Publications by authors named "Foad Abd-Allah"

52 Publications

Primary stroke prevention worldwide: translating evidence into action.

Lancet Public Health 2022 Jan 29;7(1):e74-e85. Epub 2021 Oct 29.

Institute for Health Metrics Evaluation, University of Washington, Seattle, WA, USA; National Institute for Stroke and Applied Neurosciences, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand; Scientific and Educational Department, Research Centre of Neurology, Moscow, Russia. Electronic address:

Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.
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http://dx.doi.org/10.1016/S2468-2667(21)00230-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8727355PMC
January 2022

Stroke in Africa: profile, progress, prospects and priorities.

Nat Rev Neurol 2021 10 15;17(10):634-656. Epub 2021 Sep 15.

Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria.

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.
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http://dx.doi.org/10.1038/s41582-021-00542-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8441961PMC
October 2021

The state of stroke services across the globe: Report of World Stroke Organization-World Health Organization surveys.

Int J Stroke 2021 10 27;16(8):889-901. Epub 2021 May 27.

National Institute for Stroke and Applied Neurosciences (NISAN), School of Clinical Sciences, Auckland University of Technology, New Zealand.

Background: Improving stroke services is critical for reducing the global stroke burden. The World Stroke Organization-World Health Organization- Commission on Stroke conducted a survey of the status of stroke services in low and middle-income countries (LMICs) compared to high-income countries.

Methods: Using a validated World Stroke Organization comprehensive questionnaire, we collected and compared data on stroke services along four pillars of the stroke quadrangle (surveillance, prevention, acute stroke, and rehabilitation) in 84 countries across World Health Organization regions and economic strata. The World Health Organization also conducted a survey of non-communicable diseases in 194 countries in 2019.

Results: Fewer surveillance activities (including presence of registries, presence of recent risk factors surveys, and participation in research) were reported in low-income countries than high-income countries. The overall global score for prevention was 40.2%. Stroke units were present in 91% of high-income countries in contrast to 18% of low-income countries (p < 0.001). Acute stroke treatments were offered in ∼ 60% of high-income countries compared to 26% of low-income countries (p = 0.009). Compared to high-income countries, LMICs provided less rehabilitation services including in-patient rehabilitation, home assessment, community rehabilitation, education, early hospital discharge program, and presence of rehabilitation protocol.

Conclusions: There is an urgent need to improve access to stroke units and services globally especially in LMICs. Countries with less stroke services can adapt strategies from those with better services. This could include establishment of a framework for regular monitoring of stroke burden and services, implementation of integrated prevention activities and essential acute stroke care services, and provision of interdisciplinary care for stroke rehabilitation.
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http://dx.doi.org/10.1177/17474930211019568DOI Listing
October 2021

Cerebral Venous Thrombosis Associated with COVID-19 Infection: An Observational, Multicenter Study.

Cerebrovasc Dis Extra 2021 11;11(2):55-60. Epub 2021 May 11.

Rashid Hospital, Dubai, United Arab Emirates.

Background And Purpose: Coronavirus disease 2019 (CO-VID-19) has an increased propensity for systemic hypercoagulability and thromboembolism. An association with cerebrovascular diseases, especially cerebral venous thrombosis (CVT), has been reported among these patients. The objective of the present study was to identify risk factors for CVT as well as its presentation and outcome in COVID-19 patients.

Methods: This is a multicenter and multinational observational study. Ten centers in 4 countries (Pakistan, Egypt, Singapore, and the United Arab Emirates) participated in this study. The study included patients (aged >18 years) with symptomatic CVT and recent COVID-19 infection.

Results: Twenty patients (70% men) were included. Their mean age was 42.4 years, with a male-to-female ratio of 2.3:1. Headache (85%) and seizures (65%) were the common presenting symptoms, with a mean admission Glasgow Coma Scale (GCS) score of 13. CVT was the presenting feature in 13 cases (65%), while 7 patients (35%) developed CVT while being treated for COVID-19 infection. Respiratory symptoms were absent in 45% of the patients. The most common imaging finding was infarction (65%), followed by hemorrhage (20%). The superior sagittal sinus (65%) was the most common site of thrombosis. Acute inflammatory markers were raised, including elevated serum D-dimer (87.5%), erythrocyte sedimentation rate (69%), and C-reactive protein (47%) levels. Homocysteine was elevated in half of the tested cases. The mortality rate was 20% (4 patients). A good functional outcome was seen in the surviving patients, with a mean modified Rankin Scale score at discharge of 1.3. Nine patients (45%) had a modified Rankin Scale score of 0-1 at discharge.

Conclusion: COVID-19-related CVT is more common among males at older ages when compared to previously reported non-COVID-19-related CVT cases. CVT should be suspected in COVID-19 patients presenting with headache or seizures. Mortality is high, but functional neurological outcome is good among survivors.
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http://dx.doi.org/10.1159/000516641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8215987PMC
September 2021

A WHO resolution on epilepsy and other neurological disorders.

Lancet Neurol 2021 03;20(3):171-172

Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia; Russian National Research Medical University, Moscow, Russia.

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http://dx.doi.org/10.1016/S1474-4422(21)00026-0DOI Listing
March 2021

Assessment of Intracranial Collateral Circulation Using Novel TCCS Grading System in Patients With Symptomatic Carotid Occlusion.

Front Neurol 2020 24;11:666. Epub 2020 Jul 24.

Neurology Department, Assiut University Hospitals, Assiut University, Assiut, Egypt.

To establish a novel transcranial color-coded sonography (TCCS) grading system for collateral circulation in cases of symptomatic chronic total carotid occlusion (TCO), and to correlate this new grading system with cerebrovascular reserve capacity (CVR) measured by SPECT. Thirty-four patients with symptomatic chronic TCO recruited from the neurovascular ultrasound laboratory of the department of Neurology at Cairo University Hospital during 3 years' time period and diagnosed by color-coded duplex were subjected to: clinical assessment, grading of cerebral collaterals using a proposed TCCS criteria, Brain SPECT studies at rest and with dipyridamole stress. The new grading system for cerebral collateral circulation showed a significant positive correlation with CVR ( < 0.001 and Spearman correlation coefficient 0.686). The current study showed that this new TCCS grading system for cerebral collaterals is a reliable indicator for cerebral perfusion and reserve capacity in cases of chronic symptomatic TCO.
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http://dx.doi.org/10.3389/fneur.2020.00666DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7393180PMC
July 2020

Management of acute ischemic stroke in patients with COVID-19 infection: Insights from an international panel.

Am J Emerg Med 2020 07 11;38(7):1548.e5-1548.e7. Epub 2020 May 11.

Tiantan Comprehensive Stroke Center, Beijing Tiantan Hospital, Capital Medical University Beijing, China.

Objective: To present guidance for clinicians caring for adult patients with acuteischemic stroke with confirmed or suspected COVID-19 infection.

Methods: The summary was prepared after review of systematic literature reviews,reference to previously published stroke guidelines, personal files, and expert opinionby members from 18 countries.

Results: The document includes practice implications for evaluation of stroke patientswith caution for stroke team members to avoid COVID-19 exposure, during clinicalevaluation and conduction of imaging and laboratory procedures with specialconsiderations of intravenous thrombolysis and mechanical thrombectomy in strokepatients with suspected or confirmed COVID-19 infection.

Results: Conclusions-The summary is expected to guide clinicians caring for adult patientswith acute ischemic stroke who are suspected of, or confirmed, with COVID-19infection.
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http://dx.doi.org/10.1016/j.ajem.2020.05.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7211609PMC
July 2020

Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel.

Int J Stroke 2020 07 3;15(5):540-554. Epub 2020 May 3.

Tiantan Comprehensive Stroke Center, Beijing Tiantan Hospital, Capital Medical University Beijing, China.

Background And Purpose: On 11 March 2020, World Health Organization (WHO) declared the COVID-19 infection a pandemic. The risk of ischemic stroke may be higher in patients with COVID-19 infection similar to those with other respiratory tract infections. We present a comprehensive set of practice implications in a single document for clinicians caring for adult patients with acute ischemic stroke with confirmed or suspected COVID-19 infection.

Methods: The practice implications were prepared after review of data to reach the consensus among stroke experts from 18 countries. The writers used systematic literature reviews, reference to previously published stroke guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate practice implications. All members of the writing group had opportunities to comment in writing on the practice implications and approved the final version of this document.

Results: This document with consensus is divided into 18 sections. A total of 41 conclusions and practice implications have been developed. The document includes practice implications for evaluation of stroke patients with caution for stroke team members to avoid COVID-19 exposure, during clinical evaluation and performance of imaging and laboratory procedures with special considerations of intravenous thrombolysis and mechanical thrombectomy in stroke patients with suspected or confirmed COVID-19 infection.

Conclusions: These practice implications with consensus based on the currently available evidence aim to guide clinicians caring for adult patients with acute ischemic stroke who are suspected of, or confirmed, with COVID-19 infection. Under certain circumstances, however, only limited evidence is available to support these practice implications, suggesting an urgent need for establishing procedures for the management of stroke patients with suspected or confirmed COVID-19 infection.
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http://dx.doi.org/10.1177/1747493020923234DOI Listing
July 2020

Conceptual framework for establishing the African Stroke Organization.

Int J Stroke 2021 01 6;16(1):93-99. Epub 2020 Feb 6.

Department of Cardiology, Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique.

Africa is the world's most genetically diverse, second largest, and second most populous continent, with over one billion people distributed across 54 countries. With a 23% lifetime risk of stroke, Africa has some of the highest rates of stroke worldwide and many occur in the prime of life with huge economic losses and grave implications for the individual, family, and the society in terms of mental capital, productivity, and socioeconomic progress. Tackling the escalating burden of stroke in Africa requires prioritized, multipronged, and inter-sectoral strategies tailored to the unique African epidemiological, cultural, socioeconomic, and lifestyle landscape. The African Stroke Organization (ASO) is a new pan-African coalition that brings together stroke researchers, clinicians, and other health-care professionals with participation of national and regional stroke societies and stroke support organizations. With a vision to reduce the rapidly increasing burden of stroke in Africa, the ASO has a four-pronged focus on (1) research, (2) capacity building, (3) development of stroke services, and (4) collaboration with all stakeholders. This will be delivered through advocacy, awareness, and empowerment initiatives to bring about people-focused changes in policy, clinical practice, and public education. In the spirit of the " the ASO will harness the power of diversity, inclusiveness, togetherness, and team work to build a strong, enduring, and impactful platform for tackling stroke in Africa.
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http://dx.doi.org/10.1177/1747493019897871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006214PMC
January 2021

Intracranial Stenting: Is It Still an Option for Treatment of Patients With Intracranial Atherosclerosis?

Front Neurol 2019 22;10:1248. Epub 2019 Nov 22.

Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Milan, Italy.

Intracranial atherosclerotic disease (ICAD) is considered a major cause of recurrent cerebrovascular events. ICAD continues to be a disease without an effective method of reducing the risk of recurrent stroke and death, even with aggressive, highly monitored medical treatment. We reviewed data from three randomized controlled studies that published data comparing intracranial stenting vs. medical treatment for symptomatic severe-ICAD. Ethnic, demographic, clinical, and procedural differences were observed among the data from these trials that might influence their results. Future research should aim at establishing refined selection criteria that can identify high-risk ICAD patients who may benefit from intracranial stenting.
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http://dx.doi.org/10.3389/fneur.2019.01248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6884030PMC
November 2019

Mapping 123 million neonatal, infant and child deaths between 2000 and 2017.

Nature 2019 10 16;574(7778):353-358. Epub 2019 Oct 16.

School of Health Sciences, Madda Walabu University, Bale Goba, Ethiopia.

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.
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http://dx.doi.org/10.1038/s41586-019-1545-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800389PMC
October 2019

Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life-Years for 29 Cancer Groups, 1990 to 2017: A Systematic Analysis for the Global Burden of Disease Study.

JAMA Oncol 2019 12;5(12):1749-1768

Department of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.

Importance: Cancer and other noncommunicable diseases (NCDs) are now widely recognized as a threat to global development. The latest United Nations high-level meeting on NCDs reaffirmed this observation and also highlighted the slow progress in meeting the 2011 Political Declaration on the Prevention and Control of Noncommunicable Diseases and the third Sustainable Development Goal. Lack of situational analyses, priority setting, and budgeting have been identified as major obstacles in achieving these goals. All of these have in common that they require information on the local cancer epidemiology. The Global Burden of Disease (GBD) study is uniquely poised to provide these crucial data.

Objective: To describe cancer burden for 29 cancer groups in 195 countries from 1990 through 2017 to provide data needed for cancer control planning.

Evidence Review: We used the GBD study estimation methods to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life-years (DALYs). Results are presented at the national level as well as by Socio-demographic Index (SDI), a composite indicator of income, educational attainment, and total fertility rate. We also analyzed the influence of the epidemiological vs the demographic transition on cancer incidence.

Findings: In 2017, there were 24.5 million incident cancer cases worldwide (16.8 million without nonmelanoma skin cancer [NMSC]) and 9.6 million cancer deaths. The majority of cancer DALYs came from years of life lost (97%), and only 3% came from years lived with disability. The odds of developing cancer were the lowest in the low SDI quintile (1 in 7) and the highest in the high SDI quintile (1 in 2) for both sexes. In 2017, the most common incident cancers in men were NMSC (4.3 million incident cases); tracheal, bronchus, and lung (TBL) cancer (1.5 million incident cases); and prostate cancer (1.3 million incident cases). The most common causes of cancer deaths and DALYs for men were TBL cancer (1.3 million deaths and 28.4 million DALYs), liver cancer (572 000 deaths and 15.2 million DALYs), and stomach cancer (542 000 deaths and 12.2 million DALYs). For women in 2017, the most common incident cancers were NMSC (3.3 million incident cases), breast cancer (1.9 million incident cases), and colorectal cancer (819 000 incident cases). The leading causes of cancer deaths and DALYs for women were breast cancer (601 000 deaths and 17.4 million DALYs), TBL cancer (596 000 deaths and 12.6 million DALYs), and colorectal cancer (414 000 deaths and 8.3 million DALYs).

Conclusions And Relevance: The national epidemiological profiles of cancer burden in the GBD study show large heterogeneities, which are a reflection of different exposures to risk factors, economic settings, lifestyles, and access to care and screening. The GBD study can be used by policy makers and other stakeholders to develop and improve national and local cancer control in order to achieve the global targets and improve equity in cancer care.
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http://dx.doi.org/10.1001/jamaoncol.2019.2996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6777271PMC
December 2019

Stroke in the Middle-East and North Africa: A 2-year prospective observational study of stroke characteristics in the region-Results from the Safe Implementation of Treatments in Stroke (SITS)-Middle-East and North African (MENA).

Int J Stroke 2019 10 12;14(7):715-722. Epub 2019 Mar 12.

Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.

Background And Methods: Stroke incidence and mortality are reported to have increased in the Middle-East and North African (MENA) countries during the last decade. This was a prospective observational study to examine the baseline characteristics of stroke patients in the MENA region and to compare the MENA vs. the non-MENA stroke cohort in the Safe Implementation of Treatments in Stroke (SITS) International Registry.

Results: Of the 13,822 patients with ischemic and hemorrhagic stroke enrolled in the SITS-All Patients Protocol between June 2014 and May 2016, 5897 patients (43%) were recruited in MENA. The median onset-to-door time was 5 h (IQR: 2:20-13:00), National Institutes of Health Stroke Scale (NIHSS) score was 8 (4-13) and age was 65 years (56-76). Hypertension (66%) and diabetes (38%) were the prevailing risk factors; large artery stenosis > 50% (25.3%) and lacunar strokes (24.1%) were the most common ischemic stroke etiologies. In comparison, non-MENA countries displayed an onset-to-door time of 5:50 h (2:00-18:45), a median of NIHSS 6 (3-14), and a median age of 66 (56-76), with other large vessel disease and cardiac embolism as the main ischemic stroke etiologies. Hemorrhagic strokes (10%) were less common compared to non-MENA countries (13.9%). In MENA, only a low proportion of patients (21%) was admitted to stroke units.

Conclusions: MENA patients are slightly younger, have a higher prevalence of diabetes and slightly more severe ischemic strokes, commonly of atherosclerotic or microvascular etiology. Admission into stroke units and long-term follow-up need to be improved. It is suspected that cardiac embolism and atrial fibrillation are currently underdiagnosed in MENA countries.
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http://dx.doi.org/10.1177/1747493019830331DOI Listing
October 2019

Global, Regional, and Country-Specific Lifetime Risks of Stroke, 1990 and 2016.

N Engl J Med 2018 12;379(25):2429-2437

Background: The lifetime risk of stroke has been calculated in a limited number of selected populations. We sought to estimate the lifetime risk of stroke at the regional, country, and global level using data from a comprehensive study of the prevalence of major diseases.

Methods: We used the Global Burden of Disease (GBD) Study 2016 estimates of stroke incidence and the competing risks of death from any cause other than stroke to calculate the cumulative lifetime risks of first stroke, ischemic stroke, or hemorrhagic stroke among adults 25 years of age or older. Estimates of the lifetime risks in the years 1990 and 2016 were compared. Countries were categorized into quintiles of the sociodemographic index (SDI) used in the GBD Study, and the risks were compared across quintiles. Comparisons were made with the use of point estimates and uncertainty intervals representing the 2.5th and 97.5th percentiles around the estimate.

Results: The estimated global lifetime risk of stroke from the age of 25 years onward was 24.9% (95% uncertainty interval, 23.5 to 26.2); the risk among men was 24.7% (95% uncertainty interval, 23.3 to 26.0), and the risk among women was 25.1% (95% uncertainty interval, 23.7 to 26.5). The risk of ischemic stroke was 18.3%, and the risk of hemorrhagic stroke was 8.2%. In high-SDI, high-middle-SDI, and low-SDI countries, the estimated lifetime risk of stroke was 23.5%, 31.1% (highest risk), and 13.2% (lowest risk), respectively; the 95% uncertainty intervals did not overlap between these categories. The highest estimated lifetime risks of stroke according to GBD region were in East Asia (38.8%), Central Europe (31.7%), and Eastern Europe (31.6%), and the lowest risk was in eastern sub-Saharan Africa (11.8%). The mean global lifetime risk of stroke increased from 22.8% in 1990 to 24.9% in 2016, a relative increase of 8.9% (95% uncertainty interval, 6.2 to 11.5); the competing risk of death from any cause other than stroke was considered in this calculation.

Conclusions: In 2016, the global lifetime risk of stroke from the age of 25 years onward was approximately 25% among both men and women. There was geographic variation in the lifetime risk of stroke, with the highest risks in East Asia, Central Europe, and Eastern Europe. (Funded by the Bill and Melinda Gates Foundation.).
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http://dx.doi.org/10.1056/NEJMoa1804492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6247346PMC
December 2018

Predictors of poor cerebral collaterals and cerebrovascular reserve in patients with chronic total carotid occlusion.

Int J Neurosci 2019 May 27;129(5):455-460. Epub 2018 Nov 27.

a Department of Neurology , Cairo University, Cairo , Egypt.

Background: This study aims to investigate the relationship between cerebrovascular reserve (CVR) capacity, as measured by single-photon emission computed tomography (SPECT) and collateral blood flow, according to a transcranial colour-coded duplex(TCCD), in patients with symptomatic total carotid occlusion (TCO). Additionally, the study aims to determine whether vascular risk factors have an effect on collateral blood flow, as well as on the CVR.

Methods: Thirty-four patients with chronic TCO, diagnosed by carotid duplex scanning and confirmed by other vascular imaging modalities, who had ischaemic symptoms either as stroke or transient ischaemic attack, were subjected to clinical assessment, SPECT under dipyridamole stress, and grading of cerebral collateral blood flow using TCCD. Demographics and vascular risk factors were correlated with SPECT and TCCD findings.

Results: CVR showed a significant positive correlation with the intensity of collaterals with P value <0.001 and a Spearman correlation coefficient of 0.686. Hypertension was the only predictor of poor collaterals (p value =0.049; OR =11.5 with 95% CI 1.01-131.16).Smoking was predictive of poor CVR as measured by qualitative SPECT (p value =0.02; OR =13.2 with 95% CI 1.4-120.6).

Conclusion: Cerebral collaterals have an important role in the maintenance of CVR in patients with TCO. Preventive measures should be directed towards hypertension and smoking to preserve cerebral collateral patency and consequently improve CVR in patients with TCO.
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http://dx.doi.org/10.1080/00207454.2018.1538990DOI Listing
May 2019

Screening of Asymptomatic Intracranial Arterial Stenosis among High Risk Subjects: A Pilot Study from Egypt.

J Vasc Interv Neurol 2018 Jun;10(1):68-72

Department of Neurology, Faculty of Medicine, Al-Azhar University, Damietta, Egypt.

Background: Stroke ranks as the second leading cause of death and the leading cause of morbidity worldwide. Large intracranial arterial stenosis (ICAS) is a major cause of stroke.

Methods: This study investigated the prevalence and associated vascular risk factors of ICAS in a high-risk population in Qalyeubia Governorate, Egypt. A cross-sectional pilot survey using transcranial Doppler (TCD) was conducted at Toukh Central Hospital and Aghore El-qubra primary healthcare units in the Qalyeubia Governorate from 1 January 2016 until the end of June 2016.

Results: A total of 153 participants were included in this study. The prevalence of asymptomatic ICAS was 13.1%. Among the modifiable risk factors, cardiac diseases, hypertension, diabetes, obesity, dyslipidemia, physical inactivity, and smoking were the strongest independent predictors of ICAS.

Conclusion: This pilot study concluded that the prevalence of asymptomatic ICAS is relatively high in Egypt, and modifiable risk factors were the strongest predisposing factors of ICAS. TCD is an efficient non-invasive modality for the diagnostic evaluation of ICAS.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5999306PMC
June 2018

The Burden of Cardiovascular Diseases Among US States, 1990-2016.

JAMA Cardiol 2018 05;3(5):375-389

Auckland University of Technology, Auckland, New Zealand.

Importance: Cardiovascular disease (CVD) is the leading cause of death in the United States, but regional variation within the United States is large. Comparable and consistent state-level measures of total CVD burden and risk factors have not been produced previously.

Objective: To quantify and describe levels and trends of lost health due to CVD within the United States from 1990 to 2016 as well as risk factors driving these changes.

Design, Setting, And Participants: Using the Global Burden of Disease methodology, cardiovascular disease mortality, nonfatal health outcomes, and associated risk factors were analyzed by age group, sex, and year from 1990 to 2016 for all residents in the United States using standardized approaches for data processing and statistical modeling. Burden of disease was estimated for 10 groupings of CVD, and comparative risk analysis was performed. Data were analyzed from August 2016 to July 2017.

Exposures: Residing in the United States.

Main Outcomes And Measures: Cardiovascular disease disability-adjusted life-years (DALYs).

Results: Between 1990 and 2016, age-standardized CVD DALYs for all states decreased. Several states had large rises in their relative rank ordering for total CVD DALYs among states, including Arkansas, Oklahoma, Alabama, Kentucky, Missouri, Indiana, Kansas, Alaska, and Iowa. The rate of decline varied widely across states, and CVD burden increased for a small number of states in the most recent years. Cardiovascular disease DALYs remained twice as large among men compared with women. Ischemic heart disease was the leading cause of CVD DALYs in all states, but the second most common varied by state. Trends were driven by 12 groups of risk factors, with the largest attributable CVD burden due to dietary risk exposures followed by high systolic blood pressure, high body mass index, high total cholesterol level, high fasting plasma glucose level, tobacco smoking, and low levels of physical activity. Increases in risk-deleted CVD DALY rates between 2006 and 2016 in 16 states suggest additional unmeasured risks beyond these traditional factors.

Conclusions And Relevance: Large disparities in total burden of CVD persist between US states despite marked improvements in CVD burden. Differences in CVD burden are largely attributable to modifiable risk exposures.
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http://dx.doi.org/10.1001/jamacardio.2018.0385DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6145754PMC
May 2018

Stroke burden in Egypt: data from five epidemiological studies.

Int J Neurosci 2018 Aug 4;128(8):765-771. Epub 2018 Jan 4.

d Department of Neurology , Ain Shams University , Cairo , Egypt.

Purpose: Accurate data on the epidemiology of stroke in Egypt is scarce. The aim of this review is to address this issue based on available community-based studies and compare the resulting findings to those of other regional and international studies.

Method: A systematic literature search was conducted to identify population-based epidemiological studies of stroke in Egyptians. Original articles published in English between 1990 and 2016 were included. Five studies from five different governorates in southern Egypt fulfilled the study criteria (Qena, Sohag, Assiut, New Valley and Red Sea).

Results: The mean and median crude prevalence rates (CPRs) across the five studies, which were conducted in southern Egypt were 721.6/100,000 and 655/100,000, respectively. The mean and median crude incidence rates (CIRs) were 187/100,000 and 180.5/100,000, respectively. The average CPR weighted by sample population size was 613/100,000 and the average CIR weighted by sample population size was 202/100,000.

Conclusion: The incidence and prevalence of stroke in Egypt are high. More population-based studies are urgently needed in northern Egypt and in Cairo - the capital of Egypt.
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http://dx.doi.org/10.1080/00207454.2017.1420068DOI Listing
August 2018

Public stroke knowledge, awareness, and response to acute stroke: Multi-center study from 4 Egyptian governorates.

J Neurol Sci 2018 Jan 4;384:46-49. Epub 2017 Nov 4.

Neurology Department, Faculty of Medicine, Cairo University, Egypt.

Background And Purpose: Acute stroke treatment has significantly improved over the years in Egypt. However, there is often notable delay in pre-hospital and in-hospital management of acute stroke patients. The delay may be largely attributed to poor stroke knowledge and awareness of the general public and this study was aimed at the evaluation of the abovementioned factors.

Methods: Descriptive cross-sectional study involving 1154 participants from 4 governorates using a questionnaire in Arabic, collecting sociodemographic data, participants' risk factors, and knowledge and stroke awareness (risk factors, symptoms, prevention, treatment and prognosis, action in response to acute stroke). Data were collected during the World stroke day October 29, 2015.

Results: Study participants were found to have a low level of awareness of stroke with median percent score of 35.7% and interquartile range (IQR) of 17.86. Higher income, level of education, having risk factors and knowing someone with stroke were significant predictors of a higher level of stroke awareness.

Conclusion: In general, low public stroke awareness has been detected among Egyptians, and this is a call for healthcare authorities to invest in public education programmes among the Egyptian population.
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http://dx.doi.org/10.1016/j.jns.2017.11.003DOI Listing
January 2018

Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review.

Neuroepidemiology 2017 19;49(1-2):45-61. Epub 2017 Aug 19.

Stroke Unit, Department of Neurology, Christian Medical College, Ludhiana, India.

Background: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services.

Aims And Objectives: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care.

Methods: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included.

Results: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible.

Conclusion: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.
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http://dx.doi.org/10.1159/000479518DOI Listing
May 2018

Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015.

J Am Coll Cardiol 2017 Jul 17;70(1):1-25. Epub 2017 May 17.

The University of Western Australia, Perth, Western Australia, Australia.

Background: The burden of cardiovascular diseases (CVDs) remains unclear in many regions of the world.

Objectives: The GBD (Global Burden of Disease) 2015 study integrated data on disease incidence, prevalence, and mortality to produce consistent, up-to-date estimates for cardiovascular burden.

Methods: CVD mortality was estimated from vital registration and verbal autopsy data. CVD prevalence was estimated using modeling software and data from health surveys, prospective cohorts, health system administrative data, and registries. Years lived with disability (YLD) were estimated by multiplying prevalence by disability weights. Years of life lost (YLL) were estimated by multiplying age-specific CVD deaths by a reference life expectancy. A sociodemographic index (SDI) was created for each location based on income per capita, educational attainment, and fertility.

Results: In 2015, there were an estimated 422.7 million cases of CVD (95% uncertainty interval: 415.53 to 427.87 million cases) and 17.92 million CVD deaths (95% uncertainty interval: 17.59 to 18.28 million CVD deaths). Declines in the age-standardized CVD death rate occurred between 1990 and 2015 in all high-income and some middle-income countries. Ischemic heart disease was the leading cause of CVD health lost globally, as well as in each world region, followed by stroke. As SDI increased beyond 0.25, the highest CVD mortality shifted from women to men. CVD mortality decreased sharply for both sexes in countries with an SDI >0.75.

Conclusions: CVDs remain a major cause of health loss for all regions of the world. Sociodemographic change over the past 25 years has been associated with dramatic declines in CVD in regions with very high SDI, but only a gradual decrease or no change in most regions. Future updates of the GBD study can be used to guide policymakers who are focused on reducing the overall burden of noncommunicable disease and achieving specific global health targets for CVD.
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http://dx.doi.org/10.1016/j.jacc.2017.04.052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5491406PMC
July 2017

The Burden of Mental Disorders in the Eastern Mediterranean Region, 1990-2013.

PLoS One 2017 17;12(1):e0169575. Epub 2017 Jan 17.

Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran.

The Eastern Mediterranean Region (EMR) is witnessing an increase in chronic disorders, including mental illness. With ongoing unrest, this is expected to rise. This is the first study to quantify the burden of mental disorders in the EMR. We used data from the Global Burden of Disease study (GBD) 2013. DALYs (disability-adjusted life years) allow assessment of both premature mortality (years of life lost-YLLs) and nonfatal outcomes (years lived with disability-YLDs). DALYs are computed by adding YLLs and YLDs for each age-sex-country group. In 2013, mental disorders contributed to 5.6% of the total disease burden in the EMR (1894 DALYS/100,000 population): 2519 DALYS/100,000 (2590/100,000 males, 2426/100,000 females) in high-income countries, 1884 DALYS/100,000 (1618/100,000 males, 2157/100,000 females) in middle-income countries, 1607 DALYS/100,000 (1500/100,000 males, 1717/100,000 females) in low-income countries. Females had a greater proportion of burden due to mental disorders than did males of equivalent ages, except for those under 15 years of age. The highest proportion of DALYs occurred in the 25-49 age group, with a peak in the 35-39 years age group (5344 DALYs/100,000). The burden of mental disorders in EMR increased from 1726 DALYs/100,000 in 1990 to 1912 DALYs/100,000 in 2013 (10.8% increase). Within the mental disorders group in EMR, depressive disorders accounted for most DALYs, followed by anxiety disorders. Among EMR countries, Palestine had the largest burden of mental disorders. Nearly all EMR countries had a higher mental disorder burden compared to the global level. Our findings call for EMR ministries of health to increase provision of mental health services and to address the stigma of mental illness. Moreover, our results showing the accelerating burden of mental health are alarming as the region is seeing an increased level of instability. Indeed, mental health problems, if not properly addressed, will lead to an increased burden of diseases in the region.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0169575PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5240956PMC
August 2017

The "11 O'clock Heel First" technique for microvascular end-to-side anastomosis.

Neurol India 2017 Jan-Feb;65(1):69-72

Department of Neurosurgery, Albert Einstein Medical College, New York, USA.

Background: The heel of a microvascular end-to-side anastomosis is a common site for technical imperfections. We describe a simple technique to overcome this challenge. The aim of the technique is to insert all the sutures in an inside-to-outside manner at the heel area on the donor side of the anastomosis. This technique has first been tested in a laboratory setting and then was further elaborated in a clinical setting.

Materials And Methods: One hundred and twenty adult albino Wistar rats of both genders were randomized into the following two groups: (A) Control, 48 rats, representing approximately 40% of the total sample, underwent the usual two anchoring stitch technique; (B) Study group, 72 rats, representing approximately 60% of the total sample, underwent the technique described. Patency was confirmed both clinically and by the use of fluorescein angiography. Rat weight, diameter of both the donor and recipient vessels, type of anastomosis (arterio-arterial or arterio-venous) and angiographic findings were used as variables. A P value of less than 0.05 was considered significant.

Results: The proposed technique had increased patency rates as compared to the standard technique, which was statistically significant (P = 0.021). However, there was no difference between the patency rates of arterio-arterial and arterio-venous atastomoses.

Conclusion: The proposed technique is useful for perfecting the heel area of a microvascular end-to-side anastomosis in both laboratory and clinical settings.
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http://dx.doi.org/10.4103/0028-3886.198207DOI Listing
July 2019

Burden of Diarrhea in the Eastern Mediterranean Region, 1990-2013: Findings from the Global Burden of Disease Study 2013.

Am J Trop Med Hyg 2016 Dec 10;95(6):1319-1329. Epub 2016 Oct 10.

Department of Medical Emergency, School of Paramedic, Qom University of Medical Sciences, Qom, Iran.

Diarrheal diseases (DD) are leading causes of disease burden, death, and disability, especially in children in low-income settings. DD can also impact a child's potential livelihood through stunted physical growth, cognitive impairment, and other sequelae. As part of the Global Burden of Disease Study, we estimated DD burden, and the burden attributable to specific risk factors and particular etiologies, in the Eastern Mediterranean Region (EMR) between 1990 and 2013. For both sexes and all ages, we calculated disability-adjusted life years (DALYs), which are the sum of years of life lost and years lived with disability. We estimate that over 125,000 deaths (3.6% of total deaths) were due to DD in the EMR in 2013, with a greater burden of DD in low- and middle-income countries. Diarrhea deaths per 100,000 children under 5 years of age ranged from one (95% uncertainty interval [UI] = 0-1) in Bahrain and Oman to 471 (95% UI = 245-763) in Somalia. The pattern for diarrhea DALYs among those under 5 years of age closely followed that for diarrheal deaths. DALYs per 100,000 ranged from 739 (95% UI = 520-989) in Syria to 40,869 (95% UI = 21,540-65,823) in Somalia. Our results highlighted a highly inequitable burden of DD in EMR, mainly driven by the lack of access to proper resources such as water and sanitation. Our findings will guide preventive and treatment interventions which are based on evidence and which follow the ultimate goal of reducing the DD burden.
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http://dx.doi.org/10.4269/ajtmh.16-0339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154365PMC
December 2016

Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life-years for 32 Cancer Groups, 1990 to 2015: A Systematic Analysis for the Global Burden of Disease Study.

JAMA Oncol 2017 Apr;3(4):524-548

Institute for Health Metrics and Evaluation, University of Washington, Seattle.

Importance: Cancer is the second leading cause of death worldwide. Current estimates on the burden of cancer are needed for cancer control planning.

Objective: To estimate mortality, incidence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 32 cancers in 195 countries and territories from 1990 to 2015.

Evidence Review: Cancer mortality was estimated using vital registration system data, cancer registry incidence data (transformed to mortality estimates using separately estimated mortality to incidence [MI] ratios), and verbal autopsy data. Cancer incidence was calculated by dividing mortality estimates through the modeled MI ratios. To calculate cancer prevalence, MI ratios were used to model survival. To calculate YLDs, prevalence estimates were multiplied by disability weights. The YLLs were estimated by multiplying age-specific cancer deaths by the reference life expectancy. DALYs were estimated as the sum of YLDs and YLLs. A sociodemographic index (SDI) was created for each location based on income per capita, educational attainment, and fertility. Countries were categorized by SDI quintiles to summarize results.

Findings: In 2015, there were 17.5 million cancer cases worldwide and 8.7 million deaths. Between 2005 and 2015, cancer cases increased by 33%, with population aging contributing 16%, population growth 13%, and changes in age-specific rates contributing 4%. For men, the most common cancer globally was prostate cancer (1.6 million cases). Tracheal, bronchus, and lung cancer was the leading cause of cancer deaths and DALYs in men (1.2 million deaths and 25.9 million DALYs). For women, the most common cancer was breast cancer (2.4 million cases). Breast cancer was also the leading cause of cancer deaths and DALYs for women (523 000 deaths and 15.1 million DALYs). Overall, cancer caused 208.3 million DALYs worldwide in 2015 for both sexes combined. Between 2005 and 2015, age-standardized incidence rates for all cancers combined increased in 174 of 195 countries or territories. Age-standardized death rates (ASDRs) for all cancers combined decreased within that timeframe in 140 of 195 countries or territories. Countries with an increase in the ASDR due to all cancers were largely located on the African continent. Of all cancers, deaths between 2005 and 2015 decreased significantly for Hodgkin lymphoma (-6.1% [95% uncertainty interval (UI), -10.6% to -1.3%]). The number of deaths also decreased for esophageal cancer, stomach cancer, and chronic myeloid leukemia, although these results were not statistically significant.

Conclusion And Relevance: As part of the epidemiological transition, cancer incidence is expected to increase in the future, further straining limited health care resources. Appropriate allocation of resources for cancer prevention, early diagnosis, and curative and palliative care requires detailed knowledge of the local burden of cancer. The GBD 2015 study results demonstrate that progress is possible in the war against cancer. However, the major findings also highlight an unmet need for cancer prevention efforts, including tobacco control, vaccination, and the promotion of physical activity and a healthy diet.
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http://dx.doi.org/10.1001/jamaoncol.2016.5688DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6103527PMC
April 2017

Effect of shock wave therapy on ankle plantar flexors spasticity in stroke patients.

NeuroRehabilitation 2017 ;40(1):115-118

Department of Neuromuscular Disorders, Faculty of Physical Therapy, Cairo University, Cairo, Egypt.

Background: Large number of patients with first-ever stroke developed spasticity. Spasticity can reduce the range of motion, hinder voluntary movements, provoke pain, and result in impairment of functional activities of daily living.

Objective: Demonstrate the effect of shock wave therapy on ankle plantar flexors spasticity in stroke patients.

Methods: We included forty ischemic stroke patients divided into 2 groups; group I were subjected to the selected physical therapy program and shock wave therapy whereas group II received the selected physical therapy program as well as placebo shock wave for six weeks. Both groups were subjected to pre- and post-treatment assessment by H/M ratio, dorsiflexion active range of motion, and time of ten-meters walking.

Results: Baseline characteristics showed no significant difference between the two groups regarding the grades of spasticity. Whereas After treatment, there were a highly significant difference between both groups regarding the grades of spasticity according to the 3 parameters, H/M ratio, dorsiflexion active range of motion, and time of ten-meters walking test (P values; <0.001, 0.006, and 0.009 respectively).

Conclusions: Shock wave therapy is effective in controlling spasticity, increase dorsiflexion active range of motion of ankle and improving ten- meters walking test in stroke patients.
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http://dx.doi.org/10.3233/NRE-161396DOI Listing
May 2017

Health in times of uncertainty in the eastern Mediterranean region, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

Lancet Glob Health 2016 10 25;4(10):e704-13. Epub 2016 Aug 25.

University of Rhode Island, Kingston, RI, USA.

Background: The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013.

Methods: GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically.

Findings: The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60-80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred.

Interpretation: Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts.

Funding: Bill & Melinda Gates Foundation.
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http://dx.doi.org/10.1016/S2214-109X(16)30168-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6660972PMC
October 2016
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