Topological analysis of metabolic and regulatory networks by decomposition methods

Die lebenden Organismen sind für eine wissenschaftliche Analyse zu kompliziert, wenn man sie als Ganzes und in ihrer vollen Komplexität betrachtet. Die vorliegende Arbeit behandelt die topologischen Eigenschaften von zwei wichtigen Teilen der lebenden Organismen: die metabolischen und die regulatorischen Systeme. Topolgische Eigenschaften sind solche, die durch die Netwerkstruktur bedingt werden. Ein Signalsystem ist eine spezielle Art von regulatorischem System. Zwischen den metabolischen und Signalnetzen gibt es wichtige Unterschiede, die ihre Behandlung in unterschiedlicher Weise erfordert. In der metabolischen Pfadanalyse ist das Konzept der elementaren Flussmoden bereits als ein passendes Instrument für die Charakterisierung der einfachsten essentiellen Wege in biochemischen Systemen etabliert. Wir untersuchen die Eigenschaften und Vorteile dieses Konzepts in einigen besonderen Fällen. Zuerst untersuchen wir die vielfach vorkommenden Enzyme mit niedriger Spezifität (z.B. Nukleosiddiphosphokinase, Uridinkinase, Transketolase, Transaldolase). Sie können parallel verschiedene Substrate und Produkte umwandeln. Auch die Enzym-Mechanismen sind vielfältig, wie wir mit dem Reaktionsschema für bifunktionelle Enzyme veranschaulichen. Wir betrachten dabei nur den Fall, dass ein bestimmtes aktives Zentrum mehrere Reaktionen katalysiert. Der Fall, dass das studierte Enzym mehrere solche aktiven Zentren hat, kann in den Fall mehrerer Enzyme transformiert werden, die nur ein aktives Zentrum haben. Wenn eine Krankheit das Ausgangsenzym ändert, werden dann in der Analyse auch alle ersetzenden Enzyme geändert. Es gibt zwei unterschiedliche Betrachtungsweisen, um multifunktionelle Enzyme zu beschreiben. Zum einen kann man die Gesamtreaktionen betrachten und zum anderen die elementaren Reaktionsschritte (Hemireaktionen, Halbreaktionen). Für Enzyme mit zwei oder mehr Funktionen ist es wichtig, nur linear unabhängige Funktionen zu betrachten, weil sonst zyklische elementare Moden auftreten würden, die keine Nettoumwandlung durchführen. Jedoch ist die Wahl der linear unabhängigen Funktionen nicht a priori eindeutig. Wir stellen eine Methode für das Treffen dieser Wahl vor, indem wir die konvexe Basis des Hemireaktions-Systems betrachten. Eine formale Anwendung des Algorithmus für das Berechnen der elementaren Flussmoden (Routen) erbringt das Resultat, dass die Zahl solcher Moden manchmal vom Niveau der Beschreibung abhängt, wenn einige Reaktionen reversibel sind und die Produkte der multifunktionellen Enzyme externe Metabolite sind, oder einige multifunktionelle Enzyme zum Teil die gleichen Stoffwechselprodukte umwandeln. Jedoch kann dieses Problem durch eine geeignete Deutung der Definition der elementaren Moden und die korrekte Wahl der unabhängigen Funktionen der Multifunktionsenzyme gelöst werden. Die Analyse wird durch einige kleinere Beispiele und ein größeres biochemisches Beispiel veranschaulicht, das aus dem Nukleotidmetabolismus stammt und die zwei Arten der Beschreibung für Nukleosiddiphosphokinase und Adenylatekinase vergleicht. Der Nukleotidmetabolismus spielt eine wichtige Rolle in lebenden Organismen und ist gegenüber allen möglichen Störungen in seiner internen Balance sehr empfindlich. Gefährliche Krankheiten können auftreten, wenn einige Enzyme nicht richtig funktionieren. Mit Hilfe des Konzeptes des elementaren Flussmodus erklären wir das Auftreten und den Schweregrad von Krankheiten, die auf Enzymdefizienzen basieren. Wenn ein Enzym vollständig gehemmt wird, werden einige metabolische Wege blockiert. Wenn jedoch einige alternative Wege noch bestehen, ist die Krankheit weniger gefährlich. Unsere Analyse ist darauf gerichtet, alternative Wege, wesentliche Enzyme und solche Enzyme, die immer zusammenarbeiten zu finden. Der letzte Begriff ist auch als "Enzyme subset" bekannt und stellt einen intermediären Schritt im Algorithmus zur Berechnung der elementaren Flussmoden dar. Wir diskutieren bereits bekannte und bisher nur hypothetische Mechanismen einiger Krankheiten (proliferative Krankheiten, Immundefizienzen), die auf Störungen des Nukleotidmetabolismus oder seiner Ausbeutung durch Viren und Parasiten beruhen. Die meisten Strategien, die für das Bekämpfen solcher Krankheiten eingesetzt werden, basieren auf der Unterbrechung des Nukleotidmetabolismus an bestimmten Stellen. Diese Strategien können aber auch zur Akkumulation toxischer Stoffe führen und dadurch Nebenwirkungen hervorrufen. Deswegen hilft ein besseres Verständnis dieses Systems, wirkungsvollere Medikamente zu entwickeln, und eine gute strukturelle Analyse kann viele experimentelle Bemühungen ersparen. Konzepte aus der Theorie der Petri-Netze liefern zusätzliche Werkzeuge für das Modellieren metabolischer Netzwerke. In Kapitel 4 werden die ähnlichkeiten zwischen einigen Konzepten in der traditionellen biochemischen Modellierung und analogen Konzepten aus der Petri-Netztheorie besprochen. Zum Beispiel entspricht die stochiometrische Matrix eines metabolischen Netzwerkes der Inzidenzmatrix des Petri-Netzes. Die Flussmoden und die Erhaltungs-Relationen haben die T-Invarianten beziehungsweise P-Invarianten als Gegenstücke. Wir decken die biologische Bedeutung einiger weiterer Begriffe aus der Theorie der Petri-Netze auf, nämlich "traps", "{siphons", "deadlocks" und "Lebendigkeit". Wir konzentrieren uns auf der topologischen Analyse anstatt auf die Analyse des dynamischen Verhaltens. Die geeignete Behandlung der externen Stoffwechselprodukte wird ebenfalls besprochen. Zur Illustration werden einige einfache theoretische Beispiele vorgestellt. Außerdem werden einige Petri-Netze präsentiert, die konkreten biochemischen Netzen entsprechen, um unsere Resultate zu belegen. Zum Beispiel wird die Rolle der Triosephosphatisomerase (TPI) im Metabolismus von Trypanosoma brucei ausgewertet, indem "traps" und "siphons" ermittelt werden. Alle behandelten Eigenschaften von Petri-Netzen werden anhand eines Systems illustriert, das aus dem Nukleotidmetabolismus stammt. Während viele Bemühungen für das Zerlegen metabolischer Systeme, (elementare Flußmoden, extreme Wege) erfolgt sind, sind bisher unseres Wissens keine Versuche in dieser Richtung für Signalübertragungssysteme unternommen worden. Eine spezielle Eigenschaft von Signalnetzwerken in lebenden Zellen ist, dass Aktivierungen, Hemmungen und biochemische Reaktionen normalerweise gleichzeitig anwesend sind. Selbst wenn sie nicht Reaktionen enthalten, machen Mehrfach-Aktivierungen oder Mehrfach-Hemmungen die Netzwerke in hohem Grade verzweigt. Es ist eine schwierige und sehr zeitraubende Aufgabe, alle Faktoren, die einen Einfluss auf ein gegebenes Ziel haben, ohne eine automatische Methode zu ermitteln. Bereits in Kapitel 1 heben wir die ähnlichkeiten und Unterschiede zwischen den metabolischen und Signal-Netzwerken hervor. In Kapitel 5 errichten wir einen Rahmen und präsentieren einen Algorithmus für die Zerlegung von Signalnetzwerken in kleinere Einheiten, die einfacher zu studieren und zu verstehen sind. Zwei Fälle werden untersucht: ein einfacheres, wenn nur monomolekulare Aktivierungen oder Reaktionen anwesend sind, und ein komplizierterer Fall, wenn die Aktivierungen und die Reaktionen multimolekular sein können. Ihre Beschreibung erfordert unterschiedliche Methoden: klassische Graphen bzw. Petrinetze. Wir besprechen die Probleme, die in unserem Modell wegen des Vorhandenseins von Hemmungen oder von unbekannten Effekten im Netz auftreten. Der vorgeschlagene Algorithmus ermittelt die Faktoren, die zusammenwirken und die Zielsubstanzen, die auf dem gleichen Weg beeinflusst werden. Die Zyklen, die im System auftreten, und mögliche fehlende Reaktionen werden ebenfalls ermittelt . Theoretische Beispiele veranschaulichen unsere Resultate. Anhand der T-Zell-Antigen-Rezeptor-Signalkaskade zeigen wir, wie die Methoden in realen Systemen angewendet werden können.The living organisms are too complex when considering them as a whole. The present thesis deals with the topological properties of two important parts of living organisms: the metabolic and the regulatory systems. The topological properties are those features that are determined by the network structure. A classification in metabolic and regulatory systems is often used. A signalling system is a special kind of regulatory system. Between metabolic and signalling networks, there are important differences that impose their treatment in different ways. In metabolic pathway analysis, the elementary flux mode concept is already established as a proper tool for identifying the smallest essential routes in biochemical systems. We examine its features and advantages in some particular cases. Firstly, many enzymes operate with low specificity (e.g. nucleoside diphosphokinase, uridine kinase, transketolase, transaldolase), so that various substrates and products can be converted. Also the enzymatic mechanisms are diverse, as we have illustrated with reaction schemes for bifunctional enzymes. Therefore, there are two different approaches to describe multifunctional enzymes (We considered only the case when a certain active site hosts several reactions. The case when the studied enzyme has several such active sites can be transformed into that of several enzymes having only one active site. If a disease alters the initial enzyme, also all substituting enzymes are altered.): in terms of overall reactions and in terms of reactions steps (hemi-reactions, half-reactions). For enzymes with two or more functions, it is important to consider only linearly independent functions, because otherwise cyclic elementary modes would occur which do not perform any net transformation. However, the choice of linearly independent functions is not a priori unique. In Chapter 2, we give a method for making this choice unique by considering the convex basis of the hemi-reactions system. The set of linearly independent functions provided by our algorithm coincides, in the case of transketolase in pentose phosphate pathway, with the set of linearly independent functions mentioned in literature. A formal application of the algorithm for computing elementary flux modes (pathways) yields the result that the number of such modes sometimes depends on the level of description if some reactions are reversible and the products of the multifunctional enzymes are external metabolites or some multifunctional enzymes partly share the same metabolites. However, this problem can be solved by appropriate interpretation of the definition of elementary modes and the correct choice of independent functions of multifunctional enzymes. The analysis is illustrated by a biochemical example taken from nucleotide metabolism, comparing the two ways of description for nucleoside diphosphokinase and adenylate kinase, and by several smaller examples. The nucleotide metabolism plays an important role in living organisms and is very sensitive to any perturbations in its internal balance. Dangerous diseases may occur if some enzymes do not work properly. With the help of elementary flux mode concept, we explain the occurrence and severity of diseases based on enzyme deficiencies. If an enzyme is completely inhibited, some metabolic routes are blocked. If, however, some alternative routes still exist, the disease is less dangerous. In Chapter 3, we focus on finding alternative routes, essential enzymes and enzymes operating together. The latter notion is also known as ,,enzyme subset`` and represents an intermediary step in calculating the elementary flux modes. The known or hypothesised mechanisms of several disorders, occurred due to the malfunctioning of nucleotide metabolism (proliferative diseases, immunodeficiency diseases) or due to its hijacking by viruses and parasites, are given. Most strategies adopted for curing such diseases are based on nucleotide metabolism interruption. Therefore, a better understanding of this system helps developing more effective drugs and a good structural analysis can spare many experimental efforts. Petri net concepts provide additional tools for the modelling of metabolic networks. In Chapter 4, the similarities between the counterparts in traditional biochemical modelling and Petri net theory are discussed. For example, the stoichiometry matrix of a metabolic network corresponds to the incidence matrix of the Petri net. The flux modes and conservation relations have the T-invariants, respectively, P-invariants as counterparts. We reveal the biological meaning of some notions specific to the Petri net framework (traps, siphons, deadlocks, liveness). We focus on the topological analysis rather than on the analysis of the dynamic behaviour. The treatment of external metabolites is discussed. Some simple theoretical examples are presented for illustration. Also the Petri nets corresponding to some biochemical networks are built to support our results. For example, the role of triose phosphate isomerase (TPI) in Trypanosoma brucei metabolism is evaluated by detecting siphons and traps. All Petri net properties treated in above-mentioned chapter (4) are exemplified on a system extracted from nucleotide metabolism. While for decomposing metabolic systems, many efforts have been done (elementary flux modes, convex basis, extreme pathways), for signalling maps, as far as we know, no attempt in this direction has been made. A special characteristic of signalling networks is that activations, inhibitions, and biochemical reactions are normally present in parallel. Even if they do not contain reactions, multi-part activations or inhibitions make them highly branched. To detect all factors that have an influence on a given target, without using an automatic method, is a difficult and very time-consuming effort. Already in Chapter 1 (Backgrounds), we highlight the similarities and differences between metabolic and signalling networks. In Chapter 5, we build a framework and algorithm for decomposing signalling networks in smaller units, which are easier to study and understand. Two cases are investigated: a simpler one, when only monomolecular activations or reactions are present, and a more complex case, when the activations and reactions can be multimolecular. Their description requires different instruments: classical graphs and Petri nets, respectively. We discuss the problems that occur in our model due to the presence of some inhibitions or unknown effects in the network. The algorithm that we propose detects the factors that are acting together and the targets that are affected on the same route. The cycles that occur in the system are also highlighted. We point out possible missing reactions. Theoretical examples illustrate out findings. Using the T cell antigen-receptor signalling cascade, we show how it can be applied to real systems

The burden of injury in Central, Eastern, and Western European sub-region : a systematic analysis from the Global Burden of Disease 2019 Study

Background Injury remains a major concern to public health in the European region. Previous iterations of the Global Burden of Disease (GBD) study showed wide variation in injury death and disability adjusted life year (DALY) rates across Europe, indicating injury inequality gaps between sub-regions and countries. The objectives of this study were to: 1) compare GBD 2019 estimates on injury mortality and DALYs across European sub-regions and countries by cause-of-injury category and sex; 2) examine changes in injury DALY rates over a 20 year-period by cause-of-injury category, sub-region and country; and 3) assess inequalities in injury mortality and DALY rates across the countries. Methods We performed a secondary database descriptive study using the GBD 2019 results on injuries in 44 European countries from 2000 to 2019. Inequality in DALY rates between these countries was assessed by calculating the DALY rate ratio between the highest-ranking country and lowest-ranking country in each year. Results In 2019, in Eastern Europe 80 [95% uncertainty interval (UI): 71 to 89] people per 100,000 died from injuries; twice as high compared to Central Europe (38 injury deaths per 100,000; 95% UI 34 to 42) and three times as high compared to Western Europe (27 injury deaths per 100,000; 95%UI 25 to 28). The injury DALY rates showed less pronounced differences between Eastern (5129 DALYs per 100,000; 95% UI: 4547 to 5864), Central (2940 DALYs per 100,000; 95% UI: 2452 to 3546) and Western Europe (1782 DALYs per 100,000; 95% UI: 1523 to 2115). Injury DALY rate was lowest in Italy (1489 DALYs per 100,000) and highest in Ukraine (5553 DALYs per 100,000). The difference in injury DALY rates by country was larger for males compared to females. The DALY rate ratio was highest in 2005, with DALY rate in the lowest-ranking country (Russian Federation) 6.0 times higher compared to the highest-ranking country (Malta). After 2005, the DALY rate ratio between the lowest- and the highest-ranking country gradually decreased to 3.7 in 2019. Conclusions Injury mortality and DALY rates were highest in Eastern Europe and lowest in Western Europe, although differences in injury DALY rates declined rapidly, particularly in the past decade. The injury DALY rate ratio of highest- and lowest-ranking country declined from 2005 onwards, indicating declining inequalities in injuries between European countries.Peer reviewe

Hearing loss prevalence and years lived with disability, 1990–2019: findings from the Global Burden of Disease Study 2019

Background Hearing loss affects access to spoken language, which can affect cognition and development, and can negatively affect social wellbeing. We present updated estimates from the Global Burden of Disease (GBD) study on the prevalence of hearing loss in 2019, as well as the condition's associated disability. Methods We did systematic reviews of population-representative surveys on hearing loss prevalence from 1990 to 2019. We fitted nested meta-regression models for severity-specific prevalence, accounting for hearing aid coverage, cause, and the presence of tinnitus. We also forecasted the prevalence of hearing loss until 2050. Findings An estimated 1·57 billion (95% uncertainty interval 1·51–1·64) people globally had hearing loss in 2019, accounting for one in five people (20·3% [19·5–21·1]). Of these, 403·3 million (357·3–449·5) people had hearing loss that was moderate or higher in severity after adjusting for hearing aid use, and 430·4 million (381·7–479·6) without adjustment. The largest number of people with moderate-to-complete hearing loss resided in the Western Pacific region (127·1 million people [112·3–142·6]). Of all people with a hearing impairment, 62·1% (60·2–63·9) were older than 50 years. The Healthcare Access and Quality (HAQ) Index explained 65·8% of the variation in national age-standardised rates of years lived with disability, because countries with a low HAQ Index had higher rates of years lived with disability. By 2050, a projected 2·45 billion (2·35–2·56) people will have hearing loss, a 56·1% (47·3–65·2) increase from 2019, despite stable age-standardised prevalence. Interpretation As populations age, the number of people with hearing loss will increase. Interventions such as childhood screening, hearing aids, effective management of otitis media and meningitis, and cochlear implants have the potential to ameliorate this burden. Because the burden of moderate-to-complete hearing loss is concentrated in countries with low health-care quality and access, stronger health-care provision mechanisms are needed to reduce the burden of unaddressed hearing loss in these settings

Global burden of chronic respiratory diseases and risk factors, 1990–2019: an update from the Global Burden of Disease Study 2019

Background: Updated data on chronic respiratory diseases (CRDs) are vital in their prevention, control, and treatment in the path to achieving the third UN Sustainable Development Goals (SDGs), a one-third reduction in premature mortality from non-communicable diseases by 2030. We provided global, regional, and national estimates of the burden of CRDs and their attributable risks from 1990 to 2019. Methods: Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we estimated mortality, years lived with disability, years of life lost, disability-adjusted life years (DALYs), prevalence, and incidence of CRDs, i.e. chronic obstructive pulmonary disease (COPD), asthma, pneumoconiosis, interstitial lung disease and pulmonary sarcoidosis, and other CRDs, from 1990 to 2019 by sex, age, region, and Socio-demographic Index (SDI) in 204 countries and territories. Deaths and DALYs from CRDs attributable to each risk factor were estimated according to relative risks, risk exposure, and the theoretical minimum risk exposure level input. Findings: In 2019, CRDs were the third leading cause of death responsible for 4.0 million deaths (95% uncertainty interval 3.6–4.3) with a prevalence of 454.6 million cases (417.4–499.1) globally. While the total deaths and prevalence of CRDs have increased by 28.5% and 39.8%, the age-standardised rates have dropped by 41.7% and 16.9% from 1990 to 2019, respectively. COPD, with 212.3 million (200.4–225.1) prevalent cases, was the primary cause of deaths from CRDs, accounting for 3.3 million (2.9–3.6) deaths. With 262.4 million (224.1–309.5) prevalent cases, asthma had the highest prevalence among CRDs. The age-standardised rates of all burden measures of COPD, asthma, and pneumoconiosis have reduced globally from 1990 to 2019. Nevertheless, the age-standardised rates of incidence and prevalence of interstitial lung disease and pulmonary sarcoidosis have increased throughout this period. Low- and low-middle SDI countries had the highest age-standardised death and DALYs rates while the high SDI quintile had the highest prevalence rate of CRDs. The highest deaths and DALYs from CRDs were attributed to smoking globally, followed by air pollution and occupational risks. Non-optimal temperature and high body-mass index were additional risk factors for COPD and asthma, respectively. Interpretation: Albeit the age-standardised prevalence, death, and DALYs rates of CRDs have decreased, they still cause a substantial burden and deaths worldwide. The high death and DALYs rates in low and low-middle SDI countries highlights the urgent need for improved preventive, diagnostic, and therapeutic measures. Global strategies for tobacco control, enhancing air quality, reducing occupational hazards, and fostering clean cooking fuels are crucial steps in reducing the burden of CRDs, especially in low- and lower-middle income countries

Global burden of peripheral artery disease and its risk factors, 1990–2019 : a systematic analysis for the Global Burden of Disease Study 2019

peripheral artery disease were modelled using the Global Burden of Disease, Injuries, and Risk Factors Study (GBD) 2019 database. Prevalence, disability-adjusted life years (DALYs), and mortality estimates of peripheral artery disease were extracted from GBD 2019. Total DALYs and age-standardised DALY rate of peripheral artery disease attributed to modifiable risk factors were also assessed. Findings In 2019, the number of people aged 40 years and older with peripheral artery disease was 113 million (95% uncertainty interval [UI] 99·2–128·4), with a global prevalence of 1·52% (95% UI 1·33–1·72), of which 42·6% was in countries with low to middle Socio-demographic Index (SDI). The global prevalence of peripheral artery disease was higher in older people, (14·91% [12·41–17·87] in those aged 80–84 years), and was generally higher in females than in males. Globally, the total number of DALYs attributable to modifiable risk factors in 2019 accounted for 69·4% (64·2–74·3) of total peripheral artery disease DALYs. The prevalence of peripheral artery disease was highest in countries with high SDI and lowest in countries with low SDI, whereas DALY and mortality rates showed U-shaped curves, with the highest burden in the high and low SDI quintiles. Interpretation The total number of people with peripheral artery disease has increased globally from 1990 to 2019. Despite the lower prevalence of peripheral artery disease in males and low-income countries, these groups showed similar DALY rates to females and higher-income countries, highlighting disproportionate burden in these groups. Modifiable risk factors were responsible for around 70% of the global peripheral artery disease burden. Public measures could mitigate the burden of peripheral artery disease by modifying risk factors

Burden of non-communicable diseases among adolescents aged 10–24 years in the EU, 1990–2019: a systematic analysis of the Global Burden of Diseases Study 2019

Background Disability and mortality burden of non-communicable diseases (NCDs) have risen worldwide; however, the NCD burden among adolescents remains poorly described in the EU. Methods Estimates were retrieved from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Causes of NCDs were analysed at three different levels of the GBD 2019 hierarchy, for which mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) were extracted. Estimates, with the 95% uncertainty intervals (UI), were retrieved for EU Member States from 1990 to 2019, three age subgroups (10–14 years, 15–19 years, and 20–24 years), and by sex. Spearman's correlation was conducted between DALY rates for NCDs and the Socio-demographic Index (SDI) of each EU Member State. Findings In 2019, NCDs accounted for 86·4% (95% uncertainty interval 83·5–88·8) of all YLDs and 38·8% (37·4–39·8) of total deaths in adolescents aged 10–24 years. For NCDs in this age group, neoplasms were the leading causes of both mortality (4·01 [95% uncertainty interval 3·62–4·25] per 100 000 population) and YLLs (281·78 [254·25–298·92] per 100 000 population), whereas mental disorders were the leading cause for YLDs (2039·36 [1432·56–2773·47] per 100 000 population) and DALYs (2040·59 [1433·96–2774·62] per 100 000 population) in all EU Member States, and in all studied age groups. In 2019, among adolescents aged 10–24 years, males had a higher mortality rate per 100 000 population due to NCDs than females (11·66 [11·04–12·28] vs 7·89 [7·53–8·23]), whereas females presented a higher DALY rate per 100 000 population due to NCDs (8003·25 [5812·78–10 701·59] vs 6083·91 [4576·63–7857·92]). From 1990 to 2019, mortality rate due to NCDs in adolescents aged 10–24 years substantially decreased (–40·41% [–43·00 to –37·61), and also the YLL rate considerably decreased (–40·56% [–43·16 to –37·74]), except for mental disorders (which increased by 32·18% [1·67 to 66·49]), whereas the YLD rate increased slightly (1·44% [0·09 to 2·79]). Positive correlations were observed between DALY rates and SDIs for substance use disorders (rs=0·58, p=0·0012) and skin and subcutaneous diseases (rs=0·45, p=0·017), whereas negative correlations were found between DALY rates and SDIs for cardiovascular diseases (rs=–0·46, p=0·015), neoplasms (rs=–0·57, p=0·0015), and sense organ diseases (rs=–0·61, p=0·0005)

Global investments in pandemic preparedness and COVID-19: development assistance and domestic spending on health between 1990 and 2026

Background The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness. Methods In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need. Findings In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95$7·3 trillion (95% UI 7·2–7·4) in 2019; 293·7 times the $24·8 billion (95$43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and$37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11–21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP. Interpretation There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained

Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990-2050

Background The rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020. Methods We estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050. Findings In 2019, health spending globally reached$8. 8 trillion (95% uncertainty interval UI] 8.7-8.8) or $1132 (1119-1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total,$40.4 billion (0.5%, 95% UI 0.5-0.5) was development assistance for health provided to low-income and middle-income countries, which made up 24.6% (UI 24.0-25.1) of total spending in low-income countries. We estimate that $54.8 billion in development assistance for health was disbursed in 2020. Of this,$13.7 billion was targeted toward the COVID-19 health response. $12.3 billion was newly committed and$1.4 billion was repurposed from existing health projects. $3.1 billion (22.4$2.4 billion (17.9%) was for supply chain and logistics. Only $714.4 million (7.7$1519 (1448-1591) per person in 2050, although spending across countries is expected to remain varied. Interpretation Global health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd

Syndecan-1: From a Promising Novel Cardiac Biomarker to a Surrogate Early Predictor of Kidney and Liver Injury in Patients with Acute Heart Failure

(1) Background: Acute heart failure (HF) represents a complex clinical syndrome burdened by increased mortality and a high rate of systemic complications. Although natriuretic peptides (e.g., NT-proBNP) currently represent the diagnostic and prognostic gold standard in acute HF, those molecules do not accurately reflect all the pathophysiological mechanisms involved in the progression of this pathology when determined independently. Therefore, the current paradigm tends to focus on a multi-marker approach for the risk stratification of patients with acute HF. Syndecan-1 is a less studied biomarker in cardiovascular diseases; its assessment in patients with acute HF being potentially able to reflect the myocardial pathological changes, such as fibrosis, inflammation, endothelial dysfunction or global wall stress. (2) Methods: We conducted a single center prospective study that enrolled 173 patients (120 patients admitted for acute HF, compared to 53 controls with stable chronic HF). A complete standardized clinical, echocardiography and laboratory evaluation was performed at admission, including serum samples for the determination of syndecan-1 by the enzyme-linked immunosorbent assay (ELISA) method. (3) Results: The serum concentration of syndecan-1 was significantly higher in patients with acute HF, compared to controls [121.4 (69.3–257.9) vs. 72.1 (41.4–135.8) ng/mL, p = 0.015]. Syndecan-1 was a significant predictor for the diagnosis of acute HF, expressed by an area under the curve (AUC) of 0.898, similar to NT-proBNP (AUC: 0.976) or cardiac troponin (AUC: 0.839). Moreover, syndecan-1 was independently associated with impaired kidney and liver function at admission, being also a predictor for early, subclinical organ dysfunction in patients with normal biological parameters at admission. When included in the multi-marker model, syndecan-1 levels influenced mortality more significantly than NT-proBNP or troponin. A multivariable regression including syndecan-1, NT-proBNP and troponin provided additional prognostic value compared to each independent biomarker. (4) Conclusions: Syndecan-1 can be considered a promising novel biomarker in acute HF, exhibiting adequate diagnostic and prognostic value. Additionally, syndecan-1 can be used as a surrogate biomarker for non-cardiac organ dysfunction, as its highs levels can accurately reflect early acute kidney and liver injury