Spontaneous membranous dysmenorrhea: a rare clinical entity

Membranous dysmenorrhea is a rare painful clinical condition associated with spontaneous expulsion of the endometrium as an entire piece, retaining the shape of the uterus. Authors report a case of membranous dysmenorrhea in a 36 year old multiparous woman, who was not on any hormonal therapy. She presented with history of menorrhagia for 20 days and severe dysmenorrhea for one day. During her second day of hospital admission, she expelled a fleshy mass resembling a decidual cast. Histopathological examination was consistent with diagnosis of membranous dysmenorrhea. The etiology of membranous dysmenorrhea is not very clear and hence reporting such rare cases may aid in understanding the etiology and pathophysiology of this rare condition

Antibiotic susceptibility pattern of group B streptococcal isolates from maternal genital tract

Background: Group B streptococcus (GBS) is one of the important cause of early onset neonatal sepsis in developed countries leading to increased neonatal morbidity and mortality. Penicillin and Ampicillin are the drugs of choice for prevention of GBS infections. Antibiotic resistance amongst GBS isolates is an emerging health problem affecting neonates. Hence, this study was performed to determine the antibiotic susceptibility pattern of Group B Streptococcus (GBS) in a population of pregnant women.Methods: A prospective study was done to screen pregnant women for vaginal and rectal GBS colonization during their regular visits to antenatal clinic. Todd-Hewitt broth, an enrichment medium for GBS was used for isolation. The antibiotic susceptibility pattern of the isolates were studied.  Results: A total of 300 pregnant women were screened for GBS colonization. GBS colonization rate in our study was 2.3%. The antibiotic susceptibility pattern of the isolates revealed that none of the isolates were resistant to penicillin or clindamycin, while resistance was noted to erythromycin (14.3%) and   tetracycline (71.4%).Conclusions: GBS continues to remain sensitive to Penicillin which is the drug of choice for prevention and treatment of GBS.  Consistent surveillance of antibiotic sensitivity pattern of GBS as well as for other organisms implicated in new born sepsis and maternal infections is required to formulate guidelines for prevention and treatment

Evaluation of reasons for participation refusal among pregnant women in a perinatal outcome research

Background: The number of protocol-eligible patients, refusing to participate in a biomedical research is often not mentioned in the results of the studies. There are no studies that have looked at the data on willingness to participate in a research among pregnant women in India. The aim of this study is to report the number of pregnant women who refused to participate and to evaluate the reasons for not participating in a research that was concerned with swabbing of the genital tract for culture.Methods: A prospective research study was done among healthy pregnant women, that required collection of vaginal swabs for culture to study the vaginal flora. The women eligible to participate in the study were approached for their willingness to participate in the study. The details of women who refused to participate in the study and the various self-reported reasons for their refusal were documented and analysed.Results: A total 48.2% of the total protocol-eligible group refused to participate in the study and the refusal rate was alarmingly higher than expected. Some of the common responses for their refusal include reasons such as the study involved tests from their private parts, lack of interest to participate and the need to discuss with their partner or that their partner wound not allow them to participate in research.Conclusions: It is important for research studies to include data on the refusal to participate and also the reasons why people refuse to participate in research so as to formulate strategies to improve the acceptance rate for participation in research.

Knowledge, awareness and attitude about prenatal sex determination, pre-conception and pre-natal diagnostic techniques act among pregnant women in the South Indian union territory of Puducherry

Background: This study was conducted among pregnant women in the Union territory Puducherry, South India with the aim of studying their Knowledge, awareness and attitude regarding prenatal sex determination and Pre-Natal Diagnostic Techniques Act (PCPNDT) Act.Methods: The present cross-sectional study was conducted on 160 consenting pregnant women selected using convenience sampling, attending the antenatal Out Patient Department of our hospital. The data was collected using a pre-tested semi-structured questionnaire consisting of 4 sections, Section 1: Participants general information, section 2: Awareness about pre-natal sex determination, Section 3: Awareness on the PCPNDT Act, Section 4: Attitude towards prenatal sex determination.Results: Out of a total 160 pregnant women who filled the questionnaire, 128 participants returned completed questionnaire which was used for analysis. Media was the main source of information (66.4%) followed by friends and relatives (22.66%) and health care personnel (10.94%). Ultrasonography, as a method of sex determination was known to 87.5% of pregnant women. Sixty eight percentage of participants were aware of a government act for prevention of sex determination and 84.3% knew that prenatal sex determination is a punishable offence. Seventy one percent participants knew both patients and the doctors are punishable if involved. Eight one percentage participants were willing to educate people about PCPNDT Act.Conclusions: Though higher proportion of our study participants knew about the prenatal sex determination, they were not fully aware of the punishment for prenatal sex determination. Pregnant women have to be educated about the penalization for violation of the Act and ethical issues related with female sex selective abortion and feticide. Similar studies in other settings on a larger sample size should be done for in depth understanding of this issue

Neonatal outcome in maternal genital tract group B streptococcal colonization

Background: Group B streptococcus (GBS) is a leading cause of early onset neonatal infections and associated morbidity and mortality in the western world. The objective of this study was to assess neonatal outcome in maternal genital tract Group B streptococcal (GBS) colonization.Methods: Pregnant women with gestational age greater than 24 weeks were screened for vaginal GBS colonization during their regular visits to antenatal clinic. The vaginal swabs were inoculated in Todd Hewitt broth and later sub-cultured on blood agar for isolation of GBS. The patients were followed up till delivery. Neonatal characteristics like symptoms of clinical sepsis, screening tests for sepsis, culture positivity, low birth weight, preterm delivery and survival at 1 month were recorded and analyzed.Results: A total of 316 pregnant women were enrolled in the study. GBS was isolated from 7 patients (2.3%). A statistically significant increase in occurrence of PROM in women with GBS colonization was noted. However, none of the babies born to women with GBS colonization developed any clinical or proven sepsis, low birth weight or any other negative outcomes.Conclusions: GBS colonization rate was extremely low in our study. There was significant association between maternal genital tract colonization of GBS and occurrence of PROM. However, no neonatal adverse effects were found to be associated with GBS colonization in pregnancy

Unusual complication of Mycoplasma pneumoniae in a five year old child

Mycoplasma pneumoniae is common agent causing community acquired pneumonia in children. However, the course of illness is usually benign and is rarely associated with pulmonary complications. We report a five-year-old child with massive pleural effusion and empyema secondary to Mycoplasma pneumonia infection. This potential yet rare source of infection should be considered in young patients where resolution of symptoms from pneumonia is delayed

Efficacy of cabergoline in the prevention of severe ovarian hyperstimulation syndrome in high-risk women undergoing assisted reproductive technology treatment

Background: Ovarian hyperstimulation syndrome (OHSS) is a severe and potentially life-threatening complication of controlled ovarian stimulation (COH). Cabergoline has been tried as a preventive measure for OHSS in high-risk women undergoing assisted reproductive technology (ART) treatment. Our study was done to assess the effectiveness of cabergoline in preventing severe OHSS in high-risk women undergoing ART treatment.Methods: This is a prospective interventional study done among patients undergoing ART with serum estradiol levels >4000 pg/ml on the day of hCG administration were included in the study. Women undergoing ART with serum estradiol levels >4000 pg/ml on the day of hCG administration, were assigned into two groups using random number allocation. Women in treatment group received cabergoline 0.5 mg daily for 8 days from the day of hCG administration and control group did not receive Cabergoline therapy. The patients in both groups were followed up to study the incidence and severity of OHSS in that treatment cycleResults: The incidence of severe OHSS was two in each group with clinical and ultrasound evidence of ascites. Embryo transfer was cancelled in one patient in each group in view of severe OHSS with tense ascites. One patient in treatment group had severe OHSS that needed peritoneal fluid tapping with fresh frozen plasma administration. Life threatening complications were not encountered in any of the patients with high risk for OHSS included in the study.Conclusions: Cabergoline did not prevent the incidence of severe OHSS in patients at high risk for OHSS in our study. Large randomized trials would be needed to confirm the findings of our study

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

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

Background: Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020–21 COVID-19 pandemic period. Methods: 22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution. Findings: Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5–65·1] decline), and increased during the COVID-19 pandemic period (2020–21; 5·1% [0·9–9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98–5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50–6·01) in 2019. An estimated 131 million (126–137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7–17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8–24·8), from 49·0 years (46·7–51·3) to 71·7 years (70·9–72·5). Global life expectancy at birth declined by 1·6 years (1·0–2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67–8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4–52·7]) and south Asia (26·3% [9·0–44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations. Interpretation: Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic

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

Background: Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic. Methods: The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic. Findings: Global DALYs increased from 2·63 billion (95% UI 2·44–2·85) in 2010 to 2·88 billion (2·64–3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7–17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8–6·3) in 2020 and 7·2% (4·7–10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0–234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7–198·3]), neonatal disorders (186·3 million [162·3–214·9]), and stroke (160·4 million [148·0–171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3–51·7) and for diarrhoeal diseases decreased by 47·0% (39·9–52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54–1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5–9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0–19·8]), depressive disorders (16·4% [11·9–21·3]), and diabetes (14·0% [10·0–17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7–27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6–63·6) in 2010 to 62·2 years (59·4–64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6–2·9) between 2019 and 2021. Interpretation: Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades. Funding: Bill & Melinda Gates Foundation