Baseline findings of a multicentric ambispective cohort study (2021-2022) among hospitalised mucormycosis patients in India.

In India, the incidence of mucormycosis reached high levels during 2021-2022, coinciding with the COVID-19 pandemic. In response to this, we established a multicentric ambispective cohort of patients hospitalised with mucormycosis across India. In this paper, we report their baseline profile, clinical characteristics and outcomes at discharge. Patients hospitalized for mucormycosis during March-July 2021 were included. Mucormycosis was diagnosed based on mycological confirmation on direct microscopy (KOH/Calcofluor white stain), culture, histopathology, or supportive evidence from endoscopy or imaging. After consent, trained data collectors used medical records and telephonic interviews to capture data in a pre-tested structured questionnaire. At baseline, we recruited 686 patients from 26 study hospitals, of whom 72.3% were males, 78% had a prior history of diabetes, 53.2% had a history of corticosteroid treatment, and 80% were associated with COVID-19. Pain, numbness or swelling of the face were the commonest symptoms (73.3%). Liposomal Amphotericin B was the commonest drug formulation used (67.1%), and endoscopic sinus surgery was the most common surgical procedure (73.6%). At discharge, the disease was stable in 43.3%, in regression for 29.9% but 9.6% died during hospitalization. Among survivors, commonly reported disabilities included facial disfigurement (18.4%) and difficulties in chewing/swallowing (17.8%). Though the risk of mortality was only 1 in 10, the disability due to the disease was very high. This cohort study could enhance our understanding of the disease's clinical progression and help frame standard treatment guidelines.

Systematic review and meta-analysis of early aortic valve replacement versus conservative therapy in patients with asymptomatic aortic valve stenosis with preserved left ventricle systolic function.

BACKGROUND: A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function. METHODS AND RESULTS: We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I2=31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I2=84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding. CONCLUSION: We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations. PROSPERO REGISTRATION NUMBER: CRD42022306132.

Is left bundle branch pacing (LBBP) associated with better depolarization and repolarization kinetics than right ventricular mid septal pacing (RVSP)? - Comparison of frontal QRS -T angle in patients with LBBP, RVSP and normal ventricular conduction.

AIMS: To assess the frontal QRS- T angle (f QRS- T angle) in patients with left bundle branch pacing (LBBP) as compared to right ventricular mid septal pacing (RVSP) implanted for symptomatic high degree atrioventricular (AV) block and to compare with control subjects with normal ventricular conduction (CSNVC) METHODS: A total of one-fifty subjects were chosen (50 patients with LBBP, 50 patients with RVSP and 50 CSNVC). The indication for pacemaker implantation was symptomatic high degree AV block. Baseline clinical and electrocardiogram (ECG) parameters like QRS duration (QRSD), QRS axis and f QRS-T angle and Ejection Fraction (EF) were assessed. f QRS-T angle was measured as the difference between the computerised mean frontal QRS and T wave axes in the limb leads. If the difference between the QRS axis and T-wave axis exceeds 180°, then the resultant QRS-T angle would be calculated as 360° minus the absolute angle to obtain a value between 0° and 180°. Baseline, immediate post procedural and 6 month follow up (f/u) ECGs and EF were chosen for the analysis. RESULTS: Patients who underwent LBBP had significantly shorter paced QRSD than patients who had undergone RVSP (112 ± 12 ms vs 146 ± 13 ms; 95 % confidence interval (CI): 43, -31; p<0.001). There was no significant difference in the QRSD before and after LBBP. The QRSD before and after pacing in RVSP was 111 ± 27 ms and 146 ± 13 ms; 95 % CI: 43, -28; p < 0.001. The QRSD in control patients with NVC was 82.94 ± 9.59 ms. RVSP was associated with wider f QRS-T angle when compared with LBBP (103 ± 53° vs 82 ± 43°; 95 % CI: 39, -1.0; p = 0.037). The baseline and immediate post procedure f QRS-T angle in LBBP was 70 ± 48° and 82 ± 43°; 95 % CI: 31, 5.3; p = 0.2. At 6 months f/u, the f QRS-T angle was 61 ± 43°; 95 % CI: 8.5, 35; p=0.002. The baseline and immediate post procedure f QRS-T angle in RVSP was 67 ± 51° and 103 ± 53°; 95 % CI: 54, -17; p < 0.001. At 6 months f/u, the f QRS-T angle in RVSP group was 87 ± 58°; 95 % CI: 2.6, 29; p = 0.020. The f QRS T angle in control patients with NVC was 24 ± 16°. When subgroup analysis was done the difference in the f QRS-T angle was significant between RVSP and LBBP groups only in patients who had wide QRS escape. The mean LVEF at 6-month follow-up in LBBP vs RVSP was 61 ± 3.7 % vs 57.1 ± 7.8 %; 95 % CI:1.48, 6.32, p = 0.002. In the RVSP group, three patients developed pacing induced cardiomyopathy (PIC) whereas no patients in the LBBP group developed PIC at 6-month follow-up; p=0.021. One patient with PIC had deterioration of functional status with new onset HF symptoms. The patient symptoms improved with medical therapy and needed no hospitalisation. The patient declined further interventions including upgradation to CRT or LBB pacing. No deaths or ventricular arrhythmias were observed during the study period. CONCLUSION: LBBP is associated with narrower f QRS-T angle as compared to RVSP both at post implant period and at 6 month f/u period. These findings might be due to the more physiological depolarization and repolarization kinetics associated with LBBP. RVSP was associated with 6 % incidence of PIC. Hence wide f QRS-T angle might be a predictor of PIC.

Pan-India influenza-like illness (ILI) and Severe acute respiratory infection (SARI) surveillance: epidemiological, clinical and genomic analysis.

Background: Over time, COVID-19 testing has significantly declined across the world. However, it is critical to monitor the virus through surveillance. In late 2020, WHO released interim guidance advising the use of the existing Global Influenza Surveillance and Response System (GISRS) for the integrated surveillance of influenza and SARS-CoV-2. Methods: In July 2021, we initiated a pan-India integrated surveillance for influenza and SARS-CoV-2 through the geographically representative network of Virus Research and Diagnostic Laboratories (VRDLs) across 26 hospital and laboratory sites and 70 community sites. A total of 34,260 cases of influenza-like illness (ILI) and Severe acute respiratory infection (SARI) were enrolled from 4 July 2021 to 31 October 2022. Findings: Influenza A(H3) and B/Victoria dominated during 2021 monsoon season while A(H1N1)pdm09 dominated during 2022 monsoon season. The SARS-CoV-2 "variants of concern" (VoC) Delta and Omicron predominated in 2021 and 2022, respectively. Increased proportion of SARI was seen in extremes of age: 90% cases in < 1 year; 68% in 1 to 5 years and 61% in ≥ 8 years age group. Approximately 40.7% of enrolled cases only partially fulfilled WHO ILI and SARI case definitions. Influenza- and SARS-CoV-2-infected comorbid patients had higher risks of hospitalization, ICU admission, and oxygen requirement. Interpretation: The results depicted the varying strains and transmission dynamics of influenza and SARS-CoV-2 viruses over time, thus emphasizing the need to continue and expand surveillance across countries for improved decision making. The study also describes important information related to clinical outcomes of ILI and SARI patients and highlights the need to review existing WHO ILI and SARI case definitions.

Efficacy of flupirtine for postoperative pain: A systematic review and meta-analysis.

Background and Aims: Flupirtine has been used for various chronic pain conditions, but its utility in the perioperative period as an analgesic is still inconclusive. This systematic review and meta-analysis aimed to assess the efficacy of flupirtine for postoperative pain. Methods: PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) were explored for the randomised controlled trials (RCTs) which compared flupirtine with other analgesic/placebo for perioperative pain in adult patients undergoing surgery. The standardised mean difference (SMD) of pain scores, the need for rescue analgesia and all adverse effects were assessed. Heterogeneity was assessed using Cochrane's Q statistic test and I2 statistic. Cochrane Collaboration's tool was used to evaluate the risk of bias and the quality of the RCTs. Results: A total of 13 RCTs (including 1,014 patients) that evaluated the use of flupirtine for postoperative pain were included in the study. The pooled SMD of postoperative pain scores revealed that flupirtine and other analgesics were comparable at 0, 6, 12 and 24 hours (P > 0.05), while at 48 hours, flupirtine showed poor pain control (P = 0.04) as compared to other analgesics. There were no significant differences at other time points and on comparison of flupirtine with placebo. The side effect profile was comparable between flupirtine and other analgesics. Conclusion: The current evidence suggests that perioperative flupirtine was not superior to other most commonly used analgesics and placebo for the treatment of postoperative pain.

Coronary Stent Infections - A Systematic Review and Meta-Analysis.

BACKGROUND: Coronary stent infection (CSI) represents a rare but potentially fatal complication of percutaneous coronary interventions (PCI). A systematic review and meta-analysis of published reports was performed to profile CSI and its management strategies. METHODS: Online database searches were performed using MeSH and keywords. The primary outcome of the study was in-hospital mortality. A unique Artificial Intelligence-based predictive model was developed for need for delayed surgery and probability of survival on medical therapy alone. RESULTS: A total of 79 subjects were included in the study. Twenty eight (35.0 %) patients had type 2 diabetes mellitus. Subjects most commonly reported symptoms within the first week of the procedure (43 %). Fever was the most common initial symptom (72 %). Thirty eight percent of patients presented with acute coronary syndrome. The presence of mycotic aneurysms was described in 62 % of patients. Staphylococcus species were the most common (65 %) isolated organism. The primary outcome of in-hospital mortality was seen in a total of 24 patients out of 79 (30.3 %). A comparative univariate analysis comparing those encountering in-hospital mortality versus otherwise revealed the presence of structural heart disease (83 % mortality vs 17 % survival, p = 0.009), and the presence of non ST elevation acute coronary syndrome (11 % mortality vs 88 % survival, p = 0.03), to be a statistically significant factor predicting in-hospital mortality. In an analysis between patients with successful versus failed initial medical therapy, patients from private teaching hospitals (80.0 % vs 20.0 %; p = 0.01, n = 10) had a higher survival with medical therapy alone. CONCLUSION: CSI is a highly under-studied disease entity with largely unknown risk factors and clinical outcomes. Larger studies are needed to further define the characteristics of CSI. (PROSPERO ID CRD42021216031).

Challenges in the Implementation of Human Papillomavirus Self-Sampling for Cervical Cancer Screening in India: A Systematic Review.

PURPOSE: In the light of WHO's call for elimination of cervical cancer, primary human papillomavirus (HPV) screening through self-collection is a powerful tool that can improve screening coverage. Challenges encountered during implementation of the program are unique to each country. We conducted this systematic review to list the challenges in implementing primary HPV screening through self-sampling in Indian context. METHODS: A literature search was performed in PubMed, Embase, and Google Scholar since their inception till July 2022 for peer-reviewed articles published in the English. Non-Indian studies and those which did not mention implementation challenges were excluded. Articles were screened and reviewed independently by two authors. The results were discussed using a narrative synthesis. RESULTS: All the eight original articles included in the review were of cross-sectional design. The challenges identified in these studies were grouped into beneficiary, health care provider, and health system perspectives. Beneficiary-related issues outnumbered other challenges in all the studies which included misconceptions and fear, lack of motivation, low self-efficacy in collection leading to poor sample quality, low socioeconomic status leading to lack of privacy, and refusal for screening and further treatment. CONCLUSION: This review highlights the challenges for the implementation of HPV self-sampling in India. Future programs should incorporate context-specific solutions for the success of primary HPV screening and cervical cancer elimination.

Safety and Efficacy of OPN Balloon in Patients With Calcified Coronary Artery Disease.

BACKGROUND: Patients with symptomatic calcified coronary lesions have poor outcomes. Such lesions require additional atherectomy devices for bed preparation. AIM: To assess the safety and efficacy of OPN balloon in patients with calcified coronary lesions. METHODS: This is an investigator-initiated, prospective, observational study. The primary outcome of the study was a procedural success. RESULTS: We studied 71 patients (133 lesions). Maximum lesions were located in LAD [46.6 %]. The OPN balloon was used for pre-dilatation alone in 28.6 % (Pre-stent OPN group), post-dilatation alone in 63.2 % of lesions (Post-stent OPN group), and in both situations in 8.3 % of lesions with procedural success in 98.5 % of patients. Further dilatation with different NC balloons was required in both groups (30 %). The median (IQR) OPN balloon diameter in the pre- and post-stent OPN group were 2.5 (2.5, 3.0) and 3.0 (3.0,3.0) mm (p = 0.001), respectively. The difference between the diameter of the stent and OPN balloon used in pre-stent OPN group was 0.5 (0.2, 0.5) mm while it was 0.0 (0.0,0.2) mm in the post-stent OPN group (p < 0.001). Eight complications and two deaths occured. Distal shaft rupture was also noticed. CONCLUSION: OPN balloon is safe, and effective in treating calcified coronary lesions. We propose to undersize the balloon by 0.5 mm for pre-dilatation followed by 0.25 mm larger NC balloon if needed. In the post-dilatation group, use a 1:1 size balloon in a non-tortuous straight segment. Use imaging especially when (1) the pressure taken more than the rated burst pressure, (2) an OPN balloon size is ≥3 mm (3) using 1:1 size OPN balloon in a tortuous segment.

Meta-Analysis Comparing Fractional Flow Reserve and Angiography-Guided Complete Revascularization of Nonculprit Artery for ST-Elevation Myocardial Infarction.

This study aimed to compare complete revascularization (CR) guided by angiography with a fractional flow reserve (FFR)-guided strategy in patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD). CR is preferred to culprit-only revascularization for patients with STEMI and MVD. However, whether FFR-guided CR is superior to angiography-guided CR is unclear in patients presenting with STEMI who have MVD. Randomized controlled trials comparing CR with an FFR- or angiography-guided strategy to culprit-only revascularization in patients with STEMI and MVD were systematically identified. A random-effects network meta-analysis was performed comparing clinical outcomes in the 3 arms. A total of 13 studies with a total of 8,927 patients were included in our analysis. Compared with culprit-only revascularization, angiography-guided CR was associated with a significantly decreased risk of myocardial infarction (MI) (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.37 to 0.82), all-cause death (HR 0.69, 95% CI 0.49 to 0.97), and cardiovascular death (HR 0.54, 95% CI 0.34 to 0.85) but FFR-guided CR was not (MI: HR 0.77, 95% CI 0.53 to 1.12; cardiovascular death: HR 0.89, 95% CI 0.64 to 1.24; all-cause death: HR 0.93, 95% CI 0.72 to 1.18). The network meta-analysis comparison of angiography- versus FFR-guided CR showed an HR of 0.75 (95% CI 0.50 to 1.11) for all-cause death and an HR of 0.71 (95% CI 0.54 to 1.17) for MI. In conclusion, for patients with MVD presenting with STEMI, angiography-guided CR may provide additional benefits compared with FFR-guided CR.

"Design and implementation challenges of massive open online course on research methods for Indian medical postgraduates and teachers -descriptive analysis of inaugural cycle".

BACKGROUND: In view of the growing popularity, reach and access for Massive Open Online Courses (MOOCs), India's apex body for medical education, the National Medical Commission (NMC) mandated uniform foundational course on research methods for the medical post graduates (PGs) and faculty members of the medical institutions under NMC as MOOC. This course is a pioneering effort in the field of India's PG medical education. NMC entrusted Indian Council of Medical Research (ICMR)-National Institute of Epidemiology (NIE) to design and offer the MOOC, named as Basic Course in Biomedical Research (BCBR). We describe the experience of designing and that of implementation challenges in the inaugural cycle of the course. METHODS: The course objective was to inculcate the fundamental concepts in research methods covering epidemiology and biostatistics in the form of video lectures, resource materials, discussion forum, assignments, feedback and a final proctored examination. The course was delivered over 16 weeks through MOOCs platform under the Indian Ministry of Education. We reviewed records, documents and faculty notes and described the course conceptualization, development, design and implementation process. We abstracted information from course portal on enrolment profile of the participants, self-reported course feedback (structured and open-ended on format, lectures and quality of contents), examination registration form, scores obtained in the assignments/examination and that of the participant queries. We described quantitative data using descriptive statistics. We presented the thematic analysis of qualitative data from open-ended questions in the feedback system and that of email interactions. RESULTS: The inaugural cycle (September-December 2019) was taken by 24,385 participants. Majority, 15,879 (65%) were from medical background. 13,242 (54%) were medical postgraduates and 2637 (11%) were medical teachers. Among the enrolled, 14,720 (60%) cleared the assignments. A total of 11,392 (47%), 8,205 (62%) medical PGs and 896 (34%) faculty members successfully completed the course. Feedback from 1305 (5%) participants had mean score of 4.5/5 (±0.7) for quality of teaching. We faced challenges in customizing the course for medical participants, unawareness among target group, digital illiteracy and the ongoing pandemic. CONCLUSIONS: During the inaugural cycle of the online Basic Course in Biomedical Research course, nearly half of the enrolled participants successfully completed and received the certificate. India's MOOC for enhancing research capabilities of future medical researchers encountered successes and challenges. Lessons learnt from the inaugural cycle will guide future directions and to address larger issues in terms of sustainability and replication by stakeholders in medical education in India or elsewhere.

Trans-radial approach versus trans-femoral approach in patients with acute coronary syndrome undergoing percutaneous coronary intervention: An updated meta-analysis of randomized controlled trials.

INTRODUCTION: Trans-radial approach (TRA) is recommended over trans-femoral approach (TFA) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). We intended to study the effect of access on all-cause mortality. METHODS AND RESULTS: We searched PubMed and EMBASE for randomized studies on patients with ACS undergoing PCI. The primary outcome was all-cause mortality at 30-days. The secondary outcomes included in-hospital mortality, major adverse cardiac or cerebrovascular event (MACE) as defined by the study, net adverse clinical event (NACE), non-fatal myocardial infarction, non-fatal stroke, stent thrombosis, study-defined major bleeding, and minor bleeding, vascular complications, hematoma, pseudoaneurysm, non-access site bleeding, need for transfusion, access site cross-over, contrast volume, procedure duration, and hospital stay duration. We studied 20,122 ACS patients, including 10,037 and 10,085 patients undergoing trans-radial and trans-femoral approaches, respectively. We found mortality benefit in patients with ACS for the trans-radial approach [(1.7% vs. 2.3%; RR: 0.75; 95% CI: 0.62-0.91; P = 0.004; I2 = 0%). Out of 10,465 patients with STEMI, 5,189 patients had TRA and 5,276 had TFA procedures. A similar benefit was observed in patients with STEMI alone [(2.3% vs. 3.3%; RR: 0.71; 95% CI: 0.56-0.90; P = 0.004; I2 = 0%). We observed reduced MACE, NACE, major bleeding, vascular complications, and pseudoaneurysms. No difference in re-infarction, stroke, and serious bleeding requiring blood transfusions were noted. We noticed a small decrease in contrast volume(ml) {mean difference (95% CI): -4.6 [-8.5 to -0.7]}, small but significantly increase in procedural time {mean difference (95% CI) 1.2 [0.1 to 2.3]}and fluoroscopy time {mean difference (95% CI) 0.8 [0.3 to1.4] min} in the trans-radial group. CONCLUSION: TRA has significantly reduced 30-day all-cause mortality among patients undergoing PCI for ACS. TRA should be the preferred vascular access in patients with ACS.

The Intricate Relationship Between Client Perceptions of Physician Empathy and Physician Self-Assessment: Lessons for Reforming Clinical Practice.

Objectives: Clinical empathy is an important predictor of patient outcomes. Several factors affect physician's empathy and client perceptions. We aimed to assess the association between physician and client perception of clinical empathy, accounting for client, physician, and health system factors. Methods: We conducted a hospital-based cross-sectional study in 3 departments (family medicine, internal medicine, and surgery) of King Saud Medical City in Riyadh, Saudi Arabia. We interviewed 30 physicians and 390 clients from 3 departments. Physicians completed the Jefferson Scale of Empathy (JSE) and the clients responded to the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE). We used a hierarchical multilevel generalized structural equation approach to model factors associated with JSE and JSPPPE and their inter-relationship. Results: Mean (SD) score of client-rated physician empathy was 26.6 (6) and that of physician self-rated was 111 (12.8). We found no association between the 2 (b = 0.06; 95% confidence intervals CI: -0.1, 0.21), even after adjusting for client, physician, and health system factors. Physician's nationality (0.49; 0.12, 0.85), adequate consultation time (1.05; 0.72, 1.38), and trust (1.33; 0.9, 1.75) were positively associated whereas chronic disease (-0.32; -0.56, -0.07) and higher waiting times (-0.26; -0.47, -0.05) were negatively associated. Conclusion: A physician's self-assessed empathy does not correlate with clients' perception. We recommend training and monitoring to enhance clinical empathy.

Traumatic spinal injuries in Saudi Arabia: a retrospective single-centre medical record review.

OBJECTIVES: To describe the patterns and outcomes of traumatic spinal injuries (TSIs) in a tertiary care trauma centre in Riyadh, Saudi Arabia. DESIGN: Retrospective medical record review. SETTING: Level 1 trauma centre for all patients presented from 1 February 2016 to 31 December 2018. PARTICIPANTS AND DATA: Records of patients presenting with any spinal trauma were reviewed, and the data obtained included age, gender, nationality (as Saudi and non-Saudi), date of presentation, site of fracture/injury, associated injuries, mechanism of injury, presence of neurological involvement and hospital mortality. MAIN OUTCOMES: Frequencies of different types of TSI across various subgroups. RESULTS: We identified 692 patients who presented with TSI throughout the study period. The mean age was 36.9 years. Males represented 83.2% (n=576) of the sample size, and the most common mechanism of injury was motor vehicle collision (MVC), accounting for 66.8% of cases (n=462), while fall-related injuries were seen in 31.6% of cases (n=219). A total of 454 (65.6%) of all patients were Saudi, and 332 (73.1%) of the TSIs in Saudis were due to MVC. Non-Saudi cases accounted for 238 (34.4%) of all patients, and 89 (37.4%) of the non-Saudi injuries were due to falls from height, and this association was statistically significant (p<0.001). CONCLUSION: TSI was not thoroughly examined in Saudi Arabia; therefore, this study is considered the first to be done in the Kingdom using a representative sample. The fact that non-Saudi patients had a higher proportion of falls as a mechanism of injury should be taken into consideration in terms of raising awareness and taking more safety precautions, as most construction workers tend to be expatriates.

Estimating global injuries morbidity and mortality: methods and data used in the Global Burden of Disease 2017 study.

BACKGROUND: While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria. METHODS: In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced. RESULTS: GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes. CONCLUSIONS: GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.

Global injury morbidity and mortality from 1990 to 2017: results from the Global Burden of Disease Study 2017.

BACKGROUND: Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries. METHODS: We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs). FINDINGS: In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505). INTERPRETATION: Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care.

Preparedness against self-infection and importation of Malaria - An airport survey among Saudis traveling to endemic countries.

BACKGROUND: Infected travelers returning from malaria endemic countries pose the threat of local outbreaks in nonendemic countries. Such outbreaks are becoming potential public health threats with increasing volume of international travels. AIMS: This study aimed to assess the knowledge, attitude, and practices toward malaria, its prevention and treatment among Saudi air travelers visiting malaria-endemic countries. METHODS: A cross-sectional survey was conducted among Saudi passengers who were waiting at the departure gates of the King Khalid International Airport, Riyadh to travel to five chosen malaria-endemic countries. Knowledge, attitude, practice, and health-seeking behavior for malaria were assessed using a self-administered questionnaire. Factors associated with favorable responses were identified by statistical tests. RESULTS: Among 531 travelers, adequate knowledge, favorable attitude, and healthy practices pertaining to malaria were present in 42.7%, 80.2%, and 55.7%, respectively. Traveling to India, age >=30 years, tourists and traveling businessmen, previous visit to same country or region, seeking malaria-specific advice were significantly associated with adequate knowledge. Only 11.3% had sought pretravel health advice on malaria. Lack of knowledge about the existence and importance of pretravel consultation was the common reason for not seeking advice. CONCLUSION: Knowledge about malaria and practice of preventive measures were suboptimal among Saudi travelers. Public awareness about travel consultation and chemoprophylaxis should be a part of malaria elimination and prevention efforts. Primary care physicians should take into account the level of knowledge among prospective travelers and provide opportunistic travel health services or refer them appropriately.

Mapping 123 million neonatal, infant and child deaths between 2000 and 2017.

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.

Will I, Wont I? Factors associated with self-reported prediction of future indulgence in intimate partner violence among adolescents in South India.

INTRODUCTION: Intimate partner violence (IPV) refers to acts of physical/sexual violence, emotional/psychological abuse and controlling behaviour by a current or former intimate partner. Understanding the attitudes and perspectives of adolescents towards IPV can help in its prevention. The study aimed to assess the knowledge about various domains of IPV and self-reported prediction of perpetrating IPV among adolescents in Madurai city, South India. METHODS: Students pursuing engineering, medicine and humanities were recruited conveniently. A structured self-administered questionnaire developed to cater to the objectives was used. After descriptive analysis, a modified Poisson regression with robust variance estimation was used to identify factors associated with one's self-reported prediction of becoming an IPV perpetrator and adjusted relative risks [0.95 confidence interval (CI)] were calculated. The project was approved by the Institute's Ethics Committee. RESULTS: Of the 369 students, 40% were aware of IPV prevalence among women in India. About 85% agreed with societally prescribed gender roles. More males than females found gender roles manifesting as IPV acceptable (p = 0.003). Only 6.8%, more females than males (p = 0.01), believed that no violence is permissible in intimate relationships. About 55% definitely did not foresee themselves becoming IPV perpetrators. Belief in gender roles [odds ratio (OR) = 3.85; 95% CI: 1.26, 11.74] and being a professional course student (2.48; 1.25, 4.91) were significantly associated with foreseeing oneself as an IPV perpetrator. CONCLUSION: Knowledge about IPV and its redressal mechanisms among adolescents is poor. A significant proportion of them believe in gender roles and perceive violence within an intimate relationship as acceptable. Positively influencing adolescents' beliefs in gender roles may help to control IPV and nurture healthier relationships.

Prevalence and correlates of sexual health disorders among adult men in a rural area of North India: An observational study.

BACKGROUND AND OBJECTIVES: Sexual health disorders are an important but less researched public health issue in India. We aimed to estimate the prevalence of sexual health disorders and their associated factors among adult men in a rural community of Haryana, India. MATERIALS AND METHODS: A community-based cross-sectional study was conducted among adult men aged 18-60 years using a multistage stratified random sampling. Information pertaining to sociodemographic characteristics, lifestyle and sexual practices, and self-reported sexual problems were collected. Sexual health disorders were defined based on International Statistical Classification of Diseases-10 classification of mental and behavioral disorders. Step-wise logistic regression was carried out to identify factors independently associated with sexual disorders. RESULTS: At least one sexual health disorder was reported by 81% of the men. The most commonly reported disorder was self-perceived defect in semen (64.4%), followed by loss of libido (21%), masturbation guilt (20.8%), erectile dysfunction (5%), and premature ejaculation (4.6%). Factors significantly associated with sexual health disorders among all men were being never married (odds ratio = 2.04; 95% confidence interval: 1.51, 2.77), smoking (1.57; 1.16, 2.14), cannabis use (4.20; 1.68, 10.48), diabetes (2.40; 1.22, 4.73), and hypertension (3.17; 1.12, 8.92). INTERPRETATION AND CONCLUSIONS: A high burden of sexual health disorders was identified among the rural men. Wider recognition of this issue is needed among the health-care providers and policymakers.

Comparative morbidity profile of patients attending an Ayurveda clinic and a modern medicine clinic of a primary health center in rural Haryana, India.

CONTEXT: There is a paucity of data on the profile of patients accessing traditional systems of medicine. A comparison of profile of patients attending an Ayurveda clinic with that of modern medicine clinic will help in better understanding of utilization of services and preference for system of medicine by the patients seeking health care. AIM: The aim was to study the morbidity profile of patients who attended the Ayurveda clinic of a primary health center (PHC) in rural Haryana over 1 year and compared it with that of the modern medicine clinic attendees at the same facility. MATERIALS AND METHODS: The study site was PHC, Dayalpur in block Ballabgarh, district Faridabad, Haryana, India. All new patients who attended the Ayurveda clinic of PHC Dayalpur in the year 2012 were included in the study. New attendees of modern medicine clinic of the same PHC in the year 2012 were used for comparison of profile of patients. RESULTS: In year 2012, of the total new patients registered at PHC, 26% attended Ayurveda clinic. The male-to-female ratio (0.8:1) was similar in both clinics. The representation of children up to 5 years and elderly was significantly higher (12.0% vs. 6.7% and 19.5% vs. 11.0%) in modern medicine clinic as compared to Ayurveda clinic. The most common morbidities seen in Ayurveda clinic were twak vikar or skin disease (12.3%), sandhivata or osteoarthritis (10.3%), and kasa or cough (8.5%). Three most common morbidities in modern medicine clinic were acute respiratory infection (35.7%), hypertension (10.6%), and acute febrile illness (9.2%). CONCLUSIONS: The study provided evidence that Ayurveda was popular among rural population in North India. Therefore, the Government of India's initiative of setting up Ayurveda clinic in PHCs is well founded.