itself but also on the worker’s chronotype. These findings suggest that interventions aimed to reduce Social Jetlag, especially in extreme chronotypes and working schedules, poses a great opportunity to minimize the cardiovascular health impact of shift work.

Dihydrolipoic acid enhances autophagy and alleviates neurological deficits after subarachnoid hemorrhage in rats

Autophagy is a crucial pathological process in early brain injury (EBI) after subarachnoid hemorrhage (SAH). In this study, we investigated the role of dihydrolipoic acid (DHLA) on enhancing autophagy and alleviating neurological deficits after SAH. SAH was induced by endovascular perforation in male Sprague-Dawley rats. DHLA (30 mg/kg) was administered intraperitoneally 1 h (h) after SAH. Small interfering ribonucleic acid (siRNA) for lysosome-associated membrane protein-1 (LAMP1) was administered through intracerebroventricular (i.c.v) route 48 h before SAH induction. SAH grading score, neurological score, immunofluorescence staining, Fluoro-Jade C (FJC) staining, and Western blot were examined. DHLA treatment increased autophagy-related protein expression and downregulated the apoptosis-related protein expression 24 h after SAH. In addition, the DHLA treatment reduced neuronal cell death and alleviated neurological deficits after SAH. Furthermore, knockdown of LAMP1 abolished the neuroprotective effects of DHLA. These results indicate that LAMP1 may participate in autophagy after SAH. DHLA treatment can enhance autophagy, attenuate apoptosis, and alleviate neurofunctional deficits in EBI after SAH. It may provide an effective alternative method for the treatment of EBI after SAH.

Impulsivity and compulsivity aggregate in alcohol use disorder and explain comorbidity with impulse-control and related disorders

Introduction

The conceptualization of impulsivity and compulsiveness has fluctuated between two different perspectives: they are (1) distinct and orthogonal dimensions, (2) extreme poles of the same dimension/ spectrum. We favor this latter, accepting that these dimensions contribute to the etiopathogenesis of impulsive-compulsive disorders, namely alcohol use disorder/AUD.

Objectives

To analyze: Differences of impulsivity and compulsivity levels between AUD patients vs. participants from the community; prevalence of impulsive-compulsive disorders/ICD in AUD; if impulsivity/compulsivity predict the severity of alcohol use and ICD in AUD.

Methods

32 AUD patients (21% women, mean age 46±10) answered the Portuguese versions of: Alcohol-Use-Disorders-Identification-Test, Questionnaire-for-Impulsive-Compulsive-Disorders-in-Parkinson’s-Disease, Barrat-Impulsiveness-Scale, Obsessive-Compulsive-Inventory and Depression-Anxiety-Stress-Scales; 50 adults from the community (68% women, mean age 29±14) answered the former three. Mann-Whitney-U, Spearman and regression tests were performed using SPSS.

Results

AUD individuals vs. subjects from the community presented higher levels of impulsivity and compulsivity (p<.001). AUD-group: AUDIT median score was 25 (>8 harmful use); 81% reported ICD-symptoms; impulsivity and compulsivity highly correlated (r=.639; p<.001); impulsivity levels explained the presence of certain ICD (gambling, compulsive buying, eating disorders) and depression/anxiety/stress (OR=.152; p<.05); compulsivity levels also explained the occurrence of specific ICD (compulsive buying and other repetitive automatic behaviours) and depression/anxiety/stress (OR=.131 p<.05).

Conclusions

Our results indicate that impulsivity and compulsivity co-occur and contribute to the explanation of AUD, and related comorbidity and psychological distress. This highlights the utility of considering impulsivity and compulsivity when subtyping, stratifying, and treating AUD patients. Finally, we assert that disorders of impulsivity and compulsivity (eg.: AUD and ICD) co-occur.

Conflict of interest

No significant relationships.

Adapting the concepts of proportionate and disproportionate functional mitral regurgitation to clinical practice

Funding Acknowledgements

Type of funding sources: None.

Background

  Despite its theoretical appeal, the concept of Proportionate and Disproportionate FMR has been limited by the lack of a simple way to assess it and by the paucity of data showing its prognostic superiority over currently established ways of grading FMR.

Objectives

This study sought to evaluate the prognostic value of a new and individualized method of assessing Functional Mitral Regurgitation (FMR) Proportionality.

Methods

Patients with at least mild FMR and reduced left ventricular ejection fraction (&lt; 50%) under optimal guideline-directed medical therapy were retrospectively identified at a single-center. To determine FMR proportionality status, we used a novel approach where two simple equations establish an individual cut-off of regurgitant volume/effective regurgitant orifice area, categorizing the study population into non-severe, proportionate and disproportionate FMR (Figure 1). The primary endpoint was all-cause mortality.

Results

A total of 572 patients (median age 70 years; 76% male) were included. Median LVEF was 35% (IQR 28-40) and LVEDV was 169 ml (IQR 132-215). Disproportionate FMR was present in 109 patients (19%) with a median EROA of 26 mm2 (IQR 22-31) and a median RegVol of 40 ml (IQR 34-48), proportionate FMR in 148 patients (26%) with a median EROA of 16mm2 (IQR 12-21) and a median RegVol of 26 ml (IQR 19-32). During a median follow-up of 3.8 years (interquartile range: 1.8 to 6.2 years) there were 254 deaths (44%). The unadjusted mortality incidence per 100 persons-year rose as the degree of FMR disproportionality worsened. On multivariable analysis, disproportionate FMR remained independently associated with all-cause mortality (adjusted hazard ratio: 1.785; 95% confidence interval [CI]: 1.249 to 2.550; P = 0.001). The FMR proportionality concept showed greater discriminative power (C-statistic 0.639; 95% CI: 0.597 to 0.680) than the American (C-statistic 0.588; 95% CI: 0.550 to 0.626; P for comparison = .001) and European guidelines (C-statistic 0.563; 95% CI: 0.534 to 0.591; P for comparison &lt; .001). It was also able to increase the net reclassification index (0.167 [P &lt; 0.001] and 0.084 [P = 0.001], respectively).

Conclusions

A new, simplified and individualized method of assessing FMR Proportionality showed that disproportionate FMR is independently associated with all-cause mortality. This approach seems to outperform the risk stratification of current guidelines.

Abstract Figure 1

Regurgitant volume to left ventricular end-diastolic volume ratio: another step to risk stratification in patients with secondary mitral regurgitation?

Funding Acknowledgements

Type of funding sources: None.

Background

 Quantitative evaluation of secondary mitral valve regurgitation (MR) remains an important yet challenging step in the evaluation of this entity. Its severity can be underestimated when using the proximal isovelocity surface area (PISA) method, which does not take left ventricular (LV) volume into account. Normalizing mitral regurgitant volume (Rvol) for the LV end-diastolic volume (EDV) might overcome this key limitation. This study aimed to investigate the prognostic implication of Rvol/EDV ratio in patients with secondary MR.

Methods

 Patients with at least mild secondary MR and reduced left ventricular ejection fraction (&lt;50%) under optimal guidelines-directed medical therapy were retrospectively identified at a single-center. The cohort was divided into terciles according to the RVol/EDV ratio. The primary endpoint was all-cause mortality.

Results

 A total of 572 patients (median age 70 years; 76% male) were included. Median LVEF was 35% (IQR 28-40) and LVEDV was 169 ml (IQR 132-215). Median measures of secondary MR were EROA 14 mm2 (IQR 8-22) and RegVol 23 ml (12-34). During a median follow-up of 3.8 years (interquartile range 1.8 to 6.2 years) there were 254 deaths (44%). The unadjusted mortality incidence increases across terciles distribution. Patients at the 2nd and 3rd terciles of the RVol/EDV ratio showed significantly higher mortality when compared to those at the 1st one (baseline reference) (figure 1). After multivariable analysis, terciles of the Rvol/EDV ratio remained independently associated with increased all-cause mortality (considering the 1st tercile as the reference; adjusted HR for the 2nd tercile 1.46 [95% CI 1.05- 2.02]  p = 0.023; adjusted HR for 3rd tercile 1.56 [95% CI 1.09 – 2.22], p = 0.015).

Conclusion

 In patients with secondary MR, Rvol/EDV ratio is independently associated with all-cause mortality. However, the appropriate cut-off to determine any kind of clinical decision remains to be determined.

Abstract Figure.

External validation of the unifying concept for the quantitative assessment of secondary mitral regurgitation

Funding Acknowledgements

Type of funding sources: None.

Background

  A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation (SMR) was recently proposed in order to provide a solution for the ongoing guideline controversy. However, these data were derived from a single center cohort and lacks external validation. We aimed to validate the proposed algorithm in a different patient population.

Methods

Patients with at least mild SMR and reduced left ventricular ejection fraction (&lt; 50%) under optimal guideline-directed medical therapy were retrospectively identified at a single-center. The cohort was stratified in low-risk (effective regurgitant orifice area [EROA] &lt; 20 mm2 and regurgitant volume [RegVol] &lt; 30 ml), intermediate-risk (EROA 20 to 29 mm2 and RegVol 30 to 44 ml) and high-risk (EROA ≥ 30 mm2 and RegVol ≥ 45ml) according to the defined risk-based thresholds tailored to the pathophysiological concept of SMR. In the intermediate-risk group, patients were further stratified on the basis of the hemodynamic severity of SMR, into intermediate low-risk and intermediate high-risk (regurgitant fraction &lt; 50% or ≥ 50%, respectively). The primary endpoint was all-cause mortality.

Results

A total of 572 patients (median age 70 years; 76% male) were included. Median LVEF was 35% (IQR 28-40) and LVEDV was 169 ml (IQR 132-215). Median measures of SMR severity were EROA of 14 mm2 (IQR 8-22) and RegVol of 23 ml (12-34). During a median follow-up of 3.8 years (interquartile range: 1.8 to 6.2 years) there were 254 deaths (44%). The mortality at 6-years was 38.9% for the low-risk group, 30.7% for the intermediate low-risk, 64.9% in the intermediate high-risk and 63.2% in the high-risk group. On multivariable analysis, the defined thresholds of risk for SMR severity remained independently associated with all-cause mortality (adjusted hazard ratio: 1.164; 95% confidence interval [CI]: 1.020 to 1.327; P = 0.024). The unifying concept showed similar discriminative power (C-statistic 0.588; 95% CI: 0.540 to 0.635) to the American (C-statistic 0.588; 95% CI: 0.541 to 0.635; P for comparison = 1) and European guidelines (C-statistic 0.563; 95% CI: 0.515 to 0.610; P for comparison = 0.458), but it was able to increase the net reclassification index (0.143 [P &lt; .001] and 0.026 [P = .025], respectively).

Conclusions

In this cohort of patients with SMR and LVEF &lt;50%, the proposed unifying concept based on combined assessment of the EROA, the RegVol, and the RegFrac proved to be associated with an increased risk of all-cause mortality and could improve risk prediction of current guidelines.

Abstract Figure.

Treatment outcomes of peri-articular steroid injection for patients with work-related sacroiliac joint pain and lumbar para-spinal muscle strain

OBJECTIVES

Evaluating treatment outcomes of local corticosteroid injections for work-related lower back pain (LBP) as the current evidence for the American College of Occupational and Environmental Medicine guidelines is considered insufficient to recommend this practice.

MATERIAL AND METHODS

The authors conducted a retrospective study involving the patients who were treated with peri-articular and lower lumbar corticosteroid injections for work-related LBP at their occupational medicine clinic.

RESULTS

Sixty-four patients met the inclusion criteria. The average pain level was reduced from M±SD 5.1±2.0 to M±SD 3.1±2.3 after the corticosteroid injection (p < 0.0001). Thirty-five patients (55%) were discharged to regular duty; 23 (36%) were transferred to orthopedics due to persistent pain; and 6 (9%) were lost to follow-up.

CONCLUSIONS

Corticosteroid injections for work-related LBP are effective in reducing pain and enhancing discharge to regular duty. Nonetheless, larger prospective trials are needed to validate these findings. Int J Occup Med Environ Health. 2021;34(1):111-20.

Mechanical Dispersion as a powerful echocardiographic predictor of outcomes after Myocardial Infarction

Introduction

Several studies have addressed the importance of transthoracic echocardiography (TTE) in risk prediction of subsequent adverse events after ST elevation myocardial infarction (STEMI). While several traditional echo parameters have a well-established prognostic value, data derived from 2D-Speckle Tracking Echocardiography (2DSTE) needs further investigation.

Objectives

To determine if 2DSTE parameters provide additional information beyond conventional echocardiography to predict long-term adverse outcomes in patients admitted with STEMI

Methods

Retrospective, single-center study, that included all patients without previous cardiovascular events admitted with STEMI (who underwent primary coronary angioplasty) between 2015 and 2017. Patients with poor acoustic windows, severe valvular disease, irregular heart rhythm, and those who died during hospital stay were excluded. We reviewed all pre-discharge TTE to assess conventional parameters of LV systolic and diastolic function and data obtained by 2DSTE: global longitudinal strain (GLS) and peak strain dispersion (PSD), an index that is the standard deviation from time to peak strain of all segments over the entire cardiac cycle. Demographic and clinical data was obtained through electronic hospital records. Minimum follow-up was 2 years. The primary endpoint was a composite of all-cause mortality and cardiovascular re-admission at follow-up. Survival analysis was used to determine independent predictors of the primary endpoint.

Results

377 patients were included, mean age 62±13 years, 72% male. Mean LVEF was 50±10% with 19% of patients having LVEF &lt;40%. Mean indexed left atrium volume (LAVi) was 33±10 ml/m2, mean GLS was −14±4%, and PSD was 60±22 msec. Average follow-up was 36±11 months, with a combined endpoint of mortality and hospitalization of 27% (n=102)

Univariate analysis of echocardiographic variables revealed an association between heart rate, LVEF, indexed LV end-systolic volume, indexed stroke volume, LAVi, GLS and PSD with the endpoint. However, on multivariate analysis only LAVi [HR 1.030 (95% CI 1.009 - 1.051), p-value = 0.005] and PSD [HR 1.011 (95% CI 1.002 - 1.020), p-value = 0.012] remained independent predictors of the primary endpoint.

We determined that a PSD value higher than 52 msec has a sensitivity of 76% and a negative predictive value of 83% for mortality and hospitalization, and that this cut-off point discriminates patients at a higher risk of events in Kaplan-Meier Survival analysis with a Log-Rank p-value=0.001.

Conclusion

PSD derived by longitudinal strain analysis is a promising prognostic predictor after STEMI. PSD outperformed conventional echocardiographic parameters in the risk stratification of STEMI patients at discharge.

Kaplan-Meier Survival Curves

Funding Acknowledgement

Type of funding source: None

Disproportionate functional mitral regurgitation: clinical validation of a new conceptual framework

Background

Disproportionate functional mitral regurgitation (FMR) is a novel concept that tries to identify hemodynamically significant FMR by readjusting the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) cut-offs according to left ventricular end-diastolic volume (LVEDV) and left ventricular ejection fraction (LVEF). However, this theoretical concept lacks clinical validation. The aim of this study was to assess the clinical significance of disproportionate FMR.

Methods

Patients with at least mild FMR and reduced LVEF (&lt;50%) who underwent transthoracic echocardiography between 2010 and 2014 were retrospectively identified in our laboratory database. Optimal medical therapy (including cardiac resynchronization when indicated) for ≥3 months was a prerequisite for inclusion. Hemodynamically significant FMR was defined as regurgitant fraction &gt;50% and the patient-specific theoretical RegVol cut-off was calculated according to the formula presented in Fig. 1a. The difference between the estimated RegVol by the PISA method and the theoretical RegVol cut-off was considered to represent the haemodynamic burden of MR. The primary endpoint was all-cause death. Patients were censured if mitral intervention or heart transplant was undertaken. Survival analysis was used to assess the effect of disproportionate FMR on mortality in 2 subgroups (LVEF &lt;30% and 30–49%).

Results

A total of 289 patients (median age 69 years [IQR 60–77], 75% male, 53% of ischemic aetiology) were included. More than 90% were on beta-blockers and renin-angiotensin inhibitors, 44% on aldosterone receptor antagonists, and 73% had implanted devices. The median LVEF and LVEDV were 34% (IQR 27–41) and 170mL (IQR 128–220), respectively. Median EROA was 10mm2 (IQR 3–21) and RegVol was 15 mL (IQR 4–30). RegVol distribution across the cohort was: &lt;10mL: 41%; 10–20mL: 18%; 20–30mL: 15% and &gt;30mL: 26%. Disproportionate FMR was present in 83 patients (29%). These patients had significantly higher SPAP values (41mmHg [IQR 33–50] vs. 33mmHg [IQR 29–40]; p&lt;0.001).

During a median follow-up of 44 months (IQR 19–73), 106 patients died. In the LVEF &lt;30% subgroup, age (HR 1.05 per year [1.02–1.08]; p&lt;0.001), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.042) and TAPSE (HR 0.92 per mm [0.86–0.99]; p=0.030) were independent predictors of mortality. In the LVEF 30–49% subgroup, age (HR 1.05 per year [1.02–1.08]; p=0.003), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.020) and disproportionate FMR (HR 1.02 per mL [1.01–1.03]; p=0.01) were independently associated with increased mortality.

Conclusions

Disproportionate FMR proved to be an important independent predictor of mortality in patients with LVEF between 30–49%. These findings were not replicated in those with LVEF&lt;30%, where the degree of biventricular dysfunction seems to outweigh all other echocardiographic parameters, leaving FMR as a bystander.

Figure 1

Funding Acknowledgement

Type of funding source: None

Hearing Screening in Preschool Children of a Rural Community in Portugal - A 10-year Experience

Introduction Preschool hearing screening programmes would identify later onset or progressive hearing losses and conductive hearing loss, due to the high prevalence of otitis media with effusion in childhood. Hearing loss associated with otitis media with effusion can have a great impact on reading, writing, central auditory processing and balance.

Objectives The present study aims at characterising the audiological alterations found in preschool children screened in a rural community in Portugal, and the correlation between audiological findings and otoscopy.

Methodology This is an observational study using the results obtained in a ten year audiological and otological screening of preschool children. Otoscopy, Tympanometry and Audiometry (1, 2 and 4 KHz presented at 40 and 20 dB intensity) were performed at the first stage of the screening and the results were classified as “pass” or “refer”. Every non-normal result of any category would imply a second stage consisting of observation by an ENT specialist at the site and the establishing of a follow-up plan. Written Informed Consent was obtained from the parents prior to initiating the study.

Results 595 children aged 5 and 6 years were screened between 2007 and 2017, of whom 192 (32.3%) required referral to the second stage. The most frequent alteration was found in the tympanogram. The tympanograms showed a significant correlation with the otoscopy performed by the ENT doctor, mainly type B tympanograms. The pass/refer audiometry also showed a statistically significant correlation with the medical otoscopy, although weak in all frequencies studied.

Conclusion It’s extremely important to perform a hearing screening in the age range of 5-6 years (with a high predisposition to middle ear problems), with the main objective of identifying and referring for treatment children who present alterations in order to reduce the consequences of the hearing impairment.

Stem Cell Therapy in Brain Ischemia: The Role of Mitochondrial Transfer

Mitochondrial dysfunction is an important pathological process in the setting of ischemic brain injury. Stem cell-mediated mitochondrial transfer provides an efficient intercellular process to supply additional mitochondria in the ischemic brain tissues. In this review, we summarize the mitochondrial pathology associated with brain ischemia, mechanisms of stem cell-mediated mitochondrial transfer, and in vitro/in vivo experimental findings of mitochondrial transfer from stem cells to ischemic vascular endothelial cells/neurons as potential therapeutic strategy in the management of ischemic brain injury.

NLRP3 Inflammasome in the Pathophysiology of Hemorrhagic Stroke: A Review

Hemorrhagic stroke is a devastating disease with high morbidity and mortality. There is still a lack of effective ther-apeutic approach. The recent studies have shown that the innate immune system plays a significant role in hemorrhagic stroke. Microglia, as major components in innate immune system, are activated and then can release cytokines and chemo-kines in response to hemorrhagic stroke, and ultimately led to neuroinflammation and brain injury. The NOD-like receptor family, pyrin domain containing 3 (NLRP3) inflammasome is predominantly released by microglia and is believed as the main contributor of neuroinflammation. Several studies have focused on the role of NLRP3 inflammasome in hemorrhagic stroke-induced brain injury, however, the specific mechanism of NLRP3 activation and regulation remains unclear. This re-view summarized the mechanism of NLRP3 activation and its role in hemorrhagic stroke and discussed the translational sig-nificance.

Global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017

BACKGROUND

Understanding the patterns of HIV/AIDS epidemics is crucial to tracking and monitoring the progress of prevention and control efforts in countries. We provide a comprehensive assessment of the levels and trends of HIV/AIDS incidence, prevalence, mortality, and coverage of antiretroviral therapy (ART) for 1980-2017 and forecast these estimates to 2030 for 195 countries and territories.

METHODS

We determined a modelling strategy for each country on the basis of the availability and quality of data. For countries and territories with data from population-based seroprevalence surveys or antenatal care clinics, we estimated prevalence and incidence using an open-source version of the Estimation and Projection Package-a natural history model originally developed by the UNAIDS Reference Group on Estimates, Modelling, and Projections. For countries with cause-specific vital registration data, we corrected data for garbage coding (ie, deaths coded to an intermediate, immediate, or poorly defined cause) and HIV misclassification. We developed a process of cohort incidence bias adjustment to use information on survival and deaths recorded in vital registration to back-calculate HIV incidence. For countries without any representative data on HIV, we produced incidence estimates by pulling information from observed bias in the geographical region. We used a re-coded version of the Spectrum model (a cohort component model that uses rates of disease progression and HIV mortality on and off ART) to produce age-sex-specific incidence, prevalence, and mortality, and treatment coverage results for all countries, and forecast these measures to 2030 using Spectrum with inputs that were extended on the basis of past trends in treatment scale-up and new infections.

FINDINGS

Global HIV mortality peaked in 2006 with 1·95 million deaths (95% uncertainty interval 1·87-2·04) and has since decreased to 0·95 million deaths (0·91-1·01) in 2017. New cases of HIV globally peaked in 1999 (3·16 million, 2·79-3·67) and since then have gradually decreased to 1·94 million (1·63-2·29) in 2017. These trends, along with ART scale-up, have globally resulted in increased prevalence, with 36·8 million (34·8-39·2) people living with HIV in 2017. Prevalence of HIV was highest in southern sub-Saharan Africa in 2017, and countries in the region had ART coverage ranging from 65·7% in Lesotho to 85·7% in eSwatini. Our forecasts showed that 54 countries will meet the UNAIDS target of 81% ART coverage by 2020 and 12 countries are on track to meet 90% ART coverage by 2030. Forecasted results estimate that few countries will meet the UNAIDS 2020 and 2030 mortality and incidence targets.

INTERPRETATION

Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact.

FUNDING

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

Klippel Trenaunay syndrome in the context of work-related injury: Case report and review of the literature

Background:

Uncommon diseases are usually not suspected at initial presentation, and the diagnosis might be challenging. Here we present a rare disease diagnosed in a work-related injury setting, highlighting the importance of further investigation by means of a more detail physical exam, imaging studies and involvement of other specialties.

Case Presentation:

A 21-year-old Hispanic male, who is a food service worker, presented following a work-related right elbow contusion with severe pain to his right elbow associated with swelling and purplish-red bruising/discoloration on its medial side and forearm. Physical exam demonstrated swelling, tenderness, and conspicuous dilated blood vessels across the right arm and forearm; additionally, multiple red-purplish scattered patches were found on the right arm, anterior and posterior right upper chest. His past medical history was significant for Capillary Hemangioma. He was initially treated conservatively and with work restriction; however, the pain in the forearm persisted. CT angiogram showed multiple interweaving vascular structures on the forearm, and further imaging by MR angiography depicted multiple vascular malformations in the right upper extremity and chest. Vascular surgery was consulted, and the diagnosis of Klippel-Trenaunay syndrome was made.

Conclusions:

Klippel-Trenaunay syndrome is a rare congenital disorder that could present in a wide-range of signs and symptoms. Thorough history taking and clinical examination is warranted in any work-related injuries. Further work up and referral to specialist should always be considered when diagnosis is unclear, or when initial symptoms do not resolve with treatment.

Circular RNA expression profiles alter significantly after intracerebral hemorrhage in rats

Circular RNAs (circRNAs) are a class of covalently closed non-coding RNAs, and aberrant alteration of their expression patterns is studied in numerous diseases. This study aimed to investigate whether intracerebral hemorrhage (ICH) affected circRNA expression profiles in the rat brain. Adult male Sprague-Dawley rats were subjected to intrastriatal injection of autologous artery blood to establish the ICH model. The cerebral cortex around hematoma was collected to perform circRNA microarray at 6 h, 12 h and 24 h. Quantitative reverse transcription-PCR (qRT-PCR) was used to validate the results. Bioinformatic methods were applied to predict ceRNA network and perform enrichment analyses for parent genes at three time points and target mRNAs. 111, 1145, 1751 up-regulated and 47, 732, 1329 down-regulated circRNAs were detected in the cerebral cortex of rats at 6 h, 12 h and 24 h after ICH compared with sham group. Most were from exonic regions. 93 were up-regulated and 20 were down-regulated at all three time points. Microarray results of 3 circRNAs were confirmed via qRT-PCR. GO and KEGG analyses for parent genes showed transition from protein complex assembly, cell-cell adhesion and cAMP signaling pathway at 6 h to intracellular signal transduction, protein phosphorylation and glutamatergic synapse at 12 h and 24 h. A circRNA-miRNA-mRNA network was successfully predicted. Enrichment analyses of targeted mRNAs indicated transcriptional regulations and pathways including Rap1, Ras, MAPK, PI3K-Akt, TNF and Wnt signaling and pathways in cancer. This was the first study to demonstrate that ICH significantly altered the expression of circRNAs with promising targets for therapeutic intervention.

P4657Cardiac myxomas: are we dealing with distinct clinical entities?

Background

Cardiac myxomas are rare, despite being the most common primary cardiac tumours. A significant number of myxomas are discovered accidentally in asymptomatic patients (pts), as there is increased use of non-invasive cardiac imaging. Our aim was to describe the experience of a cardiac surgery centre managing cardiac myxomas during the last 28 years.

Methods

Single-center retrospective study of consecutive pts admitted with the diagnosis of a cardiac myxomas between 1990 and 2018. Registry data concerning clinical presentation, non-invasive imaging assessment and definitive histopathology were collected.

Results

From 154 pts with the diagnosis of cardiac tumours, we identified 106 (68.8%) myxomas (67% females; mean age at diagnosis 61,5±13,1 years). Myxoma diagnosis increased throughout the 3 decades (27 cases until 2000; 26 cases in the second decade; 52 cases from 2010 until present). 30% of the pts were asymptomatic at diagnosis. Obstructive symptoms (heart failure and syncope) and embolic events were the most common complaints among symptomatic pts. Transthoracic echocardiography firstly identified the tumours in 88% of the cases. Cardiac magnetic resonance and computed tomography were performed for further investigation in 7% of the cases. Presumptive pre-operative diagnosis was correct in 83.8% pts.

Surgical excision was successfully achieved in all cases. 89% of the tumours were located in the left atrium with inter-atrial septum implantation (13 in right chambers; 1 valvular tumour). There were 10 multifocal tumours.

At histopathology myxomas were grossly described as mucous jelly appearance (80%), solid (15%) and mixed type lesions (5%). Rare histologic findings were described in 30% of the cases (8 tumours with bone tissue; 1 with forming bone marrow; 4 with endocrine type glandular epithelium; 16 with lympho-plasmocytic infiltrates; 3 with high mitotic grade; 5 with concomitant thrombus).

For a median follow up of 86 [31–214] months there were 15 deaths (2 of them with tumour related deaths). There were 3 recurrences (2 with high mitotic grade histology), mostly occurring 3 years after the first intervention.

Conclusion

In this case series cardiac myxomas are the most common cardiac tumours, with a significant proportion of asymptomatic lesions. Clinical heterogeneity followed polymorphic histology, with recognized differences when compared to classical descriptions of this kind of tumour.

The risk factors and prognosis of delayed perihematomal edema in patients with spontaneous intracerebral hemorrhage

PURPOSE

We hypothesize delayed perihematomal edema (DHE) leads to secondary injury after spontaneous intracerebral hemorrhage (sICH) with a poor prognosis. Hence, we need to investigate the risk factors of DHE and identify whether DHE will predict the poor outcome of sICH.

METHODS

We retrospectively recruited 121 patients with sICH admitted to the Department of Neurology from January 2014 to August 2018. After dividing all these patients into DHE group and non-DHE group, we analyzed the potential risk factors and outcome of DHE using a multivariate logistic regression model.

RESULTS

We conclude DHE after sICH associates with age, hospitalization time, hematoma shape, blood pressure upon admission, alcohol consumption, blood sodium level, and baseline hematoma volume within 24 hours after symptom onset, among which differences were statistically significant (P < .05). Logistic regression analysis finally identified that age (OR = 0.958, 95% CI = 0.923-0.995) and the baseline hematoma volume (OR = 1.161, 95% CI = 1.089-1.238) were the most significant risk factors for DHE, and moreover, the DHE (OR = 3.062, 95% CI = 1.196-7.839) was also a risk factor for poor prognosis in sICH patients.

CONCLUSION

We suggest DHE is a clinical predictor of secondary injury following sICH and poor prognosis. In addition, age and baseline hematoma volume are considered significant high-risk factors for DHE in patients with sICH.

P1474Simpsons Triplane versus Biplane for left ventricle ejection fraction after myocardial infarction

Introduction

Simpson's biplane (SBP) ignores the apical long-axis plane. It is estimated that 40% of myocardial infarction (MI)-related segmental abnormalities are located in this plane. The real-time triplane (RT3P) overcomes this issue, allowing to obtain all apical views simultaneously, at the same cardiac cycle. This method could be a more precise and reliable alternative to SBP in ejection fraction (EF) quantification in this setting.

Purpose

The authors aimed to compare EF assessed by two quantification methods, SBP and RT3P, using quantitative three-dimensional echocardiography (3DE) as the reference method, in patients with MI.

Methods

We have prospectively gathered data from 52 adult patients, which had recent or past history of MI. Exclusion criteria were the presence of atrial fibrillation, unknown coronary anatomy, significant valvular disease, left branch block, ventricular pacing and poor definition of endocardial borders.

Estimation of EF by SBP, RT3P and 3DE was performed in all patients and gathered by two experienced operators. The two operators were blinded for the coronary angiography results before volume quantification. They were also blinded for their own measurements, as well as for the other operator's measurements.

Spearman's correlation and linear regression were performed for correlation analysis. Bland-Altman plot was used for agreement assessment among the different methods. Interobserver agreement was assessed by Cohen's kappa.

Results

Patient characteristics are shown in table 1. EF calculation was feasible in all patients.

There were excellent correlations between EF measured by SBP vs 3DE and RT3P vs 3DE (r=0.813 and r=0.9 respectively).

Test of equality between two correlation coefficients confirmed that EF by RT3P method is significantly more correlated with the reference method, compared with EF by SBP (p=0.004).

We have also performed a further analysis to study this results in special subsets. In anterior MI subset, EF by RT3P correlated by 0.909 with 3DE, versus 0.826 from EF by SBP (p=0.019). In inferior MI subset, EF by RT3P correlated by 0.779 with the reference method, versus 0.706 from EF by SBP (p=0.246).

Fig 1 Correlation and Bland-Altman plot

Conclusions

Estimation of EF using SBP and RT3P methods by experienced operators strongly correlate with EF determined by 3DE. The RT3P method showed the strongest correlation between the two methods, which may point to its usefulness in the evaluation of EF in patients with anterior wall motion abnormalities after myocardial infarction.

Osteopontin-Enhanced Autophagy Attenuates Early Brain Injury via FAK-ERK Pathway and Improves Long-Term Outcome after Subarachnoid Hemorrhage in Rats

Osteopontin (OPN) enhances autophagy, reduces apoptosis, and attenuates early brain injury (EBI) after a subarachnoid hemorrhage (SAH). A total of 87 Sprague–Dawley rats were subjected to sham or SAH operations to further investigate the signaling pathway involved in osteopontin-enhanced autophagy during EBI, and the potential effect of recombinant OPN (rOPN) administration to improve long-term outcomes after SAH. Rats were randomly divided into five groups: Sham, SAH + Vehicle (PBS, phosphate-buffered saline), SAH + rOPN (5 μg/rat recombinant OPN), SAH + rOPN + Fib-14 (30 mg/kg of focal adhesion kinase (FAK) inhibitor-14), and SAH + rOPN + DMSO (dimethyl sulfoxide). Short-term and long-term neurobehavior tests were performed, followed by a collection of brain samples for assessment of autophagy markers in neurons, pathway proteins expression, and delayed hippocampal injury. Western blot, double immunofluorescence staining, Nissl staining, and Fluoro-Jade C staining assay were used. Results showed that rOPN administration increased autophagy in neurons and improved neurobehavior in a rat model of SAH. With the administration of FAK inhibitor-14 (Fib-14), neurobehavioral improvement and autophagy enhancement induced by rOPN were abolished, and there were consistent changes in the phosphorylation level of ERK1/2. In addition, early administration of rOPN in rat SAH models improved long-term neurobehavior results, possibly by alleviating hippocampal injury. These results suggest that FAK–ERK signaling may be involved in OPN-enhanced autophagy in the EBI phase after SAH. Early administration of rOPN may be a preventive and therapeutic strategy against delayed brain injury after SAH.

Osteopontin attenuates early brain injury through regulating autophagy-apoptosis interaction after subarachnoid hemorrhage in rats

Aim

To determine the effect of osteopontin (OPN) on autophagy and autophagy‐apoptosis interactions after SAH.

Methods

The endovascular perforation model of SAH or sham surgery was performed in a total of 86 Sprague‐Dawley male rats. The temporal expressions of endogenous OPN and autophagy‐related proteins (Beclin 1, ATG5, LC3 II to I ratio) were measured in sham and SAH rats at different time points (3, 6, 12, 24, and 72 hours). Rats were randomly divided into three groups: Sham, SAH + Vehicle (PBS, phosphate‐buffered saline), and SAH + rOPN (5 μg/rat recombinant OPN). Neurobehavioral tests were performed 24 hours after SAH, followed by the collection of brain samples for assessment of autophagy and apoptosis proteins. These tests assessed whether an autophagy‐apoptosis relationship existed on the histological level in the brain.

Results

Endogenous OPN and autophagy‐related proteins all increased after SAH. rOPN administration improved neurological dysfunction, increased the expression of autophagy‐related proteins (Beclin 1, ATG5, LC3 II to I ratio) and antiapoptotic protein Bcl‐2, while decreasing the expression of proapoptotic proteins (cleaved Caspase‐3 and Bax). rOPN also regulated autophagy‐apoptosis interactions 24 hours after SAH.

Conclusion

rOPN attenuates early brain injury and inhibits neuronal apoptosis by activating autophagy and regulating autophagy‐apoptosis interactions.

New risk score of the early period after spontaneous subarachnoid hemorrhage: For the prediction of delayed cerebral ischemia

Background and Purpose

The aim of this study is to identify the early predictors for delayed cerebral ischemia (DCI) and develop a risk stratification score by focusing on the early change after aneurysmal subarachnoid hemorrhage (aSAH).

Methods

The study retrospectively reviewed aSAH patients between 2014 and 2015. Risk factors within 72 hours after aSAH were included into univariable and multivariable logistic regression analysis to screen the independent predictors for DCI and to design a risk stratification score.

Results

We analyzed 702 aSAH patients; four predictors were retained from the final multivariable analysis: World Federation of Neurosurgical Societies scale (WFNS; OR = 4.057, P < .001), modified Fisher Scale (mFS; OR = 2.623, P < .001), Subarachnoid Hemorrhage Early Brain Edema Score (SEBES; OR = 1.539, P = .036), and intraventricular hemorrhage (IVH; OR = 1.932, P = .002). According to the regression coefficient, we created a risk stratification score ranging from 0 to 7 (WFNS = 3, mFS = 2, SEBES = 1, and IVH = 1). The new score showed a significantly higher area under curve (0.785) compared with other scores (P < .001).

Conclusion

The early DCI score provides a practical method at the early 72 hours after aSAH to predict DCI.

The vitamin D positive feedback hypothesis of inflammatory bowel diseases

While it appears that there are a variety of factors that exacerbate IBD, it is frustrating that symptoms can persist and worsen even when environmental insults are removed. We suggest that there may be a positive feedback loop which perpetuates the inflammatory response in IBD patients. The loop is triggered by vitamin D deficiency which reduces calcium uptake. Lowered vitamin D and calcium interfere with anti-inflammatory pathways. Inflammation of the mucosa inhibits absorption of calcium and thus perpetuates the reduced anti-inflammatory response. A number of predictions follow from this hypothesis and are supported by geographic and lifestyle patterns in IBD incidence and prevalence.

Simplex-Centroid mixture design applied to arsenic (V) removal from waters using synthetic minerals

Arsenic (As) is a toxic and carcinogenic element. Therefore, it is necessary to carry out research on As-contaminated water management in order to achieve the World Health Organization (WHO) standard for drinking water (0.010 mg L^-1). A Simplex-Centroid mixture design (SCMD) was used to determine the best mineral composition for both maximum adsorption capacity of As(V) (MAC-As) and residual concentration of As(V) (RC-As), using synthetic poorly crystallized aluminum hydroxide (pAlHyd), calcined layered double hydroxide (cLDH), and two-line ferrihydrite (2ℓFh). The analysis of variance results and the predicted values of models showed a good agreement with the experimental data, indicating that SCMD is a reliable method to optimize As removal through determination of the best mineral composition. The ability of pure synthetic minerals to remove As from water was different among those mixtures thereof, which indicate that the mineral components interacted with each other. Results showed that cLDH was the best As adsorbent. However, it showed a RC-As higher than the WHO standard. The pAlHyd and 2ℓFh exhibited smaller MAC-As, but they lowered RC-As to below 0.010 mg L^-1, showing no direct relationship between high MAC-As and low RC-As. Therefore, mineral compositions which combine high adsorption capacity with low residual concentration should work better for removing As from drinking water, ensuring it meets the WHO potability standard. Ternary diagrams for MAC-As and RC-As showed that the best combination for maximizing MAC-As and reducing RC-As should be a mixture of 75-90% of cLDH, 10-20% of pAlHyd, and 0-5% of 2ℓFh.

An update on promising therapies for CNS conditions

In this special edition, we present five articles that explore various neurovascular and neurodegenerative diseases and update the readers on promising therapies. We discuss where the current focus of research on central nervous conditions is heading. The topics range from discussing different brain injury models simulate human physiology, to analyzing outcomes following subdural hematoma evacuation. In addition, this special issue discusses new therapeutic targets during the acute phase of brain injury. The ideas and expert analysis regarding different neurological topics set up readers to explore future research on the subject matter.

Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Stroke is a leading cause of mortality and disability worldwide and the economic costs of treatment and post-stroke care are substantial. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic, comparable method of quantifying health loss by disease, age, sex, year, and location to provide information to health systems and policy makers on more than 300 causes of disease and injury, including stroke. The results presented here are the estimates of burden due to overall stroke and ischaemic and haemorrhagic stroke from GBD 2016.

METHODS

We report estimates and corresponding uncertainty intervals (UIs), from 1990 to 2016, for incidence, prevalence, deaths, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs). DALYs were generated by summing YLLs and YLDs. Cause-specific mortality was estimated using an ensemble modelling process with vital registration and verbal autopsy data as inputs. Non-fatal estimates were generated using Bayesian meta-regression incorporating data from registries, scientific literature, administrative records, and surveys. The Socio-demographic Index (SDI), a summary indicator generated using educational attainment, lagged distributed income, and total fertility rate, was used to group countries into quintiles.

FINDINGS

In 2016, there were 5·5 million (95% UI 5·3 to 5·7) deaths and 116·4 million (111·4 to 121·4) DALYs due to stroke. The global age-standardised mortality rate decreased by 36·2% (-39·3 to -33·6) from 1990 to 2016, with decreases in all SDI quintiles. Over the same period, the global age-standardised DALY rate declined by 34·2% (-37·2 to -31·5), also with decreases in all SDI quintiles. There were 13·7 million (12·7 to 14·7) new stroke cases in 2016. Global age-standardised incidence declined by 8·1% (-10·7 to -5·5) from 1990 to 2016 and decreased in all SDI quintiles except the middle SDI group. There were 80·1 million (74·1 to 86·3) prevalent cases of stroke globally in 2016; 41·1 million (38·0 to 44·3) in women and 39·0 million (36·1 to 42·1) in men.

INTERPRETATION

Although age-standardised mortality rates have decreased sharply from 1990 to 2016, the decrease in age-standardised incidence has been less steep, indicating that the burden of stroke is likely to remain high. Planned updates to future GBD iterations include generating separate estimates for subarachnoid haemorrhage and intracerebral haemorrhage, generating estimates of transient ischaemic attack, and including atrial fibrillation as a risk factor.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Traumatic brain injury (TBI) and spinal cord injury (SCI) are increasingly recognised as global health priorities in view of the preventability of most injuries and the complex and expensive medical care they necessitate. We aimed to measure the incidence, prevalence, and years of life lived with disability (YLDs) for TBI and SCI from all causes of injury in every country, to describe how these measures have changed between 1990 and 2016, and to estimate the proportion of TBI and SCI cases caused by different types of injury.

METHODS

We used results from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016 to measure the global, regional, and national burden of TBI and SCI by age and sex. We measured the incidence and prevalence of all causes of injury requiring medical care in inpatient and outpatient records, literature studies, and survey data. By use of clinical record data, we estimated the proportion of each cause of injury that required medical care that would result in TBI or SCI being considered as the nature of injury. We used literature studies to establish standardised mortality ratios and applied differential equations to convert incidence to prevalence of long-term disability. Finally, we applied GBD disability weights to calculate YLDs. We used a Bayesian meta-regression tool for epidemiological modelling, used cause-specific mortality rates for non-fatal estimation, and adjusted our results for disability experienced with comorbid conditions. We also analysed results on the basis of the Socio-demographic Index, a compound measure of income per capita, education, and fertility.

FINDINGS

In 2016, there were 27·08 million (95% uncertainty interval [UI] 24·30-30·30 million) new cases of TBI and 0·93 million (0·78-1·16 million) new cases of SCI, with age-standardised incidence rates of 369 (331-412) per 100 000 population for TBI and 13 (11-16) per 100 000 for SCI. In 2016, the number of prevalent cases of TBI was 55·50 million (53·40-57·62 million) and of SCI was 27·04 million (24·98-30·15 million). From 1990 to 2016, the age-standardised prevalence of TBI increased by 8·4% (95% UI 7·7 to 9·2), whereas that of SCI did not change significantly (-0·2% [-2·1 to 2·7]). Age-standardised incidence rates increased by 3·6% (1·8 to 5·5) for TBI, but did not change significantly for SCI (-3·6% [-7·4 to 4·0]). TBI caused 8·1 million (95% UI 6·0-10·4 million) YLDs and SCI caused 9·5 million (6·7-12·4 million) YLDs in 2016, corresponding to age-standardised rates of 111 (82-141) per 100 000 for TBI and 130 (90-170) per 100 000 for SCI. Falls and road injuries were the leading causes of new cases of TBI and SCI in most regions.

INTERPRETATION

TBI and SCI constitute a considerable portion of the global injury burden and are caused primarily by falls and road injuries. The increase in incidence of TBI over time might continue in view of increases in population density, population ageing, and increasing use of motor vehicles, motorcycles, and bicycles. The number of individuals living with SCI is expected to increase in view of population growth, which is concerning because of the specialised care that people with SCI can require. Our study was limited by data sparsity in some regions, and it will be important to invest greater resources in collection of data for TBI and SCI to improve the accuracy of future assessments.

FUNDING

Bill & Melinda Gates Foundation.

The Role of Autophagy in Subarachnoid Hemorrhage: An Update

BACKGROUND

Autophagy is an extensive self-degradation process for the disposition of cytosolic aggregated or misfolded proteins and defective organelles which executes the functions of pro-survival and pro-death to maintain cellular homeostasis. The pathway plays essential roles in several neurological disorders. Subarachnoid Hemorrhage (SAH) is a devastating subtype of hemorrhagic stroke with high risk of neurological deficit and high mortality. Early brain injury (EBI) plays a role in the poor clinical course and outcome after SAH. Recent studies have paid attention on the role of the autophagy pathway in the development of EBI after SAH. We aim to update the multifaceted roles of autophagy pathway in the pathogenesis of SAH, especially in the phase of EBI.

METHODS

We reviewed early researches related to autophagy and SAH. The following three aspects of contents will be mainly discussed: the process of the autophagy pathway, the role of the autophagy in SAH and the interaction between organelle dysfunction and autophagy pathway after SAH.

RESULTS

Accumulating evidence shows an increased autophagy reaction in response to early stages of SAH. However, others suggest inadequate or excessive autophagy activation can result in cell injury and death. In addition to autophagy, apoptosis and necrosis can occur in neurons simultaneously after SAH, leading to mixed features of cell death morphologies. And it is also known that there is extensive crosstalk between autophagy and apoptosis pathway. Subcellular organelles of neural cells generally participate in the formation and functional parts of autophagy process.

CONCLUSION

Autophagy plays an important role in the SAH-induced brain injury. A better understanding of the interrelationship among autophagy, apoptosis, and necrosis might provide us better therapeutic targets for the treatment of SAH.

Autophagy after Subarachnoid Hemorrhage: Can Cell Death be Good?

BACKGROUND

Autophagy is a prosurvival, reparative process that maintainsww cellular homeostasis through lysosomal degradation of selected cytoplasmic components and programmed death of old, dysfunctional, or unnecessary cytoplasmic entities. According to growing evidence, autophagy shows beneficial effects following subarachnoid hemorrhage (SAH). SAH is considered one of the most devastating forms of stroke.

METHODS

In this review lies in revealing the pathophysiological pathways and the effects of autophagy. Current results from animal studies will be discussed focusing on the effects of inhibitors and inducers of autophagy. In addition, this review discusses the clinical translation of potential neuropharmacological targets that can help prevent early brain injury (EBI) following SAH by incorporating programmed cell death into clinical management.

RESULTS

Published data showed that autophagy mechanisms have a prosurvival effect to reduce apoptotic cell death after SAH. However, if SAH exceeds a certain stress threshold, autophagy mechanisms lead to increased apoptotic cell death, more brain injury, and worse outcome.

CONCLUSION

Future investigation on the differences and molecular switches between protective mechanisms of autophagy and excessive "self-eating" autophagy leading to cell death is needed to achieve more insight into the complex pathophysiology of brain injury after SAH. If autophagy after SAH can be controlled to lead to beneficial effects only, as the physiological self-control mechanism, this could be an important target for treatment.

A Novel Mutation of Aryl Hydrocarbon Receptor Interacting Protein Gene Associated with Familial Isolated Pituitary Adenoma Mediates Tumor Invasion and Growth Hormone Hypersecretion

BACKGROUND

Germline mutations in the aryl hydrocarbon receptor-interacting protein (AIP) gene were identified in nearly 20% of families with familial isolated pituitary adenoma. Some variants of AIP have been confirmed to induce tumor cell proliferation and invasiveness; however, the mechanism is still unclear.

METHODS

A novel missense mutation (c.512C>T, p.T171I) was discovered in 3 patients from a Chinese family with familial isolated pituitary adenoma. In silico and multiplex ligation-dependent probe amplification analysis predicted the mutation to be pathogenic. GH3 and 293FT cell lines were used to verify the variant's effect on cell proliferation (Cell Counting Kit-8), invasiveness (Transwell) and growth hormone (GH) secretion (enzyme-linked immunosorbent assay) by transfection with different vectors: control, blank vector, wild-type AIP, p.T171I variant (experimental group), p.Q315* variant, and AIP small interfering RNA. Furthermore, Zac1, Sstr2, interleukin (IL)-6, and Stat3/phosphorylation-Stat3 expression (reverse transcription polymerase chain reaction, Western blot) in each group was also evaluated.

RESULTS

The experimental group, p.Q315* variant group, and AIP small interfering RNA-overexpressing group promoted cell proliferation at 24 and 48 hours, respectively (compared with the control group; P < 0.01 for both). Similarly, the cells in the experimental group manifested more invasion and GH secretion compared with the control group (P < 0.01 and P < 0.05, respectively). Furthermore, the experimental group cells expressed less Sstr2 (a prerequisite for the responsiveness to somatostatin analogues) and Zac1 (tumor suppressor gene), but more IL-6 and phosphorylated-Stat3 (GH-secretion related).

CONCLUSIONS

The novel AIP mutation c.512C>T (p.T171I) is a pathogenic variant that promoted cell proliferation, invasiveness, and GH secretion through regulation of Sstr2, Zac1, and IL-6/phosphorylated-Stat3 expression.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Bill & Melinda Gates Foundation.

Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Efforts to establish the 2015 baseline and monitor early implementation of the UN Sustainable Development Goals (SDGs) highlight both great potential for and threats to improving health by 2030. To fully deliver on the SDG aim of "leaving no one behind", it is increasingly important to examine the health-related SDGs beyond national-level estimates. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), we measured progress on 41 of 52 health-related SDG indicators and estimated the health-related SDG index for 195 countries and territories for the period 1990-2017, projected indicators to 2030, and analysed global attainment.

METHODS

We measured progress on 41 health-related SDG indicators from 1990 to 2017, an increase of four indicators since GBD 2016 (new indicators were health worker density, sexual violence by non-intimate partners, population census status, and prevalence of physical and sexual violence [reported separately]). We also improved the measurement of several previously reported indicators. We constructed national-level estimates and, for a subset of health-related SDGs, examined indicator-level differences by sex and Socio-demographic Index (SDI) quintile. We also did subnational assessments of performance for selected countries. To construct the health-related SDG index, we transformed the value for each indicator on a scale of 0-100, with 0 as the 2·5th percentile and 100 as the 97·5th percentile of 1000 draws calculated from 1990 to 2030, and took the geometric mean of the scaled indicators by target. To generate projections through 2030, we used a forecasting framework that drew estimates from the broader GBD study and used weighted averages of indicator-specific and country-specific annualised rates of change from 1990 to 2017 to inform future estimates. We assessed attainment of indicators with defined targets in two ways: first, using mean values projected for 2030, and then using the probability of attainment in 2030 calculated from 1000 draws. We also did a global attainment analysis of the feasibility of attaining SDG targets on the basis of past trends. Using 2015 global averages of indicators with defined SDG targets, we calculated the global annualised rates of change required from 2015 to 2030 to meet these targets, and then identified in what percentiles the required global annualised rates of change fell in the distribution of country-level rates of change from 1990 to 2015. We took the mean of these global percentile values across indicators and applied the past rate of change at this mean global percentile to all health-related SDG indicators, irrespective of target definition, to estimate the equivalent 2030 global average value and percentage change from 2015 to 2030 for each indicator.

FINDINGS

The global median health-related SDG index in 2017 was 59·4 (IQR 35·4-67·3), ranging from a low of 11·6 (95% uncertainty interval 9·6-14·0) to a high of 84·9 (83·1-86·7). SDG index values in countries assessed at the subnational level varied substantially, particularly in China and India, although scores in Japan and the UK were more homogeneous. Indicators also varied by SDI quintile and sex, with males having worse outcomes than females for non-communicable disease (NCD) mortality, alcohol use, and smoking, among others. Most countries were projected to have a higher health-related SDG index in 2030 than in 2017, while country-level probabilities of attainment by 2030 varied widely by indicator. Under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria indicators had the most countries with at least 95% probability of target attainment. Other indicators, including NCD mortality and suicide mortality, had no countries projected to meet corresponding SDG targets on the basis of projected mean values for 2030 but showed some probability of attainment by 2030. For some indicators, including child malnutrition, several infectious diseases, and most violence measures, the annualised rates of change required to meet SDG targets far exceeded the pace of progress achieved by any country in the recent past. We found that applying the mean global annualised rate of change to indicators without defined targets would equate to about 19% and 22% reductions in global smoking and alcohol consumption, respectively; a 47% decline in adolescent birth rates; and a more than 85% increase in health worker density per 1000 population by 2030.

INTERPRETATION

The GBD study offers a unique, robust platform for monitoring the health-related SDGs across demographic and geographic dimensions. Our findings underscore the importance of increased collection and analysis of disaggregated data and highlight where more deliberate design or targeting of interventions could accelerate progress in attaining the SDGs. Current projections show that many health-related SDG indicators, NCDs, NCD-related risks, and violence-related indicators will require a concerted shift away from what might have driven past gains-curative interventions in the case of NCDs-towards multisectoral, prevention-oriented policy action and investments to achieve SDG aims. Notably, several targets, if they are to be met by 2030, demand a pace of progress that no country has achieved in the recent past. The future is fundamentally uncertain, and no model can fully predict what breakthroughs or events might alter the course of the SDGs. What is clear is that our actions-or inaction-today will ultimately dictate how close the world, collectively, can get to leaving no one behind by 2030.

FUNDING

Bill & Melinda Gates Foundation.

Population and fertility by age and sex for 195 countries and territories, 1950-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Population estimates underpin demographic and epidemiological research and are used to track progress on numerous international indicators of health and development. To date, internationally available estimates of population and fertility, although useful, have not been produced with transparent and replicable methods and do not use standardised estimates of mortality. We present single-calendar year and single-year of age estimates of fertility and population by sex with standardised and replicable methods.

METHODS

We estimated population in 195 locations by single year of age and single calendar year from 1950 to 2017 with standardised and replicable methods. We based the estimates on the demographic balancing equation, with inputs of fertility, mortality, population, and migration data. Fertility data came from 7817 location-years of vital registration data, 429 surveys reporting complete birth histories, and 977 surveys and censuses reporting summary birth histories. We estimated age-specific fertility rates (ASFRs; the annual number of livebirths to women of a specified age group per 1000 women in that age group) by use of spatiotemporal Gaussian process regression and used the ASFRs to estimate total fertility rates (TFRs; the average number of children a woman would bear if she survived through the end of the reproductive age span [age 10-54 years] and experienced at each age a particular set of ASFRs observed in the year of interest). Because of sparse data, fertility at ages 10-14 years and 50-54 years was estimated from data on fertility in women aged 15-19 years and 45-49 years, through use of linear regression. Age-specific mortality data came from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 estimates. Data on population came from 1257 censuses and 761 population registry location-years and were adjusted for underenumeration and age misreporting with standard demographic methods. Migration was estimated with the GBD Bayesian demographic balancing model, after incorporating information about refugee migration into the model prior. Final population estimates used the cohort-component method of population projection, with inputs of fertility, mortality, and migration data. Population uncertainty was estimated by use of out-of-sample predictive validity testing. With these data, we estimated the trends in population by age and sex and in fertility by age between 1950 and 2017 in 195 countries and territories.

FINDINGS

From 1950 to 2017, TFRs decreased by 49·4% (95% uncertainty interval [UI] 46·4-52·0). The TFR decreased from 4·7 livebirths (4·5-4·9) to 2·4 livebirths (2·2-2·5), and the ASFR of mothers aged 10-19 years decreased from 37 livebirths (34-40) to 22 livebirths (19-24) per 1000 women. Despite reductions in the TFR, the global population has been increasing by an average of 83·8 million people per year since 1985. The global population increased by 197·2% (193·3-200·8) since 1950, from 2·6 billion (2·5-2·6) to 7·6 billion (7·4-7·9) people in 2017; much of this increase was in the proportion of the global population in south Asia and sub-Saharan Africa. The global annual rate of population growth increased between 1950 and 1964, when it peaked at 2·0%; this rate then remained nearly constant until 1970 and then decreased to 1·1% in 2017. Population growth rates in the southeast Asia, east Asia, and Oceania GBD super-region decreased from 2·5% in 1963 to 0·7% in 2017, whereas in sub-Saharan Africa, population growth rates were almost at the highest reported levels ever in 2017, when they were at 2·7%. The global average age increased from 26·6 years in 1950 to 32·1 years in 2017, and the proportion of the population that is of working age (age 15-64 years) increased from 59·9% to 65·3%. At the national level, the TFR decreased in all countries and territories between 1950 and 2017; in 2017, TFRs ranged from a low of 1·0 livebirths (95% UI 0·9-1·2) in Cyprus to a high of 7·1 livebirths (6·8-7·4) in Niger. The TFR under age 25 years (TFU25; number of livebirths expected by age 25 years for a hypothetical woman who survived the age group and was exposed to current ASFRs) in 2017 ranged from 0·08 livebirths (0·07-0·09) in South Korea to 2·4 livebirths (2·2-2·6) in Niger, and the TFR over age 30 years (TFO30; number of livebirths expected for a hypothetical woman ageing from 30 to 54 years who survived the age group and was exposed to current ASFRs) ranged from a low of 0·3 livebirths (0·3-0·4) in Puerto Rico to a high of 3·1 livebirths (3·0-3·2) in Niger. TFO30 was higher than TFU25 in 145 countries and territories in 2017. 33 countries had a negative population growth rate from 2010 to 2017, most of which were located in central, eastern, and western Europe, whereas population growth rates of more than 2·0% were seen in 33 of 46 countries in sub-Saharan Africa. In 2017, less than 65% of the national population was of working age in 12 of 34 high-income countries, and less than 50% of the national population was of working age in Mali, Chad, and Niger.

INTERPRETATION

Population trends create demographic dividends and headwinds (ie, economic benefits and detriments) that affect national economies and determine national planning needs. Although TFRs are decreasing, the global population continues to grow as mortality declines, with diverse patterns at the national level and across age groups. To our knowledge, this is the first study to provide transparent and replicable estimates of population and fertility, which can be used to inform decision making and to monitor progress.

FUNDING

Bill & Melinda Gates Foundation.

Research Advances of Germinal Matrix Hemorrhage: An Update Review

Germinal matrix hemorrhage (GMH) refers to bleeding that derives from the subependymal (or periventricular) germinal region of the premature brain. GMH can induce severe and irreversible damage attributing to the vulnerable structure of germinal matrix and deleterious circumstances. Molecular mechanisms remain obscure so far. In this review, we summarized the newest preclinical discoveries recent years about GMH to distill a deeper understanding of the neuropathology, and then discuss the potential diagnostic or therapeutic targets among these pathways. GMH studies mostly in recent 5 years were sorted out and the authors generalized the newest discoveries and ideas into four parts of this essay. Intrinsic fragile structure of preterm germinal matrix is the fundamental cause leading to GMH. Many molecules have been found effective in the pathophysiological courses. Some of these molecules like minocycline are suggested active to reduce the damage in animal GMH model. However, researchers are still trying to find efficient diagnostic methods and remedies that are available in preterm infants to rehabilitate or cure the sequent injury. Merits have been obtained in the last several years on molecular pathways of GMH, but more work is required to further unravel the whole pathophysiology.

Cerebral Small Vessel Disease

Cerebral small vessel disease (CSVD) is composed of several diseases affecting the small arteries, arterioles, venules, and capillaries of the brain, and refers to several pathological processes and etiologies. Neuroimaging features of CSVD include recent small subcortical infarcts, lacunes, white matter hyperintensities, perivascular spaces, microbleeds, and brain atrophy. The main clinical manifestations of CSVD include stroke, cognitive decline, dementia, psychiatric disorders, abnormal gait, and urinary incontinence. Currently, there are no specific preventive or therapeutic measures to improve this condition. In this review, we will discuss the pathophysiology, clinical aspects, neuroimaging, progress of research to treat and prevent CSVD and current treatment of this disease.