Background Data on stroke epidemiology and availability of hospital-based stroke services around the world are important for guiding policy decisions and healthcare planning. Aims To provide the most current incidence, mortality and case–fatality data on stroke and describe current availability of stroke units around the world by country. Methods We searched multiple databases (based on our existing search strategy) to identify new original manuscripts and review articles published between 1 June 2016 and 31 October 2018 that met the ideal criteria for data on stroke incidence and case–fatality. For data on the availability of hospital-based stroke services, we searched PubMed for all literature published up until 31 June 2018. We further screened reference lists, citation history of manuscripts and gray literature for this information. Mortality codes for International Classification of Diseases-9 and International Classification of Diseases-10 were extracted from the World Health Organization mortality database for each country providing these data. Population denominators were obtained from the World Health Organization, and when these were unavailable within a two-year period of mortality data, population denominators within a two-year period were obtained from the United Nations. Using country-specific population denominators and the most recent years of mortality data available for each country, we calculated both the crude mortality from stroke and mortality adjusted to the World Health Organization world population. Results Since our last report in 2017, there were two countries with new incidence studies, China (n = 1) and India (n = 2) that met the ideal criteria. New data on case–fatality were found for Estonia and India. The most current mortality data were available for the year 2015 (39 countries), 2016 (43 countries), and 2017 (7 countries). No new data on mortality were available for six countries. Availability of stroke units was noted for 63 countries, and the proportion of patients treated in stroke units was reported for 35/63 countries. Conclusion Up-to-date data on stroke incidence, case–fatality, and mortality statistics provide evidence of variation among countries and changing magnitudes of burden among high and low–middle income countries. Reporting of hospital-based stroke units remains limited and should be encouraged.
BACKGROUND AND AIMS Patients with fatty liver disease may experience stigma from the disease or comorbidities. In this cross-sectional study, we aimed to understand stigma among NAFLD patients and providers. METHODS Members of the Global NASH Council created two surveys about experiences/attitudes toward NAFLD and related diagnostic terms: 68-item patient and 41-item provider survey. RESULTS Surveys were completed by 1976 NAFLD patients [23 countries; 51% Middle East/North Africa (MENA), 19% Europe, 17% USA, 8% Southeast Asia (SEA), 5% South Asia]; 825 providers [67% GI/hepatologists, 25 countries; 39% MENA, 28% SEA, 22% USA, 6% South Asia, 3% Europe]. Of all patients, 48% ever disclosed having NAFLD/NASH to family/friends; most commonly used term was "fatty liver" (88% at least sometimes); "metabolic disease" or "MAFLD" were rarely used (never by >84%). Regarding various diagnostic terms perceptions by patients, there were no substantial differences between "NAFLD", "fatty liver disease (FLD)", "NASH", or "MAFLD". The most popular response was being neither comfortable nor uncomfortable with either term (56%-71%), with some greater discomfort with "FLD" among the U.S. and South Asian patients (47-52% uncomfortable). Although 26% of patients reported stigma related to overweight/obesity, only 8% reported history of stigmatization or discrimination due to NAFLD. Among providers, 38% believed that the term "fatty" was stigmatizing, while 34% believed that "nonalcoholic" was stigmatizing, more commonly in MENA (43%); 42% providers (GI/hepatologists 45% vs. 37% other specialties, p=0.03) believed that the name change might reduce stigma. Regarding new nomenclature [metabolic dysfunction associated steatotic liver disease (MASLD)], the percent of providers reporting "steatotic liver disease" as stigmatizing was low (14%). CONCLUSIONS Perception of NAFLD stigma varies among patients, providers, geographic locations and sub-specialties. LAY SUMMARY- Despite the increasing burden of NAFLD and the fact that over 38% of the world's adult population have NAFLD, disease awareness remains low. One potential issue that may affect awareness is the stigma associated with the terms, "non-alcoholic" and "fatty". In this global study, we found that the terms patients and physicians thought to cause stigma were different. These differences may negatively affect provider-patient communication hindering prompt intervention. These results can help inform education about this liver disease especially as the new nomenclature of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is being implemented. IMPACT AND IMPLICATIONS Over the past decades, efforts have been underway to change the nomenclature of NAFLD to better align with its underlying pathogenetic pathways and remove any potential stigma associated with the name. Given the paucity of data related to stigma in NAFLD, we undertook this global comprehensive survey to assess stigma in NAFLD among patients and providers from around the world. We found there is a disconnect between physicians and patients related to stigma and related nomenclature. With this knowledge, educational programs can be developed to better target stigma in NAFLD among all stakeholders and to provide a better opportunity for the new nomenclature to address the issues of stigma.
Hailemariam Gezie, A. Azazh, Birhanu Melaku
et al.
Background Hypertension (HTN) is a major global health problem that affects approximately 1.13 billion people worldwide, and 1–2% of this population has hypertensive crisis. Hypertensive crisis is becoming a major health issue in low-income countries. However, few studies have been conducted in developing countries such as Ethiopia. This study aimed to assess the determinants of hypertensive crisis among patients visiting adult emergency departments of public hospitals in Addis Ababa. Method A hospital-based unmatched case–control study was conducted among 85 cases with a hypertensive crisis and 170 controls with hypertension without a hypertensive crisis in the adult emergency departments of public hospitals in Addis Ababa from March 15 to May 15, 2021. Data were collected using a structured questionnaire and analyzed using SPSS version 26. Binary logistic regression and multivariable logistic regression were performed. Finally, a statistically significant level was declared at a p value of less than 0.05. The result was summarized and presented in text, tables, and graph. Result The odds of having hypertensive crisis were 3.6 times (AOR = 3.621) higher among participants with a history of hypertension compared to those without a history of hypertension. There was also 4 times increased risk of hypertensive crisis among participants who presented with diabetes mellitus than participants who presented without it (AOR = 4.179). Similarly, participants who presented with stroke had 7 times higher odds of having hypertensive crisis (AOR = 7.174) than participants without stroke. Conclusion This study demonstrated a statistically significant association between unemployment, diabetes mellitus, stroke, heart failure, history of hypertension, family history of hypertension, and regular follow-up with a hypertensive crisis. The Ethiopian Ministry of Health, Ababa City Administration Health Bureau, and hospitals shall give due attention to the HTN crisis. Health care workers, hospital managers, and other stakeholders shall work towards the early detection and management of HTN-crisis to prevent related morbidity, disability, and mortality.
Screening with Low-dose computed tomography (LDCT) of high-risk individuals with a smoking history reduces lung cancer mortality. Current screening guidelines and eligibility criteria can miss over 50% of lung cancers, and in some geographical areas, like East Asia, a large proportion of the missed lung cancers are in never-smokers. Although randomized trials demonstrated the benefits of screening for people who smoke, these trials generally excluded never-smokers. Thus, the feasibility and effectiveness of lung cancer screening of individuals never -smoked is uncertain. Several known and suspected risk factors for lung cancers in never-smokers such as exposure to secondhand smoke, occupational carcinogens, radon, air pollution, and pulmonary diseases, such as COPD and interstitial lung diseases and intrinsic factors, such as age are well noted. In this regard, knowledge of risk factors may make possible quantification and prediction of lung cancer risk in never-smokers. It is worth considering if and how never-smokers could be included in population-based screening programs. As the implementation of these programs is challenging in many countries due to multiple factors and the epidemiological differences by global regions, these issues will need to be evaluated in each country taking into account various factors, including accuracy of risk assessment and cost-effectiveness of screening in never-smokers. This report aims to outline current knowledge about risk factors for lung cancer in never-smokers, to propose research strategies for this topic, and initiate a broader discussion about lung cancer screening of never-smokers. Similar considerations can be made in current and ex-smokers, which don't fulfill the current screening inclusion criteria, but otherwise are at increased risk. Although screening of never-smokers may in the future be effectively conducted, current evidence to support widespread implementation of this practice is lacking.
BACKGROUND Venous thromboembolism (VTE), although rare, is a major cause of maternal mortality and morbidity. Some women are at increased risk of VTE during pregnancy and the early postnatal period (e.g. caesarean section, family history of VTE, or thrombophilia), and so prophylaxis may be considered. As some methods of prophylaxis carry risks of adverse effects, and risk of VTE is often low, benefits of thromboprophylaxis may be outweighed by harms. OBJECTIVES To assess the effects of thromboprophylaxis during pregnancy and the early postnatal period on the risk of venous thromboembolic disease and adverse effects in women at increased risk of VTE. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 October 2019). In addition, we searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for unpublished, planned and ongoing trial reports (18 October 2019). SELECTION CRITERIA Randomised trials comparing one method of thromboprophylaxis with placebo or no treatment, or two (or more) methods of thromboprophylaxis. DATA COLLECTION AND ANALYSIS At least two review authors assessed trial eligibility, extracted data, assessed risk of bias, and judged certainty of evidence for selected critical outcomes (using GRADE). We conducted fixed-effect meta-analysis and reported data (all dichotomous) as summary risk ratios (RRs) with 95% confidence intervals (CIs). MAIN RESULTS Twenty-nine trials (involving 3839 women), overall at moderate to high risk of bias were included. Trials were conducted across the antenatal, peripartum and postnatal periods, with most in high-income countries. Interventions included types and regimens of heparin (low molecular weight heparin (LMWH) and unfractionated heparin (UFH)), hydroxyethyl starch (HES), and compression stockings or devices. Data were limited due to a small number of trials in comparisons and/or few or no events reported. All critical outcomes (assessed for comparisons of heparin versus no treatment/placebo, and LMWH versus UFH) were considered to have very low-certainty evidence, downgraded mainly for study limitations and imprecise effect estimates. Maternal death was not reported in most studies. Antenatal (± postnatal) prophylaxis For the primary outcomes symptomatic thromboembolic events pulmonary embolism (PE) and/or deep vein thrombosis (DVT), and the critical outcome of adverse effects sufficient to stop treatment, the evidence was very uncertain. Symptomatic thromboembolic events: - heparin versus no treatment/placebo (RR 0.39; 95% CI 0.08 to 1.98; 4 trials, 476 women; very low-certainty evidence); - LMWH versus UFH (RR 0.47; 95% CI 0.09 to 2.49; 4 trials, 404 women; very low-certainty evidence); Symptomatic PE: - heparin versus no treatment/placebo (RR 0.33; 95% CI 0.02 to 7.14; 3 trials, 187 women; very low-certainty evidence); - LMWH versus UFH (no events; 3 trials, 287 women); Symptomatic DVT: - heparin versus no treatment/placebo (RR 0.33; 95% CI 0.04 to 3.10; 4 trials, 227 women; very low-certainty evidence); - LMWH versus UFH (no events; 3 trials, 287 women); Adverse effects sufficient to stop treatment: - heparin versus no treatment/placebo (RR 0.49; 95% CI 0.05 to 5.31; 1 trial, 139 women; very low-certainty evidence); - LMWH versus UFH (RR 0.07; 95% CI 0.01 to 0.54; 2 trials, 226 women; very low-certainty evidence). Peripartum/postnatal prophylaxis Vaginal or caesarean birth When UFH and no treatment were compared, the effects on symptomatic thromboembolic events (RR 0.16; 95% CI 0.02 to 1.36; 1 trial, 210 women; very low-certainty evidence), symptomatic PE (RR 0.16; 95% CI 0.01 to 3.34; 1 trial, 210 women; very low-certainty evidence), and symptomatic DVT (RR 0.27; 95% CI 0.03 to 2.55; 1 trial, 210 women; very low-certainty evidence) were very uncertain. Maternal death and adverse effects sufficient to stop treatment were not reported. Caesarean birth Symptomatic thromboembolic events: - heparin versus no treatment/placebo (RR 1.30; 95% CI 0.39 to 4.27; 4 trials, 840 women; very low-certainty evidence); - LMWH versus UFH (RR 0.33; 95% CI 0.01 to 7.99; 3 trials, 217 women; very low-certainty evidence); Symptomatic PE: - heparin versus no treatment/placebo (RR 1.10; 95% CI 0.25 to 4.87; 4 trials, 840 women; very low-certainty evidence); - LMWH versus UFH (no events; 3 trials, 217 women); Symptomatic DVT: - heparin versus no treatment/placebo (RR 1.30; 95% CI 0.24 to 6.94; 5 trials, 1140 women; very low-certainty evidence); LMWH versus UFH (RR 0.33; 95% CI 0.01 to 7.99; 3 trials, 217 women; very low-certainty evidence); Maternal death: - heparin versus placebo (no events, 1 trial, 300 women); Adverse effects sufficient to stop treatment: - heparin versus placebo (no events; 1 trial, 140 women). Postnatal prophylaxis No events were reported for LMWH versus no treatment/placebo for: symptomatic thromboembolic events, symptomatic PE and symptomatic DVT (all 2 trials, 58 women), or maternal death (1 trial, 24 women). Adverse effects sufficient to stop treatment were not reported. We were unable to conduct subgroup analyses due to lack of data. Sensitivity analysis including the nine studies at low risk of bias did not impact overall findings. AUTHORS' CONCLUSIONS The evidence is very uncertain about benefits and harms of VTE thromboprophylaxis in women during pregnancy and the early postnatal period at increased risk of VTE. Further high-quality very large-scale randomised trials are needed to determine effects of currently used treatments in women with different VTE risk factors. As sufficiently large definitive trials are unlikely to be funded, secondary data analyses based on high-quality registry data are important.
Inborn errors of immunity (IEIs) are a heterogeneous group of genetic defects of immunity, which cause high rates of morbidity and mortality mainly among children due to infectious and non-infectious complications. The IEI burden has been critically underestimated in countries from middle- and low-income regions and the majority of patients with IEI in these regions lack a molecular diagnosis. We analyzed the clinical, immunologic, and genetic data of IEI patients from 22 countries in the Middle East and North Africa (MENA) region. The data was collected from national registries and diverse databases such as the Asian Pacific Society for Immunodeficiencies (APSID) registry, African Society for Immunodeficiencies (ASID) registry, Jeffrey Modell Foundation (JMF) registry, J Project centers, and International Consortium on Immune Deficiency (ICID) centers. We identified 17,120 patients with IEI, among which females represented 39.4%. Parental consanguinity was present in 60.5% of cases and 27.3% of the patients were from families with a confirmed previous family history of IEI. The median age of patients at the onset of disease was 36 months and the median delay in diagnosis was 41 months. The rate of registered IEI patients ranges between 0.02 and 7.58 per 100,000 population, and the lowest rates were in countries with the highest rates of disability-adjusted life years (DALY) and death rates for children. Predominantly antibody deficiencies were the most frequent IEI entities diagnosed in 41.2% of the cohort. Among 5871 patients genetically evaluated, the diagnostic yield was 83% with the majority (65.2%) having autosomal recessive defects. The mortality rate was the highest in patients with non-syndromic combined immunodeficiency (51.7%, median age: 3.5 years) and particularly in patients with mutations in specific genes associated with this phenotype (RFXANK, RAG1, and IL2RG). This comprehensive registry highlights the importance of a detailed investigation of IEI patients in the MENA region. The high yield of genetic diagnosis of IEI in this region has important implications for prevention, prognosis, treatment, and resource allocation.
Objective To conduct a meta-analysis to determine the association between prenatal drug exposure and risk of sudden infant death syndrome (SIDS). Design Studies were searched using PubMed, Medline and Embase and restricted to English, with no publication date limit. Selected studies included published cohort, population or case studies comparing the incidence of SIDS among drug-exposed with drug-free controls. This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Data were pooled using a random-effects model to evaluate risk ratios (RR). Setting High-income countries. Patients Children with a history of prenatal drug exposure. Interventions None. Main outcome measures RR of SIDS between drug-exposed and control infants. Results Sixteen studies (36 730 infants with any prenatal drug exposure, 21 661 exposed to opioids, 21 571 exposed to cocaine, 5031 exposed to methadone compared with 4 201 955 with no exposure). Any prenatal drug exposure was associated with an increased crude risk of SIDS (RR 7.84, 95% CI 5.21 to 11.81). Prenatal opioid exposure had the highest associative crude risk of SIDS (RR 9.76, 95% CI 5.28 to 18.05), followed by methadone (RR 9.52, 95% CI 4.60 to 19.70) and cocaine (RR 4.40, 95% CI 2.52 to 7.67). Increased crude risk persisted after adjusting for socioeconomic factors (RR 4.24, 95% CI 1.39 to 12.88). The incidence of SIDS for this cohort decreased between 1972 and 2020 but remained significantly higher than controls. Conclusion Exposure to any drug of dependency during pregnancy is associated with an increased risk of SIDS after controlling for socioeconomic factors. Further study to evaluate mechanisms and contribution of other confounders (eg, smoking) is warranted. This meta-analyses of 4,238,685 children from high-income countries found that while prenatal exposure to any drugs of dependency increased SIDS risk this was greatest for infants prenatally exposed to opioids and methadone. Further research to examine associations in low- and middle-income countries is needed.
Alessandro di Nallo, O. Lipps, Daniel Oesch
et al.
Funding information Swiss National Science Foundation; NORFACE network Abstract Objective: This article examines how unemployment affects the separation risk of heterosexual coresiding couples, depending on couples’ household income and whether men or women become unemployed. Background: Unemployment may decrease the separation risk as a drop in resources makes separation more costly— or it may increase the separation risk if unemployment creates stress and reduces the quality of couple relations. Moreover, unemployment may be more detrimental for couples if men rather than women, or low-earners rather than high-earners, become unemployed. Method: This article adopts a couple perspective and assesses heterogeneous effects of unemployment on separation based on longitudinal data—large household panels from Germany and the UK using discrete-time event history models. Results: For both countries, results show that the annual separation rate almost doubles after an unemployment spell: It increases from 0.9% to 1.6% per year. This effect does not vary when men or women lose their job. The separation risk after unemployment is somewhat higher for low-income couples than high-income couples in the UK, but overall differences are small. Conclusion: Findings show that unemployment does not strengthen unions, but makes them more vulnerable— regardless of which partner becomes unemployed and regardless of a household’s economic resources.
Research on the dangers of democratization has long warned of the potential for elections to spark civil conflict. Yet, this work has remained surprisingly isolated from the burgeoning body of research on electoral integrity. We open the “black box” of elections to theorize how variation in their quality shapes the opportunities and incentives for military conflict. We argue that electoral integrity matters by influencing perceptions about the legitimacy of political outcomes and about actors’ willingness to play by the rules. While high-quality elections should not exacerbate the risk of civil conflict, low-integrity contests foster grievances and decrease the ability of the government and opposition to make credible commitments to avert violence. We find firm support for our hypothesis: flawed presidential elections increase the risk of conflict, especially in countries with a history of civil conflict. These findings are robust to methods to address the endogeneity of elections and electoral quality.
Background Addressing inequalities in mental healthcare utilisation among university students is important for socio-political transformation, particularly in countries with a history of educational exclusion. Methods As part of the WHO World Mental Health International College Student Initiative, we investigated inequalities in mental healthcare utilisation among first-year students at two historically “White” universities in South Africa. Data were collected via a web-based survey from first-year university students (n = 1402) to assess 12-month mental healthcare utilisation, common mental disorders, and suicidality. Multivariate logistic regression models were used to estimate associations between sociodemographic variables and mental healthcare utilisation, controlling for common mental disorders and suicidality. Results A total of 18.1% of students utilised mental healthcare in the past 12 months, with only 28.9% of students with mental disorders receiving treatment (ranging from 28.1% for ADHD to 64.3% for bipolar spectrum disorder). Of those receiving treatment, 52.0% used psychotropic medication, 47.3% received psychotherapy, and 5.4% consulted a traditional healer. Treatment rates for suicidal ideation, plan and attempt were 25.4%, 41.6% and 52.9%, respectively. In multivariate regression models that control for the main effects of mental health variables and all possible joint effects of sociodemographic variables, the likelihood of treatment was lower among males (aOR = 0.57) and Black students (aOR = 0.52). An interaction was observed between sexual orientation and first generation status; among second-generation students, the odds of treatment were higher for students reporting an atypical sexual orientation (aOR = 1.55), while among students with atypical sexual orientations, the likelihood of mental healthcare utilisation was lower for first-generation students (aOR = 0.29). Odds of treatment were significantly elevated among students with major depressive disorder (aOR = 1.88), generalised anxiety disorder (aOR = 2.34), bipolar spectrum disorder (aOR = 4.07), drug use disorder (aOR = 3.45), suicidal ideation (without plan or attempt) (aOR = 2.00), suicide plan (without attempt) (aOR = 3.64) and suicide attempt (aOR = 4.57). Likelihood of treatment increased with level of suicidality, but not number of mental disorders. Conclusion We found very low mental healthcare treatment utilisation among first-year university students in South Africa, with enduring disparities among historically marginalised groups. Campus-based i nterventions are needed to promote mental healthcare utilisation by first-year students in South Africa, especially among male and Black students and first-generation students with atypical sexual orientations.
Bangladesh has a long history of devastating tropical cyclones. In view of the effects of the storms on the country, risk assessment is essential for devising the mitigation strategies at various levels. By way of bringing the conceptual structure of general risk model in practice, this work aims to examine the spatial patterns of cyclone risk in the Cox's Bazar district (I) and Rohingya refugee camps (II) located on the southeastern coast of Bangladesh. We use 14 parameters representing the hazard, exposure, and vulnerability as the components of risk. The selected parameters were analyzed and integrated though the complementary use of Analytic Hierarchy Process (AHP) and Geographic Information System (GIS) for depicting the cyclone risk situation comprehensively at both the spatial scales. The status of the cyclone risk was identified and quantified as very high (6.84%, 3.43%), high (45.78%, 27.82%), moderate (5.97%, 39.42%), low (40.62%, 28.70%), and very low (0.81%, 0.61%) for the spatial scale I and II respectively. In general, northwestern and southern peripheral areas exhibited higher risk than the central and northeastern parts of the Cox's Bazar district; and in the refugee settlements, camp number 1E, 1W, 7, and 13 revealed relatively higher levels of the risk. The results of the assessment (I) were correlated with experiential damage from the 1991 cyclone; a reasonable consistency was noticed between the simulated scenario and the observed impacts. We assume that the deliverables of this spatial analysis could be useful to stakeholders while formulating the cyclone risk mitigation policies for the region. Furthermore, this work demonstrates that the applied method would deliver reliable results if tested in other coastal environments.