Association of iron status indicators with thyroid hormone concentrations during pregnancy: a systematic review and meta-analysis

BackgroundMaternal thyroid hormones play a vital role in fetal development, and imbalances can lead to adverse outcomes. Iron deficiency may impair thyroid function due to iron’s essential role in iodine oxidation during thyroid hormone synthesis. This review examines the relationship between various indicators of maternal iron status and thyroid function during pregnancy.MethodsWe conducted a systematic search in MEDLINE/PubMed, Web of Science, Embase, Scopus, and the Cochrane Library for studies published up to 2023. Meta-analyses determined pooled thyroid hormone levels in patients with and without iron deficiency, using serum ferritin (cut-off = 30 µg/L) and hemoglobin (cut-off = 11 g/dL). Meta-regression analyses examined linear relationships between iron status indicators and thyroid hormones.ResultsForty-seven studies involving 53,152 pregnant women were included. Meta-analysis showed no significant difference in thyroid-stimulating hormone, free T4, or total T4 when considering serum ferritin levels in iron-deficient versus iron-sufficient individuals. However, regarding hemoglobin levels, iron deficiency was associated with higher thyroid-stimulating hormone (2.31 mIU/L vs. 1.75 mIU/L) and lower free T4 (10.7 pmol/L vs. 13.3 pmol/L), but not total T4. Meta-regression revealed no significant associations between serum ferritin and thyroid hormones. Conversely, maternal hemoglobin levels were inversely associated with thyroid-stimulating hormone (P-value = 0.009) and directly associated with free T4 (P-value < 0.001), with no significant link to total T4.ConclusionsMaternal hemoglobin levels are more strongly correlated with thyroid function than serum ferritin levels. This suggests that monitoring hemoglobin could enhance the early detection and management of thyroid dysfunction during pregnancy.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO, identifier CRD4202451820

Clinical Functional Seizure Score (CFSS): a simple algorithm for clinicians to suspect functional seizures

PurposeDistinguishing functional seizures (FS) from epileptic seizures (ES) poses a challenge due to similar clinical manifestations. The creation of a clinical scoring system that assists in accurately diagnosing patients with FS would be a valuable contribution to medical practice. This score has the potential to enhance clinical decision-making and facilitate prompt diagnosis of patients with FS.MethodsParticipants who met the inclusion criteria were randomly divided into three distinct groups: training, validation, and test cohorts. Demographic and semiological variables were analyzed in the training cohort by univariate analyses. Variables that showed a significant difference between FS and ES were then further scrutinized in two multivariate logistic regression models. The CFSS was developed based on the odds ratio of the discriminating variables. Using the validation group, the optimal cutoff value was determined based on the AUC, and then the CFSS was evaluated in the test cohort to assess its performance.ResultsThe developed score yielded an AUC of 0.78 in the validation cohort, and a cutoff point of 6 was established with a focus on maximizing sensitivity without significantly compromising specificity. The score was then applied in the test cohort, where it achieved a sensitivity of 86.96% and a specificity of 73.81%.ConclusionWe have developed a new tool that shows promising results in identifying patients suspicious of FS. With further analysis through prospective studies, this innovative, simple tool can be integrated into the diagnostic process of FS

Burden of disease scenarios by state in the USA, 2022–50 : a forecasting analysis for the Global Burden of Disease Study 2021

DATA SHARING : To download the data used in these analyses, please visit the Global Health Data Exchange (https://ghdx.healthdata.org/gbd-2021/sources).AFFILIATIONS : See appendix 2 for collaborator affiliations.BACKGROUND : The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides a comprehensive assessment of health and risk factor trends at global, regional, national, and subnational levels. This study aims to examine the burden of diseases, injuries, and risk factors in the USA and highlight the disparities in health outcomes across different states. METHODS : GBD 2021 analysed trends in mortality, morbidity, and disability for 371 diseases and injuries and 88 risk factors in the USA between 1990 and 2021. We used several metrics to report sources of health and health loss related to specific diseases, injuries, and risk factors. GBD 2021 methods accounted for differences in data sources and biases. The analysis of levels and trends for causes and risk factors within the same computational framework enabled comparisons across states, years, age groups, and sex. GBD 2021 estimated years lived with disability (YLDs) and disability-adjusted life-years (DALYs; the sum of years of life lost to premature mortality and YLDs) for 371 diseases and injuries, years of life lost (YLLs) and mortality for 288 causes of death, and life expectancy and healthy life expectancy (HALE). We provided estimates for 88 risk factors in relation to 155 health outcomes for 631 risk–outcome pairs and produced risk-specific estimates of summary exposure value, relative health risk, population attributable fraction, and risk-attributable burden measured in DALYs and deaths. Estimates were produced by sex (male and female), age (25 age groups from birth to ≥95 years), and year (annually between 1990 and 2021). 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws (ie, 500 random samples from the estimate's distribution). Uncertainty was propagated at each step of the estimation process. FINDINGS : We found disparities in health outcomes and risk factors across US states. Our analysis of GBD 2021 highlighted the relative decline in life expectancy and HALE compared with other countries, as well as the impact of COVID-19 during the first 2 years of the pandemic. We found a decline in the USA's ranking of life expectancy from 1990 to 2021: in 1990, the USA ranked 35th of 204 countries and territories for males and 19th for females, but dropped to 46th for males and 47th for females in 2021. When comparing life expectancy in the best-performing and worst-performing US states against all 203 other countries and territories (excluding the USA as a whole), Hawaii (the best-ranked state in 1990 and 2021) dropped from sixth-highest life expectancy in the world for males and fourth for females in 1990 to 28th for males and 22nd for females in 2021. The worst-ranked state in 2021 ranked 107th for males (Mississippi) and 99th for females (West Virginia). 14 US states lost life expectancy over the study period, with West Virginia experiencing the greatest loss (2·7 years between 1990 and 2021). HALE ranking declines were even greater; in 1990, the USA was ranked 42nd for males and 32nd for females but dropped to 69th for males and 76th for females in 2021. When comparing HALE in the best-performing and worst-performing US states against all 203 other countries and territories, Hawaii ranked 14th highest HALE for males and fifth for females in 1990, dropping to 39th for males and 34th for females in 2021. In 2021, West Virginia—the lowest-ranked state that year—ranked 141st for males and 137th for females. Nationally, age-standardised mortality rates declined between 1990 and 2021 for many leading causes of death, most notably for ischaemic heart disease (56·1% [95% UI 55·1–57·2] decline), lung cancer (41·9% [39·7–44·6]), and breast cancer (40·9% [38·7–43·7]). Over the same period, age-standardised mortality rates increased for other causes, particularly drug use disorders (878·0% [770·1–1015·5]), chronic kidney disease (158·3% [149·6–167·9]), and falls (89·7% [79·8–95·8]). We found substantial variation in mortality rates between states, with Hawaii having the lowest age-standardised mortality rate (433·2 per 100 000 [380·6–493·4]) in 2021 and Mississippi having the highest (867·5 per 100 000 [772·6–975·7]). Hawaii had the lowest age-standardised mortality rates throughout the study period, whereas Washington, DC, experienced the most improvement (a 40·7% decline [33·2–47·3]). Only six countries had age-standardised rates of YLDs higher than the USA in 2021: Afghanistan, Lesotho, Liberia, Mozambique, South Africa, and the Central African Republic, largely because the impact of musculoskeletal disorders, mental disorders, and substance use disorders on age-standardised disability rates in the USA is so large. At the state level, eight US states had higher age-standardised YLD rates than any country in the world: West Virginia, Kentucky, Oklahoma, Pennsylvania, New Mexico, Ohio, Tennessee, and Arizona. Low back pain was the leading cause of YLDs in the USA in 1990 and 2021, although the age-standardised rate declined by 7·9% (1·8–13·0) from 1990. Depressive disorders (56·0% increase [48·2–64·3]) and drug use disorders (287·6% [247·9–329·8]) were the second-leading and third-leading causes of age-standardised YLDs in 2021. For females, mental health disorders had the highest age-standardised YLD rate, with an increase of 59·8% (50·6–68·5) between 1990 and 2021. Hawaii had the lowest age-standardised rates of YLDs for all sexes combined (12 085·3 per 100 000 [9090·8–15 557·1]), whereas West Virginia had the highest (14 832·9 per 100 000 [11 226·9–18 882·5]). At the national level, the leading GBD Level 2 risk factors for death for all sexes combined in 2021 were high systolic blood pressure, high fasting plasma glucose, and tobacco use. From 1990 to 2021, the age-standardised mortality rates attributable to high systolic blood pressure decreased by 47·8% (43·4–52·5) and for tobacco use by 5·1% (48·3%–54·1%), but rates increased for high fasting plasma glucose by 9·3% (0·4–18·7). The burden attributable to risk factors varied by age and sex. For example, for ages 15–49 years, the leading risk factors for death were drug use, high alcohol use, and dietary risks. By comparison, for ages 50–69 years, tobacco was the leading risk factor for death, followed by dietary risks and high BMI. INTERPRETATION : GBD 2021 provides valuable information for policy makers, health-care professionals, and researchers in the USA at the national and state levels to prioritise interventions, allocate resources effectively, and assess the effects of health policies and programmes. By addressing socioeconomic determinants, risk behaviours, environmental influences, and health disparities among minority populations, the USA can work towards improving health outcomes so that people can live longer and healthier lives.Bill & Melinda Gates Foundation.https://www.thelancet.com/journals/lancet/homehj2024School of Health Systems and Public Health (SHSPH)SDG-03:Good heatlh and well-bein

Global, regional, and national burden of upper respiratory infections and otitis media, 1990–2021: a systematic analysis from the Global Burden of Disease Study 2021

Background: Upper respiratory infections (URIs) are the leading cause of acute disease incidence worldwide and contribute to a substantial health-care burden. Although acute otitis media is a common complication of URIs, the combined global burden of URIs and otitis media has not been studied comprehensively. We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 to explore the fatal and non-fatal burden of the two diseases across all age groups, including a granular analysis of children younger than 5 years, in 204 countries and territories from 1990 to 2021. Methods: Mortality due to URIs and otitis media was estimated with use of vital registration and sample-based vital registration data, which are used as inputs to the Cause of Death Ensemble model to separately model URIs and otitis media mortality by age and sex. Morbidity was modelled with a Bayesian meta-regression tool using data from published studies identified via systematic reviews, population-based survey data, and cause-specific URI and otitis media mortality estimates. Additionally, we assessed and compared the burden of otitis media as it relates to URIs and examined the collective burden and contributing risk factors of both diseases. Findings: The global number of new episodes of URIs was 12·8 billion (95% uncertainty interval 11·4 to 14·5) for all ages across males and females in 2021. The global all-age incidence rate of URIs decreased by 10·1% (–12·0 to –8·1) from 1990 to 2019. From 2019 to 2021, the global all-age incidence rate fell by 0·5% (–0·8 to –0·1). Globally, the incidence rate of URIs was 162 484·8 per 100 000 population (144 834·0 to 183 289·4) in 2021, a decrease of 10·5% (–12·4 to –8·4) from 1990, when the incidence rate was 181 552·5 per 100 000 population (160 827·4 to 206 214·7). The highest incidence rates of URIs were seen in children younger than 2 years in 2021, and the largest number of episodes was in children aged 5–9 years. The number of new episodes of otitis media globally for all ages was 391 million (292 to 525) in 2021. The global incidence rate of otitis media was 4958·9 per 100 000 (3705·4 to 6658·6) in 2021, a decrease of 16·3% (–18·1 to –14·0) from 1990, when the incidence rate was 5925·5 per 100 000 (4371·8 to 8097·9). The incidence rate of otitis media in 2021 was highest in children younger than 2 years, and the largest number of episodes was in children aged 2–4 years. The mortality rate of URIs in 2021 was 0·2 per 100 000 (0·1 to 0·5), a decrease of 64·2% (–84·6 to –43·4) from 1990, when the mortality rate was 0·7 per 100 000 (0·2 to 1·1). In both 1990 and 2021, the mortality rate of otitis media was less than 0·1 per 100 000. Together, the combined burden accounted for by URIs and otitis media in 2021 was 6·86 million (4·24 to 10·4) years lived with disability and 8·16 million (4·99 to 12·0) disability-adjusted life-years (DALYs) for all ages across males and females. Globally, the all-age DALY rate of URIs and otitis media combined in 2021 was 103 per 100 000 (63 to 152). Infants aged 1–5 months had the highest combined DALY rate in 2021 (647 per 100 000 [189 to 1412]), followed by early neonates (aged 0–6 days; 582 per 100 000 [176 to 1297]) and late neonates (aged 7–24 days; 482 per 100 000 [161 to 1052]). Interpretation: The findings of this study highlight the widespread burden posed by URIs and otitis media across all age groups and both sexes. There is a continued need for surveillance, prevention, and management to better understand and reduce the burden associated with URIs and otitis media, and research is needed to assess their impacts on individuals, communities, economies, and health-care systems worldwide. Funding: Bill & Melinda Gates Foundation

A Rare Case of Inguinal Hernia of a Ureter Belonging to a Duplex Kidney

Introduction. Inguinal herniation of the ureter is a rare entity that occurs either as a complication of renal transplantation or spontaneously. Patients may suffer from obstructive uropathy or groin pain due to the unusual ectopic course of the ureter. This case report highlights the importance of recognizing a ureteroinguinal hernia. Methods. In this case report, we present a 75-year-old man with a surgical history of a right inguinal hernia repair who was referred to our center with burning left inguinal pain that persisted for two weeks. The patient’s history and physical examination were consistent with an inguinal hernia. The suspected indirect inguinal hernia was found on preoperative imaging to be a tubular structure distinct from the intestine or adjacent organs. An open exploration of the inguinal canal was performed to prevent further hernia development. Results. The unusual structure in the inguinal canal turned out to be an ectopic ureter originating from the left upper pole moiety of the left duplex kidney (i.e., with duplicated ureters) and containing concentrated urine, as confirmed on a postoperative computerized tomography urogram. Conclusion. It is crucial to perform a thorough clinical examination and utilize adequate imaging modalities before surgical procedures when encountering unidentified structures

The association of serum total bile acid levels with gestational diabetes mellitus: a systematic review and meta-analysis

Abstract Background Given the high prevalence of gestational diabetes mellitus and its significant impact on maternal and neonatal health, identifying reliable biomarkers for prediction and diagnosis is essential. The increased incidence of gestational diabetes mellitus among patients with intrahepatic cholestasis of pregnancy suggests a possible association between serum total bile acid levels and gestational diabetes mellitus. This study evaluated the relationship between total bile acid levels and gestational diabetes mellitus incidence. Methods A systematic search was performed on February 19, 2024, for studies examining the association between total bile acid levels and gestational diabetes mellitus incidence in both the general pregnant population and patients diagnosed with intrahepatic cholestasis of pregnancy. Meta-analyses were conducted to compare pooled total bile acid levels between patients with and without gestational diabetes mellitus, as well as to assess gestational diabetes mellitus prevalence in patients with mild (10 ≤ total bile acid < 40 µmol/L) vs. moderate-to-severe intrahepatic cholestasis of pregnancy (total bile acid ≥ 40 µmol/L). Results 15 observational studies involving 7,238 pregnant women were systematically reviewed. Our meta-analysis found significantly higher serum total bile acid levels in women diagnosed with gestational diabetes mellitus compared to controls in the general population (Hedge’s g = 0.29 [0.03,0.54]). However, subgroup analysis indicated that total bile acid levels were only significantly higher in patients measured earlier in pregnancy, before the gestational diabetes mellitus diagnosis, compared to healthy controls (Hedge’s g = 0.48 [0.33,0.64]), while no significant difference in total bile acid levels was observed when measurements were taken after the gestational diabetes mellitus diagnosis (Hedge’s g = 0.00 [-0.26,0.27]). Additionally, we found that the prevalence of gestational diabetes mellitus was significantly lower in patients with mild intrahepatic cholestasis of pregnancy compared to those with moderate-to-severe intrahepatic cholestasis of pregnancy (Log odds ratio=-0.56 [-0.95,-0.17]). Conclusions This study highlights a complex relationship between serum total bile acid levels and gestational diabetes mellitus incidence, influenced by the timing of measurement. Elevated total bile acid levels early in pregnancy may predict gestational diabetes mellitus, but its diagnostic value may decline later in pregnancy. Trial registration The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on 3/3/2024 under CRD42024516164

Induced abortion in Iran, Tehran University of Medical Sciences, the law and the diverging attitude of medical and health science students.

BackgroundThe topic of induced abortion has been a subject of extensive debate among various moral and religious frameworks and continues to pose significant challenges within the domains of medical ethics and policy formulation. In the context of Iran, an Islamic republic, the approach to induced abortion has been notably influenced by historical, social, and political dynamics. Following the implementation of the 'Rejuvenation of the Population and Protection of the Family Law (RPPF)' in 2021, access to induced abortion and contraceptive measures has been markedly restricted as a response to concerns surrounding population decline.ObjectiveThis study aims to assess the attitudes of Iranian medical and health science students toward induced abortion as future executives of health programs.MethodsThis cross-sectional study administered a structured questionnaire for self-completion to medical and health science students of Tehran University of Medical Sciences, including medical students, obstetrics and gynecology residents, and nursing and midwifery students. The scoring of responses was between ‒12 and + 12, with the score ranging from 0 to positive, 12 showing an attitude negative to induced abortion, and the score below zero to ‒12 reflecting a positive attitude toward induced abortion.ResultsA total of 237 participants were involved in the study, with 52% being female, and 60% originally from cities other than Tehran. The median (min, max) of the total score of the attitude toward induced abortion was ‒5.0 (12,10). The mean score varied by the age of the respondents, with ‒4.0 (‒12, 10) for those aged above 30 years compared to ‒5.0 (‒12,10) for those aged below 30 years (P-value = 0.043). The score was 0.0 (‒12,10) for married compared to ‒6.0 (‒12,10) among single participants (P-value ConclusionIranian medical and health science students support induced abortion before 16 weeks of gestation. The attitudes of medical students who are future providers of health care and implementers of RPPF and other health laws are, therefore, at variance with current laws and policies

Table_1_Clinical Functional Seizure Score (CFSS): a simple algorithm for clinicians to suspect functional seizures.DOCX

PurposeDistinguishing functional seizures (FS) from epileptic seizures (ES) poses a challenge due to similar clinical manifestations. The creation of a clinical scoring system that assists in accurately diagnosing patients with FS would be a valuable contribution to medical practice. This score has the potential to enhance clinical decision-making and facilitate prompt diagnosis of patients with FS.MethodsParticipants who met the inclusion criteria were randomly divided into three distinct groups: training, validation, and test cohorts. Demographic and semiological variables were analyzed in the training cohort by univariate analyses. Variables that showed a significant difference between FS and ES were then further scrutinized in two multivariate logistic regression models. The CFSS was developed based on the odds ratio of the discriminating variables. Using the validation group, the optimal cutoff value was determined based on the AUC, and then the CFSS was evaluated in the test cohort to assess its performance.ResultsThe developed score yielded an AUC of 0.78 in the validation cohort, and a cutoff point of 6 was established with a focus on maximizing sensitivity without significantly compromising specificity. The score was then applied in the test cohort, where it achieved a sensitivity of 86.96% and a specificity of 73.81%.ConclusionWe have developed a new tool that shows promising results in identifying patients suspicious of FS. With further analysis through prospective studies, this innovative, simple tool can be integrated into the diagnostic process of FS.</p

Vaginal CO2 Fractional Laser in Women With Vaginal Atrophy: Medical Insights on Short- and Long-term Effects on Genitourinary Symptoms: Short and Long-term effect of vaginal CO2 laser on genitourinary symptoms

Introduction: Genitourinary syndrome of menopause (GSM) is a common complication secondary to estrogen depletion which leads to tissue changes in the female genitourinary tract. Here, we sought to investigate the short- and long-term effects of CO2 laser therapy on symptoms of GSM in postmenopausal women.Methods: In this clinical trial, 47 postmenopausal women with symptoms of GSM were included. Participants underwent vaginal and extra-vaginal CO2 fractional laser treatment in three sessions, with intervals of one month between each session. Symptom severity, including itching, dyspareunia, vaginal discharge, and dryness, was assessed at each session using a modified Vaginal Health Index (VHI), where the intensity was rated on a Visual Analog Scale (VAS) from 1 to 10 (1 indicating minimal symptoms and 10 representing maximum severity). Additionally, the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) was administered. Patients were followed for one to three years after the final laser treatment session.Results: The scores of all subscales, including itching, dyspareunia, urinary incontinence, vaginal discharge, and dryness, improved significantly following three sessions of CO2 fractional laser (p values&lt;0.001). However, except for the urinary incontinence domain (P=0.058), none of the symptoms maintained improved after one to three years from the last intervention.Conclusion: CO2 fractional laser treatment is appropriate for treating symptoms related to GSM. But it seems that it needs to be used continuously for the maintenance effect on itching, dyspareunia, urinary incontinence, vaginal discharge, and dryness. The exact timing of laser sessions should be identified in further studies since the beneficial outcomes of the intervention seem temporary

Reproductive outcomes following hysteroscopic uterine septum resection in infertile women: a retrospective cohort study

Abstract Objective A septate uterus is a common congenital anomaly often identified during infertility evaluations and is associated with adverse reproductive outcomes. Hysteroscopic septum resection is widely recognized as a standard, safe, and effective treatment. This study aimed to evaluate reproductive and pregnancy outcomes in infertile women who underwent hysteroscopic septum resection. Method This retrospective cohort study included infertile women aged 18 to 45 years who were diagnosed with a uterine septum and were candidates for assisted reproductive technology (ART) between 2011 and 2021. Participants had either primary or secondary infertility and underwent hysteroscopic septoplasty. Data were collected from medical records and telephone interviews, which included demographic information and postoperative outcomes, such as chemical and clinical pregnancy rates, live birth rates, and adverse pregnancy outcomes. Statistical analyses employed descriptive methods, including frequencies and means. Results Among 735 women, 84.6% had primary infertility, and 51.5% had infertility for 1–5 years. The chemical pregnancy rate was 44.6%, clinical pregnancy 42.8%, and live birth 36.7%. No significant differences were found between primary and secondary infertility groups in pregnancy or live birth rates. Adverse outcomes included preterm labor (6.7%) and preeclampsia (4.8%). Vaginal delivery was the most common mode (81.8%). Conclusion Hysteroscopic septum resection appears to improve pregnancy outcomes and live birth rates in individuals undergoing ART. Nevertheless, prospective studies with control groups are needed to confirm these findings and establish stronger evidence