Multimorbidity and social determinants of health in the US prior to the COVID-19 pandemic and implications for health outcomes: a cross-sectional analysis based on NHANES 2017-2018.

Multimorbidity increases the risk of all-cause mortality, and along with age, is an independent risk factor for severe disease and mortality from COVID-19. Inequities in the social determinants of health contributed to increased mortality from COVID-19 among disadvantaged populations. This study aimed to evaluate the prevalence of multimorbid conditions and associations with the social determinants of health in the US prior to the pandemic.Methods Data from the 2017-18 cycle of NHANES were used to determine the prevalence of 13 chronic conditions, and the prevalence of having 0, 1, or 2 or more of those conditions, among the US adult population aged ≥ 20 years. Multimorbidity was defined as having 2 or more of these conditions. Data were stratified according to demographic, socioeconomic and indicators of health access, and analyses including logistic regression, performed to determine the factors associated with multimorbidity.Results The prevalence of multimorbidity was 58.4% (95% CI 55.2 to 61.7). Multimorbidity was strongly associated with age and was highly prevalent among those aged 20-29 years at 22.2% (95% CI 16.9 to 27.6) and continued to increase with older age. The prevalence of multimorbidity was highest in those defined as Other or multiple races (66.9%), followed in decreasing frequency by rates among non-Hispanic Whites (61.2%), non-Hispanic Blacks (57.4%), Hispanic (52.0%) and Asian (41.3%) groups.Logistic regression showed a statistically significant relationship between multimorbidity and age, as expected. Asian race was associated with a reduced likelihood of 2 or more chronic conditions (OR 0.4; 95% CI 0.35 to 0.57; P < 0.0001). Socioeconomic factors were related to multimorbidity. Being above the poverty level (OR 0.64; 95% CI 0.46 to 0.91, p = 0.013); and a lack of regular access to health care (OR 0.61 (95% CI 0.42 to 0.88, p = 0.008) were both associated with a reduced likelihood of multimorbidity. Furthermore, there was a borderline association between not having health insurance and reduced likelihood of multimorbidity (OR 0.63; 95% CI 0.40 to 1.0; p = 0.053).Conclusions There are high levels of multimorbidity in the US adult population, evident from young adulthood and increasing with age. Cardiometabolic causes of multimorbidity were highly prevalent, especially obesity, hyperlipidemia, hypertension, and diabetes; conditions subsequently found to be associated with severe disease and death from COVID-19. A lack of access to care was paradoxically associated with reduced likelihood of comorbidity, likely linked to underdiagnosis of chronic conditions. Obesity, poverty, and lack of access to healthcare are factors related to multimorbidity and were also relevant to the health impact of the COVID-19 pandemic, that must be addressed through comprehensive social and public policy measures. More research is needed on the etiology and determinants of multimorbidity, on those affected, patterns of co-morbidity, and implications for individual health and impact on health systems and society to promote optimal outcomes. Comprehensive public health policies are needed to tackle multimorbidity and reduce disparities in the social determinants of health, as well as to provide universal access to healthcare.

The rising burden of non-communicable diseases in the Americas and the impact of population aging: a secondary analysis of available data.

Background: Public health progress in the Americas has reduced the burden of many infectious diseases, helping more people live longer lives. At the same time, the burden of non-communicable diseases (NCDs) is increasing. NCD prevention rightly focuses on lifestyle risk factors, social, and economic determinants of health. There is less published information on the importance of population growth and aging to the regional NCD burden. Methods: For 33 countries in the Americas, we used United Nations population data to describe rates of population growth and aging over two generations (1980-2060). We used World Health Organization estimates of mortality and disability (disability-adjusted life years, DALYs) to describe changes in the NCD burden between 2000 and 2019. After combining these data resources, we decomposed the change in the number of deaths and DALYs to estimate the percentage change due to population growth, due to population aging, and due to epidemiological advances, measured by changing mortality and DALY rates. In a supplement, we provide a summary briefing for each country. Findings: In 1980, the proportion of the regional population aged 70 and older was 4.6%. It rose to 7.8% by 2020 and is predicted to rise to 17.4% by 2060. Across the Americas, DALY rate reductions would have decreased the number of DALYs by 18% between 2000 and 2019 but was offset by a 28% increase due to population aging and a 22% increase due to population growth. Although the region enjoyed widespread reductions in rates of disability, these improvements have not been sufficiently large to offset the pressures of population growth and population aging. Interpretation: The region of the Americas is aging and the pace of this aging is predicted to increase. The demographic realities of population growth and population aging should be factored into healthcare planning, to understand their implications for the future NCD burden, the health system needs, and the readiness of governments and communities to respond to those needs. Funding: This work was funded in part by the Pan American Health Organization, Department of Noncommunicable Diseases and Mental Health.

Inhaled bronchodilators for acute chest syndrome in people with sickle cell disease.

BACKGROUND: Bronchodilators are used to treat bronchial hyper-responsiveness in asthma. Bronchial hyper-responsiveness may be a component of acute chest syndrome in people with sickle cell disease. Therefore, bronchodilators may be useful in the treatment of acute chest syndrome. This is an update of a previously published Cochrane Review. OBJECTIVES: The aim of the review is to determine whether the use of inhaled, short-acting bronchodilators for acute chest syndrome reduces morbidity and mortality in people with sickle cell disease and to assess whether this treatment causes adverse effects. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. Additional searches were carried out on MEDLINE (1966 to 2004) and Embase (1981 to 2004) and ongoing trial registries (28 September 2022). Date of the most recent search of the Group's Haemoglobinopathies Trials Register: 25 July 2022. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials. Trials using quasi-randomisation methods will be included in future updates of this review if there is sufficient evidence that the treatment and control groups are similar at baseline. DATA COLLECTION AND ANALYSIS: We found no trials investigating the use of bronchodilators for acute chest syndrome in people with sickle cell disease. MAIN RESULTS: We found no trials investigating the use of bronchodilators for acute chest syndrome in people with sickle cell disease. AUTHORS' CONCLUSIONS: If bronchial hyper-responsiveness is an important component of some episodes of acute chest syndrome in people with sickle cell disease, the use of inhaled bronchodilators may be indicated. There is need for a well-designed, adequately-powered randomised controlled trial to assess the benefits and risks of the addition of inhaled bronchodilators to established therapies for acute chest syndrome in people with sickle cell disease.

Spleen size in homozygous sickle cell disease: trends in a birth cohort using ultrasound.

OBJECTIVES: To provide ultrasound baselines for spleen length in homozygous sickle cell disease (HbSS) and in normal controls with a HbAA genotype. METHODS: The Jamaican cohort study identified 311 babies with HbSS and 246 matched HbAA controls during the screening of 100,000 consecutive deliveries in Kingston, Jamaica from 1973 to 1981. Ultrasonography commenced in 1988 when the youngest patients were aged 6 years at which time deaths, emigrations and default had reduced the numbers to 206 HbSS and 89 controls. It continued annually until 2000. RESULTS: The spleen was visualized in all HbAA controls but in only 1103/2138 (52%) scans in HbSS. Where available, mean splenic lengths were significantly lower in HbSS (77-103 mm in males, 70-83 mm in females) compared to normal controls (89-101 mm in males, 86-95 mm in females). Assessed by statistical modelling after adjusting for body height, the splenic ratio (splenic length/body height) declined over the age range 12-20 years in HbSS, consistent with progressive splenic fibrosis. Genetic factors known to inhibit sickling, α thalassemia and fetal hemoglobin level (HbF) significantly reduced the decline in splenic ratio. Clinical splenomegaly was an insensitive measure of splenic enlargement as only 50% of patients aged 18 years and above with spleens measuring ≥150 mm on ultrasonography had palpable spleens. CONCLUSIONS: An age-related decline in splenic length occurred in HbSS and occurred more slowly with genetic factors known to inhibit sickling. The standards provided may be of value in assessing minor degrees of subclinical acute splenic sequestration. ADVANCES IN KNOWLEDGE: These are the first standards available for splenic length in HbSS. They may be useful in detecting red cell sequestration, not apparent from clinical splenomegaly and also provide a model for identifying factors inhibiting vaso-occlusion.

Newborn screening for abnormal haemoglobins in Jamaica: Practical issues in an island programme.

OBJECTIVE: To report the diagnostic challenges of newborn screening for abnormal haemoglobins. SETTING: Cord blood samples from 13 hospitals in southwest Jamaica taken in 2008-2019. METHODS: Blood spots, collected from the umbilical cord, were analysed by high pressure liquid chromatography (HPLC) to reveal phenotypes for HbSS and HbCC, but genotype confirmation may require parental studies or gene sequencing. Such cases that were successfully traced were analysed in this follow-up study. RESULTS: HPLC screening of 121,306 samples detected HbAS in 11,846 (9.8%), HbAC in 4508 (3.7%) and other electrophoretic abnormalities in 1090 babies. Among 101 previously unconfirmed cases, 34/90 (38%) with HPLC evidence of a HbSS phenotype had other genotypes, and 7/11 (64%) with a HbCC phenotype had other genotypes. Syndromes from the interaction of ß thalassaemia occurred in 112 babies (85 with HbS, 27 with HbC) and of genes for hereditary persistence of fetal haemoglobin (HPFH) in 18 (12 with HbS, 6 with HbC). Variants other than HbS and HbC occurred in 270 babies, 16 in combination with either HbS or HbC, and 254 as traits. Most variants are benign even when inherited with HbS, although HbO Arab, HbD Punjab, or Hb Lepore Washington, which occurred in 6 cases, may cause sickle cell disease. CONCLUSIONS: Genes for ß thalassaemia and HPFH are common in western Jamaica and when associated with HbS may present diagnostic challenges in newborns, as HbF and HbA2 have not reached diagnostic levels. Family and DNA studies may be necessary for genotype confirmation.

Interventions and policies aimed at improving nutrition in Small Island Developing States: a rapid review.

Objective: To describe features of nutritional interventions implemented in Small Island Developing States (SIDS) in the past 20 years. Methods: A rapid scoping review was conducted by searching PubMed and Web of Science databases for interventions conducted in SIDS that sought to improve the nutrition of their populations between 2000 and 2019 inclusive. The Noncommunicable diseases progress monitor 2020 was also examined to assess nutritional policies in SIDS. Results: A total of 174 interventions were implemented in 49 of the 58 SIDS. The greatest proportion were conducted in the Caribbean (75 interventions; 43%), with the Pacific region, and the Atlantic, Indian Ocean, Mediterranean and South China Sea region each implementing about 30% of interventions. Using the NOURISHING framework, most interventions (67%) were implemented at the community and national or policy level, using multiple components of the framework. The greatest proportion of interventions (35%) were educational and awareness raising. Restrictions on physical availability of and increased taxation on alcohol were the most commonly reported policies that were partially or fully achieved; restrictions on fats were the least commonly reported. These findings were generally consistent across the SIDS regions. Conclusions: There is a paucity of nutritional policies in SIDS; the reasons may be linked to their social, economic, and environmental vulnerabilities. Interventions should be expanded beyond education to encompass multiple components of the NOURISHING framework, with multisectoral inclusion to ensure stronger stakeholder collaboration and buy-in. A systematic review is warranted using a fuller range of sources to assess the effectiveness of interventions.

Interventions and policies aimed at improving nutrition in Small Island Developing States: a rapid review

[ABSTRACT]. Objective. To describe features of nutritional interventions implemented in Small Island Developing States (SIDS) in the past 20 years. Methods. A rapid scoping review was conducted by searching PubMed and Web of Science databases for interventions conducted in SIDS that sought to improve the nutrition of their populations between 2000 and 2019 inclusive. The Noncommunicable diseases progress monitor 2020 was also examined to assess nutritional policies in SIDS. Results. A total of 174 interventions were implemented in 49 of the 58 SIDS. The greatest proportion were conducted in the Caribbean (75 interventions; 43%), with the Pacific region, and the Atlantic, Indian Ocean, Mediterranean and South China Sea region each implementing about 30% of interventions. Using the NOURISHING framework, most interventions (67%) were implemented at the community and national or policy level, using multiple components of the framework. The greatest proportion of interventions (35%) were educational and awareness raising. Restrictions on physical availability of and increased taxation on alcohol were the most commonly reported policies that were partially or fully achieved; restrictions on fats were the least commonly reported. These findings were generally consistent across the SIDS regions. Conclusions. There is a paucity of nutritional policies in SIDS; the reasons may be linked to their social, economic, and environmental vulnerabilities. Interventions should be expanded beyond education to encompass multiple components of the NOURISHING framework, with multisectoral inclusion to ensure stronger stakeholder collaboration and buy-in. A systematic review is warranted using a fuller range of sources to assess the effectiveness of interventions.

[RESUMEN]. Objetivo. Describir las características de las intervenciones nutricionales realizadas en los pequeños Estados insulares en desarrollo durante los últimos 20 años. Métodos. Se realizó una revisión exploratoria rápida mediante búsquedas en las bases de datos PubMed y Web of Science de las intervenciones realizadas en los pequeños Estados insulares en desarrollo entre los años 2000 y 2019 con el fin de mejorar la nutrición de su población. También se examinó la publicación Monitoreo de avances en materia de las enfermedades no transmisibles 2020 para evaluar las políticas nutricionales en estos Estados. Resultados. Se efectuaron 174 intervenciones en 49 de los 58 pequeños Estados insulares en desarrollo. La mayor parte se llevaron a cabo en el Caribe (75 intervenciones; 43%), en tanto que la región del Pacífico y la región de los océanos Atlántico e Índico y de los mares de China Meridional y Mediterráneo efectuaron aproximadamente un 30% de las intervenciones cada una. Con la ayuda del marco NOURISHING, la mayor parte de las intervenciones (67%) se efectuaron a nivel de la comunidad y a nivel de país o de política utilizando distintos componentes del marco. La mayor parte de las intervenciones (35%) fueron educativas y de concientización. Entre las políticas que se notificaron con más frecuencia estuvieron las restricciones a la disponibilidad física de las bebidas alcohólicas y el aumento de los impuestos al alcohol; entre las menos frecuentes, las restricciones a las grasas. Por lo general, estos resultados fueron uniformes en todas las regiones con pequeños Estados insulares en desarrollo. Conclusiones. Los pequeños Estados insulares en desarrollo tienen pocas políticas nutricionales; esto puede estar relacionado con sus vulnerabilidades sociales, económicas y ambientales. Las intervenciones deberían ampliarse más allá de la educación para así incorporar múltiples componentes del marco NOURISHING, con una inclusión multisectorial que garantice una mayor colaboración y aceptación de las partes interesadas. Se justifica una revisión sistemática que haga uso de una gama más completa de fuentes para evaluar la efectividad de las intervenciones.

[RESUMO]. Objetivo. Descrever as características das intervenções nutricionais implementadas em pequenos Estados insulares em desenvolvimento (PEID) nos 20 últimos anos. Métodos. Uma revisão de escopo rápida foi realizada mediante pesquisa dos bancos de dados PubMed e Web of Science, buscando intervenções para melhoria nutricional da população em PEID no período entre 2000 e 2019. A publicação Noncommunicable Diseases Progress Monitor 2020 também foi consultada para avaliar as políticas nutricionais destes países. Resultados. Foram implementadas 174 intervenções em 49 dos 58 PEID, distribuídas na sua grande maioria na região do Caribe (75, 43%) e nas regiões do Pacífico e AIMS (Atlântico, Índico, Mediterrâneo e Mar do Sul da China) (cerca de 30% cada). Elaboradas a partir do NOURISHING Framework, a maior parte das intervenções (67%) teve implementação ao nível nacional, da comunidade ou de política, englobando os vários componentes deste quadro. Houve predomínio de intervenções educacionais e de sensibilização (35%). Observou-se com maior frequência o cumprimento total ou parcial de políticas de restrição à oferta física de bebidas alcoólicas e aumento de impostos sobre estas. Políticas de restrição à utilização de gorduras em alimentos foram as menos observadas. Em geral, as conclusões foram semelhantes em todas as regiões de PEID. Conclusões. Os PEID carecem de políticas nutricionais, devido a fatores possivelmente associados a vulnerabilidades ambientais e socioeconômicas. Além de educacionais, as intervenções devem ser ampliadas para englobar diversos outros componentes do NOURISHING Framework, com participação multissetorial para assegurar uma maior colaboração e comprometimento das partes envolvidas. Recomenda-se realizar uma revisão sistemática, com pesquisa de um rol mais amplo de fontes de informação, para avaliar a efetividade das intervenções.

Interventions and policies aimed at improving nutrition in Small Island Developing States: a rapid review / Intervenciones y políticas orientadas a mejorar la nutrición en los pequeños Estados insulares en desarrollo: una revisión rápida / Intervenções e políticas para melhoria da nutrição em pequenos Estados insulares em desenvolvimento: revisão rápida

ABSTRACT Objective. To describe features of nutritional interventions implemented in Small Island Developing States (SIDS) in the past 20 years. Methods. A rapid scoping review was conducted by searching PubMed and Web of Science databases for interventions conducted in SIDS that sought to improve the nutrition of their populations between 2000 and 2019 inclusive. The Noncommunicable diseases progress monitor 2020 was also examined to assess nutritional policies in SIDS. Results. A total of 174 interventions were implemented in 49 of the 58 SIDS. The greatest proportion were conducted in the Caribbean (75 interventions; 43%), with the Pacific region, and the Atlantic, Indian Ocean, Mediterranean and South China Sea region each implementing about 30% of interventions. Using the NOURISHING framework, most interventions (67%) were implemented at the community and national or policy level, using multiple components of the framework. The greatest proportion of interventions (35%) were educational and awareness raising. Restrictions on physical availability of and increased taxation on alcohol were the most commonly reported policies that were partially or fully achieved; restrictions on fats were the least commonly reported. These findings were generally consistent across the SIDS regions. Conclusions. There is a paucity of nutritional policies in SIDS; the reasons may be linked to their social, economic, and environmental vulnerabilities. Interventions should be expanded beyond education to encompass multiple components of the NOURISHING framework, with multisectoral inclusion to ensure stronger stakeholder collaboration and buy-in. A systematic review is warranted using a fuller range of sources to assess the effectiveness of interventions.

RESUMEN Objetivo. Describir las características de las intervenciones nutricionales realizadas en los pequeños Estados insulares en desarrollo durante los últimos 20 años. Métodos. Se realizó una revisión exploratoria rápida mediante búsquedas en las bases de datos PubMed y Web of Science de las intervenciones realizadas en los pequeños Estados insulares en desarrollo entre los años 2000 y 2019 con el fin de mejorar la nutrición de su población. También se examinó la publicación Monitoreo de avances en materia de las enfermedades no transmisibles 2020 para evaluar las políticas nutricionales en estos Estados. Resultados. Se efectuaron 174 intervenciones en 49 de los 58 pequeños Estados insulares en desarrollo. La mayor parte se llevaron a cabo en el Caribe (75 intervenciones; 43%), en tanto que la región del Pacífico y la región de los océanos Atlántico e Índico y de los mares de China Meridional y Mediterráneo efectuaron aproximadamente un 30% de las intervenciones cada una. Con la ayuda del marco NOURISHING, la mayor parte de las intervenciones (67%) se efectuaron a nivel de la comunidad y a nivel de país o de política utilizando distintos componentes del marco. La mayor parte de las intervenciones (35%) fueron educativas y de concientización. Entre las políticas que se notificaron con más frecuencia estuvieron las restricciones a la disponibilidad física de las bebidas alcohólicas y el aumento de los impuestos al alcohol; entre las menos frecuentes, las restricciones a las grasas. Por lo general, estos resultados fueron uniformes en todas las regiones con pequeños Estados insulares en desarrollo. Conclusiones. Los pequeños Estados insulares en desarrollo tienen pocas políticas nutricionales; esto puede estar relacionado con sus vulnerabilidades sociales, económicas y ambientales. Las intervenciones deberían ampliarse más allá de la educación para así incorporar múltiples componentes del marco NOURISHING, con una inclusión multisectorial que garantice una mayor colaboración y aceptación de las partes interesadas. Se justifica una revisión sistemática que haga uso de una gama más completa de fuentes para evaluar la efectividad de las intervenciones.

RESUMO Objetivo. Descrever as características das intervenções nutricionais implementadas em pequenos Estados insulares em desenvolvimento (PEID) nos 20 últimos anos. Métodos. Uma revisão de escopo rápida foi realizada mediante pesquisa dos bancos de dados PubMed e Web of Science, buscando intervenções para melhoria nutricional da população em PEID no período entre 2000 e 2019. A publicação Noncommunicable Diseases Progress Monitor 2020 também foi consultada para avaliar as políticas nutricionais destes países. Resultados. Foram implementadas 174 intervenções em 49 dos 58 PEID, distribuídas na sua grande maioria na região do Caribe (75, 43%) e nas regiões do Pacífico e AIMS (Atlântico, Índico, Mediterrâneo e Mar do Sul da China) (cerca de 30% cada). Elaboradas a partir do NOURISHING Framework, a maior parte das intervenções (67%) teve implementação ao nível nacional, da comunidade ou de política, englobando os vários componentes deste quadro. Houve predomínio de intervenções educacionais e de sensibilização (35%). Observou-se com maior frequência o cumprimento total ou parcial de políticas de restrição à oferta física de bebidas alcoólicas e aumento de impostos sobre estas. Políticas de restrição à utilização de gorduras em alimentos foram as menos observadas. Em geral, as conclusões foram semelhantes em todas as regiões de PEID. Conclusões. Os PEID carecem de políticas nutricionais, devido a fatores possivelmente associados a vulnerabilidades ambientais e socioeconômicas. Além de educacionais, as intervenções devem ser ampliadas para englobar diversos outros componentes do NOURISHING Framework, com participação multissetorial para assegurar uma maior colaboração e comprometimento das partes envolvidas. Recomenda-se realizar uma revisão sistemática, com pesquisa de um rol mais amplo de fontes de informação, para avaliar a efetividade das intervenções.

Anthropometric cut-offs to identify hyperglycemia in an Afro-Caribbean population: a cross-sectional population-based study from Barbados.

INTRODUCTION: Body mass index (BMI) and waist circumference (WC) cut-offs associated with hyperglycemia may differ by ethnicity. We investigated the optimal BMI and WC cut-offs for identifying hyperglycemia in the predominantly Afro-Caribbean population of Barbados. RESEARCH DESIGN AND METHODS: A cross-sectional study of 865 individuals aged ≥25 years without known diabetes or cardiovascular disease was conducted. Hyperglycemia was defined as fasting plasma glucose ≥5.6 mmol/L or hemoglobin A1c ≥5.7% (39 mmol/mol). The Youden index was used to identify the optimal cut-offs from the receiver operating characteristic (ROC) curves. Further ROC analysis and multivariable log binomial regression were used to compare standard and data-derived cut-offs. RESULTS: The prevalence of hyperglycemia was 58.9% (95% CI 54.7% to 63.0%). In women, optimal BMI and WC cut-offs (27 kg/m2 and 87 cm, respectively) performed similarly to standard cut-offs. In men, sensitivities of the optimal cut-offs of BMI ≥24 kg/m2 (72.0%) and WC ≥86 cm (74.0%) were higher than those for standard BMI and WC obesity cut-offs (30.0% and 25%-46%, respectively), although with lower specificity. Hyperglycemia was 70% higher in men above the data-derived WC cut-off (prevalence ratio 95% CI 1.2 to 2.3). CONCLUSIONS: While BMI and WC cut-offs in Afro-Caribbean women approximate international standards, our findings, consistent with other studies, suggest lowering cut-offs in men may be warranted to improve detection of hyperglycemia. Our findings do, however, require replication in a new data set.

COVID-19 in Children in the United States: Intensive Care Admissions, Estimated Total Infected, and Projected Numbers of Severe Pediatric Cases in 2020.

IMPORTANCE: A surge in severe cases of COVID-19 (coronavirus disease 2019) in children would present unique challenges for hospitals and public health preparedness efforts in the United States. OBJECTIVE: To provide evidence-based estimates of children infected with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) and projected cumulative numbers of severely ill pediatric COVID-19 cases requiring hospitalization during the US 2020 pandemic. DESIGN: Empirical case projection study. MAIN OUTCOMES AND MEASURES: Adjusted pediatric severity proportions and adjusted pediatric criticality proportions were derived from clinical and spatiotemporal modeling studies of the COVID-19 epidemic in China for the period January-February 2020. Estimates of total children infected with SARS-CoV-2 in the United States through April 6, 2020, were calculated using US pediatric intensive care unit (PICU) cases and the adjusted pediatric criticality proportion. Projected numbers of severely and critically ill children with COVID-19 were derived by applying the adjusted severity and criticality proportions to US population data, under several scenarios of cumulative pediatric infection proportion (CPIP). RESULTS: By April 6, 2020, there were 74 children who had been reported admitted to PICUs in 19 states, reflecting an estimated 176 190 children nationwide infected with SARS-CoV-2 (52 381 infants and toddlers younger than 2 years, 42 857 children aged 2-11 years, and 80 952 children aged 12-17 years). Under a CPIP scenario of 5%, there would be 3.7 million children infected with SARS-CoV-2, 9907 severely ill children requiring hospitalization, and 1086 critically ill children requiring PICU admission. Under a CPIP scenario of 50%, 10 865 children would require PICU admission, 99 073 would require hospitalization for severe pneumonia, and 37.0 million would be infected with SARS-CoV-2. CONCLUSIONS AND RELEVANCE: Because there are 74.0 million children 0 to 17 years old in the United States, the projected numbers of severe cases could overextend available pediatric hospital care resources under several moderate CPIP scenarios for 2020 despite lower severity of COVID-19 in children than in adults.

Pharmacological interventions for painful sickle cell vaso-occlusive crises in adults.

BACKGROUND: Sickle cell disease (SCD) is a group of inherited disorders of haemoglobin (Hb) structure in a person who has inherited two mutant globin genes (one from each parent), at least one of which is always the sickle mutation. It is estimated that between 5% and 7% of the world's population are carriers of the mutant Hb gene, and SCD is the most commonly inherited blood disorder. SCD is characterized by distorted sickle-shaped red blood cells. Manifestations of the disease are attributed to either haemolysis (premature red cell destruction) or vaso-occlusion (obstruction of blood flow, the most common manifestation). Shortened lifespans are attributable to serious comorbidities associated with the disease, including renal failure, acute cholecystitis, pulmonary hypertension, aplastic crisis, pulmonary embolus, stroke, acute chest syndrome, and sepsis. Vaso-occlusion can lead to an acute, painful crisis (sickle cell crisis, vaso-occlusive crisis (VOC) or vaso-occlusive episode). Pain is most often reported in the joints, extremities, back or chest, but it can occur anywhere and can last for several days or weeks. The bone and muscle pain experienced during a sickle cell crisis is both acute and recurrent. Key pharmacological treatments for VOC include opioid analgesics, non-opioid analgesics, and combinations of drugs. Non-pharmacological approaches, such as relaxation, hypnosis, heat, ice and acupuncture, have been used in conjunction to rehydrating the patient and reduce the sickling process. OBJECTIVES: To assess the analgesic efficacy and adverse events of pharmacological interventions to treat acute painful sickle cell vaso-occlusive crises in adults, in any setting. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online, MEDLINE via Ovid, Embase via Ovid and LILACS, from inception to September 2019. We also searched the reference lists of retrieved studies and reviews, and searched online clinical trial registries. SELECTION CRITERIA: Randomized, controlled, double-blind trials of pharmacological interventions, of any dose and by any route, compared to placebo or any active comparator, for the treatment (not prevention) of painful sickle cell VOC in adults. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed studies for eligibility. We planned to use dichotomous data to calculate risk ratio (RR) and number needed to treat for one additional event, using standard methods. Our primary outcomes were participant-reported pain relief of 50%, or 30%, or greater; Patient Global Impression of Change (PGIC) very much improved, or much or very much improved. Our secondary outcomes included adverse events, serious adverse events, and withdrawals due to adverse events. We assessed GRADE and created three 'Summary of findings' tables. MAIN RESULTS: We included nine studies with data for 638 VOC events and 594 participants aged 17 to 42 years with SCD presenting to a hospital emergency department in a painful VOC. Three studies investigated a non-steroidal anti-inflammatory drug (NSAID) compared to placebo. One study compared an opioid with a placebo, two studies compared an opioid with an active comparator, two studies compared an anticoagulant with a placebo, and one study compared a combination of three drugs with a combination of four drugs. Risk of bias across the nine studies varied. Studies were primarily at an unclear risk of selection, performance, and detection bias. Studies were primarily at a high risk of bias for size with fewer than 50 participants per treatment arm; two studies had 50 to 199 participants per treatment arm (unclear risk). Non-steroidal anti-inflammatory drugs (NSAID) compared with placebo No data were reported regarding participant-reported pain relief of 50% or 30% or greater. The efficacy was uncertain regarding PGIC very much improved, and PGIC much or very much improved (no difference; 1 study, 21 participants; very low-quality evidence). Very low-quality, uncertain results suggested similar rates of adverse events across both the NSAIDs group (16/45 adverse events, 1/56 serious adverse events, and 1/56 withdrawal due to adverse events) and the placebo group (19/45 adverse events, 2/56 serious adverse events, and 1/56 withdrawal due to adverse events). Opioids compared with placebo No data were reported regarding participant-reported pain relief of 50% or 30%, PGIC, or adverse events (any adverse event, serious adverse events, and withdrawals due to adverse events). Opioids compared with active comparator No data were reported regarding participant-reported pain relief of 50% or 30% or greater. The results were uncertain regarding PGIC very much improved (33% of the opioids group versus 19% of the placebo group). No data were reported regarding PGIC much or very much improved. Very low-quality, uncertain results suggested similar rates of adverse events across both the opioids group (9/66 adverse events, and 0/66 serious adverse events) and the placebo group (7/64 adverse events, 0/66 serious adverse events). No data were reported regarding withdrawal due to adverse events. Quality of the evidence We downgraded the quality of the evidence by three levels to very low-quality because there are too few data to have confidence in results (e.g. too few participants per treatment arm). Where no data were reported for an outcome, we had no evidence to support or refute (quality of the evidence is unknown). AUTHORS' CONCLUSIONS: This review identified only nine studies, with insufficient data for all pharmacological interventions for analysis. The available evidence is very uncertain regarding the efficacy or harm from pharmacological interventions used to treat pain related to sickle cell VOC in adults. This area could benefit most from more high quality, certain evidence, as well as the establishment of suitable registries which record interventions and outcomes for this group of people.

Regular long-term red blood cell transfusions for managing chronic chest complications in sickle cell disease.

BACKGROUND: Sickle cell disease is a genetic haemoglobin disorder, which can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Sickle cell disease is one of the most common severe monogenic disorders in the world, due to the inheritance of two abnormal haemoglobin (beta globin) genes. The two most common chronic chest complications due to sickle cell disease are pulmonary hypertension and chronic sickle lung disease. These complications can lead to morbidity (such as reduced exercise tolerance) and increased mortality. This is an update of a Cochrane Review first published in 2011 and updated in 2014 and 2016. OBJECTIVES: We wanted to determine whether trials involving people with sickle cell disease that compare regular long-term blood transfusion regimens with standard care, hydroxycarbamide (hydroxyurea) any other drug treatment show differences in the following: mortality associated with chronic chest complications; severity of established chronic chest complications; development and progression of chronic chest complications; serious adverse events. SEARCH METHODS: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. Date of the last search: 19 September 2019. We also searched for randomised controlled trials in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 10, 14 November 2018), MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1937), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 14 November 2018. SELECTION CRITERIA: We included randomised controlled trials of people of any age with one of four common sickle cell disease genotypes, i.e. Hb SS, Sߺ, SC, or Sß+ that compared regular red blood cell transfusion regimens (either simple or exchange transfusions) to hydroxycarbamide, any other drug treatment, or to standard care that were aimed at reducing the development or progression of chronic chest complications (chronic sickle lung and pulmonary hypertension). DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. MAIN RESULTS: No studies matching the selection criteria were found. AUTHORS' CONCLUSIONS: There is a need for randomised controlled trials looking at the role of long-term transfusion therapy in pulmonary hypertension and chronic sickle lung disease. Due to the chronic nature of the conditions, such trials should aim to use a combination of objective and subjective measures to assess participants repeatedly before and after the intervention.

Does peak expiratory flow measured sitting differ from that measured standing? A cross-over study in primary care in Barbados.

BACKGROUND: Several authorities recommend measuring peak expiratory flow (PEF) standing. Limited evidence suggests that PEF obtained sitting is similar in magnitude but there are no studies in African populations. AIM: To determine in adults aged 18-60 years if PEF measured sitting differs from that measured standing. DESIGN & SETTING: Crossover design with alternating position of initial measurement in people attending primary care clinics in Barbados. METHOD: Quota sampling by age, sex, and clinic of adults aged 18-60 years was done and an interviewer-administered questionnaire was completed. PEF sitting and standing was measured with an European Union (EU) scale Mini-Wright® meter. The highest of three readings in each position was used and the difference in means tested for significance using the paired sample t-test. RESULTS: Characteristics of the 199 participants were 44% male; 96.5% of African descent; mean age 37 years (standard deviation [SD] 12.8); 22% with an asthma diagnosis; 23% tobacco users; and 22% marijuana users. Mean PEF standing was 438.4 versus 429.7 lmin-1 sitting, mean difference 8.7 (95% confidence interval [CI] = 3.6 to 13.8). For men, mean PEF standing was 518.7 versus 506.3 lmin-1 sitting, mean difference 12.4 (95% CI = 3.3 to 21.5). For women, mean PEF was 374.7 standing versus 368.9 lmin-1 sitting, mean difference 5.8 (95% CI = 0.11 to 11.5). A Bland-Altman plot accounting for trend and a Lin's correlation coefficient of 0.935 demonstrated good agreement between standing and sitting PEF. CONCLUSION: PEF measurements are reduced when performed sitting compared to standing. The difference is small and unlikely to alter clinical management in most cases.

Sodium and potassium excretion in an adult Caribbean population of African descent with a high burden of cardiovascular disease.

BACKGROUND: High sodium diets with inadequate potassium and high sodium-to-potassium ratios are a known determinant of hypertension and cardiovascular disease (CVD). The Caribbean island of Barbados has a high prevalence of hypertension and mortality from CVD. Our objectives were to estimate sodium and potassium excretion, to compare estimated levels with recommended intakes and to identify the main food sources of sodium in Barbadian adults. METHODS: A sub-sample (n = 364; 25-64 years) was randomly selected from the representative population-based Health of the Nation cross-sectional study (n = 1234), in 2012-13. A single 24-h urine sample was collected from each participant, following a strictly applied protocol designed to reject incomplete samples, for the measurement of sodium and potassium excretion (in mg), which were used as proxy estimates of dietary intake. In addition, sensitivity analyses based on estimated completeness of urine collection from urine creatinine values were undertaken. Multiple linear regression was used to examine differences in sodium and potassium excretion, and the sodium-to-potassium ratio, by age, sex and educational level. Two 24-h recalls were used to identify the main dietary sources of sodium. All analyses were weighted for the survey design. RESULTS: Mean sodium excretion was 2656 (2488-2824) mg/day, with 67% (62-73%) exceeding the World Health Organization (WHO) recommended limit of 2000 mg/d. Mean potassium excretion was 1469 (1395-1542) mg/d; < 0.5% met recommended minimum intake levels. Mean sodium-to-potassium ratio was 2.0 (1.9-2.1); not one participant had a ratio that met WHO recommendations. Higher potassium intake and lower sodium-to-potassium ratio were independently associated with age and tertiary education. Sensitivity analyses based on urine creatinine values did not notably alter these findings. CONCLUSIONS: In this first nationally representative study with objective assessment of sodium and potassium excretion in a Caribbean population in over 20 years, levels of sodium intake were high, and potassium intake was low. Younger age and lower educational level were associated with the highest sodium-to-potassium ratios. These findings provide baseline values for planning future policy interventions for non-communicable disease prevention.

Managing acute ischaemic stroke in a small island developing state: meeting the guidelines in Barbados.

BACKGROUND: We describe hospital-based management of acute ischaemic stroke patients in 2010-2013 in Barbados, by comparing documented treatment given in the single tertiary public hospital with international guideline recommendations. METHODS: Evidence-based stroke management guidelines were identified through a systematic literature search. Comparisons were made between these guidelines and documented diagnostic practice (all strokes) and prescribed medication (ischaemic stroke only), using a combination of key informant interviews and national stroke registry data for 2010-2013. RESULTS: Several published international guidelines for the acute management of ischaemic stroke recommended patient management in a dedicated stroke unit or nearest hospital specialised in stroke care. Further, patients should receive clinical diagnosis, CT brain scan, specialist evaluation by a multidisciplinary team and, if eligible, thrombolysis with alteplase within 3-3.5 h of symptom onset. Subsequent secondary prophylaxis, with a platelet aggregation inhibitor and a statin was advised. Barbados had no stroke unit or stroke team, and no official protocol for acute stroke management during the study period. Most of the 1735 stroke patients were managed by emergency physicians at presentation; if admitted, they were managed on general medical wards. Most had a CT scan (1646; 94.9%). Of 1406 registered ischaemic stroke patients, only 6 (0.4%) had been thrombolysed, 521 (37.1%) received aspirin within 24 h of admission and 670 (47.7%) were prescribed aspirin on discharge. CONCLUSIONS: Acute ischaemic stroke diagnosis was consistent with international recommendations, although this was less evident for treatment. While acknowledging the difficulty in implementing international guidelines in a low-resource setting, there is scope for improvement in acute ischaemic stroke management and/or its documentation in Barbados. A stroke unit was established in August 2013 and written clinical protocols for acute stroke care were in development at the time of the study; future registry data will evaluate their impact. Our findings have implications for other low-resource settings with high stroke burden.

Causes of death and early life determinants of survival in homozygous sickle cell disease: The Jamaican cohort study from birth.

Globally, the majority of persons born with sickle cell disease do not have access to hydroxyurea or more expensive interventions. The objectives were to estimate the survival in homozygous sickle cell disease, unbiased by symptomatic selection and to ascertain the causes of death in a pre-hydroxyurea population. The utility of early life biomarkers and genetically determined phenotypes to predict survival was assessed. A cohort study based on neonatal diagnosis was undertaken at the Sickle Cell Unit, a specialist clinic delivering care to persons with sickle cell disease in Jamaica. Screening of 100,000 deliveries detected 315 babies with homozygous sickle cell disease of whom 311 have been followed from birth for periods up to 43 years. Pneumococcal prophylaxis and teaching mothers splenic palpation were important, inexpensive interventions. Anticipatory guidance, routine care and out-patient acute care were provided. Each participant was classified as alive, dead, or defaulted (usually emigration). Causes of death were ascertained from clinical records and/or post-mortem reports. Survival was assessed using the Kaplan-Meier function. Sex-adjusted Cox semi-parametric proportional hazards and Weibull modelling were used to assess the effects on survival of biomarkers. Survival to 40 years was 55.5% (95% CI 48.7% to 61.7%). Acute Chest Syndrome (n = 31) and septicemia (n = 14) were significant causes of death at all ages. Acute splenic sequestration (n = 12) was the most common cause of early deaths. Survival was significantly shorter in those with lower hemoglobin at 1 year, high total nucleated count at 1 year, and a history of dactylitis ever. In these hydroxyurea naïve patients, survival into midlife was common. Causes of death were often age specific and some may be preventable. Early life biomarkers predictive of decreased survival in SS disease identify a patient group likely to benefit from close clinical supervision and potentially high risk therapies.