Metformin and Intravascular Contrast Media: What to do in Patients Receiving Both: a Narrative Review

Metformin-associated lactic acidosis (M-ALA) is considered to be one of the complications caused by intravascular contrast media (CM) administration in diabetics especially those with coexisting renal or cardiac impairment. We focused on the necessity and duration of metformin suspension in diabetics with normal or impaired renal function scheduled for CT scan with IV contrast. Searching PubMed, Web of Science, and Scopus databases, we reviewed the latest relevant guidelines as well as articles published from 1994 to 2015. There is no global consensus among different guidelines on the duration of the Metformin suspension before CT scan with IV contrast. Also, lack of substantial evidence supporting M-ALA encourages specialists to take a less conservative approach.It is safe to continue Metformin in patients with normal renal function who have no co-morbidities. In cases of equivocal renal function (30<GFR<60 mL/min/1.73 m2) and also in patients with normal renal function and other co-morbidities, the decision should be made based on the patient’s clinical status. In case of severe renal failure, the use of metformin should be reassessed. Due to the probability of contrast associated nephropathy, laboratory follow up seems to be necessary for all patients

PV-Powered CoMP-Based Green Cellular Networks with a Standby Grid Supply

This paper proposes a novel framework for PV-powered cellular networks with a standby grid supply and an essential energy management technique for achieving envisaged green networks. The proposal considers an emerging cellular network architecture employing two types of coordinated multipoint (CoMP) transmission techniques for serving the subscribers. Under the proposed framework, each base station (BS) is powered by an individual PV solar energy module having an independent storage device. BSs are also connected to the conventional grid supply for meeting additional energy demand. We also propose a dynamic inter-BS solar energy sharing policy through a transmission line for further greening the proposed network by minimizing the consumption from the grid supply. An extensive simulation-based study in the downlink of a Long-Term Evolution (LTE) cellular system is carried out for evaluating the energy efficiency performance of the proposed framework. System performance is also investigated for identifying the impact of various system parameters including storage factor, storage capacity, solar generation capacity, transmission line loss, and different CoMP techniques.Comment: 14 pages, International Journal of Photoenergy, 6189468, 201

Cytomegalovirus retinitis in an immunocompetent pregnant woman

Cytomegalovirus (CMV) is a herpes virus that causes a wide spectrum of diseases. One of the most important clinical manifestations of CMV is retinitis which occurs often in immunocompromised patients and is a serious and sight‑threatening condition. The diagnosis is made clinically based on ophthalmologic examination but in equivocal situations can be confirmed by aqueous or vitreous polymerase chain reaction (PCR) testing. Here, we report one case of CMV retinitis in a pregnant woman without any obvious immunodeficiency that started with mononucleosis like syndrome at first and followed by retinal involvement. The disease was diagnosed by ophthalmologists and confirmed by aqueous PCR. The patient was treated with ganciclovir. Our opinion is that pregnancy and its mild cellular immunity can probably be considered as a cause of CMV retinitis in this patient.Keywords: Cytomegalovirus, immunocompetency, pregnancy, retiniti

Capacity building for priority setting in Farrokhshahr population

زمینه و هدف: تعیین‌ اولویت‌های پژوهشی فرآیندی‌ مهم‌ در مدیریت‌ پژوهش‌ها در تمام حوزه ها بخصوص حوزه سلامت‌ کشورها بشمار می رود که‌ اهمیت‌ آن‌ بویژه‌در زمان‌ تخصیص‌ منابع‌ محدود مالی‌ و انسانی‌ دو چندان‌ می شود. فرآیند تعیین‌ اولویت‌ها به‌ تمامی‌ کشورها در زمینه‌ طرح‌ ریزی‌ برنامه‌های‌ پژوهش‌ در حوزه‌ سلامت‌ و بسیج‌ و تخصیص‌ منابع‌ پژوهشی‌ و همچنین‌ تقویت ‌ظرفیت‌ پژوهشی‌ بومی‌ خود کمک‌ خواهد کرد. گروههای‌ ذینفعی‌ که‌ باید در فرآیند تعیین‌ اولویت‌ها شرکت‌ داده‌ شوند علاوه‌ برپژوهشگران‌ شامل‌ بهره‌ گیرندگان‌ بالقوه‌ و مردمی‌ می‌باشند که‌ از نتایج‌ پژوهش‌ تأثیر خواهند پذیرفت‌. در این مطالعه توانمند سازی مردم در تعیین اولویت های مشکلات مردم فرخشهر در استان چهار محال و بختیاری به صورت مشارکتی مورد بررسی قرار گرفته است. روش بررسی: این‌ پروژه‌ یک‌ تحقیق‌ مشارکتی است که‌ در آن‌ مشکلات‌ شناسایی‌ شده‌ با روش‌ ارزیابی‌ سریع (Rapid appraisal) در شهر فرخشهر، استان‌ چهارمحال‌ و بختیاری‌ در سال‌ 83 توسط تیم توسعه فرخشهر با مشارکت معاونت پژوهشی دانشگاه علوم پزشکی شهرکرد مورد اولویت‌ بندی‌ قرار گرفتند پس‌ از طبقه‌ بندی‌ اطلاعات‌ بدست‌ آمده‌ از نیازسنجی‌ با در نظر گرفتن‌ عوامل‌ محیطی‌، اقتصادی‌، اجتماعی‌، ساختار نهادها و مؤسسات‌ منطقه‌ و همچنین‌ شناسایی‌ عوامل‌ کند کننده‌ و مانع‌ شونده‌ و شرایط زندگی‌ و معیشتی‌ گروههای‌ مختلف‌ مردم و تعیین‌ ارتباط آن‌ با عوامل‌ فوق‌ الذکر مشکلات‌ اولویت‌ بندی‌ و تجزیه‌ و تحلیل‌ شد. در فرآیند مشارکت جامعه، پرسنل ناظر و اجرائی ابتدا هدف از تعیین اولویت هارا برای عموم شرکت کنندگان شرح دادند و تمامی نکات مبهم را روشن ساختند فرآیند مشارکت بصورت تبادل فعال مشارکت یا مشاوره که از پیشنهادات و نظرات مردم در برنامه ریزی و تصمیم گیری استفاده شود دنبال شد و در آخر تصمیم گیری در مورد تعیین اولویت ها به مردم واگذار شد کل فرآیند با مشارکت فعال اعضای تیم توسعه فرخشهر و با نظارت محققین دانشگاه که به عنوان ناظر شرکت داشتند انجام گردید. ابزارهای اولویت بندی در گروههای ذینفع شامل: ماتریس دو بعدی، دیاگرام اولویت ها، جدول تجزیه و تحلیل مشکلات، دیاگرام ون گروهها دینفع، ماتریس اختلاف و همکاری بین گروههای ذینفع بود. یافته ها: در این‌ مطالعه‌ 40 مشکل‌ مردم‌ فرخشهر شناسایی‌ و در 9 گروه طبقه‌ بندی‌ گردید: مشکلات‌ سالمندان‌، فرهنگی‌ هنری‌، عمرانی‌، ورزشی‌، زنان‌، بهداشت‌ روان‌، جوانان‌، امنیت‌ اجتماعی‌ و مشکلات‌ اشتغال طی فرآیند فوق 20 مشکل به عنوان اولویت های اول تا بیستم تعیین گردید. نهایتاَ با تجزیه و تحلیل داده های بدست آمده از ابزار های اولویت بندی، درک صحیحی از مشکلات حائز اولویت، فرصت ها، اقدامات صورت گرفته، راه حل ها و منابع بالقوه و بالفعل پیش رو برای حل مشکلات حاصل شد

Global injury morbidity and mortality from 1990 to 2017 : results from the Global Burden of Disease Study 2017

Correction:Background Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries. Methods We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs). Findings In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505). Interpretation Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care.Peer reviewe

Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.

The Global Burden of Diseases, Injuries and Risk Factors 2017 includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data. METHODS: We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting

Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.

How long one lives, how many years of life are spent in good and poor health, and how the population's state of health and leading causes of disability change over time all have implications for policy, planning, and provision of services. We comparatively assessed the patterns and trends of healthy life expectancy (HALE), which quantifies the number of years of life expected to be lived in good health, and the complementary measure of disability-adjusted life-years (DALYs), a composite measure of disease burden capturing both premature mortality and prevalence and severity of ill health, for 359 diseases and injuries for 195 countries and territories over the past 28 years. Methods We used data for age-specific mortality rates, years of life lost (YLLs) due to premature mortality, and years lived with disability (YLDs) from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to calculate HALE and DALYs from 1990 to 2017. We calculated HALE using age-specific mortality rates and YLDs per capita for each location, age, sex, and year. We calculated DALYs for 359 causes as the sum of YLLs and YLDs. We assessed how observed HALE and DALYs differed by country and sex from expected trends based on Socio-demographic Index (SDI). We also analysed HALE by decomposing years of life gained into years spent in good health and in poor health, between 1990 and 2017, and extra years lived by females compared with males. Findings Globally, from 1990 to 2017, life expectancy at birth increased by 7·4 years (95% uncertainty interval 7·1-7·8), from 65·6 years (65·3-65·8) in 1990 to 73·0 years (72·7-73·3) in 2017. The increase in years of life varied from 5·1 years (5·0-5·3) in high SDI countries to 12·0 years (11·3-12·8) in low SDI countries. Of the additional years of life expected at birth, 26·3% (20·1-33·1) were expected to be spent in poor health in high SDI countries compared with 11·7% (8·8-15·1) in low-middle SDI countries. HALE at birth increased by 6·3 years (5·9-6·7), from 57·0 years (54·6-59·1) in 1990 to 63·3 years (60·5-65·7) in 2017. The increase varied from 3·8 years (3·4-4·1) in high SDI countries to 10·5 years (9·8-11·2) in low SDI countries. Even larger variations in HALE than these were observed between countries, ranging from 1·0 year (0·4-1·7) in Saint Vincent and the Grenadines (62·4 years [59·9-64·7] in 1990 to 63·5 years [60·9-65·8] in 2017) to 23·7 years (21·9-25·6) in Eritrea (30·7 years [28·9-32·2] in 1990 to 54·4 years [51·5-57·1] in 2017). In most countries, the increase in HALE was smaller than the increase in overall life expectancy, indicating more years lived in poor health. In 180 of 195 countries and territories, females were expected to live longer than males in 2017, with extra years lived varying from 1·4 years (0·6-2·3) in Algeria to 11·9 years (10·9-12·9) in Ukraine. Of the extra years gained, the proportion spent in poor health varied largely across countries, with less than 20% of additional years spent in poor health in Bosnia and Herzegovina, Burundi, and Slovakia, whereas in Bahrain all the extra years were spent in poor health. In 2017, the highest estimate of HALE at birth was in Singapore for both females (75·8 years [72·4-78·7]) and males (72·6 years [69·8-75·0]) and the lowest estimates were in Central African Republic (47·0 years [43·7-50·2] for females and 42·8 years [40·1-45·6] for males). Globally, in 2017, the five leading causes of DALYs were neonatal disorders, ischaemic heart disease, stroke, lower respiratory infections, and chronic obstructive pulmonary disease. Between 1990 and 2017, age-standardised DALY rates decreased by 41·3% (38·8-43·5) for communicable diseases and by 49·8% (47·9-51·6) for neonatal disorders. For non-communicable diseases, global DALYs increased by 40·1% (36·8-43·0), although age-standardised DALY rates decreased by 18·1% (16·0-20·2)

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

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk–outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk–outcome pairs, and new data on risk exposure levels and risk–outcome associations. Methods We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk–outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017. Findings In 2017, 34·1 million (95% uncertainty interval [UI] 33·3–35·0) deaths and 1·21 billion (1·14–1·28) DALYs were attributable to GBD risk factors. Globally, 61·0% (59·6–62·4) of deaths and 48·3% (46·3–50·2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10·4 million (9·39–11·5) deaths and 218 million (198–237) DALYs, followed by smoking (7·10 million [6·83–7·37] deaths and 182 million [173–193] DALYs), high fasting plasma glucose (6·53 million [5·23–8·23] deaths and 171 million [144–201] DALYs), high body-mass index (BMI; 4·72 million [2·99–6·70] deaths and 148 million [98·6–202] DALYs), and short gestation for birthweight (1·43 million [1·36–1·51] deaths and 139 million [131–147] DALYs). In total, risk-attributable DALYs declined by 4·9% (3·3–6·5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23·5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18·6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low. Interpretation By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning