Integration of Non Alcoholic Fatty Liver Diseases (NAFLD) into NPCDCS programme: A recent initiative in India

Non-alcoholic fatty liver disease (NAFLD) is an emerging public health problem globally. NAFLD is one of the most common liver diseases worldwide and is the most common cause of abnormal liver enzymes in many developed countries. NAFLD is estimated to afflict approximately 1 billion individuals worldwide. An estimated 20-30 % of general population is afflicted from it globally. In India NAFLD could be a silent epidemic with its prevalence ranging from 9-32%. Studies have shown, strong association of NAFLD with major Non Communicable diseases (NCD) like Diabetes, Obesity, CVD, Chronic Kidney diseases, Cancers, etc. Perceiving the threat of NAFLD and the central role of hepatic accumulation of fat in the pathogenesis of other NCD, the Government of India (GoI) has taken steps to include NAFLD in the public health agenda. It has included it in the national NCD programme, i.e., National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) in 2021. India has become the first country in the world to start a national programme for preventive efforts for NAFLD. The present review describes public health relevance of NAFLD and the process of integration of Non Alcoholic Fatty Liver Diseases (NAFLD) into NPCDCS programme in India

Non-Alcoholic Fatty Liver Disease and other Non-Communicable Diseases: Time for an Integrated Approach

Non-Alcoholic fatty liver disease (NAFLD) is a broad term covering a spectrum of conditions ranging from hepatic steatosis, steatohepatitis and cirrhosis. NAFLD is highly prevalent across all regions of the world with its global prevalence of 25.2%(95%CI:22.1-28.7). It is commonly referred as the ‘hepatic manifestation’ of metabolic syndrome (MetS). Moreover, it is strongly associated with the individual components as well as MetS as a whole. NAFLD has been independently associated with other non-communicable diseases (NCDs) like chronic kidney disease (CKD), Polycystic ovary Syndrome (PCOS), Stroke and Cancers. This strong association of NCDs with NAFLD not only affects the prevalence but also the progression and management of the disease. Thus, this review aims at highlighting the association of NAFLD with other NCDs. A literature search was undertaken in the MEDLINE database using the necessary MeSH terms. The review concludes NAFLD is a systemic disease, not just confined to liver-specific morbidity and mortality, but also associated with numerous extra-hepatic manifestations, such as metabolic syndrome, cardiovascular diseases, chronic renal diseases, and malignancy. With co-existence of NAFLD with various NCDs it is expected to become the most overwhelming liver disease in the world in coming years. Hence, to reduce medical and economic impact associated with these comorbidities, it is recommended that all countries should estimate and predict the burden on comorbidities associated with NAFLD and galvanize its health resources in providing integrated therapeutic approaches for management of NAFLD and related comorbidities at an early stage

Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis

Objective A systematic review and meta-analysis to investigate the impact of electronic nicotine delivery systems (ENDS) and/or electronic non-nicotine delivery systems (ENNDS) versus no smoking cessation aid, or alternative smoking cessation aids, in cigarette smokers on long-term tobacco use. Data sources Searches of MEDLINE, EMBASE, PsycInfo, CINAHL, CENTRAL and Web of Science up to December 2015. Study selection Randomised controlled trials (RCTs) and prospective cohort studies. Data extraction Three pairs of reviewers independently screened potentially eligible articles, extracted data from included studies on populations, interventions and outcomes and assessed their risk of bias. We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate overall certainty of the evidence by outcome. Data synthesis Three randomised trials including 1007 participants and nine cohorts including 13?115 participants proved eligible. Results provided by only two RCTs suggest a possible increase in tobacco smoking cessation with ENDS in comparison with ENNDS (RR 2.03, 95% CI 0.94 to 4.38; p=0.07; I2=0%, risk difference (RD) 64/1000 over 6 to 12?months, low-certainty evidence). Results from cohort studies suggested a possible reduction in quit rates with use of ENDS compared with no use of ENDS (OR 0.74, 95% CI 0.55 to 1.00; p=0.051; I2=56%, very low certainty). Conclusions There is very limited evidence regarding the impact of ENDS or ENNDS on tobacco smoking cessation, reduction or adverse effects: data from RCTs are of low certainty and observational studies of very low certainty. The limitations of the cohort studies led us to a rating of very low-certainty evidence from which no credible inferences can be drawn. Lack of usefulness with regard to address the question of e-cigarettes\u27 efficacy on smoking reduction and cessation was largely due to poor reporting. This review underlines the need to conduct well-designed trials measuring biochemically validated outcomes and adverse effects

Pain Management in Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Background: Pain management is an important priority in the treatment of acute pancreatitis (AP). Current evidence and guideline recommendations are inconsistent on the most effective analgesic protocol. This systematic review and meta-analysis of randomised controlled trials (RCTs) aimed to compare the safety and efficacy of analgesics for pain relief in AP. Methods: A literature search was performed to identify all RCTs assessing analgesics in patients with AP. The primary outcome was the number of participants who needed rescue analgesia. Study quality was assessed using Jadad score. Pooled odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CI) were analysed using a random-effects model. Results: Twelve studies comprising 699 patients with AP (83% mild AP) were analysed. The tested analgesics significantly decreased the need for rescue analgesia (3 studies, OR.36, 95% CI 0.21 to 0.60) vs. placebo or conventional treatment. The analgesics also improved the pain score [Visual Analogue Scale (Δ-VAS)] at 24 h (WMD 18.46, 0.84 to 36.07) and by the 3rd to 7th days (WMD 11.57, 0.87 to 22.28). Opioids vs. non-opioids were associated with a decrease in the need for rescue analgesia (6 studies, OR 0.25, 95% CI 0.07 to 0.86, p = 0.03) but without significance in pain score. In subgroup analyses, opioids were similar to non-steroidal anti-inflammatory drugs (NSAIDs) regarding the primary outcome (4 studies, OR 0.56, 95% CI 0.24 to 1.32, p = 0.18). There were no significant differences in other clinical outcomes and rate of adverse events. Other studies, comparing epidural anaesthesia vs. patient-controlled analgesia and opioid (buprenorphine) vs. opioid (pethidine) did not show significant difference in primary outcome. Study quality issues significantly contributed to overall study heterogeneity. Conclusions: NSAIDs and opioids are equally effective in decreasing the need for rescue analgesia in patients with mild AP. The relative paucity of trials and high-quality data in this setting is notable and the optimal analgesic strategy for patients with moderately severe and severe AP still requires to be determined

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

Introduction to the GRADE tool for rating certainty in evidence and recommendations

The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) tool is a systematic approach used to assess the certainty of evidence and strength of recommendations in healthcare guidelines. It emphasizes the importance of considering the strengths and weaknesses of the evidence, as well as values, preferences, and practical considerations when making healthcare decisions. The GRADE methodology aims to enhance transparency, consistency, and rigor in evaluating evidence and informing clinical decision-making. GRADE uses a structured approach to assign a rating of high, moderate, low, or very low certainty to the evidence. Factors affecting certainty—study design, risk of bias, inconsistency, indirectness, imprecision, and publication bias—are considered in rating the certainty or confidence in evidence. The guideline recommendations emanating from applying the GRADE approach are strong or conditional/weak. The strength of a recommendation depends on the balance between the desirable and undesirable effects, the quality of evidence, values and preferences of stakeholders, and resource considerations. The Evidence to Decision (EtD) framework provides a structured approach to making recommendations based on the evidence assessment. This article describes the key components of the GRADE tool, including the factors considered in assessing evidence quality, the process for rating certainty, and the implications for developing recommendations

Social challenges experienced by Hepatitis B patients: A mixed method study

Background: Hepatitis B has a wide range of effects on patients' lives due to its chronic nature. Living with Hepatitis B has been associated with various social challenges such as stigma, disclosure, and discrimination. Aim: To assess the social challenges experienced by Hepatitis B–positive patients seeking treatment at a super specialty liver hospital of the country. Methods and Results: A mixed-method research design was used to explore various social challenges experienced by Hepatitis B–positive patients. Descriptive research design was used in the first phase and thematic analysis was done in the second phase of the study. Data were collected using a modified Hepatitis B stigma assessment tool and semi-structured interview guide. Total 180 Hepatitis B–positive patients were recruited for the first phase. Face to face interviews were recorded for the 9 patients facing high stigma in the second phase of the study. Mean age of the patients was 45 ± 13.1 years and 80% of the patients were male. Mean overall stigma score was found to be 74.34 ± 10.13. Of all, 5.1% patients experienced high stigma, 2.1% moderate stigma, and 92% patients experienced low stigma. Thematic analysis method uncovered various attributing factors to social challenges broadly classified into reaction on getting diagnosed with Hepatitis B, psychological issues, stigmatization in families, stigmatization at workplace, and stigmatization in healthcare settings. Conclusion: Patients with Hepatitis B experience social challenges in aspect of lack of awareness, psychological issues, and stigmatization by healthcare providers, family members, and by the colleagues at their workplace. A better understanding and awareness regarding Hepatitis B is needed to eliminate stigma and discrimination among these patients. Hence, a holistic approach is must to treat patients with Hepatitis B

Prevalence of hypertension among adolescents (10-19 years) in India: A systematic review and meta-analysis of cross-sectional studies.

BackgroundDespite the well-known short-term and long-term ill effects of elevated blood pressure in children and adolescents, pooled data on its burden among Indian adolescents have not yet been synthesized.ObjectivesWe did a systematic review with meta-analysis to calculate the pooled prevalence of hypertension among adolescents (10-19 years) in India.MethodsWe searched PubMed, Embase, Cochrane library, Google Scholar and IndMed, and included cross-sectional studies reporting data on hypertension prevalence among 10 to19 years old and published in English language from their inception till 1st March 2020. Modified New castle Ottawa scale was used to assess risk of bias based on research design, recruitment strategy, response rate and reliability of outcome determination. A random effects model was used to estimate pooled prevalence, and heterogeneity was assessed using Cochrane's Q statistic test of heterogeneity and I2 statistic. To explore the heterogeneity, we did a meta-regression, and sub-group analyses based on region, study setting and number of blood pressure readings.ResultsOut of 25 studies (pooled sample of 27,682 participants) six studies were of high, eighteen of moderate, and one was of low quality. The prevalence of hypertension across studies ranged from 2% to 20.5%, with a pooled estimate of 7.6% (95% CI: 6.1 to 9.1%), I2 = 96.6% (p-value ConclusionThe pooled prevalence of hypertension among adolescent in India is 7.6% with substantial heterogeneity between the studies. To tackle the high prevalence of hypertension among adolescents, early detection by screening under school health programme and opportunistic screening at Paediatric OPD should be implemented by Policy makers