Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015

SummaryBackground The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context. Methods We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors—the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI). Findings Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6–58·8) of global deaths and 41·2% (39·8–42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa. Interpretation Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden. Funding Bill & Melinda Gates Foundation

Factors influencing health self-management in adherence to care and treatment among the recipients of liver transplantation

Malihe Sadat Moayed,1 Abbas Ebadi,2 Masoud Khodaveisi,3 Mohssen Nassiri Toosi,4 Ali Reza Soltanian,5 Mahnaz Khatiban6 1Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran; 2Nursing Education, Behavioral Sciences Research Center, Life Style Institute, Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran; 3Chronic Diseases (Home Care) Research Center, Community Health Nursing Department, Hamadan University of Medical Sciences, Hamadan, Iran; 4Internal Medicine, Hepatologist, Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran; 5Modeling of Noncommunicable Diseases Research Center, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran; 6Mother and Child Care Research Center, Medical-Surgical Nursing Department, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran Introduction: Liver transplantation is the global treatment of end-stage liver diseases. Since the patients’ survival rate has been improved, the patient may experience reductions in physical, cognitive, and psychosocial functions after liver transplantation influencing their adherence to care and treatment. The transplant survival is complex and patients’ adherence to care and treatment should be considered when health care providers make decisions regarding treatment. This qualitative study aimed to explore factors influencing health self-management in adherence to care and treatment among the recipients of care and treatment.Methods: In this study, 23 interview sessions were carried out with a total 18 patients, 2 family members and 3 transplantation team members from May to November 2017. The patients were selected using the purposive method from both genders, with a various age range and initial diseases leading to liver transplantation, and time passed from liver transplantation. A semi-structured interview guide was developed based on literature review and pilot interviews. The participants were asked to describe their experiences of self-management behaviors in adherence to treatment and care. The data were analyzed using a conventional content analysis method and managing via the MAXQDA-10 software.Results: Two themes were developed during data analysis as “self-regulation” and “self-care”. “Self-regulation” consisted of “intentionally changing”, “positively thinking”, “information seeking”, “problem-solving”, “past knowledge transferring”, and “self-controlling”. “Self-care” had three sub-themes “shift to independence”, “vigilance”, and “self-care support”.Conclusion: The participants perceived the health self-management in adherence to care as a set of factors related to “self-regulation” and “self-care” behaviors. “Self-regulation” is required to create a balance in life. Also, “self-care” efforts can help with maintaining and improving patients’ health. Keywords: liver transplantation, qualitative research, self-management, self-care, self-regulation, adherence, recipient, compliance, treatmen

Trans-sternotomy, snare-assisted thoracic endovascular aortic repair for redirection of a migrated elephant trunk

The two-stage elephant trunk (ET) and thoracic endovascular aortic repair technique for type A and B aortic dissection can result in complications between the two stages. We have presented the case of a patient with an acute-on-chronic type B aortic dissection complicated by ET kinking and migration into the false lumen. We used a hybrid approach consisting of a first stage (retrograde thoracic endovascular aortic repair) and a second stage (“body floss” with antegrade thoracic endovascular aortic repair) to successfully reposition the ET back into the true lumen

Aortic remodeling following hybrid arch repair with zone 0 to 5 thoracic endovascular aortic repairs for complex arch and descending thoracic aortic pathologiesCentral MessagePerspective

Objective: For high-risk patients with aortic arch pathology, hybrid aortic arch repair with simultaneous or staged thoracic endovascular repair of the descending aorta may be a viable alternative to open repair. However, data on postintervention aortic remodeling remain limited. We report the short-term outcomes of remodeling of the thoracoabdominal aorta after hybrid arch repair + thoracic endovascular repair. Methods: All patients undergoing hybrid arch repair with planned zones 0 to 5 thoracic endovascular repair from January 2020 to March 2022 were retrospectively reviewed. Computed tomography angiography scans preoperatively, after hybrid aortic arch repair, and on long-term follow-up were analyzed for thoracoabdominal aorta remodeling. Mean change in aortic true luminal diameter and full luminal diameter was calculated at every level, and paired-samples t test was used to compare means. Results: Of 39 patients, 38 had follow-up data at a mean duration of 14.9 months. There were a total of 3 (7.7%) deaths, 0 (0.0%) strokes, and 0 (0.0%) paralysis. For the 35 patients undergoing thoracic endovascular repair for aortic dissection, at follow-up, there was a significant increase in the mean true luminal diameter at each level (P < .05), except at the aortic bifurcation and common iliac arteries. The largest increase in mean true luminal diameter (P < .01) was observed at the level of the left inferior pulmonary vein (mean difference +13.22 mm, 95% CI, 10.38-16.07), tracheal carina (mean difference +13.06 mm, 95% CI, 10.05-16.07), and inferior left atrium (mean difference +11.19 mm, 95% CI, 7.84-14.53). Conclusions: Hybrid arch repair with zones 0 to 5 leads to improved true lumen augmentation in zones 0 to 8 with complete false lumen thrombosis down to zone 5 at short-term follow-up. Zones 9 to 11, if involved, may require adjunctive treatment strategies for total aortic remodeling and complete false lumen obliteration

Superselective intranidal delivery of platinum-based high-density packing coils for treatment of arteriovenous malformations

Arteriovenous malformations (AVMs) classically feature an intervening nidus of poorly differentiated endothelium. The pillar of modern AVM treatment is intranidal delivery and deposition of various liquid embolic agents such as n-butyl cyanoacrylate, ethylene vinyl alcohol copolymer, and ethanol. These agents are cumbersome to prepare, deliver, and deploy and have been associated with complications related to limited delivery control, nonretrievability, frequent microcatheter exchanges, and nontarget embolization. Coils and other proximal occlusive agents have not been traditionally recommended as sole embolic agents for AVM treatment given the inherent lack of adequate AVM nidus penetration with previous coil technologies. In the present report, we have described a series of three patients with AVMs in whom newer generation, platinum-based, packing coils were used safely and effectively as the primary agent for superselective nidal penetration and embolization

Cutaneous leishmaniasis in Switzerland: first experience with species-specific treatment

BACKGROUND: Different species of the genus Leishmania can cause cutaneous (CL) and mucosal leishmaniasis (ML). PCR-based tests allow a rapid diagnosis and determination of the species, thereby enabling species-oriented treatment. Such treatment procedures have not been evaluated to date. METHODS: Patients presenting with CL and ML between 1999 and 2011 were analysed retrospectively. PCR technology was used to diagnose the disease and identify the protozoan to the species level. RESULTS: A total of 61 cases were reviewed, including 58 patients with CL and three patients with ML. Treatment was effective in most patients. Treatment failure was reported in six patients with L. panamensis (one fluconazole, one ketoconazole), L. infantum (one excision, one fluconazole), L. tropica (one paromomycin/methylbenzethonium), L. braziliensis (1 paromomycin/methylbenzethonium). In 11 (18 %) patients treatment had to be interrupted due to adverse events, and in eight patients (13 %) a second treatment had to be applied. Treatment with meglumine antimoniate had to be interrupted in six patients, with QTc prolongation the reason for the interruption in three patients. CONCLUSIONS: Species-related, targeted treatment resulted in good responses in CL and ML lesions. Treatment recommendations for L. panamensis were changed from ketoconazole to miltefosine because of new evidence of treatment failures. Meglumine antimoniate should be restricted to species with poor response to alternative medications and should be used with caution in patients older than 60 years because of its toxicity. Treatment in immunosuppressed patients was successful, but relapses were observed when the immune system could not be restored. This is the first report on L. aethiopica from Egypt