The health loss from ischemic stroke and intracerebral hemorrhage : evidence from the North East Melbourne Stroke Incidence Study (NEMESIS)

Background People suffering different types of stroke have differing demographic characteristics and survival. However, current estimates of disease burden are based on the same underlying assumptions irrespective of stroke type. We hypothesized that average Quality Adjusted Life Years (QALYs) lost from stroke would be different for ischemic stroke and intracerebral hemorrhage (ICH).

Methods We used 1 and 5-year data collected from patients with first-ever stroke participating in the North East Melbourne Stroke Incidence Study (NEMESIS). We calculated case fatality rates, health-adjusted life expectancy, and quality-of-life (QoL) weights specific to each age and gender category. Lifetime 'health loss' for first-ever ischemic stroke and ICH surviving 28-days for the 2004 Australian population cohort was then estimated. Multivariable uncertainty analyses and sensitivity analyses (SA) were used to assess the impact of varying input parameters e.g. case fatality and QoL weights.

Results Paired QoL data at 1 and 5 years were available for 237 NEMESIS participants. Extrapolating NEMESIS rates, 31,539 first-ever strokes were expected for Australia in 2004. Average discounted (3%) QALYs lost per first-ever stroke were estimated to be 5.09 (SD 0.20; SA 5.49) for ischemic stroke (n = 27,660) and 6.17 (SD 0.26; SA 6.45) for ICH (n = 4,291; p < 0.001). QALYs lost also differed according to gender for both subtypes (ischemic stroke: males 4.69 SD 0.38, females 5.51 SD 0.46; ICH: males 5.82 SD 0.67, females 6.50 SD 0.40).

Discussion People with ICH incurred greater loss of health over a lifetime than people with ischemic stroke. This is explained by greater stroke related case fatality at a younger age, but longer life expectancy with disability after the first 12 months for people with ICH. Thus, studies of disease burden in stroke should account for these differences between subtype and gender. Otherwise, in countries where ICH is more common, health loss for stroke may be underestimated. Similar to other studies of this type, the generalisability of the results may be limited. Sensitivity and uncertainty analyses were used to provide a plausible range of variation for Australia. In countries with demographic and life expectancy characteristics comparable to Australia, our QoL weights may be reasonably applicable.

Influence of sedation on morbidity and mortality in the intensive care unit

CONTEXTO: Embora cerca de 30% a 50% dos pacientes hospitalizados em unidades de terapia intensiva (UTI) recebam algum tipo de sedativo, existe escassez de informações sobre efeitos adversos desta prática, especialmente no Brasil. Estes efeitos podem ser significantes e o uso de sedativos é associado a elevação de infecção e mortalidade, mesmo sendo difícil avaliar o impacto clínico deste procedimento. OBJETIVO: Avaliar o impacto da sedação sobre incidência de complicações e mortalidade em doentes graves durante internação em unidade de terapia intensiva. TIPO DE ESTUDO: Estudo prospectivo. LOCAL: Unidade de Terapia Intensiva Cirúrgica da Universidade Federal de São Paulo (UNIFESP) - Escola Paulista de Medicina. PARTICIPANTES: Após excluídos pacientes que permaneceram menos de 24 horas ou sem exames indispensáveis para o cálculo do índice de gravidade (APACHE II), restaram 307 pacientes. Estes foram divididos em dois grupos: Grupo Sedado e Grupo Não Sedado. Constatada heterogeneidade com relação ao APACHE II, foram pareados 97 sedados e 97 não sedados com idênticos índices de gravidade. VARIÁVEIS ESTUDADAS: Impacto da sedação e das técnicas sobre a mortalidade, tempo de internação, além da incidência de escara de decúbito ou pressão, trombose venosa profunda e infecção. RESULTADOS: Não houve diferença na incidência de trombose venosa profunda, entre os grupos Sedado e Não Sedado, enquanto que escara de decúbito foi significativamente maior nos sedados (p = 0,03). Infecção foi detectada em 45,4% dos pacientes com sedação e em 21,6% dos pacientes sem sedação (p = 0,006). A mortalidade para os pacientes que não receberam qualquer tipo de sedativo foi de 20,6% e, para aqueles que foram sedados durante a internação, foi de 52,6% (p < 0,0001). CONCLUSÕES: Conclui-se que a sedação está associada a maior duração da internação, morbidade e mortalidade significativas. Apesar da intensidade das associações encontradas, não é possível estabelecer relação causal entre sedação e mortalidade.

An assessment of the economic impact of climate change on the health sector In Jamaica

Climate change is a naturally occurring phenomenon in which the earth‘s climate goes through cycles of warming and cooling; these changes usually take place incrementally over millennia. Over the past century, there has been an anomalous increase in global temperature, giving rise to accelerated climate change. It is widely accepted that greenhouse gas emissions from human activities such as industries have contributed significantly to the increase in global temperatures. The existence and survival of all living organisms is predicated on the ability of the environment in which they live not only to provide conditions for their basic needs but also conditions suitable for growth and reproduction. Unabated climate change threatens the existence of biophysical and ecological systems on a planetary scale. The present study aims to examine the economic impact of climate change on health in Jamaica over the period 2011-2050. To this end, three disease conditions with known climate sensitivity and importance to Jamaican public health were modelled. These were: dengue fever, leptospirosis and gastroenteritis in children under age 5. Historical prevalence data on these diseases were obtained from the Ministry of Health Jamaica, the Caribbean Epidemiology Centre, the Climate Studies Group Mona, University of the West Indies Mona campus, and the Meteorological Service of Jamaica. Data obtained spanned a twelve-year period of 1995-2007. Monthly data were obtained for dengue and gastroenteritis, while for leptospirosis, the annual number of cases for 1995-2005 was utilized. The two SRES emission scenarios chosen were A2 and B2 using the European Centre Hamburg Model (ECHAM) global climate model to predict climate variables for these scenarios. A business as usual (BAU) scenario was developed using historical disease data for the period 2000-2009 (dengue fever and gastroenteritis) and 1995-2005 (leptospirosis) as the reference decades for the respective diseases. The BAU scenario examined the occurrence of the diseases in the absence of climate change. It assumed that the disease trend would remain unchanged over the projected period and the number of cases of disease for each decade would be the same as the reference decade. The model used in the present study utilized predictive empirical statistical modelling to extrapolate the climate/disease relationship in time, to estimate the number of climate change-related cases under future climate change scenarios. The study used a Poisson regression model that considered seasonality and lag effects to determine the best-fit model in relation to the diseases under consideration. Zhang and others (2008), in their review of climate change and the transmission of vector-borne diseases, found that: ―Besides climatic variables, few of them have included other factors that can affect the transmission of vector-borne disease….‖ (Zhang 2008) Water, sanitation and health expenditure are key determinants of health. In the draft of the second communication to IPCC, Jamaica noted the vulnerability of public health to climate change, including sanitation and access to water (MSJ/UNDP, 2009). Sanitation, which in its broadest context includes the removal of waste (excreta, solid, or other hazardous waste), is a predictor of vector-borne diseases (e.g. dengue fever), diarrhoeal diseases (such as gastroenteritis) and zoonoses (such as leptospirosis). In conceptualizing the model, an attempt was made to include non-climate predictors of these climate-sensitive diseases. The importance of sanitation and water access to the control of dengue, gastroenteritis and leptospirosis were included in the Poisson regression model. The Poisson regression model obtained was then used to predict the number of disease cases into the future (2011-2050) for each emission scenario. After projecting the number of cases, the cost associated with each scenario was calculated using four cost components. 1. Treatment cost morbidity estimate. The treatment cost for the number of cases was calculated using reference values found in the literature for each condition. The figures were derived from studies of the cost of treatment and represent ambulatory and non-fatal hospitalized care for dengue fever and gastroenteritis. Due to the paucity of published literature on the health care cost associated with leptospirosis, only the cost of diagnosis and antibiotic therapy were included in the calculation. 2. Mortality estimates. Mortality estimates are recorded as case fatality rates. Where local data were available, these were utilized. Where these were unavailable, appropriate reference values from the literature were used. 3. Productivity loss. Productivity loss was calculated using a human capital approach, by multiplying the expected number of productive days lost by the caregiver and/or the infected person, by GDP per capita per day (US$ 14) at 2008 GDP using 2008 US$ exchange rates. 4. No-option cost. The no-option cost refers to adaptation strategies for the control of dengue fever which are ongoing and already a part of the core functions of the Vector Control Division of the Ministry of Health, Jamaica. An estimated US$ 2.1 million is utilized each year in conducting activities to prevent the post-hurricane spread of vector borne diseases and diarrhoea. The cost includes public education, fogging, laboratory support, larvicidal activities and surveillance. This no-option cost was converted to per capita estimates, using population estimates for Jamaica up to 2050 obtained from the Statistical Institute of Jamaica (STATIN, 2006) and the assumption of one expected major hurricane per decade. During the decade 2000-2009, Jamaica had an average inflation of 10.4% (CIA Fact book, last updated May 2011). This average decadal inflation rate was applied to the no-option cost, which was inflated by 10% for each successive decade to adjust for changes in inflation over time.

Temporal, spatial and spatiotemporal analysis of the occurrence of visceral leishmaniasis in humans in the City of Birigui, State of São Paulo, from 1999 to 2012

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Advances in the prevention, management and treatment of community-acquired pneumonia

Despite the availability of powerful antibiotics, community-acquired pneumonia (CAP) remains one of the leading reasons for morbidity and mortality worldwide, and despite the availability of powerful antibiotics, there has been only little improvement in case fatality rates for many years. Consequently, it cannot be expected that novel antibiotics will substantially improve outcomes in CAP. Therefore, this review focuses on novel approaches that may reduce CAP-related mortality: the impact of immunomodulation by macrolides and fluoroquinolones and the prevention of CAP by pneumococcal vaccines.

Bacterial meningitis: current therapy and possible future treatment options

Despite targeted therapy, case-fatality rates and neurologic sequelae of bacterial meningitis remain unacceptably high. The poor outcome is mainly due to secondary systemic and intracranial complications. These complications seem to be both a consequence of the inflammatory response to the invading pathogen and release of bacterial components by the pathogen itself. Therefore, within the last decades, research has focused on the mechanism underlying immune regulation and the inhibition of bacterial lysis in order to identify new targets for adjuvant therapy. The scope of this article is to give an overview on current treatment strategies of bacterial meningitis, to summarize new insights on the pathophysiology of bacterial meningitis, and to give an outlook on new treatment strategies derived from experimental models.

Defining barriers in caring for seriously-ill children in a resource-limited setting: An observational study of 2 children's hospitals in Haiti

Background. According to the WHO 2007 country report, Haiti lags behind the Millennium Development Goal of reducing child mortality and maintains the highest under-5 mortality rate in the Western hemisphere. 3 Overall, few studies exist that seek to better grasp barriers in caring for a seriously ill child in a resource-limited setting and only a handful propose sustainable, effective interventions. ^ Objectives. The objectives of this study are to describe the prevalence of serious illnesses among children hospitalized at 2 children's hospitals in Port au Prince, to determine the barriers faced when caring for seriously ill children, and to report hospital outcomes of children admitted with serious illnesses. ^ Methods. Data were gathered from 2 major children's hospitals in Port au Prince, Haiti (Grace Children's Hospital [GCH] and Hopital d l'Universite d'Etat d'Haiti [HUEH]) using a triangulated approach of focus group discussions, physician questionnaires, and retrospective chart review. 23 pediatric physicians participated in focus group discussions and completed a self-administered questionnaire evaluating healthcare provider knowledge, self-efficacy, and perceived barriers relating to the care of seriously ill children in a resource-limited setting. A sample of 240 patient charts meeting eligibility criteria was abstracted for pertinent elements including sociodemographics, documentation, treatment strategies, and outcomes. Factors associated with mortality were analyzed using χ2 test and Fisher exact test [Minitab v.15]. ^ Results. The most common primary diagnoses at admission were gastroenteritis with moderate dehydration (35.5%), severe malnutrition (25.8%), and pneumonia (19.3%) for GCH, and severe malnutrition (32.6%), sepsis (24.7%), and severe respiratory distress (18%) for HUEH. Overall, 12.9% and 27% of seriously ill patients presented with shock to GCH and HUEH, respectively. ^ Shortage of necessary materials and equipment represented the most commonly reported limitation (18/23 respondents). According to chart data, 9.4% of children presenting with shock did not receive a fluid bolus, and only 8% of patients presenting with altered mental status or seizures received a glucose check. 65% of patients with meningitis did not receive a lumbar puncture due to lack of materials. ^ Hospital mortality rates did not differ by gender or by institution. Children who died were more likely to have a history of prematurity (OR 4.97 [95% CI 1.32-18.80]), an incomplete vaccination record (OR 4.05 [95% CI 1.68-9.74]), or a weight for age ≤3rd percentile (OR 6.1 [95% CI 2.49-14.93]. Case-fatality rates were significantly higher among those who presented with signs of shock compared with those who did not (23.1% vs. 10.7%, RR=2.16, p=0.03). Caregivers did not achieve shock reversal in 21% of patients and did not document shock reversal in 50% of patients. ^ Conclusions. Many challenges face those who seek to optimize care for seriously ill children in resource-limited settings. Specifically, in Haiti, qualitative and quantitative data suggest major issues with lack of supplies, pre-hospital factors, including malnutrition as a comorbidity, and early recognition and management of shock. A tailored intervention designed to address these issues is needed in order to prospectively evaluate improvements in child mortality in a high-risk population.^

Burden of invasive pneumococcal disease in Harris County, Texas (2003--2010) and the implication for enhanced public health surveillance of isolates

Invasive pneumococcal disease (IPD) causes significant health burden in the US, is responsible for the majority of bacterial meningitis, and causes more deaths than any other vaccine preventable bacterial disease in the US. The estimated National IPD rate is 14.3 cases per 100,000 population with a case-fatality rate of 1.5 cases per 100,000 population. Although cases of IPD are routinely reported to the local health department in Harris County Texas, the incidence (IR) and case-fatality (CFR) rates have not been reported. Additionally, it is important to know which serotypes of S. pneumoniae are circulating in Harris County Texas and to determine if ‘replacement disease’ is occurring. ^ This study reported incidence and case-fatality rates from 2003 to 2009, and described the trends in IPD, including the IPD serotypes circulating in Harris County Texas during the study period, particularly in 2008 and 2010. Annual incidence rates were calculated and reported for 2003 to 2009, using complete surveillance-year data. ^ Geographic information system (GIS) software was used to create a series of maps of the data reported during the study period. Cluster and outlier analysis and hot spot analysis were conducted using both case counts by census tract and disease rate by census tract. ^ IPD age- and race-adjusted IR for Harris County Texas and their 95% confidence intervals (CIs) were 1.40 (95% CI 1.0, 1.8), 1.71 (95% CI 1.24, 2.17), 3.13 (95% CI 2.48, 3.78), 3.08 (95% CI 2.43, 3.74), 5.61 (95% CI 4.79, 6.43), 8.11 (95% CI 7.11, 9.1), and 7.65 (95% CI 6.69, 8.61) for the years 2003 to 2009, respectively (rates were age- and race-adjusted to each year's midyear US population estimates). A Poisson regression model demonstrated a statistically significant increasing trend of about 32 percent per year in the IPD rates over the course of the study period. IPD age- and race-adjusted case-fatality rates (CFR) for Harris County Texas were also calculated and reported. A Poisson regression model demonstrated a statistically significant increasing trend of about 26 percent per year in the IPD case-fatality rates from 2003 through 2009. A logistic regression model associated the risk of dying from IPD to alcohol abuse (OR 4.69, 95% CI 2.57, 8.56) and to meningitis (OR 2.42, 95% CI 1.46, 4.03). ^ The prevalence of non-vaccine serotypes (NVT) among IPD cases with serotyped isolates was 98.2 percent. In 2008, the year with the sample more geographically representative of all areas of Harris County Texas, the prevalence was 96 percent. Given these findings, it is reasonable to conclude that ‘replacement disease’ is occurring in Harris County Texas, meaning that, the majority of IPD is caused by serotypes not included in the PCV7 vaccine. Also in conclusion, IPD rates increased during the study period in Harris County Texas.^

Estudo descritivo de série histórica da coqueluche no Brasil no período de 2006 a 2013

A coqueluche vem reemergindo enquanto importante problema de saúde pública em vários países do mundo, apesar das altas coberturas vacinais na infância. O objetivo geral deste estudo foi avaliar a morbimortalidade da coqueluche no Brasil e os objetivos específicos foram: estimar as taxas de mortalidade, incidência e letalidade anuais, geral e por faixa etária, por unidade da federação e regiões do país; caracterizar a sazonalidade da doença; estimar as taxas de hospitalização anuais por faixa etária e verificar as características clínicas, histórico de contato e vacinação prévia dos casos notificados da doença. Métodos: estudo descritivo, baseado nos casos de coqueluche notificados ao Sistema de Informação de Agravos de Notificação (SINAN), de 2006 a 2013. Os resultados mostraram aumento nas taxas de incidência de coqueluche no Brasil, a partir de 2011. Em 2013, foram confirmados 6.523 casos de coqueluche no país, três vezes o número de casos confirmados em 2011, com incidência geral de 3,24 /100.000 habitantes e incidência em menores de um ano de 125,82/100.000 habitantes, as maiores durante o período estudado. As crianças menores de um ano foram as mais acometidas pela doença em todas as macrorregiões. Em 2013, todas as regiões, exceto a região sul, apresentaram suas maiores taxas de incidência geral, com destaque para as regiões sudeste e centro-oeste com 4,0 e 3,1 por 100.000 habitantes, respectivamente. As maiores taxas de letalidade foram observadas na faixa etária menor de dois meses de idade, variando de 4,0% (2008) a 9,5% (2010). As taxas de letalidade foram maiores em crianças menores de seis meses em todas as regiões, sendo as regiões nordeste e sudeste as que apresentaram maiores taxas ao longo dos anos, exceto em 2013, quando o centro-oeste superou o nordeste. Houve predomínio dos casos nos meses mais quentes, entre novembro e março. A maioria das hospitalizações ocorreu na faixa etária de menores de um ano, principalmente em menores de quatro meses, cuja frequência de hospitalização ficou em torno de 75%. A tosse e o paroxismo foram os sintomas mais frequentes, independente da faixa etária, e a cianose foi importante sintoma nos menores de dois meses, com uma frequência de 80% nos casos confirmados desta faixa etária. A complicação mais comum foi pneumonia (13,93%), principalmente na faixa etária menor de dois meses, com frequência de 27,5%. O critério mais utilizado para diagnóstico de coqueluche foi o clínico, seguido pelo laboratorial que aumentou a partir de 2011, ano em que foi responsável por 49,9% dos diagnósticos. A maioria dos casos confirmados (51%) não relatou contato prévio com casos suspeitos ou confirmados de coqueluche, no entanto quando presente, a maioria dos contatos ocorreu no domicílio (70,6%). Os resultados mostraram aumento dos casos de coqueluche no Brasil, a partir de 2011, com as maiores taxas de incidência, hospitalizações, complicações e letalidade na faixa etária de menores de um ano

Is the increase in coronary events on Mondays an artifact?

Background: The aim of this article was to investigate the size and possible causes of the reported excess in coronary events on Mondays. Methods: We conducted a metaanalysis of data from the World Health Organization (WHO) MONICA Project, which monitored trends and determinants in cardiovascular disease. The MONICA Project was undertaken in 21 countries from 1980 to 1995. Results: We found a small overall excess rate of coronary events on Mondays. In a population experiencing 100 events per week, we estimate there would be approximately I more event on Monday than on any other day. Hierarchical logistic regression showed that the Monday excess was greater in centers with less thorough data collection procedures. Conclusions: The excess of coronary events on Mondays is probably an artifact resulting from events with uncertain dates being coded as taking place on Mondays.

Reduced between-hospital variation in short term survival after acute myocardial infarction: the result of improved cardiac care?

Objectives: To re-examine interhospital variation in 30 day survival after acute myocardial infarction ( AMI) 10 years on to see whether the appointment of new cardiologists and their involvement in emergency care has improved outcome after AMI. Design: Retrospective cohort study. Setting: Acute hospitals in Scotland. Participants: 61 484 patients with a first AMI over two time periods: 1988 - 1991; and 1998 - 2001. Main outcome measures: 30 day survival. Results: Between 1988 and 1991, median 30 day survival was 79.2% ( interhospital range 72.1 - 85.1%). The difference between highest and lowest was 13.0 percentage points ( age and sex adjusted, 12.1 percentage points). Between 1998 and 2001, median survival rose to 81.6% ( and range decreased to 78.0 - 85.6%) with a difference of 7.6 ( adjusted 8.8) percentage points. Admission hospital was an independent predictor of outcome at 30 days during the two time periods ( p< 0.001). Over the period 1988 - 1991, the odds ratio for death ranged, between hospitals, from 0.71 ( 95% confidence interval ( CI) 0.58 to 0.88) to 1.50 ( 95% CI 1.19 to 1.89) and for the period 1998 - 2001 from 0.82 ( 95% CI 0.60 to 1.13) to 1.46 ( 95% CI 1.07 to 1.99). The adjusted risk of death was significantly higher than average in nine of 26 hospitals between 1988 and 1991 but in only two hospitals between 1998 and 2001. Conclusions: The average 30 day case fatality rate after admission with an AMI has fallen substantially over the past 10 years in Scotland. Between-hospital variation is also considerably less notable because of better survival in the previously poorly performing hospitals. This suggests that the greater involvement of cardiologists in the management of AMI has paid dividends.

Measuring the impact of a quality improvement collaboration to decrease maternal mortality in a Ghanaian regional hospital.

OBJECTIVE: To evaluate the performance of a continuous quality improvement collaboration at Ridge Regional Hospital, Accra, Ghana, that aimed to halve maternal and neonatal deaths. METHODS: In a quasi-experimental, pre- and post-intervention analysis, system deficiencies were analyzed and 97 improvement activities were implemented from January 2007 to December 2011. Data were collected on outcomes and implementation rates of improvement activities. Severity-adjustment models were used to calculate counterfactual mortality ratios. Regression analysis was used to determine the association between improvement activities, staffing, and maternal mortality. RESULTS: Maternal mortality decreased by 22.4% between 2007 and 2011, from 496 to 385 per 100000 deliveries, despite a 50% increase in deliveries and five- and three-fold increases in the proportion of pregnancies complicated by obstetric hemorrhage and hypertensive disorders of pregnancy, respectively. Case fatality rates for obstetric hemorrhage and hypertensive disorders of pregnancy decreased from 14.8% to 1.6% and 3.1% to 1.1%, respectively. The mean implementation score was 68% for the 97 improvement processes. Overall, 43 maternal deaths were prevented by the intervention; however, risk severity-adjustment models indicated that an even greater number of deaths was averted. Mortality reduction was correlated with 26 continuous quality improvement activities, and with the number of anesthesia nurses and labor midwives. CONCLUSION: The implementation of quality improvement activities was closely correlated with improved maternal mortality.

Task sharing within a managed clinical network to improve child health in Malawi

BACKGROUND: Eighty per cent of Malawi's 8 million children live in rural areas, and there is an extensive tiered health system infrastructure from village health clinics to district hospitals which refers patients to one of the four central hospitals. The clinics and district hospitals are staffed by nurses, non-physician clinicians and recently qualified doctors. There are 16 paediatric specialists working in two of the four central hospitals which serve the urban population as well as accepting referrals from district hospitals. In order to provide expert paediatric care as close to home as possible, we describe our plan to task share within a managed clinical network and our hypothesis that this will improve paediatric care and child health.

PRESENTATION OF THE HYPOTHESIS: Managed clinical networks have been found to improve equity of care in rural districts and to ensure that the correct care is provided as close to home as possible. A network for paediatric care in Malawi with mentoring of non-physician clinicians based in a district hospital by paediatricians based at the central hospitals will establish and sustain clinical referral pathways in both directions. Ultimately, the plan envisages four managed paediatric clinical networks, each radiating from one of Malawi's four central hospitals and covering the entire country. This model of task sharing within four hub-and-spoke networks may facilitate wider dissemination of scarce expertise and improve child healthcare in Malawi close to the child's home.

TESTING THE HYPOTHESIS: Funding has been secured to train sufficient personnel to staff all central and district hospitals in Malawi with teams of paediatric specialists in the central hospitals and specialist non-physician clinicians in each government district hospital. The hypothesis will be tested using a natural experiment model. Data routinely collected by the Ministry of Health will be corroborated at the district. This will include case fatality rates for common childhood illness, perinatal mortality and process indicators. Data from different districts will be compared at baseline and annually until 2020 as the specialists of both cadres take up posts.

IMPLICATIONS OF THE HYPOTHESIS: If a managed clinical network improves child healthcare in Malawi, it may be a potential model for the other countries in sub-Saharan Africa with similar cadres in their healthcare system and face similar challenges in terms of scarcity of specialists.

Ebola virus disease 2014

Ebola virus disease was irst described in 1976 originating from the Ebola River in the Democratic Republic of Congo. Since then, Ebola virus has become an important public health threat in Africa, and now it is of great concern worldwide due to the recent outbreaks (9216 cases with 4555 deaths up to October 20th, 2014), and it is so far the largest and deadliest recorded in history. Five Ebola virus species have been identiied (including Zaire, Sudan, Ivory Coast, Reston, and Bundibugyo Ebola virus), and four of them have proved to be highly pathogenic for both human and non-human primates, causing viral hemorrhagic fever with case fatality rates of up to 90%, for which no approved therapeutics or vaccines are currently available. Ebola virus infections are characterized by immune suppression and a systemic inlammatory response that causes impairment of the vascular, coagulation, and immune systems, leading to multiorgan failure and shock, and thus, in some ways, resembling septic shock. The major affected countries, Sierra Leone, Guinea, Liberia, and Nigeria, have been struggling to contain and to mitigate the outbreak. Gene sequencing of the 2014 virus (2014WA) outbreak has demonstrated 98% homology with the Zaire Ebola virus, with a 49% case fatality ratio across the affected countries. In this review the characteristics of the viruses, pathogenesis, diagnosis, treatment, and the cases reported in health care workers (HCW) are described, as well as a summary of outbreaks of the virus since its discovery, including these last two outbreaks in Africa.

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anaesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anaesthesia care, which should be available, affordable, timely, and safe to ensure good coverage, uptake, and outcomes. Despite growing need, the development and delivery of surgical and anaesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic effect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multi- disciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. We formed four working groups that focused on thedomains of health-care delivery and management; work-force, training, and education; economics and finance; and information management. Our Commission has five key messages, a set of indicators and recommendations to improve access to safe, affordable surgical and anaesthesia care in LMICs, and a template for a national surgical plan.