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Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. Gates Foundation.
For more than three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has provided a framework to quantify health loss due to diseases, injuries, and associated risk factors. This paper presents GBD 2023 findings on disease and injury burden and risk-attributable health loss, offering a global audit of the state of world health to inform public health priorities. This work captures the evolving landscape of health metrics across age groups, sexes, and locations, while reflecting on the remaining post-COVID-19 challenges to achieving our collective global health ambitions. The GBD 2023 combined analysis estimated years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 375 diseases and injuries, and risk-attributable burden associated with 88 modifiable risk factors. Of the more than 310 000 total data sources used for all GBD 2023 (about 30% of which were new to this estimation round), more than 120 000 sources were used for estimation of disease and injury burden and 59 000 for risk factor estimation, and included vital registration systems, surveys, disease registries, and published scientific literature. Data were analysed using previously established modelling approaches, such as disease modelling meta-regression version 2.1 (DisMod-MR 2.1) and comparative risk assessment methods. Diseases and injuries were categorised into four levels on the basis of the established GBD cause hierarchy, as were risk factors using the GBD risk hierarchy. Estimates stratified by age, sex, location, and year from 1990 to 2023 were focused on disease-specific time trends over the 2010-23 period and presented as counts (to three significant figures) and age-standardised rates per 100 000 person-years (to one decimal place). For each measure, 95% uncertainty intervals [UIs] were calculated with the 2·5th and 97·5th percentile ordered values from a 250-draw distribution. Total numbers of global DALYs grew 6·1% (95% UI 4·0-8·1), from 2·64 billion (2·46-2·86) in 2010 to 2·80 billion (2·57-3·08) in 2023, but age-standardised DALY rates, which account for population growth and ageing, decreased by 12·6% (11·0-14·1), revealing large long-term health improvements. Non-communicable diseases (NCDs) contributed 1·45 billion (1·31-1·61) global DALYs in 2010, increasing to 1·80 billion (1·63-2·03) in 2023, alongside a concurrent 4·1% (1·9-6·3) reduction in age-standardised rates. Based on DALY counts, the leading level 3 NCDs in 2023 were ischaemic heart disease (193 million [176-209] DALYs), stroke (157 million [141-172]), and diabetes (90·2 million [75·2-107]), with the largest increases in age-standardised rates since 2010 occurring for anxiety disorders (62·8% [34·0-107·5]), depressive disorders (26·3% [11·6-42·9]), and diabetes (14·9% [7·5-25·6]). Remarkable health gains were made for communicable, maternal, neonatal, and nutritional (CMNN) diseases, with DALYs falling from 874 million (837-917) in 2010 to 681 million (642-736) in 2023, and a 25·8% (22·6-28·7) reduction in age-standardised DALY rates. During the COVID-19 pandemic, DALYs due to CMNN diseases rose but returned to pre-pandemic levels by 2023. From 2010 to 2023, decreases in age-standardised rates for CMNN diseases were led by rate decreases of 49·1% (32·7-61·0) for diarrhoeal diseases, 42·9% (38·0-48·0) for HIV/AIDS, and 42·2% (23·6-56·6) for tuberculosis. Neonatal disorders and lower respiratory infections remained the leading level 3 CMNN causes globally in 2023, although both showed notable rate decreases from 2010, declining by 16·5% (10·6-22·0) and 24·8% (7·4-36·7), respectively. Injury-related age-standardised DALY rates decreased by 15·6% (10·7-19·8) over the same period. Differences in burden due to NCDs, CMNN diseases, and injuries persisted across age, sex, time, and location. Based on our risk analysis, nearly 50% (1·27 billion [1·18-1·38]) of the roughly 2·80 billion total global DALYs in 2023 were attributable to the 88 risk factors analysed in GBD. Globally, the five level 3 risk factors contributing the highest proportion of risk-attributable DALYs were high systolic blood pressure (SBP), particulate matter pollution, high fasting plasma glucose (FPG), smoking, and low birthweight and short gestation-with high SBP accounting for 8·4% (6·9-10·0) of total DALYs. Of the three overarching level 1 GBD risk factor categories-behavioural, metabolic, and environmental and occupational-risk-attributable DALYs rose between 2010 and 2023 only for metabolic risks, increasing by 30·7% (24·8-37·3); however, age-standardised DALY rates attributable to metabolic risks decreased by 6·7% (2·0-11·0) over the same period. For all but three of the 25 leading level 3 risk factors, age-standardised rates dropped between 2010 and 2023-eg, declining by 54·4% (38·7-65·3) for unsafe sanitation, 50·5% (33·3-63·1) for unsafe water source, and 45·2% (25·6-72·0) for no access to handwashing facility, and by 44·9% (37·3-53·5) for child growth failure. The three leading level 3 risk factors for which age-standardised attributable DALY rates rose were high BMI (10·5% [0·1 to 20·9]), drug use (8·4% [2·6 to 15·3]), and high FPG (6·2% [-2·7 to 15·6]; non-significant). Our findings underscore the complex and dynamic nature of global health challenges. Since 2010, there have been large decreases in burden due to CMNN diseases and many environmental and behavioural risk factors, juxtaposed with sizeable increases in DALYs attributable to metabolic risk factors and NCDs in growing and ageing populations. This long-observed consequence of the global epidemiological transition was only temporarily interrupted by the COVID-19 pandemic. The substantially decreasing CMNN disease burden, despite the 2008 global financial crisis and pandemic-related disruptions, is one of the greatest collective public health successes known. However, these achievements are at risk of being reversed due to major cuts to development assistance for health globally, the effects of which will hit low-income countries with high burden the hardest. Without sustained investment in evidence-based interventions and policies, progress could stall or reverse, leading to widespread human costs and geopolitical instability. Moreover, the rising NCD burden necessitates intensified efforts to mitigate exposure to leading risk factors-eg, air pollution, smoking, and metabolic risks, such as high SBP, BMI, and FPG-including policies that promote food security, healthier diets, physical activity, and equitable and expanded access to potential treatments, such as GLP-1 receptor agonists. Decisive, coordinated action is needed to address long-standing yet growing health challenges, including depressive and anxiety disorders. Yet this can be only part of the solution. Our response to the NCD syndemic-the complex interaction of multiple health risks, social determinants, and systemic challenges-will define the future landscape of global health. To ensure human wellbeing, economic stability, and social equity, global action to sustain and advance health gains must prioritise reducing disparities by addressing socioeconomic and demographic determinants, ensuring equitable health-care access, tackling malnutrition, strengthening health systems, and improving vaccination coverage. We live in times of great opportunity. Gates Foundation and Bloomberg Philanthropies.
The aim of the present study was to advance the understanding of prenatal diagnostic strategies by systematically analyzing gestational age, duration of pregnancy, clinical indications for prenatal testing, and the prevalence of chromosomal abnormalities among pregnant women undergoing amniocentesis. This retrospective study involved 6,942 pregnant women with indications for amniocentesis who visited the Maternal and Child Health Hospital in Changzhi, Shanxi Province, between January 2018 and December 2023. Both the overall cohort and the subset of positive cases were stratified according to prenatal indications for amniocentesis into the following categories: advanced maternal age (AMA), abnormal maternal serum screening (MSS), noninvasive prenatal testing (NIPT)-positive, pathological ultrasound finding (PUF), parental chromosomal abnormality carrier (PCAC), and poor obstetric history (POH). The analysis encompassed the detection rate of chromosomal abnormalities via amniocentesis, the proportion and positive predictive value (PPV) of each indication group, the distribution of maternal age and gestational age, and the characteristic patterns of confirmed diagnostic findings. Statistical differences were evaluated via the nonparametric Mann-Whitney U test. A total of 6,942 samples were included in the study. Of these, 38 samples (0.55%) with completely lost data were excluded. Samples with partially missing data were retained, including 18 cases (0.26%) lacking maternal age information, 23 cases (0.33%) missing gestational age data, and 8 cases (0.12%) without documented indications for prenatal diagnosis. The distribution of valid data was as follows: maternal age was available for 6,886 cases, gestational age was available for 6,882 cases, and prenatal diagnostic indications were available for 6,896 cases. A total of 557 cases of fetal chromosomal abnormalities were diagnosed, with an overall positive rate of 8.07%. Among the 6,882 valid gestational weeks analyzed, the overall range was 15-37 weeks. Specifically, 70.83% fell within 15-20.6 weeks, and 27.08% fell within 21-27.6 weeks, with positivity rates of 6.93% and 10.18%, respectively. A statistically significant difference was observed between the overall and positive groups (P < 0.05). Among the 6,886 cases with valid maternal age data, the overall age range was 17-50 years, with no significant difference observed between the overall population and positive cases. When the patients were stratified into A1-A6 age groups, statistically significant differences were observed among all groups except A1 (P < 0.05). Among the 6,896 valid cases with recorded prenatal indications, the percentages of MSS, AMA, MSS plus NIPT, NIPT, PUF, POH, and PCAC cases were 51.75%, 30.40%, 0.53%, 4.48%, 7.93%, 2.83%, and 0.40%, respectively. The corresponding PPVs were 4.12%, 8.05%, 94.59%, 42.81%, 8.66%, 5.56%, and 32.14%, respectively. Among the 557 positive cases, chromosomal abnormalities were distributed as follows: aneuploidy (65.35%), structural abnormalities (26.57%), mosaicism (7.18%), and marker chromosomes (0.54%). Autosomal aneuploidy was most frequently represented by trisomy 21, whereas 47,XXY was the most common sex chromosome aneuploidy. Structural abnormalities were most frequently represented by the 17p12 microdeletion. Regarding diagnostic approaches, 27.65% of the cases utilized a single method, 66.96% employed two methods, and 5.39% used three or more methods. Among the single-method cases, Chromosomal Microarray Analysis (CMA) was the most frequently selected technique (14.18%). For cases involving two diagnostic methods, the distribution was as follows (in descending order): karyotype plus QF-PCR (33.21%), QF-PCR plus FISH (17.24%), karyotype plus CMA (10.05%), CMA plus QF-PCR (6.28%), and CNV-seq plus QF-PCR (0.18%). The final analysis revealed that across different age and gestational age subgroups, prenatal indications, diagnostic outcomes, and invasive procedures were most concentrated in the 25-29-year age group and 15-20.6-week gestational age cohort. However, no statistically significant differences were observed among the subgroups (P > 0.05). This study establishes that a risk-stratified approach optimizes prenatal chromosomal diagnosis: combining maternal serum screening with NIPT enhances detection (PPV 94.59%), while karyotyping and CMA respectively address numerical and structural abnormalities. NIPT proves particularly valuable for advanced maternal age, whereas ultrasound anomalies necessitate CMA. Diagnostic yield remains significant across gestational ages, supporting tailored clinical pathways. These findings underscore the importance of integrating multiple modalities for comprehensive prenatal evaluation.
The global burden of sepsis, a life-threatening dysregulated host response to infection leading to organ dysfunction, remains challenging to quantify. We aimed to comprehensively estimate the global, regional, and national burden of sepsis, including the impact of the COVID-19 pandemic and underlying causes of sepsis-related deaths with co-occurring infectious syndromes. We used multiple cause-of-death, hospital, minimally invasive tissue sampling, and linked death certificate and hospital record data representing 149 million deaths, covering 4290 location-years with mortality estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 to capture explicit and implicit sepsis cases and deaths. We estimated age-location-sex-specific fractions of sepsis-related deaths from 195 underlying causes of death and 22 infectious syndromes from 1990 to 2021 using binomial logistic regression models, and estimated sepsis-related deaths using GBD cause-specific mortality estimates. Using 250 million hospital admissions and 7·82 million deaths from hospital data, representing 1310 location-years, we modelled case fatality rates by use of binomial logistic regression, applied to sepsis death estimates to estimate sepsis incidence by age, location, and year. In 2021, we estimated 166 million (95% uncertainty interval 135-201) sepsis cases and 21·4 million (20·3-22·5) all-cause sepsis-related deaths globally, representing 31·5% of total global deaths. Sepsis-related deaths decreased between 1990 and 2019, followed by a surge in 2020 and 2021. As of 2021, individuals aged 15 years and older experienced increases across incidence (230%) and mortality (26·3%) since 1990. Those aged 70 years and older had the highest sepsis-related mortality in 2021 (9·28 million [8·74-9·86] deaths). Sepsis-related deaths from infectious underlying causes decreased from 11·8 million (11·1-12·5) in 1990 to 8·34 million (7·72-9·01) in 2019, then increased by 86·4% to 15·5 million (14·7-16·4) in 2021. Sepsis-related mortality due to non-infectious underlying causes of death increased from 4·69 million (4·35-5·05) in 1990 to 5·81 million (5·40-6·25) in 2021; the leading non-infectious underlying causes of death with sepsis were stroke, chronic obstructive pulmonary disease, and cirrhosis. In 2021, bloodstream infections inclusive of HIV and malaria (3·08 million [2·83-3·35]) and lower respiratory infections inclusive of COVID-19 (11·33 million [1·20-1·47]) were the most prominent infectious syndromes complicating sepsis-related deaths from non-infectious underlying causes, representing a consistent trend since 1990. The global burden of sepsis increased in 2020 and 2021, reversing progress from 1990. Sepsis incidence and mortality increased in people aged 15 years and older, especially those aged 70 years and older, and as a complication of non-infectious underlying causes of death such as stroke, primarily through bloodstream infections and lower respiratory infections. The global burden of sepsis is substantial, and sepsis is increasingly a complication of non-infectious causes of death. Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.
This study aims to explore the knowledge and perceptions of health and social care professionals (HSCP) as well as cancer care managers and administrators (CCMA) in Spain regarding oncological physiotherapy. It seeks to identify barriers and propose strategies to enhance its integration into comprehensive cancer care. The World Café co-design methodology was employed to facilitate discussions among HSCP and CCMA. This approach, known for its dynamic, inclusive, and engaging nature, encouraged a wide range of perspectives and deeper insights through collaborative and adaptable conversations. The sessions were recorded, transcribed, and analyzed qualitatively using inductive thematic analysis. Nineteen participants were involved, including 11 HSCP and 8 CCMA. The analysis revealed three primary themes: "Supportive Services," "Physiotherapy Along the cancer continuum," and "What Now?". Key findings highlight the lack of awareness about the role of physiotherapy in oncology, significant barriers to its integration, and the need for more humanized healthcare. Participants emphasized the importance of interdisciplinary work, the inclusion of physiotherapy in all phases of the oncological process, and the role of case managers in coordinating care. These findings underscore significant gaps in the integration of physiotherapy into oncological care, including unmet needs due to lack of information, resources, and effective communication. Future efforts should focus on increasing the visibility of physiotherapy, integrating specialized physiotherapists into oncology teams, and enhancing the emotional education of professionals to provide more humanized care.
Stroke affects over 101 million individuals worldwide, leaving many to cope with long-term consequences. These often include physical and cognitive impairments such as muscle weakness, loss of coordination, and challenges in performing daily activities. Several quantitative indices have been developed to objectively quantify gait deviations with a focus on ensuring ease of use and accessibility within clinical settings. Among those, the most cited one is the Gait Deviation Index (GDI), originally developed with data from a population of children with cerebral palsy. This characteristic probably reduces the ability of the GDI to interpret stroke-specific deviations. To overcome this limitation, one possibility is to derive a GDI for each specific population, as demonstrated for spinal cord injury. In this study, we developed a stroke-specific GDI (STR-GDI) considering a database of 22 healthy controls and 69 post-stroke subjects. The STR-GDI with a 17-feature basis provided a more reliable reconstruction of non-native data compared to the 15-feature original GDI basis. Both GDI and STR-GDI showed excellent reliability across limbs and datasets (ICC = 0.99), although STR-GDI showed higher ICCs in the test set for the non-paretic limbs (0.95 compared to 0.91 for the GDI). Regression models between GDI and STR-GDI yielded R2 values of 0.76 and 0.81, respectively for the paretic and non-paretic limbs. The linear regressions between indexes and clinical and gait variables were less consistent but still meaningful, with R2 values lower than 0.23. These results may indicate that these metrics offer complementary information, and their combined use could provide a more comprehensive understanding of post-stroke gait impairments. STR-GDI showed slightly higher correlations than GDI with the lower-limb Fugl-Meyer Assessment, the percentage of stance phase, step length, and cadence. In conclusion, in this study we successfully adapted the original GDI methodology to create a STR-GDI to capture gait deviations specific to post-stroke individuals. This study makes a meaningful methodological contribution by developing and validating a complete automatic pipeline that could be adapted to generate other condition-specific GDIs for other neurological or musculoskeletal disorders, provided that datasets are available. Future work will expand the STR-GDI using a larger and more diverse stroke population, assess its inter-session reliability, and develop a compatible version for inertial measurement units and markerless motion capture systems, facilitating broader clinical and real-world applications.
Depot Medroxyprogesterone Acetate (DMPA) in a prefilled auto-disabled subcutaneous injectable contraceptive (Uniject™) can be administered by community health workers and clients. Self-injection of DMPA-SC is an evidence-based practice endorsed globally by the World Health Organization and approved in several countries. The Ethiopian Ministry of Health is interested in introducing DMPA-SC self-injection to expand family planning options. This research aimed to generate information on the safety, acceptability, and feasibility of the introduction and scale-up of DMPA-SC self-injection in Ethiopia. We used mixed-method research. Four hundred women aged 18-49 interested in DMPA-SC self-injection were enrolled in the study. Participants were recruited from six public health facilities with high family planning client load in Addis Ababa. In-depth interviews were conducted with 15 family planning providers trained on self-injection and provided DMPA-SC from six public health facilities. Participants' self-injection competency was assessed using a standardized checklist at enrollment and follow-up (three months post-enrollment). Quantitative data were analyzed using descriptive statistics, and the qualitative data were analyzed using thematic analysis. Self-injection competency among women at baseline (95%) was high and at three months follow-up (83%). Competency levels did not differ by sociodemographic characteristics. Participants reported increased confidence and comfort with self-injection during the three-month follow-up compared to baseline; 74% said they were confident to self-inject during enrollment compared with 93% at follow-up. 84% of participants said they were satisfied or very satisfied with DMPA-SC self-injection. Providers saw the benefit of offering DMPA-SC self-injection because it saves clients time, money, and the burden of having to come to a health facility. Providers suggested that DMPA-SC self-injection be added to the method mix and offered through community distribution by health extension workers. Results showed that women can competently self-inject DMPA-SC and that it is highly acceptable to clients and providers. If made available, most women would like to continue with the method and would recommend it to others. DMPA-SC self-injection has the potential to support the Ethiopian Ministry of Health in reaching its FP2030 targets. The results from this study further support the introduction and scale-up of DMPA-SC self-injection in Ethiopia. This study looked at whether women in Ethiopia could safely and confidently give themselves a birth control shot called DMPA-SC. The shot comes in a small, easy-to-use device and can be given under the skin. It’s already approved in many countries and supported by the World Health Organization.Researchers worked with 400 women in Addis Ababa who were interested in trying self-injection. They also spoke with 15 health workers to get their views. Most women were able to give themselves the shot correctly, both at the beginning and three months later. There was no significant difference in competency by socio-demographic characteristics. Over time, they felt more confident and comfortable doing it. Nearly all said they were satisfied and would recommend it to others. There were no reports of accidental needle pricks by the used or unused DMPA-SC units.Health workers liked the idea too—they said it saves women time and money and could be offered by community health workers. The study shows that self-injection is safe, popular, and could help more women in Ethiopia access birth control, especially as the country works toward its family planning goals.
Existential ethics (extinction ethics) evokes Van Renssalaer Potter's definition of bioethics as a science of human survival that integrates biological principles, the planetary ecosystem, and wisdom. Explored here is a thesis that virtue ethics (character ethics) should supplement deontological, consequentialist, and other approaches to decision-making relevant to extinction. Advances in philosophy, social science, and neuroscience support the idea that virtues such as faith, hope, and love should complement how virtues such as wisdom, justice, temperance, and courage are expressed when deliberating about existential ethical questions in areas such as global warming, nuclear warfare, and rogue artificial intelligence applications. It has yet to be determined whether Science, as the embodiment of a mechanical force, can rule without invoking ruin…. [T]here must be a very different civilization or there will be no civilization at all. Sir William Osler1A new type of thinking is essential [in the atomic age] if mankind is to survive and move toward higher levels. Albert Einstein2.
Existential ethics is the study of the ethical and evaluative implications of human extinction. This article examines 4 key concepts in this emerging field: (1) Going Extinct is different from Being Extinct; (2) extinction-causing catastrophes are different in kind, not just degree, from non-extinction-causing catastrophes; (3) "human extinction" can have multiple meanings, which, when applied, can yield multiple, even conflicting, conclusions about what might constitute best future outcomes; and (4) there are historical reasons why existential ethics has tended to be ignored until recently. One goal of this article is to launch a discussion about what existential health care ethics could look like. La ética existencial es el estudio de las implicaciones éticas y valorativas de la extinción humana. En este artículo, se examinan cuatro conceptos clave en este campo emergente: (1) extinguirse es diferente de estar extinto; (2) las catástrofes que causan la extinción son diferentes en tipo, no solo en grado, de aquellas que no la causan; (3) la “extinción humana” puede tener múltiples significados que, al aplicarse, pueden producir conclusiones diversas, incluso contradictorias, sobre lo que podría constituir los mejores resultados futuros; y (4) existen razones históricas por las cuales la ética existencial ha tendido a ser ignorada hasta hace poco. Uno de los objetivos de este artículo es iniciar una discusión sobre cómo podría ser una ética existencial del cuidado de la salud.
Since health is a crucial, if not the most important, feature of persons' well-being, we have good reasons to consider all present and future persons as members of a "league of patients." This article explores what this concept might mean, proposes how it could be applied in the emerging field of existential health care ethics, and draws upon it to better conceive of how to meet the health needs of current and future patients.
Although biomedical engineering (BME) is a profession with ethical responsibilities comparable to those in medicine, it has, until now, lacked a counterpart to the Hippocratic Oath. While professional societies have established codes of ethics for biomedical engineers, these documents lack the symbolic and ceremonial significance of an oath or pledge. By contrast, the recitation of the Hippocratic Oath, or its modern version, the "Physician's Pledge," serves as a powerful rite of passage for medical students, fostering a strong sense of ethical duty at the start of their professional journey. However, the content of the Hippocratic Oath includes elements specific to clinical practice and is not directly applicable to biomedical engineering. To fill this gap, we have created a "Biomedical Engineer's Pledge," comprising a preamble, ten promises, and a concluding statement, to inspire ethical awareness and establish a meaningful graduation tradition.
The Undiagnosed Diseases Network is a national consortium of clinicians and researchers working to promote diagnostic research and accurately diagnose patients with rare diseases, many of whose conditions have long gone undiagnosed. This endeavor's importance should not, however, stop us from asking good ethics and policy questions about whether and when N-of-1 diagnostic research is justifiable. This article poses and considers questions about informed consent, information privacy, and justice in this very specific kind of human subjects research.
The work of physician Abraham Jacobi was prominent in development of the field of pediatrics. He envisioned clinicians acting as caretakers and advocates for children and families, especially those who were poor. This article summarizes his work as presaging today's appreciation of many structural drivers of children's health.
Pursuit of longevity has become both a biomedical frontier and a booming consumer enterprise. Popular "anti-aging" products-ranging from dietary supplements to skin care and hormone therapies-are commonly promoted as slowing or even reversing aging. At the same time, scientific advances in geroscience are yielding candidate gerotherapeutics and biomarkers for aging that will increasingly generate questions about their applicability, utility, safety, and ethical integration into care. While geroscience holds promise for extending health span, its impact will depend on how this knowledge is integrated into practice and aligned with individual values and priorities, health equity, and prevention of age-related conditions across the lifespan. This article explores the implications of geroscience, particularly for the care of older adults, by examining clinicians' role in ethical incorporation of gerotherapeutics in practice and concludes by making systems-level recommendations.
Dementia is one of the most common developments in our increasing human lifespan. Preventing and postponing it have been important projects of health care that rely on the approval and use of interventions, sometimes in the absence of clinical or ethical consensus about what constitutes meaningful clinical improvement, outcomes, or risk factor modification. This commentary on a case considers these variables and proposes how to improve the general health and well-being of older persons.
Patient-subjects' participation in an Undiagnosed Diseases Network (UDN) protocol can afford access to innovative diagnostic techniques, especially in genomic medicine, which can shorten the time it takes to accurately diagnose a so-called "medical mystery." But UDN research processes can be complex and involve many variables, which can suggest to some patient-subjects that having enrolled in a UDN protocol was not worthwhile. This commentary on a hypothetical case rife with diagnostic ambiguity offers a dynamic model of consent that can both facilitate prospective UDN patient-subjects' assessment of potential risks and benefits of participating in diagnostic research and be a source of community engagement. La participación de los pacientes-sujetos en un protocolo de la Red de Enfermedades No Diagnosticadas (UDN) puede brindar acceso a técnicas diagnósticas innovadoras, especialmente en medicina genómica, lo que puede acortar el tiempo necesario para diagnosticar con precisión un supuesto “misterio médico”. Sin embargo, los procesos de investigación de la UDN pueden ser complejos y abarcar múltiples variables, lo que puede llevar a que algunos pacientes-sujetos consideren que haberse inscrito en un protocolo de la UDN no valió la pena. Este comentario sobre un caso con marcada ambigüedad diagnóstica propone un modelo de consentimiento dinámico que puede, por un lado, facilitar a los futuros pacientes-sujetos de la UDN la evaluación de los posibles riesgos y beneficios de participar en investigación diagnóstica y, por otro, servir como fuente de participación comunitaria.
Breast cancer (BC) remains a global health issue, with most women receiving adjuvant hormone therapy. Hot flushes and climacteric symptoms often compromise treatment adherence. Acupuncture has shown promise in alleviating these symptoms and improving quality of life (QoL). This prospective study aimed to investigate the mechanisms underlying acupuncture's effects on menopausal symptoms in breast cancer patients receiving endocrine therapy, with a secondary focus on inflammatory biomarker changes. This open-label biological study enrolled 37 early BC patients receiving endocrine treatment, and acupuncture treatment provided at IRST within the integrative care pathway, of whom 27 completed all evaluations. Participants underwent a 10-session weekly acupuncture program based on Traditional Chinese Medicine, using fixed points (SP6, CV4, LI11, BL11, GB39). Blood samples for biochemical and cytokine analysis (IL-5, IL-6, IL-10, IL-8, IL-22, TNFα) were collected at baseline (T0), post-treatment (T1), and six months later (T2) during regular clinical and laboratory workups. Clinical outcomes were assessed using the Green Climacteric Scale (GCS), EQ-5D-5L, and Brief Pain Inventory (BPI). The study followed STRICTA guidelines. Acupuncture significantly improved vasomotor and climacteric symptoms, with reduced GCS and hot flash scores at T1 and T2 (p < 0.0001). QoL and pain scores also significantly improved at both time points. Among the cytokines measured over time, a significant reduction in TNFα levels was observed (p = 0.006), though no correlation emerged between cytokine changes and clinical outcomes. Acupuncture proved effective in improving menopausal symptoms and QoL in BC patients receiving endocrine therapy. The modulation of TNFα suggests a potential biological role in the mechanism of symptom relief.
A growing body of evidence considers how addressing adverse structural drivers of health (aSDoH) can improve children's overall health, thereby reinforcing pediatricians' role in advancing health equity early in life. Yet the optimal strategy for aSDoH screening and intervention remains unclear. This article examines barriers to equitable aSDoH screening, referral, and intervention, questioning the necessity of screening tool validation when the primary goal is to connect families with necessary resources. It also explores caregiver engagement, key considerations behind documentation of results, and the need for multilingual screening. Cada vez hay más evidencia sobre cómo abordar los determinantes estructurales adversos de la salud (aSDoH, por sus siglas en inglés) puede mejorar la salud general de los niños, reforzando así el rol de los pediatras en la promoción de la equidad en salud desde las primeras etapas de la vida. Sin embargo, aún no está clara cuál es la mejor estrategia para el tamizaje y la intervención relacionadas con los aSDoH. En este artículo, se examinan las barreras para lograr un tamizaje, derivación e intervención equitativos en relación con los aSDoH, y se cuestiona la necesidad de validar las herramientas de tamizaje cuando el objetivo principal es conectar a las familias con los recursos necesarios. También se analiza la participación de los cuidadores, las consideraciones clave en torno a la documentación de los resultados y la necesidad de contar con herramientas de tamizaje multilingües.
Electronic health records (EHRs) now generally offer patients immediate access to a broad swath of health information and data they are often not fully prepared to interpret or review. This commentary on a case considers risks and benefits of open access to EHRs and strategies for mitigating patient anxiety caused by immediate access, including improving patient understanding of data, tools to promote health literacy, and customizable EHR information access options.
Access to health care is a key structural determinant of health, with lack of health insurance as a main barrier. In the United States, nearly half of children rely on Medicaid or the Children's Health Insurance Program for health insurance. Children's eligibility for coverage under these programs is income dependent and can vary over time, so changes in insurance status signal a need to screen for unmet structural needs. Clinicians, who are obligated to respond to what screening reveals, should be prepared to help deploy practice-based, health system, and community resources to help meet the needs of children and families.