The role of cellular and extracellular MicroRNAs in bovine follicular development and as potential indicators of early pregnancy

MicroRNAs (miRNAs), a class of short non-coding RNA molecules, emerged as major regulators of ~60% of all protein encoding genes. These molecules play an important role in mammalian follicular growth and embryonic development by modulating the expression of genes in follicular somatic cells and early embryos at post-transcriptional level. In addition to these cellular miRNAs, extracellular miRNAs found in virtually all biological fluids are getting great attention as potential diagnostic markers for diseases and various physiological conditions. The present study was designed to characterize the expression profile and functional role of cellular miRNAs in bovine granulosa cells and assessing the potential use of extracellular miRNAs in bovine early pregnancy diagnosis. For this, three experiments were conducted. In order to characterize specific miRNAs expression patterns, next-generation sequencing analysis in granulosa cells of preovulatory dominant and subordinate follicles obtained at day 19 of the estrous cycle revealed a total of 315 and 323 known miRNAs to be expressed, respectively. Among these, 64 miRNAs were found to be differentially expressed, of which 34 miRNAs including the miR-183-96-182 cluster were preferentially enriched, while the remaining 30 miRNAs were suppressed in preovulatory dominant follicles compared to the subordinate follicles counterpart. Moreover, the negative correlation in the expression patterns of the miR-183-96-182 cluster and its validated pro-apoptotic target gene, FOXO1 in preovulatory dominant follicles further substantiates the regulatory role of miRNAs in ovarian function during the follicular phase of the bovine estrous cycle. Functional analysis of the miR-183-96-182 cluster miRNAs in cultured granulosa cells showed that enrichment or inhibition of this miRNA cluster resulted in suppression or increased FOXO1 mRNA and protein, respectively. Concomitantly, overexpression of the miRNA cluster increased the rate of cell proliferation, decreased the proportion of cells under the G0/G1 arrest and increased the percentage of cells under the S phase. Even though inhibition of the miR-183-96-182 cluster slowed down the rate of cell proliferation, no measurable changes in the cell cycle status were observed. Furthermore, selective knockdown of FOXO1 mRNA using siRNA showed similar phenotypes as observed in the overexpression of the miRNA cluster experiment. In the third experiment, miRNA PCR array platform was used to determine the expression signature of extracellular miRNAs in serum samples from pregnant and non-pregnant cows at day 19 and 24 post-insemination. Results showed that a total of 302 and 316 miRNAs were detected in day 19 pregnant and non-pregnant cows, respectively. Similarly, 356 and 325 miRNAs were detected in day 24 pregnant and non-pregnant cows, respectively. Comparative expression analysis revealed 8 and 23 differentially expressed miRNAs in day 19 and 24 pregnant cows, respectively. Interestingly, 1 miRNA (miR-433) and 4 miRNAs (miR-487b, miR-495-3p, miR-376b-3p, and miR-323a-3p) homologous to the human pregnancy-associated C14MC miRNA cluster were among the differentially expressed miRNAs in day 19 and 24 pregnant cows, respectively. The predicted target genes of the differentially expressed extracellular miRNAs were found to be involved in pathways important in pregnancy implantation like the adherens junction and ECM-interaction. Taken all together, the present study demonstrates the functional involvement of miRNAs in the later stage of bovine follicular development by coordinately targeting key genes essential in determining the follicular fate. Moreover, this study characterizes unique expression signatures of extracellular miRNAs that could be potential indicators of early pregnancy in dairy cows.Die Rolle der zellulären und extrazellulären MicroRNAs in der Rinderfollikelentwicklung und als mögliche Indikatoren einer frühen Trächtigkeit MicroRNAs (miRNAs), eine Klasse von kurzen nicht-kodierenden RNA-Molekülen, gelten als Hauptregulatoren von ~60% aller Protein-kodierenden Gene. Diese Moleküle spielen eine wichtige Rolle beim Follikelwachstum und der embryonalen Entwicklung von Säugetieren, indem sie die Expression von Genen in follikulären somatischen Zellen und frühen Embryonen auf der posttranskriptionellen Ebene modulieren. Zusätzlich zu diesen zellulären miRNAs haben extrazelluläre miRNAs, die in praktisch allen biologischen Flüssigkeiten gefunden werden, als potentielle diagnostische Marker für Krankheiten und verschiedene physiologische Zustände große Aufmerksamkeit erlangt. In der vorliegenden Studie wurden dazu Expressionsprofile und die funktionelle Rolle dieser zellulären miRNAs in Rinder-Granulosazellen charakterisiert und der mögliche Einsatz von extrazellulären miRNAs in der Rinder-Frühträchtigkeitsdiagnose beurteilt. Dazu wurden drei Experimente durchgeführt. Zur Charakterisierung der miRNA-Expressionsmuster konnten mittels einer „Next-Generation Sequenzanalyse“ in Granulosazellen von präovulatorisch dominanten und subordinierten Follikeln vom Tag 19 des Östruszyklus insgesamt 315 bzw. 323 bekannte miRNAs identifiziert werden. Von diesen waren 64 miRNAs differentiell exprimiert, davon zeigten 34 miRNAs einschließlich des miR-183-96-182-Clusters eine Hochregulation, während die restlichen 30 miRNAs in präovulatorischen dominanten Follikeln im Vergleich zum subordinierten Follikel runterreguliert waren. Darüber hinaus bestätigt die negative Korrelation in den Expressionsmustern des miR-183-96-182-Clusters und seines validierten pro-apoptotischen Zielgens FOXO1 in präovulatorisch dominanten Follikeln die regulatorische Rolle von miRNAs während der follikulären Phase des Östruszyklus des Rindes. Die funktionelle Analyse der miR-183-96-182-Cluster-miRNAs in kultivierten Granulosazellen zeigte, dass die Hoch- oder Runterregulation dieses miRNA-Clusters zu einer Suppression bzw. Erhöhung der Expression von FOXO1-mRNA bzw. Protein führte. Gleichzeitig erhöhte die Überexpression des miRNA-Clusters die Zellproliferationsrate, verringerte den Anteil der Zellen während dem G0/G1-Zellzyklusarrest und erhöhte den Prozentsatz der Zellen während der S-Phase. Obwohl die Hemmung der Expression des miR-183-96-182-Clusters die Geschwindigkeit der Zellproliferation verlangsamte, wurden keine messbaren Veränderungen im Zellzyklusstatus beobachtet. Der selektive Knockdown von FOXO1 unter Verwendung von siRNA zeigte ähnliche Phänotypen, wie sie bei der Überexpression des miRNA-Cluster-Experiments beobachtet wurden. Im dritten Experiment wurde eine miRNA PCR-Array-Plattform verwendet, um die Expressions-Signatur von extrazellulären miRNAs in Serumproben von trächtigen und nicht-trächtigen Kühen am Tag 19 und 24 nach der Insemination zu erstellen. Es konnten in Proben vom Tag 19 insgesamt 302 und 316 miRNAs nachgewiesen wurden. ?Am Tag 24 wurden 356 und 325 miRNAs identifiziert. Die Vergleichs-Expressionsanalyse ergab 8 sowie 23 differentiell exprimierte miRNAs am Tag 19 bzw. 24 bei trächtigen Kühen. Interessanterweise waren eine miRNA (miR-433) und 4 miRNAs (miR-487b, miR-495-3p, miR-376b-3p und miR-323a-3p) homolog zu dem humanen schwangerschafts-assoziierten C14MC-miRNA-Cluster exprimiert. Es wurde festgestellt, dass die vorhergesagten Zielgene der differentiell exprimierten extrazellulären miRNAs an Signalwegen beteiligt sind, die für die Trächtigkeitsimplantation, wie die Adhärens-Junction und die ECM-Interaktion, wichtig sind. Zusammenfassend zeigt die vorliegende Studie die funktionelle Beteiligung von miRNAs im späteren Stadium der Entwicklung der Rinderfollikel durch koordinierte Ansteuerung von wichtigen Genen, die für die Bestimmung der follikulären Entwicklung wesentlich sind. Diese Studie zeigt einzigartige Expressionssignaturen von extrazellulären miRNAs, die potentielle Indikatoren für die frühe Trächtigkeit bei Milchkühen sein könnten

Sequence analysis and transcript length estimation of a normalized full-length porcine cDNA library

The Pig is one of the most important sources of animal protein and an essential animal model for human biomedical research due to its anatomical, physiological, biochemical and metabolic similarities with human being. Profound understanding of the pig genome helps to understand its biology in depth. To help this, availability of the pig genome sequence in the public databases facilitates research of wider spectrum. Generating Expressed sequence tags (EST) by partial sequencing normalized full-length cDNA libraries can improve the discovery of genes expressed in different tissues. cDNA libraries are also vital resources to elucidate alternative splicing pattern of genes and infer splice variants. The objective of this study was to pick and sequence the 5’end of 7,680 individual clones, identify clone sequences blasted against identical genes to determine the transcript size by Agarose-gel analysis and examining the presence of splice variants. Total RNA was isolated from eleven different tissues of an adult pregnant pig (113 days of gestation) and a normalized full-length cDNA library was constructed by a commercial company. Individual cDNA clones were cultured in 384-well plates and Sanger sequenced on an ABI3730 DNA analyser. The obtained sequence results were merged with results of two previous studies of the same cDNA library which resulted in 26,880 processed clones. In total 19,470 edited sequences were used for further analysis. Sequence similarity was searched using Basic Local Alignment Searching Tool (BLAST) against pig cDNA, human cDNA and mouse cDNA databases. A total of 12,461 sequences provided hit against the pig cDNA database and 8,300 sequences provided hit against the human cDNA database. 5,268 sequences provided hit against the mouse cDNA database. Moreover, the first 100 base pairs of the sequences were blasted against the newly released pig genome (build 10.2). In total of 12,222 sequences provided hit against the pig genome. Significant amount of clones provided database specific hits in either the Human or Mouse cDNA database which are important to retrieve homologous pig genes which are not mapped in the pig genome. A total of 7,074 non-redundant transcripts and 6,877 non-redundant genes were retrieved. PCR and Gel-electrophoresis protocols were optimized to determine insert the size of transcripts. Transcript length of 108 clones blasted against 10 different genes was determined and variation in size was obtained. The complete sequence of the 13 clones blasted to the same gene; the Swine Leucocyte Antigen (SLA-3) gene was obtained by sequencing with internal primers and variation in length and Exon-intron organization was confirmed. A comparison between the clone sequences and mRNA sequence stored in gene bank revealed higher degree of similarity and tissue specific transcripts were found. Large-scale screening and sequencing of cDNA libraries constructed from various tissues and development stages using the direct sequencing procedure can help to understand the pig genome. The procedure is also important to identify tissue specific splice variants

Granulosa cell-derived extracellular vesicles mitigate the detrimental impact of thermal stress on bovine oocytes and embryos

Climate change-induced global warming results in rises in body temperatures above normal physiological levels (hyperthermia) with negative impacts on reproductive function in dairy and beef animals. Extracellular vesicles (EVs), commonly described as nano-sized, lipid-enclosed complexes, harnessed with a plethora of bioactive cargoes (RNAs, proteins, and lipids), are crucial to regulating processes like folliculogenesis and the initiation of different signaling pathways. The beneficial role of follicular fluid-derived EVs in inducing thermotolerance to oocytes during in vitro maturation (IVM) has been evidenced. Here we aimed to determine the capacity of in vitro cultured granulosa cell-derived EVs (GC-EVs) to modulate bovine oocytes’ thermotolerance to heat stress (HS) during IVM. Moreover, this study tested the hypothesis that EVs released from thermally stressed GCs (S-EVs) shuttle protective messages to provide protection against subsequent HS in bovine oocytes. For this, sub-populations of GC-EVs were generated from GCs subjected to 38.5°C (N-EVs) or 42°C (S-EVs) and supplemented to cumulus-oocyte complexes (COCs) matured in vitro at the normal physiological body temperature of the cow (38.5°C) or HS (41°C) conditions. Results indicate that S-EVs improve the survival of oocytes by reducing ROS accumulation, improving mitochondrial function, and suppressing the expression of stress-associated genes thereby reducing the severity of HS on oocytes. Moreover, our findings indicate a carryover impact from the addition of GC-EVs during oocyte maturation in the development to the blastocyst stage with enhanced viability

Intervención pedagógica de la fluidez y de la comprensión lectora en el 2º grado de primaria a través de talleres de mediación entre pares

Con el objetivo de generar mejoras en la fluidez (precisión, velocidad lectora, prosodia y automatización de la lectura) y la comprensión lectora en estudiantes, a través de un diseño cuasi experimental pre test post test con grupo control. Se realizó una intervención pedagógica basada en Talleres de Mediación Entre Pares en una muestra de estudiantes de 2º grado de Primaria de Lima (grupo experimental = 127, y grupo control = 169). Los instrumentos de medición aplicados fueron: la Rúbrica de Lectura Oral RELO (fluidez y la comprensión lectora en la lectura oral) de Medina (2013) y la Prueba de Complejidad Lingüística Progresiva Nivel 2 (comprensión lectora silenciosa) de Alliende, Condemarín y Milicic (2001). Las medidas de comparativas de post test señalan una mejora significativa (p<.001) tras la intervención en la fluidez lectora, la precisión, la automaticidad de la lectura; muy significativa (p<.01) en la prosodia, y ningún efecto significativo sobre la velocidad lectora. No obstante, se aprecian incrementos en los promedios de comprensión lectora en la lectura oral, y en la comprensión a nivel literal y a nivel reorganizativo, estos no alcanzan a ser significativos, sin embargo, los análisis sí señalan que la intervención mejoró la comprensión en el nivel inferencial (p<.001) y en el nivel crítico (p<.01); la comprensión lectora a nivel de la lectura silenciosa no observó una mejora significativa. Este estudio muestra la importancia y el impacto de la mediación entre pares para enriquecer los procesos de aprendizaje de la lectura en las primeras etapas, en especial en realidades con menor avance en el aprendizaje de la fluidez y de la comprensión lectora

Endometrial DNA methylation signatures during the time of breeding in relation to the pregnancy outcome in postpartum dairy cows fed a control diet or supplemented with rumen-protected methionine

Post calving metabolic stress reduces the fertility of high producing dairy cows possibly by altering the expression of genes in the maternal environment via epigenetic modifications. Therefore, this study was conducted to identify endometrial DNA methylation marks that can be associated with pregnancy outcomes in postpartum cows at the time of breeding. For this, twelve days post-calving, cows were either offered a control diet or supplemented daily with rumen-protected methionine. Cows showing heat 50–64 days postpartum were artificially inseminated. Endometrial cytobrush samples were collected 4–8 h after artificial insemination and classified based on the pregnancy out comes as those derived from cows that resulted in pregnancy or resulted in no pregnancy. The DNAs isolated from endometrial samples were then subject to reduced representative bisulfite sequencing for DNA methylation analysis. Results showed that in the control diet group, 1,958 differentially methylated CpG sites (DMCGs) were identified between cows that resulted in pregnancy and those that resulted in no pregnancy of which 890 DMCGs were located on chr 27: 6217254–6225600 bp. A total of 537 DMCGs were overlapped with 313 annotated genes that were involved in various pathways including signal transduction, signalling by GPCR, aldosterone synthesis and secretion. Likewise, in methionine supplemented group, 3,430 CpG sites were differentially methylated between the two cow groups of which 18.7% were located on Chr27: 6217254–6225600 bp. A total of 1,781 DMCGS were overlapped with 890 genes which involved in developmental and signalling related pathways including WNT-signalling, focal adhesion and ECM receptor interaction. Interestingly, 149 genes involved in signal transduction, axon guidance and non-integrin membrane-ECM interactions were differentially methylated between the two cow groups irrespective of their feeding regime, while 453 genes involved in axon guidance, notch signalling and collagen formation were differentially methylated between cows that received rumen protected methionine and control diet irrespective of their fertility status. Overall, this study indicated that postpartum cows that could potentially become pregnant could be distinguishable based on their endometrial DNA methylation patterns at the time of breeding

Use of multidimensional item response theory methods for dementia prevalence prediction : an example using the Health and Retirement Survey and the Aging, Demographics, and Memory Study

Background Data sparsity is a major limitation to estimating national and global dementia burden. Surveys with full diagnostic evaluations of dementia prevalence are prohibitively resource-intensive in many settings. However, validation samples from nationally representative surveys allow for the development of algorithms for the prediction of dementia prevalence nationally. Methods Using cognitive testing data and data on functional limitations from Wave A (2001-2003) of the ADAMS study (n = 744) and the 2000 wave of the HRS study (n = 6358) we estimated a two-dimensional item response theory model to calculate cognition and function scores for all individuals over 70. Based on diagnostic information from the formal clinical adjudication in ADAMS, we fit a logistic regression model for the classification of dementia status using cognition and function scores and applied this algorithm to the full HRS sample to calculate dementia prevalence by age and sex. Results Our algorithm had a cross-validated predictive accuracy of 88% (86-90), and an area under the curve of 0.97 (0.97-0.98) in ADAMS. Prevalence was higher in females than males and increased over age, with a prevalence of 4% (3-4) in individuals 70-79, 11% (9-12) in individuals 80-89 years old, and 28% (22-35) in those 90 and older. Conclusions Our model had similar or better accuracy as compared to previously reviewed algorithms for the prediction of dementia prevalence in HRS, while utilizing more flexible methods. These methods could be more easily generalized and utilized to estimate dementia prevalence in other national surveys

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019 : A systematic analysis for the Global Burden of Disease Study 2019

Background Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. Interpretation The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC

Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods: GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings: Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation: As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and developm nt investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. Interpretation The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC

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