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Fulltext Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016

GBD 2016 Causes of Death Collaborators

Lancet, 2017 Sep 16;390(10100):1151-1210.
PMID: 28919116 DOI: 10.1016/S0140-6736(17)32152-9

BACKGROUND: Monitoring levels and trends in premature mortality is crucial to understanding how societies can address prominent sources of early death. The Global Burden of Disease 2016 Study (GBD 2016) provides a comprehensive assessment of cause-specific mortality for 264 causes in 195 locations from 1980 to 2016. This assessment includes evaluation of the expected epidemiological transition with changes in development and where local patterns deviate from these trends.
METHODS: We estimated cause-specific deaths and years of life lost (YLLs) by age, sex, geography, and year. YLLs were calculated from the sum of each death multiplied by the standard life expectancy at each age. We used the GBD cause of death database composed of: vital registration (VR) data corrected for under-registration and garbage coding; national and subnational verbal autopsy (VA) studies corrected for garbage coding; and other sources including surveys and surveillance systems for specific causes such as maternal mortality. To facilitate assessment of quality, we reported on the fraction of deaths assigned to GBD Level 1 or Level 2 causes that cannot be underlying causes of death (major garbage codes) by location and year. Based on completeness, garbage coding, cause list detail, and time periods covered, we provided an overall data quality rating for each location with scores ranging from 0 stars (worst) to 5 stars (best). We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to generate estimates for each location, year, age, and sex. We assessed observed and expected levels and trends of cause-specific deaths in relation to the Socio-demographic Index (SDI), a summary indicator derived from measures of average income per capita, educational attainment, and total fertility, with locations grouped into quintiles by SDI. Relative to GBD 2015, we expanded the GBD cause hierarchy by 18 causes of death for GBD 2016.
FINDINGS: The quality of available data varied by location. Data quality in 25 countries rated in the highest category (5 stars), while 48, 30, 21, and 44 countries were rated at each of the succeeding data quality levels. Vital registration or verbal autopsy data were not available in 27 countries, resulting in the assignment of a zero value for data quality. Deaths from non-communicable diseases (NCDs) represented 72·3% (95% uncertainty interval [UI] 71·2-73·2) of deaths in 2016 with 19·3% (18·5-20·4) of deaths in that year occurring from communicable, maternal, neonatal, and nutritional (CMNN) diseases and a further 8·43% (8·00-8·67) from injuries. Although age-standardised rates of death from NCDs decreased globally between 2006 and 2016, total numbers of these deaths increased; both numbers and age-standardised rates of death from CMNN causes decreased in the decade 2006-16-age-standardised rates of deaths from injuries decreased but total numbers varied little. In 2016, the three leading global causes of death in children under-5 were lower respiratory infections, neonatal preterm birth complications, and neonatal encephalopathy due to birth asphyxia and trauma, combined resulting in 1·80 million deaths (95% UI 1·59 million to 1·89 million). Between 1990 and 2016, a profound shift toward deaths at older ages occurred with a 178% (95% UI 176-181) increase in deaths in ages 90-94 years and a 210% (208-212) increase in deaths older than age 95 years. The ten leading causes by rates of age-standardised YLL significantly decreased from 2006 to 2016 (median annualised rate of change was a decrease of 2·89%); the median annualised rate of change for all other causes was lower (a decrease of 1·59%) during the same interval. Globally, the five leading causes of total YLLs in 2016 were cardiovascular diseases; diarrhoea, lower respiratory infections, and other common infectious diseases; neoplasms; neonatal disorders; and HIV/AIDS and tuberculosis. At a finer level of disaggregation within cause groupings, the ten leading causes of total YLLs in 2016 were ischaemic heart disease, cerebrovascular disease, lower respiratory infections, diarrhoeal diseases, road injuries, malaria, neonatal preterm birth complications, HIV/AIDS, chronic obstructive pulmonary disease, and neonatal encephalopathy due to birth asphyxia and trauma. Ischaemic heart disease was the leading cause of total YLLs in 113 countries for men and 97 countries for women. Comparisons of observed levels of YLLs by countries, relative to the level of YLLs expected on the basis of SDI alone, highlighted distinct regional patterns including the greater than expected level of YLLs from malaria and from HIV/AIDS across sub-Saharan Africa; diabetes mellitus, especially in Oceania; interpersonal violence, notably within Latin America and the Caribbean; and cardiomyopathy and myocarditis, particularly in eastern and central Europe. The level of YLLs from ischaemic heart disease was less than expected in 117 of 195 locations. Other leading causes of YLLs for which YLLs were notably lower than expected included neonatal preterm birth complications in many locations in both south Asia and southeast Asia, and cerebrovascular disease in western Europe.
INTERPRETATION: The past 37 years have featured declining rates of communicable, maternal, neonatal, and nutritional diseases across all quintiles of SDI, with faster than expected gains for many locations relative to their SDI. A global shift towards deaths at older ages suggests success in reducing many causes of early death. YLLs have increased globally for causes such as diabetes mellitus or some neoplasms, and in some locations for causes such as drug use disorders, and conflict and terrorism. Increasing levels of YLLs might reflect outcomes from conditions that required high levels of care but for which effective treatments remain elusive, potentially increasing costs to health systems.
FUNDING: Bill & Melinda Gates Foundation.
Malaysian collaborators: School of Medicine, Xiamen University Malaysia Campus, Sepang, Malaysia (Y J Kim PhD); School of Medical Sciences, University of Science Malaysia, Kubang Kerian, Malaysia (K I Musa MD); Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia (R Sahathevan PhD); Department of Community Medicine, International Medical University, Kuala Lumpur, Malaysia (C T Sreeramareddy MD)

Matched MeSH terms: Wounds and Injuries/mortality
Fulltext Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

GBD 2016 Disease and Injury Incidence and Prevalence Collaborators

Lancet, 2017 Sep 16;390(10100):1211-1259.
PMID: 28919117 DOI: 10.1016/S0140-6736(17)32154-2

BACKGROUND: As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016.
METHODS: We estimated prevalence and incidence for 328 diseases and injuries and 2982 sequelae, their non-fatal consequences. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between incidence, prevalence, remission, and cause of death rates for each condition. For some causes, we used alternative modelling strategies if incidence or prevalence needed to be derived from other data. YLDs were estimated as the product of prevalence and a disability weight for all mutually exclusive sequelae, corrected for comorbidity and aggregated to cause level. We updated the Socio-demographic Index (SDI), a summary indicator of income per capita, years of schooling, and total fertility rate. GBD 2016 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).
FINDINGS: Globally, low back pain, migraine, age-related and other hearing loss, iron-deficiency anaemia, and major depressive disorder were the five leading causes of YLDs in 2016, contributing 57·6 million (95% uncertainty interval [UI] 40·8-75·9 million [7·2%, 6·0-8·3]), 45·1 million (29·0-62·8 million [5·6%, 4·0-7·2]), 36·3 million (25·3-50·9 million [4·5%, 3·8-5·3]), 34·7 million (23·0-49·6 million [4·3%, 3·5-5·2]), and 34·1 million (23·5-46·0 million [4·2%, 3·2-5·3]) of total YLDs, respectively. Age-standardised rates of YLDs for all causes combined decreased between 1990 and 2016 by 2·7% (95% UI 2·3-3·1). Despite mostly stagnant age-standardised rates, the absolute number of YLDs from non-communicable diseases has been growing rapidly across all SDI quintiles, partly because of population growth, but also the ageing of populations. The largest absolute increases in total numbers of YLDs globally were between the ages of 40 and 69 years. Age-standardised YLD rates for all conditions combined were 10·4% (95% UI 9·0-11·8) higher in women than in men. Iron-deficiency anaemia, migraine, Alzheimer's disease and other dementias, major depressive disorder, anxiety, and all musculoskeletal disorders apart from gout were the main conditions contributing to higher YLD rates in women. Men had higher age-standardised rates of substance use disorders, diabetes, cardiovascular diseases, cancers, and all injuries apart from sexual violence. Globally, we noted much less geographical variation in disability than has been documented for premature mortality. In 2016, there was a less than two times difference in age-standardised YLD rates for all causes between the location with the lowest rate (China, 9201 YLDs per 100 000, 95% UI 6862-11943) and highest rate (Yemen, 14 774 YLDs per 100 000, 11 018-19 228).
INTERPRETATION: The decrease in death rates since 1990 for most causes has not been matched by a similar decline in age-standardised YLD rates. For many large causes, YLD rates have either been stagnant or have increased for some causes, such as diabetes. As populations are ageing, and the prevalence of disabling disease generally increases steeply with age, health systems will face increasing demand for services that are generally costlier than the interventions that have led to declines in mortality in childhood or for the major causes of mortality in adults. Up-to-date information about the trends of disease and how this varies between countries is essential to plan for an adequate health-system response.
FUNDING: Bill & Melinda Gates Foundation, and the National Institute on Aging and the National Institute of Mental Health of the National Institutes of Health.
Malaysian collaborators: School of Medicine, Xiamen University Malaysia Campus, Sepang, Malaysia (Y J Kim PhD); School of Medical Sciences, University of Science Malaysia, Kubang Kerian, Malaysia (K I Musa MD); Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia (R Sahathevan PhD); Department of Community Medicine, International Medical University, Kuala Lumpur, Malaysia (C T Sreeramareddy MD)

Matched MeSH terms: Wounds and Injuries/mortality
Experimental Characterization of the Chronic Constriction Injury-Induced Neuropathic Pain Model in Mice

Gopalsamy B, Sambasevam Y, Zulazmi NA, Chia JSM, Omar Farouk AA, Sulaiman MR, et al.

Neurochem Res, 2019 Sep;44(9):2123-2138.
PMID: 31376053 DOI: 10.1007/s11064-019-02850-0

Number of ligations made in the chronic constriction injury (CCI) neuropathic pain model has raised serious concerns. We compared behavioural responses, nerve morphology and expression of pain marker, c-fos among CCI models developed with one, two, three and four ligations. The numbers of ligation(s) on sciatic nerve shows no significant difference in displaying mechanical and cold allodynia, and mechanical and thermal hyperalgesia throughout 84 days. All groups underwent similar levels of nerve degeneration post-surgery. Similar c-fos level in brain cingulate cortex, parafascicular nuclei and amygdala were observed in all CCI models compared to sham-operated group. Therefore, number of ligations does not impact intensity of pain symptoms, pathogenesis and neuronal activation. A single ligation is sufficient to develop neuropathic pain, in contrast to the established model of four ligations. This study dissects and characterises the CCI model, ascertaining a more uniform animal model to surrogate actual neuropathic pain condition.

Matched MeSH terms: Sciatic Nerve/injuries
Fulltext Association between prehospital field to emergency department delta shock index and in-hospital mortality in patients with torso and extremity trauma: A multinational, observational study

Kim DK, Jeong J, Shin SD, Song KJ, Hong KJ, Ro YS, et al.

PLoS One, 2021;16(10):e0258811.
PMID: 34695147 DOI: 10.1371/journal.pone.0258811

Hemorrhage, a main cause of mortality in patients with trauma, affects vital signs such as blood pressure and heart rate. Shock index (SI), calculated as heart rate divided by systolic blood pressure, is widely used to estimate the shock status of patients with hemorrhage. The difference in SI between the emergency department and prehospital field can indirectly reflect urgency after trauma. We aimed to determine the association between delta SI (DSI) and in-hospital mortality in patients with torso or extremity trauma. Patients with DSI >0.1 are expected to be associated with high mortality. This retrospective, observational study used data from the Pan-Asian Trauma Outcomes Study. Patients aged 18-85 years with abdomen, chest, upper extremity, lower extremity, or external injury location were included. Patients from China, Indonesia, Japan, Philippines, Thailand, and Vietnam; those who were transferred from another facility; those who were transferred without the use of emergency medical service; those with prehospital cardiac arrest; those with unknown exposure and outcomes were excluded. The exposure and primary outcome were DSI and in-hospital mortality, respectively. The secondary and tertiary outcome was intensive care unit (ICU) admission and massive transfusion, respectively. Multivariate logistic regression analysis was performed to test the association between DSI and outcome. In total, 21,534 patients were enrolled according to the inclusion and exclusion criteria. There were 3,033 patients with DSI >0.1. The in-hospital mortality rate in the DSI >0.1 and ≤0.1 groups was 2.0% and 0.8%, respectively. In multivariate logistic regression analysis, the DSI ≤0.1 group was considered the reference group. The unadjusted and adjusted odds ratios of in-hospital mortality in the DSI >0.1 group were 2.54 (95% confidence interval [CI] 1.88-3.42) and 2.82 (95% CI 2.08-3.84), respectively. The urgency of traumatic hemorrhage can be determined using DSI, which can help hospital staff to provide proper trauma management, such as early trauma surgery or embolization.

Matched MeSH terms: Wounds and Injuries/complications*
Fulltext Radiotherapy concurrently with weekly cisplatin, followed by adjuvant chemotherapy, for N2-3 nasopharyngeal cancer: a multicenter trial of the Forum for Nuclear Cooperation in Asia

Ohno T, Thinh DH, Kato S, Devi CR, Tung NT, Thephamongkhol K, et al.

J Radiat Res, 2013 May;54(3):467-73.
PMID: 23192700 DOI: 10.1093/jrr/rrs115

The purpose of this study was to evaluate the efficacy and toxicity of radiotherapy concurrently with weekly cisplatin, followed by adjuvant chemotherapy, for the treatment of N2-3 nasopharyngeal cancer (NPC) in Asian countries, especially regions of South and Southeast Asian countries where NPC is endemic. Between 2005 and 2009, 121 patients with NPC (T1-4 N2-3 M0) were registered from Vietnam, Malaysia, Indonesia, Thailand, The Philippines, China and Bangladesh. Patients were treated with 2D radiotherapy concurrently with weekly cisplatin (30 mg/m (2)), followed by adjuvant chemotherapy, consisting of cisplatin (80 mg/m(2) on Day 1) and fluorouracil (800 mg/m(2) on Days 1-5) for 3 cycles. Of the 121 patients, 56 patients (46%) required interruption of RT. The reasons for interruption of RT were acute non-hematological toxicities such as mucositis, pain and dermatitis in 35 patients, hematological toxicities in 11 patients, machine break-down in 3 patients, poor general condition in 2 patients, and others in 8 patients. Of the patients, 93% completed at least 4 cycles of weekly cisplatin during radiotherapy, and 82% completed at least 2 cycles of adjuvant chemotherapy. With a median follow-up time of 46 months for the surviving 77 patients, the 3-year locoregional control, distant metastasis-free survival and overall survival rates were 89%, 74% and 66%, respectively. No treatment-related deaths occurred. Grade 3-4 toxicities of mucositis, nausea/vomiting and leukopenia were observed in 34%, 4% and 4% of the patients, respectively. In conclusion, further improvement in survival and locoregional control is necessary, although our regimen showed acceptable toxicities.

Matched MeSH terms: Radiation Injuries/mortality*
Median Nerve Stimulation as a Nonpharmacological Approach to Bypass Analgesic Tolerance to Morphine: A Proof-of-Concept Study in Mice

Lee MT, Chen YH, Mackie K, Chiou LC

J Pain, 2021 03;22(3):300-312.
PMID: 33069869 DOI: 10.1016/j.jpain.2020.09.003

Analgesic tolerance to opioids contributes to the opioid crisis by increasing the quantity of opioids prescribed and consumed. Thus, there is a need to develop non-opioid-based pain-relieving regimens as well as strategies to circumvent opioid tolerance. Previously, we revealed a non-opioid analgesic mechanism induced by median nerve electrostimulation at the overlaying PC6 (Neiguan) acupoint (MNS-PC6). Here, we further examined the efficacy of MNS-PC6 in morphine-tolerant mice with neuropathic pain induced by chronic constriction injury (CCI) of the sciatic nerve. Daily treatments of MNS-PC6 (2 Hz, 2 mA), but not electrostimulation at a nonmedian nerve-innervated location, for a week post-CCI induction significantly suppressed established mechanical allodynia in CCI-mice in an orexin-1 (OX1) and cannabinoid-1 (CB1) receptor-dependent fashion. This antiallodynic effect induced by repeated MNS-PC6 was comparable to that induced by repeated gabapentin (50 mg/kg, i.p.) or single morphine (10 mg/kg, i.p.) treatments, but without tolerance, unlike repeated morphine-induced analgesia. Furthermore, single and repeated MNS-PC6 treatments remained fully effective in morphine-tolerant CCI-mice, also in an OX1 and CB1 receptor-dependent fashion. In CCI-mice receiving escalating doses of morphine for 21 days (10, 20 and 50 mg/kg), single and repeated MNS-PC6 treatments remained fully effective. Therefore, repeated MNS-PC6 treatments induce analgesia without tolerance, and retain efficacy in opioid-tolerant mice via a mechanism that involves OX1 and CB1 receptors. This study suggests that MNS-PC6 is an alternative pain management strategy that maybe useful for combatting the opioid epidemic, and opioid-tolerant patients receiving palliative care. PERSPECTIVE: Median nerve stimulation relieves neuropathic pain in mice without tolerance and retains efficacy even in mice with analgesic tolerance to escalating doses of morphine, via an opioid-independent, orexin-endocannabinoid-mediated mechanism. This study provides a proof of concept for utilizing peripheral nerve stimulating devices for pain management in opioid-tolerant patients.

Matched MeSH terms: Sciatic Nerve/injuries
Functional Outcomes After Heel Pad Reconstruction: A Review of 7 Cases

Khai Luen K, Wan Sulaiman WA

J Foot Ankle Surg, 2017 8 27;56(5):1114-1120.
PMID: 28842095 DOI: 10.1053/j.jfas.2017.04.024

Sensate, durable heel pad reconstruction is challenging. The present study assessed the functional outcomes after heel pad reconstruction using various flap techniques at our institution. From June 2011 to June 2016 (5-year period), 7 consecutive patients underwent heel pad reconstruction for various etiologies, with 3 microvascular free flaps (42.9%; 2 musculocutaneous flaps [66.7%] and 1 contralateral medial plantar flap [33.3%]) and 4 local pedicle flaps (57.1%; 3 instep medial plantar artery flaps [75.0%] and 1 distally based reverse sural flap [25.0%]). The patient records and demographic data were reviewed, and surgically related information was obtained and analyzed. The subjective components of the American Orthopaedic Foot and Ankle Society hindfoot clinical ratings scale were used to evaluate the pain and functional outcomes. Sensation was assessed using Semmes-Weinstein monofilaments, and ulcer recurrence was recorded. The mean age of the patients was 41.7 (range 11 to 70) years, the mean defect size was 59 (range 12 to 270) cm2, and the mean follow-up duration was 22 (range 15 to 43) months. Complete flap survival was achieved without significant complications in all 7 patients. Patients treated with the sensate medial plantar artery flap recorded the highest mean American Orthopaedic Foot and Ankle Society score of 57.3 (maximum score of 60) and experienced a return of deep sensation at 6 (range 6 to 24) months and protective sensation at 1 year. This was followed by the reverse sural flap and the musculocutaneous flap. No recurrent heel ulceration was observed in our series of patients. In conclusion, the sensate medial plantar flap is a satisfactory method for coverage of small- to moderate-size heel defects.

Matched MeSH terms: Soft Tissue Injuries/surgery
Safe zone in anterior mandible related to the genial tubercle for implant osteotomy in a Chinese-Malaysian population: A CBCT study

Voon YS, Patil PG

J Prosthet Dent, 2018 Apr;119(4):568-573.
PMID: 28838820 DOI: 10.1016/j.prosdent.2017.05.011

STATEMENT OF PROBLEM: The genial tubercle is a clinically palpable landmark in the mandible and can be identified in cone beam computed tomography (CBCT). Its location can be used to measure the safe zone in the interforaminal region of the mandible. These measurements may be helpful for implant treatment planning in patients with complete edentulism.
PURPOSE: The purpose of this clinical study was to evaluate the safe distance in the interforaminal region of the mandible measured from the genial tubercle level for implant osteotomy in a Chinese-Malaysian population.
MATERIAL AND METHODS: A total of 201 Digital Imaging and Communications in Medicine (DICOM) files were selected for the study from the CBCTs of dentate or edentulous Chinese-Malaysian adult patients with ongoing or completed treatments. Measurements were made with implant planning software. The anatomy of the whole mandible was assessed in the coronal cross-sectional, horizontal view and in panoramic view. Measurements were obtained in millimeters on one side by locating and marking a genial tubercle and then marking the mesial margin of the mental foramen and the anterior loop of the inferior alveolar nerve. The corresponding points of these landmarks were identified on the crest of the mandibular ridge to measure the linear distances. All the measurement steps were repeated on the other side. The linear distance of 2 mm was deducted from the total distance between the genial tubercle and the anterior loop separately for left and right side measurements to identify the safe zone. The mixed 2-way analysis of variance (ANOVA) test was used to analyze side and sex-related variations.
RESULTS: The mean safe zone measured at the crestal level from the genial tubercle site on the left side of the mandible was 21.12 mm and 21.67 mm on the right side. A statistically significant (P

Matched MeSH terms: Cranial Nerve Injuries/prevention & control
Child and Adolescent Mortality Across Malaysia's Epidemiological Transition: A Systematic Analysis of Global Burden of Disease Data

Abdul-Razak S, Azzopardi PS, Patton GC, Mokdad AH, Sawyer SM

J Adolesc Health, 2017 Oct;61(4):424-433.
PMID: 28838752 DOI: 10.1016/j.jadohealth.2017.05.014

PURPOSE: A rapid epidemiological transition in developing countries in Southeast Asia has been accompanied by major shifts in the health status of children and adolescents. In this article, mortality estimates in Malaysian children and adolescents from 1990 to 2013 are used to illustrate these changes.
METHODS: All-cause and cause-specific mortality estimates were obtained from the 2013 Global Burden of Disease Study. Data were extracted from 1990 to 2013 for the developmental age range from 1 to 24 years, for both sexes. Trends in all-cause and cause-specific mortality for the major epidemiological causes were estimated.
RESULTS: From 1990 to 2013, all-cause mortality decreased in all age groups. Reduction of all-cause mortality was greatest in 1- to 4-year-olds (2.4% per year reduction) and least in 20- to 24-year-olds (.9% per year reduction). Accordingly, in 2013, all-cause mortality was highest in 20- to 24-year-old males (129 per 100,000 per year). In 1990, the principal cause of death for 1- to 9-year boys and girls was vaccine preventable diseases. By 2013, neoplasms had become the major cause of death in 1-9 year olds of both sexes. The major cause of death in 10- to 24-year-old females was typhoid in 1990 and neoplasms in 2013, whereas the major cause of death in 10- to 24-year-old males remained road traffic injuries.
CONCLUSIONS: The reduction in mortality across the epidemiological transition in Malaysia has been much less pronounced for adolescents than younger children. The contribution of injuries and noncommunicable diseases to adolescent mortality suggests where public health strategies should focus.

Matched MeSH terms: Wounds and Injuries/mortality
It is the first birth that does the damage: a cross-sectional study 20 years after delivery

Kamisan Atan I, Lin S, Dietz HP, Herbison P, Wilson PD, ProLong Study Group

Int Urogynecol J, 2018 Nov;29(11):1637-1643.
PMID: 29564511 DOI: 10.1007/s00192-018-3616-4

INTRODUCTION AND HYPOTHESIS: Levator ani muscle (LAM) and anal sphincter tears are common after vaginal birth and are associated with female pelvic organ prolapse and anal incontinence. The impact of subsequent births on LAM and external anal sphincter (EAS) integrity is less well defined. The objective of this study was to determine the prevalence of LAM and EAS trauma in primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally to assess if there were differences between the two groups. The null hypothesis was: there is no significant difference in the prevalence of LAM and EAS trauma between the two groups.
METHODS: This was a cross-sectional study involving 195 women, participants of the Dunedin arm of the ProLong study (PROlapse and incontinence LONG-term research study) seen 20 years after their index birth. Assessment included a standardized questionnaire, ICS POP-Q and 4D translabial ultrasound. Post-imaging analysis of LAM and EAS integrity was undertaken blinded against other data. Statistical analysis was performed using Fisher's exact test and results were expressed as odds ratios (OR).
RESULTS: LAM avulsion and EAS defects were diagnosed in 31 (16%) and 24 (12.4%) women respectively. No significant difference in the prevalence of levator avulsion and EAS defects between primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally (OR 1.9, 95% CI 0.72-5.01, p = 0.26) and (OR 1.2, 95% CI 0.4-3.8, p = 0.76) respectively.
CONCLUSIONS: Most LAM avulsions and EAS defects seem to be caused by the first vaginal birth. Subsequent vaginal deliveries after the first were unlikely to cause further LAM trauma.

Matched MeSH terms: Anal Canal/injuries*
Fulltext Silicone Y-stent insertion under extracorporeal membrane oxygenation (ECMO) in a patient with tracheal tear

Mohd Esa NY, Faisal M, Vengadesa Pilla S, Abdul Rahaman JA

BMJ Case Rep, 2020 Dec 22;13(12).
PMID: 33370965 DOI: 10.1136/bcr-2020-236414

Tracheal tear after endotracheal intubation is extremely rare. The role of silicone Y-stent in the management of tracheal injury has been documented in the previous studies. However, none of the studies have mentioned the deployment of silicone Y-stent via rigid bronchoscope with the patient solely supported by extracorporeal membrane oxygenation (ECMO) without general anaesthesia delivered via the side port of the rigid bronchoscope. We report a patient who had a tracheal tear due to endotracheal tube migration following a routine video-assisted thoracoscopic surgery sympathectomy, which was successfully managed with silicone Y-stent insertion. Procedure was done while she was undergoing ECMO; hence, no ventilator connection to the side port of the rigid scope was required. This was our first experience in performing Y-stent insertion fully under ECMO, and the patient had a successful recovery.

Matched MeSH terms: Trachea/injuries*
Fulltext Global and National Burden of Diseases and Injuries Among Children and Adolescents Between 1990 and 2013: Findings From the Global Burden of Disease 2013 Study

Global Burden of Disease Pediatrics Collaboration, Kyu HH, Pinho C, Wagner JA, Brown JC, Bertozzi-Villa A, et al.

JAMA Pediatr, 2016 Mar;170(3):267-87.
PMID: 26810619 DOI: 10.1001/jamapediatrics.2015.4276

IMPORTANCE: The literature focuses on mortality among children younger than 5 years. Comparable information on nonfatal health outcomes among these children and the fatal and nonfatal burden of diseases and injuries among older children and adolescents is scarce.
OBJECTIVE: To determine levels and trends in the fatal and nonfatal burden of diseases and injuries among younger children (aged <5 years), older children (aged 5-9 years), and adolescents (aged 10-19 years) between 1990 and 2013 in 188 countries from the Global Burden of Disease (GBD) 2013 study.
EVIDENCE REVIEW: Data from vital registration, verbal autopsy studies, maternal and child death surveillance, and other sources covering 14,244 site-years (ie, years of cause of death data by geography) from 1980 through 2013 were used to estimate cause-specific mortality. Data from 35,620 epidemiological sources were used to estimate the prevalence of the diseases and sequelae in the GBD 2013 study. Cause-specific mortality for most causes was estimated using the Cause of Death Ensemble Model strategy. For some infectious diseases (eg, HIV infection/AIDS, measles, hepatitis B) where the disease process is complex or the cause of death data were insufficient or unavailable, we used natural history models. For most nonfatal health outcomes, DisMod-MR 2.0, a Bayesian metaregression tool, was used to meta-analyze the epidemiological data to generate prevalence estimates.
FINDINGS: Of the 7.7 (95% uncertainty interval [UI], 7.4-8.1) million deaths among children and adolescents globally in 2013, 6.28 million occurred among younger children, 0.48 million among older children, and 0.97 million among adolescents. In 2013, the leading causes of death were lower respiratory tract infections among younger children (905.059 deaths; 95% UI, 810,304-998,125), diarrheal diseases among older children (38,325 deaths; 95% UI, 30,365-47,678), and road injuries among adolescents (115,186 deaths; 95% UI, 105,185-124,870). Iron deficiency anemia was the leading cause of years lived with disability among children and adolescents, affecting 619 (95% UI, 618-621) million in 2013. Large between-country variations exist in mortality from leading causes among children and adolescents. Countries with rapid declines in all-cause mortality between 1990 and 2013 also experienced large declines in most leading causes of death, whereas countries with the slowest declines had stagnant or increasing trends in the leading causes of death. In 2013, Nigeria had a 12% global share of deaths from lower respiratory tract infections and a 38% global share of deaths from malaria. India had 33% of the world's deaths from neonatal encephalopathy. Half of the world's diarrheal deaths among children and adolescents occurred in just 5 countries: India, Democratic Republic of the Congo, Pakistan, Nigeria, and Ethiopia.
CONCLUSIONS AND RELEVANCE: Understanding the levels and trends of the leading causes of death and disability among children and adolescents is critical to guide investment and inform policies. Monitoring these trends over time is also key to understanding where interventions are having an impact. Proven interventions exist to prevent or treat the leading causes of unnecessary death and disability among children and adolescents. The findings presented here show that these are underused and give guidance to policy makers in countries where more attention is needed.

Matched MeSH terms: Wounds and Injuries/epidemiology*
Fulltext Anaesthetic management in a patient requiring one lung ventilation during COVID-19 pandemic

Teah MK, Yap KY, Ismail AJ, Yeap TB

BMJ Case Rep, 2021 Feb 17;14(2).
PMID: 33597165 DOI: 10.1136/bcr-2020-241148

Placement of a double-lumen tube to achieve one lung ventilation is an aerosol-generating procedure. Performing it on a patient with COVID-19 will put healthcare workers at high risk of contracting the disease. We herein report a case of its use in a patient with traumatic diaphragmatic rupture, who was also suspected to have COVID-19. This article aims to highlight the issues, it presented and ways to address them as well as the perioperative impact of personal protective equipment.

Matched MeSH terms: Diaphragm/injuries
Fulltext Preliminary analysis of knee stress in full extension landing

Makinejad MD, Abu Osman NA, Abu Bakar Wan Abas W, Bayat M

Clinics (Sao Paulo), 2013 Sep;68(9):1180-8.
PMID: 24141832 DOI: 10.6061/clinics/2013(09)02

This study provides an experimental and finite element analysis of knee-joint structure during extended-knee landing based on the extracted impact force, and it numerically identifies the contact pressure, stress distribution and possibility of bone-to-bone contact when a subject lands from a safe height.

Matched MeSH terms: Knee Injuries/physiopathology
Fulltext Safety of thoracic pedicle screw application using the funnel technique in Asians: a cadaveric evaluation

Chan CY, Kwan MK, Saw LB

Eur Spine J, 2010 Jan;19(1):78-84.
PMID: 19763636 DOI: 10.1007/s00586-009-1157-8

The objective of this cadaveric study is to determine the safety and outcome of thoracic pedicle screw placement in Asians using the funnel technique. Pedicle screws have superior biomechanical as well as clinical data when compared to other methods of instrumentation. However, misplacement in the thoracic spine can result in major neurological implications. There is great variability of the thoracic pedicle morphometry between the Western and the Asian population. The feasibility of thoracic pedicle screw insertion in Asians has not been fully elucidated yet. A pre-insertion radiograph was performed and surgeons were blinded to the morphometry of the thoracic pedicles. 240 pedicle screws were inserted in ten Asian cadavers from T1 to T12 using the funnel technique. 5.0 mm screws were used from T1 to T6 while 6.0 mm screws were used from T7 to T12. Perforations were detected by direct visualization via a wide laminectomy. The narrowest pedicles are found between T3 and T6. T5 pedicle width is smallest measuring 4.1 +/- 1.3 mm. There were 24 (10.0%) Grade 1 perforations and only 1 (0.4%) Grade 2 perforation. Grade 2 or worse perforation is considered significant perforation which would threaten the neural structures. There were twice as many lateral and inferior perforations compared to medial perforations. 48.0% of the perforations occurred at T1, T2 and T3 pedicles. Pedicle fracture occurred in 10.4% of pedicles. Intra-operatively, the absence of funnel was found in 24.5% of pedicles. In conclusion, thoracic pedicle screws using 5.0 mm at T1-T6 and 6.0 mm at T7-T12 can be inserted safely in Asian cadavers using the funnel technique despite having smaller thoracic pedicle morphometry.

Matched MeSH terms: Spinal Cord Injuries/etiology; Spinal Cord Injuries/physiopathology; Spinal Cord Injuries/prevention & control
The use of an In House Scoring System Scale versus Glasgow Coma Scale in non-traumatic altered states of consciousness patients: can it be used for triaging patients in Southeast Asian developing countries?

Maheswaran M, Adnan WA, Ahmad R, Ab Rahman NH, Naing NN, Abdullah J

Southeast Asian J. Trop. Med. Public Health, 2007 Nov;38(6):1126-40.
PMID: 18613557

Non-traumatic Altered States of Consciousness (ASC) are a non-specific consequence of various etiologies, and are normally monitored by Glasgow Coma Scale (GCS). The GCS gives varriable results among untrained emergency medicine personel in developing countries where English is not the first language. An In House Scoring System (IHSS) scale was made by the first author for the purpose of triaging so as to quickly asses patients when seen by medical personel. This IHSS scale was compared to the GCS to determine it's specificity and sensitivity in the accident and emergency department (ED) of Hospital University Sains Malaysia (HUSM). All patients with non-traumatic ASC were selected by purposive sampling according to pre-determined criteria. Patients were evaluated by the two systems, IHSS and GCS, by emergency physicians who were on call. Patient demographics, clinical features, investigations, treatment given and outcomes were collected and followed for a period of 14 days. A total of 221 patients with non-traumatic ASC were studied, 54.3% were males. The mean age of the patients was 56 years old. The mean overall GCS score on presentation to the ED was 10.3. The mean duration of ASC was 11.6 hours. One hundred thirty patients (58.8%) experienced ASC secondary to general or focal cerebral disorders. The mortality rate was 40.3% 2 weeks after the ED visit. Fifty-four point three percent of the patients were awake and considered to have good outcomes while 45.7% of the patients had poor outcomes (comatose or dead) 2 weeks after the ED visit. The mean overall GCS score, verbal and motor subscores as well as the IHSS had significantly decreased (worsened) after treatment in the ED. A poor IHSS scale, hypertension, current smoking, abnormal pupillary reflexes and acidosis were associated with a worse 2-week outcome. The mean age and WBC count was lower and the mean overall GCS score and eye, verbal and motor subscores were higher as well as those having a lower IHSS scale for the good outcome category. Multivariate analysis revealed that smokers and hypertensives were at higher risk for a poor outcome. Higher eye scores on the GCS were associated fewer poor outcomes. There was significant agreement between the IHSS scale and GCS scores in the assessment of non-traumatic ASC. The sensitivity and specificity of the IHSS score versus GCS were 71.9% and 100.0%, respectively.

Matched MeSH terms: Wounds and Injuries
Fulltext Awareness of post-exposure prophylaxis guidelines against occupational exposure to HIV in Hospital Sungai Petani

Bairy KL, Ganaraja B, Indira B, Thiyagar N, Choo CM, See CK

Med J Malaysia, 2005 Mar;60(1):10-4.
PMID: 16250274

Occupational risk of Human Immunodeficiency Virus (HIV) infection is a matter of concern for health care workers. We conducted a study to gauge the level of awareness amongst HCW (doctors and nurses) working in Hospital Sungai Petani regarding the post-exposure prophylaxis in case of needle stick injuries from confirmed or suspected cases of HIV. Nineteen Doctors (56%) and 13 nurses (25%) were aware of correct risk of transmission. None identified all the four risk fluids correctly. 94% of doctors and 98% of nurses correctly stated that washing the site with soap and water is the initial procedure, but only few (1/10 of doctors and 1/3 of nurses) knew whom to contact immediately after injury. Twenty three doctors (67%) and 41(78%) nurses were aware of the use of Zidovudine but only 10 participants were aware of the use of second drug. Only 6 doctors (17%) and 8 nurses (15%) knew the correct duration of post-exposure prophylaxis. Twenty-three doctors (67%) and 35 nurses (67%) knew that the drugs were available in Hospital Pharmacy and 11 doctors and 12 nurses knew the approximate cost of therapy. On the average about 50% of doctors and nurses have fair knowledge of post exposure prophylaxis against HIV. Ongoing awareness and training are necessary to improve the same.

Matched MeSH terms: Needlestick Injuries
External laryngeal nerve in thyroid surgery: is the nerve stimulator necessary?

Aina EN, Hisham AN

Eur J Surg, 2001 Sep;167(9):662-5.
PMID: 11759734 DOI: 10.1080/11024150152619282

OBJECTIVE: To find out the incidence and type of external laryngeal nerves during operations on the thyroid, and to assess the role of a nerve stimulator in detecting them.
DESIGN: Prospective, non-randomised study.
SETTING: Teaching hospital, Malaysia.
SUBJECTS: 317 patients who had 447 dissections between early January 1998 and late November 1999.
MAIN OUTCOME MEASURES:
Number and type of nerves crossing the cricothyroid space, and the usefulness of the nerve stimulator in finding them.
RESULTS: The nerve stimulator was used in 206/447 dissections (46%). 392 external laryngeal nerves were seen (88%), of which 196/206 (95%) were detected with the stimulator. However, without the stimulator 196 nerves were detected out of 241 dissections (81%). The stimulator detected 47 (23%) Type I nerves (nerve > 1 cm from the upper edge of superior pole); 86 (42%) Type IIa nerves (nerve < 1 cm from the upper edge of superior pole); and 63 (31%) Type IIb nerves (nerve below upper edge of superior pole). 10 nerves were not detected. When the stimulator was not used the corresponding figures were 32 (13%), 113 (47%), and 51 (21%), and 45 nerves were not seen. If the nerve cannot be found we recommend dissection of capsule close to the medial border of the upper pole of the thyroid to avoid injury to the nerve.
CONCLUSION: Although the use of the nerve stimulator seems desirable, it confers no added advantage in finding the nerve. In the event of uncertainty about whether a structure is the nerve, the stimulator may help to confirm it. However, exposure of the cricothyroid space is most important for good exposure in searching for the external laryngeal nerve.

Matched MeSH terms: Laryngeal Nerve Injuries
Fulltext Initial leucocytosis and other significant indicators of poor outcome in severe traumatic brain injury: an observational study

Vijian K, Teo EG, Kanesen D, Wong ASH

Chinese neurosurgical journal, 2020;6:5.
PMID: 32922934 DOI: 10.1186/s41016-020-0185-4

Background: Globally, severe traumatic brain injury (TBI) has been the principal cause of mortality among individuals aged 45 and below. The incidence of road traffic accidents in Malaysia is one of the highest in the world with thousands of victims sustaining severe disabilities. The aim of this study is to determine the association between leucocytosis and extended Glasgow Outcome Scale (GOSE) scores as well the relationship of other factors and the outcomes of severe TBI.
Methods: This was a retrospective observational study. A total of 44 consecutive patients who were admitted to Sarawak General Hospital from January 1, 2018, to September 30, 2018, with severe TBI were included. Data were collected from discharge summaries and hospital medical records. Chi-square and t test were used. SPSS was employed.
Results: Of a total of 44 patients with severe TBI, 18 patients (41%) died during the same admission. The mean age of patients was 37.1 years with 93.2% of affected patients being male. 56.9% of patients presented with a Glasgow Coma Scale (GCS) of 6 and less. A large percentage (86.3%) were discharged with a GOSE of less than 7. Older age and low admission GCS (6 and less) were significantly associated with poor GOSE scores on discharge and after 6 months (p < 0.05) on multivariate analysis. Leucocytosis on admission was also associated with poor outcomes where patients with higher total white counts on presentation attaining lower GOSE scores (p < 0.05).
Conclusion: We concluded that leucocytosis was significantly associated with poor outcomes in severe TBI patients in addition to other factors such as advanced age and poor GCS on arrival.

Matched MeSH terms: Brain Injuries, Traumatic
Fulltext Treatment of spinal cord injury with mesenchymal stem cells

Liau LL, Looi QH, Chia WC, Subramaniam T, Ng MH, Law JX

Cell Biosci, 2020;10:112.
PMID: 32983406 DOI: 10.1186/s13578-020-00475-3

Background: Spinal cord injury (SCI) is the damage to the spinal cord that can lead to temporary or permanent loss of function due to injury to the nerve. The SCI patients are often associated with poor quality of life.
Results: This review discusses the current status of mesenchymal stem cell (MSC) therapy for SCI, criteria to considering for the application of MSC therapy and novel biological therapies that can be applied together with MSCs to enhance its efficacy. Bone marrow-derived MSCs (BMSCs), umbilical cord-derived MSCs (UC-MSCs) and adipose tissue-derived MSCs (ADSCs) have been trialed for the treatment of SCI. Application of MSCs may minimize secondary injury to the spinal cord and protect the neural elements that survived the initial mechanical insult by suppressing the inflammation. Additionally, MSCs have been shown to differentiate into neuron-like cells and stimulate neural stem cell proliferation to rebuild the damaged nerve tissue.
Conclusion: These characteristics are crucial for the restoration of spinal cord function upon SCI as damaged cord has limited regenerative capacity and it is also something that cannot be achieved by pharmacological and physiotherapy interventions. New biological therapies including stem cell secretome therapy, immunotherapy and scaffolds can be combined with MSC therapy to enhance its therapeutic effects.

Matched MeSH terms: Spinal Cord Injuries

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