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Objective: Detection of vascular endothelial growth factor (VEGF) levels in ocular tissue may perhaps provide insight into the role of VEGF in the pathogenesis and progression of diabetic retinopathy (DR). The aim of this study was to evaluate the levels of VEGF in tears and serum amongst type 2 diabetes mellitus (DM) patients. Methods: A comparative cross-sectional study was conducted between August 2016 and May 2018 involving type 2 DM patients with no DR, non-proliferative DR (NPDR), and proliferative DR (PDR). Tear samples were collected using no.41 Whatman filter paper (Schirmer strips) and 5 mL blood samples were drawn by venous puncture. VEGF levels in tears and serum were measured by enzyme-linked immunosorbent assay. Results: A total of 88 type 2 DM patients (no DR: 30 patients, NPDR: 28 patients, PDR: 30 patients) were included in the study. Mean tear VEGF levels were significantly higher in the NPDR and PDR groups (114.4 SD 52.5 pg/mL and 150.8 SD 49.7 pg/mL, respectively) compared to the no DR group (40.4 SD 26.5 pg/mL, p < 0.001). There was no significant difference in the mean serum VEGF levels between the three groups. There was a fair correlation between serum and tear VEGF levels (p = 0.015, r = 0.263). Conclusion: VEGF levels in tears were significantly higher amongst diabetic patients with DR compared to those without DR and were significantly associated with the severity of DR. There was a fair correlation between serum and tear VEGF levels. Detection of VEGF in tears is a good non-invasive predictor test for the severity of DR. A large cohort study is needed for further evaluation. [ABSTRACT FROM AUTHOR]

Aim: To provide a comprehensive overview of cardiovascular disease (CVD) risk prediction models for women and models that include female-specific predictors. Methods: We performed a systematic review of CVD risk prediction models for women in the general population by updating a previous review. We searched Medline and Embase up to July 2017 and included studies in which; (a) a new model was developed, (b) an existing model was validated, or (c) a predictor was added to an existing model. Results: A total of 285 prediction models for women have been developed, of these 160 (56%) were female-specific models, in which a separate model was developed solely in women and 125 (44%) were sex-predictor models. Out of the 160 female-specific models, 2 (1.3%) included one or more female-specific predictors (mostly reproductive risk factors). A total of 591 validations of sex-predictor or female-specific models were identified in 206 papers. Of these, 333 (56%) validations concerned nine models (five versions of Framingham, SCORE, Pooled Cohort Equations and QRISK). The median and pooled C statistics were comparable for sex-predictor and female-specific models. In 260 articles the added value of new predictors to an existing model was described, however in only 3 of these female-specific predictors (reproductive risk factors) were added. Conclusions: There is an abundance of models for women in the general population. Female-specific and sex-predictor models have similar predictors and performance. Female-specific predictors are rarely included. Further research is needed to assess the added value of female-specific predictors to CVD models for women and provide physicians with a well-performing prediction model for women. [ABSTRACT FROM AUTHOR]

Objectives: The present paper aims to characterize the Angiotensin-converting enzyme (ACE) genotype, with particular emphasis on its association with arterial oxygen saturation, arterial blood pressure, hemoglobin [Hb] concentration, and ventilatory measures among the Tawang Monpa, a high-altitude native population of the Eastern Himalaya, India. Methods: A cross-sectional sample of 168Monpa participants from Tawang town, Arunachal Pradesh, India, was selected who live at an altitude of ∼3,200 meters (m) above sea level. For each participant, height, weight, and skinfold thickness were measured, based on which body mass index (BMI, kg/m2) and percentage of body fat (%BF) were calculated. Physiological measures, such as the transcutaneous arterial oxygen saturation (SaO2), hemoglobin [Hb] concentration, forced vital capacity (FVC), forced expiratory volume in 1-second (FEV1), and systemic arterial blood pressure were measured. First, the peripheral venous blood samples (four ml) were drawn, and then white blood cells were separated for the ACE genotyping of each participant. Results: Unlike high-altitude natives from Peru and Ladakh, who exhibit high frequencies of II homozygotes, the Tawang Monpa shows a significantly high frequency of ID heterozygotes (p<0.0001). In addition, no significant association was identified between ACE gene polymorphism and arterial blood pressure, oxygen saturation at rest, vital capacity, or [Hb] concentration. Discussion: The results suggest that the association of the ACE gene with resting SaO2 is inconsistent across native populations living under hypobaric hypoxia. Further, ACE I/D gene polymorphism may not be under natural selection in specific native populations, including Tawang Monpa, for their adaptation to high-altitude hypoxia. [ABSTRACT FROM AUTHOR]

In March 2020, the World Health Organisation named the severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2), which causes corona virus disease 2019 (COVID –19), as a pandemic. Pregnant women were considered at increased risk of developing severe COVID-19 after viral infection. In response maternity services reduced face-to-face consultations with high-risk pregnant women by supplying blood pressure monitors for supported self-monitoring. This paper explores the experiences of patients and clinicians of the rapid roll-out of supported self-monitoring programme in Scotland during the first and second wave of the COVID-19 pandemic. We conducted semi-structured telephone interviews with high-risk women and healthcare professionals who were using supported self-monitoring of blood pressure (BP) In four case studies during the COVID-19 pandemic. 20 women, 15 midwives and 4 obstetricians took part in the interviews. Interviews with healthcare professionals showed that while implementation occurred at pace and at scale across the National Health Service (NHS) in Scotland, implementation differed locally, resulting in mixed experiences. Study Participants observed several barriers and facilitators to implementation. Women value the simplicity of use and convenience of the digital communications platforms while health professionals were more interested in their impact on reducing workload for both women and health professionals largely found self-monitoring acceptable, with only a few exceptions. These results show that rapid change can occur in the NHS at a national level when there is a shared motivation. While self-monitoring is acceptable to most women, decisions regarding self-monitoring should be made jointly and on an individual basis. [ABSTRACT FROM AUTHOR]

Introduction: Hypertension is a widespread condition when the blood's force on the artery walls is extremely high to develop adverse health effects. This paper aimed to jointly model the longitudinal change of blood pressures (systolic and diastolic) and time to the first remission of hypertensive outpatients receiving treatment. Methods: A retrospective study design was used to collect appropriate data on longitudinal changes in blood pressure and time-to-event from the medical charts of 301 hypertensive outpatients under follow-up at Felege Hiwot referral hospital, Ethiopia. The data exploration was done using summary statistics measures, individual profile plots, Kaplan-Meier plots, and log-rank tests. To get wide-ranging information about the progression, joint multivariate models were employed. Results: A total of 301 hypertensive patients who take treatment was taken from Felege Hiwot referral hospital recorded between Sep. 2018 to Feb. 2021. Of this 153 (50.8%) were male, and 124 (49.2%) were residents from rural areas. About 83(27.6%), 58 (19.3%), 82 (27.2%), and 25 (8.3%) have a history of diabetes mellitus, cardiovascular disease, stroke, and HIV respectively. The median time of hypertensive patients to have first remission time was 11 months. The hazard of the patient's first remission time for males was 0.63 times less likely than the hazard for females. The time to attain the first remission for patients who had a history of diabetes mellitus was 46% lower than for those who had no history of diabetes mellitus. Conclusion: Blood pressure dynamics significantly affect the time to the first remission of hypertensive outpatients receiving treatment. The patients who had a good follow-up, lower BUN, lower serum calcium, lower serum sodium, lower hemoglobin, and take the treatment enalapril showed an opportunity in decreasing their blood pressure. This compels patients to experience the first remission early. Besides, age, patient's history of diabetes, patient's history of cardiovascular disease, and treatment type were the joint determinant factors for the longitudinal change of BP and the first remission time. The Bayesian joint model approach provides specific dynamic predictions, wide-ranging information about the disease transitions, and better knowledge of disease etiology. [ABSTRACT FROM AUTHOR]

Background: COBRA-BPS (Control of Blood Pressure and Risk Attenuation-Bangladesh, Pakistan, Sri Lanka), a multicomponent, community health-worker (CHW)-led hypertension management program, has been shown to be effective in rural communities in South Asia. This paper presents the acceptability of COBRA-BPS multicomponent intervention among the key stakeholders. Methods: We conducted post-implementation interviews of 87 stakeholder including 23 community health workers (CHWs), 19 physicians and 45 patients in 15 rural communities randomized to COBRA-BPS multicomponent intervention in in Bangladesh, Pakistan, and Sri Lanka. We used Theoretical Framework for Acceptability framework (TFA) with a focus on affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness and self-efficacy. Results: COBRA-BPS multicomponent intervention was acceptable to most stakeholders. Despite some concerns about workload, most CHWs were enthusiastic and felt empowered. Physicians appreciated the training sessions and felt trusted by their patients. Patients were grateful to receive the intervention and valued it. However, patients in Pakistan and Bangladesh expressed the need for supplies of free medicines from the primary health facilities, while those in Sri Lanka were concerned about supplies' irregularities. All stakeholders favoured scaling-up COBRA-BPS at a national level. Conclusions: COBRA-BPS multicomponent intervention is acceptable to the key stakeholders in Bangladesh, Pakistan and Sri Lanka. Community engagement for national scale-up of COBRA-BPS is likely to be successful in all three countries. [ABSTRACT FROM AUTHOR]

Background: Fear of orthostatic hypotension (OH) and a reported association with an increased risk of cardiovascular (CV) events may limit antihypertensive treatment after stroke/TIA. In the NAILED trial, systematic titration of antihypertensive treatment resulted in lower blood pressure (BP) and reduced the incidence of stroke. Our aim was to assess the association between OH and CV events or death in a stroke/TIA population and the association between group allocation in the NAILED trial and risk of OH during follow-up. Methods and findings: This post-hoc analysis included all patients with complete BP measurement at baseline in the NAILED trial (n = 814). OH was defined as a drop in systolic BP ≥20 or diastolic BP ≥10 mmHg 1 minute after standing from a seated position. The association between OH and a composite of stroke, myocardial infarction, or death was assessed using an adjusted Cox regression model with OH as a time-varying variable. The association between group allocation (intervention vs. control) and OH was assessed using logistic regression. During a mean follow-up of 4.8 years, 35.3% of patients had OH at some point. OH was not significantly associated with the composite outcome (HR: 1.11, 95% CI: 0.80–1.54). Allocation to the intervention group in the NAILED trial was not associated with OH during follow-up (OR: 0.84, 95% CI: 0.62–1.13). Conclusions: OH was not associated with an increased risk of CV events or death in this stroke/TIA population. Systematic titration of antihypertensive treatment did not increase the prevalence of OH compared to usual care. Thus, OH did not reduce the gains of antihypertensive treatment. [ABSTRACT FROM AUTHOR]

Background: Physical activity, a first-line approach for the treatment of non-gestational hypertension globally, has been shown to benefit most pregnant women in many respects. The benefits and risks of prenatal physical activity in complicated pregnancies, such as preeclampsia and chronic hypertension, require further investigation. It is worth conducting studies to address questions about physical activity during pregnancy in women with chronic hypertension, such as the benefits and risks, frequency, duration, and intensity. This prospective cohort study aims to investigate whether moderate-intensity daily physical activity reduces ambulatory blood pressure in pregnant women with chronic hypertension. Methods: Pregnant women with chronic hypertension at 11+0 to 13+6 gestational weeks will be recruited from the outpatient clinic and divided into moderate- and light-intensity physical activity groups according to the intensity of the 7-day physical activity monitored using the model wGT3X-BT accelerometer. 24-h ambulatory blood pressure monitoring will be performed at enrollment as a baseline and will be repeated in the second and third trimesters. The primary outcome is the difference in the change in 24-h ambulatory systolic blood pressure from the first to the third trimester between the groups. Secondary outcomes include the difference of change in other ambulatory (24-h diastolic, daytime, and nighttime) and office blood pressure variables from the first to the second and third trimesters, the incidence of severe hypertension (≥160/110 mmHg), and changes in the type and dosage of antihypertensive medication. The primary and secondary outcomes related to changes in blood pressure from baseline to the second and third trimesters between the groups will be analyzed using Student's independent t-test or the Mann–Whitney U test. Discussion: This cohort study will provide a basis for randomized controlled trials and verify an easily achieved, economical, and non-fetotoxic approach for adjuvant blood pressure management in pregnant women with chronic hypertension. Registry: This study is registered with the Chinese Clinical Trials Registry (NO. ChiCTR2200062094). Date Registered: 21/07/2022. [ABSTRACT FROM AUTHOR]

This paper addresses patient-reported outcomes (PROs) and telemonitoring in congestive heart failure (CHF), both increasingly important topics. The interest in CHF trials is shifting from hard end-points such as hospitalization and mortality, to softer end-points such health-related quality of life. However, the relation of these softer end-points to objective parameters is not well studied. Telemonitoring is suitable for collecting both patient-reported outcomes and objective parameters. Most telemonitoring studies, however, do not take full advantage of the available sensor technology and intelligent data analysis. The Chiron clinical observational study was performed among 24 CHF patients (17 men and 7 women, age 62.9 ± 9.4 years, 15 NYHA class II and 9 class III, 10 of ishaemic, aetiology, 6 dilated, 2 valvular, and 6 of multiple aetiologies or cardiomyopathy) in Italy and UK. A large number of physiological and ambient parameters were collected by wearable and other devices, together with PROs describing how well the patients felt, over 1,086 days of observation. The resulting data were mined for relations between the objective parameters and the PROs. The objective parameters (humidity, ambient temperature, blood pressure, SpO2, and sweeting intensity) could predict the PROs with accuracies up to 86% and AUC up to 0.83, making this the first report providing evidence for ambient and physiological parameters to be objectively related to PROs in CHF patients. We also analyzed the relations in the predictive models, gaining some insights into what affects the feeling of health, which was also generally not attempted in previous investigations. The paper strongly points to the possibility of using PROs as primary end-points in future trials. [ABSTRACT FROM AUTHOR]

Objective: This paper reflected on the prevalence of hypertension and diabetes in Bangladesh, which is spreading rapidly in low-income countries. The rationale of constructing more health centers for addressing NCDs was assessed in this paper by determining the relationship between prevalence of NCDs, particularly hypertension and diabetes, and distance to health facilities. Methods: From BDHS (Bangladesh Health and Demographic Survey) 2011 data set, 7544 samples were analyzed to demonstrate association between Non-communicable diseases (NCD) and distance from respondents’ home to health facilities like hospitals, community clinics, pharmacies or doctors’ chambers, and community facilities like market, post office or cinema hall. Bivariate analysis was conducted between accessibility to health facilities and prevalence of the diseases. The causal relationship between the spatial effects and the prevalence of the diseases were analyzed by applying Generalized Linear Mixed Model (GLMM) was fitted. Results: Fitting linear mixed effect models, we found that hypertension and diabetes react differently with various spatial effects. Distance from home to hospital had significant effect (P < 0.001) on hypertension showing people living further from the facilities or town centers seemed to be less hypertensive, whereas diabetes showed no such affiliation. Conclusion: Higher prevalence of diabetes (40.9%) over hypertension (26.5%) in people aging 35 or higher, have appeared to have caused the difference, which concluded that each non-communicable disease should be dealt to its own merit for policy making instead considering as a group of diseases. [ABSTRACT FROM AUTHOR]

Antibiotic resistance is a worldwide problem that is increasing largely due to the misuse of antibiotics in human health and agriculture. This situation is further exacerbated by a dearth of new antibiotic development, the focus of pharmaceutical companies having shifted to more lucrative treatments for chronic conditions such as elevated blood pressure. To conserve the efficacy of the current crop of antibiotics, it is vital that they are used appropriately by individuals. Effective education may be a means to achieve such appropriate use. This paper reports on a large-scale, mixed methods study, which employed a survey and oral questionnaires, undertaken with senior secondary Omani students. The study explored students' understanding of antibiotic resistance as well as their attitudes to the issue of antibiotic resistance. The study findings indicated that, although some students had a reasonably clear understanding of antibiotic resistance, many had serious misconceptions that could result in misuse of antibiotics. The article concludes with suggestions for amending secondary school pedagogy in Oman to address the misconceptions. [ABSTRACT FROM AUTHOR]

Objectives: Little is known about the gender and age differences associated with the effects of economic fluctuations on hospitalization for cardiovascular diseases. This paper investigates the impact of economic fluctuations on hospitalization for ischemic heart disease (IHD), stroke, and hypertension by age and gender between January 1996 and December 2012 in Taiwan. Methods: We adopted a multiple-input time series analysis to examine the strength of the immediate and latent effects of the 17-year quarterly unemployment rates (UR), air pollution exposure (APE), gross domestic product (GDP), per capita consumption expenditure in cigarette and alcohol (ECA), and per capita healthcare expenditure (HE) on the adjusted quarterly incidence rate of hospitalization. The data used in this paper were retrieved from the National Health Insurance Research Database and the website of the Directorate-General of Budget, Accounting and Statistics (DGBAS), Executive Yuan. Results: Our findings indicate that higher UR increased IHD hospitalization in young men and women and middle-aged women but reduced stroke hospitalization in young men. Higher APE increased IHD hospitalization in young men but reduced it for young women, increased stroke hospitalization in old men and middle-aged women but reduced it for young men, and increased hypertension hospitalization in middle-aged men and young women. Higher ECA reduced IHD hospitalization in middle-aged men, increased stoke hospitalization in middle-aged and old men and middle-aged women. Higher HE reduced IHD hospitalization in old men, young and old women, reduced stroke hospitalization in old women, and reduced hypertension hospitalization in young and middle-aged women. Conclusions: Overall, we found that the economic fluctuations caused increased harmful effects in certain population subgroups but also brought some soothing effects to some groups. [ABSTRACT FROM AUTHOR]

Background and objectives: ECG signal is relatively weak and vulnerable to various noise interferences, such as electromyography. There will be robustness problems when detecting the instantaneous heart rate independently. In some cases, multiple human physiologic parameters are monitored to help in heart rate detection. Methods: In this paper, an algorithm that marks the R-wave peaks with the help of simultaneously recorded continuous blood pressure is proposed and tested on two databases. One database, called the challenge database, is provided by the PhysioNet/Computing in Cardiology Challenge 2014, and the other is the MGH/MF waveform database. Results: The final scores of the proposed algorithm are 97.3% for the challenge database and 96.6% for the MGH/MF waveform database. Conclusions: The experimental results show that this algorithm has high detection accuracy and a relatively strong robustness. [ABSTRACT FROM AUTHOR]

Introduction: Previous research has shown that statin adherence for the primary prevention of CVD is lower compared to secondary prevention populations. Therefore the aim of this systematic review was to review predictors of statin adherence for the primary prevention of CVD. Methods: A systematic search of papers published between Jan 1984 and May 2017 was conducted in PubMed, PsycINFO, EMbase and CINAHL databases. A study was eligible for inclusion if; 1) it was a study of the general population or of patients with familial hypercholesterolemia, hypertension, diabetes or arthritis; 2) statins were prescribed; 3) adherence was defined and measured as the extent to which patients followed their statin regimen during the period of prescription, and 4) it was an original trial or observational study (excluding case reports). A study was subsequently excluded if 1) results were not presented separately for primary prevention; 2) it was a trial of an intervention (for example patient education). Papers were reviewed by two researchers and consensus agreed with a third. A quality assessment (QA) tool was used to formally assess each included article. To evaluate the effect of predictors, data were quantitatively and qualitatively synthesised. Results: In total 19 studies met the inclusion criteria and nine were evaluated as high quality using the QA tool. The proportion of patients classed as “adherent” ranged from 17.8% to 79.2%. Potential predictors of statin adherence included traditional risk factors for CVD such as age, being male, diabetes and hypertension. Income associated with adherence more strongly in men than women, and highly educated men were more likely and highly educated women less likely to be adherent. Alcohol misuse and high BMI associated with non-adherence. There was no association between polypharmacy and statin adherence. The evidence base for the effect of other lifestyle factors and health beliefs on statin adherence was limited. Conclusion: Current evidence suggests that patients with more traditional risk factors for CVD are more likely to be adherent to statins. The implications for future research are discussed. [ABSTRACT FROM AUTHOR]

Introduction: Stroke is a prominent cause of death, disability, and dementia in sub-Saharan Africa (SSA). The Stroke Investigative Research and Education Network works collaboratively with stroke survivors and individuals serving as community controls to comprehensively characterize the genomic, sociocultural, economic and behavioral risk factors for stroke in SSA. Purpose: In this paper, we aim to: i) explore the attitudes, beliefs, and practices related to stroke in Ghana and Nigeria using the process of qualitative description; and ii) propose actions for future research and community-based participation and education. Methods: Stroke survivors, their caregivers, health care professionals, and community representatives and faith-based leaders participated in one of twenty-six focus groups, which qualitatively explored community beliefs, attitudes and practices related to stroke in Ghana and Nigeria. Arthur Kleinman’s Explanatory Model of Illness and the Social Ecological Model guided the questions and/or thematic analysis of the qualitative data. We hereby describe our focus group methods and analyses of qualitative data, as well as the findings and suggestions for improving stroke outcomes. Results and discussion: The major findings illustrate the fears, causes, chief problems, treatment, and recommendations related to stroke through the views of the participants, as well as recommendations for working effectively with the SIREN communities. Findings are compared to SIREN quantitative data and other qualitative studies in Africa. As far as we are aware, this is the first paper to qualitatively explore and contrast community beliefs, attitudes, and practices among stroke survivors and their caregivers, community and faith-based leaders, and health professionals in multiple communities within Nigeria and Ghana. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic, telehealth became a vital resource to contain the virus's spread and ensure continuity of care of patients with a chronic condition, notably arterial hypertension and heart disease. This paper reports the experience based on a telehealth platform used at scale to manage chronic disease patients in the Italian community. Methods and findings: Patients' health status was remotely monitored through ambulatory blood pressure monitoring (ABPM), resting or ambulatory electrocardiogram (ECG), spirometry, sleep oximetry, and cardiorespiratory polysomnography performed in community pharmacies or general practitioners' offices. Patients also monitored their blood pressure (BP), heart rate (HR), blood oxygen saturation (SpO2), body temperature, body weight, waist circumference, blood glucose, and lipids at home through a dedicated smartphone app. All data conveyed to the web-based telehealth platform were used to manage critical patients by doctors promptly. Data were analyzed and compared across three consecutive periods of 2 months each: i) before the national lockdown, ii) during the lockdown (from March 9 to May 17, 2020), and iii) after the end of the containment measures. Overall, 13,613 patients visited community pharmacies or doctors' offices. The number of overall tests dropped during and rose after the lockdown. The overall proportion of abnormal tests was larger during the outbreak. A significant increase in the prevalence of abnormal ECGs due to myocardial ischemia, contrasted by a significantly improved BP control, was observed. The number of home users and readings exchanged increased during the pandemic. In 226 patients, a significant increase in the proportion of SpO2 readings and a significant reduction in the entries for all other parameters, except BP, was observed. The proportion of abnormal SpO2 and BP values was significantly lower during the lockdown. Following the lockdown, the proportion of abnormal body weight or waist circumference values increased. Conclusions: Our study results support the usefulness of a telehealth solution to detect deterioration of the health status during the COVID-19 pandemic. Trial registration: The study is registered with ClinicalTrials.gov at number NCT03781401. [ABSTRACT FROM AUTHOR]

Background: The use of food supplements containing botanicals is increasing in European markets. Although intended to maintain the health status, several cases of adverse effects to Plant Food Supplements (PFS) have been described. Objectives: To describe the self-reported adverse effects collected during the European PlantLIBRA PFS Consumer Survey 2011–2012, with a critical evaluation of the plausibility of the symptomatology reported using data from the literature and from the PlantLIBRA Poisons Centers' survey. Subjects/Setting: From the total sample of 2359 consumers involved in the consumers' survey, 82 subjects reported adverse effects due to a total of 87 PFS. Results: Cases were self-reported, therefore causality was not classified on the basis of clinical evidence, but by using the frequency/strength of adverse effects described in scientific papers: 52 out of 87 cases were defined as possible (59.8%) and 4 as probable (4.6%). Considering the most frequently cited botanicals, eight cases were due to Valeriana officinalis (garden valerian); seven to Camellia sinensis (tea); six to Ginkgo biloba (Maidenhair tree) and Paullinia cupana (guarana). Most adverse events related to the gastrointestinal tract, nervous and cardiovascular systems. Conclusions: Comparing the data from this study with those published in scientific papers and obtained by the PlantLIBRA Poisons Centers' survey, some important conclusions can be drawn: severe adverse effects to PFS are quite rare, although mild or moderate adverse symptoms can be present. Data reported in this paper can help health professionals (and in particular family doctors) to become aware of possible new problems associated with the increasing use of food supplements containing botanicals. [ABSTRACT FROM AUTHOR]

Linear Parameter Varying (LPV) systems and their control have gained attraction recently as they approximate nonlinear systems with higher order than ordinary linear systems. On the other hand, time delay is an inherent part of various real-life applications. A supervisory control structure is proposed in this paper for LPV systems subject to time delays. In the proposed control structure, a supervisor selects the most suitable controller from a bank of controllers; which desires to enhance the performance of closed-loop system in contrast with using a single robust controller. The analysis is based on the celebrated Smith predictor for time delay compensation and we provide a sufficient condition to assure the stability of the closed-loop switched system in terms of dwell time. Simulations on blood pressure control of hypertension patients in postoperative scenario are used to exemplify the effectiveness of the utilized technique. The operating region of the system is partitioned into five smaller operating regions to construct corresponding robust controllers and perform hysteresis switching amongst them. Simulation results witnessed that the proposed control scheme demonstrated a pressure undershoot less than the desired value of 10 mmHg while the Mean Arterial Pressure (MAP) remains within ±5 mmHg of the desired value. [ABSTRACT FROM AUTHOR]

Background: The primary objective of National NCD monitoring survey (NNMS) was to generate national-level estimates of key NCD indicators identified in the national NCD monitoring framework. This paper describes survey study protocol and prevalence of risk factors among adults (18–69 years). Materials and methods: NNMS was a national level cross-sectional survey conducted during 2017–18. The estimated sample size was 12,000 households from 600 primary sampling units. One adult (18–69 years) per household was selected using the World Health Organization-KISH grid. The study tools were adapted from WHO-STEPwise approach to NCD risk factor surveillance, IDSP-NCD risk factor survey and WHO-Global adult tobacco survey. Total of 8/10 indicators of adult NCD risk factors according to national NCD disease monitoring framework was studied. This survey for the first time estimated dietary intake of salt intake of population at a national level from spot urine samples. Results: Total of 11139 households and 10659 adults completed the survey. Prevalence of tobacco and alcohol use was 32.8% (95% CI: 30.8–35.0) and 15.9% (95% CI: 14.2–17.7) respectively. More than one-third adults were physically inactive [41.3% (95% CI: 39.4–43.3)], majority [98.4% (95% CI: 97.8–98.8)] consumed less than 5 servings of fruits and / or vegetables per day and mean salt intake was 8 g/day (95% CI: 7.8–8.2). Proportion with raised blood pressure and raised blood glucose were 28.5% (95% CI: 27.0–30.1) and 9.3% (95% CI: 8.3–10.5) respectively. 12.8% (95% CI: 11.2–14.5) of adults (40–69 years) had ten-year CVD risk of ≥30% or with existing CVD. Conclusion: NNMS was the first comprehensive national survey providing relevant data to assess India's progress towards targets in National NCD monitoring framework and NCD Action Plan. Established methodology and findings from survey would contribute to plan future state-based surveys and also frame policies for prevention and control of NCDs. [ABSTRACT FROM AUTHOR]

Background: Peroxisome proliferator-activated receptor gamma (PPARG) plays an important role in the pathogenesis and maintenance of essential hypertension (EH). It has been suggested that polymorphisms of PPARG are associated with the risk of EH. However, findings to date remain controversial. To elucidate the associations between the PPARG Pro12Ala and C161T polymorphisms and EH risk, a meta-analysis was carried out. Methods: A comprehensive literature search of PubMed, Embase, CNKI (Chinese National Knowledge Infrastructure), VIP and Wanfang databases was conducted. The pooled odds ratios (ORs) and 95% confidence interval (CI) were calculated to estimate the size of the effect using the random-effects model. At the same time, the pooled standardized mean difference (SMD) with 95% CI was used for the meta-analysis of the PPARG Pro12Ala polymorphism and blood pressure. Results: Finally, Fifteen papers (seventeen studies) including 4,151 cases and 4,997 controls to evaluate the association of the PPARGPro12Ala polymorphism and EH risk, were included in this study. Overall, the results suggested that Ala allele was associated with the decreased EH risk (for allelic model, OR = 0.757, 95%CI: 0.624–0.918, P = 0.005; for dominant model, OR = 0.771, 95%CI: 0.627–0.946, P = 0.013). The subgroup analysis stratified by ethnicity showed that the significant association between the PPARG Pro12Ala polymorphism and EH was only detected in the Asian subgroup. There was no difference in blood pressure values between Ala carriers and non-carriers. For the C161T polymorphism, only 5 studies comprising 1,118 cases and 1,357 controls met the inclusion criteria. The overall results showed that the PPARG C161T polymorphism was not associated with the risk of EH. But in the subgroup analysis, we found that the PPARG C161T polymorphism significantly associated with the risk of EH in the Asian subgroup (for allelic model, OR = 0.719, 95% CI: 0.537–0.963, P = 0.027; for dominant model, OR = 0.653, 95% CI: 0.439–0.972, P = 0.036). Conclusion: Our meta-analysis suggested that the PPARG polymorphisms might be associated with the risk of EH. [ABSTRACT FROM AUTHOR]

Background: Non-communicable disease (NCD) prevention strategies now prioritise four major risk factors: food, tobacco, alcohol and physical activity. Dietary salt intake remains much higher than recommended, increasing blood pressure, cardiovascular disease and stomach cancer. Substantial reductions in salt intake are therefore urgently needed. However, the debate continues about the most effective approaches. To inform future prevention programmes, we systematically reviewed the evidence on the effectiveness of possible salt reduction interventions. We further compared “downstream, agentic” approaches targeting individuals with “upstream, structural” policy-based population strategies. Methods: We searched six electronic databases (CDSR, CRD, MEDLINE, SCI, SCOPUS and the Campbell Library) using a pre-piloted search strategy focussing on the effectiveness of population interventions to reduce salt intake. Retrieved papers were independently screened, appraised and graded for quality by two researchers. To facilitate comparisons between the interventions, the extracted data were categorised using nine stages along the agentic/structural continuum, from “downstream”: dietary counselling (for individuals, worksites or communities), through media campaigns, nutrition labelling, voluntary and mandatory reformulation, to the most “upstream” regulatory and fiscal interventions, and comprehensive strategies involving multiple components. Results: After screening 2,526 candidate papers, 70 were included in this systematic review (49 empirical studies and 21 modelling studies). Some papers described several interventions. Quality was variable. Multi-component strategies involving both upstream and downstream interventions, generally achieved the biggest reductions in salt consumption across an entire population, most notably 4g/day in Finland and Japan, 3g/day in Turkey and 1.3g/day recently in the UK. Mandatory reformulation alone could achieve a reduction of approximately 1.45g/day (three separate studies), followed by voluntary reformulation (-0.8g/day), school interventions (-0.7g/day), short term dietary advice (-0.6g/day) and nutrition labelling (-0.4g/day), but each with a wide range. Tax and community based counselling could, each typically reduce salt intake by 0.3g/day, whilst even smaller population benefits were derived from health education media campaigns (-0.1g/day). Worksite interventions achieved an increase in intake (+0.5g/day), however, with a very wide range. Long term dietary advice could achieve a -2g/day reduction under optimal research trial conditions; however, smaller reductions might be anticipated in unselected individuals. Conclusions: Comprehensive strategies involving multiple components (reformulation, food labelling and media campaigns) and “upstream” population-wide policies such as mandatory reformulation generally appear to achieve larger reductions in population-wide salt consumption than “downstream”, individually focussed interventions. This ‘effectiveness hierarchy’ might deserve greater emphasis in future NCD prevention strategies. [ABSTRACT FROM AUTHOR]

This paper proposes a model-based estimation of left ventricular (LV) pressure for the evaluation of constructive and wasted myocardial work of patients with aortic stenosis (AS). A model of the cardiovascular system is proposed, including descriptions of i) cardiac electrical activity, ii) elastance-based cardiac cavities, iii) systemic and pulmonary circulations and iv) heart valves. After a sensitivity analysis of model parameters, an identification strategy was implemented using a Monte-Carlo cross-validation approach. Parameter identification procedure consists in two steps for the estimation of LV pressures: step 1) from invasive, intraventricular measurements and step 2) from non-invasive data. The proposed approach was validated on data obtained from 12 patients with AS. The total relative errors between estimated and measured pressures were on average 11.9% and 12.27% and mean R2 were equal to 0.96 and 0.91, respectively for steps 1 and 2 of parameter identification strategy. Using LV pressures obtained from non-invasive measurements (step 2) and patient-specific simulations, Global Constructive (GCW), Wasted (GWW) myocardial Work and Global Work Efficiency (GWE) parameters were calculated. Correlations between measures and model-based estimations were 0.88, 0.80, 0.91 respectively for GCW, GWW and GWE. The main contributions concern the proposal of the parameter identification procedure, applied on an integrated cardiovascular model, able to reproduce LV pressure specifically to each AS patient, by non-invasive procedures, as well as a new method for the non-invasive estimation of constructive, wasted myocardial work and work efficiency in AS. [ABSTRACT FROM AUTHOR]

Background: Quality improvement collaboratives (QICs) have been used to improve health care for decades. Evidence on QIC effectiveness has been reported, but systematic reviews to date have little information from low- and middle-income countries (LMICs). Objective: To assess the effectiveness of QICs in LMICs. Methods: We conducted a systematic review following Cochrane methods, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for quality of evidence grading, and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement for reporting. We searched published and unpublished studies between 1969 and March 2019 from LMICs. We included papers that compared usual practice with QICs alone or combined with other interventions. Pairs of reviewers independently selected and assessed the risk of bias and extracted data of included studies. To estimate strategy effectiveness from a single study comparison, we used the median effect size (MES) in the comparison for outcomes in the same outcome group. The primary analysis evaluated each strategy group with a weighted median and interquartile range (IQR) of MES values. In secondary analyses, standard random-effects meta-analysis was used to estimate the weighted mean MES and 95% confidence interval (CI) of the mean MES of each strategy group. This review is registered with PROSPERO (International Prospective Register of Systematic Reviews): CRD42017078108. Results: Twenty-nine studies were included; most (21/29, 72.4%) were interrupted time series studies. Evidence quality was generally low to very low. Among studies involving health facility-based health care providers (HCPs), for “QIC only”, effectiveness varied widely across outcome groups and tended to have little effect for patient health outcomes (median MES less than 2 percentage points for percentage and continuous outcomes). For “QIC plus training”, effectiveness might be very high for patient health outcomes (for continuous outcomes, median MES 111.6 percentage points, range: 96.0 to 127.1) and HCP practice outcomes (median MES 52.4 to 63.4 percentage points for continuous and percentage outcomes, respectively). The only study of lay HCPs, which used “QIC plus training”, showed no effect on patient care-seeking behaviors (MES -0.9 percentage points), moderate effects on non-care-seeking patient behaviors (MES 18.7 percentage points), and very large effects on HCP practice outcomes (MES 50.4 percentage points). Conclusions: The effectiveness of QICs varied considerably in LMICs. QICs combined with other invention components, such as training, tended to be more effective than QICs alone. The low evidence quality and large effect sizes for QIC plus training justify additional high-quality studies assessing this approach in LMICs. [ABSTRACT FROM AUTHOR]

Background: Although clozapine is the gold-standard for treatment refractory schizophrenia, it has the worst metabolic profile of all antipsychotics. This is partly mediated by clozapine’s impact on glucagon-like peptide (GLP-1). There is an absence of robust evidence for effective treatments for clozapine associated weight gain and metabolic syndrome. Metformin, with its role in increasing GLP-1 may aid weight loss among people on clozapine. Methods: We conducted a systematic-review and meta-analysis of metformin versus placebo for change in weight and metabolic syndrome for people on clozapine without diabetes mellitus. We searched the Cochrane Schizophrenia Group’s trial register, Pubmed and Embase, as well as the following Chinese databases: the Chinese Biomedical Literature Service System and China Knowledge Resource Integrated Database. This was supplemented by hand searches of key papers. Results: Eight studies, of which three were from Chinese databases, with 478 participants were included. We found that metformin was superior to placebo in terms of weight loss (-3.12kg, 95%CI -4.88kg to -1.37kg) and BMI (-1.18kg/m2, 95%CI -1.76kg/m2 to -0.61kg/m2). Metformin significantly improved three of the five components of metabolic syndrome; waist circumference, fasting glucose and triglycerides. Sensitivity analysis on study quality and duration did not greatly impact results. Conclusions: Metformin led to clinically meaningful weight loss among people on clozapine, and may reduce the rates of metabolic syndrome. Inclusion of metformin into the treatment protocols of people on clozapine, as tolerated, should be considered. Trial Registration: PROSPERO registration number: CRD42015029723 [ABSTRACT FROM AUTHOR]

A number of circular regression models have been proposed in the literature. In recent years, there is a strong interest shown on the subject of outlier detection in circular regression. An outlier detection procedure can be developed by defining a new statistic in terms of the circular residuals. In this paper, we propose a new measure which transforms the circular residuals into linear measures using a trigonometric function. We then employ the row deletion approach to identify observations that affect the measure the most, a candidate of outlier. The corresponding cut-off points and the performance of the detection procedure when applied on Down and Mardia’s model are studied via simulations. For illustration, we apply the procedure on circadian data. [ABSTRACT FROM AUTHOR]

Background: Identifying individuals at increased risk for depression allows for earlier intervention and treatment, ultimately leading to better outcomes and potentially preventing severe symptoms. However, to date, no systematic reviews or meta-analyses have estimated the prevalence of depression among hypertensive patients. Thus, this review was initiated to determine the prevalence and factors associated with depression among patients with hypertension in Ethiopia. Methods: Multiple databases, such as PubMed, African Journals Online, the Cochrane Library, and Google Scholar, were used to ensure wider coverage of relevant studies. The data extracted from Microsoft Excel were imported into STATA version 11 (Stata Corp LLC, TX, USA) for further analysis. The pooled prevalence of depression was estimated using a random effects model. To evaluate statistical heterogeneity, the Cochrane Q test and I2 statistic were used. Results: The random effect model indicated that the pooled prevalence of depression in 12 studies conducted in Ethiopia was 32.43% (95% CI: 25.18, 39.67%). Being female (POR = 2.41; 95% CI: 1.89, 3.07, I2 = 17.7%, P = 0.302), having comorbid illnesses (POR = 3.80; 95% CI: 2.09, 6.90, I2 = 81%, P = 0.005), having poor blood pressure control (POR = 3.58; 95% CI: 2.51, 5.12, I2 = 0.0%, P = 0.716), having a family history of depression (POR = 3.43; 95% CI: 1.98, 5.96, I2 = 62.6%, P = 0.069), being single (POR = 2.30; 95% CI: 1.35, 3.99, I2 = 48.0%, P = 0.146) and having poor social support (POR = 4.24; 95% CI: 1.29, 13.98, I2 = 95.8%, P<0.001) were positively associated with depression among hypertensive patients. Conclusion: Overall, the results of our review showed that depression affects a significant number of Ethiopians who have hypertension. Being female, being single, having comorbidities, having poor blood pressure control, having a family history of depression, and having poor social support were factors associated with depression among patients with hypertension. For those who are depressed, improving the psycho-behavioral treatment linkage with the psychiatric unit can result in improved clinical outcomes. Trial registration: Prospero Registration number: CRD42024498447. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024498447. [ABSTRACT FROM AUTHOR]

Background: For behaviour-change interventions to be successful they must be acceptable to users and overcome barriers to behaviour change. The Person-Based Approach can help to optimise interventions to maximise acceptability and engagement. This article presents a novel, efficient and systematic method that can be used as part of the Person-Based Approach to rapidly analyse data from development studies to inform intervention modifications. We describe how we used this approach to optimise a digital intervention for patients with hypertension (HOME BP), which aims to implement medication and lifestyle changes to optimise blood pressure control., Methods: In study 1, hypertensive patients (N = 12) each participated in three think-aloud interviews, providing feedback on a prototype of HOME BP. In study 2 patients (N = 11) used HOME BP for three weeks and were then interviewed about their experiences. Studies 1 and 2 were used to identify detailed changes to the intervention content and potential barriers to engagement with HOME BP. In study 3 (N = 7) we interviewed hypertensive patients who were not interested in using an intervention like HOME BP to identify potential barriers to uptake, which informed modifications to our recruitment materials. Analysis in all three studies involved detailed tabulation of patient data and comparison to our modification criteria., Results: Studies 1 and 2 indicated that the HOME BP procedures were generally viewed as acceptable and feasible, but also highlighted concerns about monitoring blood pressure correctly at home and making medication changes remotely. Patients in study 3 had additional concerns about the safety and security of the intervention. Modifications improved the acceptability of the intervention and recruitment materials., Conclusions: This paper provides a detailed illustration of how to use the Person-Based Approach to refine a digital intervention for hypertension. The novel, efficient approach to analysis and criteria for deciding when to implement intervention modifications described here may be useful to others developing interventions.

An Acute Hypotensive Episode (AHE) is the sudden onset of a sustained period of low blood pressure and is one among the most critical conditions in Intensive Care Units (ICU). Without timely medical care, it can lead to an irreversible organ damage and death. By identifying patients at risk for AHE early, adequate medical intervention can save lives and improve patient outcomes. In this paper, we design a novel dual-boundary classification based approach for identifying patients at risk for AHE. Our algorithm uses only simple summary statistics of past Blood Pressure measurements and can be used in an online environment facilitating real-time updates and prediction. We perform extensive experiments with more than 4,500 patient records and demonstrate that our method outperforms the previous best approaches of AHE prediction. Our method can identify AHE patients two hours in advance of the onset, giving sufficient time for appropriate clinical intervention with nearly 80% sensitivity and at 95% specificity, thus having very few false positives.

Introduction: If interprofessional collaborative practice is to be an important component of healthcare reform, then an evidentiary base connecting interprofessional education to interprofessional practice with significantly improved health and healthcare outcomes is an unconditional necessity. This study is a scoping review of the current peer reviewed literature linking interprofessional collaborative care and interprofessional collaborative practice to clearly identified healthcare and/or patient health-related outcomes. The research question for this review was: What does the evidence from the past decade reveal about the impact of Interprofessional collaborative practice on patient-related outcomes in the US healthcare system? Materials and methods: A modified preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach was followed. Results: Of an initial 375 articles retrieved 20 met review criteria. The most common professions represented in the studies reviewed were physicians, pharmacists and nurses. Primary care was the most common care delivery setting and measures related to chronic disease the most commonly measured outcomes. No study identified negative impacts of interprofessional collaborative practice. Eight outcome categories emerged from a content analysis of the findings of the reviewed studies. Conclusions: The results suggest a need for more research on the measurable impact of interprofessional collaborative practice and/or care on patient health-related outcomes to further document its benefits and to explore the models, systems and nature of collaborations that best improve population health, increase patient satisfaction, and reduce cost of care. [ABSTRACT FROM AUTHOR]

Physical activity (PA) is a key component of a healthy life, and it is hypothesised that individuals with higher levels of PA utilise fewer hospital resources. Quantifying the association between PA and hospital resource use is of interest to both payers and planners but estimates of its size in the general population are rare. In this paper we provide estimates of the association between PA and payments to hospitals in the Australian population over age 45. We use data from 45 and Up Study, a survey that contains health and lifestyle factors information about approximately 260,000 individuals over age 45 living in NSW, linked to hospital and death data. The linked data set allows to define a unique indicator for the level of PA over the week prior to the survey interview and to calculate payments to hospitals over the next year. We use Coarsened Exact Matching and multivariate analysis to study the relationship between PA and hospital payments, controlling for chronic health conditions, risk factors, standard socioeconomic variables and death. Our results clearly indicate that there is a statistically significant association between PA and lower hospital payments. While the size of the association depends to some extent on the covariates used in the model the conclusions are robust to changes in model specification. We also perform a sub-group analysis and show that the cost savings associated with PA are significantly larger for older and lower income populations. This study shows that if one is interested in lowering hospital expenditures then increasing PA levels is a policy that has the potential of being effective. It also shows that one does not need to target the entire population to achieve cost savings but can limit the intervention to the older population and/or the one in the lowest socioeconomic status. [ABSTRACT FROM AUTHOR]

This paper aims to develop a novel computational technique for the detection of the transit through the anaerobic threshold. This technique uses only cardiac intervals derived from the electrocardiogram and is based on algebraic relationships between RR and QRS intervals. Electrocardiograms are measured during the load and the recovery processes. Algebraic relationships between cardiac intervals are used not only to identify the anaerobic threshold but also to characterise individual features of the person during the transit through the threshold. The ratio between carbon dioxide and oxygen in the exhaled air is used to validate the results. The algebraic relationship between cardiac intervals serves as a stand-alone indicator for both the determination of the anaerobic threshold and the characterization of the performance of the person during the load and the recovery processes. [ABSTRACT FROM AUTHOR]

Introduction: A large body of evidence has established a pattern of altered functioning in the immune system, autonomic nervous system and hypothalamic pituitary adrenal axis in chronic fatigue syndrome. However, the relationship between components within and between these systems is unclear. In this paper we investigated the underlying network structure of the autonomic system in patients and controls, and a larger network comprising all three systems in patients alone. Methods: In a sample of patients and controls we took several measures of autonomic nervous system output during 10 minutes of supine rest covering tests of blood pressure variability, heart rate variability and cardiac output. Awakening salivary cortisol was measured on each of two days with participants receiving 0.5mg dexamethasone during the afternoon of the first day. Basal plasma cytokine levels and the in vitro cytokine response to dexamethasone were also measured. Symptom outcome measures used were the fatigue impact scale and cognitive failures questionnaire. Mutual information criteria were used to construct networks describing the dependency amongst variables. Data from 42 patients and 9 controls were used in constructing autonomic networks, and 15 patients in constructing the combined network. Results: The autonomic network in patients showed a more uneven distribution of information, with two distinct modules emerging dominated by systolic blood pressure during active stand and end diastolic volume and stroke volume respectively. The combined network revealed strong links between elements of each of the three regulatory systems, characterised by three higher modules the centres of which were systolic blood pressure during active stand, stroke volume and ejection fraction respectively. Conclusions: CFS is a complex condition affecting physiological systems. It is important that novel analytical techniques are used to understand the abnormalities that lead to CFS. The underlying network structure of the autonomic system is significantly different to that of controls, with a small number of individual nodes being highly influential. The combined network suggests links across regulatory systems which shows how alterations in single nodes might spread throughout the network to produce alterations in other, even distant, nodes. Replication in a larger cohort is warranted. [ABSTRACT FROM AUTHOR]

Introduction: In many sub-Saharan African countries, confronting the dual epidemic of HIV and NCDs is a public health priority especially in high HIV burden countries such as South Africa. Evidence shows that poor health as a consequence of NCDs and HIV among the workforce increases absenteeism and leads to decrease in productivity. However, the prevalence of these co-occurring chronic conditions and associated factors is unknown in the educator workforce. Improved understanding has implications for their management and wellbeing of educators. This paper reports the prevalence of selected NCDs and associated factors among HIV positive educators in South Africa using the 2015/6 survey of Educators in Public Schools in South Africa. Methods: This was a second-generation surveillance undertaken among educators in selected public schools in all nine provinces in South Africa. A multi-stage stratified cluster design with probability proportional to size sampling was used to draw a random sample of schools. Factors associated with presence of NCDs were determined using a multivariate backward stepwise logistic regression analysis. Results: A total of 1 365 schools were sampled within which 21 495 (85.5%) educators were interviewed. Out of 2691, HIV Positive educators that responded to the questions on NCDs, 36.9% reported having NCDs. The most commonly reported NCDs were high blood pressure (17.4%), and stomach ulcers (13.5%). The increased odds of reporting the presence of NCDs was significantly associated with being female than male [aOR = 1.5: 95% CI (1.1–1.9), p<0.002], age 45 to 54 years [aOR = 1.8: 95% CI (1.4–2.2), p = p<0.001], and age 55 years and older than those 18 to 24 years [aOR = 2.7: 95% CI (1.8–3.9), p<0.001). The decreased odds of reporting the presence of NCDs was significantly associated with not being absent from school for health reasons [aOR = 0.7: 95% CI (0.6–0.9), p = 0.003]. Conclusion: NCDs care and active screening should be an integral part of HIV programmes including interventions such as prevention, treatment, care and support amongst public school educators in SA. The education department will need to invest in health promotion intervention programmes to prevent and mitigate the negative impact of NCDs and HIV on the sector. [ABSTRACT FROM AUTHOR]

Background: Bhutan, a small land-locked country in the eastern Himalayas has been undergoing an epidemiological and nutritional transition in the last two decades. The objective of this paper was to determine the prevalence and explore the risk factors of self-reported diabetes among Bhutanese adults. Methods: We conducted a secondary data analysis among adults 18 years and older Bhutanese using the data from the National Health Survey 2012 (NHS, 2012) of Bhutan. The self-reported information on risk factors was obtained using standard protocols of the WHO STEPwise approach to Surveillance. The outcome of interest was self-reported diabetes on medication. Adjusted and unadjusted logistic regression analyses were performed to identify the risk factor of diabetes. Results: A total of 31,066 participants aged 18 years and older were included for the analysis. The prevalence of self-reported hypertension was 1.8% (491). Risk factors for diabetes were: age groups: 35–44 years adjusted odds ratio (AOR) = 2.82 (95% CI, 1.07, 7.41), 45–54 years AOR = 6.02 (95% CI, 2.29, 15.83), 55–64 year AOR = 15.7 (95% CI 5.93, 41.55) and >65 years AOR = 19.60 (95% CI, 6.93, 55.71); high school and diploma/certificate education AOR = 2.57, (95% CI 1.62, 4.07) and AOR = 3.92 (95% CI 1.70, 9.07); and urban dwellers AOR = 2.37, (95% 1.58, 3.57); hypertension AOR = 3.3, (95% CI 2.47, 4.41); and fruit servings of 1–3 per week AOR = 1.63 (95% CI 1.15, 2.31). Conclusion: The number of Bhutanese adults with diabetes and co-morbidities associated with it is likely to increase with the ageing of the population, nutrition transition, and high rural-urban migration in the near future. This calls for an urgent need to implement strategies to prevent diabetes in the Bhutanese population targeting risk factors including healthy lifestyle with increased physical activities and reduced smoking. At the same time treating other chronic morbidities including hypertension. [ABSTRACT FROM AUTHOR]

The University of British Columbia Nepal Expedition took place over several months in the fall of 2016 and was comprised of an international team of 37 researchers. This paper describes the objectives, study characteristics, organization and management of this expedition, and presents novel blood gas data during acclimatization in both lowlanders and Sherpa. An overview and framework for the forthcoming publications is provided. The expedition conducted 17 major studies with two principal goals—to identify physiological differences in: 1) acclimatization; and 2) responses to sustained high-altitude exposure between lowland natives and people of Tibetan descent. We performed observational cohort studies of human responses to progressive hypobaric hypoxia (during ascent), and to sustained exposure to 5050 m over 3 weeks comparing lowlander adults (n = 30) with Sherpa adults (n = 24). Sherpa were tested both with (n = 12) and without (n = 12) descent to Kathmandu. Data collected from lowlander children (n = 30) in Canada were compared with those collected from Sherpa children (n = 57; 3400–3900m). Studies were conducted in Canada (344m) and the following locations in Nepal: Kathmandu (1400m), Namche Bazaar (3440m), Kunde Hospital (3480m), Pheriche (4371m) and the Ev-K2-CNR Research Pyramid Laboratory (5050m). The core studies focused on the mechanisms of cerebral blood flow regulation, the role of iron in cardiopulmonary regulation, pulmonary pressures, intra-ocular pressures, cardiac function, neuromuscular fatigue and function, blood volume regulation, autonomic control, and micro and macro vascular function. A total of 335 study sessions were conducted over three weeks at 5050m. In addition to an overview of this expedition and arterial blood gas data from Sherpa, suggestions for scientists aiming to perform field-based altitude research are also presented. Together, these findings will contribute to our understanding of human acclimatization and adaptation to the stress of residence at high-altitude. [ABSTRACT FROM AUTHOR]

Background: Modifications to lifestyle risk factors for stroke may help prevent stroke events. This systematic review aimed to identify and summarise the evidence of acupuncture interventions for those people with lifestyle risk factors for stroke, including alcohol-dependence, smoking-dependence, hypertension, and obesity. Methods: MEDLINE, CINAHL/EBSCO, SCOPUS, and Cochrane Database were searched from January 1996 to December 2016. Only randomised controlled trials (RCTs) with empirical research findings were included. PRISMA guidelines were followed and risk of bias was assessed via the Cochrane Collaboration risk of bias assessment tool. The systematic review reported in this paper has been registered on the PROSPERO (#CRD42017060490). Results: A total of 59 RCTs (5,650 participants) examining the use of acupuncture in treating lifestyle risk factors for stroke met the inclusion criteria. The seven RCTs focusing on alcohol-dependence showed substantial heterogeneity regarding intervention details. No evidence from meta-analysis has been found regarding post-intervention or long-term effect on blood pressure control for acupuncture compared to sham intervention. Relative to sham acupuncture, individuals receiving auricular acupressure for smoking-dependence reported lower numbers of consumed cigarettes per day (two RCTs, mean difference (MD) = -2.75 cigarettes/day; 95% confidence interval (CI) = -5.33, -0.17; p = 0.04). Compared to sham acupuncture those receiving acupuncture for obesity reported lower waist circumference (five RCTs, MD = -2.79 cm; 95% CI: -4.13, -1.46; p<0.001). Overall, only few trials were considered of low risk of bias for smoking-dependence and obesity, and as such none of the significant effects in favour of acupuncture interventions were robust against potential selection, performance, and detection bias. Conclusions: This review found no convincing evidence for effects of acupuncture interventions for improving lifestyle risk factors for stroke. [ABSTRACT FROM AUTHOR]

Objective: To examine whether childbearing before age 18 in Sub-Saharan Africa is associated with increased risk of maternal and child complications through a systematic literature review and meta-analysis. Methods: The literature on adolescent pregnancy and associated complications in Sub-Saharan Africa was reviewed. A systematic electronic database search in Medline and Embase identified relevant papers. Studies were eligible for inclusion if they had numeric data on maternal mortality, pre-eclampsia, eclampsia, preterm birth, low birth weight, small for gestational age, stillbirth, neonatal death or perinatal death. We included studies on adolescents aged 17 years or younger, and with a comparison group of adult women aged between 20 and 35 years. The quality of the articles was assessed. Meta-analyses were conducted when there were at least three included studies with minor clinical heterogeneity in population and outcome measures. Results: Eighteen studies met our inclusion criteria. There were many studies from Sub-Saharan Africa with data on the age group 15–19 years old, but few studies had separate data on adolescents <18 years old. All included studies were of either moderate or low quality. Adolescents had an increased risk of low birth weight, pre-eclampsia/eclampsia, preterm birth and maternal and perinatal mortality. We found a lower, nonsignificant risk of stillbirth and for small for gestational age babies among the young mothers. Conclusion: In this systematic review, the findings indicate that young maternal age is associated with some unfavorable outcomes in Sub-Saharan Africa. High quality observational studies that adjust for sociodemographic factors are lacking. [ABSTRACT FROM AUTHOR]

Proposal: This paper investigates a novel screening tool for Obstructive Sleep Apnea Syndrome (OSAS), which aims at efficient population-wide monitoring. To this end, we introduce SASscore which provides better OSAS prediction specificity while maintaining a high sensitivity. Methods: We process a cohort of 2595 patients from 4 sleep laboratories in Western Romania, by recording over 100 sleep, breathing, and anthropometric measurements per patient; using this data, we compare our SASscore with state of the art scores STOP-Bang and NoSAS through area under curve (AUC), sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). We also evaluate the performance of SASscore by considering different Apnea–Hypopnea Index (AHI) diagnosis cut-off points and show that custom refinements are possible by changing the score’s threshold. Results: SASscore takes decimal values within the interval (2, 7) and varies linearly with AHI; it is based on standardized measures for BMI, neck circumference, systolic blood pressure and Epworth score. By applying the STOP-Bang and NoSAS questionnaires, as well as the SASscore on the patient cohort, we respectively obtain the AUC values of 0.69 (95% CI 0.66-0.73, p < 0.001), 0.66 (95% CI 0.63-0.68, p < 0.001), and 0.73 (95% CI 0.71-0.75, p < 0.001), with sensitivities values of 0.968, 0.901, 0.829, and specificity values of 0.149, 0.294, 0.359, respectively. Additionally, we cross-validate our score with a second independent cohort of 231 patients confirming the high specificity and good sensitivity of our score. When raising SASscore’s diagnosis cut-off point from 3 to 3.7, both sensitivity and specificity become roughly 0.6. Conclusions: In comparison with the existing scores, SASscore is a more appropriate screening tool for monitoring large populations, due to its improved specificity. Our score can be tailored to increase either sensitivity or specificity, while balancing the AUC value. [ABSTRACT FROM AUTHOR]

Purposes: The objectives of this paper are to study the impact of low level isopropyl alcohol exposure on blood pressure and to explore its potential mechanism., Methods: This cross-sectional study was based on a prospective occupational cohort in south China, which focusing on occupational risk factors related cardiovascular health problems. A total of 283 participants (200 low isopropyl alcohol exposed workers and 83 controls) was finally enrolled in this study. Linear regression models were used to analyze the relationship between arterial blood pressures and low level isopropyl alcohol exposure. We used mediation method to explore possible mediated roles of neurogenic factors., Results: Systolic blood pressure (SBP, 123±10 vs. 118±11), diastolic blood pressure (DBP, 79±7 vs. 74±7) and mean blood pressure (MBP, 93±8 vs. 89±9) were different between the exposed group and the control group (p < 0.01). After adjusting for covariates, the difference was still significant. Besides, isopropyl alcohol and smoking had an interactive effect on DBP and MBP (p < 0.05). Furthermore, we observed a mediated effect of 5-hydroxyindole acetic acid (5-HIAA) on isopropyl alcohol exposure induced arterial blood pressure increase, which accounted for about 25%., Conclusions: Our results suggest that low level isopropyl alcohol exposure is a potential risk factor for the increased arterial blood pressure and 5-HIAA partly mediates the association between low level isopropyl alcohol exposure and arterial blood pressures., Competing Interests: The authors have declared that no competing interests exist.

Researchers interested in the effect of health on various life outcomes (such as employment, earnings and life satisfaction) often use self-reported health and disease status as an indicator of true, underlying health status. Self-reports appear to be reasonable measures of overall health. For example, self-assessed overall health has been found to be a reliable predictor of mortality. However, the validity of self-reports is questionable when investigating specific diseases such as diabetes and hypertension. A small and nascent body of research comparing self-reported status on certain diseases with the true status based on clinical diagnoses has found significant gaps. These validation exercises predominantly use data from high-income countries. In this paper, we use survey data from India to compare self-reports of disease prevalence to diagnostic tests conducted on the same individuals. We focus on hypertension and lung disease, two of the primary causes of death in India. We find that self-reported measures substantially understate the true disease burden for both conditions. The attenuation bias from using self-reports is over 80 percent for both diseases, and bigger than estimates from high-income countries. We test and reject the hypothesis that self-reports of the disease status are identical to the true disease status in expectation. We identify characteristics associated with false negative reporting (reporting not having the disease but testing positive for it) for both diseases. The large awareness gap between self-reports and true disease burden indicates multiple deficiencies in India’s public health policy. The survey data depicts limited access to medical facilities, high levels of health illiteracy, low rates of health insurance, and other barriers related to poverty and lack of equity in the delivery of health services. These factors prevent timely intervention for managing health and controlling disease, invariably leading to morbidity and often to premature death. [ABSTRACT FROM AUTHOR]

The aim of this paper was to compare the cardiorespiratory effects of the two combinations (medetomidine-tiletamine-zolazepam (MTZ) or dexmedetomidine-tiletamine-zolazepam (DTZ)) used for Asiatic black bear (Ursus thibetanus) immobilization. A retrospective analysis was carried out, reviewing the anesthetic records of captive bears. Sixty-six records were reviewed. The bears were immobilized, and general anesthesia was maintained with isoflurane vaporized in 100% oxygen. The mean sedation time and score were evaluated. The cardiorespiratory parameters were recorded every 10 minutes from intubation until extubation. Mean sedation time was 26.1 ± 14.5 minutes for the MTZ group and 25.6 ± 19.4 minutes for the DTZ group. The heart rate and the respiratory rate were higher in the bears immobilized with DTZ (66 ± 19 beats/min; 13 ± 5.2 breaths/min) as compared with the bears immobilized with MTZ (57 ± 14.5 beats/min; 10 ± 4.7 breaths/min) whereas the mean arterial pressure did not differ significantly between the groups. The body temperature was in the normal range throughout the procedures in all bears (MTZ 36.3 ± 0.9°C; DTZ 37 ± 1°C). In conclusion, the two protocols used in this study have been proven to be safe and reliable for the immobilization of Asiatic black bears, and the DTZ combination seemed to be associated with less cardiorespiratory depression than the MTZ one. [ABSTRACT FROM AUTHOR]

Objectives: This paper aims to evaluate the association between serum uric acid (SUA) levels, arterial hypertension (HT) prevalence, blood pressure values control, kidney function and intima media thickness (IMT), as a surrogate marker of early atherosclerosis, in a representative group of Romanian adult population. Materials and methods: The study sample consists in 1920 adults included in SEPHAR III (Study for the Evaluation of Prevalence of Hypertension and cArdiovascular Risk in Romania) survey (mean age 48.63 years, 52.76% females) collecting data for SUA levels, blood pressure (BP) measurements, kidney function by estimated glomerular filtration rate (eGFR) and carotid IMT. SUA levels between 2,40–5,70mg/dl in females and 3,40–7,00mg/dl in males respectively were considered normal. HT and HT control were defined according to the current guidelines. IMT evaluation was assessed by B-mode Doppler ultrasound evaluation. Results: Hypertensive subjects had significantly higher values of SUA compared with normotensive subjects, hypertensive patients were 1.713 times more likely to have higher values of SUA. Among treated hypertensive patients, those without optimal BP control had significantly higher SUA levels compared with those with optimal BP control, the presence of hyperuricemia increasing the odds of suboptimal BP control by 1.023. Hyperuricemic subjects had significantly lower eGFR values compared with normouricemic ones, on an average with 14.28ml/min/1.73m2 by Modification of Diet in Renal Disease formula (MDRD) and with 16.64ml/min/1.73m2 by Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI), with an indirect association between SUA levels and eGFR values (rs = -0.319 / -0.347), independent of age. IMT values recorded in hyperuricemic subjects were significantly increased, on an average with 0.08mm, compared with normouricemic subjects, with a direct association between SUA levels and IMT values (rs = 0.263), independent of BP values. Conclusion: The results of our study offers support that increased SUA levels are associated with arterial hypertension and with suboptimal BP control in treated hypertensive subjects. The decline in kidney function, independent of age, and also increased IMT values as a marker of atherosclerosis, were also correlated with elevated SUA values. Hyperuricemia screening may have a role in identifying patients at risk of developing HT and lowering SUA levels may improve not only BP control in treated HT patients but also decrease total cardiovascular mortality by slowing the progression of atherosclerosis and renal failure in hypertensive patients. [ABSTRACT FROM AUTHOR]

Despite the double burden of infectious and chronic non-communicable diseases in Africa, health care expenditure disproportionately favours infectious diseases. In this paper, we examine quantitatively the extent of this disproportionate access to diagnoses and treatment of diabetes, hypertension and malaria in Ghana. A total of 220 health facilities was surveyed across the country in 2011. Findings indicate that diagnoses and treatment of infectious diseases were more accessible than NCDs. In terms of treatment, 78% and 87% of health facilities had two of the recommended malaria drugs while less than 35% had essential diabetes and hypertension drugs. There is a significant unmet need for diagnoses and treatment of NCDs in Ghana. These inequities have implications for high morbidity and mortality from NCDs. We recommend the use of task shifting as a model to increase the delivery of NCD services. [ABSTRACT FROM AUTHOR]

Antenatal care is essential to improve maternal and newborn health and wellbeing. The majority of pregnant women in Tanzania attend at least one visit. Since implementation of the focused antenatal care model, quality of care assessments have mostly focused on utilization and coverage of routine interventions for antenatal care. This study aims to assess the quality of antenatal care provision from a holistic perspective in a rural district in Tanzania. Structure, process and outcome components of quality are explored. This paper reports on data collected over several periods from 2012 to 2015 through facility audits of supplies and services, ANC observations and exit interviews with pregnant women. Additional qualitative methods were used such as interviews, focus group observations and participant observations. Findings indicate variable performance of routine ANC services, partly explained by insufficient resources. Poor performance was also observed for appropriate history taking, attention for client’s wellbeing, basic physical examination and adequate counseling and education. Achieving quality improvement for ANC requires increased attention for the process of care provision beyond coverage, including attention for response-based services, which should be assessed based on locally determined criteria. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to systematically review intervention studies on self-management of type 2 diabetes in Gulf Cooperation Council (GCC) countries to determine the most effective self-management strategies for individuals with type 2 diabetes in this region. Methods: A search strategy was developed using multiple databases: Medline and Embase (via Ovid), CINAHL (via EBSCO), and PubMed. Study and intervention characteristics, intervention structure, content, cultural adaptation, and outcomes were extracted from the included studies. To be included in the review the studies should have met the following criteria: have examined the effectiveness of at least one intervention involving a type 2 DSME programme, have involved participants over 18 years old diagnosed with type 2 diabetes, have taken place to in a GCC country, have a study design that was observational, quasi-experimental or controlled, have reported at least one individual and have a quantitative outcome. A narrative data synthesis was used to describe the studies and comment on their methodological quality. Results: Of the 737 retrieved papers, only eight met the inclusion criteria. Only one study was a randomised controlled trial. A statistically significant improvement in HbA1c was reported in five of the eight studies. There was a significant improvement in physical activity levels as reported in four of the eight studies. Only three studies referred to aspects of cultural design or adaptation of the intervention implemented. Conclusions: Self-management interventions may have a positive impact on HbA1 levels in patients with type 2 diabetes in the GCC area. A greater emphasis placed on culturally appropriate self-management programmes may improve the effectiveness of self-management interventions for adults with type 2 diabetes in the GCC. [ABSTRACT FROM AUTHOR]

Introduction: Cardiovascular diseases (CVDs) are the most common cause of non-communicable disease mortality in sub-Saharan African (SSA) countries. Gaps in knowledge of CVD conditions and their risk factors are important barriers in effective prevention and treatment. Yet, evidence on the awareness and knowledge level of CVD and associated risk factors among populations of SSA is scarce. This review aimed to synthesize available evidence of the level of knowledge of and perceptions towards CVDs and risk factors in the SSA region. Methods: Five databases were searched for publications up to December 2016. Narrative synthesis was conducted for knowledge level of CVDs, knowledge of risk factors and clinical signs, factors influencing knowledge of CVDs and source of health information on CVDs. The review was registered with Prospero (CRD42016049165). Results: Of 2212 titles and abstracts screened, 45 full-text papers were retrieved and reviewed and 20 were included: eighteen quantitative and two qualitative studies. Levels of knowledge and awareness for CVD and risk factors were generally low, coupled with poor perception. Most studies reported less than half of their study participants having good knowledge of CVDs and/or risk factors. Proportion of participants who were unable to identify a single risk factor and clinical symptom for CVDs ranged from 1.8% in a study among hospital staff in Nigeria to a high of 73% in a population-based survey in Uganda and 7% among University staff in Nigeria to 75.1% in a general population in Uganda respectively. High educational attainment and place of residence had a significant influence on the levels of knowledge for CVDs among SSA populations. Conclusion: Low knowledge of CVDs, risk factors and clinical symptoms is strongly associated with the low levels of educational attainment and rural residency in the region. These findings provide useful information for implementers of interventions targeted at the prevention and control of CVDs, and encourages them to incorporate health promotion and awareness campaigns in order to enhance knowledge and awareness of CVDs in the region. [ABSTRACT FROM AUTHOR]

Using a standardized instrument to evaluate patients’ stress reactions has become more important in daily clinical routines. Different signs or symptoms of stress are often unilaterally explored: the physiological, psychological or social aspects of stress disorders are each viewed on a single dimension. However, all dimensions afflict patients who have persistent health problems due to chronic stress. Therefore, it is important to use a multidimensional approach to acquire data. The ‘Psycho-Physiological-Stress-Test’ (PPST) was established to achieve a comprehensive understanding of stress and was further developed at the Charité—Universitätsmedizin Berlin in collaboration with the Psychological Department of Freie Universität Berlin. The PPST includes a series of varying stress phases, embedded in two periods of rest. Physiological and psychological parameters are simultaneously measured throughout the test session. Specifically, the PPST activates the sympathetic stress axis, which is measured by heart rate, blood pressure, respiration depth and rate, electro dermal activation and muscle tension (frontalis, masseter, trapezius). Psychological data are simultaneously collected, and include performance, motivation, emotion and behavior. After conducting this diagnostic test, it is possible to identify individual stress patterns that can be discussed with the individual patient to develop and recommend (outpatient) treatment strategies. This paper introduces the PPST as a standardized way to evaluate stress reactions by presenting the results from a sample of psychosomatic inpatients (n = 139) who were treated in Charité—Universitätsmedizin Berlin, Germany. We observed that the varying testing conditions provoked adjusted changes in the different physiological parameters and psychological levels. [ABSTRACT FROM AUTHOR]

Patients with chronic kidney disease (CKD) have an increased incidence of cardiovascular events (CVE). The contribution of subclinical atheromatosis extent, including femoral arteries, to CVE in CKD patients has not been investigated. In this paper, we examine the prognostic value of subclinical atheromatosis extent, assessed as the number of arterial territories with plaque, in predicting the incidence of major and minor CVE. The NEFRONA is a multicenter, prospective cohorts study that recruited 2445 CKD subjects and 559 controls, free from previous cardiovascular disease, in 81 medical centers across Spain. The presence of atheroma plaque was assessed by arterial ultrasound in ten arterial territories (carotid and femoral). The predictive power of the presence or absence of atheroma plaque in any territory was compared with the quantification of atheroma extent as the number of territories with plaque. During the median follow up of 48 months, 216 CVE were reported. Factors predicting the incidence of CVE in the whole cohort were being male, CKD patient, lower levels of 25(OH) vitamin D, higher levels of cholesterol and the extent of subclinical atheromatosis, yielding a higher concordance (C) index than the presence or absence of plaque. In stratified analysis including specific factors of CKD patients not on dialysis, the variables predicting CVE were the same as in the whole cohort, plus higher levels of potassium. Again, the inclusion of the information about atheromatosis as number of territories with plaque, presented a higher C index than the presence or absence of plaque. In the dialysis population, significant variables were older age, diabetes, dialysis vintage and higher levels of cholesterol and phosphate. In this case the higher C index was obtained with the information about plaque presence. Subclinical atheromatosis extent, including femoral arteries, influences CVE in CKD and its detection could improve the prediction of cardiovascular events. [ABSTRACT FROM AUTHOR]

Introduction: The development of a translatable brain death animal model has significant potential to advance not only transplant research, but also the understanding of the pathophysiologic changes that occur in brain death and severe traumatic brain injury. The aim of this paper is to describe a rhesus macaque model of brain death designed to simulate the average time and medical management described in the human literature. Methods: Following approval by the Institutional Animal Care and Use Committee, a brain death model was developed. Non-human primates were monitored and maintained for 20 hours after brain death induction. Vasoactive agents and fluid boluses were administered to maintain hemodynamic stability. Endocrine derangements, particularly diabetes insipidus, were aggressively managed. Results: A total of 9 rhesus macaque animals were included in the study. The expected hemodynamic instability of brain death in a rostral to caudal fashion was documented in terms of blood pressure and heart rate changes. During the maintenance phase of brain death, the animal’s temperature and hemodynamics were maintained with goals of mean arterial pressure greater than 60mmHg and heart rate within 20 beats per minute of baseline. Resuscitation protocols are described so that future investigators may reproduce this model. Conclusion: We have developed a reproducible large animal primate model of brain death which simulates clinical scenarios and treatment. Our model offers the opportunity for researchers to have translational model to test the efficacy of therapeutic strategies prior to human clinical trials. [ABSTRACT FROM AUTHOR]

A recent paper in Neurology used statistical techniques to investigate the integrity of the randomization in 33 clinical trials conducted by a group of investigators. Without justification, the approach assumed that there would be no impact of correlation among baseline variables. We investigated the impact of correlation on the conclusions of the approach in several large-scale simulation studies that replicated the sample sizes and baseline variables of the clinical trials in question and utilized proper randomization. Additionally, we considered scenarios with larger numbers of baseline variables. We found that, with even moderate correlation, there can be substantial inflation of the type I error of statistical tests of randomization integrity. This is also the case under no correlation, in the presence of some discrete baseline variables, with a large number of variables. Thus, statistical techniques for assessing randomization integrity should be applied with extreme caution given that very low p-values, which are taken as evidence against valid randomization, can arise even in the case of valid randomization, in the presence of correlation. More generally, the use of tests of goodness of fit to uniformity for the purpose of testing a global null hypothesis is not advisable in the presence of correlation. [ABSTRACT FROM AUTHOR]