Management of the N0 neck is a challenging clinical decision. Most of the literature relied on for clinical decision-making are studies with subjects being treated for cT1/cT2 N0 disease. The purpose of this American Association of Oral and Maxillofacial Surgeons (AAOMS) position paper is to provide a narrative review that summarizes and synthesizes the current literature evidence and provides current treatment strategies for cT1 and cT2 N0 (not cT1/cT2 combined) patients, as well as identify knowledge gaps to suggest future research needs for this critical clinical question. For enhanced clarity and in contrast to other organizations, AAOMS suggests that these 2 patient groups be considered distinct from data, research, and clinical perspective to provide for treatment decisions at present and future research direction within the scientific community. A comprehensive search of the literature related to treatment of the neck in oral cancer was completed using PubMed for articles published between January 1, 2000, and February 28, 2026. Keywords for the search included clinically negative neck, N0 neck in oral cancer, depth of invasion guided neck dissection, sentinel lymph node biopsy in squamous cell carcinoma of the oral cavity, cT1 oral cavity cancer, cT2 oral cavity cancer, and supraomohyoid neck dissection. The list of articles was then cross-referenced with position statement recommendations from the National Comprehensive Cancer Network, the American Society of Clinical Oncology, and the British Association of Head & Neck Oncologists. A working group of the AAOMS Committee on Head and Neck Oncologic and Reconstructive Surgery reviewed these findings and agreed to serve as authors. Sixty-two articles were included in the final review as were guideline recommendations from National Comprehensive Cancer Network, American Society of Clinical Oncology, and British Association of Head & Neck Oncologists. Literature regarding the treatment of cT1 and cT2 N0 patients is biased due to the combining of these groups into single recommendations. Three accepted treatment options exist: elective neck dissection, sentinel node biopsy, and depth and site-guided elective neck dissection, each with advantages and disadvantages. Best literature evidence and surgeon skillset should guide the recommendations of surgeons and treatment of patients when entering a shared decision-making model for treatment or observation of the neck in oral cancer. Recommendations made in this position paper can assist in the process of clinical decision-making and communication with patients. Treatment decisions and research moving forward should appreciate and attempt to fill current knowledge gaps by enhancing focus of cT1N0 and cT2N0 as distinct patient populations from a data and analysis perspective including in clinical trial design.
Oral squamous cell carcinoma (OSCC) is the most common cancer in the oral and maxillofacial region. While the 5-year survival rate ranges from 75% to 94% when detected early, the majority of cases are diagnosed at an advanced stage, where survival drops to 20%-40%, underscoring the critical need for improved early detection strategies. This study aimed to non-invasively detect OSCC by measuring the thermal difference between carcinogenic tissue and healthy mucosa using an infrared sensor and to assess the accuracy of this diagnostic modality. A novel intraoral infrared device was designed and manufactured to non-invasively measure intraoral tissue temperature. Twenty participants (13 males and 7 females) were examined, including 10 patients and 10 healthy individuals. The temperature of the lesion and contralateral healthy mucosa in the patients' group as well as both sides of the tongue in the control group were measured. The temperature differences were analyzed using the t-test. The accuracy of the device was evaluated using the receiver operating characteristic (ROC) curve. A significant difference was observed in the temperature of the tumoral tissue and healthy mucosa in the patients' group (p < 0.001). The assessment of the device's accuracy in detecting OSCC revealed that a temperature differential greater than 0.97°C between the measured sides indicates the potential presence of a lesion on the higher temperature side (sensitivity = 1, specificity = 1). Regions exhibiting temperatures higher than 38.42°C were identified as potentially indicating the presence of malignant lesions (sensitivity = 1, specificity = 0.9). Thermography can serve as an effective non-invasive diagnostic modality for detecting suspicious oral lesions by leveraging temperature differences. The designed device facilitates early detection of these lesions based on thermal variations, offering a promising tool for timely and accurate diagnosis. IRCT20181130041806N1.
This guideline is an update of the 2021 ESGE Guideline on Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage. The following are the new and/or revised recommendations. 1: ESGE does not recommend the routine use of video capsule endoscopy or telemetric blood-sensing capsules in the management of patients with suspected upper gastrointestinal hemorrhage (UGIH). 2: ESGE suggests, if intravenous erythromycin is unavailable, pre-endoscopy administration of intravenous metoclopramide in selected patients with clinically severe or ongoing active UGIH. 3: ESGE suggests that pre-endoscopy high dose intravenous proton pump inhibitor (PPI) therapy be considered in patients presenting with acute UGIH; however, this should not delay early endoscopy. 4: ESGE does not recommend emergent (≤6 hours) or urgent (≤12 hours) upper GI endoscopy unless the patient remains hemodynamically unstable despite adequate resuscitation. 5: ESGE suggests that patients with peptic ulcers presenting with an adherent clot (Forrest IIb) should undergo endoscopic therapy, with clot removal and subsequent endoscopic hemostasis if indicated, provided that the endoscopist has the technical competence to safely remove the clot and manage potential conversion to a higher risk bleeding lesion. 6: ESGE could not reach a consensus for or against the routine use of a Doppler endoscopic probe in treatment decisions of high risk endoscopic stigmata of peptic ulcer bleeding. 7: ESGE suggests the use of over-the-scope (OTS) clips as monotherapy as an alternative to combination therapy as first-line therapy for peptic ulcer bleeding with high risk stigmata (FIa, FIb) owing to a lower risk of further bleeding compared with standard endoscopic hemostatic therapy. 8: ESGE recommends, for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy (e.g. through-the-scope or OTS clips), or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. 9: ESGE suggests, for patients with an ulcer with a nonbleeding visible vessel (FIIa), OTS clips may be used as alternative monotherapy. 10: ESGE suggests hemostatic forceps with soft coagulation may be used as monotherapy in the treatment of peptic ulcer bleeding with high risk stigmata (FIa, FIb, and FIIa). 11: ESGE suggests that hemostatic agents should not be used as monotherapy in the first-line treatment of patients with high risk stigmata of peptic ulcer bleeding. 12: ESGE suggests that, in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic agent or OTS clips should be considered. 13: ESGE recommends that, in patients with persistent bleeding refractory to all modalities of endoscopic hemostasis, including topical hemostatic agents and OTS clips, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after unsuccessful TAE. 14: ESGE suggests that prophylactic TAE be considered in selected high risk cases of peptic ulcer bleeding (e.g. patients with hemodynamic instability at presentation, posterior duodenal wall ulcer location, large ulcer size [>2 cm], or when durable endoscopic hemostasis is considered uncertain). 15: ESGE could not reach a consensus for or against the routine use of potassium-competitive acid blockers for patients who have undergone endoscopic hemostasis. 16: ESGE recommends that, for patients with clinical evidence of recurrent peptic ulcer bleeding, use of an OTS clip should be considered. Should this second attempt at endoscopic hemostasis also be unsuccessful, TAE should be considered. Surgery is indicated when TAE is either locally unavailable or after unsuccessful TAE. 17: ESGE recommends that, in patients with peptic ulcer hemorrhage who require ongoing anticoagulation therapy, anticoagulation should be resumed as soon as clinically indicated based on thromboembolic risk. 18: ESGE suggests that iron therapy be initiated prior to hospital discharge in patients with peptic ulcer bleeding and iron deficiency and/or anemia. 19: ESGE suggests that early oral nutrition, within 24 hours following endoscopic hemostasis, be initiated in patients with peptic ulcer bleeding in whom durable hemostasis has been achieved.
Health care accounts for 4.6% of Canada's greenhouse gas (GHG) emissions, 25% of which comes from medications. Antimicrobials with high bioavailability offer no additional benefit when given intravenously, except when oral (PO) administration is not feasible. Intravenous (IV) formulations have a higher carbon footprint than their PO counterparts. IV-to-PO switch strategies benefit patients and the health care system by reducing line-related adverse events, nursing time, length of hospital stay, and costs and can also reduce carbon emissions.Our primary objective was to quantify IV use of bioequivalent antimicrobials when PO administration is feasible. Secondary objectives were to determine GHG emissions and antimicrobial costs associated with unnecessary IV use of bioequivalent antimicrobials. We performed a retrospective, cross-sectional study of hospitalized adults who received IV azithromycin, ciprofloxacin, clindamycin, cotrimoxazole, fluconazole, levofloxacin, linezolid, metronidazole, moxifloxacin, or voriconazole at Vancouver General Hospital on five dates. We determined the proportion of patients receiving these antimicrobials who met criteria for PO administration. We also applied a life cycle assessment (LCA) to assess the GHG emissions of the antimicrobial drug delivery systems using OpenLCA with the Ecoinvent database. Using these data, we calculated the GHG emissions and costs associated with unnecessary IV use. In total, 128 patients were identified. Seventy-eight (61%) met IV-to-PO switch criteria on the audit dates. Most eligible patients were admitted to general surgery, internal medicine, or critical care. The antimicrobial with the highest IV-to-PO switch eligibility was metronidazole (51%), most often prescribed for intra-abdominal infections. Over the five study dates, potential GHG savings were about 80,000 gCO2-eq. Potential annual cost savings were about $59,000. Over 60% of patients receiving highly bioavailable IV antimicrobials were eligible for PO therapy, highlighting an opportunity to optimize prescribing. Promoting an IV-to-PO switch can improve patient outcomes and reduce environmental impact, supporting both patient-centred care and planetary health. Climate change is one of the most precarious issues that we are facing as a society. By making informed, sustainability-conscious choices in these areas, clinicians can help protect both current patients and the broader ecosystems on which future health depends. Switching bioequivalent antimicrobials from intravenous (IV) to oral (PO) administration, when appropriate, confers benefits to patients and the health care system but can also benefit our environment and planet. Identifying antimicrobial regimens with a lower carbon footprint while optimizing patient outcomes is an example of how we can align prescribing practices with both patient-centred care and environmental sustainability. Antimicrobials with high bioavailability offer no additional benefit when given intravenously, except when PO administration is not feasible. An IV-to-PO switch has numerous benefits, including reduced line-related adverse reactions, nursing time, length of hospital stay, and costs. Our primary objective was to quantify the proportion of patients receiving highly bioavailable antimicrobials intravenously when PO administration is feasible. Secondary objectives were to determine greenhouse gas (GHG) emissions and antimicrobial costs that could have been saved if the antimicrobials were administered orally. Our cross-sectional, retrospective study found that 61% of patients met IV-to-PO switch criteria on the audit dates. The antimicrobial with the highest IV-to-PO switch eligibility was metronidazole (51%), most often prescribed for intra-abdominal infections. Over the five study dates, potential GHG savings were about 80,000 gCO2-eq, and potential annual cost savings were about $59,000. Les soins de santé représentent 4,6 % des émissions de gaz à effet de serre (GES) au Canada, dont 25 % proviennent des médicaments. Les antimicrobiens ayant une forte biodisponibilité n'apportent aucun avantage supplémentaire lorsqu'ils sont administrés par voie intraveineuse, sauf lorsqu'il est impossible de les administrer par voie orale (PO). Les formulations intraveineuses (IV) ont une empreinte carbone plus élevée que leurs homologues PO. Les stratégies de transition de l'IV à la PO sont bénéfiques aux patients et au système de santé, car elles réduisent les événements indésirables liés aux cathéters, la durée des soins infirmiers, la durée du séjour hospitalier et les coûts, sans compter qu'elles peuvent également réduire les émissions de carbone.L'objectif primaire de la présente étude consistait à quantifier l'utilisation d'antimicrobiens bioéquivalents IV lorsqu'il est possible de les administrer PO. Quant aux objectifs secondaires, ils visaient à déterminer la quantité d’émissions de GES et le coût des antimicrobiens associés à l'utilisation inutile d'antimicrobiens bioéquivalents IV. Les auteurs ont procédé à une étude rétrospective transversale des adultes hospitalisés qui avaient reçu de l'azithromycine, de la ciprofloxacine, de la clindamycine, du cotrimoxazole, du fluconazole, de la lévofloxacine, du linézolide, du métronidazole, de la moxifloxacine ou du voriconazole IV au Vancouver General Hospital à cinq dates différentes. Ils ont déterminé la proportion de patients qui avaient reçu ces antimicrobiens, mais respectaient les critères d'administration PO. De plus, ils ont appliqué une évaluation du cycle de vie (ÉCV) à l'aide des bases de données Ecoinvent d'OpenÉCV pour déterminer les émissions de GES attribuables aux modes d'administration des antimicrobiens. À partir de ces données, ils ont calculé les émissions de GES et les coûts associés à l'utilisation inutile d'IV. Au total, 128 patients ont été détectés, et 78 (61 %) avaient respecté les critères de transition de l'IV à la PO aux dates des audits. La plupart des patients admissibles avaient été admis en chirurgie générale, en médecine interne ou en soins intensifs. Le métronidazole (51 %), surtout prescrit pour des infections intra-abdominales, était l'antimicrobien le plus admissible à la transition de l'IV à la PO. Aux cinq dates de l’étude, les épargnes potentielles de GES s’élevaient à environ 80 000 éq. G CO2. Par ailleurs, les économies potentielles annuelles atteignaient environ 59 000 $. Plus de 60 % des patients qui ont reçu des antimicrobiens IV hautement biodisponibles étaient admissibles à un traitement PO, ce qui démontre la possibilité d'optimiser les prescriptions. La promotion d'une transition de l'IV à la PO peut améliorer les résultats cliniques des patients et limiter les conséquences environnementales, ce qui contribue à la fois à des soins axés sur les patients et à la santé de la planète.
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.
The 2023 iteration of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) estimated prevalence, incidence, and health burden for 375 diseases and injuries, including 12 mental disorders. We assess past, current, and emerging trends in the prevalence and burden of mental disorders across sexes and age groups, for 21 regions, 204 countries and territories, and by Socio-demographic Index (SDI) quintile, from 1990 to 2023. Mental disorders included in GBD 2023 were anxiety disorders, major depressive disorder, dysthymia, bipolar disorder, schizophrenia, autism spectrum disorders, conduct disorder, attention-deficit hyperactivity disorder, anorexia nervosa, bulimia nervosa, idiopathic developmental intellectual disability, and a residual category of other mental disorders. A literature review identified epidemiological data for each disorder. These were analysed via a Bayesian meta-regression to estimate prevalence by disorder, sex, age, location, and year. Disorder-specific prevalence was multiplied by disability weights representing the severity of health loss associated with each disorder to estimate years lived with disability (YLDs). Deaths due to anorexia nervosa were assessed with a Cause of Death Ensemble modelling strategy to estimate deaths by sex, age, location, and year, and then multiplied by the standard life expectancy at age of death to estimate years of life lost (YLLs). YLDs equalled disability-adjusted life-years (DALYs) for all mental disorders except anorexia nervosa (the only mental disorder considered as an underlying cause of death in GBD), for which DALYs represented the sum of YLDs and YLLs. We presented prevalence, deaths, YLDs, YLLs, and DALYs as counts, age-specific rates per 100 000 population, and age-standardised rates per 100 000 population. We estimated 1·17 billion (95% uncertainty interval 1·06-1·31) prevalent cases of mental disorders globally in 2023, equivalent to an age-standardised prevalence rate of 14 210·7 cases (12 849·5-15 940·1) per 100 000 population. These estimates represented a 95·5% (75·0-121·2) increase in prevalent cases and 24·2% (11·4-41·4) increase in age-standardised prevalence rate between 1990 and 2023. All mental disorders showed increases in prevalent cases between 1990 and 2023, while notable increases were seen in age-standardised prevalence rates for anxiety disorders, major depressive disorder, dysthymia, anorexia nervosa, bulimia nervosa, schizophrenia, and conduct disorder. There were an estimated 171 million (127-228) DALYs due to mental disorders globally across sex and age in 2023, equivalent to an age-standardised DALY rate of 2070·5 DALYs (1519·1-2750·5) per 100 000 population. Mental disorders contributed to 6·1% (4·8-7·6) of all-cause DALYs in 2023, making them the fifth leading cause of global DALYs (up from 12th in 1990). DALYs were almost entirely composed of YLDs. Mental disorders were the leading cause of YLDs in 2023 (up from second in 1990), explaining 17·3% (14·8-20·6) of all-cause global YLDs. Leading causes of mental disorder DALYs were anxiety disorders (ranked 11th among the 304 diseases and injuries at Level 4 of the GBD cause hierarchy), major depressive disorder (15th), and schizophrenia (41st). Globally in 2023, mental disorder age-standardised DALY rates were higher among females (2239·6 [1643·7-3014·1] per 100 000) than among males (1900·2 [1399·8-2510·8] per 100 000), and peaked in the 15-19 years age group (2617·3 [1850·6-3696·8] per 100 000). All locations showed increased mental disorder DALY rates in 2023 compared with 1990, ranging across countries and territories from 1302·4 (952·7-1683·7) per 100 000 in Viet Nam to 3555·8 (2661·9-4715·0) per 100 000 in the Netherlands. Across SDI quintiles, DALY rates ranged from 1853·0 (1352·1-2469·3) per 100 000 for middle SDI to 2184·1 (1606·1-2890·3) per 100 000 for high SDI. A significant health burden was imposed by mental disorders in all countries and territories in 2023, irrespective of the health resources available. In some instances, this burden has increased over time and is unevenly distributed across populations. Stronger surveillance systems, particularly in low-income and middle-income countries, are required. Additionally, we need more coordinated and inclusive policies to reduce the burden through early treatment and prevention, tailored to sex and age differences across locations. Responding to the mental health needs of our global population, especially those most vulnerable, is an obligation, not a choice. Gates Foundation, Queensland Health, and University of Queensland.
Enteric infectious diseases claim more than 1 million lives annually and are among the top ten causes of death in children younger than 5 years. Remarkable global investment has been dedicated to enteric infectious disease prevention and control; however, the shifting global health landscape is testing the continuance of progress. To evaluate the current status and guide future interventions, we present the latest epidemiological estimates of enteric infectious diseases from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 and assess progress towards the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) mortality target of fewer than 20 deaths per 100 000 children younger than 5 years by 2025. We quantified the incidence, mortality, and disability-adjusted life-years (DALYs) of enteric infectious diseases by age, sex, and year across 204 countries and territories from 1990 to 2023. In GBD 2023, the following were considered under the category of enteric infectious diseases: diarrhoeal diseases, enteric fever (typhoid and paratyphoid), invasive non-typhoidal Salmonella spp (iNTS) infections, and other intestinal infectious diseases. We also examined 15 aetiologies contributing to diarrhoeal diseases. Incidence and prevalence were estimated with DisMod-MR (version 2.1), a Bayesian meta-regression tool, drawing on data from systematic reviews, population-based surveys, claims data, and hospital sources. Cause-specific mortality was modelled with Cause of Death Ensemble Modelling based on data from sources including vital registration, mortality surveillance, verbal autopsy, and minimally invasive tissue sampling. Years of life lost and years lived with disability were computed and combined to derive DALYs. For aetiology-specific estimation, population-attributable fractions (PAFs) for 15 pathogens were derived with a counterfactual framework. Point estimates and 95% uncertainty intervals (UIs) were generated from 250 draws from the posterior distribution. In 2023, enteric infectious diseases resulted in an estimated 1·27 million (95% UI 0·963-1·68) deaths globally, declining from 3·69 million (3·04-4·56) in 1990. The global age-standardised mortality rate (ASMR) decreased from 74·1 (62·0-92·9) per 100 000 population to 16·4 (12·6-21·3) per 100 000 population during the same period. Diarrhoeal diseases accounted for most deaths in 2023 (1·11 million [0·811-1·54]), followed by enteric fever and iNTS. South Asia and sub-Saharan Africa remained the most affected regions in 2023, with 599 000 (441 000-882 000) and 501 000 (373 000-648 000) deaths due to enteric infectious diseases, respectively, predominantly from diarrhoeal disease. Rotavirus was the leading cause of all-age diarrhoeal disease deaths (PAF 16·3% [12·0-21·5]), followed by norovirus (10·2% [2·4-17·0]) and Shigella spp (9·3% [5·4-15·2]). Among children younger than 5 years, PAFs of deaths due to diarrhoeal diseases were 40·2% (32·5-48·5) for rotavirus, 24·0% (15·1-36·7) for Shigella spp, and 23·4% (13·7-34·3) for adenovirus. Across 204 countries and territories, 141 met the GAPPD mortality target in 2023. The driving aetiologies among countries that did not meet the target in 2023 varied slightly by GBD super-region, but the highest or second-highest number of deaths in children younger than 5 years were consistently attributed to rotavirus. Astrovirus and sapovirus, newly included in GBD 2023, were responsible for 24 600 (6290-49 000) and 18 800 (4650-44 400) deaths, respectively, in 2023, mainly in children younger than 5 years. Our findings show that mortality and ASMRs of enteric infectious diseases declined substantially between 1990 and 2023. This decline is consistent with the expansion of public health measures and broader socioeconomic development. However, the burden in 2023 remains considerably high, with the highest mortality concentrated in sub-Saharan Africa and south Asia. Considering that more than a quarter of all countries had yet to meet the GAPPD mortality target in 2023, sustained efforts are needed to address the persistent burden in affected countries and to adapt to the changing global health landscape. Gates Foundation.
Surgeons in the United Kingdom and the United States often perform identical oral and maxillofacial operations with strikingly different instrument sets. The extent and practical significance of this divergence have not, to our knowledge, been previously reported. We conducted a descriptive comparative review of contemporary UK and US practice (2023-2024), cataloguing instruments through clinical observation and discussions with peers and scrub teams, then verifying nomenclature, design, and provenance against reference texts and manufacturers' catalogues. Functionally equivalent but non-identical instruments were paired and profiled for origin, form, and typical use. Findings show a small common core (Freer elevator, Minnesota retractor, Austin retractor, DeBakey forceps, Adson forceps, Metzenbaum scissors, and Mayo scissors) with nearly all other instruments differing, illustrating parallel solutions to the same operative tasks. British instruments and their American counterparts (for example, Molt #9, Woodson #1, Seldin elevator, Molt #4, Dean scissors, Army-Navy retractor, Sweetheart retractor, Sistrunk retractor, Hargis retractor, 301 elevator, and Cogswell elevators) were assembled into a practical compendium, with the aim of encouraging cross-pollination of surgical practice. Awareness of transatlantic instrument choices presents an opportunity to refine one's armamentarium. Through selective adoption of unfamiliar but potentially advantageous instruments, the open-minded surgeon can discover new ways to enhance operative precision, efficiency, or ergonomics.
Advancements in three-dimensional (3D) printing have introduced innovative tools for medical and dental education. In dental surgery, 3D-printed simulation models offer valuable presurgical training. This review explores the scope, study types, key findings, limitations, and future research needs to enhance their application in dental education. A comprehensive literature search was conducted across seven major health and education databases for studies published up to June 2025. A structured search strategy was developed using a combination of MeSH terms and keywords related to dental and oral surgical procedures, educational interventions, and 3D printing. Two reviewers independently screened and evaluated the retrieved articles. Studies were included if they investigated the use of 3D-printed models as hands-on simulation tools for intraoral surgery education. Only peer-reviewed articles published in English were considered. A total of 3686 studies were identified, 34 of which met the inclusion criteria after screening. These studies, largely published within the past decade, evaluated the use of 3D-printed models as training tools across five core areas of intraoral surgery, with the greatest focus on minor oral surgery (32%) and maxillofacial related procedures: orthognathic procedures (26%), followed by cleft palate surgery (15%), implant surgery (15%), and periodontal interventions (12%). Various printers and materials were employed, with an emphasis on model fabrication and evaluation through trainee feedback. The models were widely accepted by trainees, who reported improved technical skills, increased confidence, and reduced procedure time. However, challenges remain, particularly the need for advanced soft tissue-replicating material to enhance anatomical realism. 3D-printed models are effective tools for pre-operative planning and hands-on training in oral surgery. Future research should focus on developing cost-efficient printing technologies and advanced materials to better replicate hard and soft tissues in these models. Furthermore, well-designed studies are needed to support changes to implementation into current curricula and enhance the delivery of surgical education.
While many studies have explored the drivers of health-worker emigration, there is limited understanding of the factors that potentially encourage them to remain or return after migration. We explored three interrelated questions: what factors encouraged some members of the study population to remain in Nigeria?; what circumstances might encourage those intending to migrate to reconsider their plans?; and what conditions could encourage those who have already emigrated to consider returning? We conducted a sequential explanatory mixed-methods study among a cohort of Nigerian-trained doctors and dentists. In the quantitative phase, 274 cohort members completed a structured survey assessing drivers of migration. In the qualitative phase, 50 participants across three migration status groups (emigrated, intending to migrate, and not intending to migrate) were interviewed. Thematic analysis was conducted. Overall, 49.3% (135/274) of the cohort had already migrated within 15 years of qualifying, while 63.6% (82/139) of those still in Nigeria expressed an intention to migrate. Qualitative findings reinforced the quantitative results, highlighting shared potential enablers of staying (among those intending to migrate) or returning (among already migrated), including improved security, economic stability, better remuneration, stronger healthcare infrastructure, and enhanced training opportunities. Most of those who had already migrated expressed a willingness to return, though often as a long-term plan. Those with no intention to migrate cited a sense of duty and patriotism, family responsibilities, thriving businesses, and professional or age-related factors as reasons for staying back. This study offers actionable insights to inform policies on health-worker migration. Main findings: Despite the dearth of digital data capture and clinical decision support systems for newborn care outside of tertiary settings, we found healthcare professionals in lower-level facilities were highly motivated to use an adapted digital quality improvement system to support the delivery of newborn care.Added knowledge: In our intervention adaptation process, we found that lower-level facilities providing basic essential newborn care in Malawi are falling short of global standards, with respect to training, routine data collection and basic equipment.Global health impact for policy and action: International guidance for the provision of newborn care across all levels of the health system need to be adopted within national contexts, thereby ensuring implementers have contextually relevant benchmarks to achieve quality improvements across the care continuum.
At around 10 years ago, at the time of the first publication by the Gut Microbiota for Health Expert Panel of the British Society of Gastroenterology, recognition of the gut microbiome's importance in health and disease was transitioning from fringe interest towards major global pursuit. A decade on, we appraise the considerable progress made in the field, while acknowledging ongoing challenges. Earlier human work characterising the 16S rRNA gene amplicon signature of particular conditions in small cohorts has been superseded by larger, multicentre studies with extensive metadata. Studies increasingly employ shotgun metagenomics and other 'omic' techniques-coupled with refined bioinformatic tools and disease models-to better characterise perturbation in gut microbiome functionality. The arrival of 'gold standard' pipelines for microbiome analysis and increased mechanistic validation of signals are key developments towards more clinically-translatable outcomes. Novel clinical areas where the gut microbiome has relevance have emerged, including early life and the efficacy of certain treatments (including immune checkpoint inhibitors and vaccination). Enthusiasm for 'microbiome diagnostics and treatments' has grown, but barriers to widespread adoption remain. Faecal microbiota transplant (FMT) is established for treating recurrent Clostridioides difficile infection, with donor-derived 'next generation' FMT products licensed for this condition in certain countries. Beyond FMT, other microbial therapeutic techniques-including nutritional, bacteriophage and probiotic therapies-show promise, but have not fulfilled their high expectations yet. Gut microbiome research is now well-established and shows significant translational potential; the future focus will be translational work to drive its utility in clinical diagnostics, prognostics and therapeutics.
Osteoporosis is a major and growing health concern in the Asia-Pacific region, y et it remains widely underdiagnosed and undertreated due to limited access to dual-energy X-ray absorptiometry (DXA) in many areas. Artificial intelligence (AI) offers new opportunities to improve osteoporosis screening and management, but unvalidated tools pose risks of inconsistent care. This consensus was developed to provide regionally harmonized guidance on the safe, effective, and equitable use of AI in osteoporosis care. The aim of this work was to establish expert consensus recommendations on the role of AI in osteoporosis screening and management in the Asia-Pacific region. Key objectives were to define appropriate applications of AI (e.g., imaging-based bone assessment and fracture risk prediction) and specify minimum standards for validation and reporting, addressing region-specific implementation challenges and ensuring that AI use aligns with clinical guidelines and ethical principles. This consensus was developed through multidisciplinary collaboration among experts across the Asia-Pacific region. Each participant reviewed draft statements, contributed feedback during virtual meetings, and provided insights based on clinical experience and current evidence. Consensus was reached iteratively until full agreement was achieved for all statements. The process integrated global best practices and regional adaptations, drawing from peer-reviewed studies, international AI guidelines, and local fracture registry data. The final recommendations emphasize the validation, transparency, and ethical implementation of AI within regional healthcare systems, ensuring compatibility with local regulations. Ultimately, twelve consensus statements were established to guide the responsible use of AI for osteoporosis screening and management in the Asia-Pacific region. The panel produced 12 consensus statements covering the role of AI as an adjunct for opportunistic osteoporosis screening rather than a diagnostic tool, requirements for imaging quality and AI model transparency, standards for validation and performance reporting, integration of AI with clinical risk stratification, demonstration of clinical utility in real-world settings, adherence to data protection laws and ethical AI principles, training of clinicians in AI use, strategies for implementation and monitoring (including post-market surveillance and feedback loops), and recognition of technical, clinical, and equity limitations of AI. All 12 statements give extensive recommendations for using AI to improve osteoporosis management while ensuring patient safety, accuracy, and equity. This first Asia-Pacific consensus on AI in osteoporosis concludes that AI, when appropriately validated and implemented, can help bridge the osteoporosis care gap by identifying high-risk patients who would otherwise remain undiagnosed, thus facilitating earlier intervention. It emphasizes that AI should complement-not replace-standard diagnostic methods and clinical judgment. The guidance emphasizes validation, transparency, and ethical oversight to facilitate early intervention while minimizing risks associated with unvalidated or premature AI adoption.
Nodular prurigo (NP) is a chronic skin condition. Lesions can be either single or widespread on the body. Thus, it can have a negative impact on a person’s quality of life. The exact cause of NP is unknown, as several mechanisms play a role. These mechanisms sometimes overlap between physical and brain–behavioural elements. Dermatologists diagnose NP based on a history of long-lasting itching and scratching. A Guideline Development Group met to produce a new guideline for treating people with NP. The group included consultant dermatologists, a psychotherapist, dermatology trainees, a general practitioner and people with lived experience of NP. The group identified and reviewed the current literature on treating NP. They discussed the findings at length before producing a set of recommendations. The guideline will provide up-to-date management guidance for healthcare practitioners. Initial steps included taking a full history and examination of patients. This included causes of itch, patient education and reversing the itch–scratch habit. The first treatment option is usually topical therapy (applied to the skin). If this fails, other options include phototherapy and oral medications. Further treatments include nonsedating antihistamines and low-dose antidepressants. Steroid injections or cryotherapy (freezing with liquid nitrogen) are options for single lesions. The guideline provides recommendations for treating people with NP. It also includes recommendations for future research and audit points for hospitals. A patient information leaflet is available on the British Association of Dermatologists’ website (https://www.skinhealthinfo.org.uk/condition/nodular-prurigo).
This study aimed to investigate three-dimensional (3D) positional changes of the mandibular condyles following bimaxillary orthognathic surgery performed using the surgery-first approach (SFA) in skeletal Class III patients. The associations between condylar positional changes, other clinical variables, and postsurgical mandibular skeletal relapse were also assessed. Twenty-five adult skeletal Class III patients who underwent bimaxillary orthognathic surgery with the SFA were included retrospectively. Cone-beam computed tomography (CBCT) scans were acquired at three time points: preoperatively (T0), immediately postoperatively (T1), and at 1-year follow-up (T2). 3D translational and rotational condylar displacements, as well as dental and skeletal changes and postoperative stability, were quantified using analysis software. Repeated-measures analysis of variance (ANOVA), Pearson or Spearman correlation tests, and multiple linear regression were used for statistical analysis. A significant anterosuperior mandibular relapse was observed at the 1-year follow-up (T2). Immediately after surgery (T1), the condyles showed significant posterior and inferior translational displacement, accompanied by clockwise pitch and medial yaw rotation. While these positional changes tended to return toward their preoperative position by T2, no significant correlation was found between the magnitude or direction of condylar displacement and mandibular skeletal relapse. In contrast, the initial sagittal position and the surgical change in the upper incisors were significant predictors of relapse. Specifically, the initial anteroposterior position accounted for 20.3% of the variance in sagittal mandibular relapse, indicating that greater dental compensation of the upper incisors was associated with increased mandibular relapse. The modest proportion of explained variance suggests that other unmeasured factors also play important roles in postsurgical stability. Although postoperative condylar positional changes commonly occur following the SFA in skeletal Class III patients, these changes do not appear to be a primary contributor to mandibular skeletal relapse. Instead, postoperative mandibular stability seems more closely associated with surgical compensatory patterns, particularly upper incisor protrusion. While the SFA demonstrates acceptable skeletal stability, meticulous evaluation and appropriate control of dental decompensation during treatment planning are crucial to minimize postoperative relapse. The study was registered at the Chinese Clinical Trial Registry on October 24, 2025 (Identification number: ChiCTR2500111068).
Chronic respiratory diseases are an important global issue, particularly in Asia, where burden patterns vary widely across countries. With more than half the world's population living in Asia, understanding the national and regional burden of chronic respiratory diseases is essential; however, research on this area remains inadequate. We aimed to investigate the burden of chronic respiratory diseases in Asia at national and regional levels, and to identify key risk factors. The Global Burden of Diseases, Injuries, and Risk Factors Study 2023 provides estimates for assessing the burden of chronic respiratory diseases, including chronic obstructive pulmonary disease (COPD), asthma, pneumoconiosis, interstitial lung disease (ILD), and pulmonary sarcoidosis. We focused on 34 countries in Asia, encompassing the high-income Asia Pacific region and central, east, south, and southeast Asia. Estimates for age-standardised prevalence and disability-adjusted life-year (DALY) rates per 100 000 population, including 95% uncertainty intervals (UIs), were extracted by location, sex, year, and Socio-demographic Index (SDI). The average annual percentage change was calculated and presented as a percentage with 95% CIs. Estimates of modifiable attributable risk factors for DALYs and mortality were also included. In Asia, the age-standardised prevalence and DALY rates for chronic respiratory diseases generally declined from 1990 to 2023; however, the trend varied substantially by disease and country. In 2023, the age-standardised prevalence rate of COPD was highest in south Asia (3044·18 [95% UI 2748·67-3303·04] per 100 000 population), while the age-standardised asthma prevalence rate was highest in the high-income Asia Pacific region (4870·24 [4046·70-5962·78] per 100 000 population) and southeast Asia (4778·18 [3970·25-5735·61] per 100 000 population). Despite southeast Asia and the high-income Asia Pacific region having a similar age-standardised asthma prevalence rate, southeast Asia had a higher age-standardised DALY rate (508·67 [95% UI 394·89-669·92] per 100 000 population) compared with the high-income Asia Pacific region (204·40 [129·23-290·41] per 100 000 population). A decrease in the age-standardised DALY rate for chronic respiratory diseases was observed with increasing SDI, contrasting with its prevalence patterns. Age-standardised DALY rates of COPD decreased in all Asian countries except for Georgia (average annual percentage change 1·37 [95% CI 1·26-1·48]) and Kazakhstan (0·73 [0·55-0·93]), and age-standardised DALY rates of asthma decreased in all countries. Smoking and ambient particulate matter pollution were identified as leading attributable risk factors for chronic respiratory diseases across Asia. Household air pollution from solid fuels was a regionally pronounced risk factor for chronic respiratory diseases, particularly in south Asia (age-standardised DALY rate 657·58 [95% UI 485·04-880·45] per 100 000 population). Although smoking was a major risk factor in males, ambient particulate matter pollution and secondhand smoke emerged as important attributable risk factors for chronic respiratory diseases in females. Countries with lower SDI had markedly higher DALY rates, highlighting the need to address socioeconomic and health-care inequities. Household air pollution from solid fuels continues to impose a substantial but preventable burden in south Asia, calling for clean energy adoption and improved ventilation. Gates Foundation.
This multicentre randomized controlled clinical trial aims to investigate the regenerative effects of various thicknesses and types of barrier materials with and without bone grafting in a rabbit calvaria model. One hundred male rabbits were partitioned into two groups: one without bone graft (NB) and one with bone grafting (BG). The groups were further divided into five subgroups, n = 10 each: C (control); SC (0.3 mm single-layered collagen); DC (0.6 mm double-layered collagen); L1 (0.5 mm cortical collagenated bone barrier); and L2 (1.0 mm cortical collagenated bone barrier). In all experimental groups, each distinct type of barrier was applied following the creation of a 10 mm circular defect in the calvaria of each rabbit. After 24 weeks, the calvariae were examined by histologic and histomorphometric analyses. The utilization of cortical bone barriers increased bone formation in all experimental groups. For Group NB, the histological score significantly differed among subgroups (p < 0.001). L1 and L2 subgroups had more favorable histological scores than the control groups (p < 0.001). Furthermore, the L2 subgroup had a higher histological score than the SC subgroup (p < 0.001). In Group BG, histological score significantly differed among subgroups (p < 0.001). DC, L1, and L2 subgroups had higher histological scores than the controls (p < 0.02), (p < 0.001), and (p < 0.001), respectively. The L2 subgroup had a higher histological score than the SC subgroup (p < 0.01). The BG group had significantly higher histological scores overall compared to the NB group based on barriers (p < 0.05). Within the limits of this model, the 1.0 mm cortical lamina barrier demonstrated the most favorable regenerative performance, consistently achieving higher histologic scores and more advanced tissue maturation than thinner cortical lamina or collagen membranes. These findings indicate that barrier architecture, particularly thickness and mechanical stability, plays an important role in promoting predictable bone regeneration.
AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews, version 2) and ROBIS are tools used to assess the methodological quality and the risk of bias in a systematic review (SR). We applied AMSTAR-2 and ROBIS to a sample of 200 published SRs. We investigated the overlap in their methodological constructs, responses by item, and overall, percentage agreement, direction of effect, and timing of assessments. AMSTAR-2 contains 16 items and ROBIS 24 items. Three items in AMSTAR-2 and nine in ROBIS did not overlap in construct. Of the 200 SRs, 73% were low or critically low quality using AMSTAR-2, and 81% had a high risk of bias using ROBIS. The median time to complete AMSTAR-2 and ROBIS was 51 and 64 minutes, respectively. When assessment times were calibrated to the number of items in each tool, each item took an average of 3.2 minutes per item for AMSTAR-2 compared to 2.7 minutes for ROBIS. Nine percent of SRs had opposing ratings (i.e., AMSTAR-2 was high quality while ROBIS was high risk). In both tools, three-quarters of items showed more than 70% agreement between raters after extensive training and piloting. AMSTAR-2 and ROBIS provide complementary rather than interchangeable assessments of systematic reviews. AMSTAR-2 may be preferable when efficiency is prioritized and methodological rigour is the focus, whereas ROBIS offers a deeper examination of potential biases and external validity. Given the widespread reliance on systematic reviews for policy and practice, selecting the appropriate appraisal tool remains crucial. Future research should explore strategies to integrate the strengths of both instruments while minimizing the burden on assessors.
The global prevalence of obesity and diabetes continues to rise, with metabolic-bariatric surgery recognised as an effective intervention for obesity and type 2 diabetes, offering potential for type 2 diabetes remission and improved glycaemic control. This guideline, developed by the Joint British Diabetes Societies for Inpatient Care (JBDS-IP), provides recommendations for the management of diabetes in individuals undergoing metabolic-bariatric surgery. It emphasises the importance of multidisciplinary care and individualised treatment plans to optimise outcomes. Key recommendations include pre-operative glycaemic optimisation, targeting HbA1c <69 mmol/mol (<8.5%) where safe to do so, prevention of hypoglycaemia throughout all phases of care and providing a framework for medication adjustments during the liver reduction diet (LRD), peri-operative and post-operative phases. For type 2 diabetes, oral and non-insulin therapies such as metformin, DPP4 inhibitors and GLP-1 based therapies may be continued during LRD, while sulfonylureas, meglitinides and SGLT2 inhibitors should be discontinued to reduce the risk of hypoglycaemia. For those with type 2 diabetes on insulin, doses should be reduced by 35%-50% during LRD and adjusted post-operatively based on individual glycaemic control. To prevent diabetic ketoacidosis (DKA) in those with type 1 diabetes, insulin must never be stopped and careful planning with diabetes teams is essential. Post-operatively, regular glucose monitoring, hypoglycaemia surveillance, medication adjustments, and follow-up with diabetes specialists are recommended. This document serves as a guide for clinicians and service commissioners, aiming to improve inpatient diabetes care and outcomes for individuals undergoing metabolic-bariatric surgery.
Information on childhood cancer burden is crucial for effective cancer policy planning. Unfortunately, observed paediatric cancer data are not available in every country, and previous global burden estimates have not discretely reported several common cancers of childhood. We aimed to inform efforts to address childhood cancer burden globally by analysing results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, which now include nine additional cancer causes compared with previous GBD analyses. GBD 2023 data sources for cancer estimation included population-based cancer registries, vital registration systems, and verbal autopsies. For childhood cancers (defined as those occurring at ages 0-19 years), mortality was estimated using cancer-specific ensemble models and incidence was estimated using mortality estimates and modelled mortality-to-incidence ratios (MIRs). Years of life lost (YLLs) were estimated by multiplying age-specific cancer deaths by the standard life expectancy at the age of death. Prevalence was estimated using survival estimates modelled from MIRs and multiplied by sequelae-specific disability weights to estimate years lived with disability (YLDs). Disability-adjusted life-years (DALYs) were estimated as the sum of YLLs and YLDs. Estimates are presented globally and by geographical and resource groupings, and all estimates are presented with 95% uncertainty intervals (UIs). Globally, in 2023, there were an estimated 377 000 incident childhood cancer cases (95% UI 288 000-489 000), 144 000 deaths (131 000-162 000), and 11·7 million (10·7-13·2) DALYs due to childhood cancer. Deaths due to childhood cancer decreased by 27·0% (15·5-36·1) globally, from 197 000 (173 000-218 000) in 1990, but increased in the WHO African region by 55·6% (25·5-92·4), from 31 500 (24 900-38 500) to 49 000 (42 600-58 200) between 1990 and 2023. In 2023, age-standardised YLLs due to childhood cancer were inversely correlated with country-level Socio-demographic Index. Childhood cancer was the eighth-leading cause of childhood deaths and the ninth-leading cause of DALYs among all cancers in 2023. The percentage of DALYs due to uncategorised childhood cancers was reduced from 26·5% (26·5-26·5) in GBD 2017 to 10·5% (8·1-13·1) with the addition of the nine new cancer causes. Target cancers for the WHO Global Initiative for Childhood Cancer (GICC) comprised 47·3% (42·2-52·0) of global childhood cancer deaths in 2023. Global childhood cancer burden remains a substantial contributor to global childhood disease and cancer burden and is disproportionately weighted towards resource-limited settings. The estimation of additional cancer types relevant in childhood provides a step towards alignment with WHO GICC targets. Efforts to decrease global childhood cancer burden should focus on addressing the inequities in burden worldwide and support comprehensive improvements along the childhood cancer diagnosis and care continuum. St Jude Children's Research Hospital, Gates Foundation, and St Baldrick's Foundation.
To investigate the development of oral premalignant and malignant lesions as a major long-term complication following hematopoietic stem cell transplantation. This single-center retrospective study identified 17 patients who developed 26 pathology-confirmed oral premalignant and malignant lesions after hematopoietic stem cell transplantation, with a latency period ranged from 5 months to nearly 18 years. Twelve high-grade lesions developed in nine patients at a median of 9 years post-hematopoietic stem cell transplantation, most commonly on the tongue. All high-grade lesions were surgically treated, with complete response in most cases. One patient developed nodal disease 9.6 years after surgery, and another experienced local recurrence of moderate dysplasia 2 years post-treatment, which was controlled by cryogun cryotherapy. Most patients had chronic graft-versus-host disease and histories of immunosuppressant therapy. Cryogun cryotherapy was used to treat 10 premalignant lesions across seven patients, involving the tongue, gingiva, and buccal or labial mucosa. This treatment achieved an 80% complete response rate with minimal scarring. Verrucous hyperplasia was the most common diagnosis (n = 9). Routine, long-term oral screening is critical for patients after hematopoietic stem cell transplantation. Cryogun cryotherapy shows promise as an effective, minimally invasive option for managing early oral verrucous lesions.