Long-Term Virological Response to Multiple Sequential Regimens of Highly Active Antiretroviral Therapy for HIV Infection

Objective

Information about the virological response to sequential highly active antiretroviral therapy (HAART) for HIV infection is limited. The virological response to four consecutive therapies was evaluated in the Swiss HIV Cohort.

Design

Retrospective analysis in an observational cohort.

Methods

1140 individuals receiving uninterrupted HAART for 4.8 ±0.6 years were included. The virological response was classified as success (<400 copies/ml), low-level (LF: 400–5000 copies/ml) or high-level failure (HF: >5000 copies/ml). Potential determinants of the virological response, including patient demographics, treatment history and virological response to previous HAART regimens were analysed using survival and logistic regression analyses.

Results

40.1% failed virologically on the first (22.0% LF; 18.1% HF), 35.1% on the second (14.2% LF; 20.9% HF), 34.2% on the third (9.9% LF; 24.3% HF) and 32.7% on the fourth HAART regimen (9% LF; 23.7% HF). Nucleoside pre-treatment (OR: 2.34; 95% CI: 1.67–3.29) and low baseline CD4 T-cell count (OR: 0.79/100 cells rise; 95% CI: 0.72–0.88) increased the risk of HF on the first HAART. Virological failure on HAART with HIV-1 RNA levels exceeding 1000 copies/ml predicted a poor virological response to subsequent HAART regimens. A switch from a protease inhibitor- to a non-nucleoside reverse transcriptase inhibitor-containing regimen significantly reduced the risk of HF. Multiple switches of HAART did not affect the recovery of CD4 T lymphocytes.

Conclusion

Multiple sequential HAART regimens do not per se reduce the likelihood of long-term virological suppression and immunological recovery. However, early virological failure increases significantly the risk of subsequent unfavourable virological responses. The choice of a potent initial antiretroviral drug regimen is therefore critical. This study has been presented in part at the 10th Conference on Retroviruses & Opportunistic Infections. Boston, Mass., USA, 2003. Abstract #571.

Effect of Individual Cognitive Behaviour Intervention on Adherence to Antiretroviral Therapy: Prospective Randomized Trial

Objective

A high level of adherence to antiretroviral therapy is required for complete suppression of HIV replication, immunological and clinical effectiveness. We investigated whether cognitive behaviour therapy can improve medication adherence.

Design

Prospective randomized 1-year trial.

Setting

Collaboration of HIV university outpatient clinic and psychotherapists in private practice.

Participants

60 HIV-infected persons on stable anti-retroviral combination therapy and viral load below 50 copies/ml.

Intervention

Cognitive behaviour intervention in individual patients, in addition to standard of care.

Main outcome measures

Feasibility and acceptance of intervention; adherence to therapy assessed using medication event monitoring system (MEMS) and self-report questionnaire; virological failure; psychosocial measures.

Results

The median number of sessions for cognitive behaviour intervention per patient during the 1-year trial was 11 (range 2–25). At months 10–12, mean adherence to therapy as assessed using MEMS was 92.8% in the intervention and 88.9% in the control group ( P=0.2); the proportion of patients with adherence ≥95% was 70 and 50.0% ( P=0.014), respectively. While there was no significant deterioration of adherence during the study in the intervention arm, adherence decreased by 8.7% per year ( P=0.006) in the control arm. No differences between the intervention group and standard of care group were found regarding virological outcome. Compared with the control group, participants in the intervention group perceived a significant improvement of their mental health during the study period.

Conclusions

Cognitive behavioural support in addition to standard of care of HIV-infected persons is feasible in routine practice, and can improve medication adherence and mental health.

Impact of Genotypic Resistance Testing on Selection of Salvage Regimen in Clinical Practice

Objective

To determine whether genotypic resistance testing leads to selection of more potent drug regimens when compared to regimens based on treatment history only.

Design

Prospective, tertiary care centre-based study. Patients: One-hundred-and-forty-five HIV-infected adults on stable antiretroviral therapy (ART) for >6 months experiencing virological failure.

Methods

The physicians’ decision-making process when choosing a salvage regimen was prospectively documented: at time of virological failure, on ‘failing ART’, genotyping was performed and a hypothetical ‘clinical expert ART’ based upon patient's drug history was documented. Subsequently, data on resistance mutations, rating by a decision support software and drug history were used to define ‘genotyping ART’. After discussion with the patient, final treatment, ‘new personalized ART’ was chosen and prescribed. To compare the relative potency of the four ART regimens in a standardized manner, a resistance score ranging from 1 (best) to 8 (worst) based on drug ranking by decision support software was attributed to each ART regimen. Virological and immunological outcomes were analysed based on the magnitude of the resistance score.

Results

Median follow-up was 1.5 years. In all 145 patients, median resistance scores for the stepwise selected ART regimens were: ‘failing ART’: 4.5, ‘clinical expert ART’: 1.8, ‘genotyping ART’: 1.5 and ‘new personalized ART’: 2. The latter was 1.5 in patients who effectively switched to ‘new personalized ART’ ( n=89). Lower resistance scores translated into significantly improved virological response after initiation of ‘new personalized ART’. In multivariable analysis, lower resistance scores, lower baseline HIV RNA levels and use of novel antiretroviral drugs were associated with the probability of reducing plasma viraemia to <50 copies/ml. Conclusions: This study suggests that treatment choices including genotype and decision support software were virologically superior to those based on drug history only.

[Epidemiology of end-stage renal failure: comparison between 2 Swiss cantons]

Since a previous survey in the Valais Canton had shown a disparity in the prevalence of chronic dialysis patients compared to the national mean, an epidemiological survey was conducted in the cantons of Valais (VS) and Vaud (VD) among all the dialysis units (VS 6, VD 6) and all adult dialysis patients (VS 130, VD 187). The survey confirms the disparity in prevalence: VS 476, VD 340 and Switzerland 329 per million inhabitants (p.m.h.). This disparity also exists among different parts of the VS canton: Haut-Valais 316, Valais Central 650 and Bas-Valais 409 per million d'habitants. The mean age at start of therapy and at the time of the survey are comparable: 57 +/- 17 vs 55 +/- 15 years and 62 +/- 15 vs 61 +/- 14 respectively. Among the different etiological diseases, vascular nephropathies are less frequent and hereditary diseases more frequent in the VS canton. Co-morbidity factors were comparable. In VS there are less patients on peritoneal dialysis (6 vs 19%) and on the transplant waiting list (12 vs 16%). Globally, disparities exist in the prevalence of dialysis patients between the 2 cantons; they can be explained by both medical factors (type of nephropathies) and different options in the treatment modalities.

Anxiety in a cohort of Swiss women participating in a mammographic screening programme

OBJECTIVES

To follow up anxiety in a cohort of women screened for breast cancer.

METHODS

Within the framework of a pilot screening programme for breast cancer in the Canton of Vaud (Switzerland), a cohort of 924 participants aged 50-70 years were invited to answer questions on anxiety related to mammography screening. Anxiety was measured using a specific tool, the psychological consequences questionnaire (PCQ), and a new single item, direct question, breast cancer anxiety indicator (BCA). Participants were asked to fill in the questionnaire at four different phases: at screening, before the result, and 2 and 8 weeks after the result. The final response rate was 93.7%. Predictors of anxiety at each phase were assessed using multiple regression.

RESULTS

Among those screening negative (94.7%), anxiety at screening was very low and remained so during the screening process. Among those screening false positive, anxiety was significantly higher 8 weeks after having received a negative diagnosis. Predictors of anxiety before screening were lower education and higher age, with a strong exogenous anxiety component. For subsequent phases, the initial anxiety score and education were the main determinants. Furthermore, a false positive result at screening was the most important predictor of anxiety 2 months after negative diagnosis. Anxiety measured with the BCA was strongly correlated with the PCQ.

CONCLUSION

Anxiety was very low at screening and remained so during the process for negative women. Initial anxiety level was a strong predictor of anxiety during the entire process, up to 8 weeks after a negative result, and could be easily assessed using the BCA. The sustained higher anxiety level among those screening false positive is an undesirable side effect of the programme.

Prevalence and risk factors for overweight and obesity in children from Seychelles, a country in rapid transition: the importance of early growth

OBJECTIVES

To establish the prevalence of overweight and obesity and related risk factors in children from Seychelles (Indian Ocean), a country in rapid economic and epidemiological transition.

DESIGN

Cross-sectional study with retrospective access to early life data.

SUBJECTS

All children from all schools of Seychelles, in four selected school grades (kindergarten, fourth, seventh and tenth year of obligatory school) in 1999. A total of 5514 children aged 4.5-17.4 y were measured, corresponding to 83.5% of the eligible population.

MEASUREMENTS

Overweight and obesity, using age- and sex-specific body mass index (BMI) cut-off points as defined by the International Obesity Task Force.

RESULTS

Some 12.6% (95% confidence interval: 11.8-13.5%) of the children were overweight and 3.8% (3.3-4.4%) were obese. Weight gain (kg) during the first year of life was strongly associated with subsequent overweight (odds ratio 1.46, 95% confidence interval 1.27-1.67) and obesity (1.59, 1.29-1.97) in childhood, independently of birth weight. Increased maternal BMI (kg/m(2)) was also associated with overweight (1.07, 1.03-1.10) and obesity (1.09, 1.04-1.14) in the offspring.

CONCLUSION

Prevalence of overweight and obesity among school children in Seychelles was as high as or higher than in some industrialized countries. If confirmed in other environments, the strong association between weight gain during the first year of life and subsequent obesity in childhood could affect the way optimal infant weight gain is defined in countries where public health priorities are changing.

Body mass index, abdominal adiposity and blood pressure: consistency of their association across developing and developed countries

BACKGROUND

Obesity is increasing worldwide because developing countries are adopting Western high-fat foods and sedentary lifestyles. In parallel, in many of them, hypertension is rising more rapidly, particularly with age, than in Western countries.

OBJECTIVE

To assess the relationship between adiposity and blood pressure (BP) in a developing country with high average BP (The Seychelles, Indian Ocean, population mainly of African origin) in comparison to a developed country with low average BP (Switzerland, population mainly of Caucasian origin).

DESIGN

Cross-sectional health examination surveys based on population random samples.

SETTING

The main Seychelles island (Mahé) and two Swiss regions (Vaud-Fribourg and Ticino).

SUBJECTS

Three thousand one hundred and sixteen adults (age range 35-64) untreated for hypertension.

MEASUREMENTS

Body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), systolic and diastolic blood pressure (SBP and DBP, mean of two measures).

METHODS

Scatterplot smoothing techniques and gender-specific linear regression models.

RESULTS

On average, SBP and DBP were found to increase linearly over the whole variation range of BMI, WHR and WC. A modest, but statistically significant linear association was found between each indicator of adiposity and BP levels in separate regression models controlling for age. The regression coefficients were not significantly different between the Seychelles and the two Swiss regions, but were generally higher in women than in men. For the latter, a gain of 1.7 kg/m(2) in BMI, of 4.5 cm in WC or of 3.4% in WHR corresponded to an elevation of 1 mmHg in SBP. For women, corresponding figures were 1.25 kg/m(2), 2.5 cm and 1.8% respectively. Regression coefficients for age reflected a higher effect of this variable on both SBP and DBP in the Seychelles than in Switzerland.

CONCLUSION

These findings suggest a stable linear relation of adiposity with BP, independent of age and body fat distribution, across developed and developing countries. The more rapid increase of BP with age observed in the latter countries are likely to reflect higher genetic susceptibility and/or higher cumulative exposure to another risk factor than adiposity.

Body mass index: comparing mean values and prevalence rates from telephone and examination surveys

BACKGROUND

Cost effective means of assessing the levels of risk factors in the population have to be defined in order to monitor these factors over time and across populations. This study is aimed at analyzing the difference in population estimates of the mean levels of body mass index (BMI) and the prevalences of overweight, between health examination survey and telephone survey.

METHODS

The study compares the results of two health surveys, one by telephone (N=820) and the other by physical examination (N=1318). The two surveys, based on independent random samples of the population, were carried out over the same period (1992-1993) in the same population (canton of Vaud, Switzerland).

RESULTS

Overall participation rates were 67% and 53% for the health interview survey (HIS) and the health examination survey (HES) respectively. In the HIS, the reporting rate was over 98% for weight and height values. Self-reported weight was on average lower than measured weight, by 2.2 kg in men and 3.5 kg in women, while self-reported height was on average greater than measured height, by 1.2 cm in men and 1.9 cm in women. As a result, in comparison to HES, HIS led to substantially lower mean levels of BMI, and to a reduction of the prevalence rates of obesity (BMI>30 kg/m(2)) by more than a half. These differences are larger for women than for men.

CONCLUSION

The two surveys were based on different sampling procedures. However, this difference in design is unlikely to explain the systematic bias observed between self-reported and measured values for height and weight. This bias entails the overall validity of BMI assessment from telephone surveys.

Physicians' attitudes towards prevention: importance of intervention-specific barriers and physicians' health habits

BACKGROUND

Several studies have explored physicians' attitudes towards prevention and barriers to the delivery of preventive health interventions. However, the relative importance of these previously identified barriers, both in general terms and in the context of a number of specific preventive interventions, has not been identified. Certain barriers may only pertain to a subset of preventive interventions.

OBJECTIVES

We aimed to determine the relative importance of identified barriers to preventive interventions and to explore the association between physicians' characteristics and their attitudes towards prevention.

METHODS

We conducted a cross-sectional survey of 496 of the 686 (72.3% response rate) generalist physicians from three Swiss cantons through a questionnaire asking physicians to rate the general importance of eight preventive health strategies and the relative importance of seven commonly cited barriers in relation to each specific preventive health strategy.

RESULTS

The proportion of physicians rating each preventive intervention as being important varied from 76% for colorectal cancer screening to 100% for blood pressure control. Lack of time and lack of patient interest were generally considered to be important barriers by 41% and 44% of physicians, respectively, but the importance of these two barriers tended to be specifically higher for counselling-based interventions. Lack of training was most notably a barrier to counselling about alcohol and nutrition. Four characteristics of physicians predicted negative attitudes toward alcohol and smoking counselling: consumption of more than three alcoholic drinks per day [odds ratio (OR) = 8.4], sedentary lifestyle (OR = 3.4), lack of national certification (OR = 2.2) and lack of awareness of their own blood pressure (OR = 2.0).

CONCLUSIONS

The relative importance of specific barriers varies across preventive interventions. This points to a need for tailored practice interventions targeting the specific barriers that impede a given preventive service. The negative influence of physicians' own health behaviours indicates a need for associated population-based interventions that reduce the prevalence of high-risk behaviours in the population as a whole.

High prevalence of peripheral atherosclerosis in a rapidly developing country

Cardiovascular disease is rapidly increasing in developing countries experiencing epidemiological transition. We investigated the prevalence of peripheral atherosclerosis in a rapidly developing country and compared our findings with data previously reported in Western populations. A cardiovascular risk factor survey was conducted in 1067 individuals aged 25-64 randomly selected from the general population of Seychelles. High-resolution ultrasonography of the right and left carotid and femoral arteries was performed in a random subgroup of 503 subjects (245 men and 258 women). In each of the four arteries, arterial wall thickness (in plaque-free segments) and atherosclerotic plaques (i.e. focal wall thickening at least 1.0 mm thick) were measured separately. The prevalence of peripheral atherosclerosis was high in this population. For instance, at least one plaque > or =1.0 mm was found in, respectively, 34.9 and 27.5% of men and women aged 25-34 and at least one plaque > or =2.5 mm was found in, respectively, 58.2 and 36.9% of men and women aged 55-64. With reference to data found in the literature, the prevalence of carotid atherosclerosis appeared to be significantly higher in Seychelles than in Western populations. This study provides further evidence for the importance of cardiovascular disease in developing countries. Determinants should be identified and relevant prevention and control programs implemented.

One-year prevalence of low back pain in two Swiss regions: estimates from the population participating in the 1992-1993 MONICA project

STUDY DESIGN

A cross-sectional survey was performed.

OBJECTIVE

To estimate the extent of low back pain as a public health problem.

SUMMARY OF BACKGROUND DATA

Health surveys converge on very high estimates of low back pain in general populations, but few studies have included severity criteria in their definition and conclusions. Because it is unlikely that interventions will influence the prevalence of minimal and infrequent symptoms, greater attention should be paid to characteristics of low back pain that indicate some impact on the life of survey respondents.

METHODS

Two regions participated in the MONICA (MONitoring of trends and determinants in CArdiovascular disease) project in Switzerland. Participants randomly selected from the general population completed a standard self-administered questionnaire on cardiovascular risk factors. A special section on low back pain was added in the third (1992-1993) MONICA survey and completed by 3227 participants.

RESULTS

A regional difference found in the 12-month prevalence rate disappeared with the inclusion of severity criteria. Low back pain over more than seven cumulated days was reported among men by 20.2% (age range, 25-34 years) to 28.5% (age range, 65-74 years), respectively, among women by 31.1% to 38.5%. Similar rates of reduction in activity (professional, housekeeping, and leisure time) and medical consultation (conventional and nonconventional) motivated by low back pain characterized the two participating regions. The cumulative duration of pain was related to all the indicators showing the impact of low back pain on everyday life.

CONCLUSIONS

Determining the cumulative duration of low back pain over the preceding year is a straightforward task, and a cutoff at 1 week seems appropriate for distinguishing between low- and high-impact low back pain.

Performance of classic electrocardiographic criteria for left ventricular hypertrophy in an African population

ECG criteria for left ventricular hypertrophy (LVH) have been almost exclusively elaborated and calibrated in white populations. Because several interethnic differences in ECG characteristics have been found, the applicability of these criteria to African individuals remains to be demonstrated. We therefore investigated the performance of classic ECG criteria for LVH detection in an African population. Digitized 12-lead ECG tracings were obtained from 334 African individuals randomly selected from the general population of the Republic of Seychelles (Indian Ocean). Left ventricular mass was calculated with M-mode echocardiography and indexed to body height. LVH was defined by taking the 95th percentile of body height-indexed LVM values in a reference subgroup. In the entire study sample, 16 men and 15 women (prevalence 9.3%) were finally declared to have LVH, of whom 9 were of the reference subgroup. Sensitivity, specificity, accuracy, and positive and negative predictive values for LVH were calculated for 9 classic ECG criteria, and receiver operating characteristic curves were computed. We also generated a new composite time-voltage criterion with stepwise multiple linear regression: weighted time-voltage criterion=(0.2366R(aVL)+0.0551R(V5)+0.0785S(V3)+ 0.2993T(V1))xQRS duration. The Sokolow-Lyon criterion reached the highest sensitivity (61%) and the R(aVL) voltage criterion reached the highest specificity (97%) when evaluated at their traditional partition value. However, at a fixed specificity of 95%, the sensitivity of these 10 criteria ranged from 16% to 32%. Best accuracy was obtained with the R(aVL) voltage criterion and the new composite time-voltage criterion (89% for both). Positive and negative predictive values varied considerably depending on the concomitant presence of 3 clinical risk factors for LVH (hypertension, age >/=50 years, overweight). Median positive and negative predictive values of the 10 ECG criteria were 15% and 95%, respectively, for subjects with none or 1 of these risk factors compared with 63% and 76% for subjects with all of them. In conclusion, the performance of classic ECG criteria for LVH detection was largely disparate and appeared to be lower in this population of East African origin than in white subjects. A newly generated composite time-voltage criterion might provide improved performance. The predictive value of ECG criteria for LVH was considerably enhanced with the integration of information on concomitant clinical risk factors for LVH.

Screening for gestational diabetes: variation in guidelines

OBJECTIVE

To compare published guidelines concerning screening for gestational diabetes.

STUDY DESIGN

Systematic search and comparative analysis of published guidelines. Appraisal of guidelines quality. Simulation analysis.

RESULTS

Ten published guidelines proposed either universal screening (5), selective screening (3) or screening when clinically indicated (2). Variations of testing schedules and blood glucose thresholds were observed. The quality of the published guidelines was low, on average 22 (8-51) percentage points on the assessment scale. These differences would have led to large variations in the number of patients to be screened.

CONCLUSIONS

Large variations between guidelines have been observed which would translate in large practice variations, if the guidelines were systematically applied. These variations are partially explained by the absence of definite evidence that universal or selective screening for gestational diabetes do more good than harm on infant and maternal health. The methodology of developing guidelines should be more evidence based, systematic and explicit.

Promotion of condom use in a high-risk setting in Nicaragua: a randomised controlled trial

BACKGROUND

In Latin America, motels rent rooms for commercial and non-commercial sex. We investigated the impact of providing health-education material and condoms on condom use in Managua, Nicaragua.

METHODS

In a randomised controlled trial, in 19 motels, we gave condoms on request, made them available in rooms, or gave condoms directly to couples, with and without the presence of health-education material in the rooms. In a factorial design we assessed condom use directly by searching the rooms after couples had left.

FINDINGS

11 motels were used mainly by sex workers and their clients and eight mainly for non-commercial sex. 6463 couples attended the motels in 24 days. On 3106 (48.0%) occasions, at least one used condom was retrieved. Condom use was more frequent for commercial sex than for non-commercial sex (60.5 vs 20.2%). The presence of health-education material lowered the frequency of condom use for commercial sex (odds ratio 0.89 [95% CI 0.84-0.94]) and had no effect on use for non-commercial sex (1.03 [0.97-1.08]). Condom use increased for commercial (1.31 [1.09-1.75]) and non-commercial sex (1.81 (1.14-2.81) if condoms were available in rooms. Directly handing condoms to couples was similarly effective for commercial sex but less effective for non-commercial sex (1.32 [1.03-1.61] vs 1.52 [1.01-2.38]).

INTERPRETATION

In Latin America, motels are key locations for promoting the use of condoms. Making condoms available in rooms is the most effective strategy to increase condom use, whereas use of health-education material was ineffective. These findings have important implications for HIV-prevention policies.

Anxiety, depressive, or cognitive disorders in rehabilitation patients: effect on length of stay

OBJECTIVE

To test the hypothesis that anxiety, depressive, or cognitive disorders are associated with an increase in length of stay of physical rehabilitation inpatients.

DESIGN

Secondary analysis of a 1-yr prospective data recording. Three treatment and rehabilitation centers in the Canton of Vaud (Switzerland). Ninety-five percent of inpatients admitted from November 15, 1990, to November 14, 1991, agreed to participate. Apart from length of stay, data consisted of demographic and medical data results from the Hospital Anxiety and Depression Scale, Mini-Mental State Score, and Functional Autonomy Measurement System. Multivariate linear regression was used in the analysis.

RESULTS

The presence of anxiety or depression altered length of stay in a bivariate analysis, although all effects disappeared in a multivariate approach. Factors that had an independent association with length of stay were gender, length of stay in an acute care hospital before hospitalization, treatment and rehabilitative centers, Functional Autonomy Measurement System mobility score, and Functional Autonomy Measurement System Activities of Daily Living score. Results concerning the association between cognition abilities and length were similar.

CONCLUSIONS

Our results recognize that an influence of psychiatric disorders acted on length of stay through a relationship between the psychiatric status and the control variables. If mental state influences physical state, then early intervention studies are desirable. If somatic state induces mental alterations, then interventions directed toward the psychiatric sphere will bring mostly qualitative benefits (amelioration of well-being without remarkable effects on length of stay).

Dyslipidemia and abdominal obesity: an assessment in three general populations

Several studies show a relationship between abdominal obesity and cardiovascular diseases, partially mediated through an altered metabolism of dyslipidemia. The present study was aimed at testing the robustness of this association across three contrasted populations and at assessing the performances of abdominal obesity as a screening tool for dyslipidemia. Data were drawn from three population health surveys recently conducted in two regions of a developed country (Switzerland, mostly of Caucasian origin, n = 2650) and in a less developed country (Seychelles, Indian Ocean, mostly of black descent, n = 806). Dyslipidemia was defined as a ratio of total cholesterol to high-density lipoprotein cholesterol (TC-HDL) greater than 5. Two anthropometric circumference measurements, waist-to-hip ratio (WHR) and waist circumference (WC), were used to define abdominal obesity either as WHR >/= 0.9 in men and WHR >/= 0.8 in women or as WC >/= 94 cm and WC >/= 80 cm, respectively. A consistent direct association between abdominal obesity and dyslipidemia (odds ratios varying from 1.85 to 4.56) was found in the three populations, independently of gender, age, body mass index, blood pressure, and smoking. This consistency across ethnicities and environments strengthens the hypothesis of a common etiopathological mechanism. The sensitivity for detecting dyslipidemia was generally higher for abdominal obesity, based on either WHR or WC, than for criteria based on the other risk factors under study. In addition, the sensitivity was higher in the study populations with a low prevalence of dyslipidemia (Swiss women and Seychellois of both sexes) than in the others. These findings support that WHR and WC may be useful as simple and inexpensive screening tools to select individuals eligible for more sophisticated and costly serum lipid determinations, especially in developing countries.

Prevention of recurrent hip fracture

Our objective was to describe the interventions aimed at preventing a recurrent hip fracture, and other injurious falls, which were provided during hospitalization for a first hip fracture and during the two following years. A secondary objective was to study some potential determinants of these preventive interventions. The design of the study was an observational, two-year follow-up of patients hospitalized for a first hip fracture at the University Hospital of Lausanne, Switzerland. The participants were 163 patients (median age 82 years, 83% women) hospitalized in 1991 for a first hip fracture, among 263 consecutively admitted patients (84 did not meet inclusion criteria, e.g., age>50, no cancer, no high energy trauma, and 16 refused to participate). Preventive interventions included: medical investigations performed during the first hospitalization and aimed at revealing modifiable pathologies that raise the risk of injurious falls; use of medications acting on the risk of falls and fractures; preventive recommendations given by medical staff; suppression of environmental hazards; and use of home assistance services. The information was obtained from a baseline questionnaire, the medical record filled during the index hospitalization, and an interview conducted 2 years after the fracture. Potential predictors of the use of preventive interventions were: age; gender; destination after discharge from hospital; comorbidity; cognitive functioning; and activities of daily living. Bi- and multivariate associations between the preventive interventions and the potential predictors were measured. In hospital investigations to rule out medical pathologies raising the risk of fracture were performed in only 20 patients (12%). Drugs raising the risk of falls were reduced in only 17 patients (16%). Preventive procedures not requiring active collaboration by the patient (e.g., modifications of the environment) were applied in 68 patients (42%), and home assistance was provided to 67 patients (85% of the patients living at home). Bivariate analyses indicated that prevention was less often provided to patients in poor general conditions, but no ascertainment of this association was found in multivariate analyses. In conclusion, this study indicates that, in the study setting, measures aimed at preventing recurrent falls and injuries were rarely provided to patients hospitalized for a first hip fracture at the time of the study. Tertiary prevention could be improved if a comprehensive geriatric assessment were systematically provided to the elderly patient hospitalized for a first hip fracture, and passive preventive measures implemented.

Electrocardiographic findings in a middle-aged African population in the Seychelles islands

This study describes major electrocardiogram (ECG) measurements and diagnoses in a population of African individuals; most reference data have been collected in Caucasian populations and evidence exists for interethnic differences in ECG findings. This study was conducted in the Seychelles islands (Indian Ocean) and included 709 black individuals (343 men and 366 women) aged 25 to 64 years randomly selected from the general population. Resting ECG were recorded by using a validated ECG unit equipped with a measurement and interpretation software (Cardiovit AT-6, Schiller, Switzerland). The epidemiology of 14 basic ECG measurements, 6 composite criteria for left ventricular hypertrophy and 19 specific ECG diagnoses including abnormal rhythms, conduction abnormalities, repolarization abnormalities, and myocardial infarction were examined. Substantial gender and age differences were found for several ECG parameters. Moreover, tracings recorded in African individuals of the Seychelles differed from those collected similarly in Caucasian populations in many respects. For instance, heart rate was approximately 5 beats per minute lower in the African individuals than in selected Caucasian populations, prevalence of first degree atrio-ventricular block was especially high (4.8%), and the average Sokolow-Lyon voltage was markedly higher in African individuals of the Seychelles compared with black and white Americans. The integrated interpretation software detected "old myocardial infarction" in 3.8% of men and 0% of women and "old myocardial infarction possible" in 6.1% and 3%, respectively. Cardiac infarction injury scores are also provided. In conclusion, the study provides reference values for ECG findings in a specific population of people of African descent and stresses the need to systematically consider gender, age, and ethnicity when interpreting ECG tracings in individuals.

Patterns of alcohol consumption in the Seychelles Islands (Indian Ocean)

Self-reported drinking habits were examined in a random sample of 1067 persons aged 25-64 years in the Seychelles, a country in epidemiological transition where consumption of home-brewed, mostly unregistered beverages has been traditionally high. Alcohol consumption was calculated from respondents reporting at least one drink per week ('regular drinkers'). Among men, 51.1% were regular drinkers and had average intake of 112.1 ml alcohol a day. Among women, 5.9% were regular drinkers and had 49.7 ml alcohol a day. Frequency of drinking, but not amount per drinker, was slightly less in the 25-34-year than older-age categories. Home-brews (mostly palm toddy and fermented sugar cane juice) were consumed by 52% of regular drinkers and accounted for 54% of the total alcohol intake reported by all regular drinkers. Based on the reported consumption by regular drinkers only, the average annual alcohol consumption amounted respectively to 20.7 litres and 1.2 litres per man and woman aged 25-64 years, or, using extrapolation, 13.2 litres and 0.8 litres per man and woman respectively of the total population. These values may underestimate the true figures by half, since reported beer consumption accounted for 53% of beer sales. Socio-economic status was associated strongly and inversely with home-brew consumption, but slightly and positively with consumption of commercially marketed beverages. Alcohol intake was associated with smoking, high-density lipoprotein cholesterol, carbohydrate-deficient transferrin and blood pressure, but not with age and body mass index. In conclusion, these data show high alcohol consumption in the Seychelles with an important gender difference, a large proportion of alcohol derived from home-brews, and opposite tendencies for the relationships between socio-economic status and home-made or commercially marketed beverages.