METHODS: To estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10-54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression-Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values-a metric assessing gain in forecasting accuracy-by comparing predicted versus observed ASFRs from the past 15 years (2007-21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline.
FINDINGS: During the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63-5·06) to 2·23 (2·09-2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137-147), declining to 129 million (121-138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1-canonically considered replacement-level fertility-in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7-29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59-2·08) in 2050 and 1·59 (1·25-1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6-43·1) in 2050 and 54·3% (47·1-59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions-decreasing, for example, in south Asia from 24·8% (23·7-25·8) in 2021 to 16·7% (14·3-19·1) in 2050 and 7·1% (4·4-10·1) in 2100-but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40-1·92) in 2050 and 1·62 (1·35-1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction.
INTERPRETATION: Fertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world.
FUNDING: Bill & Melinda Gates Foundation.
METHODS: This cross-sectional study examined demographic, clinical and biochemical data of all newly diagnosed Malaysian children aged 0-18 years with T1DM over 11 years from a single centre. Regression analyses were used to determine predictors and trends.
RESULTS: The overall DKA rate was 73.2%, 54.9% of the DKA cases were severe. Age ≥5 years [odds ratio (OR): 12.29, 95% confidence interval (CI): 1.58, 95.58, p=0.017] and misdiagnosis (OR: 3.73, 95% CI: 1.36, 10.24 p=0.01) were significant predictors of a DKA presentation. No significant trends in the annual rates of DKA, severe DKA nor children <5 years presenting with DKA were found during study period.
CONCLUSION: DKA rates at initial diagnosis of T1DM in Malaysian children are high and severe DKA accounts for a notable proportion of these. Though misdiagnosis and age ≥5 years are predictors of DKA, misdiagnosis can be reduced through better awareness and education. The lack of downward trends in DKA and severe DKA highlights the urgency to develop measures to curb its rates.
METHODS: A retrospective, single-centre cohort study was performed on all paediatric patients who had undergone laryngoscopy and LUS at Starship Children's Health in Auckland, NZ, between 2020 and 2023. An eight-question survey was also developed and distributed to better understand clinicians' use of LUS in their clinical practice to diagnose paediatric VFI globally.
RESULTS: Twenty-nine paediatric patients met the inclusion criteria. LUS demonstrated good sensitivity (80.95%) for detecting VFI and increased to 93.33% for the detection of unilateral VFI. Of the 87 respondents to the survey, 41.38% utilise LUS in their clinical practice in the paediatric population. The main barriers to implementation of LUS as identified by non-users were lack of equipment, expertise, and training.
CONCLUSIONS: These findings support the use of LUS as an accurate diagnostic tool for the detection of unilateral VFI. Further studies in non-surgical populations and in patients with bilateral VFI, as well as standardised guidelines for LUS technique and reporting, are required.
MATERIALS AND METHODS: We conducted a retrospective cross-sectional study on the VNS done in Malaysia. We included DRE patients from all age groups who underwent VNS from 1st January 2000 to 31st December 2022. We analysed the efficacy of VNS for patients with at least one year of implantation.
RESULTS: A total of 62 implantations were performed from 2000 to 2022. Most patients (52.5%) had implantation at <18 years old, 54.0% had focal seizures, 34.4% had Lennox Gastaut Syndrome and 23.0% had developmental epileptic encephalopathy. A total of 22.6%, 42.8%, and 63.3% of patients achieve ≥ 50% seizure reduction at three months, six months, and one-year post-implantation, respectively. At their last follow-up, 73.5% of patients had ≥ 50% seizure reduction. The majority of responders were at a current intensity of ≥ 2mA (98.0%) and 81.6% were at a duty cycle of ≥35%. No significant difference was found between responders and non-responders by age at implantation, duration of epilepsy, and seizure type.
CONCLUSION: VNS is effective for patients with refractory epilepsy in Malaysia with two-third achieving more than 50% seizure reduction at one year and the last follow-up.
MATERIALS AND METHODS: An interview-based qualitative study was conducted in a public university hospital in Malaysia, utilizing in-depth interviews. Audio recordings of the interviews were transcribed verbatim. The transcript data were coded, and the codes were then organized into themes using a thematic analysis approach.
RESULTS: Data from twelve mothers and three fathers among a total of fifteen children with CP were acquired. Nine themes were derived from transcript data namely : HT is a simple home prescription,HT empowers and enhances experiences of care, Negative experience, goal-directed positive attitude, External Support System, physical health as a barrier, psychological health as barrier, limited time and limited external support system.
CONCLUSION: Real-life experiences of parents with CP children regarding HT was explored and valuable outcomes were derived from this study to help clinicians to manage children with CP more efficiently and understand their family dynamics better in the local context. Overall, parents perceived HT as doable and it provided physical, functional, and psychological benefits for them as well as improved their confidence and skills to perform exercises on their children and empowered them to monitor their children's progression.
MATERIALS AND METHODS: A cross-sectional study was conducted by recruiting normal-hearing children aged 3-8 years old with ASD presenting to a national referral ENT clinic between October and December 2023. The severity of ASD was assessed using the Childhood Autism Rating Scale (CARS), while hyperacusis was diagnosed using Modified Check List for Autism in Toddlers, Revised (M-CHAT-R).
RESULTS: A total of 26 children with ASD, 23 of whom were male (88%), aged 3-8 years, were included in the analyses. Among these children, 18 (69.2%) had hyperacusis. Analysis of ABR click revealed a prolonged interpeak latency wave I and III (88.5%), followed by a prolonged latency in wave III (42.3%) and V (21.2%). Neither ABR wave latencies nor hyperacusis were correlated with the severity of ASD, although there was a marginally significant association between wave III latency and CARS score in the left ear (r=0.359, p=0.072). However, wave V latency and interpeak wave I-V latency were significantly longer in children without hyperacusis (right ear: p=0.042 and p=0.050; left ear: p=0.005 and p=0.004), while interpeak wave III-V only in the left ear (p=0.006) and wave III only in the right ear (p=0.029).
CONCLUSION: There was no significant correlation between ABR wave latencies or hyperacusis and the severity of ASD, while ABR wave latencies were generally longer in children without hyperacusis. Further large studies involving a broader spectrum of children with ASD are warranted to confirm our findings.
AIM: This study seeks to evaluate the effective radiation doses associated with common diagnostic and treatment procedures, as well as propose diagnostic reference levels (DRLs), within two nuclear medicine centers in Madinah, Saudi Arabia.
METHODOLOGY: Data from 445 patients were gathered from two nuclear medicine centers in the Madinah region of Saudi Arabia. The data were categorized based on the type of nuclear medicine (NM) procedure, the chemical composition of the administered radiopharmaceutical, as well as patient age and weight. Effective radiation doses for prevalent NM procedures were computed, and suggested DRLs were formulated.
RESULTS: Effective radiation doses were analyzed for 16 adult and 2 pediatric NM procedures (divided into 8 groups). The effective radiation doses for adult diagnostic nuclear medicine procedures range from 0.05 mSv (Nanocoloid) to 29 mSv (67Ga-citrate). For pediatric procedures, the doses range from 0.80 mSv (5-year-old undergoing renal DTPA) to 1.6 mSv (1-year-old undergoing renal DMSA). Furthermore, DRL values were determined for both adult and pediatric NM procedures. The study's findings demonstrated a high degree of concordance between effective radiation doses and DRL values, aligning well with previously published research.
CONCLUSION: While the effective radiation doses outlined in this study were generally within acceptable limits and consistent with prior research findings, optimizing radiation doses remains imperative, particularly for pediatric NM procedures.
METHODS: Caregivers (n = 59) of children with ALL were allocated to both groups (intervention, n = 29; TAU control, n = 30) via the SNOSE method. The intervention is a physical copy of a 2-week psychosocial self-help guidebook. Scores on the PCL-5, BDI and BAI were recorded at baseline, post-intervention and 1-month follow-up.
RESULTS: There was a statistically significant difference in traumatic stress symptoms post intervention (F(1, 57) = 5.760, p = .020, np2 = 0.093) in favor of the intervention group. No statistical significance was found for its effect at one-month follow-up, overall depression and anxiety.
CONCLUSION: A psychosocial module developed for caregivers of children with ALL was found to be effective in reducing symptoms of traumatic stress and potentially depression. However, the maintenance of its effectiveness and the effectiveness on anxiety requires further study.
METHODS: We estimated all-age and age-specific deaths and disability-adjusted life-years (DALYs) attributable to and associated with bacterial AMR for 22 pathogens, 84 pathogen-drug combinations, and 11 infectious syndromes in 204 countries and territories from 1990 to 2021. We collected and used multiple cause of death data, hospital discharge data, microbiology data, literature studies, single drug resistance profiles, pharmaceutical sales, antibiotic use surveys, mortality surveillance, linkage data, outpatient and inpatient insurance claims data, and previously published data, covering 520 million individual records or isolates and 19 513 study-location-years. We used statistical modelling to produce estimates of AMR burden for all locations, including those with no data. Our approach leverages the estimation of five broad component quantities: the number of deaths involving sepsis; the proportion of infectious deaths attributable to a given infectious syndrome; the proportion of infectious syndrome deaths attributable to a given pathogen; the percentage of a given pathogen resistant to an antibiotic of interest; and the excess risk of death or duration of an infection associated with this resistance. Using these components, we estimated disease burden attributable to and associated with AMR, which we define based on two counterfactuals; respectively, an alternative scenario in which all drug-resistant infections are replaced by drug-susceptible infections, and an alternative scenario in which all drug-resistant infections were replaced by no infection. Additionally, we produced global and regional forecasts of AMR burden until 2050 for three scenarios: a reference scenario that is a probabilistic forecast of the most likely future; a Gram-negative drug scenario that assumes future drug development that targets Gram-negative pathogens; and a better care scenario that assumes future improvements in health-care quality and access to appropriate antimicrobials. We present final estimates aggregated to the global, super-regional, and regional level.
FINDINGS: In 2021, we estimated 4·71 million (95% UI 4·23-5·19) deaths were associated with bacterial AMR, including 1·14 million (1·00-1·28) deaths attributable to bacterial AMR. Trends in AMR mortality over the past 31 years varied substantially by age and location. From 1990 to 2021, deaths from AMR decreased by more than 50% among children younger than 5 years yet increased by over 80% for adults 70 years and older. AMR mortality decreased for children younger than 5 years in all super-regions, whereas AMR mortality in people 5 years and older increased in all super-regions. For both deaths associated with and deaths attributable to AMR, meticillin-resistant Staphylococcus aureus increased the most globally (from 261 000 associated deaths [95% UI 150 000-372 000] and 57 200 attributable deaths [34 100-80 300] in 1990, to 550 000 associated deaths [500 000-600 000] and 130 000 attributable deaths [113 000-146 000] in 2021). Among Gram-negative bacteria, resistance to carbapenems increased more than any other antibiotic class, rising from 619 000 associated deaths (405 000-834 000) in 1990, to 1·03 million associated deaths (909 000-1·16 million) in 2021, and from 127 000 attributable deaths (82 100-171 000) in 1990, to 216 000 (168 000-264 000) attributable deaths in 2021. There was a notable decrease in non-COVID-related infectious disease in 2020 and 2021. Our forecasts show that an estimated 1·91 million (1·56-2·26) deaths attributable to AMR and 8·22 million (6·85-9·65) deaths associated with AMR could occur globally in 2050. Super-regions with the highest all-age AMR mortality rate in 2050 are forecasted to be south Asia and Latin America and the Caribbean. Increases in deaths attributable to AMR will be largest among those 70 years and older (65·9% [61·2-69·8] of all-age deaths attributable to AMR in 2050). In stark contrast to the strong increase in number of deaths due to AMR of 69·6% (51·5-89·2) from 2022 to 2050, the number of DALYs showed a much smaller increase of 9·4% (-6·9 to 29·0) to 46·5 million (37·7 to 57·3) in 2050. Under the better care scenario, across all age groups, 92·0 million deaths (82·8-102·0) could be cumulatively averted between 2025 and 2050, through better care of severe infections and improved access to antibiotics, and under the Gram-negative drug scenario, 11·1 million AMR deaths (9·08-13·2) could be averted through the development of a Gram-negative drug pipeline to prevent AMR deaths.
INTERPRETATION: This study presents the first comprehensive assessment of the global burden of AMR from 1990 to 2021, with results forecasted until 2050. Evaluating changing trends in AMR mortality across time and location is necessary to understand how this important global health threat is developing and prepares us to make informed decisions regarding interventions. Our findings show the importance of infection prevention, as shown by the reduction of AMR deaths in those younger than 5 years. Simultaneously, our results underscore the concerning trend of AMR burden among those older than 70 years, alongside a rapidly ageing global community. The opposing trends in the burden of AMR deaths between younger and older individuals explains the moderate future increase in global number of DALYs versus number of deaths. Given the high variability of AMR burden by location and age, it is important that interventions combine infection prevention, vaccination, minimisation of inappropriate antibiotic use in farming and humans, and research into new antibiotics to mitigate the number of AMR deaths that are forecasted for 2050.
FUNDING: UK Department of Health and Social Care's Fleming Fund using UK aid, and the Wellcome Trust.
AIMS: The PEACH in Asia pilot study aimed to test the feasibility of a standardized protocol for investigating SCEs in anesthesia practices across Asia, evaluate the data acquisition processes, and determine the sample size for a main study.
METHODS: This multicenter pilot study involved ten institutions across nine Asian countries, including children from birth to 15 years undergoing diagnostic or surgical procedures. Data on SCEs were collected using standardized definitions. The study assessed the feasibility and estimated the sample size needed for the main study.
RESULTS: The pilot study enrolled 330 patients, with a SCE incidence of 12.4% (95% CI: 9.2-16.4%). Respiratory events were observed in 7.0% of cases, cardiovascular instability in 4.9%, and drug errors in 0.6%. Based on the SCE incidence observed in the pilot study, the estimated sample size required for the main study is at least 10 958 patients. The pilot study demonstrated the feasibility of the study protocol but identified several challenges, particularly in resource-limited settings. These challenges included a significant burden associated with data collection, technical issues with electronic case report forms (e-CRFs), variability in patient enrollment across institutions (ranging from 4 to 86 patients per site), and incomplete data acquisition (24.8% of height data and 9.7% of disposition data were missing).
CONCLUSIONS: The PEACH in Asia pilot study successfully validated a protocol for investigating SCEs in pediatric anesthesia across Asia. Addressing the challenges identified in the pilot study will be crucial for generating robust data to improve pediatric anesthesia safety in the region. Key issues to address include improving data collection methods, resolving e-CRF technical difficulties, and ensuring consistent institutional support.
METHODS: A cohort of 556 mothers with preschoolers completed surveys to examine maternal mindful parenting, depression, parent-child relationships, and their children's emotional regulation ability. The inquiry attempted to understand the complex dynamics between the variables under consideration using moderated mediation analysis.
RESULTS: The findings revealed that higher levels of closeness in the parent-child relationship attenuated the link between maternal mindful parenting and maternal depressive symptoms. Conversely, parent-child relationships with less conflict intensified the connections between maternal mindful parenting and both maternal depression and the emotional regulation ability of preschoolers.
CONCLUSION: These findings enhance comprehension regarding the interconnectedness of maternal mindful parenting and preschoolers' emotional regulation ability within the Chinese cultural and familial milieu.
DESIGN: Cross-sectional study.
SETTING: Lahore, the second largest metropolis in Pakistan.
PARTICIPANTS: This study was conducted among parents residing in Lahore from March to April 2023. Participants were recruited via convenience sampling.
OUTCOME MEASURES: Data were collected using a prevalidated questionnaire that consisted of four sections: (1) informed consent, (2) demographic details, (3) COVID-19 vaccine uptake in children aged 5-17 years, parents' experience with childhood COVID-19 vaccination and their intention to vaccinate their unvaccinated children and (4) a modified 5C scale tailored to determine parents' confidence, complacency, constraints, calculation and collective responsibility with regard to COVID-19 vaccination.
RESULTS: This study included 414 parents (median age=37 years; mothers=62%). COVID-19 vaccination rates for children in the age groups 12-17 years and 5-11 years were 72.5% and 30.1%, respectively. Transient adverse events following immunisation were reported by 32.7% of parents. Of parents with unvaccinated children aged 12-17 years, only 35% intended to vaccinate them. The majority of parents were not willing to vaccinate their children below 11 years of age. Parents with a self-reported positive history of COVID-19 disease (OR=2.531, p=0.016), and confident in the vaccine's safety and efficacy (OR=1.968, p=0.010), were more inclined to vaccinate their 5-11 years. In terms of vaccination of children below 5 years, confidence in the vaccine (OR=2.942, p=0.003) and a sense of collective responsibility were positive predictors (OR=2.260, p=0.035), while calculation was identified as a negative predictor of parents' intention to vaccinate their under 5 years (OR=0.421, p=0.018).
CONCLUSION: CVH was significantly higher among parents of children aged 5-11 years and children younger than 5 years old. Priority should be given by health authorities to address parental concerns about vaccines and ensure that parents understand the significance of vaccination in protecting their children, to increase vaccination rates. This is because hesitancy towards one specific vaccine can negatively impact hesitancy rates in general.