Measuring disability-adjusted life years (DALYs) due to low back pain in Malta

Background: Low back pain (LBP) is a public health concern and a leading cause of ill health. A high prevalence of musculoskeletal complaints has been reported for Malta, a small European state. The aim was to estimate for the first time the burden of LBP at population level in Malta in terms of disability-adjusted life years (DALYs) and compare to estimates obtained by the Global Burden of Disease (GBD) study. Method: The Maltese European Health Interview Survey dataset for 2015 provided the LBP prevalence data through representative self-reported history of chronic LBP within the past 12 months in combination with limitations to daily activities. Proportions of LBP severity (with and without leg pain – mild, moderate, severe and most severe) and their corresponding disability weights followed values reported in the GBD study. Years lived with disability (YLD) for LBP were estimated for the whole population by age and sex. Since LBP does not carry any mortality, YLD reflected DALYs. The estimated local DALYs per 100,000 were compared to the GBD 2017 study results for Malta for the same year. Results: LBP with activity limitation gave a point prevalence of 6.4% (95% Uncertainty Interval [UI] 5.7–7.2%) (5.6% males [95% UI 4.6–6.6%]; 7.3% females [95% UI 6.2–8.4%]), contributing to a total of 23,649 (95% UI 20,974–26,463) Maltese suffering from LBP. The LBP DALYs were of 716 (95% UI 558–896) per 100,000. Females experienced higher LBP burden (739 [95% UI 575–927] DALYs per 100,000) than males (693 [95% UI 541–867] DALYs per 100,000). Our DALY estimates were lower than those reported by the GBD 2017 study (i.e., 1829 [95% UI 1300–2466] per 100,000). Conclusions: LBP imposes a substantial burden on the Maltese population. Differences observed between national estimates and those of the GBD study suggest the integration of updated locally sourced data into the model and encouraging local contributors in order to improve the DALY estimates of each country. Keywords: Low back pain, Epidemiology, Burden, Outcome research, Malta, Burden of disease, YLL, YLD, DALYs, GBD, European burden of disease networkpeer-reviewe

Observations and 3D Magnetohydrodynamic Modeling of a Confined Helical Jet Launched by a Filament Eruption

We present a detailed analysis of a confined filament eruption and jet associated with a C1.5 class solar flare. Multiwavelength observations from the Global Oscillations Network Group and Solar Dynamics Observatory reveal the filament forming over several days following the emergence and then partial cancellation of a minority polarity spot within a decaying bipolar active region. The emergence is also associated with the formation of a 3D null point separatrix that surrounds the minority polarity. The filament eruption occurs concurrently with brightenings adjacent to and below the filament, suggestive of breakout and flare reconnection, respectively. The erupting filament material becomes partially transferred into a strong outflow jet (∼60 km s−1 ) along coronal loops, becoming guided back toward the surface. Utilizing high-resolution Hα observations from the Swedish Solar Telescope/CRisp Imaging SpectroPolarimeter, we construct velocity maps of the outflows, demonstrating their highly structured but broadly helical nature. We contrast the observations with a 3D magnetohydrodynamic simulation of a breakout jet in a closed-field background and find close qualitative agreement. We conclude that the suggested model provides an intuitive mechanism for transferring twist/helicity in confined filament eruptions, thus validating the applicability of the breakout model not only to jets and coronal mass ejections but also to confined eruptions and flares

Generalised models for torsional spine and fan magnetic reconnection

Three-dimensional null points are present in abundance in the solar corona, and the same is likely to be true in other astrophysical environments. Recent studies suggest that reconnection at such 3D nulls may play an important role in the coronal dynamics. In this paper the properties of the torsional spine and torsional fan modes of magnetic reconnection at 3D nulls are investigated. New analytical models are developed, which for the first time include a current layer that is spatially localised around the null, extending along either the spine or the fan of the null. These are complemented with numerical simulations. The principal aim is to investigate the effect of varying the degree of asymmetry of the null point magnetic field on the resulting reconnection process - where previous studies always considered a non-generic radially symmetric null. The geometry of the current layers within which torsional spine and torsional fan reconnection occur is found to be strongly dependent on the symmetry of the magnetic field. Torsional spine reconnection still occurs in a narrow tube around the spine, but with elliptical cross-section when the fan eigenvalues are different, and with the short axis of the ellipse being along the strong field direction. The spatiotemporal peak current, and the peak reconnection rate attained, are found not to depend strongly on the degree of asymmetry. For torsional fan reconnection, the reconnection occurs in a planar disk in the fan surface, which is again elliptical when the symmetry of the magnetic field is broken. The short axis of the ellipse is along the weak field direction, with the current being peaked in these weak field regions. The peak current and peak reconnection rate in this case are clearly dependent on the asymmetry, with the peak current increasing but the reconnection rate decreasing as the degree of asymmetry is increased

The use of statistical parametric mapping (SPM96) as a decision aid in the differential diagnosis of dementia using 99mTc-HMPAO SPECT. Behav Neurol

In this study standard patterns of cerebral perfusion based on classifications described in the literature have been chosen and the ability of experienced imaging specialists to categorise the 99m Tc HMPAO SPECT scans of patients referred to the department for investigation of dementia has been compared before and after the calculation of Statistical Parametric Maps (SPM -Wellcome Dept of Cognitive Neurology). The primary aim was to investigate whether SPM is an effective decision aid and whether it impacts on the confidence of image reporting. The secondary aim was to examine the influence of SPM on the agreement between image reporting and clinical diagnosis. The results showed that there was a slight decrease in agreement between the imaging specialists after the introduction of additional information from SPM (K = 0.57 to K = 0.5) and that agreement between imaging reporting (including information from SPM) and clinical diagnosis was moderate (K = 0.28). This study was able to confirm that SPM is capable of producing meaningful significance maps of individual patients in a routine clinical environment. However, there was no overwhelming evidence that SPM was able to resolve many of the dilemmas associated with the use of SPECT for the differential diagnosis of dementia. In particular, interpretation of SPECT perfusion patterns in dementia is a bigger problem than the initial identification of abnormalities

Estimating the direct Covid-19 disability-adjusted life years impact on the Malta population for the first full year

Background: Disability-adjusted life years (DALYs) combine the impact of morbidity and mortality, allowing for comprehensive comparisons of the population. The aim was to estimate the DALYs due to Covid-19 in Malta (March 2020–21) and investigate its impact in relation to other causes of disease at a population level. Methods: Mortality and weekly hospital admission data were used to calculate DALYs, based on the European Burden of Disease Network consensus Covid-19 model. Covid-19 infection duration of 14 days was considered. Sensitivity analyses for different morbidity scenarios, including post-acute consequences were presented. Results: An estimated 70,421 people were infected (with and without symptoms) by Covid-19 in Malta (March 2020–1), out of which 1636 required hospitalisation and 331 deaths, contributing to 5478 DALYs. These DALYs positioned Covid-19 as the fourth leading cause of disease in Malta. Mortality contributed to 95% of DALYs, while post-acute consequences contributed to 60% of morbidity. Conclusions: Covid-19 over 1 year has impacted substantially the population health in Malta. Post-acute consequences are the leading morbidity factors that require urgent targeted action to ensure timely multidisciplinary care. It is recommended that DALY estimations in 2021 and beyond are calculated to assess the impact of vaccine roll-out and emergence of new variants.peer-reviewe

Association of opioid prescribing practices with chronic pain and benzodiazepine co-prescription:a primary care data linkage study

Background: Opioid prescribing is increasing worldwide with associated increases in misuse and other harms. We studied variations in national opioid prescription rates, indicators of prescribing quality, co-prescribing of benzodiazepines and relationship with pain severity in Scotland. Methods: Electronic linkages of opioid prescribing in Scotland were determined from: (i) national data from Information Services Division, NHS Scotland (2003–2012); and (ii) individual data from Generation Scotland: Scottish Family Health Study. Descriptive analyses were conducted on national data, multilevel modelling to examine factors associated with variations in prescribing rates. χ2 tests examined associations between individual pain severity and opioid prescriptions. Results: The number of strong opioid prescriptions more than doubled from 474 385 in 2003 to 1 036 446 in 2012, and weak opioid prescribing increased from 3 261 547 to 4 852 583. In Scotland, 938 674 individuals were prescribed an opioid in 2012 (18% of the population). Patients in the most deprived areas were 3.5 times more likely to receive a strong opioid than patients in the least deprived. There was significant variation in prescribing rates between geographical areas, with much of this explained by deprivation. Of women aged 25–40 yr prescribed a strong opioid, 40% were also prescribed a benzodiazepine. There was significant association between pain severity and receipt of opioid prescription. Over 50% of people reporting severe pain were not prescribed an opioid analgesic. Conclusions: We found opioid prescribing in primary care to be common and increasing in Scotland, particularly for severe pain. Co-prescribing of opioids and benzodiazepines was common

Can changes in spending on health and social care explain the recent mortality trends in Scotland? A protocol for an observational study

Introduction: There have been steady reductions in mortality rates in the majority of high-income countries, including Scotland, since 1945. However, reductions in mortality rates have slowed down since 2012–2014 in these nations; and have reversed in some cases. Deaths among those aged 55+ explain a large amount of these changing mortality trends in Scotland. Increased pressures on health and social care services have been suggested as one factor explaining these changes. This paper outlines a protocol for the approach to testing the extent to which health and social care pressures can explain recent mortality trends in Scotland. Although a slower rate of mortality improvements have affected people of all ages, certain ages have been more negatively affected than the others. The current analyses will be run by age-band to test if the service pressure-mortality link varies across age-group. Methods and analysis: This will be an observational ecological study based on the Scottish population. The exposures of interest will be the absolute (primary outcome) and percentage (secondary outcome) change in real terms per capita spending on social and healthcare services between 2011 and 2017. The outcome of interest will be the absolute (primary outcome) and percentage (secondary outcome) change in age-standardised mortality rate between 2012 and 2018 for men and women separately. The units of analysis will be the 32 local authorities and the 14 territorial health boards. The analyses will be run for both all age-groups combined and for the following age bands: <1, 1–15, 16–44, 45–64, 65–74, 75–84 and 85+. A series of descriptive analyses will summarise the distribution of health and social care expenditure and mortality trends between 2011 and 2018. Linear regression analysis will be used to investigate the direct association between health care spending and mortality rates. Ethics and dissemination: The data used in this study will be publicly available and aggregated and will not be individually identifiable; therefore, ethical committee approval is not needed. This work will not result in the creation of a new data set. On completion, the study will be stored within the National Health Service research governance system. All of the results will be published once they have been shared with partner agencies

Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017 : a systematic analysis for the global burden of disease study 2017

Background: Global development goals increasingly rely on country-specific estimates for benchmarking a nation's progress. To meet this need, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 estimated global, regional, national, and, for selected locations, subnational cause-specific mortality beginning in the year 1980. Here we report an update to that study, making use of newly available data and improved methods. GBD 2017 provides a comprehensive assessment of cause-specific mortality for 282 causes in 195 countries and territories from 1980 to 2017. Methods: The causes of death database is composed of vital registration (VR), verbal autopsy (VA), registry, survey, police, and surveillance data. GBD 2017 added ten VA studies, 127 country-years of VR data, 502 cancer-registry country-years, and an additional surveillance country-year. Expansions of the GBD cause of death hierarchy resulted in 18 additional causes estimated for GBD 2017. Newly available data led to subnational estimates for five additional countries—Ethiopia, Iran, New Zealand, Norway, and Russia. Deaths assigned International Classification of Diseases (ICD) codes for non-specific, implausible, or intermediate causes of death were reassigned to underlying causes by redistribution algorithms that were incorporated into uncertainty estimation. We used statistical modelling tools developed for GBD, including the Cause of Death Ensemble model (CODEm), to generate cause fractions and cause-specific death rates for each location, year, age, and sex. Instead of using UN estimates as in previous versions, GBD 2017 independently estimated population size and fertility rate for all locations. Years of life lost (YLLs) were then calculated as the sum of each death multiplied by the standard life expectancy at each age. All rates reported here are age-standardised. Findings: At the broadest grouping of causes of death (Level 1), non-communicable diseases (NCDs) comprised the greatest fraction of deaths, contributing to 73·4% (95% uncertainty interval [UI] 72·5–74·1) of total deaths in 2017, while communicable, maternal, neonatal, and nutritional (CMNN) causes accounted for 18·6% (17·9–19·6), and injuries 8·0% (7·7–8·2). Total numbers of deaths from NCD causes increased from 2007 to 2017 by 22·7% (21·5–23·9), representing an additional 7·61 million (7·20–8·01) deaths estimated in 2017 versus 2007. The death rate from NCDs decreased globally by 7·9% (7·0–8·8). The number of deaths for CMNN causes decreased by 22·2% (20·0–24·0) and the death rate by 31·8% (30·1–33·3). Total deaths from injuries increased by 2·3% (0·5–4·0) between 2007 and 2017, and the death rate from injuries decreased by 13·7% (12·2–15·1) to 57·9 deaths (55·9–59·2) per 100 000 in 2017. Deaths from substance use disorders also increased, rising from 284 000 deaths (268 000–289 000) globally in 2007 to 352 000 (334 000–363 000) in 2017. Between 2007 and 2017, total deaths from conflict and terrorism increased by 118·0% (88·8–148·6). A greater reduction in total deaths and death rates was observed for some CMNN causes among children younger than 5 years than for older adults, such as a 36·4% (32·2–40·6) reduction in deaths from lower respiratory infections for children younger than 5 years compared with a 33·6% (31·2–36·1) increase in adults older than 70 years. Globally, the number of deaths was greater for men than for women at most ages in 2017, except at ages older than 85 years. Trends in global YLLs reflect an epidemiological transition, with decreases in total YLLs from enteric infections, respiratory infections and tuberculosis, and maternal and neonatal disorders between 1990 and 2017; these were generally greater in magnitude at the lowest levels of the Socio-demographic Index (SDI). At the same time, there were large increases in YLLs from neoplasms and cardiovascular diseases. YLL rates decreased across the five leading Level 2 causes in all SDI quintiles. The leading causes of YLLs in 1990—neonatal disorders, lower respiratory infections, and diarrhoeal diseases—were ranked second, fourth, and fifth, in 2017. Meanwhile, estimated YLLs increased for ischaemic heart disease (ranked first in 2017) and stroke (ranked third), even though YLL rates decreased. Population growth contributed to increased total deaths across the 20 leading Level 2 causes of mortality between 2007 and 2017. Decreases in the cause-specific mortality rate reduced the effect of population growth for all but three causes: substance use disorders, neurological disorders, and skin and subcutaneous diseases. Interpretation: Improvements in global health have been unevenly distributed among populations. Deaths due to injuries, substance use disorders, armed conflict and terrorism, neoplasms, and cardiovascular disease are expanding threats to global health. For causes of death such as lower respiratory and enteric infections, more rapid progress occurred for children than for the oldest adults, and there is continuing disparity in mortality rates by sex across age groups. Reductions in the death rate of some common diseases are themselves slowing or have ceased, primarily for NCDs, and the death rate for selected causes has increased in the past decade. Funding: Bill & Melinda Gates Foundation

Identifying risk factors for progression to critical care admission and death among individuals with acute pancreatitis : a record linkage analysis of Scottish healthcare databases

This study was commissioned by GSK through the Farr Institute/SHIP/eDRIS single portal. DJM is a Clinician Scientist Fellow funded by the Health Foundation/Academy of Medical Sciences.Objectives: Acute pancreatitis (AP) can initiate systemic complications that require support in critical care (CC). Our objective was to use the unified national health record to define the epidemiology of AP in Scotland, with a specific focus on deterministic and prognostic factors for CC admission in AP. Setting: Health boards in Scotland (n=4). Participants: We included all individuals in a retrospective observational cohort with at least one episode of AP (ICD10 code K85) occurring in Scotland from 1 April 2009 to 31 March 2012. 3340 individuals were coded as AP. Methods: Data from 16 sources, spanning general practice, community prescribing, Accident and Emergency attendances, hospital in-patient, CC and mortality registries, were linked by a unique patient identifier in a national safe haven. Logistic regression and gamma models were used to define independent predictive factors for severe AP (sAP) requiring CC admission or leading to death. Results: 2053 individuals (61.5% (95% CI 59.8% to 63.2%)) met the definition for true AP (tAP). 368 patients (17.9% of tAP (95% CI 16.2% to 19.6%)) were admitted to CC. Predictors of sAP were pre-existing angina or hypertension, hypocalcaemia and age 30-39 years, if type 2 diabetes mellitus was present. The risk of sAP was lower in patients with multiple previous episodes of AP. In-hospital mortality in tAP was 5.0% (95% CI 4.1% to 5.9%) overall and 21.7% (95% CI 19.9% to 23.5%) in those with tAP necessitating CC admission. Conclusions: National record-linkage analysis of routinely collected data constitutes a powerful resource to model CC admission and prognosticate death during AP. Mortality in patients with AP who require CC admission remains high.Publisher PDFPeer reviewe