Effect of Magnesium Sulphate in Mothers suffering from Toxemia of Pregnancy and their Neonates

Background: Severe pre-eclampsia is one of the major causes of high maternal mortality rate in both developed and developing countries. The goals of management are to prevent progression to eclampsia thus preventing convulsions, to control the blood pressure and to prevent untoward effects in the foetus. The first-line option for the treatment and prevention of eclamptic seizures is magnesium sulphate. Objective: To determine the serum magnesium, urea and electrolyte levels in neonates of mothers treated with magnesium sulphate and compare the findings with the levels in non-exposed neonates. Methodology: A quasi experimental design was adopted where test subjects were neonates of mothers suffering from preeclampsia and severe eclampsia and were being treated with magnesium sulphate just before delivery at Pumwani Maternity hospital. The control group comprised neonates of hypertensive mothers without preeclampsia being treated using other drugs. Blood samples were obtained from the mother at onset of labor and from the neonates at birth and analyzed in the clinical chemistry laboratory of the University of Nairobi. Results:  A total of 54 mothers and their neonates were enrolled with 27 in each arm of the study. The mean maternal serum magnesium in the test group was significantly higher than in the control group (p = 0.008). The mean neonatal serum magnesium in the test group was also significantly higher compared to the control group (p = 0.008). There were statistically significant differences in serum sodium (p = 0.015), urea (p = 0.043) and creatinine (p = 0.008) levels between the maternal test and control groups. There were significant differences in serum urea (p = 0.007) and chloride (p = 0.017) between the neonatal test and control groups. The calcium and potassium levels were elevated in the test group but not to significant levels. There was a positive correlation between maternal and neonatal serum magnesium levels in both groups stronger in the test group (r = 0.56, p = 0.003) as compared to the control group (r = 0.35, p = 0.087). Conclusion: Maternally administered magnesium sulphate raises urea and creatinine levels to significant levels in mothers. Calcium levels are also raised while in mothers not receiving magnesium sulphate they were slightly lower. In neonates the urea and chloride levels are elevated to significant levels while the calcium and potassium levels are not significantly elevated. We suggest monitoring of both in the immediate post-partum period. Keywords: Preeclampsia, eclampsia, magnesium sulphate, neonate, serum urea and electrolytes

Is youth unemployment really the major worry? (AOM)

Youth unemployment is neither the only nor the basic problem of the European labour market. The comparative analysis of unemployment data demonstrates that the unemployment of older people is even more serious. The article proves that the weight of young people in total unemployment has as a tendency been declining in the “inner periphery” of the EU, among them in Central and Eastern European member states (CEECs). The trend is just the opposite in the developed or “core” countries of the Union where youngsters took a higher share in total unemployment in 2012 than 10-12 years ago. In Europe there are millions of young people beyond the active unemployed who do not want to work or think they cannot find a job that fulfils their expectations and refuse to take part in any kind of education or training (NEETs-“Not in Employment, Education or Training”). By estimating the rate of NEETs in the adult population the article claims that the NEETs-phenomenon is not the differentia specifica of the youth. At the end the article details two suggestions for the mitigation of the problem. It concludes that the joblessness in Europe is an old and tendencially worsening problem that cannot be solved by particular policies

Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data. Methods: We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting. Findings: Globally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1-4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0-8·4) while the total sum of global YLDs increased from 562 million (421-723) to 853 million (642-1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6-9·2) for males and 6·5% (5·4-7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782-3252] per 100 000 in males vs 1400 [1279-1524] per 100 000 in females), transport injuries (3322 [3082-3583] vs 2336 [2154-2535]), and self-harm and interpersonal violence (3265 [2943-3630] vs 5643 [5057-6302]). Interpretation: Global all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury

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

Background: Assessments of age-specific mortality and life expectancy have been done by the UN Population Division, Department of Economics and Social Affairs (UNPOP), the United States Census Bureau, WHO, and as part of previous iterations of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD). Previous iterations of the GBD used population estimates from UNPOP, which were not derived in a way that was internally consistent with the estimates of the numbers of deaths in the GBD. The present iteration of the GBD, GBD 2017, improves on previous assessments and provides timely estimates of the mortality experience of populations globally. Methods: The GBD uses all available data to produce estimates of mortality rates between 1950 and 2017 for 23 age groups, both sexes, and 918 locations, including 195 countries and territories and subnational locations for 16 countries. Data used include vital registration systems, sample registration systems, household surveys (complete birth histories, summary birth histories, sibling histories), censuses (summary birth histories, household deaths), and Demographic Surveillance Sites. In total, this analysis used 8259 data sources. Estimates of the probability of death between birth and the age of 5 years and between ages 15 and 60 years are generated and then input into a model life table system to produce complete life tables for all locations and years. Fatal discontinuities and mortality due to HIV/AIDS are analysed separately and then incorporated into the estimation. We analyse the relationship between age-specific mortality and development status using the Socio-demographic Index, a composite measure based on fertility under the age of 25 years, education, and income. There are four main methodological improvements in GBD 2017 compared with GBD 2016: 622 additional data sources have been incorporated; new estimates of population, generated by the GBD study, are used; statistical methods used in different components of the analysis have been further standardised and improved; and the analysis has been extended backwards in time by two decades to start in 1950. Findings: Globally, 18·7% (95% uncertainty interval 18·4–19·0) of deaths were registered in 1950 and that proportion has been steadily increasing since, with 58·8% (58·2–59·3) of all deaths being registered in 2015. At the global level, between 1950 and 2017, life expectancy increased from 48·1 years (46·5–49·6) to 70·5 years (70·1–70·8) for men and from 52·9 years (51·7–54·0) to 75·6 years (75·3–75·9) for women. Despite this overall progress, there remains substantial variation in life expectancy at birth in 2017, which ranges from 49·1 years (46·5–51·7) for men in the Central African Republic to 87·6 years (86·9–88·1) among women in Singapore. The greatest progress across age groups was for children younger than 5 years; under-5 mortality dropped from 216·0 deaths (196·3–238·1) per 1000 livebirths in 1950 to 38·9 deaths (35·6–42·83) per 1000 livebirths in 2017, with huge reductions across countries. Nevertheless, there were still 5·4 million (5·2–5·6) deaths among children younger than 5 years in the world in 2017. Progress has been less pronounced and more variable for adults, especially for adult males, who had stagnant or increasing mortality rates in several countries. The gap between male and female life expectancy between 1950 and 2017, while relatively stable at the global level, shows distinctive patterns across super-regions and has consistently been the largest in central Europe, eastern Europe, and central Asia, and smallest in south Asia. Performance was also variable across countries and time in observed mortality rates compared with those expected on the basis of development. Interpretation: This analysis of age-sex-specific mortality shows that there are remarkably complex patterns in population mortality across countries. The findings of this study highlight global successes, such as the large decline in under-5 mortality, which reflects significant local, national, and global commitment and investment over several decades. However, they also bring attention to mortality patterns that are a cause for concern, particularly among adult men and, to a lesser extent, women, whose mortality rates have stagnated in many countries over the time period of this study, and in some cases are increasing

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Antimicrobial Susceptibility of Bacteria that cause Wound Sepsis in the Paediatric Surgical Patients at Kenyatta National Hospital

Background: Despite improvement in the practice of medicine and attempts to provide aseptic conditions in the surgical wards, the incidence of wound infection is increasing.  Management of wound infection remains a challenge in the surgical areas with the increasing resistance to antimicrobials. Local bacterial sensitivity data is therefore an important guide for antibiotic selection. Objective: To determine the aetiology and antimicrobial sensitivity patterns of bacteria that cause wound sepsis in the paediatric surgical wards at the Kenyatta National Hospital. Methodology: A cross- sectional study was carried out on 150 paediatric patients admitted in the surgical wards from mid April 2014 to mid June, 2014.  The patients were selected by convenient sampling.   Data was abstracted from patient files and specimens from the infected wounds were identified and analyzed for antibiotic susceptibility. Results: The prevalence of wound infection was 82%.   Staphylococcus aureus (52.7%) was the most prevalent infective agent followed by Pseudomonas aeruginosa (17.3%). Staphylococcus aureus was the most resistant organism with susceptibility of less than 50% to most drugs.  About 50.6% of the Staphylococcus isolates were methicillin resistant.  Streptococcus was less resistant with more than 80% susceptibility to all tested drugs except cefuroxime. Escherichia coli were sensitive to ciprofloxacin.  All gram negative bacteria were highly sensitive to ciprofloxacin with the following susceptibilities: Pseudomonas aeruginosa (92.3%), Proteus mirabilis (71.4%) and others 100%.  Imipenem which is a new and relatively expensive monobactam demonstrated reduced activity with the following susceptibilities: Staphylococcus aureus (38%), Streptococcus (80%) and all the gram negative bacteria (70%). Conclusion: The most common causative agent was Staphylococcus aureus and less than 50% of the isolates were susceptible to all tested antibiotics. Key words: Antibiotic, antibiotic resistance, antibiotic susceptibility, wound infection

Determinants of Adherence to Anticonvulsants Therapy among Outpatient Epileptic Children in a Kenyan Referral Hospital

Background: Epilepsy is a chronic disease requiring prolonged adherence to treatment. Adherence to anticonvulsants by epileptic children is important as studies have shown that about two-thirds of epileptic children can be completely freed from seizure if they persistently adhere to treatment for a period of 2-5 years.  Conversely, non-adherence to anticonvulsants may lead to increased frequencies of status epilepticus and sudden unexplained death from epilepsy. There is scant literature on factors impacting on the adherence to anticonvulsants among children. Objectives: To determine rate of adherence and parents/caregivers’ factors influencing adherence to anticonvulsants among outpatient epileptic children attending neurology clinic. Methods: Cross-sectional study design was carried out at Kenyatta National Hospital from May to July 2014. Systematic sampling was used to recruit a sample of 176 parents/guardians of children with epilepsy. Predesigned questionnaires and Morisky tool for assessing medication adherence were used to capture participant’s socio-demographics and factors impacting on adherence to antiepileptics.  Data were analysed using STATA software version 10.  Discrete variables were summarized with frequencies and percentages while continuous variables were summarized using measures of central tendency and dispersion. Results: The rates of adherence, when classified in terms of high, medium and low, were 36.9 %, 39.8 % and 23.3 %, respectively.  Adherence rate was associated with parents/guardian marital status (Adjusted OR= 5.72, 95% CI= (1.50, 21.78), p=0.01) and education level (Adjusted OR=5.16, 95% CI= (1.88, 14.02), p< 0.01). Unavailability and inaccessibility of drugs were also shown to influence adherence. Conclusion: Adherence to antiepileptic medication was poor.  This was partly due to parents/guardian’s related factors.  Health care workers should explore ways and means of minimising these factors to improve on adherence. Key words: Adherence, anticonvulsants, epilepsy, children

Effect of Pesticide Exposure on Serum Cholinesterase Levels among Asthmatic Children in Naivasha Sub-County, Kenya

Background: Pesticide exposure is a risk factor for asthma exacerbations in flower farm regions in the world.  Data on levels of serum cholinesterase among asthmatic children exposed to pesticides in Kenya is scanty. Objectives: To compare and identify variables which affect the concentration of serum cholinesterases in children who are exposed and unexposed to pesticides. Methodology: The design was a comparative cross-sectional study that involved exposed and unexposed children.  The study was conducted between May and July, 2014 in Naivasha, Kenya.  Patients were interviewed and serum samples were analysed for cholinesterase levels.  Multi-linear regression was done to identify variables that affected cholinesterase activity. Results: Children who were exposed to pesticides had a lower median ChE activity of 5828 [IQR 4863, 6443] compared to the unexposed arm whose median was 7133 [IQR 6063, 8179].  Five predictor variables were found to be significantly associated with depression of serum cholinesterase levels.  The most important predictor variable for the levels of ChE in children, was not using protective clothing by the parent [adjusted β -1457.0 (95% CI - 2594, 1319.8)].  Others were not using household pesticides [adjusted β 96.3, (95% CI 22.6, 170.0)], female sex [adjusted β -695.7 (95% CI -1296.2, - 95.3)], non school attendance [adjusted β -1676.8 (95% CI -3371.6, 18.1)] and not taking a break after spraying [adjusted β 1105.5 (95% CI (315.0, 1895.2)]. Conclusion: Children who were exposed to pesticides had low cholinesterase levels. Parents should therefore be encouraged to wear protective gear as this conferred protection of children from the effects of pesticide exposure. Key words: asthma, exposure, children, pesticides, cholinesterase