Prevalence and determinants of heterosexual anal-intercourse among female sex workers in India: Findings from nationwide cross-sectional biological and behavioural survey

BACKGROUND

The vulnerability of female sex workers (FSWs) to HIV infection increases if unprotected heterosexual anal intercourse (HAI) is practiced.

OBJECTIVES

To estimate the prevalence of HAI among FSWs, and associated factors, and prevalence of consistent condom use (CCU) during HAI and associated factors.

METHODS

Analysis of cross-sectional data from nationwide biological and behavioural survey, conducted at 73 randomly selected domains with sample size of 27,000 in India.

RESULTS

A total of 25,932 FSWs were included in the analysis, after excluding 1075 (3.9%) FSWs for which the data were incomplete. The prevalence of HAI was 29.9% (95% CI, 29.3, 30.4); The CCU during HAI in the last one month was 58.9%. Younger age at the start of sex work, use of mobile phone/internet for soliciting client, home as a place of sex work, consumption of alcohol/drug, and physical violence against FSWs were associated with higher odds of HAI. Frequent contact with outreach workers, awareness of sexually transmitted infection, and older age at the start of sex work was associated with CCU.

CONCLUSION

Prevalence of HAI was high among FSW in India. The national program could target those factors that reduce the odds of HAI and/or promote CCU.

Lichen amyloidosis: towards pathogenesis-driven targeted treatment

Lichen amyloidosis (LA) is an uncommon, primary cutaneous amyloidosis associated with chronic, idiopathic pruritus. We report the case of a 66-year-old woman who presented to clinic with intense pruritus of the shins for 40 years. This patient showed a complete response to the Janus kinase (JAK) inhibitor upadacitinib and we therefore suggest JAK inhibition as a targeted treatment strategy for LA.

A Distance Vector Hop and Differential Evolution based Interception Strategy for detecting Cross Border Infiltration in Underground Tunnel

Securing the external border of a nation through potential surveillance is considered to be highly essential for safeguarding them from terrorists and other national armies that intentionally try to conquer regions. The infiltration of trespassers and terrorists into a territory is considered to greatly influence the harmony and peace of a nation. In this context, conventional border surveillance systems safeguard the border regions based on the pre-determined routes at various time intervals. However, the intensive involvement of human in patrolling is determined as the major challenge in the process of safeguarding longer border areas. Moreover, detecting the infiltration of terrorists through the underground tunnel is considered to be the other challenge. At this juncture, wireless sensor networks are considered to be the best suitable candidate for safeguarding the external borders through real-time monitoring to attain maximized accuracy, efficiency in the detection and least human intervention. In this paper, Distance Vector-Hop (DV-Hop) and Differential Evolution (DE)-based Interception Strategy (DV-Hop-DE-IS) is proposed for accurate detection of cross border infiltration in the underground tunnel. This proposed DV-Hop-DE-IS includes the merits of converting the discrete values of hop count into a highly accurate continuous value depending on the information received from the number of shared one-hop nodes that exists between neighbouring nodes. This problem of intruder detection is formulated as the minimum optimization problem that could be optimally solved through the utilization of the Differential Evolution algorithm with maximized efficiency. The simulation results of the DV-Hop-DE-IS confirmed better detection rate, accuracy with a reduced false positive rate compared to the benchmarked intruder detection approaches.

Non-participation of female sex workers in HIV sentinel surveillance 2017 in the central zone, and its effect on observed HIV prevalence rate

Background

During HIV sentinel surveillance (HSS) 2017 round, the sampling strategy to recruit female sex workers (FSWs) was changed from consecutive to random sampling. This may affect the participation and HIV positivity rates among FSWs.

Objective

The objective of this study is to estimate the nonparticipation rates among FSWs and its effect on the observed HIV prevalence rate during HSS-2017.

Methods

The data were collected from FSW sentinel sites located in the states of Delhi, Jharkhand, Uttar Pradesh, and Uttarakhand (Central Zone). The HIV positivity rate among FSWs who participated in HSS-2017 was compared with the HIV positivity rate of those who did not participate. HIV status of the participants was obtained from HSS-2017 data. The master list of participating targeted intervention sites was accessed to obtain the last known HIV status of the eligible nonparticipants.

Results

Nonparticipation rate of FSWs from the central zone during HSS2017 was 10.8%. The HIV positivity rate among nonparticipant FSW was four times and six times higher in Delhi and UP, respectively.

Conclusion

Selective nonparticipation of eligible FSWs might have led to the underestimation of the HIV positivity rate in the central zone during the HSS-2017 round.

Findings from the 2017 HIV estimation round & trend analysis of key indicators 2010-2017: Evidence for prioritising HIV/AIDS programme in India

Background & objectives:

The National AIDS Control Organisation (NACO) and the ICMR-National Institute of Medical Statistics, the nodal agency for conducting HIV estimations in India, have been generating HIV estimates regularly since 2003. The objective of this study was to describe India's biennial HIV estimation 2017 process, data inputs, tool, methodology and epidemiological assumptions used to generate the HIV estimates and trends of key indicators for 2010-2017 at national and State/Union Territory levels.

Methods:

Demographic Projection (DemProj) and AIDS Impact Modules (AIM) of Spectrum 5.63 software recommended by the United Nations Programme on HIV and AIDS Global Reference Group on HIV Estimates, Modelling and Projections, were used for generating HIV estimations on key indicators. HIV sentinel surveillance, epidemiological and programme data were entered into Estimation Projection Package (EPP), and curve fitting was done using EPP classic model. Finally, calibration was done using the State HIV prevalence of two rounds of National Family Health Survey (NFHS) -3 and -4 and Integrated Biological and Behavioural Surveillance (IBBS), 2014-2015.

Results:

The national adult prevalence of HIV was estimated to be 0.22 per cent in 2017. Mizoram, Manipur and Nagaland had the highest prevalence over one per cent. An estimated 2.1 million people were living with HIV in 2017, with Maharashtra estimated to have the highest number. Of the 88 thousand annual new HIV infections estimated nationally in 2017, Telangana accounted for the largest share. HIV incidence was found to be higher among key population groups, especially people who inject drugs. The annual AIDS-related deaths were estimated to be 69 thousand nationally. For all indicators, geographic variation in levels and trends between States existed.

Interpretation & conclusions:

With a slow decline in annual new HIV infections by only 27 per cent from 2010 to 2017 against the national target of 75 per cent by 2020, the national target to end AIDS by 2030 may be missed; although at the sub-national level some States have made better progress to reduce new HIV infection. It calls for reinforcement of HIV prevention, diagnosis and treatment efforts by geographical regions and population groups.

Adagrad Optimizer with Elephant Herding Optimization based Hyper Parameter Tuned Bidirectional LSTM for Customer Churn Prediction in IoT Enabled Cloud Environment

At recent times, customer churn is an important activity in quickly developing industries such as telecom, banking, e-commerce, etc. Earlier studies revealed that the cost of getting a new customer is considerably higher than the cost of retaining the existing ones. Therefore, it becomes essential to predict the nature of customer churn for retaining the customers to a greater extent. The advent of deep learning (DL) models have begun to be employed for efficient CCP. This paper presents a new Adagrad Optimizer with Elephant Herding Optimization (EHO) based Hyper-parameter Tuned Bidirectional Long Short Term Memory (AG-EHO-BiLSTM) for CCP in Internet of Things (IoT) enabled Cloud Environment. The proposed AG-EHO-BiLSTM model initially acquires the customer data using its devices like smart phones, laptop, smart watch, etc. Next, the gathered data will be classified by the use of Bi-LSTM model, which determines the customers as churner or non-churner. The efficiency of the Bi-LSTM model can be increased through hyper parameter tuning techniques, namely Adagrad optimizer and EHO algorithm to optimally select the parameter values namely learning rate, number of hidden layer and epochs. The performance validation of the AG-EHO-BiLSTM model takes place on benchmark dataset and the simulation outcome reported the supremacy of the AG-EHO-BiLSTM model over the comparative methods.

Leprosy: Treatment and management of complications

In the second article in this continuing medical education series, we review the treatment of leprosy, its immunologic reactions, and important concepts, including disease relapse and drug resistance. A fundamental understanding of the treatment options and management of neuropathic sequelae are essential to reduce disease burden and improve patients' quality of life.

Leprosy: Clinical aspects and diagnostic techniques

Leprosy, also known as Hansen's disease, is a curable infectious disease that remains endemic in >140 countries around the world. Despite being declared "eliminated" as a global public health problem by the World Health Organization in the year 2000, approximately 200,000 new cases were reported worldwide in 2017. Widespread migration may bring leprosy to nonendemic areas, such as North America. In addition, there are areas in the United States where autochthonous (person-to-person) transmission of leprosy is being reported among Americans without a history of foreign exposure. In the first article in this continuing medical education series, we review leprosy epidemiology, transmission, classification, clinical features, and diagnostic challenges.

Purification of Matrixins from Marine Cephalopod

Matrixins play a major role in tissue regeneration and also in various patho-physiological processes. Discovery of matrix metallo proteins (MMPs) and their detailed structural and functional analysis would lead to the development of numerous potent synthetic inhibitors of matrixins to treat certain diseases. In the present investigation, a marine cephalopod- Octopus sp. collected from Cochin, in the south western Indian Ocean was used as animal model for purification of matrixins. The measurements, count, indices and other morphometric characters were noted down before assessing the presence of matrixins in the crude extract of Octopus samples. Purification of matrixins was carried out employing gel filtration chromatography and the purified matrixins was confirmed by gelatin zymogram. The purity of the protein was checked by both native and SDS-PAGE. The studies have provided clear indications of production of MMPs or matrixins with gelatinolytic activity in Octopus sp.

Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluid and electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN.

Bayesian strategy selection identifies optimal solutions to complex problems using an example from GP prescribing

Complex health problems require multi-strategy, multi-target interventions. We present a method that uses machine learning techniques to choose optimal interventions from a set of possible interventions within a case study aiming to increase General Practitioner (GP) discussions of physical activity (PA) with their patients. Interventions were developed based on a causal loop diagram with 26 GPs across 13 clinics in Geelong, Australia. GPs prioritised eight from more than 80 potential interventions to increase GP discussion of PA with patients. Following a 2-week baseline, a multi-arm bandit algorithm was used to assign optimal strategies to GP clinics with the target outcome being GP PA discussion rates. The algorithm was updated weekly and the process iterated until the more promising strategies emerged (a duration of seven weeks). The top three performing strategies were continued for 3 weeks to improve the power of the hypothesis test of effectiveness for each strategy compared to baseline. GPs recorded a total of 11,176 conversations about PA. GPs identified 15 factors affecting GP PA discussion rates with patients including GP skills and awareness, fragmentation of care and fear of adverse outcomes. The two most effective strategies were correctly identified within seven weeks of the algorithm-based assignment of strategies. These were clinic reception staff providing PA information to patients at check in and PA screening questionnaires completed in the waiting room. This study demonstrates an efficient way to test and identify optimal strategies from multiple possible solutions.

Treatment of unresectable cutaneous squamous cell carcinoma with pembrolizumab

Currently, there are few effective therapies for locally advanced and metastatic cutaneous squamous cell carcinoma (cSCC); however, there is recent evidence supporting the use of immunological therapies in cSCC given the typically high mutation burden and association with immunosuppressed states. This report describes a 56-year-old man presenting with synchronous, invasive cSCC on the right temple and right dorsum of the hand deemed unfavourable for surgical resection. The patient was treated with nine infusions of programmed cell death protein 1 (PD-1) inhibitor therapy, pembrolizumab, with clinical and radiographical resolution of his lesions. This case illustrates the potential use of anti-PD-1 antibody as a first-line treatment in the setting of advanced, unresectable cSCC.

MITF Expression Predicts Therapeutic Vulnerability to p300 Inhibition in Human Melanoma

Histone modifications, largely regulated by histone acetyltransferases (HAT) and histone deacetylases, have been recognized as major regulatory mechanisms governing human diseases, including cancer. Despite significant effort and recent advances, the mechanism by which the HAT and transcriptional coactivator p300 mediates tumorigenesis remains unclear. Here, we use a genetic and chemical approach to identify the microphthalmia-associated transcription factor (MITF) as a critical downstream target of p300 driving human melanoma growth. Direct transcriptional control of MITF by p300-dependent histone acetylation within proximal gene regulatory regions was coupled to cellular proliferation, suggesting a significant growth regulatory axis. Further analysis revealed forkhead box M1 (FOXM1) as a key effector of the p300-MITF axis driving cell growth that is selectively activated in human melanomas. Targeted chemical inhibition of p300 acetyltransferase activity using a potent and selective catalytic p300/CBP inhibitor demonstrated significant growth inhibitory effects in melanoma cells expressing high levels of MITF. Collectively, these data confirm the critical role of the p300-MITF-FOXM1 axis in melanoma and support p300 as a promising novel epigenetic therapeutic target in human melanoma. SIGNIFICANCE: These results show that MITF is a major downstream target of p300 in human melanoma whose expression is predictive of melanoma response to small-molecule inhibition of p300 HAT activity.

Comparative Genetic Variability in HIV-1 Subtype C vpu Gene in Early Age Groups of Infants

OBJECTIVE

Identifying the genetic variability in vertically transmitted viruses in early infancy is important to understand the disease progression. Being important in HIV-1 disease pathogenesis, vpu gene, isolated from young infants was investigated to understand the viral characteristics.

METHOD

Blood samples were obtained from 80 HIV-1 positive infants, categorized in two age groups; acute (<6 months) and early (>6-18 months). A total of 77 PCR positive samples, amplified for vpu gene, were sequenced and analyzed.

RESULTS

73 isolates belonged to subtype C. Analysis of heterogeneity of amino acid sequences in infant groups showed that in the sequences of acute age group both insertions and deletions were present while in the early age group only deletions were present. In the acute age group, a deletion of 3 residues (RAE) in the first alfa helix in one sequence and insertions of 1-2 residues (DM, GH, G and H) in the second alfa helix in 4 sequences were observed. In the early age group, deletion of 2 residues (VN) in the cytoplasmic tail region in 2 sequences was observed. Length of the amino terminal was observed to be gradually increasing with the increasing age of the infants. Protein Variation Effect Analyzer software showed that deleterious mutations were more in the acute than the early age group. Entropy analysis revealed that heterogeneity of the residues was comparatively higher in the sequences of acute than the early age group.

CONCLUSION

Mutations observed in the helixes may affect the conformation and lose the ability to degrade CD4 receptors. Heterogeneity was decreasing with the increasing ages of the infants, indicating positive selection for robust virion survival.

Parotid Gland Tumors: 2-Year Prospective Clinicopathological Study

Context:

Parotid gland tumors account for 80% of all salivary gland neoplasms. Most parotid masses are operated on before obtaining the final histological diagnosis, which complicates the management of the facial nerve damage during parotid surgery.

Aims:

The aim of this study is to analyze the age- and gender-wise incidence of parotid gland tumors, the incidence of various types of tumors, to assess their clinical modes of presentation, the efficacy of treatment, and to evaluate the complications ensuing therein, because of intervention.

Settings and Design:

The present study was conducted in the Department of Oral and Maxillofacial Surgery, A. B. Shetty Memorial Institute of Dental Sciences and Justice K. S. Hegde Charitable Hospital, Nitte University, Mangalore.

Subjects and Methods:

A clinicopathological study of parotid gland tumors was undertaken in a tertiary care hospital. Patients with parotid swelling were clinically evaluated, followed by fine-needle aspiration cytology (FNAC). Surgery was planned and performed based on the tumor location and FNAC report. Patients were followed up for postoperative complications.

Results:

The study comprised 59 patients with parotid gland tumors. The age range of the patient affected was between 18 and 75 years. Benign tumors are more common than malignant tumor in the ratio of 3.5:1. Slow progressively parotid swelling was the common presenting complaint. Superficial parotidectomy was the most common surgery (69.49%) performed. The most common postoperative complication encountered was transient facial palsy (22.03%). Benign tumors were more common (77.97%). The most common benign tumor was pleomorphic adenoma, and malignant tumor was mucoepidermoid carcinoma.

Conclusions:

The incidence of parotid salivary gland tumors is increasing in recent years. Parotidectomy is safe procedure for treating parotid tumors. Transient facial palsy is the most common postoperative complication, which is reduced in superficial parotidectomy.

An Exact Localization of Adductor Canal and Its Clinical Significance: A Cadaveric Study

Background and Objectives:

Adductor canal block is a regional anesthetic block procedure commonly employed for knee surgeries. This study aims at locating the adductor canal precisely which will be of great use for the surgeons operating on knee.

Materials and Methods:

Forty cadaveric lower limbs fixed with formalin were utilized for the study. The length of the lower limb from anterior superior iliac spine to the base of patella is measured, and the midpoint between the two is marked. Adductor canal is dissected and the distance between proximal foramen and the midpoint of thigh, the length of the adductor canal, and the distance between the distal foramen and the base of the patella are measured.

Results:

The mean value of the adductor canal is about 10.5 cm. The average distance from anterior superior iliac spine to proximal foramen is 25 cm. The average distance from base of patella to distal foramen is 8.5 cm. In 36 (90%) lower limbs, the proximal foramen is 3 cm distal to the midpoint of the thigh.

Interpretation and Conclusion:

This study suggests that a point more than 3 cm below the midpoint of thigh will be the ideal location for the approach of adductor canal block.

The impact of air pollution on deaths, disease burden, and life expectancy across the states of India: the Global Burden of Disease Study 2017

BACKGROUND

Air pollution is a major planetary health risk, with India estimated to have some of the worst levels globally. To inform action at subnational levels in India, we estimated the exposure to air pollution and its impact on deaths, disease burden, and life expectancy in every state of India in 2017.

METHODS

We estimated exposure to air pollution, including ambient particulate matter pollution, defined as the annual average gridded concentration of PM2.5, and household air pollution, defined as percentage of households using solid cooking fuels and the corresponding exposure to PM2.5, across the states of India using accessible data from multiple sources as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. The states were categorised into three Socio-demographic Index (SDI) levels as calculated by GBD 2017 on the basis of lag-distributed per-capita income, mean education in people aged 15 years or older, and total fertility rate in people younger than 25 years. We estimated deaths and disability-adjusted life-years (DALYs) attributable to air pollution exposure, on the basis of exposure-response relationships from the published literature, as assessed in GBD 2017; the proportion of total global air pollution DALYs in India; and what the life expectancy would have been in each state of India if air pollution levels had been less than the minimum level causing health loss.

FINDINGS

The annual population-weighted mean exposure to ambient particulate matter PM2·5 in India was 89·9 μg/m3 (95% uncertainty interval [UI] 67·0-112·0) in 2017. Most states, and 76·8% of the population of India, were exposed to annual population-weighted mean PM2·5 greater than 40 μg/m3, which is the limit recommended by the National Ambient Air Quality Standards in India. Delhi had the highest annual population-weighted mean PM2·5 in 2017, followed by Uttar Pradesh, Bihar, and Haryana in north India, all with mean values greater than 125 μg/m3. The proportion of population using solid fuels in India was 55·5% (54·8-56·2) in 2017, which exceeded 75% in the low SDI states of Bihar, Jharkhand, and Odisha. 1·24 million (1·09-1·39) deaths in India in 2017, which were 12·5% of the total deaths, were attributable to air pollution, including 0·67 million (0·55-0·79) from ambient particulate matter pollution and 0·48 million (0·39-0·58) from household air pollution. Of these deaths attributable to air pollution, 51·4% were in people younger than 70 years. India contributed 18·1% of the global population but had 26·2% of the global air pollution DALYs in 2017. The ambient particulate matter pollution DALY rate was highest in the north Indian states of Uttar Pradesh, Haryana, Delhi, Punjab, and Rajasthan, spread across the three SDI state groups, and the household air pollution DALY rate was highest in the low SDI states of Chhattisgarh, Rajasthan, Madhya Pradesh, and Assam in north and northeast India. We estimated that if the air pollution level in India were less than the minimum causing health loss, the average life expectancy in 2017 would have been higher by 1·7 years (1·6-1·9), with this increase exceeding 2 years in the north Indian states of Rajasthan, Uttar Pradesh, and Haryana.

INTERPRETATION

India has disproportionately high mortality and disease burden due to air pollution. This burden is generally highest in the low SDI states of north India. Reducing the substantial avoidable deaths and disease burden from this major environmental risk is dependent on rapid deployment of effective multisectoral policies throughout India that are commensurate with the magnitude of air pollution in each state.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Comparative genetic variability in HIV-1 subtype C p24 Gene in early age groups of infants

It is important to study the molecular properties of vertically transmitted viruses in early infancy to understand disease progression. P24 having an important role in virus assembly and maturation was selected to explore the genotypic characteristics. Blood samples, obtained from 82 HIV-1 positive infants, were categorized into acute (≤ 6 months) and early (> 6-18 months) age groups. Of the 82 samples, 79 gave amplification results for p24, which were then sequenced and analysed. Amino acid heterogeneity analysis showed that substitutions were more frequent. Several substitution mutations were present in some of the sequences of both the age groups in the functional motifs of the gene namely Beta hairpin, CyPA binding loop, residues L136 and L190, linker region and major homology region. In the acute age group, an insertion of Asparagine residue (N5NL6) was observed in the β hairpin region in one of the sequences. This insertion was accompanied with analogous substitutions of N5Q, Q7L and G8R. In the early age group, a deletion of two residues; VK_181-182, was observed at the C-terminal end in one of the sequences. These mutations may impair the structure of the protein leading to defective virus assembly. Protein variation effect analyzer software showed that deleterious mutations were more in the acute than the early age group. Variability analysis revealed that the amino acid heterogeneity was comparatively higher in the acute than the early age group. Variability in the virus was decreasing with the increasing age of the infants indicating that the virus is gradually evolving under positive selection pressure. HLA class 1 binding peptide analysis showed that the epitopes TPQDLNTML and RMYSPVSIL may be helpful in designing epitope based vaccine.

Peer reviews: the dreaded rejection

This commentary considers the reasons for rejection of manuscripts during the peer-review process. Poor methodology, inappropriate statistical analysis, irrelevance, and technical errors are cited frequently as motives for manuscript rejection. Guidance, such as selecting an applicable journal, conducting a rigorous study, and writing efficiently, is provided for authors to prevent initial rejection. Researchers are reassured that rejection is a common consequence of peer-review and subsequent submissions to other journals are often successful publications.

Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016.

METHODS

We estimated prevalence and incidence for 328 diseases and injuries and 2982 sequelae, their non-fatal consequences. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between incidence, prevalence, remission, and cause of death rates for each condition. For some causes, we used alternative modelling strategies if incidence or prevalence needed to be derived from other data. YLDs were estimated as the product of prevalence and a disability weight for all mutually exclusive sequelae, corrected for comorbidity and aggregated to cause level. We updated the Socio-demographic Index (SDI), a summary indicator of income per capita, years of schooling, and total fertility rate. GBD 2016 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

FINDINGS

Globally, low back pain, migraine, age-related and other hearing loss, iron-deficiency anaemia, and major depressive disorder were the five leading causes of YLDs in 2016, contributing 57·6 million (95% uncertainty interval [UI] 40·8-75·9 million [7·2%, 6·0-8·3]), 45·1 million (29·0-62·8 million [5·6%, 4·0-7·2]), 36·3 million (25·3-50·9 million [4·5%, 3·8-5·3]), 34·7 million (23·0-49·6 million [4·3%, 3·5-5·2]), and 34·1 million (23·5-46·0 million [4·2%, 3·2-5·3]) of total YLDs, respectively. Age-standardised rates of YLDs for all causes combined decreased between 1990 and 2016 by 2·7% (95% UI 2·3-3·1). Despite mostly stagnant age-standardised rates, the absolute number of YLDs from non-communicable diseases has been growing rapidly across all SDI quintiles, partly because of population growth, but also the ageing of populations. The largest absolute increases in total numbers of YLDs globally were between the ages of 40 and 69 years. Age-standardised YLD rates for all conditions combined were 10·4% (95% UI 9·0-11·8) higher in women than in men. Iron-deficiency anaemia, migraine, Alzheimer's disease and other dementias, major depressive disorder, anxiety, and all musculoskeletal disorders apart from gout were the main conditions contributing to higher YLD rates in women. Men had higher age-standardised rates of substance use disorders, diabetes, cardiovascular diseases, cancers, and all injuries apart from sexual violence. Globally, we noted much less geographical variation in disability than has been documented for premature mortality. In 2016, there was a less than two times difference in age-standardised YLD rates for all causes between the location with the lowest rate (China, 9201 YLDs per 100 000, 95% UI 6862-11943) and highest rate (Yemen, 14 774 YLDs per 100 000, 11 018-19 228).

INTERPRETATION

The decrease in death rates since 1990 for most causes has not been matched by a similar decline in age-standardised YLD rates. For many large causes, YLD rates have either been stagnant or have increased for some causes, such as diabetes. As populations are ageing, and the prevalence of disabling disease generally increases steeply with age, health systems will face increasing demand for services that are generally costlier than the interventions that have led to declines in mortality in childhood or for the major causes of mortality in adults. Up-to-date information about the trends of disease and how this varies between countries is essential to plan for an adequate health-system response.

FUNDING

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

Association of acute toxic encephalopathy with litchi consumption in an outbreak in Muzaffarpur, India, 2014: a case-control study

BACKGROUND

Outbreaks of unexplained illness frequently remain under-investigated. In India, outbreaks of an acute neurological illness with high mortality among children occur annually in Muzaffarpur, the country's largest litchi cultivation region. In 2014, we aimed to investigate the cause and risk factors for this illness.

METHODS

In this hospital-based surveillance and nested age-matched case-control study, we did laboratory investigations to assess potential infectious and non-infectious causes of this acute neurological illness. Cases were children aged 15 years or younger who were admitted to two hospitals in Muzaffarpur with new-onset seizures or altered sensorium. Age-matched controls were residents of Muzaffarpur who were admitted to the same two hospitals for a non-neurologic illness within seven days of the date of admission of the case. Clinical specimens (blood, cerebrospinal fluid, and urine) and environmental specimens (litchis) were tested for evidence of infectious pathogens, pesticides, toxic metals, and other non-infectious causes, including presence of hypoglycin A or methylenecyclopropylglycine (MCPG), naturally-occurring fruit-based toxins that cause hypoglycaemia and metabolic derangement. Matched and unmatched (controlling for age) bivariate analyses were done and risk factors for illness were expressed as matched odds ratios and odds ratios (unmatched analyses).

FINDINGS

Between May 26, and July 17, 2014, 390 patients meeting the case definition were admitted to the two referral hospitals in Muzaffarpur, of whom 122 (31%) died. On admission, 204 (62%) of 327 had blood glucose concentration of 70 mg/dL or less. 104 cases were compared with 104 age-matched hospital controls. Litchi consumption (matched odds ratio [mOR] 9·6 [95% CI 3·6 - 24]) and absence of an evening meal (2·2 [1·2-4·3]) in the 24 h preceding illness onset were associated with illness. The absence of an evening meal significantly modified the effect of eating litchis on illness (odds ratio [OR] 7·8 [95% CI 3·3-18·8], without evening meal; OR 3·6 [1·1-11·1] with an evening meal). Tests for infectious agents and pesticides were negative. Metabolites of hypoglycin A, MCPG, or both were detected in 48 [66%] of 73 urine specimens from case-patients and none from 15 controls; 72 (90%) of 80 case-patient specimens had abnormal plasma acylcarnitine profiles, consistent with severe disruption of fatty acid metabolism. In 36 litchi arils tested from Muzaffarpur, hypoglycin A concentrations ranged from 12·4 μg/g to 152·0 μg/g and MCPG ranged from 44·9 μg/g to 220·0 μg/g.

INTERPRETATION

Our investigation suggests an outbreak of acute encephalopathy in Muzaffarpur associated with both hypoglycin A and MCPG toxicity. To prevent illness and reduce mortality in the region, we recommended minimising litchi consumption, ensuring receipt of an evening meal and implementing rapid glucose correction for suspected illness. A comprehensive investigative approach in Muzaffarpur led to timely public health recommendations, underscoring the importance of using systematic methods in other unexplained illness outbreaks.

FUNDING

US Centers for Disease Control and Prevention.

Patient and Healthcare System Delays in the Start of Pulmonary Tuberculosis Treatment Among Tribal Patients Registered Under DOTS, Odisha

INTRODUCTION

Tuberculosis (TB) is a highly infectious disease which continues to be an important public health problem worldwide.

AIM

This study puts an effort to determine patient and health system delay in diagnosis and treatment and association to specific types of delay among tribals in Mayurbhanj district, Odisha.

MATERIALS AND METHODS

A total of 261 TB patients reporting to 4 TB Units of Mayurbhanj were interviewed using pre-tested structured questionnaire. Extra-pulmonary TB patients and death cases were excluded. Data entry and analysis was carried out in Epi-info 3.32 version. Chi-square test was used to test the association between dependant variable (patient and health system delays) with different independent variables (age, sex, reasons for delay etc.).

RESULTS

Median patient, health system and total delay were 24, 3 and 24 days respectively. Risk factors that were significantly associated with patient delay were education (95% CI= 1.01-1.11, p=0.015), cost of treatment/transport (95% CI=0.87-1.01, p=0.020), distance (95% CI=1.00-1.29, p=0.002) and lack of awareness about TB (95% CI=1.01-1.34, p=0.001). Health system delay risk factors were distance (95% CI=0.32-0.96, p=0.043), delay due to administrative verification (95% CI=1.18-57.97, p= 0.005) and delay due to traditional healers/ private practitioners (95% CI=1.61-15.45, p=0.0008).

CONCLUSION

This study revealed longer patient delay compared to health system delay. Therefore, public awareness in tribal dialect about chest symptoms and availability of free diagnostics services should be increased along with involvement of traditional healers.

Molecular epidemiological analysis of three hepatitis C virus outbreaks in Jammu and Kashmir State, India

Outbreaks of hepatitis C virus (HCV) infection are associated with unsafe injection practices, intravenous drug abuse and other exposure to blood and body fluids. We report here three outbreaks of HCV infection from Jammu and Kashmir (J&K) State, India, which occurred over a period of 3 years and in which molecular epidemiological investigations identified a presumptive common source of infection, most likely a single healthcare venue. Representative blood samples collected from cases of hepatitis C were sent to the National Centre for Disease Control (NCDC) for molecular characterization. These samples were positive by HCV ELISA. Subsequently, specimens were also tested for the presence of HCV RNA by RT-PCR. Sequencing was carried out for all positive samples. A total of 812 cases were laboratory confirmed by HCV ELISA; a total of 115 samples were sent to the NCDC for RT-PCR, and 77 were positive. Subtype 3a of HCV was found in all samples from Anantnag (February 2013); and for subtype 3b, in all samples from Srinagar (May 2015). Subtypes 3a and 3g were identified from two samples from the Kulgam outbreak (July 2014). A detailed epidemiological investigation should be conducted whenever a cluster of HCV cases is revealed, as this potentially allows for the identification of larger outbreaks. Epidemiological investigations of outbreaks should be further supported by inclusion of molecular tests. Efforts to limit therapeutic injections to only those cases having strong medical/surgical indications and to restrict the use of non-sterile needles are essential to prevent transmission of HCV.

W-band sparse synthetic aperture for computational imaging

We present a sparse synthetic-aperture, active imaging system at W-band (75 - 110 GHz), which uses sub-harmonic mixer modules. The system employs mechanical scanning of the receiver module position, and a fixed transmitter module. A vector network analyzer provides the back end detection. A full-wave forward model allows accurate construction of the image transfer matrix. We solve the inverse problem to reconstruct scenes using the least squares technique. We demonstrate far-field, diffraction limited imaging of 2D and 3D objects and achieve a cross-range resolution of 3 mm and a depth-range resolution of 4 mm, respectively. Furthermore, we develop an information-based metric to evaluate the performance of a given image transfer matrix for noise-limited, computational imaging systems. We use this metric to find the optimal gain of the radiating element for a given range, both theoretically and experimentally in our system.

Eradicating successfully yaws from India: The strategy & global lessons

Yaws, a non-venereal treponematosis, affecting primarily the tribal populations, has been considered historically as one of the most neglected tropical diseases in the world. In 1996, India piloted an initiative to eradicate yaws based on a strategy consisting of active case finding through house-to-house search and treatment of cases and their contacts with long acting penicillin. Thereafter, the campaign implemented in all 51 endemic districts in 10 States of the country led to the achievement of a yaws-free status in 2004. In the post-elimination phase, surveillance activities accompanied by serological surveys were continued in the erstwhile endemic districts. These surveys carried out among children between the age of 1-5 yr, further confirmed the absence of community transmission in the country. The experience of India demonstrates that yaws can be eradicated in all endemic countries of Africa and Asia, provided that political commitment can be mobilized and community level activities sustained until the goal is achieved.

3D printed microfluidic circuitry via multijet-based additive manufacturing

The miniaturization of integrated fluidic processors affords extensive benefits for chemical and biological fields, yet traditional, monolithic methods of microfabrication present numerous obstacles for the scaling of fluidic operators. Recently, researchers have investigated the use of additive manufacturing or "three-dimensional (3D) printing" technologies - predominantly stereolithography - as a promising alternative for the construction of submillimeter-scale fluidic components. One challenge, however, is that current stereolithography methods lack the ability to simultaneously print sacrificial support materials, which limits the geometric versatility of such approaches. In this work, we investigate the use of multijet modelling (alternatively, polyjet printing) - a layer-by-layer, multi-material inkjetting process - for 3D printing geometrically complex, yet functionally advantageous fluidic components comprised of both static and dynamic physical elements. We examine a fundamental class of 3D printed microfluidic operators, including fluidic capacitors, fluidic diodes, and fluidic transistors. In addition, we evaluate the potential to advance on-chip automation of integrated fluidic systems via geometric modification of component parameters. Theoretical and experimental results for 3D fluidic capacitors demonstrated that transitioning from planar to non-planar diaphragm architectures improved component performance. Flow rectification experiments for 3D printed fluidic diodes revealed a diodicity of 80.6 ± 1.8. Geometry-based gain enhancement for 3D printed fluidic transistors yielded pressure gain of 3.01 ± 0.78. Consistent with additional additive manufacturing methodologies, the use of digitally-transferrable 3D models of fluidic components combined with commercially-available 3D printers could extend the fluidic routing capabilities presented here to researchers in fields beyond the core engineering community.