Burden of disease scenarios for 204 countries and territories, 2022-2050: a forecasting analysis for the Global Burden of Disease Study 2021

BACKGROUND

Future trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050.

METHODS

Using forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline.

FINDINGS

In the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8-63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0-45·0] in 2050) and south Asia (31·7% [29·2-34·1] to 15·5% [13·7-17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4-40·3) to 41·1% (33·9-48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6-25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5-43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5-17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7-11·3) in the high-income super-region to 23·9% (20·7-27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5-6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2-26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [-0·6 to 3·6]).

INTERPRETATION

Globally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions.

FUNDING

Bill & Melinda Gates Foundation.

"In times of stress, it is good to be with them": experience of dog owners from a rural district of Sri Lanka

BACKGROUND

The dog has been man's best companion since ancient times. And, dog ownership is associated with improved physical activity and cardiovascular health. We aim to explore the experience of dog owners on dog ownership and its effects on personal and family health in Anuradhapura, Sri Lanka. Such studies are scarce in developing countries and rural regions.

METHODS

A qualitative study was conducted using in-depth interviews with dog owners in the Anuradhapura district, Sri Lanka. Interviews were tape-recorded and transcribed and thematic analysis was performed.

RESULTS

The study findings were reported under the themes of experience of dog owners, pet dogs for children, village dogs as pets, the role of pet dogs in personal and family health, and participants' advice on dog ownership. Participants highlighted companionship as a positive aspect of pet dogs. However, expenses and reduced travel were the concerns of dog ownership. A child's preference was important in owning a pet dog. Also, participants were willing to adopt the village dogs. Further, they perceived stress reduction and mental satisfaction when interacting with their pet dogs. Moreover, participants seldom experienced major health risks from their pet dogs.

CONCLUSIONS

Human-dog interaction seems to improve the participants' mental well-being, and future research should focus on its possible consequences. Further, the village dogs were adopted as pets. Guided promotion of such activities could ease concerns related to village dogs in developing and rural regions.

Household preferences for pet keeping: Findings from a rural district of Sri Lanka

Pet ownership is an integral part of a modern-day family. It provides a wide range of benefits to humans. However, data on pet ownership are relatively limited from rural regions, Southern Asia and low-middle-income countries. We aim to report the prevalence and associated factors for pet ownership and veterinary visits in Anuradhapura, Sri Lanka. A community-based, cross-sectional study was conducted. An interviewer-administered questionnaire was used. Binary logistic regression was performed to determine significant associations between variables of interest and pet ownership (p < 0.05). Out of the 532 households, 57% currently owned a pet. The most common pet was the dog owned by 41% of the households and the cat was the second most owned by 17%. Security (69% - 152/220) was the most common role for dogs at home while it was companionship for cats (31% - 27/88) and hobby for both birds (64% - 18/28) and fish (54% - 14/26). Most dogs (54% - 118/220) had one veterinary visit within the last year. Households with >1 adult female [p = 0.02; OR = 1.61 (95% CI 1.09 to 2.36)], participants living alone [p = 0.03; OR = 0.24 (95% CI 0.07 to 0.86)] and Buddhists [p = 0.02; OR = 2.56 (95% CI 1.16 to 5.63)] were significantly associated with pet ownership. Pet ownership is common among people in Anuradhapura, Sri Lanka, with a few demographic factors having a significant association with pet ownership. Dogs are the most common type of pet and highlight the opportunity for research related to canine companionship and human health. Future research on such topics should consider the above-mentioned socio-demographic predictors as potential confounders.

Human Papillomavirus-Associated Oral Squamous Cell Carcinoma Among Adults Living in South-Central Asia: A Systematic Review

Human papillomavirus (HPV) related oral cancers are increasing and are associated with sexual risk behaviours. An increase in the incidence of oral cancer has been observed in South-central Asian countries. The objective was to systematically review the evidence on the association of HPV and oral squamous cell carcinoma (OSCC) among adults living in South-central Asia. We searched multiple databases and reference lists of relevant articles in December 2018. Quality assessment of the selected articles were done using the Newcastle-Ottawa quality assessment scale. Thirteen out of 150 articles met the eligibility criteria. Most studies were from India (10/13) followed by Pakistan (2/13) and Bangladesh (1/13). Half (7/13) of the studies found a positive association between HPV with OSCC. HPV 16, HPV 18 and HPV 16/18 were found to be the most common types implicated in HPV infection associated with OSCC. Moreover, buccal mucosa was the most common site of oral cancer. The review found equivocal evidence in relation to the association of HPV with oral squamous cell carcinoma among people living in South Asia.

The role of cortisol in the association of canine-companionship with blood pressure, glucose, and lipids: a systematic review

INTRODUCTION

The dog is known as man's best friend and canine-companionship is associated with positive effects on cardiovascular health.

AIM

We aim to review the role of cortisol in the association of canine-companionship with human blood pressure, glucose and lipid profile.

METHODS

Electronic databases, and reference lists of the selected articles were searched for original articles in English which evaluate the role of cortisol in the association of canine-companionship with human blood pressure, glucose and lipid profile. Appropriate tools from the National Institute of Health were used for the quality assessment.

RESULTS

Of the 2108 articles included for screening, 6 studies fulfilled the selection criteria. The USA had produced the highest number of studies (50%, 3/6). Pre-post studies (83%, 5/6) were the predominant type, and the overall quality of the selected studies was acceptable. The majority of studies showed a significant reduction of cortisol with dog companionship or therapy (67%, 4/6) along with a significant reduction of heart rate (2/4), systolic blood pressure (1/4), mean arterial blood pressure (1/4), or total cholesterol level (1/4). The role of cortisol in the association of canine-companionship with human blood pressure, glucose and lipid profile was scarcely studied with no studies from lower-middle-income countries, where the disease burden is on the rise.

CONCLUSION

A significant reduction of few cardiovascular risk factors was found along with a significant reduction of cortisol in canine companionship in few studies. Future comparative or higher-level studies are essential on the association between canine companionship, cortisol and cardiovascular risk factors, especially in lower-middle-income countries.

Prevalence, associated factors and reasons for antibiotic self-medication among dwellers in Anuradhapura: a community-based study

Background Antimicrobial resistance is cited as one of the leading causes for the increased morbidity and mortality in infectious diseases globally. Antibiotic misuse can accelerate the advent and spread of resistant antimicrobial strains and antibiotic self-medication is one of the main practices of antibiotic misuse. Even though plethora of evidence is available on antibiotic self-medication among health care providers, evidence derived from community-based studies are scarce. Objective We aimed to determine the prevalence, associated factors and reasons for antibiotic self-medication among dwellers of Anuradhapura, Sri Lanka. Setting The study was conducted in Nuwaragam Palatha East, Medical Officer of Health area, Anuradhapura, Sri Lanka. Method A community-based, cross-sectional study was conducted to collect data on antibiotic self-medication during the last 3 months from all selected households using a self-administered questionnaire. Binary logistic regression was performed to determine the significant associations between variables of interest and the practice of antibiotic self-medication. Main outcome measure The prevalence of antibiotic self-medication was computed as a point estimate with 95% Confidence Interval. The reasons for antibiotic self-medication were presented as frequency and percentages. Results Of the 384 participants selected from 125 households, 211 (55%) had consumed antibiotics during the last three months and only ten were found to have self-medicated antibiotics. Hence, the prevalence was 2.6% (95% Confidence Interval = 1.0 to 4.2). The practice of antibiotic self-medication was not significantly associated with age, household size, sex, family income, employment or education level (P > 0.05). The most common symptom and reason to take antibiotics without a prescription was runny nose (80%-8/10) and convenience (70%-7/10) respectively. All have purchased the antibiotic for self-medication from a pharmacy. Information on the use of the antibiotic and the dosage were obtained from a physician's previous prescription (60%-6/10) or a pharmacist (40%-4/10). Conclusion The study revealed a very low prevalence of antibiotic self-medication. However, continuous surveillance of retail pharmacies and training of health care providers is needed to curtail errors in the use of antibiotics.

Cytokine response in human leptospirosis with different clinical outcomes: a systematic review

Background

Leptospirosis is a neglected zoonotic disease which is a major challenge for clinicians and public health professionals in tropical countries. The cytokine storm during the second (immune) phase is thought to be a major contributory factor for the leptospirosis disease severity. We aim to summarize evidence for cytokine response in leptospirosis at different clinical outcomes.

Methods

A systematic review was carried out to examine the cytokine response in leptospirosis patients using relevant scientific databases. Reference lists of the selected articles were also screened. Quality of the selected studies was assessed by using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

Results

Of the 239 articles retrieved in the initial search, 18 studies fulfilled the selection criteria. India and Thailand have produced the highest number of studies (17% each, n = 3). The majority were comparative cross-sectional studies (72%, n = 13). Overall the quality of the selected studies was fair regardless of few drawbacks such as reporting of sample size and the lack of adjustment for confounders. Microscopic agglutination test (67% - 12/18) and enzyme-linked immunosorbent assay (50% - 9/18) were commonly used for the confirmation of leptospirosis and the measurement of cytokines respectively. IL-1b, IL-2, IL-4, IL-6, IL-8, IL-10 and TNF-α levels were found to be significantly higher in severe than in mild leptospirosis. There were equivocal findings on the association between IL-1β, TNF-α and IL-10/TNF-α ratio and disease severity.

Conclusions

Leptospirosis had a wide-range of elevated cytokines. However, prospective studies in-relation to the onset of the symptom are required to better understand the pathophysiology of cytokine response in leptospirosis.

Prevalence, associated factors and medication for symptoms related to gastroesophageal reflux disease among 1114 private-tuition students of Anuradhapura, Sri Lanka

Background

Gastroesophageal reflux disease (GORD) is a chronic and a common condition worldwide which causes mild to severe symptoms. Private tuition attendees are a group which could have potential risk factors for GORD. Therefore, we aimed to determine the prevalence, associated factors and medication for symptoms related to GORD among advanced level private-tuition attendees of Anuradhapura, Sri Lanka.

Methods

A descriptive cross-sectional study was conducted among students aged ≥18 years. A self-administered questionnaire was used to collect data. Students scoring ≥ eight on the Frequency Scale for Symptoms of GORD were categorised to have symptoms related to GORD. Logistic regression was performed to determine the significant association between the variables of interest and the presence of symptoms related to GORD (P < 0.05).

Results

Data of 1114 students were included for the analysis. A high prevalence of symptoms related to GORD (52% - 580/1114) was noted. Heartburn received the highest score among GORD symptoms. Biology students had the highest prevalence of GORD symptoms (63% - 127/201). Also, Biology students had the highest percentage for the utilisation of overall (17% - 35/201) and prescribed (13% - 27/201) medication for GORD symptoms. Presence of symptoms related to GORD was significantly associated with female sex [OR - 0.436 (95% CI 0.342–0.555)], being boarded [OR - 2.021 (95% CI 1.325–3.083)], chronic illness [OR - 2.632 (95% CI 1.439–4.813)], midnight snack [OR - 1.776 (95% CI 1.379–2.287)], frequent lack of breakfast [OR - 2.145 (95% CI 1.688, 2.725)], quick eating [OR - 1.394 (95% CI 1.091–1.780)] and inadequate sleep [OR - 2.077 (95% CI 1.624–2.655)].

Conclusion

A high prevalence of symptoms related to GORD in comparison to previous literature was found among private tuition attendees. Possible reasons for the above findings were discussed.

A compulsive act of excess water intake leading to hyponatraemia and rhabdomyolysis: a case report

Background

Primary polydipsia is commonly seen in patients with psychiatric illnesses. Excess water intake is also seen in patient with anorexia and anticholinergic medications. We report a patient who had hyponatraemia and rhabdomyolysis after consuming excess water for ureteric calculus.

Case presentation

A healthy middle-aged male presented with an episode of generalized tonic-clonic seizure and reduced level of consciousness preceded by consumption of excess water. He was recently diagnosed to have a ureteric calculus and was advised to consume plenty of water. On examination, he was disoriented in place, person and time. Except for the generalized diminished reflexes, other neurological and systemic examinations were normal. He had severe hyponatraemia, mild hypokalaemia and myoglobulinuria. His serum creatinine phosphokinase and aspartate aminotransferase were markedly elevated. The diagnosis of rhabdomyolysis in the setting of acute water intoxication was made. Optimum fluid and electrolyte management achieved a dramatic recovery of consciousness, hyponatraemia and rhabdomyolysis.

Discussion

The patient has had excess water intake due to a compulsive act in the background fear of ureteric calculus. Such act could lead to severe hyponatraemia and rhabdomyolysis. Therefore, future similar acts could be prevented by proper medical advice. Further, emergency physicians should be vigilant for rhabdomyolysis in patients with hyponatraemia or hypokalaemia.

Takotsubo syndrome in patients with myasthenia gravis: a systematic review of previously reported cases

Background

Myasthenia gravis associated takotsubo syndrome is a rare condition. This study aimed to explore its typical presentation, investigations and treatment through a systematic review of previously reported cases.

Methods

Databases and reference lists of the selected articles were searched for case reports on Myasthenia gravis associated takotsubo syndrome. CARE guidelines were used for the quality assessment of the selected articles.

Results

Sixteen cases were selected out of 580 search results. Western Pacific, American and European regions contributed to 88% of the cases. Females were most affected (81%). Features of both myasthenia gravis and takotsubo syndrome were the common clinical presentations. All cases had a myasthenic crisis. Half of the cases had no prior diagnosis of myasthenia gravis. Pyridostigmine and prednisolone were useful for myasthenia gravis while dobutamine was most commonly used for takotsubo syndrome. All cases survived except four (25%).

Conclusions

Myasthenia gravis associated takotsubo syndrome via a myasthenic crisis is rare but life-threatening. Therefore, predisposition due to emotional and physical triggers needs to be avoided for its prevention. The rare entity should be suspected even in patients without a prior diagnosis of Myasthenia gravis.

In vivo, ex vivo and in vitro evidence for atropine-mediated attenuation of glucagon-like peptide-1 secretion: findings from a systematic review

Glucagon-like peptide-1 (GLP-1) is involved in postprandial glucose homeostasis. Secretion of which involves a cholinergic pathway. Anticholinergic agent like atropine could act as a competitive antagonist of acetylcholine at muscarinic receptors. This review explores studies that assess the role of atropine in GLP-1 secretion. We selected published original articles from PubMed, Science Direct, The Cochrane Library, Trip, Google and the reference lists of the selected articles. Reporting was done according to the PRISMA statement. Relevant standard and previously published tools were used to assess the risk of bias of the selected articles. Twelve articles out of 185 search results fulfilled the review criteria. Eight were in vivo studies (six animal and two human studies), three were ex vivo studies and one was an in vitro study. Animal studies had rats, mice, pigs and monkeys as the subjects. Human studies involved healthy men and women. Majority of the studies reported an atropine-mediated attenuation of GLP-1 secretion and postprandial secretion of GLP-1 was mainly affected. However, atropine failed to significantly affect GLP-1 secretion when dipeptidyl peptidase-4 (DPP-4) enzyme was inhibited.

Concurrent presentation of thyroid storm and diabetic ketoacidosis: a systematic review of previously reported cases

BACKGROUND

Simultaneous development of thyroid storm and diabetic ketoacidosis (DKA) is a rare condition. The review aims to summarise its clinical presentation, investigation findings and treatment options.

METHODS

Databases and reference lists of the selected articles were searched for case reports in English which describe concurrent presentation of thyroid storm and diabetic ketoacidosis. CARE guidelines were used for the quality assessment of the selected articles.

RESULTS

Twenty-six cases from twenty-one articles were selected out of 198 search results. Western Pacific, and American regions contributed to 77% of the cases. Females were most affected (88%). Features of Graves' disease like hyperthermia and tachycardia, gastrointestinal and neuro-psychiatric disturbances were the common clinical presentations. In most of the cases, previous diagnosis of diabetes mellitus preceded that of Graves' disease (46%). Among patients having their drug compliance reported, all had poor compliance to their routine anti-thyroid (9/9) and anti-diabetic (2/2) agents. Moreover, in all cases where HbA_1C (7/7) and T4 (16/16) were measured, the results were elevated and where TSH (17/17) was measured, the results were low. The recommended treatment for DKA and thyroid storm was used in most cases and methimazole was the thionamide of choice in the latest four cases reported. All cases survived except four (15%).

CONCLUSIONS

Concurrent presentation of thyroid storm and diabetic ketoacidosis is rare but life-threatening. Therefore, efforts should be made to maximise patient compliance to anti-thyroid and anti-diabetic agents in treating such patients.

Comparison of medication adherence between type 2 diabetes mellitus patients who pay for their medications and those who receive it free: a rural Asian experience

BACKGROUND

Treatment plans fail if patients have poor medication adherence. Our aim was to compare medication adherence, reasons for non-adherence, and satisfaction with community support among type 2 diabetes mellitus patients who pay for their medications and those who receive it free.

METHODS

A descriptive cross-sectional study was conducted at Anuradhapura, Sri Lanka, among patients who were on oral anti-diabetic drugs for at least 3 months. They were grouped into two: universal-free group and fee-paying group. Three different scales were used to score medication adherence, reasons for non-adherence, and satisfaction with community support. Fisher's exact test was performed to determine if there was a significant difference between the two groups (p < 0.05) concerning medication adherence and satisfaction with community support.

RESULTS

The median (IQR) medication adherence scores for fee-paying group and universal-free group were 3 (2-3) and 3 (3-3), respectively; the median (IQR) scores for satisfaction with community support were 5 (2-6) and 4 (4-6), respectively. Both the adherence and the satisfaction failed to show a significant difference between the two groups. Forgetfulness, being away from home, complex drug regime, and willingness to avoid side effects were common reasons of non-adherence for both the groups.

CONCLUSIONS

There was no significant difference in medication adherence between the universal-free group and fee-paying group, despite of having a significantly different income. The universal-free health service would be a probable reason.

Comparison of biochemical parameters among DPP4 inhibitor users and other oral hypoglycaemic drug users: a cross-sectional study from Anuradhapura, Sri Lanka

BACKGROUND

Higher efficacy of incretin-based therapies for type 2 diabetes mellitus has been reported from Asia. Pancreatitis and hepatitis have also been suspected to occur due to dipeptidyl peptidase-4 inhibitor (DPP4I) treatment. The present study aims at comparing selected biochemical parameters among DPP4 inhibitor users and other oral hypoglycaemic drug users.

METHODS

Patients were recruited from the State Pharmaceutical Corporation, Anuradhapura, Sri Lanka, for a comparative cross-sectional study. Two groups were involved: "DPP4I" user group (n = 63) and "other oral hypoglycaemic" user group (n = 126). Mann-Whitney U test was performed to find a significant difference (p < 0.05) in the distributions of HbA_1C, pancreatic amylase, serum lipase, AST and ALT levels between the two groups.

RESULTS

Contradicting to previous Asian studies, distribution of HbA_1C (p = 0.569) between anti-diabetic regimes with and without DPP4 inhibitors showed no significant difference. Also, amylase (p = 0.171), AST (p = 0.238) and ALT (p = 0.347) failed to show significance. However, lipase was significantly (p = 0.012) high in the DPP4I group.

CONCLUSION

The study showed a significantly higher lipase level among the DPP4I users in comparison to other oral hypoglycaemic drug users, and possible reasons were discussed.

A low GLP-1 response among patients treated for acute organophosphate and carbamate poisoning: a comparative cross-sectional study from an agrarian region of Sri Lanka

Higher incidence of diabetes along with increased use of pesticides is seen in Southeast Asia. Recent hypothesis postulated a link between acetylcholinesterase inhibitor insecticides and type 2 diabetes through the GLP-1 pathway. This study compares the GLP-1 response between groups with low and high red blood cell acetylcholinesterase (RBC-AChE) activity. A comparative cross-sectional study was conducted amongst patients who were within 3 months after an acute organophosphate or carbamate poisoning (acute group) and amongst vegetable farmers with low (chronic group) and high (control group) RBC-AChE activity. Acute (366 mU/μM Hb) and chronic (361 mU/μM Hb) groups had significantly lower RBC-AChE activity in comparison to the control (471 mU/μM Hb) group (P < 0.0001). Only the acute group, which has had atropine therapy, showed a significantly lower 120 min value in comparison to the control group (P = 0.0028). Also, the acute group had significantly low late (P = 0.0287) and total (P = 0.0358) responses of GLP-1 in comparison to the control group. The findings of the study allude towards attenuation of GLP-1 response amongst patients after acute organophosphate and carbamate poisoning. The possibility of an atropine-mediated attenuation of GLP-1 response was discussed.

A significant association between examination results and self-satisfaction with English language proficiency: preliminary findings among pre-clinical undergraduates

Objectives

Learning methods and other related factors influence the success of medical undergraduates. This study aims at finding factors associated with the end of pre-clinical stream examination results among medical undergraduates of the Rajarata University of Sri Lanka. The results of this study will inform the tutors to plan and implement teaching methods as well as to guide the social welfare of the undergraduates. In general, we believe this study has the potential to improve the medical undergraduate’s academic performance.

Results

Eighty-six per cent (112/130) of medical undergraduates have passed the examination and rest was referred. Logistic regression revealed a significant association between examination results and self-satisfaction for English language proficiency (P = 0.048). Passing the examination was more likely with high self-satisfaction for English language proficiency [odds ratio = 6.063 (95% CI 1.014 to 36.249)]. Also, a significant association between obtaining a class at the examination and using peer-revision notes (P = 0.019) was revealed. Obtaining a class at the examination was less likely with the frequent use of peer-revision notes [odds ratio = 0.228 (95% CI 0.066 to 0.790)].

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3912-6) contains supplementary material, which is available to authorized users.

Acetylcholinesterase inhibitor insecticides related acute poisoning, availability and sales: trends during the post-insecticide-ban period of Anuradhapura, Sri Lanka

Background

Acetylcholinesterase inhibitor insecticides (AChEIIs) were used extensively in the agrarian region of Anuradhapura for the past few decades. As a result, the region faced a heightened risk of toxicity. Carbaryl, carbofuran, chlorpyrifos, dimethoate, and fenthion were the five hazardous AChEIIs banned from Anuradhapura in 2014. Assessment of post-ban trends in acute poisoning will reveal the impact of the ban. Data on availability and sales of remaining AChEIIs will guide towards preventive measures against related toxicities.

Methods

Cross-sectional surveys were conducted at Anuradhapura district of Sri Lanka. Details related to acute AChEII poisoning were sorted from the Teaching Hospital Anuradhapura. Main insecticide vendors in Anuradhapura were surveyed to find information on availability and sales of AChEIIs. Chi-square for goodness of fit was performed for trends in acute poisoning and sales.

Results

Hospital admissions related to acute AChEII poisoning have declined from 554 in 2013 to 272 in 2017. Deaths related to acute AChEII poisoning have declined from 27 in 2013 to 13 in 2017. Sales of all five banned AChEIIs had reduced by 100%. Sales of the remaining AChEIIs were declining, except for acephate, phenthoate, and profenofos. However, one of the top selling, most frequently abused carbosulfan, had the highest risk of toxicity. Chi-square for goodness of fit showed a significance (P < 0.001) between the trends of hospital admissions for acute AChEII poisoning and the sales related to AChEIIs.

Conclusions

Hospital admissions related to acute poisoning was declining along with the overall sales of remaining AChEIIs, during the post-AChEII ban period. Nevertheless, future vigilance is needed on the remaining AChEIIs to predict and prevent related toxicities.

Electronic supplementary material

The online version of this article (10.1186/s12199-018-0716-1) contains supplementary material, which is available to authorized users.

Red blood cell acetylcholinesterase activity among healthy dwellers of an agrarian region in Sri Lanka: a descriptive cross-sectional study

BACKGROUND

Assessment of acetylcholinesterase-inhibitor insecticide (AChEII) toxicity depends on the measurement of red blood cell acetylcholinesterase (RBC-AChE) activity. Its interpretation requires baseline values which is lacking in scientific literature. We aim to find the measures of central tendency and variation for RBC-AChE activity among dwellers of Anuradhapura, where the use and abuse of AChEIIs were rampant for the last few decades.

METHODS

A descriptive cross-sectional study with a community-based sampling for 100 healthy non-farmers (male:female = 1:1) was done using pre-determined selection criteria. Duplicate measurements of RBC-AChE activity were performed according to the modified Ellman procedure. Pearson's correlation and regression analysis were sort for RBC-AChE activity against its possible determinants.

RESULTS

RBC-AChE activity had a mean of 449.8 (SD 74.2) mU/μM Hb with a statistical power of 0.847. It was similar to values of "healthy controls" from previous Sri Lankan toxicological studies but was low against international reference value [586.1 (SD 65.1) mU/μM Hb]. None of the possible determinants showed a significant strength of relationship with RBC-AChE activity.

CONCLUSION

The baseline RBC-AChE activity among people of Anuradhapura is low in comparison with international reference values. This arises a need to find a causative mechanism.

Tuberculosis induced autoimmune haemolytic anaemia: a systematic review to find out common clinical presentations, investigation findings and the treatment options

Background

Tuberculosis induced autoimmune haemolytic anaemia is a rare entity. The aim of this study was to explore its common presentations, investigation findings and treatment options through a systematic review of published reports.

Methods

PubMed, Trip, Google Scholar, Science Direct, Cochrane Library, Open-Grey, Grey literature report and the reference lists of the selected articles were searched for case reports in English on tuberculosis induced auto-immune haemolytic anaemia. PRISMA statement was used for systematic review. Quality assessment of the selected reports was done using the CARE guidelines.

Results

Twenty-one articles out of 135 search results were included. Thirty-three percent of patients were reported from India. More than half had fever and pallor. The mean haemoglobin was 5.77 g/dl (SD 2.2). Positive direct coombs test was seen in all patients. Pulmonary tuberculosis (43%) was most prevalent. Twenty-nine percent of patients needed a combination of anti-tuberculosis medicines, blood transfusion and steroids. Higher percentage of disseminated TB induced AIHA (67%) needed steroids in comparison to the other types of TB induced AIHA (13%).

Conclusions

Rarer complications of tuberculosis such as auto-immune haemolytic anaemia should be looked for especially in disease-endemic areas. Blood transfusion and steroids are additional treatment options along with the anti-tuberculosis medicines.

Electronic supplementary material

The online version of this article (10.1186/s13223-018-0236-y) contains supplementary material, which is available to authorized users.

Pharmacology education and antibiotic self-medication among medical students: a cross-sectional study

OBJECTIVE

Pharmacology teaches rational prescribing. Self-medication among medical students is recognised as a threat to rational prescribing. Antibiotic self-medication could cause antibiotic resistance among medical students. We aimed to find an association between pharmacology education and antibiotic self-medication.

RESULTS

Overall, 39% [(110/285) 95% CI 32.9-44.3] of students were found to have antibiotic self-medication. The percentage for antibiotic self-medication progressively increased with the year of study. The percentage of antibiotic self-medication was significantly high in the "Formal Pharmacology Education" group (47%-77/165) in comparison to the "No Formal Pharmacology Education" group (28%-33/120) (P = 0.001032). Overall, the most common self-prescribed antibiotic was amoxicillin (56%-62/110).

Availability of essential medicines in selected public, primary and secondary health care institutions of a rural Sri Lankan district: a spot survey

Background

Assessment of the availability of essential medicines, in rural areas of countries with free state health care system, is scarce. Dependence on essential medicines among the population in rural sector is considered to be high. Assessing the availability of essential medicines in selected state owned primary and secondary health care institutions of a rural district will help to identify areas where improvement is needed.

Methods

A descriptive cross sectional study, covering selected five primary and one secondary care institutions of a rural Sri Lankan district, was conducted. The national list of essential medicines, Sri Lanka was used as the check list and the guidelines of the WHO–Health Action International were adapted.

Results

The secondary care institution recorded an overall availability of 71%, whereas the average overall availability of the primary care institutions was 56%. Central dispensaries recorded the lowest availability. Lack of availability of medicines needed for the management of chronic kidney disease, snake bite and poisoning was noted.

Conclusions

Availability of essential medicines in most of the primary and the secondary care institutions were fairly high. Deficiency in medicines needed for the management of emergencies was noted. A need based annual estimate of medicines based on an essential medicine list is suggested.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1969-2) contains supplementary material, which is available to authorized users.

Drug utilization, prescription errors and potential drug-drug interactions: an experience in rural Sri Lanka

BACKGROUND

Prescription writing is a process which transfers the therapeutic message from the prescriber to the patient through the pharmacist. Prescribing errors, drug duplication and potential drug-drug interactions (pDDI) in prescriptions lead to medication error. Assessment of the above was made in prescriptions dispensed at State Pharmaceutical Corporation (SPC), Anuradhapura, Sri Lanka.

METHODS

A cross sectional study was conducted. Drugs were classified according to the WHO anatomical, therapeutic chemical classification system. A three point Likert scale, a checklist and Medscape online drug interaction checker were used to assess legibility, completeness and pDDIs respectively.

RESULTS

Thousand prescriptions were collected. Majority were hand written (99.8 %) and from the private sector (73 %). The most frequently prescribed substance and subgroup were atorvastatin (4 %, n = 3668) and proton pump inhibitors (7 %, n = 3668) respectively. Out of the substances prescribed from the government and private sectors, 59 and 50 % respectively were available in the national list of essential medicines, Sri Lanka. Patients address (5 %), Sri Lanka Medical Council (SLMC) registration number (35 %), route (7 %), generic name (16 %), treatment symbol (48 %), diagnosis (41 %) and refill information (6 %) were seen in less than half of the prescriptions. Most were legible with effort (65 %) and illegibility was seen in 9 %. There was significant difference in omission and/or errors of generic name (P = 0.000), dose (P = 0.000), SLMC registration number (P = 0.000), and in evidence of pDDI (P = 0.009) with regards to the sector of prescribing. The commonest subgroup involved in duplication was non-steroidal anti-inflammatory drugs (NSAIDs) (43 %; 56/130). There were 1376 potential drug interactions (466/887 prescriptions). Most common pair causing pDDI was aspirin with losartan (4 %, n = 1376).

CONCLUSION

Atorvastatin was the most frequently prescribed substance. Fifteen percent of the prescriptions originate from government sector. SLMC registration number and trade names were seen more in prescriptions originating from the private sector. Most prescriptions were legible with effort. NSAIDs were the commonest implicated in drug class duplication. Fifty three percent of prescriptions have pDDI.