An international review of the characteristics of viral nucleic acid-amplification testing (NAT) reveals a trend towards the use of smaller pool sizes and individual donation NAT.

BACKGROUND AND OBJECTIVES: Nucleic acid-amplification testing (NAT) is used for screening blood donations/donors for blood-borne viruses. We reviewed global viral NAT characteristics and NAT-yield confirmatory testing used by blood operators. MATERIALS AND METHODS: NAT characteristics and NAT-yield confirmatory testing used during 2019 was surveyed internationally by the International Society of Blood Transfusion Working Party Transfusion-Transmitted Infectious Diseases. Reported characteristics are presented herein. RESULTS: NAT was mainly performed under government mandate. Human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV) NAT was performed on all donors and donation types, while selective testing was reported for West Nile virus, hepatitis E virus (HEV), and Zika virus. Individual donation NAT was used for HIV, HCV and HBV by ~50% of responders, while HEV was screened in mini-pools by 83% of responders performing HEV NAT. Confirmatory testing for NAT-yield samples was generally performed by NAT on a sample from the same donation or by NAT and serology on samples from the same donation and a follow-up sample. CONCLUSION: In the last decade, there has been a trend towards use of smaller pool sizes or individual donation NAT. We captured characteristics of NAT internationally in 2019 and provide insights into confirmatory testing approaches used for NAT-yields, potentially benefitting blood operators seeking to implement NAT.

International review of blood donation nucleic acid amplification testing.

BACKGROUND AND OBJECTIVES: Nucleic acid amplification testing (NAT), in blood services context, is used for the detection of viral and parasite nucleic acids to reduce transfusion-transmitted infections. This project reviewed NAT for screening blood donations globally. MATERIALS AND METHODS: A survey on NAT usage, developed by the International Society of Blood Transfusion Working Party on Transfusion-transmitted Infectious Diseases (ISBT WP-TTID), was distributed through ISBT WP-TTID members. Data were analysed using descriptive statistics. RESULTS: Forty-three responses were received from 32 countries. Increased adoption of blood donation viral screening by NAT was observed over the past decade. NAT-positive donations were detected for all viruses tested in 2019 (proportion of donations positive by NAT were 0.0099% for human immunodeficiency virus [HIV], 0.0063% for hepatitis C virus [HCV], 0.0247% for hepatitis B virus [HBV], 0.0323% for hepatitis E virus [HEV], 0.0014% for West Nile virus [WNV] and 0.00005% for Zika virus [ZIKV]). Globally, over 3100 NAT-positive donations were identified as NAT yield or solely by NAT in 2019 and over 22,000 since the introduction of NAT, with HBV accounting for over half. NAT-positivity rate was higher in first-time donors for all viruses tested except WNV. During 2019, a small number of participants performed NAT for parasites (Trypanosoma cruzi, Babesia spp., Plasmodium spp.). CONCLUSION: This survey captures current use of blood donation NAT globally. There has been increased NAT usage over the last decade. It is clear that NAT contributes to improving blood transfusion safety globally; however, there is a need to overcome economic barriers for regions/countries not performing NAT.

Assessing COVID-19 pandemic policies and behaviours and their economic and educational trade-offs across US states from Jan 1, 2020, to July 31, 2022: an observational analysis.

BACKGROUND: The USA struggled in responding to the COVID-19 pandemic, but not all states struggled equally. Identifying the factors associated with cross-state variation in infection and mortality rates could help to improve responses to this and future pandemics. We sought to answer five key policy-relevant questions regarding the following: 1) what roles social, economic, and racial inequities had in interstate variation in COVID-19 outcomes; 2) whether states with greater health-care and public health capacity had better outcomes; 3) how politics influenced the results; 4) whether states that imposed more policy mandates and sustained them longer had better outcomes; and 5) whether there were trade-offs between a state having fewer cumulative SARS-CoV-2 infections and total COVID-19 deaths and its economic and educational outcomes. METHODS: Data disaggregated by US state were extracted from public databases, including COVID-19 infection and mortality estimates from the Institute for Health Metrics and Evaluation's (IHME) COVID-19 database; Bureau of Economic Analysis data on state gross domestic product (GDP); Federal Reserve economic data on employment rates; National Center for Education Statistics data on student standardised test scores; and US Census Bureau data on race and ethnicity by state. We standardised infection rates for population density and death rates for age and the prevalence of major comorbidities to facilitate comparison of states' successes in mitigating the effects of COVID-19. We regressed these health outcomes on prepandemic state characteristics (such as educational attainment and health spending per capita), policies adopted by states during the pandemic (such as mask mandates and business closures), and population-level behavioural responses (such as vaccine coverage and mobility). We explored potential mechanisms connecting state-level factors to individual-level behaviours using linear regression. We quantified reductions in state GDP, employment, and student test scores during the pandemic to identify policy and behavioural responses associated with these outcomes and to assess trade-offs between these outcomes and COVID-19 outcomes. Significance was defined as p<0·05. FINDINGS: Standardised cumulative COVID-19 death rates for the period from Jan 1, 2020, to July 31, 2022 varied across the USA (national rate 372 deaths per 100 000 population [95% uncertainty interval [UI] 364-379]), with the lowest standardised rates in Hawaii (147 deaths per 100 000 [127-196]) and New Hampshire (215 per 100 000 [183-271]) and the highest in Arizona (581 per 100 000 [509-672]) and Washington, DC (526 per 100 000 [425-631]). A lower poverty rate, higher mean number of years of education, and a greater proportion of people expressing interpersonal trust were statistically associated with lower infection and death rates, and states where larger percentages of the population identify as Black (non-Hispanic) or Hispanic were associated with higher cumulative death rates. Access to quality health care (measured by the IHME's Healthcare Access and Quality Index) was associated with fewer total COVID-19 deaths and SARS-CoV-2 infections, but higher public health spending and more public health personnel per capita were not, at the state level. The political affiliation of the state governor was not associated with lower SARS-CoV-2 infection or COVID-19 death rates, but worse COVID-19 outcomes were associated with the proportion of a state's voters who voted for the 2020 Republican presidential candidate. State governments' uses of protective mandates were associated with lower infection rates, as were mask use, lower mobility, and higher vaccination rate, while vaccination rates were associated with lower death rates. State GDP and student reading test scores were not associated with state COVD-19 policy responses, infection rates, or death rates. Employment, however, had a statistically significant relationship with restaurant closures and greater infections and deaths: on average, 1574 (95% UI 884-7107) additional infections per 10 000 population were associated in states with a one percentage point increase in employment rate. Several policy mandates and protective behaviours were associated with lower fourth-grade mathematics test scores, but our study results did not find a link to state-level estimates of school closures. INTERPRETATION: COVID-19 magnified the polarisation and persistent social, economic, and racial inequities that already existed across US society, but the next pandemic threat need not do the same. US states that mitigated those structural inequalities, deployed science-based interventions such as vaccination and targeted vaccine mandates, and promoted their adoption across society were able to match the best-performing nations in minimising COVID-19 death rates. These findings could contribute to the design and targeting of clinical and policy interventions to facilitate better health outcomes in future crises. FUNDING: Bill & Melinda Gates Foundation, J Stanton, T Gillespie, J and E Nordstrom, and Bloomberg Philanthropies.

Preoperative frailty assessment in older patients with colorectal cancer: use of clinical and radiological tool.

PURPOSE: The Memorial Sloan Kattering Frailty Index (MSK-FI) and the Skeletal Muscle Index (SMI) have recently gained attention as markers of frailty and decreased physiologic reserve, and are promising as predictors of adverse postoperative outcomes in patients undergoing oncologic surgery. The objective of this study was to establish the prognostic accuracy of these indexes in a cohort of patients with colorectal cancer subjected to surgical intervention. METHODS: We performed an observational study including all patients older than 60 years, subjected to colorectal cancer surgery between January 2010 and May 2020, and stratified our cohort based on the presence of frailty, as defined by MSK-FI ≥ 3. Computed tomography was used to calculate SMI, using a standardized institutional protocol. A multivariable analysis was used to study the association between these novel indexes with adverse postoperative outcomes in our cohort. RESULTS: A total of 216 patients were included. Among these, 56 (26%) qualified as frail and 132 (62%) had a low SMI. On multivariable analysis (adjusted by patient and intraoperative characteristics), frailty was associated with increased risk of having a major postoperative complication (OR 29.78, 95%CI 10.36-85.71) and increased admission to the intensive care unit (OR 4.99, 95%CI 1.55-16.06), while both frailty and low SMI were associated with prolonged length of stay (OR 11.22, 95%CI 8.91-13.53 and OR 0.14, 95% CI 0.06-0.20, respectively). CONCLUSION: MSK-FI ≥ 3 and low SMI are associated with adverse postoperative outcomes in elderly patients undergoing colorectal cancer surgery. Implementing this practical tool in routine clinical practice, may help identify patients that would benefit from surgical prehabilitation and preoperative optimization to improve outcomes.

Stressful Events During Last Year, Violence and Anxiety and Depression: A Moderated Mediation Model by Sex.

The literature suggests that being subject to a stressful life and victimization may negatively affect mental health, and that women and men seem to differ in these variables. Nevertheless, neither the mediating role of victimization experiences in the relationship between stress and mental health, nor the moderated role of sex have been explored. A sample of 826 adults, aged from 18 to 77 years old, completed a set of self-reported questionnaires (69.4% women). Results revealed significant mediation effects of psychological violence on the relationship between stress, depression and anxiety. Participants who reported more stressful life events in the previous year, also reported higher psychological abuse, which in turn predicted higher depression and anxiety. Furthermore, the moderating effects of sex were found to be statistically significant. Results suggest that interventions should be tailored to individual needs in order to prevent secondary victimization derived from biased beliefs related to stress, violence and gender in professional practice.

The Frailty Based on the Memorial Sloan Kettering Frailty Index for Prediction of Surgical Outcome in Advance Epithelial Ovarian Cancer-Experience of a Single Center in Mexico.

Retrospective impact evaluation of frailty as measured by the Memorial Sloan Kettering Frailty Index (MSK-FI) on outcomes in older women surgically treated for advanced epithelial ovarian cancer (EOC). Women ≥ 60 years with stage IIIC/IV EOC who underwent primary debulking surgery (PDS) or interval debulking surgery (IDS) were included. Medical records were reviewed for patients' characteristics and outcomes. We retrospectively applied the MSK-FI which included 10 comorbidities and functional assessment that were extracted from medical records. The MSK-FI ranges from 0 to 11; a score of ≥ 3 was considered frail. Associations were assessed using logistic regression and Cox proportional hazards regression. We identified 79 patients treated with PDS (n = 36, 45.5%) or IDS (n = 43, 54.4%) with complete data. The prevalence of frailty based on MSK-FI was 25%. Almost half of the frail patients (47.3%) were admitted to the ICU compared to 16% of non-frail patients (p = 0.006). In univariable analysis, the MSK-FI was associated with postoperative complications [OR 1.57 (95% CI 1.04-2.37), p = 0.03] and ICU admission [OR 2.05 (95% CI 1.30-3.23), p = 0.002], but not with readmission rate [OR 1.29 (95% CI 0.65-2.59), p = 0.5], postoperative mortality [OR 1.02 (95% CI 0.51-2.00), p = 0.9], and hospital stay [ß 0.60 (95% CI - 1.19-2.41)]. In multivariable analysis, the frailty index was independently associated with postoperative complications [OR 1.54 (95% CI 1.02-2.34), p = 0.04] and ICU admissions [OR 1.97 (95% CI 1.23-3.16), p = 0.004]. Frailty, based on the Memorial Sloan Kettering Frailty Index, is associated with adverse postoperative outcomes in older women with advanced ovarian cancer, suggesting that MSK-FI can improve the predictive ability of current surgical assessment tools.

Postoperative liver function tests can predict anastomotic dysfunction after bile duct injury repair.

Liver function tests help in the follow-up of postoperative patients with iatrogenic bile duct injury. There is not clear evidence regarding their predictive role on anastomosis dysfunction. We describe our experience with postoperative liver function tests and a predictive model of long-term patency after repair. This is retrospective cohort study of patients with bilioenteric anastomosis for bile duct injury and their long-term follow-up. A binomial logistic regression model was performed to ascertain the effects of the grade of bile duct injury and liver function test in the postoperative period. A total of 329 patients were considered for the analysis. In the logistic regression model two predictor variables were statistically significant for anastomosis stenosis: type of bilioenteric anastomosis and alkaline phosphatase levels. A ROC curve analysis was made for alkaline phosphatase with an area under the curve of 0.758 (95% CI 0.67-0.84). A threshold of 323 mg/dL was established (OR 6.0, 95% CI 2.60-13.83) with a sensitivity of 75%, specificity of 67%, PPV of 20%, NPV of 96%, PLR of 2.27 and NLR of 0.37. Increased alkaline phosphatase (above 323 mg/dL) after the fourth operative week was found to be a predictor of long-term dysfunction.

Acute hemolytic reaction by anti-Wra: Case report and review of the hemovigilance database of a tertiary care hospital.

Wra is the most common LIA in white population. The incidence of Wra antigen in Spanish population has been estimated to be 1 in 785 in blood donors, while anti-Wra was found in 2.7 % and 3.6 % of healthy donors and transfused patients respectively. Severe, even fatal hemolytic transfusion reactions and hemolytic disease of the newborn caused by anti-Wra have been reported. Since the reagent red blood cells used for antibody screening usually lack Wra antigen, the anti-Wra is not detected and hemolytic reaction could occur if transfusion is performed by type and screen approach. We report an acute hemolytic reaction due to anti-Wra in a patient with negative antibody screening. We have also reviewed the records of the hospital hemovigilance database in order to collect the previous hemolytic cases due to anti-Wra. During a 21-year period 461,539 red blood cell units have been transfused to 81,614 patients in our hospital. Alloimmnunization was detected in 3840 patients (0.83 %) and anti-Wra was detected in 22 patients (1/3709), 10 of whom had other alloantibodies, and only in 1 occasion (this case) has been implicated in mild hemolytic acute transfusion reaction. In our experience, the risk of fatal hemolytic reaction due to LIA in hospitals with blood services using the type and screen policy is extremely low.

Preservation of anti-SARS-CoV-2 neutralising antibodies in convalescent plasma after pathogen reduction with methylene blue and visible light.

BACKGROUND: COVID-19 convalescent plasma (CCP) is an experimental treatment against SARS-CoV-2. Although there has so far been no evidence of transmission through transfusion, pathogen reduction technologies (PRT) have been applied to CCP to mitigate risk of infectious disease. This study aims to assess the impact of methylene blue (MB) plus visible light PRT on the virus-neutralising activity of the specific antibodies against SARS-CoV-2. MATERIAL AND METHODS: Thirty-five plasma doses collected by plasmapheresis from COVID-19 convalescent donors were subjected to MB plus visible light PRT. Anti-SARS-CoV-2 RBD S1 epitope IgGs antibodies were quantified by ELISA. Titres of SARS-CoV-2 neutralising antibodies (NtAbs) were measured before and after the PRT process. A Spearman's correlation was run to determine the relationship between antibody neutralisation ability and SARS-CoV-2 IgG ELISA ratio. Pre- and post-inactivation neutralising antibody titres were evaluated using a Wilcoxon test. RESULTS: The plasma pathogen reduction procedure did not diminish NtAbS titres and so did not cause a change in the viral neutralisation capacity of CCP. There was a strong correlation between pre-and post-PRT NtAbs and anti-SARS-CoV-2 IgGs titres. DISCUSSION: Our results showed PRT with MB did not impair the CCP passive immunity preserving its potential therapeutic potency. Therefore, PRT of CCP should be recommended to mitigate the risk for transmission of transfusion-associated infectious disease. There is a good correlation between SARS-CoV-2 IgG titres determined by ELISA and the neutralising capacity. This allows blood centres to select CCP donors based on IgG ELISA titres avoiding the much more labour-intensive laboratory processes for determining neutralising antibodies.

Estimating global and regional disruptions to routine childhood vaccine coverage during the COVID-19 pandemic in 2020: a modelling study.

BACKGROUND: The COVID-19 pandemic and efforts to reduce SARS-CoV-2 transmission substantially affected health services worldwide. To better understand the impact of the pandemic on childhood routine immunisation, we estimated disruptions in vaccine coverage associated with the pandemic in 2020, globally and by Global Burden of Disease (GBD) super-region. METHODS: For this analysis we used a two-step hierarchical random spline modelling approach to estimate global and regional disruptions to routine immunisation using administrative data and reports from electronic immunisation systems, with mobility data as a model input. Paired with estimates of vaccine coverage expected in the absence of COVID-19, which were derived from vaccine coverage models from GBD 2020, Release 1 (GBD 2020 R1), we estimated the number of children who missed routinely delivered doses of the third-dose diphtheria-tetanus-pertussis (DTP3) vaccine and first-dose measles-containing vaccine (MCV1) in 2020. FINDINGS: Globally, in 2020, estimated vaccine coverage was 76·7% (95% uncertainty interval 74·3-78·6) for DTP3 and 78·9% (74·8-81·9) for MCV1, representing relative reductions of 7·7% (6·0-10·1) for DTP3 and 7·9% (5·2-11·7) for MCV1, compared to expected doses delivered in the absence of the COVID-19 pandemic. From January to December, 2020, we estimated that 30·0 million (27·6-33·1) children missed doses of DTP3 and 27·2 million (23·4-32·5) children missed MCV1 doses. Compared to expected gaps in coverage for eligible children in 2020, these estimates represented an additional 8·5 million (6·5-11·6) children not routinely vaccinated with DTP3 and an additional 8·9 million (5·7-13·7) children not routinely vaccinated with MCV1 attributable to the COVID-19 pandemic. Globally, monthly disruptions were highest in April, 2020, across all GBD super-regions, with 4·6 million (4·0-5·4) children missing doses of DTP3 and 4·4 million (3·7-5·2) children missing doses of MCV1. Every GBD super-region saw reductions in vaccine coverage in March and April, with the most severe annual impacts in north Africa and the Middle East, south Asia, and Latin America and the Caribbean. We estimated the lowest annual reductions in vaccine delivery in sub-Saharan Africa, where disruptions remained minimal throughout the year. For some super-regions, including southeast Asia, east Asia, and Oceania for both DTP3 and MCV1, the high-income super-region for DTP3, and south Asia for MCV1, estimates suggest that monthly doses were delivered at or above expected levels during the second half of 2020. INTERPRETATION: Routine immunisation services faced stark challenges in 2020, with the COVID-19 pandemic causing the most widespread and largest global disruption in recent history. Although the latest coverage trajectories point towards recovery in some regions, a combination of lagging catch-up immunisation services, continued SARS-CoV-2 transmission, and persistent gaps in vaccine coverage before the pandemic still left millions of children under-vaccinated or unvaccinated against preventable diseases at the end of 2020, and these gaps are likely to extend throughout 2021. Strengthening routine immunisation data systems and efforts to target resources and outreach will be essential to minimise the risk of vaccine-preventable disease outbreaks, reach children who missed routine vaccine doses during the pandemic, and accelerate progress towards higher and more equitable vaccination coverage over the next decade. FUNDING: Bill & Melinda Gates Foundation.

Hydroxyethyl starch is an alternative washing solution for peripheral bloodstem cells products.

Cryopreservation of hematopoietic stem cells (HSC) involves slow rate cooling in the presence of a cryoprotectant (DMSO) to avoid the damaging effects of intracellular ice formation. The infusion of DMSO with the thawed product has been related to adverse events. Reduction of DMSO content by washing the HSCs after thawing has been suggested as a method to avoid infusion-related side-effects. Albumin-dextran washing methods have proved useful in thawing HSC products. Dextran40 shortages prompted us to search for suitable alternatives. We report the results of a comparative study of the use of hydroxyethyl starch (HES) as an alternative to dextran40 for washing thawed HSCs products. A total of 10 HSC bags cryopreserved with 10 % DMSO were used. We conducted a paired study; one of the bags was thawed and washed with our standard washing solution (Dextran 40) and the paired bag with HES solution with a final HES and Human Serum Albumin (HSA) concentration of 2.4 % and 4.2 % respectively. Each final product was tested immediately after washing (sample 0') and after 90 min (sample 90') for total nucleated cells (TNC) recovery, acridine orange viability, viable CD34+ enumeration, and clonogenicity. No significant difference was found for any of the cell counts, viability tests, cell recovery, or potency. We can state that the washing solution based on 2.4 % HES and 4.2 % HSA is equivalent to that used in our routine practice. Therefore, we could use the solution with HES, paying special attention to the renal function of the recipient.

Experiências de cardiopatas submetidos à cirurgia cardíaca: um estudo exploratório / Experiences of cardiopaths submitted to cardiac surgery: an exploratory study / Experiencias de cardiopatas sometidos a la cirugía cardíaca: estudio exploratório

Os objetivos deste estudo foram investigar e descrever os significados atribuídos às experiências de cardiopatas que se submeteram à cirurgia cardíaca, utilizando como base teórica a Gestalt-terapia. Cinco pacientes pós-operatórios foram entrevistados, sendo uma mulher e quatro homens, idades entre 52 e 65 anos, casados, autodeclarados brancos e pardos, escolaridade entre os níveis fundamental e médio. A análise dos dados foi realizada através da análise de conteúdo temática. Os resultados evidenciam que os principais significados atribuídos à experiência de cirurgia cardíaca se referem a ameaça à sobrevivência, perda do controle sobre si mesmos, perda da autonomia e da independência. O processo cirúrgico demanda um constante trabalho do sistema de orientação dos pacientes para que haja a manutenção da homeostase no organismo, havendo uma diversidade de reações regulatórias individuais que contribuem para a restauração do equilíbrio no meio em que se encontram.

This paper aims to investigate and describe significations of the experience of cardiopaths who were submitted to cardiac surgery, using the Gestalt-therapy as theoretical basis. The sample was composed by five post surgical pacientes, one woman and four men, ageing between 52 and 65 years old, married, self-declared white and brown, with scholarly between fundamental and medium levels. After the semiestructered intervieweds were done, the data was analysed through the tematic content analysis. The results of this study expose that the main significations related to the cardiac surgery refer to the threat to surviving, lost of control over yourself, lost of authonomy and independence. The surgical process demands a constant work of the pacient orientation system in order to exist the maintenance of the homeostasis in the organism, existing a diversity of individual regulatory reactions which contributes for the restauration of the balance of the environment in which they are located.

Los objetivos de este estudio fueron investigar y describir los significados asignados a las experiencias de cardiopatas que se sometieron a la cirugía cardíaca, utilizando como base teórica la Gestalt-terapia. Cinco pacientes de postoperatorio fueron entrevistados, siendo una mujer y cuatro hombres, edades entre 52 y 65 años, casados, etnias blanca y parda, escolaridad entre los niveles fundamental y medio. Los resultados evidencian que los principales significados asignados a la experiencia de cirugía cardíaca se refieren a la amenaza de supervivencia, pérdida del control sobre sí mismos, pérdida de la autonomía y de la independencia. El proceso quirúrgico demanda un trabajo constante del sistema de orientación de los pacientes para que haya el mantenimiento de la homeostasis en el organismo, habiendo una diversidad de reacciones regulatorias individuales que contribuyen para el restablecimiento del equilibrio en el ambiente que se encuentran.

Fertility, mortality, migration, and population scenarios for 195 countries and territories from 2017 to 2100: a forecasting analysis for the Global Burden of Disease Study.

BACKGROUND: Understanding potential patterns in future population levels is crucial for anticipating and planning for changing age structures, resource and health-care needs, and environmental and economic landscapes. Future fertility patterns are a key input to estimation of future population size, but they are surrounded by substantial uncertainty and diverging methodologies of estimation and forecasting, leading to important differences in global population projections. Changing population size and age structure might have profound economic, social, and geopolitical impacts in many countries. In this study, we developed novel methods for forecasting mortality, fertility, migration, and population. We also assessed potential economic and geopolitical effects of future demographic shifts. METHODS: We modelled future population in reference and alternative scenarios as a function of fertility, migration, and mortality rates. We developed statistical models for completed cohort fertility at age 50 years (CCF50). Completed cohort fertility is much more stable over time than the period measure of the total fertility rate (TFR). We modelled CCF50 as a time-series random walk function of educational attainment and contraceptive met need. Age-specific fertility rates were modelled as a function of CCF50 and covariates. We modelled age-specific mortality to 2100 using underlying mortality, a risk factor scalar, and an autoregressive integrated moving average (ARIMA) model. Net migration was modelled as a function of the Socio-demographic Index, crude population growth rate, and deaths from war and natural disasters; and use of an ARIMA model. The model framework was used to develop a reference scenario and alternative scenarios based on the pace of change in educational attainment and contraceptive met need. We estimated the size of gross domestic product for each country and territory in the reference scenario. Forecast uncertainty intervals (UIs) incorporated uncertainty propagated from past data inputs, model estimation, and forecast data distributions. FINDINGS: The global TFR in the reference scenario was forecasted to be 1·66 (95% UI 1·33-2·08) in 2100. In the reference scenario, the global population was projected to peak in 2064 at 9·73 billion (8·84-10·9) people and decline to 8·79 billion (6·83-11·8) in 2100. The reference projections for the five largest countries in 2100 were India (1·09 billion [0·72-1·71], Nigeria (791 million [594-1056]), China (732 million [456-1499]), the USA (336 million [248-456]), and Pakistan (248 million [151-427]). Findings also suggest a shifting age structure in many parts of the world, with 2·37 billion (1·91-2·87) individuals older than 65 years and 1·70 billion (1·11-2·81) individuals younger than 20 years, forecasted globally in 2100. By 2050, 151 countries were forecasted to have a TFR lower than the replacement level (TFR <2·1), and 183 were forecasted to have a TFR lower than replacement by 2100. 23 countries in the reference scenario, including Japan, Thailand, and Spain, were forecasted to have population declines greater than 50% from 2017 to 2100; China's population was forecasted to decline by 48·0% (-6·1 to 68·4). China was forecasted to become the largest economy by 2035 but in the reference scenario, the USA was forecasted to once again become the largest economy in 2098. Our alternative scenarios suggest that meeting the Sustainable Development Goals targets for education and contraceptive met need would result in a global population of 6·29 billion (4·82-8·73) in 2100 and a population of 6·88 billion (5·27-9·51) when assuming 99th percentile rates of change in these drivers. INTERPRETATION: Our findings suggest that continued trends in female educational attainment and access to contraception will hasten declines in fertility and slow population growth. A sustained TFR lower than the replacement level in many countries, including China and India, would have economic, social, environmental, and geopolitical consequences. Policy options to adapt to continued low fertility, while sustaining and enhancing female reproductive health, will be crucial in the years to come. FUNDING: Bill & Melinda Gates Foundation.

Cost-utility and budget impact of methylene blue-treated plasma compared to quarantine plasma.

BACKGROUND: Methylene blue and visible light treatment and quarantine are two methods used to reduce adverse events, mostly infections, associated with the transfusion of fresh-frozen plasma. The objective of this study was to estimate and compare the budget impact and cost-utility of these two methods from a payer's perspective. MATERIALS AND METHODS: A budget impact and cost-utility model simulating the risks of hepatitis B virus, hepatitis C virus, cytomegalovirus, a West Nile virus-like infection, allergic reactions and febrile non-haemolytic transfusion reactions achieved using plasma treated with methylene blue and visible light (MBP) and quarantine plasma (QP) was constructed for Spain. QP costs were estimated using data from one blood centre in Spain and published literature. The costs of producing fresh-frozen plasma from whole blood, apheresis plasma, and multicomponent apheresis, and separately for passive and active methods of donor recall for QP were included. Costs and outcomes over a 5-year and lifetime time horizon were estimated. RESULTS: Compared to passive QP, MBP led to a net increase of € 850,352, and compared to active QP, MBP led to a net saving of € 5,890,425 over a 5-year period. Compared to passive QP, MBP increased the cost of fresh-frozen plasma per patient by € 7.21 and had an incremental cost-utility ratio of € 705,126 per quality-adjusted life-year. Compared to active QP, MBP reduced cost by € 50.46 per patient and was more effective. DISCUSSION: Plasma collection method and quarantine approach had the strongest influence on the budget impact and cost-utility of MBP. If QP relies on plasma from whole blood collection and passive quarantine, it is less costly than MBP. However, MPB was estimated to be more effective than QP in all analyses.

Ajustamento criativo e estresse na hipertensão arterial sistêmica / Creative adjustments and stress in hypertension / Ajuste creativo y el estrés en la hipertensión

A hipertensão arterial sistêmica é problema de saúde pública e tem etiologia multifatorial, incluindo fatores psicológicos. Estes fatores interferem na instalação da doença e na forma como o paciente lida com ela. O estresse é apontado como importante fator predisponente da hipertensão, associado a outros fatores de risco, influenciando na reatividade cardiovascular. O objetivo deste trabalho é rever a literatura sobre aspectos psicológicos envolvidos no desencadeamento e na manutenção da hipertensão, destacando o estresse e os conceitos de ajustamento criativo e de mecanismos neuróticos da Gestalt-terapia, apontando a participação dos fatores subjetivos neste processo e a importância do trabalho do psicólogo com pacientes hipertensos. A Gestalt-terapia, enquanto abordagem psicológica organísmica e holística, pode ter importantes contribuições para a compreensão deste fenômeno e no acompanhamento de pacientes hipertensos, favorecendo seus processos de ampliação da awareness, de responsabilização e os ajustamentos criativos.(AU)

Hypertension is a public health problem and has a multifactorial etiology, including psychological factors. These factors influence the onset of the disease and how patients cope with it. Stress is considered an important predisposing factor for hypertension associated with other risk factors, influencing the cardiovascular reactivity. The objective of this paper is to review the literature on psychological aspects involved in the initiation and maintenance of hypertension, highlighting the stress and the concepts of creative adjustment and neurotic mechanisms of Gestalt therapy, pointing the participation of subjective factors in this process and the importance of the psychologists work with hipertensive patients. Gestalt therapy, while organismic and holistic psychological approach may have important contributions to the understanding of this phenomenon and monitoring of hypertensive patients, favoring processes of expansion of awareness, accountability and creative adjustments.(AU)

La hipertensión arterial es un problema de salud pública y tiene una etiología multifactorial, incluyendo factores psicológicos. Estos factores interfieren en la aparición de la enfermedad y em la forma cómo los pacientes lidian con ella. El estrés es apontado como un importante factor predisponente para la hipertensión, asociado a otros factores de riesgo, influyendo en la reactividad cardiovascular. El objetivo de este trabajo es revisar la literatura sobre los aspectos psicológicos implicados en el inicio y mantenimiento de la hipertensión, destacando el estres y los conceptos de ajuste creativo y mecanismos neuróticos de la Terapia Gestalt, senalando la participación de los factores subjetivos en este proceso y la importancia de trabajo psicológico con los pacientes hipertensos. La Terapia Gestalt, mientras que el enfoque psicológico organismico y holístico, puede tener importantes contribuciones a la comprensión de este fenómeno y en el acompanhamento de los pacientes hipertensos, favorecendo los procesos de expansión de la awareness, la responsabilizacion y los ajustes creativos.(AU)

Ajustamento criativo e estresse na hipertensão arterial sistêmica / Creative adjustments and stress in hypertension / Ajuste creativo y el estrés en la hipertensión

A hipertensão arterial sistêmica é problema de saúde pública e tem etiologia multifatorial, incluindo fatores psicológicos. Estes fatores interferem na instalação da doença e na forma como o paciente lida com ela. O estresse é apontado como importante fator predisponente da hipertensão, associado a outros fatores de risco, influenciando na reatividade cardiovascular. O objetivo deste trabalho é rever a literatura sobre aspectos psicológicos envolvidos no desencadeamento e na manutenção da hipertensão, destacando o estresse e os conceitos de ajustamento criativo e de mecanismos neuróticos da Gestalt-terapia, apontando a participação dos fatores subjetivos neste processo e a importância do trabalho do psicólogo com pacientes hipertensos. A Gestalt-terapia, enquanto abordagem psicológica organísmica e holística, pode ter importantes contribuições para a compreensão deste fenômeno e no acompanhamento de pacientes hipertensos, favorecendo seus processos de ampliação da awareness, de responsabilização e os ajustamentos criativos.

Hypertension is a public health problem and has a multifactorial etiology, including psychological factors. These factors influence the onset of the disease and how patients cope with it. Stress is considered an important predisposing factor for hypertension associated with other risk factors, influencing the cardiovascular reactivity. The objective of this paper is to review the literature on psychological aspects involved in the initiation and maintenance of hypertension, highlighting the stress and the concepts of creative adjustment and neurotic mechanisms of Gestalt therapy, pointing the participation of subjective factors in this process and the importance of the psychologists work with hipertensive patients. Gestalt therapy, while organismic and holistic psychological approach may have important contributions to the understanding of this phenomenon and monitoring of hypertensive patients, favoring processes of expansion of awareness, accountability and creative adjustments.

La hipertensión arterial es un problema de salud pública y tiene una etiología multifactorial, incluyendo factores psicológicos. Estos factores interfieren en la aparición de la enfermedad y em la forma cómo los pacientes lidian con ella. El estrés es apontado como un importante factor predisponente para la hipertensión, asociado a otros factores de riesgo, influyendo en la reactividad cardiovascular. El objetivo de este trabajo es revisar la literatura sobre los aspectos psicológicos implicados en el inicio y mantenimiento de la hipertensión, destacando el estres y los conceptos de ajuste creativo y mecanismos neuróticos de la Terapia Gestalt, senalando la participación de los factores subjetivos en este proceso y la importancia de trabajo psicológico con los pacientes hipertensos. La Terapia Gestalt, mientras que el enfoque psicológico organismico y holístico, puede tener importantes contribuciones a la comprensión de este fenómeno y en el acompanhamento de los pacientes hipertensos, favorecendo los procesos de expansión de la awareness, la responsabilizacion y los ajustes creativos.

First report of Babesia divergens infection in an HIV patient.

Human babesiosis is a zoonosis primarily transmitted through Ixodes ticks and alternatively by routes such as blood transfusions from asymptomatic donors. We report the first case of human babesiosis caused by Babesia divergens in a patient with HIV. This study also focuses on elucidating the possible transmission route of infection in this patient, who received numerous blood transfusions but showed patent symptoms only after splenectomy. A battery of detection tools along with a novel Western-Blot Assay and Enzyme Linked Immunosorbent Assay using the major surface protein of B. divergens (Bd37) as a target were used to evaluate the presence of B. divergens or antibodies against the parasite in samples from the patient and the blood donors involved in this case. A retrospective study of the humoral status against the parasite revealed B. divergens IgG antibodies in one of the implicated donors, but also showed that the patient had been already exposed to the parasite before any transfusion. Thus, this analysis of natural and transfusion transmission routes suggests a pre-existing subclinical babesiosis in the patient.