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Cardiovascular diseases (CVDs) are the leading cause of mortality and are among the foremost causes of disability globally. CVD burden has continued to increase in most countries since 1990, with trends driven by changing exposures to harmful risk factors, population growth, and population aging. We report estimates of global, national, and subnational CVD burden, including 18 subdiseases and 12 associated modifiable risk factors. We analyzed change in CVD burden from 1990 to 2023 and identified drivers of change including population growth, population aging, and risk factor exposure. The Global Burden of Disease (GBD) 2023 study, a multinational collaborative research study, quantified burden due to 375 diseases including CVD burden and identified drivers of change from 1990 to 2023 using all available data and statistical models. GBD 2023 estimated the population-level burden of diseases in 204 countries and territories from 1990 to 2023. CVDs were the leading cause of disability-adjusted life years (DALYs) and deaths estimated in the GBD. As of 2023, there were 437 million (95% UI: 401 to 465 million) CVD DALYs globally, a 1.4-fold increase from the number in 1990 of 320 million (292 to 344 million). Ischemic heart disease, intracerebral hemorrhage, ischemic stroke, and hypertensive heart disease were the leading cardiovascular causes of DALYs in 2023 globally. As of 2023, age-standardized CVD DALY rates were highest in low and low-middle Socio-demographic Index (SDI) settings and lowest in high SDI settings. The number of CVD deaths increased globally from 13.1 million (95% UI: 12.2 to 14.0 million) in 1990 to 19.2 million (95% UI: 17.4 to 20.4 million) in 2023. The number of prevalent cases of CVD more than doubled since 1990, with 311 million (95% UI: 294 to 333 million) prevalent cases of CVD in 1990 and 626 million (95% UI: 591 to 672 million) prevalent cases in 2023 globally. A total of 79.6% (95% UI: 75.7% to 82.5%) of CVD burden is attributable to modifiable risk factors 347 million [95% UI: 318 to 373 million] DALYs in 2023). Globally, high systolic blood pressure, dietary risks, high low-density lipoprotein cholesterol, and air pollution were the modifiable risks responsible for most attributable CVD burden in 2023. Since 1990, changes in exposure to modifiable risk factors have had mixed effects on CVD burden, with increases in high body mass index, high fasting plasma glucose, and low physical activity leading to higher burden, while reductions in tobacco usage have mitigated some of these increases. Population growth and population aging were the main drivers of the increasing burden since 1990, adding 128 million (95% UI: 115 to 139 million) and 139 million (95% UI: 126 to 151 million) CVD DALYs to the increase in CVD burden since 1990. CVD remains the leading cause of disease burden and death worldwide with the greatest burden in low, low-middle, and middle SDI regions. Large variation exists in CVD burden even for countries at similar levels of development, a gap explained substantially by known, modifiable risk factors that are inadequately controlled. The decades-long increase in CVD burden was the result of population growth, population aging, and increased exposure to a subset of risk factors led by metabolic risks. Countries will need to adopt effective health system and public health strategies if they are to progress in achieving global goals to reduce the burden of CVD.
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease, is one of the most prevalent liver diseases globally, contributing to both economic and health-related challenges. We aimed to evaluate the global, regional, and national burden of MASLD from 1990 to 2023, quantify the contribution of identified modifiable risk factors, and project future prevalence up to the year 2050. Estimates of MASLD prevalence and disability-adjusted life-years (DALYs) were produced by age, sex, region, Socio-demographic Index (SDI), and Healthcare Access and Quality (HAQ) index across 204 countries and territories from 1990 to 2023 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023. The MASLD burden attributable to three risk factors (smoking, high BMI, and high fasting plasma glucose) was assessed as part of the GBD comparative risk assessment. As a secondary analysis, we used these estimates to forecast MASLD prevalence up to 2050 using fasting plasma glucose and mean BMI as predictors. Furthermore, to examine the relative contributions of population ageing, population growth, and changes in MASLD prevalence rate to the forecasted changes in case counts from 2023 to 2050, we conducted a decomposition analysis. In 2023, approximately 1·3 billion (95% uncertainty interval [UI] 1·2 to 1·4) individuals were estimated to be living with MASLD (ie, 16·1% of the global population), with an age-standardised prevalence rate of 14 429·3 (95% UI 13 268·3 to 15 990·6) per 100 000 population, representing a percentage increase of 142·7% (95% UI 139·2 to 146·7) in crude numbers from 1990 (0·5 billion [0·5 to 0·6]) and of 28·6% (27·8 to 29·5) in the rate (11 217·2 [10 276·8 to 12 467·0] per 100 000 in 1990). An estimated 3·6 million (2·8 to 4·5) total DALYs were attributable to MASLD worldwide in 2023, corresponding to an age-standardised DALY rate of 39·6 (31·2 to 49·9) per 100 000 population. Despite a 116·3% (93·3 to 139·4) increase in crude DALYs (from 1·7 million [1·3 to 2·1] in 1990), its age-standardised estimate remained consistent (1·8% [-8·6 to 12·8]) from 1990 (38·9 [30·1 to 49·8] per 100 000) to 2023. There was substantial variation in age-standardised estimates across regions. North Africa and the Middle East had the highest prevalence rate (29 246·1 [26 848·3 to 32 048·7] per 100 000) and Andean Latin America showed the highest DALY rate (152·3 [114·1 to 194·7] per 100 000). By contrast, the high-income Asia Pacific region had the lowest prevalence rate (8653·5 [7923·7 to 9592·8] per 100 000) and east Asia had the lowest DALY rate (16·3 [13·5 to 19·9] per 100 000) among all GBD regions. North Africa and the Middle East showed disproportionately higher prevalence rates relative to other regions with similar SDIs. Lower SDIs and HAQs were associated with higher age-standardised DALY rates. The age-standardised prevalence rate was consistently higher in males (15 616·4 [14 349·2 to 17 263·3] per 100 000 people in 2023) than in females (13 245·2 [12 132·0 to 14 692·6] per 100 000 people), and peaked at age 80-84 years in both sexes. The number of MASLD prevalent cases was the highest in younger adults, peaking at age 35-39 years for males and age 55-59 years for females. Among the risk factors for MASLD, high fasting plasma glucose presented the largest contribution to the age-standardised DALY rate of total MASLD in 2023 (2·2 [95% UI 1·6 to 3·1] per 100 000 people), followed by high BMI (1·4 [0·6 to 2·4] per 100 000 people) and smoking (1·0 [0·3 to 1·8] per 100 000 people). Our forecasting model estimates that 1·8 billion (95% UI 1·6 to 2·0) individuals are likely to have MASLD by 2050, representing a 42·0% increase from 2023. The age-standardised prevalence rate is expected to increase to 15 774·9 (95% UI 14 613·9 to 17 336·2) per 100 000 people in 2050, representing an average annual percentage change of 0·3% (95% UI 0·3-0·3). According to our decomposition analysis, this change will be primarily due to population growth, particularly in sub-Saharan Africa and North Africa and Middle East, and less by population ageing or epidemiological change. With a global prevalence of 16·1% and approximately 1·3 billion people already living with MASLD in 2023, the condition has and will continue to have substantial health and economic impacts worldwide. An inverse association between the HAQ Index and age-standardised DALY rates suggests that countries with lower health-care access and quality might be less well positioned to manage the growing MASLD burden, underscoring the need for strengthened health-system capacity in these settings. Gates Foundation.
Clostridioides difficile infection (CDI) continues to be a challenging issue for health care providers and place a heavy burden on health care facilities. The prevention of community-acquired and healthcare-acquired CDI rests on reducing the person-level risk factors (most commonly exposure to antibiotics and reducing the disruption of the normally protective intestinal microbiota). Prevention of facility-level CDI rests on multifaceted infection control practices that include antibiotic stewardship programs, prompt diagnosis and isolation of CDI cases, environmental disinfection and cleaning, and training of multidisciplinary teams. Use of probiotics of specific strains in high-risk patients is worthy of future investigation.
Cirrhosis is an increasingly prevalent condition, with significant associated morbidity and mortality due to the development of several complications, including portal hypertension and hepatocellular carcinoma (HCC). Early detection of significant liver fibrosis can lead to interventions to forestall complications and early detection of hepatic decompensation or liver cancer. Several noninvasive blood and imaging-based biomarkers exist for the detection of liver fibrosis, stratification of patients with cirrhosis for the risk of portal hypertensive complications, and for the early detection of HCC. We aim to summarize the data on promising biomarkers for the detection and risk stratification of patients with cirrhosis.
Digital technology development is accelerating, with extended reality, artificial intelligence, and methods for information sharing leading the charge in broad medical specialties including pediatric neurogastroenterology. This rapid advancement must be acknowledged by clinicians given the potential for improved quality and experience by health care stakeholders, and decisions about when and how to use novel digital technology must consider practical and ethical implementation challenges. Growing evidence of technology acceptance and favorable health outcomes exists, and best practice for using these digital tools in clinical practice remains to be determined.
Clostridioides difficile infection (CDI) is a leading cause of hospital-acquired infectious diarrhea, often triggered by disruption of the gut microbiota. Recurrence is common after antibiotic treatment, prompting interest in microbial therapies such as probiotics. While some studies suggest probiotics may help prevent initial or recurrent CDI episodes, overall evidence remains inconsistent. Data on prebiotics and synbiotics are even more limited. Although generally safe, probiotics may delay restoration of the normal microbiome, which is key to preventing recurrence. Current guidelines vary from cautious support to discouragement of their use, leaving the role of these therapies in CDI management uncertain and investigational.
Irreversible intestinal failure is associated with significant morbidity secondary to parenteral nutrition, including liver dysfunction, infections, and loss of vascular access. Living donor intestinal transplantation (LDITx) offers a potentially curative option, particularly in regions with limited deceased donors. The procedure is technically demanding, requiring meticulous management of small-caliber vascular pedicles and careful perioperative monitoring to minimize vascular complications. Ensuring donor safety through structured multidisciplinary evaluation is paramount. This article provides a detailed overview of LDITx, emphasizing operative techniques, graft procurement, and recipient procedure, highlighting strategies that optimize both donor and recipient outcomes while restoring intestinal function and quality of life.
Clostridioides difficile is a gram-positive bacterium and major cause of infectious colitis, in hospital and health care settings, where it remains a significant public health threat. Accurate diagnosis of C difficile infection (CDI) is challenging and requires a clinical assessment supported by laboratory stool testing. Reliance on laboratory tests can lead to both overdiagnosis and underdiagnosis. This article outlines the pathophysiology of C difficile, with emphasis on aspects related to diagnostic testing, and discusses the clinical approach to clinical diagnosis. New therapies for the treatment and prevention of CDI all rely on accurate clinical and laboratory identification of true infection.
Both temporary nasogastric tubes and durable enteral feeding tubes provide critical means of nutrition support for a variety of pediatric patient phenotypes. It is often difficult for families and clinicians to navigate the care for these tubes across complex medical systems. The build of an interdisciplinary program designed to take care of patients' tubes, throughout the life of the tube, has improved processes and outcomes at a pediatric medical center. Reimagining the best and safest care for these patients has resulted in the development of clinical pathways to navigate this system, resulting in several improved outcomes.
Disorders of gut-brain interaction (DGBI) in pediatrics such as irritable bowel syndrome, functional abdominal pain, and functional dyspepsia pose a challenging set of syndromes that limit patient quality of life and may impair optimal nutritional intake. Nutrition plays a key role in management of DGBI by promoting gut motility and modulating visceral sensations. Therapeutic diets can be safely implemented toward the treatment of pediatric DGBI, but it is essential that providers understand the roles and limitations of various diets and assess for restrictive patterns of eating.
The management of pediatric intestinal failure (IF) has evolved over the last 2 decades, transforming it from a bleak diagnosis with high morbidity and mortality, to one of hope and survival with good long-term outcomes. The overarching goal of intestinal rehabilitation is to allow patients to achieve enteral autonomy, namely, freedom from dependence on parenteral nutrition. The following article describes the epidemiology and definitions in pediatric IF, highlights the role of the intestinal rehabilitation programs, and provides an overview of management strategies with a focus on medical management including the prevention and treatment of complications.
Barrett's esophagus (BE) is a major risk factor for the development of esophageal adenocarcinoma (EAC) and is the only known precursor lesion for this lethal cancer. Although BE is relatively common among patients with gastroesophageal reflux disease, most patients with BE will never progress to EAC. Moreover, the cadence of progression from nondysplastic BE to dysplasia to EAC may be variable. The histologic grading of dysplasia during endoscopy is the most widely used prognosticator for risk stratification and management of BE based on its stepwise progression from low-grade dysplasia to high-grade dysplasia to mucosal EAC, and finally, to invasive EAC.
The intestinal microbiome encompasses a complex network of microorganisms that is now recognized to make wide contributions to health and disease but remains incompletely understood. Recent studies provide new insights into distinct roles of the microbiome in specific gastrointestinal diseases and support the possibility of developing new clinical microbial biomarkers for disease diagnosis, risk stratification for disease progression, and prediction of response to therapeutic interventions. Here, we discuss the various potential taxonomic, metabolic, and serologic biomarkers that have been highlighted in recent studies.
Living donor liver transplantation has become an established treatment option for patients with end-stage liver disease, offering superior outcomes when performed at experienced centers. This article addresses the perioperative management of adult living liver donors undergoing hemi-hepatectomyl. Current topics include donor selection criteria, surgical technique, anesthetic management, postoperative care including Enhanced Recovery After Surgery protocols, and long-term donor outcomes with emphasis on quality of life.
Clostridioides difficile infection (CDI) epidemiology has evolved over the past 3 decades. In the early 2000s, incidence and severity surged, driven by hypervirulent strains, extensive use of broad-spectrum antibiotics, an aging population, suboptimal infection-control practices, and highly sensitive molecular diagnostics. During the same period, community-associated CDI (CA-CDI) emerged affecting a different population. Recent optimization of infection prevention, antimicrobial stewardship, and multi-step diagnostic algorithms have helped curb hospital-acquired CDI. However, CA-CDI accounts for approximately half of all CDI cases and is rising. These trends underscore the need for continued surveillance, targeted prevention strategies, and enhanced access to effective treatments.
Living donor liver transplantation offers life-saving therapy with excellent donor safety and long-term outcomes. Most donors achieve full recovery within months, though some experience persistent physical, psychological, and financial challenges. Mortality rates remain below 0.4%, and health-related quality of life typically equals or exceeds population norms. Predictors of poorer outcomes include smaller remnant liver size, female sex, prolonged recovery, and limited social or financial support. Advances in minimally invasive techniques have further improved short-term donor experience without compromising outcomes. Comprehensive long-term surveillance and individualized psychosocial support remain integral to donor care.
This article highlights the evolving role of dietary strategies in the management of pediatric inflammatory bowel disease (IBD). Advances in understanding diet's influence on IBD pathogenesis and disease progression have renewed interest in the role of diet in the treatment of IBD. Exclusive enteral nutrition remains the gold standard, but whole food diets that mimic the composition of EEN or eliminate foods that negatively impact the intestinal microbiome and immune response have shown promise. Additional research that includes larger patient populations and objective data is needed to expand applicability and develop patient-centered recommendations.
Colorectal cancer (CRC) is a major global health burden. Although colonoscopy remains the gold standard for screening, less invasive biomarker-based stool and blood tests including FIT, multi-target stool DNA/RNA assays, and blood-based biomarker tests are emerging with promising diagnostic performance. In the post-treatment setting of localized CRC, ctDNA has emerged as a powerful tool, with studies showing it can predict recurrence earlier than imaging or traditional tumor biomarkers. ctDNA testing is used for genomic profiling of CRC to guide therapy decisions. Ongoing research aims to refine ctDNA-based surveillance and integrate it with other biomarkers to transform CRC monitoring and treatment.
Severe and fulminant Clostridioides difficile infection (CDI) represent distinct clinical entities that portend poor outcomes and require close monitoring and multidisciplinary management. Early recognition is key, and CDI-directed antimicrobials are the mainstay of therapy. If patients fail to improve despite maximal medical therapy, fecal microbiota transplantation (FMT) or surgical intervention should be considered. If FMT is performed, repeated dosing is often required. Surgical interventions such as colectomy or loop ileostomy are necessary in FMT nonresponders or those who have developed a complication such as perforation.
Clostridioides difficile is a gram-positive, anaerobic bacteria that is ubiquitous. Oral-fecal transmission of the organism and its spores leads to C difficile colonization and infection (CDI) within the human gastrointestinal tract. Patients with inflammatory bowel disease (IBD) are more likely to be colonized with C difficile, develop CDI, and experience recurrence when compared to the general population. The biggest challenge of managing CDI in IBD remains diagnostic uncertainty and relies on clinicians' judgment.