Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa: an analysis of verbal autopsy data from six countries.

OBJECTIVE: To compare the causes of death for women who died during pregnancy and within the first 42 days postpartum with those of women who died between >42 days and within 1 year postpartum. DESIGN: Open population cohort (Health and Demographic Surveillance Systems). SETTING: Ten Health and Demographic Surveillance Systems (HDSS) in The Gambia, Kenya, Malawi, Tanzania, Ethiopia and South Africa. POPULATION: 2114 deaths which occurred within 1 year of the end of pregnancy where a verbal autopsy interview was conducted from 2000 to 2019. METHODS: InterVA5 and InSilicoVA verbal autopsy algorithms were used to attribute the most likely underlying cause of death, which were grouped according to adapted International Classification of Diseases-Maternal Mortality categories. Multinomial regression was used to compare differences in causes of deaths within 42 days versus 43-365 days postpartum adjusting for HDSS and time period (2000-2009 and 2010-2019). MAIN OUTCOME MEASURES: Cause of death and the verbal autopsy Circumstances of Mortality Categories (COMCATs). RESULTS: Of 2114 deaths, 1212 deaths occurred within 42 days postpartum and 902 between 43 and 365 days postpartum. Compared with deaths within 42 days, deaths from HIV and TB, other infectious diseases, and non-communicable diseases constituted a significantly larger proportion of late pregnancy-related deaths beyond 42 days postpartum, and health system failures were important in the circumstances of those deaths. The contribution of HIV and TB to deaths beyond 42 days postpartum was greatest in Southern Africa. The causes of pregnancy-related mortality within and beyond 42 days postpartum did not change significantly between 2000-2009 and 2010-2019. CONCLUSIONS: Cause of death data from the extended postpartum period are critical to inform prevention. The dominance of HIV and TB, other infectious and non-communicable diseases to (late) pregnancy-related mortality highlights the need for better integration of non-obstetric care with ante-, intra- and postpartum care in high-burden settings.

Estimating 1a0 and 4a1 in a Life Table: A Model Approach Based on Newly Collected Data.

The average age of infant deaths, a10, and the average number of years lived-in the age interval-by those dying between ages 1 and 5, a41, are important quantities allowing the construction of any life table including these ages. In many applications, the direct calculation of these parameters is not possible, so they are estimated using the infant mortality rate-or the death rate from 0 to 1-as a predictor. Existing methods are general approximations that do not consider the full variability in the age patterns of mortality below the age of 5. However, at the same level of mortality, under-five deaths can be more or less concentrated during the first weeks and months of life, thus resulting in very different values of a10 and a41. This article proposes an indirect estimation of these parameters by using a recently developed model of under-five mortality and taking advantage of a new, comprehensive database by detailed age-which is used for validation. The model adapts to a variety of inputs (e.g., rates, probabilities, or the proportion of deaths by sex or for both sexes combined), providing more flexibility for the users and increasing the precision of the estimates. This fresh perspective consolidates a new method that outperforms all previous approaches.

Lifetime risk of maternal near miss morbidity: a novel indicator of maternal health.

BACKGROUND: The lifetime risk of maternal death quantifies the probability that a 15-year-old girl will die of a maternal cause in her reproductive lifetime. Its intuitive appeal means it is a widely used summary measure for advocacy and international comparisons of maternal health. However, relative to mortality, women are at an even higher risk of experiencing life-threatening maternal morbidity called 'maternal near miss' (MNM) events-complications so severe that women almost die. As maternal mortality continues to decline, health indicators that include information on both fatal and non-fatal maternal outcomes are required. METHODS: We propose a novel measure-the lifetime risk of MNM-to estimate the cumulative risk that a 15-year-old girl will experience a MNM in her reproductive lifetime, accounting for mortality between the ages 15 and 49 years. We apply the method to the case of Namibia (2019) using estimates of fertility and survival from the United Nations World Population Prospects along with nationally representative data on the MNM ratio. RESULTS: We estimate a lifetime risk of MNM in Namibia in 2019 of between 1 in 40 and 1 in 35 when age-disaggregated MNM data are used, and 1 in 38 when a summary estimate for ages 15-49 years is used. This compares to a lifetime risk of maternal death of 1 in 142 and yields a lifetime risk of severe maternal outcome (MNM or death) of 1 in 30. CONCLUSIONS: The lifetime risk of MNM is an urgently needed indicator of maternal morbidity because existing measures (the MNM ratio or rate) do not capture the cumulative risk over the reproductive life course, accounting for fertility and mortality levels.

Amantadine and/or transcranial magnetic stimulation for fatigue associated with multiple sclerosis (FETEM): study protocol for a phase 3 randomised, double-blind, cross-over, controlled clinical trial.

INTRODUCTION: Fatigue is one of the most disabling symptoms of multiple sclerosis (MS), and effective treatments are lacking. Amantadine is one of the most used treatments, although its efficacy is under debate. Transcranial magnetic stimulation (TMS) is a promising intervention that has shown positive effects in some preliminary investigations. We aim to investigate the effect of 6 weeks of amantadine and/or TMS in fatigue due to MS. METHODS AND ANALYSIS: The study is a national, multicentre, phase 3, randomised, double-blind, cross-over, placebo-controlled and sham-controlled clinical trial. Adult patients with relapsing-remitting MS, Expanded Disability Status Scale score of 1.5-4.5 and Fatigue Severity Score>4 are eligible for the trial. Participants will be randomised to one of the sequences of the study. Each sequence consists of four periods of 6 weeks of treatment and three washout periods of 12-18 weeks. All patients will receive all the combinations of therapies. The primary outcome is the Modified Fatigue Impact Scale. The secondary outcomes are the Symbol Digit Modalities Test (cognition), Beck Depression Inventory-II (depressive symptoms) and Short-Survey 12 (quality of life). Safety and cost-effectiveness will also be evaluated. An exploratory substudy including MRI and blood biomarkers will be conducted. ETHICS AND DISSEMINATION: The study is approved by the Ethics Committee of the Hospital Clinico San Carlos and the Spanish Agency of Medications and Medical Devices. All study findings will be published in scientific peer-reviewed journals and presented at relevant scientific conferences. TRIAL REGISTRATION NUMBER: EudraCT 2021-004868-95; NCT05809414.

Lipogranuloma esclerosante escrotal primario simulando un tumor testicular. Presentación de un caso / Primary sclerosing lipogranuloma of the scrotum resembling a testicular tumour. A case report

El lipogranuloma esclerosante (LGE) de los genitales externos masculinos es una enfermedad rara y benigna que se presenta habitualmente como masas subcutáneas. El proceso patológico subyacente es una reacción granulomatosa en el tejido graso. Las causas de esta enfermedad no están del todo definidas, pero en muchos casos se ha propuesto la ocurrencia de una degeneración de los lípidos como consecuencia de la inyección de cuerpos extraños (LGE secundario). Sin embargo, también se ha reportado la aparición de degeneración de lípidos endógena asociada a infecciones, trauma o alergias (LGE primario). Presentamos un caso de LGE aparentemente primario de localización escrotal en un paciente de 23 años de edad. Se realiza una revisión de los hallazgos patológicos y el manejo clínico de esta enfermedad (AU)

Sclerosing lipogranuloma (SLG) of the male external genitalia is a rare benign condition which presents as subcutaneous masses. The underlying pathological process is a granulomatous reaction of fatty tissue. The cause of this disease is unclear but in many cases lipid degeneration secondary to injection of foreign bodies (secondary SLG) has been proposed. However, endogenous lipid degeneration from other causes such as infection, trauma, and allergic mechanisms has also been reported as primary SLG. Here we present a case of a 23-year-old man with apparent primary SLG of the external genitalia (scrotum). The pathological features and clinical management are discussed (AU)

Miopatía del enfermo crítico. Valoración neurofisiológica y biopsia muscular en 33 pacientes / Critical illness myopathy. Neurophysiological and muscular biopsy assessment in 33 patients

Introducción. Los enfermos críticos pueden desarrollar cuadros de debilidad importante en la Unidad de Cuidados Intensivos (UCI). Debido a la diversidad de criterios diagnósticos utilizados, existe desacuerdo sobre el origen miopático o neuropático de este cuadro. Objetivos. Describir las alteraciones neurofisiológicas de enfermos críticos, establecer grupos de pacientes según los datos electrofisiológicos de miopatía y determinar su correspondencia con los resultados de la biopsia muscular. Pacientes y métodos. Se estudiaron prospectivamente 33 pacientes en UCI con debilidad importante, mediante electromiografía, electroneurografía y biopsia muscular percutánea. En nueve casos se amplió el estudio con estimulación muscular directa y en 14 con estimulación repetitiva. Resultados. Aplicando criterios neurofisiológicos de miopatía, se describieron tres grupos de pacientes: miopatía definida (33%), miopatía probable (46%) y miopatía incierta (21%). En la biopsia muscular, las alteraciones miopáticas más intensas, con atrofia y necrosis fibrilar, vacuolas y alteraciones miosínicas y mitocondriales, se observaron en los grupos con miopatía definida y probable (26 casos). En 17 de ellos, los potenciales de acción muscular compuestos fueron de baja amplitud y los potenciales de acción del nervio sensitivo normales. Once pacientes mostraron polineuropatía axonal sensitivomotora, que en siete de ellos se asociaba con datos de miopatía. Conclusiones. En enfermos críticos con debilidad intensa, las alteraciones miopáticas en el estudio neurofisiológico son mucho más frecuentes que la afectación neuropática. En concordancia con estos hallazgos, las alteraciones miopáticas en la biopsia muscular son manifiestas y abundantes. Los datos histopatológicos y neurofisiológicos de esta serie no sustentan una hipotética neuropatía axonal motora pura (AU)

Introduction. Critical illness patients may show marked weakness acquired in the Intensive Care Unit (ICU). There are some disagreements about the myopathic versus neuropathic damage in this condition, presumably due to the lack of reliable diagnostic criteria. Aims. To report the neurophysiological findings in critical patients, to classify them in groups according to the electrophysiological data of myopathy, and to ascertain the rapport between the neurophysiological classification of myopathy and the muscle biopsy results. Patients and methods. A prospective assessment of 33 ICU patients with marked weakness by means of needle electromyography, electroneurography, and percutaneous muscle biopsy was carried out. Direct muscle stimulation was performed in 9 patients and repetitive nerve stimulation in 14 cases. Results. According to neurophysiological criteria, patients were classified in 3 groups: definite (33%), probable (46%), and uncertain (21%) myopathy. The most conspicuous myopathic pathological findings including fibrillar atrophy and necrosis,vacuoles, and myosin and mitochondrial anomalies, were observed in both, definite and probable groups (26 patients). In 17 of these cases, low amplitude of the compound motor action potentials and normal sensory nerve action potentials were found. Axonal sensory-motor neuropathy was present in 11 patients, concomitant with neurophysiological data of myopathy in 7 cases. Conclusions. Based on the neurophysiological criteria for the assessment and classification of acquired weakness in critically ill patients, myopathy is highly predominant over the neuropathic impairment. Histopathological findings are closely related to the electrophysiological diagnosis of myopathy. Neither neurophysiological nor pathological data support a hypothetic motor axonal neuropathy in this series (AU)