Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

Background Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies. Methods For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia. Findings Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8–13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05–6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50–75% of children and adolescents with familial hypercholesterolaemia not being identified. Interpretation Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life. Funding Pfizer, Amgen, Merck Sharp & Dohme, Sanofi–Aventis, Daiichi Sankyo, and Regeneron

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Endophytic Fungi from Frankincense Tree Improves Host Growth and Produces Extracellular Enzymes and Indole Acetic Acid

<div><p><i>Boswellia sacra</i>, an economically important frankincense-producing tree found in the desert woodlands of Oman, is least known for its endophytic fungal diversity and the potential of these fungi to produce extracellular enzymes and auxins. We isolated various fungal endophytes belonging to Eurotiales (11.8%), Chaetomiaceae (17.6%), Incertae sadis (29.5%), Aureobasidiaceae (17.6%), Nectriaceae (5.9%) and Sporomiaceae (17.6%) from the phylloplane (leaf) and caulosphere (stem) of the tree. Endophytes were identified using genomic DNA extraction, PCR amplification and sequencing the internal transcribed spacer regions, whereas a detailed phylogenetic analysis of the same gene fragment was made with homologous sequences. The endophytic colonization rate was significantly higher in the leaf (5.33%) than the stem (0.262%). The Shannon-Weiner diversity index was <i>H</i>′ 0.8729, while Simpson index was higher in the leaf (0.583) than in the stem (0.416). Regarding the endophytic fungi’s potential for extracellular enzyme production, fluorogenic 4-methylumbelliferone standards and substrates were used to determine the presence of cellulases, phosphatases and glucosidases in the pure culture. Among fungal strains, <i>Penicillum citrinum</i> BSL17 showed significantly higher amounts of glucosidases (62.15±1.8 μM^-1min^-1mL) and cellulases (62.11±1.6 μM^-1min^-1mL), whereas <i>Preussia</i> sp. BSL10 showed significantly higher secretion of glucosidases (69.4±0.79 μM^-1min^-1mL) and phosphatases (3.46±0.31μM^-1min^-1mL) compared to other strains. <i>Aureobasidium</i> sp. BSS6 and <i>Preussia</i> sp. BSL10 showed significantly higher potential for indole acetic acid production (tryptophan-dependent and independent pathways). <i>Preussia</i> sp. BSL10 was applied to the host <i>B</i>. <i>sacra</i> tree saplings, which exhibited significant improvements in plant growth parameters and accumulation of photosynthetic pigments. The current study concluded that endophytic microbial resources producing extracellular enzymes and auxin could establish a unique niche for ecological adaptation during symbiosis with the host Frankincense tree.</p></div

Indole acetic acid (IAA) content in the culture filtrate of various endophytic fungal strains.

<p>L-tryptophan-dependent Czapek media was used to grow fungal strains for 7 days. A standard in the same media was also read to yield a standard curve (R² = 0.9985). A total of five replications (100 ml in each Erlenmeyer flask) were used to make sure the validation of IAA results. The bars representing different letters show that the mean values are significantly different from each other, as evaluated by the DMRT test (<i>P<</i>0.05).</p

Influence of endophyte inoculation on Host growth.

<p>Effect of the application of endophytic fungus (<i>Preussia sp</i>. BSL10) on the growth dynamics and photosynthetic pigments of <i>Boswellia sacra</i> tree saplings. Each treatment included nine replications. The photosynthetic pigments were measured after 21 DAT. The graphs show the mean value of three replications with standard deviations. 0 DAT shows the readings without any treatments applied.</p

Endophytic fungal strains isolated from the stem and leaf parts of the Frankincense tree.

<p>Endophytic fungal strains isolated from the stem and leaf parts of the Frankincense tree.</p

Sample collection and processing for the isolation of fungal endophytes from the frankincense (<i>Boswellia sacra</i>) tree.

<p>(<b>A</b>) Shows the hot and dry habitat of the frankincense tree; (<b>B</b>) resin emerging from the mature leaf of tree branches; (<b>C</b>) the milk-like resin oozing out from the lower epidermal layer of the tree; (<b>D</b>) the inner bark or the cortex region of the tree did not contain resinous ducts and was also evaluated for the presence of endophytes; (<b>E</b>) dried wounded outer bark in which the white milk was converted into crystalline gum (<b>F</b>); leaf pattern of the frankincense tree; (<b>G</b>) smaller parts of the tree (leaf, stem and bark parts) were used for isolation. A total of 208 10-mm tissue samples from the leaf and stem (bark) were used to isolate endophytic fungi. The black line is equivalent to 1 inch.</p

Phylogenetic analysis of endophytes.

<p>Maximum Parsimony analysis of isolated endophytes based on the sequences obtained from the sequencing process of the internal transcribed spacer (ITS) region. The phylogeny was constructed using the homologous fungal sequences deposited in GenBank. The percentage of replicate trees in which the associated species clustered together in the bootstrap test (2000 replicates) are shown next to the branches. The analysis involved 84 nucleotide sequences. All positions containing gaps and missing data were eliminated. There were a total of 296 positions in the final dataset. Evolutionary analyses were conducted in MEGA 6.0 [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0158207#pone.0158207.ref030" target="_blank">30</a>].</p

Principal Component Analysis (PCA) analysis.

<p>PCA showing the correlation between different endophytic fungi and their enzyme production abilities. In PCA, a full cross-validation was used to validate the enzyme production ability among different species.</p