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The approximately 40 percent of remaining coun- mortality by sex across regions contribute to the variable tries either have no recent data or no data at all that can be pattern of population sex ratios described earlier generic 250mg trecator sc with amex. The used to estimate causes of death or the level of adult mor- theory of demographic transition suggests that the rapid tality directly buy genuine trecator sc line. To help interpret vival by the global public health community have yielded the broad regional demographic patterns described earlier order trecator sc 250 mg on line, a either direct or indirect estimates of child mortality for all but review of trends in mortality and the causes underlying such a handful of countries (Hill and others 1999; Lopez and trends is useful. Based on a careful review of the time trend of Demographic and Epidemiological Characteristics of Major Regions, 1990–2001 | 21 Low- and middle-income countries East Asia and Pacific Europe and Central Asia 80 60 40 20 0 Latin America and the Caribbean Middle East and North Africa South Asia 80 60 40 20 0 Sub-Saharan Africa High-income countries World 80 60 40 20 0 5 0 5 5 0 5 5 0 5 Average annual percentage change Average annual percentage change Average annual percentage change Source: Calculated from United Nations 2003. These countries include China unavailable for only about 10 countries that together account and India, where application of such methods suggest that for about 2 percent of child deaths (Lopez and others 2002). Uncertainty directly from the registration data and from population about these predicted mean values of adult mortality is censuses. For those countries where registration data are considerable given the few observations with comparatively 22 | Global Burden of Disease and Risk Factors | Alan D. Lopez, Stephen Begg, and Ed Bos Low- and middle-income countries East Asia and Pacific Europe and Central Asia 80 60 40 20 0 Latin America and the Caribbean Middle East and North Africa South Asia 80 60 40 20 0 Sub-Saharan Africa High-income countries World 80 60 40 20 0 0. The estimated and Annex 2A provides detailed estimates of summary measures predicted levels of child and adult mortality, respectively, of mortality by country for the two years based on these were then applied to the modiﬁed life table system by methods. The annex also shows the percentage decline in selecting the best match from among 50,000 life tables to child mortality during the period. This method was applied patterns of mortality is difﬁcult to ascertain given the for all but about 70 countries. For adult mortality rates) in particular need to be viewed with a comparison of mortality estimates for 2001, see Lopez and caution, because the rates for many countries in these others (2002). Regional estimates of child mortality 5q0 (the Demographic and Epidemiological Characteristics of Major Regions, 1990–2001 | 23 a. Males Life Expectancy at Birth (Years) Probability of Mortality: Children under Five (per 1,000) 80 200 Sub-Saharan Africa High-income countries 70 Latin America and 150 the Caribbean East Asia and Pacific South Asia Middle East and North Africa East Asia and 60 Europe and 100 Pacific South Asia Central Asia Middle East and North Africa Europe and 50 50 Central Asia Sub-Saharan Africa Latin America and the Caribbean High-income countries 40 0 40 50 60 70 80 0 50 100 150 200 Probability of Mortality: 15- to 59-Year-Olds (per 1,000) Probability of Mortality: 60- to 79-Year-Olds (per 1,000) 500 800 Sub-Saharan Africa Sub-Saharan Africa 750 Europe and 400 Central Asia South Asia 700 Latin America and Middle East and North Africa 300 the Caribbean South Asia Latin America and Europe and Central Asia the Caribbean East Asia and Pacific 650 East Asia and Pacific 200 Middle East and North Africa 600 High-income countries High-income countries 100 550 100 200 300 400 500 550 600 650 700 750 800 Authors’ estimates Authors’ estimates Figure 2. That is,we have estimated larger sex mortality differ- Paciﬁc (which is dominated by China). Recent evidence, however, has suggest- mortality is not of major consequence for older ages. Demographic and Epidemiological Characteristics of Major Regions, 1990–2001 | 25 Table 2. Economic development and better coverage of the popu- lation with essential child health services have ensured con- Trends in Mortality Levels tinued declines in levels of child mortality, as measured by The 1990s were characterized by signiﬁcant economic gains the risk of death from birth to age ﬁve, in all regions. The in most regions, with growth in gross national product per notable exception is Sub-Saharan Africa, where child mor- capita ranging from 18 percent in South Asia and Sub- tality among girls remained unchanged at around 165 per Saharan Africa to more than 100 percent in East Asia and the 1,000, with only a modest decline (5 percent) in the risk of Paciﬁc and the Middle East and North Africa (table 2. One would expect this to have led to a signiﬁcant child death declined from 90 per 1,000 in 1990 to 80 per improvement in life expectancy, and this indeed occurred in 1,000 in 2001, with the risk being remarkably similar for most regions with the notable exception of Europe and males and females (table 2. In the former region, life expectancy was largely populations is stark, with a newborn in Sub-Saharan Africa 26 | Global Burden of Disease and Risk Factors | Alan D. For most regions, the risk of gains elsewhere, with the result that the global risk of adult death between ages 15 and 60 fell by about 10 to 17 percent death has remained essentially unchanged for males, and over the decade. This was not the case in Europe and Central may even have risen slightly for females. Asia, where policy shifts, particularly in relation to alcohol, Taken together, the probability of death up to the age of together with broader social change, have largely been ﬁve and between the ages of 15 and 60 are a better reﬂection responsible for the 15 percent rise in adult male mortality of the risk of premature death than either alone, although and the 6 percent increase in the risk of death for women. One might Note that these estimates mask the large cyclical ﬂuctuations argue that health policy should be equally concerned with in adult mortality in Russia, in particular, that characterized keeping adults alive into old age as it is with keeping children the region’s mortality trends in the 1990s. Signiﬁcant improve- proportionately greater consequence for women, with the ments in this summary measure of premature death can be rise in their risk of death (67 percent) being twice that of observed in all regions except Europe and Central Asia and males, among whom other causes of death such as violence Sub-Saharan Africa. If these estimates are correct, then improved slightly for males and not at all for females. Demographic and Epidemiological Characteristics of Major Regions, 1990–2001 | 27 Other features of global mortality summarized in comparative magnitude of causes of death for children than table 2. The fact that the demographic “envelope” of child dence of a continued decline in mortality among older age deaths is reasonably well understood in all regions limits groups in high-income countries that began in the early excessive claims about deaths due to individual causes, a 1970s. The risk of a 60-year-old dying before age 80 declined constraint that is not a feature of adult mortality given the by about 15 percent for both men and women in high- relative ignorance of age-speciﬁc death rates in many income countries so that at 2001 rates, less than 30 percent countries. In addition, the need for data on cause-speciﬁc of women who reach age 60 will be dead by age 80, as will outcomes to assess and monitor the impact of various child less than 50 percent of men. Second, crude death rates in survival programs in recent decades has led to a reasonably East Asia and the Paciﬁc, Latin America and the Caribbean, substantial epidemiological literature that might permit and the Middle East and North Africa are lower than in cause-speciﬁc estimation, but under an unacceptably large high-income countries, reﬂecting the impact of the older number of assumptions (Black, Morris, and Bryce 2003). Third, the proportion of assessment of data sets for biases, study methods, and gen- deaths that occur below age ﬁve, while declining in all eralizability of results. Investigators have undertaken a num- regions, varies enormously across them, from just over 1 per- ber of efforts to estimate the causes of child mortality over cent in high-income countries to just over 40 percent in the past decade or so (Bryce and others 2005; Lopez 1993; Sub-Saharan Africa. In some low- and middle-income Morris, Black, and Tomaskovic 2004; Williams and others regions, particularly East Asia and the Paciﬁc, Europe and 2002), but undoubtedly the most comprehensive was the Central Asia, and Latin America and the Caribbean, the pro- study by Murray and Lopez (1996) and its 2001 revision portion is well below 20 percent. Verbal autopsies, that is, struc- estimates between 1990 and 2001 arise in part because the tured interviews with relatives of the deceased about countries included in the regions differed and, more impor- symptoms experienced prior to death, will not yield the tant, because of better information for more recent periods. Causes that appear to have declined substan- during the 1990s, with 80 percent of the deaths occurring in tially include acute respiratory infections (2. Thus, While these changes may be in accord with what is despite the substantial and continued declines in mortality known about regional health development and economic from major vascular diseases in high-income countries, growth, they need to be conﬁrmed. Some of the suggested worldwide the risk of death in adulthood did not change in changes warrant further investigation, for example, death the 1990s, although some gains in reducing mortality in the rates from perinatal causes appear to have risen in both elderly were achieved, particularly in rich countries. East Asia and the Paciﬁc and South Asia and remained The trend in child mortality during the 1990s was only unchanged in Latin America and the Caribbean, which may marginally more satisfactory. While most regions achieved or may not be in line with what is known about develop- signiﬁcant gains in child survival, progress was modest in ments in prenatal care and safe motherhood initiatives. Sub-Saharan Africa, and as a result, the global decline in Similarly, measles appears to have disappeared as a cause of child mortality slowed to an annual average of about 1 per- child death in Latin America and the Caribbean. Similarly, the large international survey programs and the efforts of agencies suggested declines in the risk of child deaths because of such as the United Nations Children’s Fund mean that injury in South Asia and Sub-Saharan Africa appear unlike- trends in overall child mortality, and the numbers of child ly and may largely reﬂect better data and methods for meas- deaths they imply, can be established with reasonable uring injury deaths. The trends in the leading causes of child mortality are, however, much more difﬁcult to establish (Rudan and others 2005). Knowledge about the size and composition of popula- is diagnosed via verbal autopsies, which, where studied, have tions and how they are changing is critical for health been shown to be a poor diagnostic tool for malaria (Snow planning and priority setting. The truth may well lie somewhere in and how much is due to different interpretations of available between and requires urgent resolution if measles control data in 1990 and 2001 remains unknown. One of these is no doubt malnutrition, extent of the impact on child mortality continues to be because it is a major risk factor for both conditions (Black, debated. Increased use of oral rehy- of recent reversals in the decline in child mortality in Sub- dration therapy and improved access to safe water and san- Saharan Africa (Walker, Schwartzlander, and Bryce 2002) itation in the 1990s would suggest some decline in mortal- and that its effect on child survival in the 1990s may not ity from diarrheal disease, but whether they were sufﬁcient have been as great as initially thought (Adetunji 2000). The large absolute decline in childhood diarrheal and sepsis, are undoubtedly a major cause of death among deaths from 2. Effective vaccination coverage is a primary determi- study (Murray and Lopez 1996) and repeated for the 2001 nant of mortality from measles, and further increases in vac- estimates (chapter 3 in this volume). This has undoubtedly cination coverage in the 1990s should have led to lower removed a major source of uncertainty about mortality mortality.
The cardiologist might say that you have a 5% risk of not surviving a pregnancy; the obstetrician is more likely to say you have a 95% chance of surviving cheap trecator sc 250mg. You will need to balance carefully what both the cardiologist and obstetrician say and be aware of their different points of view discount trecator sc 250 mg overnight delivery. However order 250mg trecator sc, in some cases of very severe heart disease (such as Eisenmenger’s syndrome or primary pulmonary hypertension), the risk of death is as high as 25–40% (one in four to almost one in two). It is often difficult to give a precise estimate of risk for the more unusual forms of heart defect. Some women with a very high risk will survive, and some with a very low risk will die. You need to discuss with your partner and your family what risk you are prepared to take. The heart pumps blood around the body, and the blood carries oxygen and nourishment. If the pump does not work as well as normal, the developing baby may not get all the oxygen and food it needs. It may therefore not grow as well as normal (fetal growth restriction) or it may be born premature (or ‘preterm’ as we now say). With good neonatal care, many small babies can do well after they are born, but some may have a permanent handicap. In addition, the tendency to have a heart defect is hereditary; if you have one your baby will probably have a 3–5% risk (one in 20) of having one too (the risk varies somewhat, depending on the precise condition). Nowadays, up to 80% of heart abnormalities can be detected using ultrasound scanning. If an abnormality is detected, you will be offered the possibility of terminating the pregnancy. These days, much medical care, including antenatal care, is done as an ‘outpatient’. However, if your heart has difficulty pumping well enough to meet both your needs and the needs of the developing baby, extra rest will be necessary. Sometimes, adequate rest can be obtained only by admitting the mother to hospital, where she needs to do nothing except grow the baby. In addition, close observation of your heart and of the developing baby may be necessary on a day-to-day basis. All this means that you need to plan for the possibility of spending quite a lot of time in hospital, and in a few cases this can be most of the pregnancy. A supportive family structure is very helpful in safeguarding the child’s interests. The demand on the heart increases from very early pregnancy, as the hormones adjust the mother’s body to help the developing baby (fetus). You should see your obstetrician very early (at about eight weeks from the beginning of the last period, which is about six weeks from conception of the baby). Your pregnancy should be jointly supervised by a cardiologist and an obstetrician, ideally at the same clinic. It is very important to see the obstetrician frequently, so that they can get used to you and how you are, and you can get to know them. This way, they will be much more able to pick up early signs of any problem developing. Depending on her cardiac status, the woman should be seen by an appropriately experienced consultant obstetrician every two to four weeks until 20 weeks, then every two weeks until 24 weeks, and then weekly thereafter. At each visit, you will be asked about shortness of breath (especially at night) and your exercise tolerance (can you still climb stairs or walk at your normal pace), palpitations (irregular heart beat) and your own feelings of how things are going (for example, are you feeling the baby move). They will measure your pulse rate and rhythm, your blood pressure, whether you have any fluid collection at the ankles (oedema) and the size of the uterus to judge how well the baby is growing. They will also listen to your lungs (again to check for any collection of fluid, or pulmonary oedema) and your heart (to detect any changes in murmurs which might indicate a deterioration in the functioning of a valve, or infection of the heart). You will also see a midwife who will advise you about the normal aspects of pregnancy and birth. It is important to minimise the strain on the heart by vigorous treatment of any infections (for example chest, urinary). If the heart beat has any tendency to be irregular, drugs such as atenolol or digoxin may be given to control the rate. If there is any anxiety about your condition, or that of your baby, you are likely to be admitted to hospital for rest and tests. The main aim is to limit the demands on the heart, and for this reason good pain relief (usually with an epidural, an injection of local anaesthetic around the spinal cord) is very important. Also, bearing down (‘pushing the baby out’) at the end of labour can be very exhausting, so it is often recommended that this part is assisted by the doctors (using either a suction cup or forceps on the baby’s head). Antibiotics are occasionally given to prevent infection of the heart (although they are not necessary if the birth is entirely normal, whereas they are routine anyway if delivery is by caesarean section). This may be as early as four weeks after delivery if you are not fully breastfeeding. Don’t forget that if you decide to get pregnant, taking extra folic acid (easily obtainable from most pharmacies) for three months before and after conceiving will reduce substantially the risk of the baby having spina bifida (this applies to all women, not just those with heart disease). You should also make sure you have a good diet, and aim for a good body weight (not too fat or too thin). It is also advisable to get a blood test from your doctor to make sure that you are immune to rubella (German measles), because if you are not, it is a good idea to be vaccinated before you become pregnant (rubella is very dangerous to the baby if you become pregnant). And of course, if you are a smoker, you should do your very best to stop before you become pregnant. It is important that everyone caring for the woman during pregnancy is aware of her prepregnancy symptoms, firstly so that they do not overreact to similar symptoms during pregnancy, and secondly so that they can detect as soon as possible any deterioration in symptomatic status. Many pregnant women will experience deterioration of one class as pregnancy progresses, and they should be warned about this. They may need to take more rest than usual during pregnancy, although it is also important for them to maintain their fitness as much as possible. Clinicians should be familiar with the appropriate questions to elicit symptoms accurately. For example, in response to the question ‘do you get short of breath climbing stairs? The correct question is ‘how many flights of stairs can you climb at a steady pace without having to stop because of shortness of breath? Most pregnant women complain of tiredness, and women with cardiac disease are no exception. This is why continuity of carer is so important, because sometimes deterioration in the woman’s condition is more apparent in her demeanour and the way she answers questions than in the precise answers she gives. A useful tactic is to call a woman to your consulting room yourself and watch how quickly she can walk from the waiting area to your consulting room, how short of breath this makes her, and what her pulse rate and rhythm is when she first sits down (a ‘mini exercise test’).
In the event of an infestation order trecator sc with a visa, care should be taken to keep the larvae from falling to the ground buy trecator sc with amex, where they can then trans- form into pupae buy generic trecator sc 250 mg on line. However, since the flies cover a large range of territory, a control program needs to cover an extensive area in order to be effective. The success of a program also entails the collaboration of cattlemen and control of animal movement. Use of the sterile insect technique to control and eradicate the fly has been tested in large-scale breeding stud- ies, but this approach has a disadvantage in the case of Dermatobia because, unlike C. They finally appear as third- stage larvae under the skin, where they form subcutaneous furunculoid nodules. Approximately one month after the initial infestation, these nodules rupture, and the larvae fall to the ground and begin to pupate. In cats, the larvae may be found in subcutaneous pruriginous lesions, frequently in the nape of the neck or the sub- mandibular region. In addition, there have been serious or fatal cases in which the par- asite was found in the eyeball or surrounding tissue, trachea, or central nervous sys- tem of cats (Glass et al. Most of these cases involved second- or third-stage larvae that had formed furuncular lesions in the neck, chest, or back, and they occurred at the end of summer or in early autumn. It is unusual to recover first-stage larvae; when this happens, the parasite is found in the vitreous humor or the upper respiratory tract, and the lesions appear at the end of spring or in early summer. The times of the year when the first-, second-, and third-stage larvae of Cuterebra appear would suggest that the parasite migrates through the lungs and the head before maturing in subcutaneous tissue. This myiasis is caused by the larvae of two fly species, Hypoderma lineatum and H. Parasitized cattle have occasionally been introduced in Australia, South Africa, and several South American countries, but the species did not become permanently established. In cattle, they lay their eggs on hairs on the lower part of the body, preferentially the feet. The larvae are born after two to six days and invade the subcuta- neous connective tissue, from which they migrate to the rest of the body. In both cases, the larvae remain for a while in their respective sites, and then in winter (January and February), they finally migrate to the subcutaneous tissue of the dor- solumbar region, where they arrive as second-stage larvae and mature into third- stage larvae within 10 to 11 weeks. During this time, they form cysts about 3 cm in diameter, with a pore through which to breathe. The larvae spend about 10 months of their 11- to 12-month development cycle inside the animal’s body. In their final stage, the larvae emerge through the hole in the cyst, fall to the ground, and pupate. An abundance of adult flies causes restlessness in cattle and can provoke stampedes and interfere with their feeding. These losses are due to delayed growth, lowered milk and meat production, and damage to the hides. Development of the par- asite in humans is usually arrested in the first larval stage and rarely reaches the third, or mature, stage. A serologic study of more than 100 cases in France led to the conclu- sion that the species that most frequently affects man is H. The myiasis it causes is subcutaneous and only occasionally conjunctival or palpebral-conjunctival. The cutaneous forms can be mani- fested as a serpiginous myiasis, similar to cutaneous larva migrans, or as a subcuta- neous myiasis with moving furuncles that appear and disappear. Authors have described several cases of eosinophilic syndrome with fever and muscle pain, as well as respira- tory, muscular, cardiac, dermal, or neurologic symptoms, in patients who turned out to have myiasis caused by H. In several of these cases, the diagnosis was made when furuncular lesions appeared, usually in the scalp, and the symptoms disappeared spontaneously after they were excised (Navajar et al. It is possible that the human parasitosis is more common than has been believed in the past, but that it goes unnoticed. The use of insecticides or repellents in animals at risk can be successful if they are applied at the appropriate time of year, since the season for adult infestation is relatively brief. Most of the development of Hypoderma takes place inside the animal (10 months to a year), and hence the larval phase is a good point at which to attack the fly. Control consists of treating cattle with larvicides at the beginning of autumn to prevent the lar- vae from completing their development cycle and becoming established under the skin. Treatment at this point interrupts the life cycle of the fly and at the same time avoids damage to the hide. To prevent neurological damage to the animals, the larvicide should not be applied in late autumn, when H. In animals being raised for food, the application of insecticides should take into account the time lapse required between administration of the insecticide and use of the meat or milk. Also, delayed treatment can be given in the spring when the subcutaneous larvae are first noticed; in this case, topical insecticides are used, reaching the larvae through the furuncular orifices. Promising results have also been obtained in Ireland, where the infestation rate has been reduced to very low levels. Myiasis Caused by Larvae of Oestrus ovis and Rhinoestrus purpureus The adult fly of Oestrus ovis is gray and measures 10–12 mm in length. It is larviparous and deposits its larvae in the nostrils of sheep, goats, and, occasionally, man. The larval forms are obligate parasites of equines—in whose nostrils and lar- ynx they develop—found in Africa, Asia, and Europe. The first-stage larvae enter the nasal fossae, where they feed on mucus and desquamated cells, and they then move on to the frontal or maxillary sinuses, where they mature. After 2 to 10 months, the mature larvae return to the nasal fossae, where they are expelled by sneezing, fall to the ground, and pupate for four to five weeks. The adult flies are annoying to the animals, and when they are very abundant, they cause the animals to become restless. The pathology of this condition has been attributed to the mechanical effect of the size of the larvae and the irritation caused by their spines on the mucosae of the nose, pharynx, and sinuses. Some findings indicate that hypersensitivity, probably IgE-mediated, plays an important role. The examination of human cases, however, has not demonstrated the presence of hypersensitivity in man (Dorchies, 1997). The parasitosis occurs most often in sheep herders and is also seen in urban dwellers who keep sheep in residential areas (Dar et al. The form for which people most often seek treatment is invasion of the conjunctiva, evidenced by lacrimation and the sensation of a foreign body in the eye. Of 112 sheep herders interviewed in Italy, 80% stated that they had had the infestation at some time, and 54% reported that more than one site had been infected at the same time. The sites where larvae were found most fre- quently were the larynx (77 times), the conjunctiva (56 times), and the nasal fossae (32 times).