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Abstract In integrated photonic circuits, microring resonators are essential building blocks but are susceptible to phase errors due to fabrication imperfections and optical power fluctuations. Conventional active phase tuning methods are power-intensive and challenging to integrate into densely packed photonic chips. This study proposes a solution by integrating a thin 2D layer of In4/3P2Se6 (InPSe) onto silicon microring resonators (Si-MRR). This approach mitigates sensitivity to laser power and achieves non-volatile wavelength trimming. Under bias voltage, the device exhibits electro-optic behavior, offering a non-volatile phase trimming rate of −2.62 pm/V to −4.62 pm/V, corresponding to InPSe thicknesses of 45 nm to 120 nm. Low optical losses of 0.0091 to 0.0361 dB/μm were also measured, corresponding to thicknesses of 30 nm to 120 nm. The devices demonstrate stable in-situ resonance wavelength stabilization and bidirectional trimming, ensuring cyclic stability for non-volatile phase control. This advancement enhances the performance of silicon photonics across diverse applications, facilitating high-capacity, high-power operation in compact designs.

While computer animations have the potential to assist learners in understanding difficult concepts and eliminating misconceptions, studies supporting this claim are scarce. This study investigated how the 7E instructional model integrated with computer animations affected students' conceptual understanding and misconceptions about food making and plant growth. Experimental groups were taught the 7E learning cycle model [7E LCM], and 7E LCM with computer animation [CA] while the control group was taught the conventional instruction method. A two-tiered conceptual understanding multiple-choice test and semi-structured interviews were used to collect the data. ANOVA analysis revealed no significant differences between groups or genders in pre-food making and growth in plant conceptual understanding [pre-FMGPCU] and pre-misconceptions test scores [pre-MC]. There were, however, significant differences in post-FMGPCU and post-MC mean scores, with the 7E LCM with CA showing better results in improving conceptual understanding and minimizing misconceptions. MANOVA revealed no statistically significant difference between male and female students' post-FMGPCU and post-MC results. It was concluded that the 7E LCM with CA enhances students' conceptual understanding and minimizes misconceptions more effectively than other instructional approaches. It is recommended that similar designs be used in biology teaching.

Background: Indomethacin has analgesic and antipyretic properties. It is a common treatment for pain and rheumatoid diseases, but it has many side effects. We speculate that the natural antioxidants of Moringa oleifera could be a remedy for the long list of side effects. This study aimed to determine the possible protective effect of Moringa oleifera leaf extract on the indomethacin-induced degenerated testes and uterus in albino rat. Methods: Forty-eight white albino rats were assigned randomly into six groups consisting of eight rats. Group, I was the Normal control. Group II was animals induced with indomethacin but not treated. Group III was dosed with 500 mg/kg Moringa oleifera leaf extract while Groups IV-VI were induced with indomethacin and treated with 100, 250, and 500 mg/kg Moringa oleifera leaf extract respectively for 28 days. Animals were euthanized after the treatment period. The uterus and testes were excised and processed using the paraffin wax method and stained with haematoxylin and eosin. Results: Animals exposed to indomethacin became drowsy and lethargic with deep red teary eyes. The first mortality was recorded among animals administered with indomethacin without treatment. Histopathology of the testes showed that indomethacin caused degeneration of the seminiferous tubules and diminished the spermatozoa. The histology of the uterus was distorted, the endometrium and myometrium layers of the uterus were disintegrated. However, animals treated with Moringa oleifera showed dose-related improvements in the histology of the testes and uterus compared to the control group. Conclusion: Moringa oleifera leaf extract improved the histology of indomethacin-induced toxicity of the testes and uterine in white albino rats.

Background: A needs assessment identifies the differences between actual and ideal situations to facilitate the development of a new programme or improve existing services. Objectives: This article shares our experiences conducting the needs assessment in a context where people had limited or no understanding of the need being assessed. Method: Adhering to a three-phase model – comprising pre-assessment, assessment, and post-assessment – we employed diverse data collection methods, including quantitative survey, qualitative interviews, and environmental scan. Results: The findings underscored the necessity of expanding rehabilitation services in Ethiopia, with a shift from a purely medical focus to addressing issues associated with daily functioning and community engagement. These issues align closely with the core expertise and responsibilities of occupational therapists. Participants expressed support for the introduction of occupational therapy in Ethiopia and willingness to incorporate the practice of occupational therapists in their settings. The challenges encountered were how to ask about occupational therapy when it is not well known by members of the local population and how to introduce the profession without biasing participants’ responses. Conclusion: Conducting a needs assessment was critical to developing occupational therapy services in Ethiopia. We welcome others to learn from our experiences. Contribution: This manuscript details the assessment process and delves into the challenges we encountered and lessons learned. It extends methodological suggestions to inform future evaluations and contributes valuable insights to the broader discourse on needs assessment and programme development in a context where people have limited awareness of services, such as occupational therapy.

It is often challenging for youth with disabilities to access university education in Africa, and for those who manage to make it to university, while there, their experiences are still not barrier-free. The purpose of this study was to uncover the experiences of the barriers and facilitators to inclusion for youth with disabilities in universities in South Africa, Ghana and Ethiopia. This qualitative project applied a critical, participatory research approach to exploring youth experiences. Youth with disabilities and their colleagues conducted seven focus group discussions, with an average of five students in each focus group, and we used a qualitative descriptive method to analyze data. The findings uncovered similarities and differences in the barriers and facilitators to inclusive education among students with disabilities across all sites. Participants noted limited financial support and university services, and how inaccessible spaces and harmful attitudes are all barriers that hinder their access to education and inclusion. The identified facilitators include support systems and self-directed facilitation. Although the students self-advocated and reported some support to assist in their inclusion in university, it was still insufficient. Notably, some universities are making a concerted effort toward inclusion and accessibility, but more work needs to be done.

Abstract Background Integrated transmission assessment surveys (iTAS) have been recommended for evaluation of the transmission of both lymphatic filariasis (LF) and onchocerciasis as the prevalence of both diseases moves toward their respective elimination targets in Nigeria. Therefore, we conducted an iTAS between May and December 2017 in five local government areas (LGAs), also known as implementation units (IUs), in states of Cross River, Taraba and Yobe in Nigeria. Methods The TAS comprised two phases: the Pre-iTAS and the iTAS itself. Three states (Cross River, Taraba and Yobe), comprising five LGAs and 20 communities that have completed five rounds of combined treatment with ivermectin and albendazole for LF and 12 total rounds of ivermectin, were selected for inclusion in the study. All participants were tested with the Filariasis Test Strip (FTS; Alere Inc.) and the Biplex rapid Diagnostic Test (RDT; identifying filaria antigens Ov16/Wb123; Abbott diagnosctics Korea Inc.). Pre iTAS included 100 children ages 5-9 in each 4 communities and 300 individuals ages 10 and older in a subset of two communities. For the iTAS, only LGAs where antigenemia prevalence in all sampled communities during the Pre-iTAS was < 2% for LF were selected. Results Of the five LGAs included in the study, four met the cutoff of the Pre-iTAS and were included in the iTAS; the Ikom LGA was excluded from the iTAS due to antigenemia prevalence. A total of 11,531 school-aged children from 148 schools were tested for LF and onchocerciasis across these four LGAs, including 2873 children in Bade, 2622 children in Bekwara, 3026 children in Gashaka and 3010 children in Karim Lamido. Using the FTS, all samples from Bade and Karim Lamido were negative, whereas 0.2% of the samples from Bekwara and Gashaka were positive. Using the Biplex RDT, LF prevalence in Bade, Bekwara, Gashaka and Karim Lamido was

Primary intraosseous synovial sarcoma is an extremely rare malignancy that occurs primarily in young adults. We present a case of a primary intraosseous synovial sarcoma of the right distal ulna in a 19-year-old female. It has a propensity to mimic other radiologic and pathologic diagnosis. Histopathology after a surgical excisional biopsy with a wide margin plus adjunct radio and chemotherapy are necessary to improve prognosis.

Abstract Introduction Leishmania aethiopica (L. aethiopica) is responsible for different forms of cutaneous leishmaniasis (CL) in Ethiopia. Treatment heavily depends on limited drugs, together with drawbacks like toxicity and microbial resistance. The current research aimed to investigate in vitro growth inhibitory activity of Medicines for Malaria Ventures - Pathogen Box (MMV - PB) compounds against L. aethiopica clinical isolate. Methodology Four hundred MMV – PB compounds were screened against L. aethiopica using resazurin based colourimetric assay. Compounds with > 70% inhibition were further tested using macrophage based intracellular amastigote assay. Cytotoxic and hemolytic activity of candidate hits were assessed on THP1- cells and sheep red blood cells (RBCs), respectively. In vitro drug interaction study was also conducted for the most potent hit using the combination index method. Results At the test concentration of 1 μM, twenty-three compounds showed > 50% inhibition of promastigotes parasite growth, of which 11 compounds showed > 70% inhibition. The 50% growth inhibition (IC50) of the 11 compounds was ranged from 0.024 to 0.483 μM in anti-promastigote assay and from 0.064 to 0.899 μM in intracellular amastigote assay. Candidate compounds demonstrated good safety on sheep RBCs and THP-1 cell lines. MMV688415 demonstrated a slight hemolytic activity on sheep RBC (5.3% at 25 μM) and THP-1 cell line (CC20 = 25 μM) while MMV690102 inhibited half of THP-1 cells at 36.5 μM (selectivity index = 478). No synergistic activity was observed from the combinations of MMV690102 and amphotericin B (CI > 1), and MMV690102 and Pentamidine (CI > 1) at lower and higher combination points. Conclusion The present study identified a panel of compounds that can be used as a novel starting point for lead optimization. MMV690102 appears to be the most potent inhibitor against L. aethiopica promastigotes and amastigotes. Future works should investigate the antileishmanial mechanism of action and in vivo antileishmanial activities of identified hits.

An accurate forest inventory is crucial for forest monitoring and quantifying forest aboveground biomass (AGB). This study aimed to investigate the feasibility of Terrestrial Laser Scanning (TLS) in forest inventory and AGB estimation in the tropical forest of Malaysia. Individual trees were detected using manual and automatic detection methods. An average tree detection rate of 99.55% and 93.75% were achieved using the manual and automatic detection method respectively. The accuracy of the diameter at breast height (DBH) of trees measured from TLS was validated using field DBH as reference. A root means square error (RMSE) of 1.37 cm (6.60%) and 2.36 cm (11.47%), respectively, were obtained for manually and automatically measured TLS DBH. Similarly, TLS based tree height was validated using Airborne Laser Scanner (ALS) height as a reference and resulted in RMSE of 1.74 m (9.30%) and 3.17 m (17.40%) with manual and automatic method respectively. Finally, AGB was calculated using the variables derived from the TLS data. Results show an R2 value of 0.98 and RMSE of 0.08 Mg. The results of this study confirmed that TLS as a nondestructive approach can provide a very good estimation of forest attributes and AGB in the dense tropical forest conditions.

Musculoskeletal injuries remain a global problem for the Thoroughbred racing industry and there is conflicting evidence regarding the effect of age on the incidence of injuries. The ideal time to commence race training is strongly debated, with limited supporting literature. There is also conflicting evidence regarding the effect of high-speed exercise on musculoskeletal injuries. There is a strong interest in developing training and management strategies to reduce the frequency of injuries. The types of musculoskeletal injuries vary between 2-year-old and older horses, with dorsal metacarpal disease the most common injury in 2-year-old horses. It is likely that risk factors for injury in 2-year-old horses are different than those for older horses. It is also likely that the risk factors may vary between types of injury. This study aimed to determine the risk factors for musculoskeletal injuries and dorsal metacarpal disease. We report the findings of a large scale, prospective observational study of 2-year-old horses in Queensland, Australia. Data were collected weekly for 56-weeks, from 26 trainers, involving 535 2-year-old Thoroughbred racehorses, 1, 258 training preparations and 7, 512-weeks of exercise data. A causal approach was used to develop our statistical models, to build on the existing literature surrounding injury risk, by incorporating the previously established causal links into our analyses. Where previous data were not available, industry experts were consulted. Survival analyses were performed using Cox proportional hazards or Weibull regression models. Analysis of musculoskeletal injuries overall revealed the hazard was reduced with increased exposure to high-speed exercise [Hazard ratio (HR) 0.89, 95% Confidence Interval (CI) 0.84, 0.94, p < 0.001], increased number of training preparations (HR 0.58, 95% CI 0.50, 0.67, p < 0.001), increased rest before the training preparation (HR 0.89, 95% CI 0.83, 0.96, p = 0.003) and increased dam parity (HR 0.86, 95% CI 0.77, 0.97, p = 0.01). The hazard of injury was increased with increasing age that training commenced (HR 1.13, 95% CI 1.06, 1.19, p < 0.001). Analyses were then repeated with the outcome of interest dorsal metacarpal disease. Factors that were protective against dorsal metacarpal disease and musculoskeletal injuries overall included: increased total cumulative distance (HR 0.89, 95% CI 0.82, 0.97, p = 0.001) and total cumulative days exercised as a gallop (HR 0.96, 95% CI 0.92, 0.99, p = 0.03), the number of the training preparations (HR 0.43, 95% CI 0.30, 0.61, p < 0.001). The age that training commenced was harmful for both dorsal metacarpal disease (HR 1.17, 95% CI 1.07, 1.28, p < 0.001 and overall musculoskeletal injuries.). The use of non-ridden training modalities was protective for dorsal metacarpal disease (HR 0.89, 95% CI 0.81, 0.97, p = 0.008), but not musculoskeletal injuries overall. The male sex increased the hazard of DMD compared to females (HR 2.58, 95% CI 1.20, 5.56, p = 0.02), but not MSI overall. In summary, the hazard of musculoskeletal injury is greatest for 2-year-old horses that are born from uniparous mares, commence training at a later age, are in their first training preparation, have undertaken little high-speed exercise or had limited rest before their training preparation. The hazard of dorsal metacarpal disease is greatest for 2-year-old horses that are males, commence training at a later age, are in their first training preparation, have undertaken little high-speed exercise or had limited use of non-ridden training modalities. Close monitoring of these high-risk horses during their training program could substantially reduce the impact of MSI. Furthermore, an understanding of how training methodologies affect the hazard of MSI facilitates modification of training programs to mitigate the risk impact of injury. The strengths of this study include a large sample size, a well-defined study protocol and direct trainer interviews. The main limitation is the inherent susceptibility to survival bias.

Q fever caused by the gram negative bacteria, Coxiella burnetii, is an occupational hazard for those who live and work in rural settings and those who are in contact with animals, especially abattoir and slaughterhouse workers. Australia is the only country to register a vaccine to prevent Q fever (Q-vax®, Seqirus, Australia) that is used in high risk populations. Seroprevalence studies conducted to determine the burden of Q fever (C. burnetii infection) in different settings have demonstrated high levels of heterogeneity with estimates of the percent positive ranging from 30% to 70%. There is a need for a more systematic evaluation of the findings of these studies in order to provide summary estimates of the seroprevalence in different settings.We searched for published articles using PubMed, MEDLINE-EMBASE, and Scopus databases using search terms obtained from an initial review of published reports of recent Q fever outbreaks. Data on the seroprevalence of C. burnetii infection (Q fever) was extracted from the selected studies and a random effects meta-analysis was performed with stratification by outbreak status, year, country and serological techniques used. Results were visualised with a forest plot with 95% CI and measures of heterogeneity (I2) for the random effects model.A total of 19 articles that met the search criteria were included. The reported seroprevalence rate ranged from 4.7% to 91.7% among abattoir and slaughterhouse workers. No inter-group heterogeneity was observed (p = 0.956), supporting the pooling of all studies into one pooled measure. The pooled estimate of seropositivity for C. burnetii infection in people working in abattoirs and slaughterhouses was 26% (95% CI: 18–35%) regardless of the evidence of an “outbreak”, the time of year or country. Seropositivity for C burnetii was independent of a person's age and years of occupational experience. Within abattoirs and slaughterhouses, slaughtering of cattle, sheep and goats are the most important risk factors associated with seropositivity and for those who showed over symptoms upon infection.We recommend that vaccination programmes are directed towards people employed in the meat processing industry to mitigate the significant health and economic impacts of Q fever. Keywords: Q fever, Coxiella burnetii, Abattoir, Slaughterhouse, Butcher, Meta-analysis

Summary: Background: An estimated 5·1 million stillbirths and neonatal deaths occur annually. Household surveys, most notably the Demographic and Health Survey (DHS), run in more than 90 countries and are the main data source from the highest burden regions, but data-quality concerns remain. We aimed to compare two questionnaires: a full birth history module with additional questions on pregnancy losses (FBH+; the current DHS standard) and a full pregnancy history module (FPH), which collects information on all livebirths, stillbirths, miscarriages, and neonatal deaths. Methods: Women residing in five Health and Demographic Surveillance System sites within the INDEPTH Network (Bandim in Guinea-Bissau, Dabat in Ethiopia, IgangaMayuge in Uganda, Matlab in Bangladesh, and Kintampo in Ghana) were randomly assigned (individually) to be interviewed using either FBH+ or FPH between July 28, 2017, and Aug 13, 2018. The primary outcomes were stillbirths and neonatal deaths in the 5 years before the survey interview (measured by stillbirth rate [SBR] and neonatal mortality rate [NMR]) and mean time taken to complete the maternity history section of the questionnaire. We also assessed between-site heterogeneity. This study is registered with the Research Registry, 4720. Findings: 69 176 women were allocated to be interviewed by either FBH+ (n=34 805) or FPH (n=34 371). The mean time taken to complete FPH (10·5 min) was longer than for FBH+ (9·1 min; p

Oxidative stress is a common feature of tuberculosis (TB), and persons with reduced antioxidants are at more risk of TB. TB patients with relatively severe oxidative stress had also more advanced disease as measured by the Karnofsky performance index. Since adverse effects from anti-TB drugs are also mediated by free radicals, TB patients are prone to side effects, such as hearing loss. In previous articles, researchers appealed for clinical trials aiming at evaluating N-acetyl cysteine (NAC) in attenuating the dreaded hearing loss during multidrug-resistant TB (MDR-TB) treatment. However, before embarking on such trials, considerations of NAC’s overall impact on TB treatment are crucial. Unfortunately, such a comprehensive report on NAC is missing in the literature and this manuscript reviews the broader effect of NAC on TB treatment. This paper discusses NAC’s effect on mycobacterial clearance, hearing loss, drug-induced liver injury, and its interaction with anti-TB drugs. Based on the evidence accrued to date, NAC appears to have various beneficial effects on TB treatment. However, despite the favorable interaction between NAC and first-line anti-TB drugs, the interaction between the antioxidant and some of the second-line anti-TB drugs needs further investigations.

Background: Labor and delivery process is an exciting, anxiety-provoking, but rewarding time for a woman and her family after successful delivery of a newborn. The intrapartum period is the time where mothers expect more care from nurses/midwives. Taking care of a mother in delivery with no side effects is the task of a professional midwife who is trained to care of mothers and babies. Therefore, the aim of this study was to explore mother’s experiences regarding intrapartum quality of care. Methods: Focused ethnographic study was employed. Data were collected from May to June 2016 using semi structured interview guide. Purposive sampling was employed to recruit 20 participants. Eight individual interviews were conducted in postnatal ward of the Tamale Teaching Hospital in Ghana after 48 hours of delivery, followed by three focus group discussions two weeks after delivery when mothers visited postnatal clinic. Interviews lasted for about 30-45 minutes during each session. Data were analyzed using thematic analysis. Results: The average age of women were 29years with ages ranging from 19years to 43years. Participants’ experiences of nursing/midwifery care during birth were influenced by reception and respect, provision of information, technical skill, providers’ behavior, pain management and availability of nurses/midwives. Conclusion: The study findings have revealed that women’s experience of care is affected by a wide range of determinants. Therefore, maternal health programmes and policies in Ghana must take into account women’s expectations on the care they need and their feedback on services they receive. Nursing education should re-enforce communication/relational skills. Keywords: Nursing Care, Labor, Delivery, Qualitative Study

The contextual perspective that this article challenges is the neglect of significant contributions of indigenous African missionaries and Christians by some early missionary historiographers whose writings largely focused on European missionaries. This created a lacuna in the proper documentation of African missionary enterprises. The research will not only serve as a platform to discover the socio-religious importance of past African Christian heroes of Nigerian origin but also provide additional information on existing African historiography not from the perspective of Europeans but Africans, using both theological and scientific approaches with the aim of presenting more accurate records in church history. This will serve as a biography of African Christianity. Intradisciplinary and/or interdisciplinary implications: This article has intra- and interdisciplinary implications for African philosophy, African traditional religion and ethics because most theories and views of Africans in these fields are yet to be largely researched to bring into the limelight their relevance to African realities.

Worldwide, musculoskeletal injuries remain a major problem for the Thoroughbred racing industry. There is a strong interest in developing training and management strategies to reduce the impact of musculoskeletal injuries, however, progress has been limited by studies reporting conflicting findings, and a limited understanding of the role of different training methods in preventing injury. There is little data on patterns of rest periods and exercise data and how these vary between trainers. This prospective study of two-year-old racehorses was conducted in Queensland, Australia and involved weekly personal structured interviews with 26 trainers over 56 weeks. Detailed daily exercise data for 535 horses providing 1258 training preparations and 7512 weeks at risk were collected. Trainers were categorised into three groups by the mean number of two-year-old horses that they had in work each week over the study duration: (1) Small stables with five or less, (2) Medium stables with 6 to 15 and (3) Large stables with greater than 15 horses in training. Differences between trainers with small, medium and large stable sizes were evaluated using linear regression, Kruskal–Wallis equality-of-populations rank test if linear models were mis-specified or Chi-squared tests for categorical variables. Significant differences were observed between trainers, with horses from larger stables accumulating a greater high-speed exercise volume (p < 0.001), attaining training milestones more frequently (p = 0.01) and taking less time to reach their training milestones (p = 0.001). This study provides detailed data to which training practices from other locations can be compared. Presenting actual training data rather than trainers’ estimation of a typical program provides a more accurate assessment of training practices. Understanding how training practices vary between regions improves comparability of studies investigating risk factors and is an important step towards reducing the impact of musculoskeletal injuries.

Equine advanced imaging research involving racehorse fetlock pathology commonly uses cadaver limbs and a freeze-thaw process. The presence of short tau inversion recovery (STIR) signal intensity in the distal third metacarpal/metatarsal bone is of particular interest and may be clinically relevant in the diagnosis of horses at risk of fracture. However, little is known about the effect of the freeze-thaw process on the MRI appearance of STIR hyperintensity in these bones. This study compares the low-field MRI appearance of the distal third metacarpal/metatarsal bone from cadaver limbs of Thoroughbreds in race training before and after a freeze-thaw protocol. Blinded and unblinded comparisons were made using objective SNR values and subjective grading. Fifteen cadaver limbs with STIR hyperintensity in the distal third metacarpal/metatarsal bone were included. No overall clinical or statistical significance was detected in STIR signal intensity and distribution after freeze-thaw. Three limbs from one horse had individual changes in STIR hyperintensity that were hypothesized to be attributable to ante-mortem haemodynamic abnormalities caused by anaesthesia. These results indicate that the distribution and intensity of STIR hyperintensity in freeze-thawed cadaver fetlocks can be considered representative of the appearance of pathology in the recently euthanized horse. However, care should be taken with horse selection and handling of the cadaver limbs to ensure reliable appearance of STIR signal after freeze-thaw.

There is international public concern regarding retirement of racehorses, including the reason for retirement and the outcome for horses after racing. However, there are currently no prospective studies investigating these factors. A recent independent inquiry in Queensland, Australia, highlighted that the true outcomes for horses after retirement from racing are largely unknown. Furthermore, there are currently no measures to monitor the outcome for racehorses and their welfare once they have left the care of the trainer. This study investigated these gaps in knowledge through a weekly survey conducted over a 13-month period. We aimed to evaluate: (1) the incidence of retirement, (2) the reasons and risk factors for retirement and (3) the medium-term (greater than 6 months) outcomes for horses after retirement. Data were collected through personal structured weekly interviews with participating trainers and analysed using negative binomial and logistic regression. There was a low incidence of retirements, namely 0.4% of horses in training per week. The season and training track did not affect the incidence of retirement. Musculoskeletal injuries were the most common reason for retirement (40/110 horses, 36%). Involuntary retirements accounted for 56/100 (51%) of retirements, whereby musculoskeletal injuries, respiratory or cardiac conditions and behavioural problems prevented the horse from racing The odds of voluntary retirement, whereby the horse was retired due to racing form or impending injury, increased with each additional race start (OR 1.05; p = 0.01) and start/year of racing (OR 1.21; p = 0.03) but decreased with increasing percentage of first, second and third places (OR 0.94; p < 0.001). Medium-term follow-up (median 14 months, IQR 11, 18, range 8–21) revealed that most horses (108/110; 98%) were repurposed after retirement, almost half as performance horses (50/110; 46%). Horses that voluntarily retired had 2.28 times the odds of being repurposed as performance horses than those retired involuntarily (p = 0.03). Whether retirement was voluntary or involuntary did not influence whether horses were used for breeding or pleasure. The primary limitation of this study is that our results reflect retirement in racehorses in South East Queensland, Australia, and may not be globally applicable. Furthermore, we were unable to monitor the long-term outcome and welfare of horses in their new careers. It is vital that the industry is focused on understanding the risks for voluntary rather than involuntary retirement and optimising the long-term repurposing of horses. There is a need for traceability and accountability for these horses to ensure that their welfare is maintained in their new careers.

Musculoskeletal injuries (MSI) continue to affect Thoroughbred racehorses internationally. There is a strong interest in developing training and management strategies to reduce their impact, however, studies of risk factors report inconsistent findings. Furthermore, many injuries and fatalities occur during training rather than during racing, yet most studies report racing data only. By combining racing and training data a larger exposure to risk factors and a larger number of musculoskeletal injuries are captured and the true effect of risk factors may be more accurately represented. Furthermore, modifications to reduce the impact of MSI are more readily implemented at the training level. Our study aimed to: (1) determine the risk factors for musculoskeletal injuries and whether these are different for two-year-old and older horses and (2) determine whether risk factors vary with type of injury. This was performed by repeating analyses by age category and injury type. Data from 202 cases and 202 matched controls were collected through weekly interviews with trainers and analysed using conditional logistic regression. Increasing dam parity significantly reduced the odds of injury in horses of all age groups because of the effect in two-year-old horses (odds ratio (OR) 0.08; 95% confidence interval (CI) 0.02, 0.36; p < 0.001). Increasing total preparation length is associated with higher odds of injury in horses of all ages (OR 5.56; 95% CI 1.59, 19.46; p = 0.01), but particularly in two-year-old horses (OR 8.05; 95% CI 1.92, 33.76; p = 0.004). Increasing number of days exercised at a slow pace decreased the odds of injury in horses of all ages (OR 0.09; 95% CI 0.03, 0.28; p < 0.001). The distance travelled at three-quarter pace and above (faster than 13 m/s; 15 s/furlong; 800 m/min; 48 km/h) and the total distance travelled at a gallop (faster than 15 m/s; 13 s/furlong; 900 m/min; 55 km/h) in the past four weeks significantly affected the odds of injury. There was a non-linear association between high-speed exercise and injury whereby the odds of injury initially increased and subsequently decreased as accumulated high-speed exercise distance increased. None of the racing career and performance indices affected the odds of injury. We identified horses in this population that have particularly high odds of injury. Two-year-old horses from primiparous mares are at increased odds of injury, particularly dorsal metacarpal disease. Two-year-old horses that have had a total preparation length of between 10 and 14 weeks also have increased odds of injury. Horses of all ages that travelled a total distance of 2.4–3.8 km (12–19 furlongs) at a gallop in the last four weeks and horses three years and older that travelled 3.0–4.8 km (15–24 furlongs) at three-quarter pace and above also have increased odds of injury. We recommend that these horses should be monitored closely for impending signs of injury. Increasing the number of days worked at a slow pace may be more effective for preventing injury, if horses are perceived at a higher risk, than resting the horse altogether. Early identification of horses at increased risk and appropriate intervention could substantially reduce the impact of musculoskeletal injuries in Thoroughbred racehorses.

Accurately measuring body temperature in horses will improve the management of horses suffering from or being at risk of developing postrace exertional heat illness. PTSM has the potential for measuring body temperature accurately, safely, rapidly, and noninvasively. This study was undertaken to investigate the relation between the core body temperature and PTSM temperatures prior to, during, and immediately after exercise. The microchips were implanted into the nuchal ligament, the right splenius, gluteal, and pectoral muscles, and these locations were then compared with the central venous temperature, which is considered to be the “gold standard” for assessing core body temperature. The changes in temperature of each implant in the horses were evaluated in each phase (prior to, during, and immediately postexercise) and combining all phases. There were strong positive correlations ranging from 0.82 to 0.94 (p < 0.001) of all the muscle sites with the central venous temperature when combining all the phases. Additionally, during the whole period, PTSM had narrow limits of agreement (LOA) with central venous temperature, which inferred that PTSM is essentially equivalent in measuring horse body temperature. Overall, the pectoral PTSM provided a valid estimation of the core body temperature.

Purpose of the review: This review was performed to create a repository of information on One Health research and training in Australia and New Zealand (ANZ). The review sought to determine 1) how many training activities there are in ANZ, 2) how much research on zoonotic diseases is undertaken by multidisciplinary teams, and 3) how collaborative and integrated they are. Recent findings: There are few opportunities for training in One Health in ANZ. The majority require enrolment in a postgraduate degree programme, and there is only one postgraduate level course that is also available for continuing professional development (CPD). Of the broad range of One Health research performed in ANZ, the majority is performed by teams with limited disciplinary diversity, although diversity is improving. Summary: Progress has been made in building collaboration between human, animal, and environmental health professions. However, the lack of clearly defined competencies and agreed purpose for One Health may be impeding collaboration.

Background:. There have been many technical and scientific advances over the last decade in peripheral nerve surgery. Human acellular nerve graft (HANA) has become increasingly popular but current practice patterns among hand surgeons have yet to be defined. Coding practices may not have kept up with this innovation. A 26 question survey of hand surgeons was performed to evaluate the adoption of HANA, and current coding and billing practices. The survey was sent to hand surgeons trained in orthopedic, plastic, general, and neuro surgery. The survey was designed and implemented by the Mayo Clinic Survey Center. Results:. Four hundred sixty-one responses to the survey were received. Most respondents currently use HANA (70%). Of those surgeons who do use HANA, nearly all use it less than 10 times per month (98%). There was no significant difference in the use of HANA across different specialties. There was a significant difference in HANA use depending on practice type with higher use by those in group private practice (57%) compared with academic practice (28%), solo practice (12%), and other practice environment (3%). There was a significant difference in HANA use depending on the number of years in practice. Those in practice less than 5 years used HANA the most (32%), followed by > 20 years in practice (27%), 6–10 years in practice (16%), 16–20 years in practice (14%), and 11–15 years in practice (11%). When asked the Current Procedural Terminology code they would use to bill for the procedure of choice, the most common response was 64910 (nerve repair with synthetic conduit or vein allograft). Conclusions:. HANA has surpassed nerve conduit as the traditional gold standard in our study with nearly 70% of hand surgeons using HANA in their practice and a greater percentage of respondents choosing HANA as their first choice to repair as compared with nerve conduit, nerve autograft, or vein graft. There remains confusion regarding appropriate billing practices for the use of HANA. Due to its common use, a Current Procedural Terminology code should specifically designated for the use of HANA in the hand.

Abstract Background Herbal remedies are widely used in many malaria endemic countries to treat patients, in particular in the absence of anti-malarial drugs and in some settings to prevent the disease. Herbal medicines may be specifically designed for prophylaxis and/or for blocking malaria transmission to benefit both, the individual consumer and the community at large. Neem represents a good candidate for this purpose due to its inhibitory effects on the parasite stages that cause the clinical manifestations of malaria and on those responsible for infection in the vector. Furthermore, neem secondary metabolites have been shown to interfere with various physiological processes in insect vectors. This study was undertaken to assess the impact of the standardised neem extract NeemAzal® on the fitness of the malaria vector Anopheles stephensi following repeated exposure to the product through consecutive blood meals on treated mice. Methods Batches of An. stephensi mosquitoes were offered 5 consecutive blood meals on female BALB/c mice treated with NeemAzal® at an azadirachtin A concentration of 60, 105 or 150 mg/kg. The blood feeding capacity was estimated by measuring the haematin content of the rectal fluid excreted by the mosquitoes during feeding. The number of eggs laid was estimated by image analysis and their hatchability assessed by direct observations. Results A dose and frequency dependent impact of NeemAzal® treatment on the mosquito feeding capacity, oviposition and egg hatchability was demonstrated. In the 150 mg/kg treatment group, the mosquito feeding capacity was reduced by 50% already at the second blood meal and by 50 to 80% in all treatment groups at the fifth blood meal. Consequently, a 50 – 65% reduction in the number of eggs laid per female mosquito was observed after the fifth blood meal in all treatment groups. Similarly, after the fifth treated blood meal exposure, hatchability was found to be reduced by 62% and 70% in the 105 and 150 mg/kg group respectively. Conclusions The findings of this study, taken together with the accumulated knowledge on neem open the challenging prospects of designing neem-based formulations as multi-target phytomedicines exhibiting preventive, parasite transmission-blocking as well as anti-vectorial properties.

Orientation: Focus was on the role of reward and attitudes as major determinants in enhancing the effectiveness of performance appraisal systems. Research purpose: To develop a structural model from the qualitative and quantitative findings from which to address the identified gaps in order to improve the effectiveness of appraisals. Motivation for the study: The attention that role players tended to give to the rewarding of employees during the appraisal process made it appear as the only important determinant of an appraisal’s success. In appraisals in many public institutions, reward has been given unnecessary prominence over other drivers, such as management and development. That led most key role players (leaders, managers and employees) to perceive the current employee performance management and development system (EPMDS) to be purely for monetary (salary increments and cash bonuses) and non-monetary (promotion) purposes, which, in turn, compromised its effectiveness. Research design, approach and method: Structural equation modelling (SEM) was utilised as a statistical technique for testing and estimating causal relations using a combination of statistical data and qualitative causal assumptions. This allowed both confirmatory and exploratory modelling to be undertaken, which is suited to both theory testing and theory development. A triangulation of quantitative (questionnaire) and qualitative (interview) study was conducted. A total of 300 questionnaires were distributed to nine government hospitals in the Free State province, namely Mofumahadi Manapo Mopeli, Dihlabeng, and Boitumelo regional hospitals, as well as Elizabeth Ross, Thebe, Phekolong, Mpumelelo, Reitz and Ficksburg district hospitals. There was a high response rate of 96 per cent, a total of 287 completed questionnaires. Respondents ranged from top executives, middle management, line management, to employees of all categories. Main findings: Reward and attitudes were found to the unintended outcomes of an effective performance appraisal. Practical/managerial implications: Remunerative rewards should be part of a holistic appraisal approach and not simply a one-sided approach. Contribution/value-add: This article addressed the void or the wrong perception regarding the role of reward and attitudes in appraisals, and established that they were outcomes, and not determinants, of appraisal effectiveness.

Background Only 5-20% of stroke survivors exhibit almost complete motor recovery at six months post-stroke. The Stroke Recovery and Rehabilitation Roundtable (SRRR) Taskforce has recommended the use of performance assays that predict recovery. However, not much is known about the differences across various stroke severity groups. The purpose of this study was to determine whether kinematic parameters of time, average velocity, shoulder angles and elbow angles were able to distinguish upper extremity movement capacity in individuals with varying levels of stroke severity and healthy controls. Methods: This is a cross-sectional study, which is part of a large cohort study. 27 sub-acute stroke survivors (58.8 ± 12.7 years; 18 males, 9 females; categorized into mild (51-66), moderate (25-50) and severe ( Results: Movement time was significantly different between severe and all other stroke groups (mild [p Conclusions: Kinematic analysis of a reach-to-grasp-to-mouth task helps to differentiate between varying groups of severity post-stroke such as mild, moderate and severe, based on Fugl Meyer for Upper Extremity scores.

Accumulating evidence indicates that environmental temperature substantially affects economic outcomes and violence, but the reasons for this linkage are not well understood. We systematically evaluate the effect of thermal stress on multiple dimensions of economic decisionmaking, judgment, and destructive behavior with 2,000 participants in Kenya and the US who were randomly assigned to different temperatures in a laboratory. We find that most dimensions of decision-making are unaffected by temperature. However, heat causes individuals to voluntarily destroy other participants' assets, with more pronounced effects during a period of heightened political conflict in Kenya.

This article contextualizes Hong Kong's Umbrella Movement that emerged in the fall of 2014. We argue that first, the Umbrella Movement was not merely about democracy but must be understood in the context of widening inequality and an ongoing housing and wage crisis; second, that it is part of a broader epoch of contention informed by, third, a distinct "rhizomatic movement logic" that is defined by a diversity of actors and struggles, use of social media, leaderless and grassroots mobilizing, distrust of institutional actors. Fueled by shifts in capital accumulation and changes in communication technologies, the currently dominant movement logic is distinct from previous movement politics. Since the Zapatista uprising in Chiapas, Mexico, in 1994, it has informed movements such as Occupy, the Arab Spring, and more recently the Gilets Jaunes as well as the Umbrella Movement. To be sure, we are not claiming that all these struggles are the same. We stress the similarities exhibited by these movements' "deep grammar," so to speak, while recognizing that each must be understood in its particularities. We thus specify the context of Hong Kong and provide illustrations of how this logic has impacted the Umbrella Movement's actors, organizing, and movement-building dynamics. [ABSTRACT FROM AUTHOR]

BackgroundPopulation estimates underpin demographic and epidemiological research and are used to track progress on numerous international indicators of health and development. To date, internationally available estimates of population and fertility, although useful, have not been produced with transparent and replicable methods and do not use standardised estimates of mortality. We present single-calendar year and single-year of age estimates of fertility and population by sex with standardised and replicable methods.MethodsWe estimated population in 195 locations by single year of age and single calendar year from 1950 to 2017 with standardised and replicable methods. We based the estimates on the demographic balancing equation, with inputs of fertility, mortality, population, and migration data. Fertility data came from 7817 location-years of vital registration data, 429 surveys reporting complete birth histories, and 977 surveys and censuses reporting summary birth histories. We estimated age-specific fertility rates (ASFRs; the annual number of livebirths to women of a specified age group per 1000 women in that age group) by use of spatiotemporal Gaussian process regression and used the ASFRs to estimate total fertility rates (TFRs; the average number of children a woman would bear if she survived through the end of the reproductive age span [age 10-54 years] and experienced at each age a particular set of ASFRs observed in the year of interest). Because of sparse data, fertility at ages 10-14 years and 50-54 years was estimated from data on fertility in women aged 15-19 years and 45-49 years, through use of linear regression. Age-specific mortality data came from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 estimates. Data on population came from 1257 censuses and 761 population registry location-years and were adjusted for underenumeration and age misreporting with standard demographic methods. Migration was estimated with the GBD Bayesian demographic balancing model, after incorporating information about refugee migration into the model prior. Final population estimates used the cohort-component method of population projection, with inputs of fertility, mortality, and migration data. Population uncertainty was estimated by use of out-of-sample predictive validity testing. With these data, we estimated the trends in population by age and sex and in fertility by age between 1950 and 2017 in 195 countries and territories.FindingsFrom 1950 to 2017, TFRs decreased by 49·4% (95% uncertainty interval [UI] 46·4-52·0). The TFR decreased from 4·7 livebirths (4·5-4·9) to 2·4 livebirths (2·2-2·5), and the ASFR of mothers aged 10-19 years decreased from 37 livebirths (34-40) to 22 livebirths (19-24) per 1000 women. Despite reductions in the TFR, the global population has been increasing by an average of 83·8 million people per year since 1985. The global population increased by 197·2% (193·3-200·8) since 1950, from 2·6 billion (2·5-2·6) to 7·6 billion (7·4-7·9) people in 2017; much of this increase was in the proportion of the global population in south Asia and sub-Saharan Africa. The global annual rate of population growth increased between 1950 and 1964, when it peaked at 2·0%; this rate then remained nearly constant until 1970 and then decreased to 1·1% in 2017. Population growth rates in the southeast Asia, east Asia, and Oceania GBD super-region decreased from 2·5% in 1963 to 0·7% in 2017, whereas in sub-Saharan Africa, population growth rates were almost at the highest reported levels ever in 2017, when they were at 2·7%. The global average age increased from 26·6 years in 1950 to 32·1 years in 2017, and the proportion of the population that is of working age (age 15-64 years) increased from 59·9% to 65·3%. At the national level, the TFR decreased in all countries and territories between 1950 and 2017; in 2017, TFRs ranged from a low of 1·0 livebirths (95% UI 0·9-1·2) in Cyprus to a high of 7·1 livebirths (6·8-7·4) in Niger. The TFR under age 25 years (TFU25; number of livebirths expected by age 25 years for a hypothetical woman who survived the age group and was exposed to current ASFRs) in 2017 ranged from 0·08 livebirths (0·07-0·09) in South Korea to 2·4 livebirths (2·2-2·6) in Niger, and the TFR over age 30 years (TFO30; number of livebirths expected for a hypothetical woman ageing from 30 to 54 years who survived the age group and was exposed to current ASFRs) ranged from a low of 0·3 livebirths (0·3-0·4) in Puerto Rico to a high of 3·1 livebirths (3·0-3·2) in Niger. TFO30 was higher than TFU25 in 145 countries and territories in 2017. 33 countries had a negative population growth rate from 2010 to 2017, most of which were located in central, eastern, and western Europe, whereas population growth rates of more than 2·0% were seen in 33 of 46 countries in sub-Saharan Africa. In 2017, less than 65% of the national population was of working age in 12 of 34 high-income countries, and less than 50% of the national population was of working age in Mali, Chad, and Niger.InterpretationPopulation trends create demographic dividends and headwinds (ie, economic benefits and detriments) that affect national economies and determine national planning needs. Although TFRs are decreasing, the global population continues to grow as mortality declines, with diverse patterns at the national level and across age groups. To our knowledge, this is the first study to provide transparent and replicable estimates of population and fertility, which can be used to inform decision making and to monitor progress.FundingBill & Melinda Gates Foundation.

BackgroundGlobal development goals increasingly rely on country-specific estimates for benchmarking a nation's progress. To meet this need, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 estimated global, regional, national, and, for selected locations, subnational cause-specific mortality beginning in the year 1980. Here we report an update to that study, making use of newly available data and improved methods. GBD 2017 provides a comprehensive assessment of cause-specific mortality for 282 causes in 195 countries and territories from 1980 to 2017.MethodsThe causes of death database is composed of vital registration (VR), verbal autopsy (VA), registry, survey, police, and surveillance data. GBD 2017 added ten VA studies, 127 country-years of VR data, 502 cancer-registry country-years, and an additional surveillance country-year. Expansions of the GBD cause of death hierarchy resulted in 18 additional causes estimated for GBD 2017. Newly available data led to subnational estimates for five additional countries-Ethiopia, Iran, New Zealand, Norway, and Russia. Deaths assigned International Classification of Diseases (ICD) codes for non-specific, implausible, or intermediate causes of death were reassigned to underlying causes by redistribution algorithms that were incorporated into uncertainty estimation. We used statistical modelling tools developed for GBD, including the Cause of Death Ensemble model (CODEm), to generate cause fractions and cause-specific death rates for each location, year, age, and sex. Instead of using UN estimates as in previous versions, GBD 2017 independently estimated population size and fertility rate for all locations. Years of life lost (YLLs) were then calculated as the sum of each death multiplied by the standard life expectancy at each age. All rates reported here are age-standardised.FindingsAt the broadest grouping of causes of death (Level 1), non-communicable diseases (NCDs) comprised the greatest fraction of deaths, contributing to 73·4% (95% uncertainty interval [UI] 72·5-74·1) of total deaths in 2017, while communicable, maternal, neonatal, and nutritional (CMNN) causes accounted for 18·6% (17·9-19·6), and injuries 8·0% (7·7-8·2). Total numbers of deaths from NCD causes increased from 2007 to 2017 by 22·7% (21·5-23·9), representing an additional 7·61 million (7·20-8·01) deaths estimated in 2017 versus 2007. The death rate from NCDs decreased globally by 7·9% (7·0-8·8). The number of deaths for CMNN causes decreased by 22·2% (20·0-24·0) and the death rate by 31·8% (30·1-33·3). Total deaths from injuries increased by 2·3% (0·5-4·0) between 2007 and 2017, and the death rate from injuries decreased by 13·7% (12·2-15·1) to 57·9 deaths (55·9-59·2) per 100 000 in 2017. Deaths from substance use disorders also increased, rising from 284 000 deaths (268 000-289 000) globally in 2007 to 352 000 (334 000-363 000) in 2017. Between 2007 and 2017, total deaths from conflict and terrorism increased by 118·0% (88·8-148·6). A greater reduction in total deaths and death rates was observed for some CMNN causes among children younger than 5 years than for older adults, such as a 36·4% (32·2-40·6) reduction in deaths from lower respiratory infections for children younger than 5 years compared with a 33·6% (31·2-36·1) increase in adults older than 70 years. Globally, the number of deaths was greater for men than for women at most ages in 2017, except at ages older than 85 years. Trends in global YLLs reflect an epidemiological transition, with decreases in total YLLs from enteric infections, respiratory infections and tuberculosis, and maternal and neonatal disorders between 1990 and 2017; these were generally greater in magnitude at the lowest levels of the Socio-demographic Index (SDI). At the same time, there were large increases in YLLs from neoplasms and cardiovascular diseases. YLL rates decreased across the five leading Level 2 causes in all SDI quintiles. The leading causes of YLLs in 1990-neonatal disorders, lower respiratory infections, and diarrhoeal diseases-were ranked second, fourth, and fifth, in 2017. Meanwhile, estimated YLLs increased for ischaemic heart disease (ranked first in 2017) and stroke (ranked third), even though YLL rates decreased. Population growth contributed to increased total deaths across the 20 leading Level 2 causes of mortality between 2007 and 2017. Decreases in the cause-specific mortality rate reduced the effect of population growth for all but three causes: substance use disorders, neurological disorders, and skin and subcutaneous diseases.InterpretationImprovements in global health have been unevenly distributed among populations. Deaths due to injuries, substance use disorders, armed conflict and terrorism, neoplasms, and cardiovascular disease are expanding threats to global health. For causes of death such as lower respiratory and enteric infections, more rapid progress occurred for children than for the oldest adults, and there is continuing disparity in mortality rates by sex across age groups. Reductions in the death rate of some common diseases are themselves slowing or have ceased, primarily for NCDs, and the death rate for selected causes has increased in the past decade.FundingBill & Melinda Gates Foundation.

BackgroundThe Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data.MethodsWe estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting.FindingsGlobally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1-4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0-8·4) while the total sum of global YLDs increased from 562 million (421-723) to 853 million (642-1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6-9·2) for males and 6·5% (5·4-7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782-3252] per 100 000 in males vs s1400 [1279-1524] per 100 000 in females), transport injuries (3322 [3082-3583] vs 2336 [2154-2535]), and self-harm and interpersonal violence (3265 [2943-3630] vs 5643 [5057-6302]).InterpretationGlobal all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury.FundingBill & Melinda Gates Foundation.

BackgroundEfforts to establish the 2015 baseline and monitor early implementation of the UN Sustainable Development Goals (SDGs) highlight both great potential for and threats to improving health by 2030. To fully deliver on the SDG aim of "leaving no one behind", it is increasingly important to examine the health-related SDGs beyond national-level estimates. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), we measured progress on 41 of 52 health-related SDG indicators and estimated the health-related SDG index for 195 countries and territories for the period 1990-2017, projected indicators to 2030, and analysed global attainment.MethodsWe measured progress on 41 health-related SDG indicators from 1990 to 2017, an increase of four indicators since GBD 2016 (new indicators were health worker density, sexual violence by non-intimate partners, population census status, and prevalence of physical and sexual violence [reported separately]). We also improved the measurement of several previously reported indicators. We constructed national-level estimates and, for a subset of health-related SDGs, examined indicator-level differences by sex and Socio-demographic Index (SDI) quintile. We also did subnational assessments of performance for selected countries. To construct the health-related SDG index, we transformed the value for each indicator on a scale of 0-100, with 0 as the 2·5th percentile and 100 as the 97·5th percentile of 1000 draws calculated from 1990 to 2030, and took the geometric mean of the scaled indicators by target. To generate projections through 2030, we used a forecasting framework that drew estimates from the broader GBD study and used weighted averages of indicator-specific and country-specific annualised rates of change from 1990 to 2017 to inform future estimates. We assessed attainment of indicators with defined targets in two ways: first, using mean values projected for 2030, and then using the probability of attainment in 2030 calculated from 1000 draws. We also did a global attainment analysis of the feasibility of attaining SDG targets on the basis of past trends. Using 2015 global averages of indicators with defined SDG targets, we calculated the global annualised rates of change required from 2015 to 2030 to meet these targets, and then identified in what percentiles the required global annualised rates of change fell in the distribution of country-level rates of change from 1990 to 2015. We took the mean of these global percentile values across indicators and applied the past rate of change at this mean global percentile to all health-related SDG indicators, irrespective of target definition, to estimate the equivalent 2030 global average value and percentage change from 2015 to 2030 for each indicator.FindingsThe global median health-related SDG index in 2017 was 59·4 (IQR 35·4-67·3), ranging from a low of 11·6 (95% uncertainty interval 9·6-14·0) to a high of 84·9 (83·1-86·7). SDG index values in countries assessed at the subnational level varied substantially, particularly in China and India, although scores in Japan and the UK were more homogeneous. Indicators also varied by SDI quintile and sex, with males having worse outcomes than females for non-communicable disease (NCD) mortality, alcohol use, and smoking, among others. Most countries were projected to have a higher health-related SDG index in 2030 than in 2017, while country-level probabilities of attainment by 2030 varied widely by indicator. Under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria indicators had the most countries with at least 95% probability of target attainment. Other indicators, including NCD mortality and suicide mortality, had no countries projected to meet corresponding SDG targets on the basis of projected mean values for 2030 but showed some probability of attainment by 2030. For some indicators, including child malnutrition, several infectious diseases, and most violence measures, the annualised rates of change required to meet SDG targets far exceeded the pace of progress achieved by any country in the recent past. We found that applying the mean global annualised rate of change to indicators without defined targets would equate to about 19% and 22% reductions in global smoking and alcohol consumption, respectively; a 47% decline in adolescent birth rates; and a more than 85% increase in health worker density per 1000 population by 2030.InterpretationThe GBD study offers a unique, robust platform for monitoring the health-related SDGs across demographic and geographic dimensions. Our findings underscore the importance of increased collection and analysis of disaggregated data and highlight where more deliberate design or targeting of interventions could accelerate progress in attaining the SDGs. Current projections show that many health-related SDG indicators, NCDs, NCD-related risks, and violence-related indicators will require a concerted shift away from what might have driven past gains-curative interventions in the case of NCDs-towards multisectoral, prevention-oriented policy action and investments to achieve SDG aims. Notably, several targets, if they are to be met by 2030, demand a pace of progress that no country has achieved in the recent past. The future is fundamentally uncertain, and no model can fully predict what breakthroughs or events might alter the course of the SDGs. What is clear is that our actions-or inaction-today will ultimately dictate how close the world, collectively, can get to leaving no one behind by 2030.FundingBill & Melinda Gates Foundation.

BackgroundAssessments of age-specific mortality and life expectancy have been done by the UN Population Division, Department of Economics and Social Affairs (UNPOP), the United States Census Bureau, WHO, and as part of previous iterations of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD). Previous iterations of the GBD used population estimates from UNPOP, which were not derived in a way that was internally consistent with the estimates of the numbers of deaths in the GBD. The present iteration of the GBD, GBD 2017, improves on previous assessments and provides timely estimates of the mortality experience of populations globally.MethodsThe GBD uses all available data to produce estimates of mortality rates between 1950 and 2017 for 23 age groups, both sexes, and 918 locations, including 195 countries and territories and subnational locations for 16 countries. Data used include vital registration systems, sample registration systems, household surveys (complete birth histories, summary birth histories, sibling histories), censuses (summary birth histories, household deaths), and Demographic Surveillance Sites. In total, this analysis used 8259 data sources. Estimates of the probability of death between birth and the age of 5 years and between ages 15 and 60 years are generated and then input into a model life table system to produce complete life tables for all locations and years. Fatal discontinuities and mortality due to HIV/AIDS are analysed separately and then incorporated into the estimation. We analyse the relationship between age-specific mortality and development status using the Socio-demographic Index, a composite measure based on fertility under the age of 25 years, education, and income. There are four main methodological improvements in GBD 2017 compared with GBD 2016: 622 additional data sources have been incorporated; new estimates of population, generated by the GBD study, are used; statistical methods used in different components of the analysis have been further standardised and improved; and the analysis has been extended backwards in time by two decades to start in 1950.FindingsGlobally, 18·7% (95% uncertainty interval 18·4-19·0) of deaths were registered in 1950 and that proportion has been steadily increasing since, with 58·8% (58·2-59·3) of all deaths being registered in 2015. At the global level, between 1950 and 2017, life expectancy increased from 48·1 years (46·5-49·6) to 70·5 years (70·1-70·8) for men and from 52·9 years (51·7-54·0) to 75·6 years (75·3-75·9) for women. Despite this overall progress, there remains substantial variation in life expectancy at birth in 2017, which ranges from 49·1 years (46·5-51·7) for men in the Central African Republic to 87·6 years (86·9-88·1) among women in Singapore. The greatest progress across age groups was for children younger than 5 years; under-5 mortality dropped from 216·0 deaths (196·3-238·1) per 1000 livebirths in 1950 to 38·9 deaths (35·6-42·83) per 1000 livebirths in 2017, with huge reductions across countries. Nevertheless, there were still 5·4 million (5·2-5·6) deaths among children younger than 5 years in the world in 2017. Progress has been less pronounced and more variable for adults, especially for adult males, who had stagnant or increasing mortality rates in several countries. The gap between male and female life expectancy between 1950 and 2017, while relatively stable at the global level, shows distinctive patterns across super-regions and has consistently been the largest in central Europe, eastern Europe, and central Asia, and smallest in south Asia. Performance was also variable across countries and time in observed mortality rates compared with those expected on the basis of development.InterpretationThis analysis of age-sex-specific mortality shows that there are remarkably complex patterns in population mortality across countries. The findings of this study highlight global successes, such as the large decline in under-5 mortality, which reflects significant local, national, and global commitment and investment over several decades. However, they also bring attention to mortality patterns that are a cause for concern, particularly among adult men and, to a lesser extent, women, whose mortality rates have stagnated in many countries over the time period of this study, and in some cases are increasing.FundingBill & Melinda Gates Foundation.

BackgroundHow long one lives, how many years of life are spent in good and poor health, and how the population's state of health and leading causes of disability change over time all have implications for policy, planning, and provision of services. We comparatively assessed the patterns and trends of healthy life expectancy (HALE), which quantifies the number of years of life expected to be lived in good health, and the complementary measure of disability-adjusted life-years (DALYs), a composite measure of disease burden capturing both premature mortality and prevalence and severity of ill health, for 359 diseases and injuries for 195 countries and territories over the past 28 years.MethodsWe used data for age-specific mortality rates, years of life lost (YLLs) due to premature mortality, and years lived with disability (YLDs) from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to calculate HALE and DALYs from 1990 to 2017. We calculated HALE using age-specific mortality rates and YLDs per capita for each location, age, sex, and year. We calculated DALYs for 359 causes as the sum of YLLs and YLDs. We assessed how observed HALE and DALYs differed by country and sex from expected trends based on Socio-demographic Index (SDI). We also analysed HALE by decomposing years of life gained into years spent in good health and in poor health, between 1990 and 2017, and extra years lived by females compared with males.FindingsGlobally, from 1990 to 2017, life expectancy at birth increased by 7·4 years (95% uncertainty interval 7·1-7·8), from 65·6 years (65·3-65·8) in 1990 to 73·0 years (72·7-73·3) in 2017. The increase in years of life varied from 5·1 years (5·0-5·3) in high SDI countries to 12·0 years (11·3-12·8) in low SDI countries. Of the additional years of life expected at birth, 26·3% (20·1-33·1) were expected to be spent in poor health in high SDI countries compared with 11·7% (8·8-15·1) in low-middle SDI countries. HALE at birth increased by 6·3 years (5·9-6·7), from 57·0 years (54·6-59·1) in 1990 to 63·3 years (60·5-65·7) in 2017. The increase varied from 3·8 years (3·4-4·1) in high SDI countries to 10·5 years (9·8-11·2) in low SDI countries. Even larger variations in HALE than these were observed between countries, ranging from 1·0 year (0·4-1·7) in Saint Vincent and the Grenadines (62·4 years [59·9-64·7] in 1990 to 63·5 years [60·9-65·8] in 2017) to 23·7 years (21·9-25·6) in Eritrea (30·7 years [28·9-32·2] in 1990 to 54·4 years [51·5-57·1] in 2017). In most countries, the increase in HALE was smaller than the increase in overall life expectancy, indicating more years lived in poor health. In 180 of 195 countries and territories, females were expected to live longer than males in 2017, with extra years lived varying from 1·4 years (0·6-2·3) in Algeria to 11·9 years (10·9-12·9) in Ukraine. Of the extra years gained, the proportion spent in poor health varied largely across countries, with less than 20% of additional years spent in poor health in Bosnia and Herzegovina, Burundi, and Slovakia, whereas in Bahrain all the extra years were spent in poor health. In 2017, the highest estimate of HALE at birth was in Singapore for both females (75·8 years [72·4-78·7]) and males (72·6 years [69·8-75·0]) and the lowest estimates were in Central African Republic (47·0 years [43·7-50·2] for females and 42·8 years [40·1-45·6] for males). Globally, in 2017, the five leading causes of DALYs were neonatal disorders, ischaemic heart disease, stroke, lower respiratory infections, and chronic obstructive pulmonary disease. Between 1990 and 2017, age-standardised DALY rates decreased by 41·3% (38·8-43·5) for communicable diseases and by 49·8% (47·9-51·6) for neonatal disorders. For non-communicable diseases, global DALYs increased by 40·1% (36·8-43·0), although age-standardised DALY rates decreased by 18·1% (16·0-20·2).InterpretationWith increasing life expectancy in most countries, the question of whether the additional years of life gained are spent in good health or poor health has been increasingly relevant because of the potential policy implications, such as health-care provisions and extending retirement ages. In some locations, a large proportion of those additional years are spent in poor health. Large inequalities in HALE and disease burden exist across countries in different SDI quintiles and between sexes. The burden of disabling conditions has serious implications for health system planning and health-related expenditures. Despite the progress made in reducing the burden of communicable diseases and neonatal disorders in low SDI countries, the speed of this progress could be increased by scaling up proven interventions. The global trends among non-communicable diseases indicate that more effort is needed to maximise HALE, such as risk prevention and attention to upstream determinants of health.FundingBill & Melinda Gates Foundation.

BackgroundAlcohol use is a leading risk factor for death and disability, but its overall association with health remains complex given the possible protective effects of moderate alcohol consumption on some conditions. With our comprehensive approach to health accounting within the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we generated improved estimates of alcohol use and alcohol-attributable deaths and disability-adjusted life-years (DALYs) for 195 locations from 1990 to 2016, for both sexes and for 5-year age groups between the ages of 15 years and 95 years and older.MethodsUsing 694 data sources of individual and population-level alcohol consumption, along with 592 prospective and retrospective studies on the risk of alcohol use, we produced estimates of the prevalence of current drinking, abstention, the distribution of alcohol consumption among current drinkers in standard drinks daily (defined as 10 g of pure ethyl alcohol), and alcohol-attributable deaths and DALYs. We made several methodological improvements compared with previous estimates: first, we adjusted alcohol sales estimates to take into account tourist and unrecorded consumption; second, we did a new meta-analysis of relative risks for 23 health outcomes associated with alcohol use; and third, we developed a new method to quantify the level of alcohol consumption that minimises the overall risk to individual health.FindingsGlobally, alcohol use was the seventh leading risk factor for both deaths and DALYs in 2016, accounting for 2·2% (95% uncertainty interval [UI] 1·5-3·0) of age-standardised female deaths and 6·8% (5·8-8·0) of age-standardised male deaths. Among the population aged 15-49 years, alcohol use was the leading risk factor globally in 2016, with 3·8% (95% UI 3·2-4·3) of female deaths and 12·2% (10·8-13·6) of male deaths attributable to alcohol use. For the population aged 15-49 years, female attributable DALYs were 2·3% (95% UI 2·0-2·6) and male attributable DALYs were 8·9% (7·8-9·9). The three leading causes of attributable deaths in this age group were tuberculosis (1·4% [95% UI 1·0-1·7] of total deaths), road injuries (1·2% [0·7-1·9]), and self-harm (1·1% [0·6-1·5]). For populations aged 50 years and older, cancers accounted for a large proportion of total alcohol-attributable deaths in 2016, constituting 27·1% (95% UI 21·2-33·3) of total alcohol-attributable female deaths and 18·9% (15·3-22·6) of male deaths. The level of alcohol consumption that minimised harm across health outcomes was zero (95% UI 0·0-0·8) standard drinks per week.InterpretationAlcohol use is a leading risk factor for global disease burden and causes substantial health loss. We found that the risk of all-cause mortality, and of cancers specifically, rises with increasing levels of consumption, and the level of consumption that minimises health loss is zero. These results suggest that alcohol control policies might need to be revised worldwide, refocusing on efforts to lower overall population-level consumption.FundingBill & Melinda Gates Foundation.

BackgroundA key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016.MethodsDrawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita.FindingsIn 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries.InterpretationGBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations.FundingBill & Melinda Gates Foundation.

Oxytocin (Oxt) is a neuropeptide with many functions, including modulation of social behavior(s) and anxiety. Due to its notable pro-social effects, it has been proposed as a treatment in the management of neuropsychiatric disorders, such as autism spectrum disorder (ASD), schizophrenia, and social anxiety; however, effects of long-term daily treatment are still being explored. Previously, we have shown that in male prairie voles (Microtus ochrogaster) exposure to Oxt during the peri-adolescent period impaired adult pair bonding in a dose-dependent fashion. In females, the medium dose used (0.8 IU/kg) appeared to facilitate pair bonding, and the low and medium doses were associated with fewer lines crossed in the open field. In this study, we examined central receptor binding and immunoreactive (IR) protein for Oxt and vasopressin (Avp), a closely related peptide. Voles were treated with saline vehicle, or one of three doses of Oxt (0.08, 0.8, 8.0 IU/kg) for three weeks from postnatal days 21 to 42, and euthanized as adults. We used autoradiography to examine Oxt and Avp receptor binding and immunohistochemistry to examine Oxt and Avp - IR cells in the paraventricular (PVN) and supraoptic (SON) nuclei of the hypothalamus. Females that received the medium dose of Oxt had higher Oxt receptor binding in the nucleus accumbens shell (NAS), while males that received the medium dose had lower Avp-IR cells in the PVN. In summary, we found sex-specific effects of long-term exposure to intranasal Oxt on the Oxt and Avp systems at the weight-adjusted dose currently being used in clinical trials in humans.