The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

The time is now.

WHO – Definition, Diagnosis and Classification of Diabetes

Background 

Established in 2000, Millennium Development Goal 4 (MDG4) catalysed extraordinary political, financial, and social commitments to reduce under-5 mortality by two-thirds between 1990 and 2015. At the country level, the pace of progress in improving child survival has varied markedly, highlighting a crucial need to further examine potential drivers of accelerated or slowed decreases in child mortality. The Global Burden of Disease 2015 Study (GBD 2015) provides an analytical framework to comprehensively assess these trends for under-5 mortality, age-specific and cause-specific mortality among children under 5 years, and stillbirths by geography over time.

 Methods 

Drawing from analytical approaches developed and refined in previous iterations of the GBD study, we generated updated estimates of child mortality by age group (neonatal, post-neonatal, ages 1–4 years, and under 5) for 195 countries and territories and selected subnational geographies, from 1980–2015. We also estimated numbers and rates of stillbirths for these geographies and years. Gaussian process regression with data source adjustments for sampling and non-sampling bias was applied to synthesise input data for under-5 mortality for each geography. Age-specific mortality estimates were generated through a two-stage age–sex splitting process, and stillbirth estimates were produced with a mixed-effects model, which accounted for variable stillbirth definitions and data source-specific biases. For GBD 2015, we did a series of novel analyses to systematically quantify the drivers of trends in child mortality across geographies. First, we assessed observed and expected levels and annualised rates of decrease for under-5 mortality and stillbirths as they related to the Soci-demographic Index (SDI). Second, we examined the ratio of recorded and expected levels of child mortality, on the basis of SDI, across geographies, as well as differences in recorded and expected annualised rates of change for under-5 mortality. Third, we analysed levels and cause compositions of under-5 mortality, across time and geographies, as they related to rising SDI. Finally, we decomposed the changes in under-5 mortality to changes in SDI at the global level, as well as changes in leading causes of under-5 deaths for countries and territories. We documented each step of the GBD 2015 child mortality estimation process, as well as data sources, in accordance with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

 Findings 

Globally, 5·8 million (95% uncertainty interval [UI] 5·7–6·0) children younger than 5 years died in 2015, representing a 52·0% (95% UI 50·7–53·3) decrease in the number of under-5 deaths since 1990. Neonatal deaths and stillbirths fell at a slower pace since 1990, decreasing by 42·4% (41·3–43·6) to 2·6 million (2·6–2·7) neonatal deaths and 47·0% (35·1–57·0) to 2·1 million (1·8-2·5) stillbirths in 2015. Between 1990 and 2015, global under-5 mortality decreased at an annualised rate of decrease of 3·0% (2·6–3·3), falling short of the 4·4% annualised rate of decrease required to achieve MDG4. During this time, 58 countries met or exceeded the pace of progress required to meet MDG4. Between 2000, the year MDG4 was formally enacted, and 2015, 28 additional countries that did not achieve the 4·4% rate of decrease from 1990 met the MDG4 pace of decrease. However, absolute levels of under-5 mortality remained high in many countries, with 11 countries still recording rates exceeding 100 per 1000 livebirths in 2015. Marked decreases in under-5 deaths due to a number of communicable diseases, including lower respiratory infections, diarrhoeal diseases, measles, and malaria, accounted for much of the progress in lowering overall under-5 mortality in low-income countries. Compared with gains achieved for infectious diseases and nutritional deficiencies, the persisting toll of neonatal conditions and congenital anomalies on child survival became evident, especially in low-income and low-middle-income countries. We found sizeable heterogeneities in comparing observed and expected rates of under-5 mortality, as well as differences in observed and expected rates of change for under-5 mortality. At the global level, we recorded a divergence in observed and expected levels of under-5 mortality starting in 2000, with the observed trend falling much faster than what was expected based on SDI through 2015. Between 2000 and 2015, the world recorded 10·3 million fewer under-5 deaths than expected on the basis of improving SDI alone.

 Interpretation 

Gains in child survival have been large, widespread, and in many places in the world, faster than what was anticipated based on improving levels of development. Yet some countries, particularly in sub-Saharan Africa, still had high rates of under-5 mortality in 2015. Unless these countries are able to accelerate reductions in child deaths at an extraordinary pace, their achievement of proposed SDG targets is unlikely. Improving the evidence base on drivers that might hasten the pace of progress for child survival, ranging from cost-effective intervention packages to innovative financing mechanisms, is vital to charting the pathways for ultimately ending preventable child deaths by 2030.

 Funding 

Bill & Melinda Gates Foundation.

Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: A systematic analysis for the Global Burden of Disease Study 2015

Background Incidence of Acute Kidney Injury (AKI) among Type 2 diabetic patients is significantly increasing. But, earlier studies has focused on the admitted patients which may hide the true nature of the Acute Kidney Injury among Type 2 Diabetic (T2D) patients. So, this study was conducted to determine the time to Acute Kidney Injury and its predictors among Type 2 Diabetic patients in Harari Region, East Ethiopia. Methods We conducted a retrospective cohort study among type 2 diabetic patients who had been receiving treatment at government hospitals of Harari region, Ethiopia from 2013 to 2017. We extracted data from patients’ medical records. We estimated incidence rate and compared survival curves between different exposure groups using Kaplan-Meier and log-rank test. Weibull regression model was fitted to the data to identify the predictor variables. Variables with p-value <0.05 were considered statistically significant. Results Overall, 14.5% (95%CI: 11.7–17.9) of the study population developed acute kidney injury, with median survival time of 57 months. The significant predictors were physical activity [Adjusted Time Ratio (ATR):95%CI; 0.6 (0.49–0.75)], congestive heart failure [ATR:95%CI; 0.84 (0.71–0.99)], chronic kidney disease [ATR:95%CI; 0.77(0.65–0.91)], hypertension [ATR:95%CI; 0.78(0.65–0.91)], obesity [ATR:95%CI; 0.84(0.74–0.96)], diabetic nephropathy [ATR:95%CI; 0.80(0.65–0.98)], diuretics & beta blockers [ATR:95%CI; 0.85(0.74–0.97)], and delay of follow-up [ATR:95%CI; 0.97(0.96–0.98)]. Conclusions Incidence of acute kidney injury was high in our study area. Hence, identification and controlling of comorbidities along with regular monitoring of kidney function are needed to prevent or delay the risk of acute kidney injury in type 2 diabetic patients.

Time to acute kidney injury and its predictors among newly diagnosed Type 2 diabetic patients at government hospitals in Harari Region, East Ethiopia.

Background The perinatal mortality rate in Ethiopia is among the highest in Sub Saharan Africa. The aim of this study was to identify the spatial patterns and determinants of perinatal mortality in the country using a national representative 2016 Ethiopia Demographic and Health Survey (EDHS) data. Methods The analysis was completed utilizing data from 2016 Ethiopian Demographic and Health Survey. This data captured the information of 5 years preceding the survey period. A total of 7230 women who at delivered at seven or more months gestational age nested within 622 enumeration areas (EAs) were used. Statistical analysis was performed by using STATA version 14.1, by considering the hierarchical nature of the data. Multilevel logistic regression models were fitted to identify community and individual-level factors associated with perinatal mortality. ArcGIS version 10.1 was used for spatial analysis. Moran’s, I statistics fitted to identify global autocorrelation and local autocorrelation was identified using SatSCan version 9.6. Results The spatial distribution of perinatal mortality in Ethiopia revealed a clustering pattern. The global Moran’s I value was 0.047 with p-value <0.001. Perinatal mortality was positively associated with the maternal age, being from rural residence, history of terminating a pregnancy, and place of delivery, while negatively associated with partners’ educational level, higher wealth index, longer birth interval, female being head of household and the number of antenatal care (ANC) follow up. Conclusions In Ethiopia, the perinatal mortality is high and had spatial variations across the country. Strengthening partner’s education, family planning for longer birth interval, ANC, and delivery services are essential to reduce perinatal mortality and achieve sustainable development goals in Ethiopia. Disparities in perinatal mortality rates should be addressed alongside efforts to address inequities in maternal and neonatal healthcare services all over the country.

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Spatial pattern of perinatal mortality and its determinants in Ethiopia: Data from Ethiopian Demographic and Health Survey 2016.

Background: Cardiovascular disease (CVD) is the most prevalent complication and the leading cause of death among patients with diabetes mellitus (DM) Type 2 diabetes mellitus (T2DM) patients have a 2- to 4-fold increased risk of CVD There is a scarcity of data about the magnitude of CVD among patients with diabetes in Ethiopia This study aimed to assess the prevalence and associated factors of CVD among T2DM patients at selected hospitals of Harari regional state of Ethiopia Methods: This hospital-based retrospective data review was conducted among T2DM patients on follow-up in the diabetes clinics of selected hospitals of Harari regional state The records of T2DM patients who have been diagnosed between January 1, 2013, and December 31, 2017, were reviewed from March to April 2018 Data were collected by using structured checklists from all necessary documents of T2DM patients Statistical analysis was done using STATA 141 Bivariate and multivariate logistic regressions were used to identify factors associated with CVD Result: The records of 454 T2DM patients were extracted from three government hospitals in Harari regional state Their age was ranging from 15 to 86 years with a mean age (±SD) of 4539 (1476) The overall prevalence of CVD among T2DM patients was 4251%, composed of hypertensive heart diseases (3899%), heart failure (683%), and stroke (220%) The final multivariate logistic regression model revealed that age older than 60 years [adjusted odds ratio (AOR) = 322; 95% CI: 171-609], being physically inactive (AOR = 145; 95 CI: 106-238), drinking alcohol (AOR = 239; 95% CI: 117-606), hypertension (AOR = 241; 95% CI: 152-383), body mass index >249 kg/m2 (AOR = 181; 95% CI: 107-307), and experiencing microvascular diabetic complications (AOR = 362; 95% CI: 201-653) were significantly associated with the odds of having CVD Conclusion: The prevalence of CVD was high and associated with advanced age, physical inactivity, drinking alcohol, higher body mass index, hypertension, and having microvascular complications Health care workers should educate T2DM patients about healthy lifestyles like physical activity, weight reduction, blood pressure control, and alcohol secession, which can reduce the risk of CVD

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Prevalence of Cardiovascular Disease and Associated Factors Among Type 2 Diabetes Patients in Selected Hospitals of Harari Region, Eastern Ethiopia.

Adolescents at secondary schools are susceptible to engaging in risky sexual behavior (RSB) due to their teenage stage and the new environment they face. Limited researches in district towns have evaluated the RSB among adolescents with various findings. This study aimed to assess the RSB and associated factors among sexually experienced secondary school students. School-based cross-sectional study was conducted in Guduru district from March 4-8, 2019. A total of 1236 secondary school students were undergoing a survey. The data were collected using a pretested anonymously self-administered questionnaire and students who reported having ever had sex were evaluated for RSB. From all participants, 352 (29.8%) had ever started sexual intercourse from which 240 (68.2%) students were involved in RSB. During the multivariable logistic regression analysis, sex (AOR: 3.73; 95%CI: [1.71-8.14]), father educational level (AOR: 0.37; 95%CI: [0.16-0.84]), drinking alcohol (AOR: 2.76; 95%CI: [1.29-5.69]), perceived peer pressure (AOR: 4.22; 95%CI: [1.59, 11.24]), communication with parents (AOR: 9.58, 95%CI: [3.53, 25.94]), and perceived parental monitoring (AOR: 0.33; 95%CI: [0.14-79]) were significantly associated with RSB. This study outlined that the majority of sexually active adolescents are involved in RSB. Interventions at the health facility and school level should focus on the identified determinants of sexual behaviors among adolescents to minimize the risky consequences.

Risky sexual behavior and associated factors among sexually experienced secondary school students in Guduru, Ethiopia.

Introduction:Diabetic foot disease is a growing major public health problem and the leading cause of prolonged hospital admission, health-related costs, and reduced quality of life for diabetes pat...

https://journals.sagepub.com/doi/pdf/10.1177/2050312120987385

Prevalence and associated factors of diabetic foot ulcers among type 2 diabetic patients attending chronic follow-up clinics at governmental hospitals of Harari Region, Eastern Ethiopia: A 5-year (2013-2017) retrospective study.

Lemma Demissie Regassa

Papers

Time to acute kidney injury and its predictors among newly diagnosed Type 2 diabetic patients at government hospitals in Harari Region, East Ethiopia.

Spatial pattern of perinatal mortality and its determinants in Ethiopia: Data from Ethiopian Demographic and Health Survey 2016.

Prevalence of Cardiovascular Disease and Associated Factors Among Type 2 Diabetes Patients in Selected Hospitals of Harari Region, Eastern Ethiopia.

Risky sexual behavior and associated factors among sexually experienced secondary school students in Guduru, Ethiopia.

Prevalence and associated factors of diabetic foot ulcers among type 2 diabetic patients attending chronic follow-up clinics at governmental hospitals of Harari Region, Eastern Ethiopia: A 5-year (2013-2017) retrospective study.