Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BackgroundDisorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.MethodsWe estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.FindingsGlobally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378–521), affecting 3·40 billion (3·20–3·62) individuals (43·1%, 40·5–45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7–26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6–38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5–32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7–2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.InterpretationAs the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed

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

Comparing cardiac asymmetric septal hypertrophy in hypothyroid patients before and after Levothyroxine therapy

Asymmetrical septal hypertrophy (ASH)is the echocardiographic manifestationof hypertrophic cardiomyopathy(HCM). HCM is characterized by inappropriate left ventriclehypertrophy with preferential involvement of theinterventricular symptom causing increased ventricularstiffness, which in turn results in diastolic dysfunction anddynamic left ventricular outflow tract pressure gradient.The study population included 65 newly diagnosed clinicalhypothyroidism patients (52 female and 13 male with themean age: 36.7±11.5), who were referred to endocrinologyclinic of Shiraz University of Medical Sciences, Shiraz,Iran. All analyses were performed using SPSS for the window,version 15.0. Continuous variables are presented asmean±SD, while categorical variables are presented as percentage.The prevalence of ASH (IP ratio ≥1.3) was 20%(13 in 65 patients), which was statistically very significant(in relation to 0.2% seen in the total population). In thepresent study, we investigated the prevalence of ASH inclinical hypothyroidism and also myocardial systolic anddiastolic parameter in these patients before and after thetreatment. It is conceivable that hypothyroidism is associatedwith both global LV dysfunction and localized septalmyocardial abnormality. Since the clinical significance ofthis reversible cardiomyopathy is unclear, routine echocardiogramsare not indicated in hypothyroidism. However,any patient with hypothyroidism with symptoms of cardiovasculardysfunction (such as dyspnea, dizziness syncope,pericardial pain resembling angina pectoris) should undergothe echocardiographic examination to exclude HCM

Case Report: Polyarteritis nodosa or complicated Henoch-Schonlein purpura (IgAV), a rare case [version 2; referees: 2 approved]

Background: Polyarteritis nodosa (PAN) is a vasculitis that affects medium-sized arteries. PAN is a rare disease and requires a high clinical suspicion for diagnosis. PAN and HSP (newly named Immunoglobulin A-associated vasculitis) have narrowing differential diagnosis. Here, we reported a case of PAN. Case presentation: Our patient was a 65-year-old woman that came to hospital due to abdominal pain and skin lesion on the right upper and right lower extremities. All rheumatologic tests were negative. A biopsy of the skin lesion was reported as mild hyperkeratosis, slight spongiosis with intact basal layer. The dermis showed moderate to severe perivascular PMN infiltration with vessel wall degeneration and extravasation of RBCs. A colonoscopy reported diffuse mucosal erythema and erosions were seen in the rectum until 6cm of anal verge. An electromyogram test and nerve conduction velocity study of the upper extremities reported bilateral mild carpal tunnel syndrome, and in the right lower extremities mononeuritis multiplex could not be ruled out. Abdominopelvic CT scan reported diffuse wall thickening of terminal ileum associated with mesenteric fat and narrow enhancement of inferior Mesenteric artery with patchy filling defect. After evaluation, the patient received corticosteroid pulses plus cyclophosphamide. Conclusion: Diagnosis and treatment of PAN are important and PAN should be considered in a patient with skin lesions and neurological impairment

Comparing Home-based Pulmonary Rehabilitation Nursing on Fatigue and quality of life in Patients with COPD

  Background & Objective:The aim of the present study is to compare the effects of home-based pulmonary rehabilitation nursing care on Fatigue and QOL in patients with COPD. Materials & Methods: This study was a semi experimental research. The samples were consisted of 36 patients who were selected based on inclusion and exclusion criteria into control and experimental groups through random block sampling. For each of the experimental group 3 sessions of 1 hour raining over three consecutive days were done individually and it continuous up to 7 days after the patients discharged from the hospital. However, the control group was under the regular manner. Fatigue and quality of life in both groups before the intervention and 7 weeks after discharge using the Fatigue Severity Scale (FSS) and quality of life questionnaire SF-12 were compared. The data were analyzed through inferential and descriptive statistic (Independent and paired t-test, chi-square and covariance analysis). Results: Eta squared values ​​obtained in this experiment also showed that the effect of home-based pulmonary rehabilitation program on fatigue (89%) is greater than the quality of life (50%), respectively. Conclusion: As the findings indicate, the effect of home-based pulmonary rehabilitation nursing care, which has the decreasing factor on fatigue is more than the quality of life in patients with COPD.&nbsp

Epstein-Barr virus hepatitis can cause transient hepatopulmonary syndrome

Introduction: Hepatopulmonary syndrome is commonly seen in the patients with chronic liver disease. Acute liver diseases are rarely associated with HPS. We have reported here a case of Transient HPS caused by Epstein-Barr virus hepatitis. Case report: The patient was a 31 years old man that came to hospital due to RUQ pain and yellowish skin. In examination the patient was tachypnic and O2 saturation was 71% with prominent JVP. ver enzyme and bilirubin were high. All viral hepatitis was negative except anti viral capsid antigen-antibody of EBV. In Blood gas PaO2 was 54 mmHg, O2 saturation 73% and alveolar-arterial gradient was 18 mmHg. Stress Echocardiography with saline injection reported pulmonary arterial pressure 32 cmHg with delayed opacification of left atrium. Conclusion: transient HPS can be manifestation in the acute hepatitis caused by EBV infection. Keywords: Epstein-Barr virus, Hepatitis, Hepatopulmonary syndrom

Case Report: Pulmonary and Liver Sarcoidosis Suspected of Metastasis [version 2; referees: 2 approved]

Introduction: Sarcoidosis is a granulomatous disease with unknown cause that can vary from an asymptomatic condition. Almost half of the patients with sarcoidosis have no symptoms. In this article, we describe a sarcoidosis patient with lung and liver engagement; it may be confused with metastasis. Case report: A 39-year-old man, with known as hypothyroidism who had come to the emergency ward with dyspnea and coughing after exposure to detergents in a closed environment. The patient smoked for 10 years (3 pack/year). No other findings were found in clinical examinations except for wheezing in the right lung. The patient's chest radiography was shown a mass. For further investigation, spiral CT scan was performed. Large lymph nodes on the right side of the trachea, measuring about 23 mm and a mass of 70 × 77 mm in the vicinity of the right lung hilum and a hypodense nodule in the posterior part of the liver with malignancy suspicious were reported. After several biopsy results was shown chronic granulomatous inflammation, the most important differential diagnosis is tuberculosis (TB) and sarcoidosis. Sputum smear, culture, and PCR were performed for tuberculosis. Also, the level of angiotensin-converting enzyme (ACE) was measured for sarcoidosis. the results ruled out TB and shown a higher level of ACE (ACE = 88 IU/L).After diagnosis treatment started with prednisolone. Now, the patient is in the follow- up. Conclusion: In hilar lymphadenopathy of lung sarcoidosis is the importance differential diagnosis that should be considered