University of Colombo

Objectives To describe new WHO 2020 guidelines on physical activity and sedentary behaviour. Methods The guidelines were developed in accordance with WHO protocols. An expert Guideline Development Group reviewed evidence to assess associations between physical activity and sedentary behaviour for an agreed set of health outcomes and population groups. The assessment used and systematically updated recent relevant systematic reviews; new primary reviews addressed additional health outcomes or subpopulations. Results The new guidelines address children, adolescents, adults, older adults and include new specific recommendations for pregnant and postpartum women and people living with chronic conditions or disability. All adults should undertake 150–300 min of moderate-intensity, or 75–150 min of vigorous-intensity physical activity, or some equivalent combination of moderate-intensity and vigorous-intensity aerobic physical activity, per week. Among children and adolescents, an average of 60 min/day of moderate-to-vigorous intensity aerobic physical activity across the week provides health benefits. The guidelines recommend regular muscle-strengthening activity for all age groups. Additionally, reducing sedentary behaviours is recommended across all age groups and abilities, although evidence was insufficient to quantify a sedentary behaviour threshold. Conclusion These 2020 WHO guidelines update previous WHO recommendations released in 2010. They reaffirm messages that some physical activity is better than none, that more physical activity is better for optimal health outcomes and provide a new recommendation on reducing sedentary behaviours. These guidelines highlight the importance of regularly undertaking both aerobic and muscle strengthening activities and for the first time, there are specific recommendations for specific populations including for pregnant and postpartum women and people living with chronic conditions or disability. These guidelines should be used to inform national health policies aligned with the WHO Global Action Plan on Physical Activity 2018–2030 and to strengthen surveillance systems that track progress towards national and global targets.

Fungi play major roles in ecosystem processes, but the determinants of fungal diversity and biogeographic patterns remain poorly understood. Using DNA metabarcoding data from hundreds of globally distributed soil samples, we demonstrate that fungal richness is decoupled from plant diversity. The plant-to-fungus richness ratio declines exponentially toward the poles. Climatic factors, followed by edaphic and spatial variables, constitute the best predictors of fungal richness and community composition at the global scale. Fungi show similar latitudinal diversity gradients to other organisms, with several notable exceptions. These findings advance our understanding of global fungal diversity patterns and permit integration of fungi into a general macroecological framework.

IMPORTANCE: The Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019) provided systematic estimates of incidence, morbidity, and mortality to inform local and international efforts toward reducing cancer burden. OBJECTIVE: To estimate cancer burden and trends globally for 204 countries and territories and by Sociodemographic Index (SDI) quintiles from 2010 to 2019. EVIDENCE REVIEW: The GBD 2019 estimation methods were used to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) in 2019 and over the past decade. Estimates are also provided by quintiles of the SDI, a composite measure of educational attainment, income per capita, and total fertility rate for those younger than 25 years. Estimates include 95% uncertainty intervals (UIs). FINDINGS: In 2019, there were an estimated 23.6 million (95% UI, 22.2-24.9 million) new cancer cases (17.2 million when excluding nonmelanoma skin cancer) and 10.0 million (95% UI, 9.36-10.6 million) cancer deaths globally, with an estimated 250 million (235-264 million) DALYs due to cancer. Since 2010, these represented a 26.3% (95% UI, 20.3%-32.3%) increase in new cases, a 20.9% (95% UI, 14.2%-27.6%) increase in deaths, and a 16.0% (95% UI, 9.3%-22.8%) increase in DALYs. Among 22 groups of diseases and injuries in the GBD 2019 study, cancer was second only to cardiovascular diseases for the number of deaths, years of life lost, and DALYs globally in 2019. Cancer burden differed across SDI quintiles. The proportion of years lived with disability that contributed to DALYs increased with SDI, ranging from 1.4% (1.1%-1.8%) in the low SDI quintile to 5.7% (4.2%-7.1%) in the high SDI quintile. While the high SDI quintile had the highest number of new cases in 2019, the middle SDI quintile had the highest number of cancer deaths and DALYs. From 2010 to 2019, the largest percentage increase in the numbers of cases and deaths occurred in the low and low-middle SDI quintiles. CONCLUSIONS AND RELEVANCE: The results of this systematic analysis suggest that the global burden of cancer is substantial and growing, with burden differing by SDI. These results provide comprehensive and comparable estimates that can potentially inform efforts toward equitable cancer control around the world.

STUDY QUESTION: What is the recommended assessment and management of women with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise and consumer preference? SUMMARY ANSWER: International evidence-based guidelines, including 166 recommendations and practice points, addressed prioritized questions to promote consistent, evidence-based care and improve the experience and health outcomes of women with PCOS. WHAT IS KNOWN ALREADY: Previous guidelines either lacked rigorous evidence-based processes, did not engage consumer and international multidisciplinary perspectives, or were outdated. Diagnosis of PCOS remains controversial, and assessment and management are inconsistent. The needs of women with PCOS are not being adequately met and evidence practice gaps persist. STUDY DESIGN, SIZE, DURATION: International evidence-based guideline development engaged professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Appraisal of Guidelines for Research and Evaluation (AGREE) II-compliant processes were followed, with extensive evidence synthesis. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength. PARTICIPANTS/MATERIALS, SETTING, METHODS: Governance included a six continent international advisory and a project board, five guideline development groups, and consumer and translation committees. Extensive health professional and consumer engagement informed guideline scope and priorities. Engaged international society-nominated panels included pediatrics, endocrinology, gynecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, public health and other experts, alongside consumers, project management, evidence synthesis and translation experts. In total, 37 societies and organizations covering 71 countries engaged in the process. Twenty face-to-face meetings over 15 months addressed 60 prioritized clinical questions involving 40 systematic and 20 narrative reviews. Evidence-based recommendations were developed and approved via consensus voting within the five guideline panels, modified based on international feedback and peer review, with final recommendations approved across all panels. MAIN RESULTS AND THE ROLE OF CHANCE: The evidence in the assessment and management of PCOS is generally of low to moderate quality. The guideline provides 31 evidence based recommendations, 59 clinical consensus recommendations and 76 clinical practice points all related to assessment and management of PCOS. Key changes in this guideline include: (i) considerable refinement of individual diagnostic criteria with a focus on improving accuracy of diagnosis; (ii) reducing unnecessary testing; (iii) increasing focus on education, lifestyle modification, emotional wellbeing and quality of life; and (iv) emphasizing evidence based medical therapy and cheaper and safer fertility management. LIMITATIONS, REASONS FOR CAUTION: Overall evidence is generally low to moderate quality, requiring significantly greater research in this neglected, yet common condition, especially around refining specific diagnostic features in PCOS. Regional health system variation is acknowledged and a process for guideline and translation resource adaptation is provided. WIDER IMPLICATIONS OF THE FINDINGS: The international guideline for the assessment and management of PCOS provides clinicians with clear advice on best practice based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation program supports the guideline with an integrated evaluation program. STUDY FUNDING/COMPETING INTEREST(S): The guideline was primarily funded by the Australian National Health and Medical Research Council of Australia (NHMRC) supported by a partnership with ESHRE and the American Society for Reproductive Medicine. Guideline development group members did not receive payment. Travel expenses were covered by the sponsoring organizations. Disclosures of conflicts of interest were declared at the outset and updated throughout the guideline process, aligned with NHMRC guideline processes. Full details of conflicts declared across the guideline development groups are available at https://www.monash.edu/medicine/sphpm/mchri/pcos/guideline in the Register of disclosures of interest. Of named authors, Dr Costello has declared shares in Virtus Health and past sponsorship from Merck Serono for conference presentations. Prof. Laven declared grants from Ferring, Euroscreen and personal fees from Ferring, Euroscreen, Danone and Titus Healthcare. Prof. Norman has declared a minor shareholder interest in an IVF unit. The remaining authors have no conflicts of interest to declare. The guideline was peer reviewed by special interest groups across our partner and collaborating societies and consumer organizations, was independently assessed against AGREE-II criteria, and underwent methodological review. This guideline was approved by all members of the guideline development groups and was submitted for final approval by the NHMRC.

Updates: This is the fourteenth version (thirteenth update) of the living guideline, replacing earlier versions (available as data supplements). New recommendations will be published as updates to this guideline. Clinical question: What is the role of drugs in the treatment of patients with covid-19? Context: The evidence base for therapeutics for covid-19 is evolving with numerous randomised controlled trials (RCTs) recently completed and underway. Emerging SARS-CoV-2 variants and subvariants are changing the role of therapeutics. What is new?: The guideline development group (GDG) defined 1.5% as a new threshold for an important reduction in risk of hospitalisation in patients with non-severe covid-19. Combined with updated baseline risk estimates, this resulted in stratification into patients at low, moderate, and high risk for hospitalisation. New recommendations were added for moderate risk of hospitalisation for nirmatrelvir/ritonavir, and for moderate and low risk of hospitalisation for molnupiravir and remdesivir. New pharmacokinetic evidence was included for nirmatrelvir/ritonavir and molnupiravir, supporting existing recommendations for patients at high risk of hospitalisation. The recommendation for ivermectin in patients with non-severe illness was updated in light of additional trial evidence which reduced the high degree of uncertainty informing previous guidance. A new recommendation was made against the antiviral agent VV116 for patients with non-severe and with severe or critical illness outside of randomised clinical trials based on one RCT comparing the drug with nirmatrelvir/ritonavir. The structure of the guideline publication has also been changed; recommendations are now ordered by severity of covid-19. About this guideline: This living guideline from the World Health Organization (WHO) incorporates new evidence to dynamically update recommendations for covid-19 therapeutics. The GDG typically evaluates a therapy when the WHO judges sufficient evidence is available to make a recommendation. While the GDG takes an individual patient perspective in making recommendations, it also considers resource implications, acceptability, feasibility, equity, and human rights. This guideline was developed according to standards and methods for trustworthy guidelines, making use of an innovative process to achieve efficiency in dynamic updating of recommendations. The methods are aligned with the WHO Handbook for Guideline Development and according to a pre-approved protocol (planning proposal) by the Guideline Review Committee (GRC). A box at the end of the article outlines key methodological aspects of the guideline process. MAGIC Evidence Ecosystem Foundation provides methodological support, including the coordination of living systematic reviews with network meta-analyses to inform the recommendations. The full version of the guideline is available online in MAGICapp and in PDF on the WHO website, with a summary version here in The BMJ. These formats should facilitate adaptation, which is strongly encouraged by WHO to contextualise recommendations in a healthcare system to maximise impact. Future recommendations: Recommendations on anticoagulation are planned for the next update to this guideline. Updated data regarding systemic corticosteroids, azithromycin, favipiravir and umefenovir for non-severe illness, and convalescent plasma and statin therapy for severe or critical illness, are planned for review in upcoming guideline iterations.

OBJECTIVE: To revise FIGO staging of carcinoma of the cervix uteri, allowing incorporation of imaging and/or pathological findings, and clinical assessment of tumor size and disease extent. METHODS: Review of literature and consensus view of the FIGO Gynecologic Oncology Committee and related societies and organizations. RESULTS: In stage I, revision of the definition of microinvasion and lesion size as follows. Stage IA: lateral extension measurement is removed; stage IB has three subgroups-stage IB1: invasive carcinomas ≥5 mm and <2 cm in greatest diameter; stage IB2: tumors 2-4 cm; stage IB3: tumors ≥4 cm. Imaging or pathology findings may be used to assess retroperitoneal lymph nodes; if metastatic, the case is assigned stage IIIC; if only pelvic lymph nodes, the case is assigned stage IIIC1; if para-aortic nodes are involved, the case is assigned stage IIIC2. Notations 'r' and 'p' will indicate the method used to derive the stage-i.e., imaging or pathology, respectively-and should be recorded. Routine investigations and other methods (e.g., examination under anesthesia, cystoscopy, proctoscopy, etc.) are not mandatory and are to be recommended based on clinical findings and standard of care. CONCLUSION: The revised cervical cancer staging is applicable to all resource levels. Data collection and publication will inform future revisions.

BACKGROUND: The Asia-Pacific region is home to nearly half of the world's population. The region has seen a recent rapid increase in the prevalence of obesity, type-2 diabetes and cardiovascular disease. The present systematic review summarizes the recent prevalence and trends of Metabolic Syndrome (MetS) among adults in countries of the Asia-Pacific Region. METHODS: Data on MetS in Asia-Pacific countries were obtained using a stepwise process by searching the online Medline database using MeSH terms 'Metabolic Syndrome X' and 'Epidemiology/EP'. For the purpose of describing prevalence data for the individual countries, studies that were most recent, nationally representative or with the largest sample size were included. When evaluating secular trends in prevalence in a country we only considered studies that evaluated the temporal change in prevalence between similar populations, prospective studies based on the same population or National surveys conducted during different time periods. RESULTS: This literature search yielded a total of 757 articles, and five additional article were identified by screening of reference lists. From this total, 18 studies were eligible to be included in the final analysis. Of the 51 Asia-Pacific countries (WHO) we only located data for 15. There was wide between country variation in prevalence of MetS. A national survey from Philippines conducted in 2003 revealed the lowest reported prevalence of 11.9% according to NCEP ATP III criteria. In contrast, the highest recorded prevalence in the region (49.0%) came from a study conducted in urban Pakistan (Karachchi, 2004). Most studies reported a higher prevalence of MetS in females and urban residents. Data on secular trends were available for China, South Korea and Taiwan. An increase in the prevalence of MetS was observed in all three countries. CONCLUSION: Despite differences in methodology, diagnostic criteria and age of subjects studied, the Asia-Pacific region is facing a significant epidemic of MetS. In most countries nearly 1/5th of the adult population or more were affected by MetS with a secular increase in prevalence. Strategies aimed at primary prevention are required to ameliorate a further increase in the epidemic and for the reduction of the morbidity and mortality associated with MetS.

BACKGROUND: Here we describe the consensus guideline methodology, summarise the evidence-based recommendations we provided to the World Health Organisation (WHO) for their consideration in the development of global guidance and present a narrative review on the management of anovulatory infertility in women with polycystic ovary syndrome (PCOS). OBJECTIVE AND RATIONALE: The aim of this paper was to present an evidence base for the management of anovulatory PCOS. SEARCH METHODS: The evidence to support providing recommendations involved a collaborative process for: (i) identification of priority questions and critical outcomes, (ii) retrieval of up-to-date evidence and exiting guidelines, (iii) assessment and synthesis of the evidence and (iv) the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation, the methodologist evaluated the quality of the supporting evidence that was then graded as very low, low, moderate or high for consideration during consensus. OUTCOMES: and lifestyle therapy has failed. Carefully conducted and monitored pharmacological ovulation induction can achieve good cumulative pregnancy rates and multiple pregnancy rates can be minimized with adherence to recommended protocols. CC should be first-line pharmacotherapy for ovulation induction and letrozole can also be used as first-line therapy. Metformin alone has limited benefits in improving live birth rates. Gonadotropins and laparoscopic surgery can be used as second-line treatment. There is no clear evidence for efficacy of acupuncture or herbal mixtures in women with PCOS. For women with PCOS who fail lifestyle and ovulation induction therapy or have additional infertility factors, IVF can be used with the safer gonadotropin releasing hormone (GnRH) antagonist protocol. If a GnRH-agonist protocol is used, metformin as an adjunct may reduce the risk of ovarian hyperstimulation syndrome. Patients should be informed of the potential side effects of ovulation induction agents and of IVF on the foetus, and of the risks of multiple pregnancy. Increased risks for the mother during pregnancy and for the child, including the exacerbating impact of obesity on adverse outcomes, should also be discussed. WIDER IMPLICATIONS: This guidance generation and evidence-synthesis analysis has been conducted in a manner to be considered for global applicability for the safe administration of ovulation induction for anovulatory women with PCOS.

A growing body of literature on the 2019 novel coronavirus (SARS-CoV-2) is becoming available, but a synthesis of available data has not been conducted. We performed a scoping review of currently available clinical, epidemiological, laboratory, and chest imaging data related to the SARS-CoV-2 infection. We searched MEDLINE, Cochrane CENTRAL, EMBASE, Scopus and LILACS from 01 January 2019 to 24 February 2020. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. Qualitative synthesis and meta-analysis were conducted using the clinical and laboratory data, and random-effects models were applied to estimate pooled results. A total of 61 studies were included (59,254 patients). The most common disease-related symptoms were fever (82%, 95% confidence interval (CI) 56%–99%; n = 4410), cough (61%, 95% CI 39%–81%; n = 3985), muscle aches and/or fatigue (36%, 95% CI 18%–55%; n = 3778), dyspnea (26%, 95% CI 12%–41%; n = 3700), headache in 12% (95% CI 4%–23%, n = 3598 patients), sore throat in 10% (95% CI 5%–17%, n = 1387) and gastrointestinal symptoms in 9% (95% CI 3%–17%, n = 1744). Laboratory findings were described in a lower number of patients and revealed lymphopenia (0.93 × 109/L, 95% CI 0.83–1.03 × 109/L, n = 464) and abnormal C-reactive protein (33.72 mg/dL, 95% CI 21.54–45.91 mg/dL; n = 1637). Radiological findings varied, but mostly described ground-glass opacities and consolidation. Data on treatment options were limited. All-cause mortality was 0.3% (95% CI 0.0%–1.0%; n = 53,631). Epidemiological studies showed that mortality was higher in males and elderly patients. The majority of reported clinical symptoms and laboratory findings related to SARS-CoV-2 infection are non-specific. Clinical suspicion, accompanied by a relevant epidemiological history, should be followed by early imaging and virological assay.

Deliberate self-poisoning has become an increasingly common response to emotional distress in young adults,1 and it is now one of the most frequent reasons for emergency hospital admission.2 In industrialized countries, the drugs that people commonly take in overdose—analgesics, tranquillisers, antidepressants3—are relatively non-toxic. The estimated case fatality for overdose in England, for example, is around 0.5%.4 Most individuals who self-harm do not intend to die. Studies carried out in industrialized countries have found that only 2% go on to commit suicide in the subsequent 12 months.5 In developing countries the situation is quite different.6 The substances most commonly used for self-poisoning are agricultural pesticides.6–11 Overall case fatality ranges from 10% to 20%.12 For this reason, deaths from pesticide poisoning make a major contribution to patterns of suicide in developing nations, particularly in rural areas.6 In rural China, for example, pesticides account for over 60% of suicides.8 Similarly high proportions of suicides are due to pesticides in rural areas of Sri Lanka (71%),13 Trinidad (68%),14 and Malaysia (>90%).10 There is, however, no evidence that levels of suicidal intent associated with pesticide ingestion in these countries are any higher than those associated with drug overdose in industrialized countries, where the drugs taken in overdose are less toxic. In countries where the use of pesticides for self-harm is commonplace conventional epidemiological features of suicide appear to be distorted. In industrialized nations, suicide rates are two to three times higher in men than women, and its incidence tends to increase with age, although in some countries recent rises in young male suicides have distorted this pattern.15 The incidence of non-fatal self-harm in industrialized countries is 20+ times higher than that of suicide; in contrast to suicide, self-harm rates peak in 15–24 year olds and are generally highest in women (Figure 1a).16 A possible explanation for these differences in the age- and sex-patterning of fatal and non-fatal self-harm is that young people, particularly females, are more likely to engage in impulsive acts of self-harm—as indicated by the comparatively lower levels of suicidal intent in young people.17 Because these acts are unplanned, the methods used are those that are readily available at the time of acute distress—prescribed and non-prescribed medicines—and these are relatively non-toxic. If more lethal methods of self-harm, such as pesticides, were favoured and readily accessible in industrialized nations the epidemiology of suicide in these countries might be quite different. Thus the widespread availability of pesticides may contribute to the difference in the age- and sex-patterning of suicide in China,18 Sri Lanka,19 India,20 and several other developing countries compared with that commonly seen in industrialized nations (Figure 2). In these developing countries some of the highest rates are seen in young adults and the ratio of male:female suicide approaches or exceeds unity at this age. In China, whilst suicide rates do tend to increase with age, there is a notable peak in rates amongst males and females aged 20–24 (Figure 2); recent data show that this peak is more prominent in rural localities.18 In rural India rates of suicide in 15–24 year old females are higher than rates in males of the same age and most other female age groups.20 Similar patterns are seen in Sri Lanka (Figure 2). In both China and Sri Lanka pesticides are the most frequently used method of suicide, likewise in India self-poisoning is the commonest method20 and pesticides are the most frequently used agents.9,21 It is of note that the age- and sex-patterns of self-poisoning in Sri Lanka in the younger age groups are similar to those in industrialized countries, (Figure 1b) although in contrast, the case fatality in Sri Lanka is much higher.38 Part of the distinct age- and gender-patterns of suicide deaths in the developing world may therefore reflect a mixture of deaths with high suicidal intent (predominantly in the elderly) and an excess of deaths with low suicidal intent amongst the young where the method chosen for impulsive acts of self-harm (pesticide ingestion) is highly lethal. A possibility strikingly born out in Western Samoa in the 1980s, where two-thirds of all suicides were a result of pesticide ingestion and the age- and sex-patterning of suicide and non-fatal self-harm were almost identical.22 The common use of pesticides for self-harm in part reflects their ease of availability. Whilst their use in agriculture is widespread in industrialized countries, large-scale farming is practised by a small number of landowners, thus reducing the number of people with direct access to pesticides. In contrast, most people living in rural regions of developing countries are involved in agriculture and farm small areas of land. Subsistence farmers keep their own supply of pesticides, commonly within, or close to, the household.23 A recent study in China found that 65% of pesticide suicides used chemicals stored in the home.8 There is general consensus that the ease of availability of particularly lethal means of self-harm may influence patterns of suicide. Suicidal impulses are often short lived and if time can be ‘bought’ allowing such impulses to pass—by making the means of suicide less readily available—a proportion of suicides will be prevented.24 The best documented evidence of this was the effect of the detoxification of the domestic gas supply in Britain in the 1960s25—this was thought to have contributed to the prevention of an estimated 6700 suicides.26 Similarly, temporal and geographical variations in the availability of other commonly used methods have influenced patterns of suicide in Australia (barbiturates),27 USA (firearms),28,29 and Britain (catalytic converters for car exhaust fumes).30 This evidence has prompted the inclusion of policies aimed at reducing access to, or the lethality of, commonly used methods within national and international suicide prevention strategies.31–33 In Britain attention has focused on restricting the availability of paracetamol (acetaminophen)34,35 and in the USA there are similar concerns about the ease of availability of firearms.28,29 The number of deaths caused by pesticides36 make Western concerns about these two methods of suicide appear somewhat trivial. For example, in Britain where paracetamol suicide is comparatively common,34 there are only around 200 paracetamol suicides per year (<4% of all suicides).35 If a similar proportion of suicides were due to paracetamol worldwide (an overestimate34) then using the WHO’s current estimate of 849 000 suicides worldwide each year37 a maximum of 34 000 of these might be attributable to paracetamol. In contrast, the WHO estimated in 1990 that there are around 3 million hospital admissions for pesticide poisoning each year, 2 million of which are as a result of deliberate ingestion, and these result in around 220 000 deaths.36 The size of the problem is probably larger now—there have, for example, been well-recognized increases in pesticide poisonings in South Asia.21 The best evidence for estimating the global burden of suicide deaths from pesticide ingestion comes from China and South East Asia. In 2001 there were an estimated 517 000 suicides in developing countries in these regions37and research evidence (see above) suggests pesticide ingestion accounts for over 60% of these suicides. We therefore estimate there are around 300 000 pesticide suicides each year in these regions alone. As pesticide suicides from other developing nations in Africa and South America are not included in this figure the global toll is likely to be higher. Deaths from pesticide ingestion are a major contributor to the global burden of suicide and premature mortality. This burden is increased by the economic and indirect health care effects of self-harm following ingestion of pesticides. Such effects have been less well documented in the research literature. The hospital management of pesticide poisoning often requires intensive care, in particular ventilation. In 1995–1996, in one general hospital in Sri Lanka, 41% of bed occupancy on medical intensive care beds was for the treatment of pesticide poisoning.38 This not only drains limited healthcare budgets but also prevents the treatment of other patients requiring intensive care. Furthermore, the loss through premature death, of young, economically active, community members and the impact of their death on others (spouses, children, friends, and family) may influence productivity in communities that are on the margins of subsistence. The costs of self-harm should be balanced against the agricultural benefits of pesticides. These have not been formally quantified and work over the last 20 years with integrated pest management has shown that reduced use of pesticides can be compatible with at least stable levels of crop production.39,40 Pesticides are also used to control disease vectors (e.g. mosquito vectors of dengue and malaria) but supplies of pesticides used for this purpose are kept in official store rooms and are therefore less likely to be available for acts of self-harm. Any analysis of the competing adverse and beneficial effects of pesticides should incorporate the possibility of replacing pesticides which are toxic to humans with less toxic, but equally effective alternatives.6 Likewise the short-term effects on crop yields should be balanced against wider effects on the environment, development of parasite resistance, and possible longer-term effects of pesticide exposure on human health.6 Possible approaches to reducing deaths from pesticide ingestion are outlined in the Table. The importance of broad-based commitment from industry as well as Non-Governmental Organizations (NGO), and national and international health and regulatory organizations is highlighted. The first broad approach is to restrict the availability of pesticides either directly, for example through restricting the import and use of pesticides, or indirectly through ensuring supplies are kept in a secure facility in each geographical locality. Restricting availability could be achieved by either direct control of particular pesticides (banning, requiring licences for use or prescriptions) or through the promotion of practices that minimize their use. Such health protection approaches appear to have led to a reduction in serious paracetamol poisonings in England35 and a decline in barbiturate suicides in Australia.27 The WHO has encouraged countries to restrict the availability of more lethal pesticides32 and countries such as Sri Lanka have followed this approach.41 In Jordan, a steady rise in fatal pesticide poisonings was reversed by increased awareness of the problem, decreased imports of some toxic pesticides, and bans on the imports of others.42 Similar effects have been observed in Western Samoa after reduced use of paraquat and a campaign to raise awareness of suicide; however, here fluctuations in imports were driven by the nation’s financial problems rather than a concern with suicide.22 The second approach is to improve public education regarding the dangers of pesticide poisoning and the safekeeping of pesticides—through media campaigns and clear labelling of product containers. The effects are difficult to predict and there is a suggestion that enhanced knowledge concerning the toxicity of pesticides resulted in an increase in their use for self-harm in some settings.12 Furthermore, it is widely recognized that media portrayal of acts of self-harm can lead to increases in ‘copy-cat’ suicides.43 The third general approach is to encourage manufacturers to improve the safety of their products. This may be achieved by diluting the concentrations of liquid pesticides, incorporating emetics or agents to make them unpleasant to taste or, more fundamentally, to produce pesticides which are non-toxic to humans.44 Company responsibility for the safe use of pesticides should extend for the entire life cycle of their use. Lastly, if the occurrence and lethality of pesticide ingestions cannot be prevented then improved medical management is crucial.12 The lethality of pesticide poisoning is for the most part due to the difficulty of treatment and their greater toxicity compared with substances taken in overdose in industrialized countries. Antidotes to pesticides are not completely effective. In rural areas, where the majority of cases occur, health care is often distant and of poor ‘quality’. In the UK, where paracetamol is the most common poison used for self-harm, a similar situation could be envisaged if all the antidotes became unavailable—the medical wards might once again become filled with paracetamol-poisoned patients with either anticipated or florid liver failure. The problem of death from pesticide self-poisoning is neither new12,45–48 nor unique to a few countries, so reasons for the lack of a global response need to be understood if this continuing tragedy is to be reversed. Five main factors appear to contribute. First, the pattern of agriculture practised in developing countries—where most people living in rural areas cultivate small areas of land—is quite different from that in industrialized nations where a small number of farmers cultivate large tracts of land. In industrialized countries access to pesticides is therefore largely restricted to the few individuals engaged in farming. In developing nations pesticides are available within most peoples’ place of residence. Interventions to limit access in such settings are complex and need to involve most rural adults, rather than a select few. Second, the sale of pesticides is a multi-billion dollar business. In all, 1.5 million tons of pesticides are sold annually and sales are worth an estimated US$30 billion.6 Tensions commonly exist between commercial interests and population health, furthermore industry has not always acknowledged the impact of the easy availability of lethal suicide methods on patterns of suicide.49 In describing Western Samoa’s preventive considerations following the epidemic rise in pesticide suicides in that country Bowles noted: There was at that time a contentious debate about actually banning paraquat [(the pesticide)] entirely. We knew however that there were powerful and influential people who had a vested interest in continuing the importation and we did not want to be aligned with a lobby group likely to fail.22 Third, the issue of pesticide self-poisoning has never been taken up as a campaign issue by any of the international organizations. The WHO is the pre-eminent public health organization and its Department of Mental Health and Substance Dependence (MNH) is responsible for suicide prevention.50 It has managed to successfully draw mental health up the worldwide political agenda over the last 10 years.32 It has also emphasized the global health importance of suicide, organizing workshops across the world to discuss strategies for reducing self-harm, but it has not taken up pesticides as a central issue. Recent WHO publications with major input from the MNH32,51 have put greater emphasis on psychiatric and social models of self-harm aetiology. While pesticide self-poisoning was mentioned in both reports, it received much less attention than its importance warrants. The International Programme on Chemical Safety (IPCS) is the major WHO programme dealing with pesticides.52 It was set up in 1980 by the United Nations Environment Programme, the International Labour Organization, and the WHO, to establish the scientific basis for safe use of chemicals and to strengthen national capabilities for chemical safety. Current IPCS activities aim to increase knowledge of the epidemiology of pesticide poisoning and to encourage the setting up of poisoning information centres.52,53 The IPCS has not, however, actively taken up the issue of intentional pesticide self-poisoning, concentrating instead on occupational and environmental poisoning.54 This is unfortunate since its own studies have indicated the great importance of self-poisoning in the Asia Pacific region.53 The interests of its parent organizations may be the reason for this lack of advocacy for the problem of intentional poisoning. Fourth, the self-inflicted nature of suicide, together with the fact there are fewer suicide deaths than deaths from other global health problems such as human immunodeficiency virus (HIV)/AIDS, tuberculosis, and malaria, may have lead to policy makers giving it lower priority than the number of premature deaths warrant. Fifth, pesticide self-poisoning is ideologically and politically inconvenient. Pesticide use has adverse effects on the environment and human health.55–57 This has become a major global political issue. Many of the adverse effects of pesticides are considered to result from their overuse and poor treatment of workers and communities due to globalization58—in which pesticide corporations are major participants. The issue has been taken up by numerous national and international non-governmental organizations (NGO), in continual ‘battle’ with the pesticide companies. In this battle, the fact that the vast majority of severe and fatal pesticide cases are self-inflicted may be inconvenient to the environmentalists. If the pesticide industry can argue that they should not be held responsible for people who drink pesticides, then this may be seen as undermining the environmentalists’ case. People therefore want to avoid the issue of self-poisoning and deal with issues where the pesticide industry, and globalization in general, can be held responsible. This need not be true. An overall assessment of public health, environmental and agricultural factors should determine regulatory actions, not simply their political appropriateness. Pesticide self-harm is just as important as occupational poisoning for regulatory issues and, in some countries, regulatory authorities have been very effective in banning the pesticides that have been problems only for self-harm.41 Pesticide self-poisoning is a major contributor to population patterns of morbidity and mortality in developing nations. The use of pesticides for self-poisoning may distort conventional epidemiological features of suicide in these countries and contribute to their excess premature mortality. We estimate there are around 300 000 self-inflicted pesticide deaths worldwide each year. Research dating back over 30 years has documented the size of this problem and yet contemporary research bears witness to its continuing impact. Research to identify the most acceptable means of restricting the availability of pesticides within rural communities is urgently required together with randomized controlled trials to determine the best means of treatment and cost-effectiveness of possible interventions. Some of this research is now underway (M Eddleston, unpublished). Preventive measures must take account of the local needs and context and should be rigorously evaluated. Thus far there has been no global leadership to respond to the problem. Engagement of national governments and leadership of the WHO, in particular the MNH and IPCS sections, on the issue is essential. Commitment from industry and the need for them to acknowledge their responsibility for some of these deaths is vital (Table), as is the need to ensure they understand the scale, importance, and preventability of the problem. Reducing the number of pesticide deaths by 50% could rapidly reduce the number of suicides worldwide by 150 000. This is quite possible. Possible approaches to reducing deaths from intentional pesticide ingestion Possible approaches to reducing deaths from intentional pesticide ingestion Hospital admissions for self-poisoning. a. England (Source: Hospital Episode Statistics April 1999–March 2000), b. Sri Lanka (Source: Eddleston and colleagues unpublished data: data are for the two secondary referral hospitals in North Central Province: April 2002–March data for Sri Lanka are as rather than rates as there are no population and patterns of suicide. a. In China (Source: b. Sri Lanka (Source: and India (Source: We and for and and and for some of the suicide Hospital Statistics data were available by the Department of Health to the of the and by a South and The Research Health are data and also some of the The Department of is the lead of the Health Research is a in by

The informal settlements of the Global South are the least prepared for the pandemic of COVID-19 since basic needs such as water, toilets, sewers, drainage, waste collection, and secure and adequate housing are already in short supply or non-existent. Further, space constraints, violence, and overcrowding in slums make physical distancing and self-quarantine impractical, and the rapid spread of an infection highly likely. Residents of informal settlements are also economically vulnerable during any COVID-19 responses. Any responses to COVID-19 that do not recognize these realities will further jeopardize the survival of large segments of the urban population globally. Most top-down strategies to arrest an infectious disease will likely ignore the often-robust social groups and knowledge that already exist in many slums. Here, we offer a set of practice and policy suggestions that aim to (1) dampen the spread of COVID-19 based on the latest available science, (2) improve the likelihood of medical care for the urban poor whether or not they get infected, and (3) provide economic, social, and physical improvements and protections to the urban poor, including migrants, slum communities, and their residents, that can improve their long-term well-being. Immediate measures to protect residents of urban informal settlements, the homeless, those living in precarious settlements, and the entire population from COVID-19 include the following: (1) institute informal settlements/slum emergency planning committees in every urban informal settlement; (2) apply an immediate moratorium on evictions; (3) provide an immediate guarantee of payments to the poor; (4) immediately train and deploy community health workers; (5) immediately meet Sphere Humanitarian standards for water, sanitation, and hygiene; (6) provide immediate food assistance; (7) develop and implement a solid waste collection strategy; and (8) implement immediately a plan for mobility and health care. Lessons have been learned from earlier pandemics such as HIV and epidemics such as Ebola. They can be applied here. At the same time, the opportunity exists for public health, public administration, international aid, NGOs, and community groups to innovate beyond disaster response and move toward long-term plans.

We carried out a genome-wide association study of type-2 diabetes (T2D) in individuals of South Asian ancestry. Our discovery set included 5,561 individuals with T2D (cases) and 14,458 controls drawn from studies in London, Pakistan and Singapore. We identified 20 independent SNPs associated with T2D at P < 10(-4) for testing in a replication sample of 13,170 cases and 25,398 controls, also all of South Asian ancestry. In the combined analysis, we identified common genetic variants at six loci (GRB14, ST6GAL1, VPS26A, HMG20A, AP3S2 and HNF4A) newly associated with T2D (P = 4.1 × 10(-8) to P = 1.9 × 10(-11)). SNPs at GRB14 were also associated with insulin sensitivity (P = 5.0 × 10(-4)), and SNPs at ST6GAL1 and HNF4A were also associated with pancreatic beta-cell function (P = 0.02 and P = 0.001, respectively). Our findings provide additional insight into mechanisms underlying T2D and show the potential for new discovery from genetic association studies in South Asians, a population with increased susceptibility to T2D.

BACKGROUND: For more than three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has provided a framework to quantify health loss due to diseases, injuries, and associated risk factors. This paper presents GBD 2023 findings on disease and injury burden and risk-attributable health loss, offering a global audit of the state of world health to inform public health priorities. This work captures the evolving landscape of health metrics across age groups, sexes, and locations, while reflecting on the remaining post-COVID-19 challenges to achieving our collective global health ambitions. METHODS: The GBD 2023 combined analysis estimated years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 375 diseases and injuries, and risk-attributable burden associated with 88 modifiable risk factors. Of the more than 310 000 total data sources used for all GBD 2023 (about 30% of which were new to this estimation round), more than 120 000 sources were used for estimation of disease and injury burden and 59 000 for risk factor estimation, and included vital registration systems, surveys, disease registries, and published scientific literature. Data were analysed using previously established modelling approaches, such as disease modelling meta-regression version 2.1 (DisMod-MR 2.1) and comparative risk assessment methods. Diseases and injuries were categorised into four levels on the basis of the established GBD cause hierarchy, as were risk factors using the GBD risk hierarchy. Estimates stratified by age, sex, location, and year from 1990 to 2023 were focused on disease-specific time trends over the 2010-23 period and presented as counts (to three significant figures) and age-standardised rates per 100 000 person-years (to one decimal place). For each measure, 95% uncertainty intervals [UIs] were calculated with the 2·5th and 97·5th percentile ordered values from a 250-draw distribution. FINDINGS: Total numbers of global DALYs grew 6·1% (95% UI 4·0-8·1), from 2·64 billion (2·46-2·86) in 2010 to 2·80 billion (2·57-3·08) in 2023, but age-standardised DALY rates, which account for population growth and ageing, decreased by 12·6% (11·0-14·1), revealing large long-term health improvements. Non-communicable diseases (NCDs) contributed 1·45 billion (1·31-1·61) global DALYs in 2010, increasing to 1·80 billion (1·63-2·03) in 2023, alongside a concurrent 4·1% (1·9-6·3) reduction in age-standardised rates. Based on DALY counts, the leading level 3 NCDs in 2023 were ischaemic heart disease (193 million [176-209] DALYs), stroke (157 million [141-172]), and diabetes (90·2 million [75·2-107]), with the largest increases in age-standardised rates since 2010 occurring for anxiety disorders (62·8% [34·0-107·5]), depressive disorders (26·3% [11·6-42·9]), and diabetes (14·9% [7·5-25·6]). Remarkable health gains were made for communicable, maternal, neonatal, and nutritional (CMNN) diseases, with DALYs falling from 874 million (837-917) in 2010 to 681 million (642-736) in 2023, and a 25·8% (22·6-28·7) reduction in age-standardised DALY rates. During the COVID-19 pandemic, DALYs due to CMNN diseases rose but returned to pre-pandemic levels by 2023. From 2010 to 2023, decreases in age-standardised rates for CMNN diseases were led by rate decreases of 49·1% (32·7-61·0) for diarrhoeal diseases, 42·9% (38·0-48·0) for HIV/AIDS, and 42·2% (23·6-56·6) for tuberculosis. Neonatal disorders and lower respiratory infections remained the leading level 3 CMNN causes globally in 2023, although both showed notable rate decreases from 2010, declining by 16·5% (10·6-22·0) and 24·8% (7·4-36·7), respectively. Injury-related age-standardised DALY rates decreased by 15·6% (10·7-19·8) over the same period. Differences in burden due to NCDs, CMNN diseases, and injuries persisted across age, sex, time, and location. Based on our risk analysis, nearly 50% (1·27 billion [1·18-1·38]) of the roughly 2·80 billion total global DALYs in 2023 were attributable to the 88 risk factors analysed in GBD. Globally, the five level 3 risk factors contributing the highest proportion of risk-attributable DALYs were high systolic blood pressure (SBP), particulate matter pollution, high fasting plasma glucose (FPG), smoking, and low birthweight and short gestation-with high SBP accounting for 8·4% (6·9-10·0) of total DALYs. Of the three overarching level 1 GBD risk factor categories-behavioural, metabolic, and environmental and occupational-risk-attributable DALYs rose between 2010 and 2023 only for metabolic risks, increasing by 30·7% (24·8-37·3); however, age-standardised DALY rates attributable to metabolic risks decreased by 6·7% (2·0-11·0) over the same period. For all but three of the 25 leading level 3 risk factors, age-standardised rates dropped between 2010 and 2023-eg, declining by 54·4% (38·7-65·3) for unsafe sanitation, 50·5% (33·3-63·1) for unsafe water source, and 45·2% (25·6-72·0) for no access to handwashing facility, and by 44·9% (37·3-53·5) for child growth failure. The three leading level 3 risk factors for which age-standardised attributable DALY rates rose were high BMI (10·5% [0·1 to 20·9]), drug use (8·4% [2·6 to 15·3]), and high FPG (6·2% [-2·7 to 15·6]; non-significant). INTERPRETATION: Our findings underscore the complex and dynamic nature of global health challenges. Since 2010, there have been large decreases in burden due to CMNN diseases and many environmental and behavioural risk factors, juxtaposed with sizeable increases in DALYs attributable to metabolic risk factors and NCDs in growing and ageing populations. This long-observed consequence of the global epidemiological transition was only temporarily interrupted by the COVID-19 pandemic. The substantially decreasing CMNN disease burden, despite the 2008 global financial crisis and pandemic-related disruptions, is one of the greatest collective public health successes known. However, these achievements are at risk of being reversed due to major cuts to development assistance for health globally, the effects of which will hit low-income countries with high burden the hardest. Without sustained investment in evidence-based interventions and policies, progress could stall or reverse, leading to widespread human costs and geopolitical instability. Moreover, the rising NCD burden necessitates intensified efforts to mitigate exposure to leading risk factors-eg, air pollution, smoking, and metabolic risks, such as high SBP, BMI, and FPG-including policies that promote food security, healthier diets, physical activity, and equitable and expanded access to potential treatments, such as GLP-1 receptor agonists. Decisive, coordinated action is needed to address long-standing yet growing health challenges, including depressive and anxiety disorders. Yet this can be only part of the solution. Our response to the NCD syndemic-the complex interaction of multiple health risks, social determinants, and systemic challenges-will define the future landscape of global health. To ensure human wellbeing, economic stability, and social equity, global action to sustain and advance health gains must prioritise reducing disparities by addressing socioeconomic and demographic determinants, ensuring equitable health-care access, tackling malnutrition, strengthening health systems, and improving vaccination coverage. We live in times of great opportunity. FUNDING: Gates Foundation and Bloomberg Philanthropies.

Changes in indices of climate extremes are studied on the basis of daily series of temperature and precipitation observations from 116 meteorological stations in central and south Asia. Averaged over all stations, the indices of temperature extremes indicate warming of both the cold tail and the warm tail of the distributions of daily minimum and maximum temperature between 1961 and 2000. For precipitation, most regional indices of wet extremes show little change in this period as a result of low spatial trend coherence with mixed positive and negative station trends. Relative to the changes in the total amounts, there is a slight indication of disproportionate changes in the precipitation extremes. Stations with near‐complete data for the longer period of 1901–2000 suggest that the recent trends in extremes of minimum temperature are consistent with long‐term trends, whereas the recent trends in extremes of maximum temperature are part of multidecadal climate variability.

BACKGROUND: Hirsutism, defined by the presence of excessive terminal hair in androgen-sensitive areas of the female body, is one of the most common disorders in women during reproductive age. METHODS: We conducted a systematic review and critical assessment of the available evidence pertaining to the epidemiology, pathophysiology, diagnosis and management of hirsutism. RESULTS: The prevalence of hirsutism is ~10% in most populations, with the important exception of Far-East Asian women who present hirsutism less frequently. Although usually caused by relatively benign functional conditions, with the polycystic ovary syndrome leading the list of the most frequent etiologies, hirsutism may be the presenting symptom of a life-threatening tumor requiring immediate intervention. CONCLUSIONS: Following evidence-based diagnostic and treatment strategies that address not only the amelioration of hirsutism but also the treatment of the underlying etiology is essential for the proper management of affected women, especially considering that hirsutism is, in most cases, a chronic disorder needing long-term follow-up. Accordingly, we provide evidence-based guidelines for the etiological diagnosis and for the management of this frequent medical complaint.

Objective To systematically review the research conducted on prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries (LMICs) and to estimate the pooled prevalence of frailty and prefrailty in community-dwelling older adults in LMICs. Design Systematic review and meta-analysis. PROSPERO registration number is CRD42016036083. Data sources MEDLINE, EMBASE, AMED, Web of Science, CINAHL and WHO Global Health Library were searched from their inception to 12 September 2017. Setting Low-income and middle-income countries. Participants Community-dwelling older adults aged ≥60 years. Results We screened 7057 citations and 56 studies were included. Forty-seven and 42 studies were included in the frailty and prefrailty meta-analysis, respectively. The majority of studies were from upper middle-income countries. One study was available from low-income countries. The prevalence of frailty varied from 3.9% (China) to 51.4% (Cuba) and prevalence of prefrailty ranged from 13.4% (Tanzania) to 71.6% (Brazil). The pooled prevalence of frailty was 17.4% (95% CI 14.4% to 20.7%, I 2 =99.2%) and prefrailty was 49.3% (95% CI 46.4% to 52.2%, I 2 =97.5%). The wide variation in prevalence rates across studies was largely explained by differences in frailty assessment method and the geographic region. These findings are for the studies with a minimum recruitment age 60, 65 and 70 years. Conclusion The prevalence of frailty and prefrailty appears higher in community-dwelling older adults in upper middle-income countries compared with high-income countries, which has important implications for healthcare planning. There is limited evidence on frailty prevalence in lower middle-income and low-income countries. PROSPERO registration number CRD42016036083 .

BACKGROUND: In traditional medicine Cinnamon is considered a remedy for respiratory, digestive and gynaecological ailments. In-vitro and in-vivo studies from different parts of the world have demonstrated numerous beneficial medicinal effects of Cinnamomum zeylanicum (CZ). This paper aims to systematically review the scientific literature and provide a comprehensive summary on the potential medicinal benefits of CZ. METHODS: A comprehensive systematic review was conducted in the following databases; PubMed, Web of Science, SciVerse Scopus for studies published before 31st December 2012. The following keywords were used: "Cinnamomum zeylanicum", "Ceylon cinnamon", "True cinnamon" and "Sri Lankan cinnamon". To obtain additional data a manual search was performed using the reference lists of included articles. RESULTS: The literature search identified the following number of articles in the respective databases; PubMed=54, Web of Science=76 and SciVerse Scopus=591. Thirteen additional articles were identified by searching reference lists. After removing duplicates the total number of articles included in the present review is 70. The beneficial health effects of CZ identified were; a) anti-microbial and anti-parasitic activity, b) lowering of blood glucose, blood pressure and serum cholesterol, c) anti-oxidant and free-radical scavenging properties, d) inhibition of tau aggregation and filament formation (hallmarks of Alzheimer's disease), e) inhibitory effects on osteoclastogenesis, f) anti-secretagogue and anti-gastric ulcer effects, g) anti-nociceptive and anti-inflammatory activity, h) wound healing properties and i) hepato-protective effects. The studies reported minimal toxic and adverse effects. CONCLUSIONS: The available in-vitro and in-vivo evidence suggests that CZ has many beneficial health effects. However, since data on humans are sparse, randomized controlled trials in humans will be necessary to determine whether these effects have public health implications.

The objective of this review is to explore green human resource management practices of organisations based on the existent literature. In this emerging field, it has been generally observed that the existent literature has to be extended further from the perspective of functions of Human Resource Management (HRM). It reveals that much of the past research focused on a few functions of HRM such as recruitment, training and development, performance evaluation and reward management in integrating environmental management with HRM though HRM has more potential and scope in improving organisation’s environmental performance. Hence, this review incorporates diverse functions of HRM to explore the respective green HRM practices under those functions. The findings of the review have identified and highlighted several green HRM practices under the 12 functions of HRM such as job design, job analysis, human resource planning, recruitment, selection, induction, performance evaluation, training and development, reward management, discipline management, health and safety management and employee relations. The contribution of this paper lies in extending the scope and depth of green HRM in materializing sustainable environmental performance of organisations.

Abstract A laboratory investigation of electric charge transfer during the impact of vapour‐grown ice crystals and supercooled water droplets upon a simulated soft‐hailstone target has shown that the magnitude of the charge transferred to the riming surface when crystals separate from it is a function of temperature, crystal dimension, relative velocity, liquid water content, and impurity content of the water droplets and hence the impurity content of the riming target. The sign of the charge transfer depends on temperature, liquid water content and droplet and rime impurity content. In the absence of crystals, no charge transfer was detected during riming. In the absence of supercooled water droplets, crystals impacting at 10ms 1 on an evaporating rime target produced a small negative charge on the rime of less than − 0.25fC per separating crystal. When the target surface grew by vapour diffusion it gained a small positive charge during such interactions. Much larger charges and completely different charge transfer behaviour was noted during riming. The target became positively charged at high liquid water contents and temperatures above a critical value, but negatively charged at lower temperatures or with lower liquid water contents. The critical sign reversal temperature at a liquid water content of 1 gm −3 was about − 20°C. At − 10°C with a liquid water content of 2gm −3 , a 125 μm crystal impacting at 3ms −1 charged the target by +101C upon separation. The charge transfer increased sharply with impact speed and crystal size. Warming the positively charging rime to cause it to evaporate failed to reverse the sign of the charge transfer. Experiments with impurities showed that the sign reversal temperature increased if the droplets contained contaminants at concentrations found in cloud water. It is suggested that there are two distinct charge transfer processes during crystal interactions with an ice target, the dominant one requiring the presence of supercooled water droplets. Careful control and knowledge of the microphysical properties of the clouds used in these experimental simulations has permitted an examination of charge transfer under many of the conditions used in previous studies. The results provide an understanding of the differences and a reconciliation between some of the previously disparate findings in terms of the two distinct charge transfer regimes.

BACKGROUND: The objectives were to assess thoughts about suicide, plans to commit suicide and suicide attempts in the community, to investigate the use of health services following a suicide attempt, and to describe basic socio-cultural indices of the community. METHOD: The community survey was one component of the larger WHO multisite intervention study on suicidal behaviours (SUPRE-MISS). In each site, it aimed at randomly selecting and interviewing at least 500 subjects of the general population living in the catchment area of the emergency department where the intervention component of the study was conducted. Communities of eight SUPRE-MISS sites (in Brazil, China, Estonia, India, Iran, South Africa, Sri Lanka, and Viet Nam) participated plus two additional sites from Australia and Sweden conducting similar surveys. RESULTS: Suicide attempts (0.4-4.2%), plans (1.1-15.6%), and ideation (2.6-25.4%) varied by a factor of 10-14 across sites, but remained mostly within the ranges of previously published data. Depending on the site, the ratios between attempts, plans, and thoughts of suicide differed substantially. Medical attention following a suicide attempt varied between 22% and 88% of the attempts. CONCLUSIONS: The idea of the suicidal process as a continuous and smooth evolution from thoughts to plans and attempts of suicide needs to be further investigated as it seems to be dependent on the cultural setting. There are indications, that the burden of undetected attempted suicide is high in different cultures; an improved response from the health sector on how to identify and support these individuals is needed.