A case of tracheal tumor with unusual bronchoscopic presentation: A case report

Primary tumor of the trachea and bronchial tree is rare. Primary tracheobronchial malignancies make up about 0.1% of all pulmonary tumors. The survival rate depends on several factors which include the malignant potential of the tumor, the patient’s comorbidities, and the location of the tumor. The index case is a 60-year-old woman who had 7 months history of globus with an associated history of central chest discomfort and cough of 3 months duration. There was a positive history of dysphagia to solid meals, odynophagia, dyspepsia, nausea, excessive belching, bloating, and regurgitation. These symptoms led to the diagnosis of gastroesophageal reflux disease. However, the persistent symptom of globus and worsening cough necessitated her referral to the chest clinic. Chest radiograph revealed opacity in the left upper lobe. Chest computerized tomographic scan showed a solitary, lobulated, and calcified soft-tissue mass in the apicoposterior segment of the left upper lobe with loss of volume. Bronchoscopy showed multiple planes of non-glistering submucosa lesions which were biopsied. The histology report revealed invasive adenocarcinoma of the airway. The surgical resection of tumors with stents was done and she was discharged home 2 weeks later. However, the patient refused adjunct chemotherapy. She is alive and well with complete resolution of symptoms. Early presentation, availability of investigative tools, and prompt treatment may improve survival in cases of trachea tumors as seen in the index case. A high index of suspicion is also needed to make a prompt diagnosis of trachea tumors, especially in patients presenting with globus

Latent Tuberculosis Infection and Isoniazid Preventive Therapy among Human Immunodeficiency Virus positive adults in Southern Nigeria

Aim/objectives: It was aimed to assess the prevalence of latent TB among HIV+ patients, evaluate the coverage of isoniazid preventive therapy (IPT), the  continuous risk of latent tuberculosis infection, and factors associated with the presence of latent Tb in HIV+ patients. Methods: This is an analytical cross-sectional study of HIV+ patients attending the HIV clinic or admitted not previously treated for TB and did not have  clinical and laboratory evidence of active TB and matched HIV-negative population attending our GOC. Data collected with a pre-tested investigator  administered questionnaire included the age, sex, height and weight, medical and drug history, and relevant physical examination findings such as body  temperature and respiratory rate. Active TB was excluded by history, sputum AFB Z-N staining, or GeneXpert test and chest radiography. Whole blood  samples were collected from participants for QuantiFERON TB Gold Plus for quantification of Interferon Gamma Release assay (IGRA) in order to  diagnose or exclude latent TB. Data were analyzed using IBM SPSS version 25.0 software at a level of significance of p < 0.05. Association between means  and qualitative variables was analyzed with student-t-test and Chi-square test Results: The mean ages of the HIV+ and control groups were 42.69 ± 9.91 and 41.29 ± 9.20 years respectively with no significant statistical difference.  76(95.0%) of HIV+ patients and 74(92.5%) controls had no symptoms of TB and chronic lung disease. 18(22.5%) HIV+ patients and 2(2.5%) controls were  exposed to persons with chronic cough (p=<0.001). The prevalence of latent TB among HIV+ patients was 22.50% and 10.0% among controls (p-  value=0.001). 8(44.4%) out of 18 with latent TB had prior use of IPT compared with 24 (38.7%) out of 62 without latent TB (p-value =0.67). CD4 count was a  significant factor associated with the presence of latent TB among HIV+ persons (p-0.03). Similarly, there was a significant association between viral load  and positive IGRA (p<0.001). Conclusion: Latent TB infection remains significantly higher among HIV+ than HIV-negative patients which may account for the higher incidence of active  disease amongst them. Isoniazid preventive therapy coverage was poor amongst HIV+ patients in this study.&nbsp

Is Pulmonary Thromboembolism uncommon in Nigeria? A case series in a private tertiary hospital in Ogun State, Nigeria

Background: Pulmonary thromboembolism is total or partial obstruction of one or more divisions of pulmonary arterial vasculature. It is a common disease presentation that is well studied and documented in the United States of America and Western Europe. It is often the result of part of a thrombotic lesion in deep veins (Deep Vein Thrombosis) elsewhere in the body most commonly the lower limbs and the pelvic region. There are few documented cases in Nigeria and sub-Saharan Africa as a result of poorly equipped hospitals and poorly trained health care personnel. Case presentation: Twenty-Nine (29) cases were seen in a Private Tertiary institution in Ogun State, Nigeria. Computerized Tomography with Pulmonary Angiography had helped to confirm these cases, with prompt intervention thereby reducing morbidity and mortality significantly. Only 3(three) mortality was recorded out of 29 cases seen between July 2016 and June 2020. Discussion and conclusion: Pulmonary thromboembolism is not uncommon in Nigerians and black Africans as available data previously suggested. All hands must be on deck to identify potential cases and investigate at-risk individuals who have clinical symptoms that are often misdiagnosed as other disease entities

Nigerian undergraduate students’ perception towards COVID-19 prevention: Implications for policy

Objective: Universities provide a supportive and safe learning environment for students. To limit the transmission of COVID-19, the WHO has recommended several preventive measures including frequent washing of hands, hand sanitizer usage, the wearing of masks, social distancing, covering of mouth while sneezing, etc. Students need to comply with these personal hygiene practices to limit the transmission of COVID-19. Methodology: A descriptive cross-sectional study design was used to assess the knowledge and practice of COVID-19 prevention among undergraduate students of Babcock University, Ilishan-Remo Ogun State, Nigeria. 430 respondents were selected using a multistage sampling technique. Data were analyzed using SPSS for Windows Version 21. A p-value of < 0.05 was regarded as statistically significant. Results: 98.8%, 96.4%, and 84.1% of the respondents knew about COVID-19, know that it is a contagious disease, and know that a virus causes COVID-19 respectively. 60.4% and 56.7% heard about COVID-19 from the news and social media and had good knowledge of COVID-19 respectively. 38.2%, 36.7%, and 63.3% of the respondents have an average level of practice of COVID-19 prevention, had been vaccinated majorly with AstraZeneca brand of vaccine (20.6%), and are yet to be vaccinated respectively. There is no association between the knowledge of the prevention of COVID-19 and practice among undergraduate students of Babcock University (0.258, χ2=5.300). Conclusion: The majority of the students had good and average knowledge of COVID-19 and its prevention respectively. There was no significant association between knowledge and practice of COVID-19 prevention

HIV Patients’ Satisfaction with Services Provided at Tertiary Health Institutions in Ogun East Senatorial District, Ogun State, Nigeria: Public-private Comparison

Background: Patient satisfaction is defined as the extent to which patients feel that their needs and expectations are being met by the services provided. A good number of HIV patients often drop out of treatment programs because they are not satisfied with some aspects of the services provided. This study assessed and compared HIV patients’ satisfaction with health services provided at public and privately owned tertiary health institutions in Ogun State, Nigeria.Methods: This is a facility-based 2-center (a government-funded and a privately funded), cross-sectional comparative study carried out among HIV-positive patients who received care at these two tertiary hospitals. HIV patients’ satisfaction was assessed using PSQ III. Two hundred patients were recruited from each institution. A comparison of mean satisfaction scores was done using the student’s t-test. Logistic regression analysis was used to predict the factors associated with patients’ satisfaction.Results: The mean ages of study participants were 42.25±10.81 and 44.04±9.97 for public and private health facilities, respectively (t=-1.717 P=0.087). The mean satisfaction scores of the private health facility (3.48+0.42) were higher compared to those of the public health facility (3.29±0.54) (t=-3.912, P=0.000). Also, more patients in the private health facility were satisfied with the care received compared to the public health facility in six domains out of the seven domains studied.Conclusion: Patients’ satisfaction evaluation should be done periodically in health facilities to continually identify the gaps in service delivery and monitor progress towards the ending of HIV/ AIDS epidemics which is one of the targets of the sustainable development goals

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 burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions

Global investments in pandemic preparedness and COVID-19: development assistance and domestic spending on health between 1990 and 2026

Background The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness. Methods In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need. Findings In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95$7·3 trillion (95% UI 7·2–7·4) in 2019; 293·7 times the $24·8 billion (95$43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and$37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11–21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP. Interpretation There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained

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

COVID-19 Vaccination Associated Bilateral Pulmonary Embolism: Cause or Coincidence

Background. Acute pulmonary embolism (APE) is a common cause of morbidity and mortality all over the world. Sudden onset dyspnea and chest pain are characteristic. Prior to our index case, only two previous cases of bilateral pulmonary thromboembolism were reported in black Africans and the first to be associated with COVID-19 vaccination. These cases were seen and described in middle-aged men. Case Summary. A 59-year-old man presented with a 2 week history of sudden onset dyspnea and a week history of productive cough. No associated chest pain or hemoptysis. No preceding history suggestive of leg pain/swelling. The patient had the booster dose of moderna (mRNA) COVID-19 vaccine a month before the onset of symptoms. There was associated anorexia, generalized body pain, joint pain, and weakness. He had reduced oxygen saturation at presentation with tachycardia. CTPA showed nearly occlusive right and left pulmonary arteries. Conclusion. Bilateral acute pulmonary embolism is rare all over the world. Its association with COVID-19 vaccine administration is even rarer. However, the clinical presentations and investigation findings are similar to the descriptions available in the literature for unilateral APE