Selected major risk factors and global and regional burden of disease

Hypertension management in older adults

Vascular aging leads to arterial hypertension, which is the leading cause of cardiovascular mortality and morbidity in older adults. Blood pressure reduction is effective in reducing the cardiovascular risk and is safe in ambulatory older adults. It is important to note that blood pressure control in this group of patients is challenging because of comorbidities, polypharmacy, and frailty. Choice of pharmacotherapy is not simple and should be individualized.

A comparison of health indicators and social determinants of health between Israel and the Occupied Palestinian Territories

Despite the proximity and interconnections between Israel and the Occupied Palestinian Territories (oPt), great disparities persist in health status between these two regions. This disparity is seen in infant, child and maternal mortality, life expectancy, mortality rates for leading causes of death and measures of mental well-being. This paper compares health indicators between oPt and Israel and examines the social determinants of health that may be responsible for differences between them. Data on health indicators were obtained from publicly available publications or websites of the World Health Organization and The World Bank, as well as the database of the Global Burden of Disease Project of the Institute of Health Metrics and Evaluation. Data on the social determinants of health were obtained from publications and websites of the United Nations, the World Bank, the U.S. Central Intelligence Agency, Palestinian and Israeli government reports, reports from non-governmental organisations, peer-reviewed studies and news articles. The health disparities are due to a complex mix of factors involving economic conditions, food insecurity, environmental exposures, psychological trauma and stress, and access to health services, most of which can be related directly or indirectly to the Israeli military occupation of oPt.

Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries

BACKGROUND

Smokeless tobacco (ST) is consumed by more than 300 million people worldwide. The distribution, determinants and health risks of ST differ from that of smoking; hence, there is a need to highlight its distinct health impact. We present the latest estimates of the global burden of disease due to ST use.

METHODS

The ST-related disease burden was estimated for all countries reporting its use among adults. Using systematic searches, we first identified country-specific prevalence of ST use in men and women. We then revised our previously published disease risk estimates for oral, pharyngeal and oesophageal cancers and cardiovascular diseases by updating our systematic reviews and meta-analyses of observational studies. The updated country-specific prevalence of ST and disease risk estimates, including data up to 2019, allowed us to revise the population attributable fraction (PAF) for ST for each country. Finally, we estimated the disease burden attributable to ST for each country as a proportion of the DALYs lost and deaths reported in the 2017 Global Burden of Disease study.

RESULTS

ST use in adults was reported in 127 countries; the highest rates of consumption were in South and Southeast Asia. The risk estimates for cancers were also highest in this region. In 2017, at least 2.5 million DALYs and 90,791 lives were lost across the globe due to oral, pharyngeal and oesophageal cancers that can be attributed to ST. Based on risk estimates obtained from the INTERHEART study, over 6 million DALYs and 258,006 lives were lost from ischaemic heart disease that can be attributed to ST. Three-quarters of the ST-related disease burden was among men. Geographically, > 85% of the ST-related burden was in South and Southeast Asia, India accounting for 70%, Pakistan for 7% and Bangladesh for 5% DALYs lost.

CONCLUSIONS

ST is used across the globe and poses a major public health threat predominantly in South and Southeast Asia. While our disease risk estimates are based on a limited evidence of modest quality, the likely ST-related disease burden is substantial. In high-burden countries, ST use needs to be regulated through comprehensive implementation of the World Health Organization Framework Convention for Tobacco Control.

Blood pressure targets in atrial fibrillation

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Folate Deficiency Inhibits Development of the Mammary Gland and its Associated Lymphatics in FVB Mice

BACKGROUND

Folate is essential for DNA synthesis, DNA repair, cell proliferation, development, and morphogenesis. Folic acid (FA) is a nutritional supplement used to fortify human diets.

OBJECTIVES

We investigated the effects of dietary FA on early mammary gland (MG) development and hyperplasia.

METHODS

Study 1: nulliparous female FVB wild-type (WT) mice were fed control (Con; 2 mg FA/kg), deficient (Def; 0 mg FA/kg), excess (Ex; 5 mg FA/kg), or super excess (S-Ex; 20 mg FA/kg) diets for 8 wk before mating to WT or heterozygous FVB/N-Tg[mouse mammary tumor virus long terminal repeat (MMTV)-polyomavirus middle T antigen (PyVT)]634Mul/J (MMTV-PyMT+/-) transgenic males. Dams were fed these diets until they weaned WT or MMTV-PyMT+/- pups, which were fed the dam's diet from postnatal day (PND) 21 to 42. Tissues were collected from female progeny at PNDs 1, 21, and 42. Study 2: Con or Def diets were fed to WT intact females and males from PND 21 to 56, or to ovariectomized females from PND 21 to 77; tissues were collected at PND 56 or 77. Growth of all offspring, development of MGs, MG hyperplasia, supramammary lymph nodes, thymus and spleen, cell proliferation, and expression of MG growth factors were measured.

RESULTS

Study 1: Ex or S-Ex did not affect postnatal MG development or hyperplasia. The rate of isometric MG growth (PND 1-21) was reduced by 69% in Def female progeny (P < 0.0001). Similarly, hyperplastic growth in MGs of Def MMTV-PyMT+/- offspring was 18% of Con (P < 0.05). The Def diet reduced supramammary lymph node size by 20% (P < 0.0001) and increased MG insulin-like growth factor 2 mRNA by 200% (P < 0.05) and protein by 130%-150% (P < 0.05). Study 2: the Def diet did not affect MG growth, but it did reduce supramammary lymph node size (P < 0.05), spleen weight (P < 0.001), and thymic medulla area (P < 0.05).

CONCLUSIONS

In utero and postnatal folate deficiency reduced the isometric development of the MGs and early MG hyperplasia. Postnatal folate deficiency reduced the development of lymphatic tissues.

Accuracy of blood-pressure monitors owned by patients with hypertension (ACCU-RATE study): a cross-sectional, observational study in central England

Background

Home blood-pressure (BP) monitoring is recommended in guidelines and is increasingly popular with patients and health professionals, but the accuracy of patients’ own monitors in real-world use is not known.

Aim

To assess the accuracy of home BP monitors used by people with hypertension, and to investigate factors affecting accuracy.

Design and setting

Cross-sectional, observational study in urban and suburban settings in central England.

Method

Patients (n = 6891) on the hypertension register at seven practices in the West Midlands, England, were surveyed to ascertain whether they owned a BP monitor and wanted it tested. Monitor accuracy was compared with a calibrated reference device at 50 mmHg intervals between 0–280/300 mmHg (static pressure test); a difference from the reference monitor of +/−3 mmHg at any interval was considered a failure. Cuff performance was also assessed. Results were analysed by frequency of use, length of time in service, make and model, monitor validation status, purchase price, and any previous testing.

Results

In total, 251 (76%, 95% confidence interval [95% CI] = 71 to 80%) of 331 tested devices passed all tests (monitors and cuffs), and 86% (CI] = 82 to 90%) passed the static pressure test; deficiencies were, primarily, because of monitors overestimating BP. A total of 40% of testable monitors were not validated. The pass rate on the static pressure test was greater in validated monitors (96%, 95% CI = 94 to 98%) versus unvalidated monitors (64%, 95% CI = 58 to 69%), those retailing for >£10 (90%, 95% CI = 86 to 94%), those retailing for ≤£10 (66%, 95% CI = 51 to 80%), those in use for ≤4 years (95%, 95% CI = 91 to 98%), and those in use for >4 years (74%, 95% CI = 67 to 82%). All in all, 12% of cuffs failed.

Conclusion

Patients’ own BP monitor failure rate was similar to that demonstrated in studies performed in professional settings, although cuff failure was more frequent. Clinicians can be confident of the accuracy of patients’ own BP monitors if the devices are validated and ≤4 years old.

Nitrate-Rich Beetroot Juice Reduces Blood Pressure in Tanzanian Adults with Elevated Blood Pressure: A Double-Blind Randomized Controlled Feasibility Trial

BACKGROUND

In Sub-Saharan Africa, current strategies are struggling to control the burgeoning hypertension epidemic. Dietary interventions such as inorganic nitrate or folic acid supplementation could represent promising strategies for reducing blood pressure (BP) in this setting.

OBJECTIVES

This feasibility study explores the effects of dietary inorganic nitrate supplementation, alone or in combination with folic acid, on BP in Tanzanian adults with elevated BP in Tanzania.

METHODS

A placebo-controlled, double-blind, randomized controlled feasibility trial was conducted. Forty-seven middle-aged and older participants (age: 50-70 y, BMI: 26.3-29.1 kg/m2) were randomly assigned to 3 conditions for a period of 60 d: 1) high-nitrate beetroot juice (∼400 mg nitrate) and folic acid (∼5 mg folic acid) (N + F), 2) high-nitrate beetroot juice and placebo (N + P), or 3) nitrate-depleted beetroot juice and placebo (P + P). Clinic and 24-h ambulatory BP and measurements of compliance in plasma (nitrate and folate concentrations) and saliva (nitrate and nitrite) were obtained at baseline, 30 d, and 60 d.

RESULTS

Baseline resting systolic and diastolic BP (mean ± SD) was 151.0 ± 19.4 mm Hg and 91.8 ± 11.7 mm Hg, respectively. Compliance to the interventions was high (>90%) in all groups which was confirmed by the significant increase in nitrate and folic acid concentrations in plasma and saliva samples in the treatment arms. After 60 d, 24-h systolic BP dropped by -10.8 ± 9.8 mm Hg (P < 0.001), -6.1 ± 13.2 mm Hg (P = 0.03), and -0.3 ± 9.7 mm Hg (P = 0.83) in the N + P, N + F, and P + P groups, respectively. There was a significant decrease in 24-h diastolic BP in the N + P group (-5.4 ± 5.0 mm Hg, P = 0.004), whereas changes were not significant in the N + F (-1.8 ± 8.1 mm Hg, P = 0.32) and P + P (1.6 ± 8.3 mm Hg, P = 0.43) groups.

CONCLUSIONS

Dietary inorganic nitrate represents a potential nutritional strategy to lessen the hypertension epidemic in Sub-Saharan Africa. These findings support the rationale for future long-term investigations exploring the efficacy of dietary nitrate for lowering BP and attenuating cardiovascular disease risk in this setting.This trial was registered at isrctn.com as ISRCTN67978523.

Inhibition of sodium-proton-exchanger subtype 3-mediated sodium absorption in the gut: A new antihypertensive concept

Arterial hypertension is one of the main contributors to cardiovascular diseases, including stroke, heart failure, and coronary heart disease. Salt plays a major role in the regulation of blood pressure and is one of the most critical factors for hypertension and stroke. At the individual level, effective salt reduction is difficult to achieve and available methods for managing sodium balance are lacking for many patients. As part of the ingested food, salt is absorbed in the gastrointestinal tract by the sodium proton exchanger subtype 3 (NHE3 also known as Slc9a3), influencing extracellular fluid volume and blood pressure. In this review, we discuss the beneficial effects of pharmacological inhibition of NHE3-mediated sodium absorption in the gut and focus on the effect on blood pressure and end-organ damage.

The U-shaped association between achieved blood pressure and risk of cardiovascular events and mortality in elderly and younger patients

OBJECTIVE

The main objective is to assess the appropriate level of achieved SBP and DBP to prevent cardiovascular events.

METHODS

We used the National Sample Cohort from the National Health Insurance Service in Korea and analyzed data of 44 462 hypertensive patients aged 20--84 years. Achieved SBP and DBP were categorized according to average achieved SBP (<120, 120-129, 130-139, 140-149, and ≥150 mmHg) and DBP (<70, 70-79, 80-89, 90-99, and ≥100 mmHg). We examined the association between achieved BP and composite outcome including cardiovascular death, admission of stroke, myocardial infarction, or heart failure, and all-caused death in elderly aged more than 65 years and in younger patients.

RESULTS

After a median follow-up of 6.8 years, achieved SBP less than 120 mmHg and at least 150 mmHg in elderly and younger patients, respectively, were significantly associated with a higher risk of composite outcome than achieved SBP of 120-129 mmHg. Cox's proportional hazard analysis showed that the association between achieved SBP and risk of composite outcome and all-cause death had U-shaped relationships and identified a nadir of SBP of 135.6 and 128.9 mmHg, respectively, for composite outcome and 135.1 and 131.4 mmHg, respectively, for all-cause death in elderly and younger patients.

CONCLUSION

Compared with SBP of 120-129 mmHg, not only low achieved SBP of less than 120 mmHg but also high BP are associated with risk of adverse cardiovascular event and all-cause death in both elderly and younger patients with a distinct U-shaped relationship.

An untargeted metabolomics study of blood pressure: findings from the Bogalusa Heart Study

OBJECTIVE

To identify novel and confirm previously reported metabolites associated with SBP, DBP, and hypertension in a biracial sample of Bogalusa Heart Study (BHS) participants.

METHODS

We employed untargeted, ultra-high performance liquid chromatography tandem mass spectroscopy metabolomics profiling among 1249 BHS participants (427 African-Americans and 822 whites) with BP and covariable data collected during the 2013 to 2016 visit cycle. A total of 1202 metabolites were tested for associations with continuous and binary BP phenotypes using multiple linear and logistic regression models, respectively, in overall and race-stratified analyses.

RESULTS

A total of 24 novel metabolites robustly associated with BP, achieving Bonferroni-corrected P less than 4.16 × 10 in the overall analysis and consistent effect sizes across race groups. The identified metabolites included three amino acid and nucleotide metabolites from histidine, pyrimidine, or tryptophan metabolism sub-pathways, seven cofactor and vitamin or xenobiotic metabolites from the ascorbate and aldarate metabolism, bacterial/fungal, chemical, and food component sub-pathways, 10 lipid metabolites from the eicosanoid, phosphatidylcholine, phosphatidylethanolamine, and sphingolipid metabolism sub-pathways, and four still unnamed metabolites. Six previously described metabolites were robustly confirmed by our study (Bonferroni-corrected P < 4.95 × 10 and consistent effect directions across studies). Furthermore, previously reported metabolites for SBP, DBP, and hypertension demonstrated 5.92-fold, 4.77-fold, and 4.54-fold enrichment for nominally significant signals in the BHS (P = 3.08 × 10, 5.93 × 10, and 2.30 × 10, respectively).

CONCLUSION

In aggregate, our study provides new information about potential molecular mechanisms underlying BP regulation. We also demonstrate reproducibility of findings across studies despite differences in study populations and metabolite profiling methods.

Dietary Patterns and Their Association with CVD Risk Factors among Bangladeshi Adults: A Cross-Sectional Study

PURPOSE

The objective of this study was to evaluate the association between dietary patterns and CVD risk factors among adults.

METHODS

Demographic data, knowledge, attitude, practices toward CVD related data, dietary data, and some biochemical data were collected from 250 participants at Coronary Care Unit of Jashore 250 bedded Sadar Hospital in Jashore district. A multinomial logit regression method was used to examine the association between LDL and TG levels with the dietary diversity of CVD risk patients.

RESULTS

According to the BMI, most of the respondents were overweight. The respondent's practice level was poor than their knowledge and attitude level toward CVD. A positive correlation was found among the respondents' knowledge, attitude, and practice. Most of the CVD patient's troponin value and BP level were found higher than the acceptable limit. Along with their lipid profile level was not good. Most of them were in borderline risk condition of CVD and some had high risk. The patients who consumed a higher amount of red meat, egg, cheese, fast food, soft drinks, and salty snacks had more probability of increasing LDL and TG level in blood which was the major risk factors of CVD than the patients who consumed fish, chicken, pulse, nuts, fruits, and vegetables in their diet regularly.

CONCLUSION

This study suggests that the consumption of fatty foods, fast foods, and soft drinks leads to the probability of increasing LDL and TG levels in CVD risk patients.

Lights triggered differential accumulation of antioxidant and antidiabetic secondary metabolites in callus culture of Eclipta alba L

Eclipta alba L., also known as false daisy, is well known and commercially attractive plant with excellent hepatotoxic and antidiabetic activities. Light is considered a key modulator in plant morphogenesis and survival by regulating important physiological cascades. Current study was carried out to investigate growth and developmental aspects of E. alba under differential effect of multispectral lights. In vitro derived callus culture of E. alba was exposed to multispectral monochromatic lights under controlled aseptic conditions. Maximum dry weight was recorded in culture grown under red light (11.2 g/L) whereas negative effect was observed under exposure of yellow light on callus growth (4.87 g/L). Furthermore, red light significantly enhanced phenolics and flavonoids content (TPC: 57.8 mg/g, TFC: 11.1 mg/g) in callus cultures compared to rest of lights. HPLC analysis further confirmed highest accumulation of four major compounds i.e. coumarin (1.26 mg/g), eclalbatin (5.00 mg/g), wedelolactone (32.54 mg/g) and demethylwedelolactone (23.67 mg/g) and two minor compounds (β-amyrin: 0.38 mg/g, luteolin: 0.39 mg/g) in red light treated culture whereas stigmasterol was found optimum (0.22 mg/g) under blue light. In vitro based biological activities including antioxidant, antidiabetic and lipase inhibitory assays showed optimum values in cultures exposed to red light, suggesting crucial role of these phytochemicals in the enhancement of the therapeutic potential of E. alba. These results clearly revealed that the use of multispectral lights in in vitro cultures could be an effective strategy for enhanced production of phytochemicals.

Credibility of self-reported health parameters in elderly population

AIM

Examining the credibility of self-reported height, weight, and blood pressure by the elderly population using a tablet in a retirement residence, and examining the influence of health beliefs on the self-reporting credibility.

BACKGROUND

Obesity is a major problem with rising prevalence in the western world. Hypertension is also a significant risk factor for cardiovascular diseases. Self-report, remotely from the clinic, becomes even more essential when patients are encouraged to avoid visiting the clinic as during the COVID-19 pandemic. Self-reporting of height and weight is suspected of leading to underestimation of obesity prevalence in the population; however, it has not been well studied in the elderly population.The Health Belief Model tries to predict and explain decision making of patients based on the patient's health beliefs.

METHODS

Residents of a retirement home network filled a questionnaire about their health beliefs regarding hypertension and obesity and self-reported their height, weight, and blood pressure. Blood pressure, height, and weight were then measured and compared to the patients' self-reporting.

FINDINGS

Ninety residents, aged 84.90 ± 5.88, filled the questionnaire. From a clinical perspective, the overall gap between the measured and the self-reported BMI (M = 1.43, SD = 2.72), which represents an absolute gap of 0.74 kilograms and 2.95 centimeters, is expected to have only a mild influence on the physician's clinical evaluation of the patient's medical condition. This can allow the physician to estimate their patient's BMI status before the medical consultation and physical examination upon the patient's self-reporting. Patients' dichotomous (normal/abnormal) self-report of their blood pressure condition was relatively credible: positive predictive value (PPV) of 77.78% for normal blood pressure (BP) and 78.57% for abnormal BP. The relatively high PPV of BP self-reporting demonstrates an option for the physician to recognize patients at risk. Regression analysis found no correlation between the anthropometric parameters and the Health Belief Model.

Circulating level of interleukin-6 in relation to body mass indices and lipid profile in Egyptian adults with overweight and obesity

Background

Obesity is an important feature of metabolic syndrome, and the link between them has been attributed to the state of chronic inflammatory process.

The purpose of the study is to investigate the relation of circulating level of IL-6 as an inflammatory cytokine to body mass index and lipid profile in adults with overweight and obesity.

Methods

This cross-sectional study included 15 adults with overweight, 45 with obesity (15 grade I, 15 grade II, and 15 grade III), and 25 average weight controls. Circulating IL-6 level and lipid profile were measured.

Results

Highly significant differences were found between study groups in different grades of obesity as regards weight, body mass index, serum triglycerides, and serum LDL-C. Circulating levels of IL6 were significantly higher in subjects with overweight and obesity. There were significantly positive correlations between circulating levels of IL6 and BMI in subjects with grade III obesity and negative correlation with serum HDL-C in subjects with grade II obesity.

Conclusion

High circulating level of IL-6 could reflect the intensity of the chronic and systemic inflammation that develops with high degrees of obesity, which might contribute to the development of atherosclerosis and coronary heart diseases, both directly and by reducing HDL-C levels.

Non-Adherence to WHO Recommendations Regarding Infant Feeding Practices Results in Dilemma of Malnourishment: A Community-Based Prospective Cohort Study Conducted in Karachi, Pakistan

Background The prevalence of chronic malnutrition and its associated morbid outcomes has been a significant cause of health loss globally, affecting millions of children hampering their mental, physical, social, and immune system development. World Health Organization's (WHO) recommendations presenting infant feeding guidelines have largely controlled this burden. However, developing countries including Pakistan have failed to promote these guidelines and still succumb to a huge burden of morbidity and mortality secondary to malnourishment among infants. Methodology Our study is a prospective cohort including 300 infants without predisposing congenital anomaly, followed from 6 months to 18 months of age. The primary outcome involved was classifying patients as malnourished based on anthropometric measurements, assessing the prevalence of co-morbidities and comparison of results in compliance with WHO guidelines. Results A total of 276 infants were included and the rest were lost to follow-up. Stratification on socioeconomic status was done; 53% of infants were diagnosed as malnourished, either due to stunted growth, underweight, or both. The odds of development of malnourishment based on non-adherence to WHO guidelines on breastfeeding were 2.87 (p=0.001). The incidence of morbid complications was higher in the malnourished group, including gastrointestinal and respiratory tract infections. Conclusion The implementation of WHO recommendations on infant feeding techniques can prove to be a pivotal instrument to control the soaring index of morbidities and mortalities associated with malnourishment. A strong focus on parental education and awareness among masses is required for its promulgation and controlling the infant health burden linked to this preventable condition.

Physical inactivity and head and neck cancer mortality

BACKGROUND

This study was performed to examine the association between adulthood recreational physical inactivity (PIA) and mortality among patients with cancers of the head and neck.

METHODS

Patients with head and neck cancer at Roswell Park between years 1990 to 1998 were included (N = 305). Multivariable Cox proportional hazard ratios (HR) with corresponding 95% confidence intervals (CI) were used to analyze the association between PIA and risk of dying.

RESULTS

There was a 1.40-fold increase in risk of dying among PIA patients, when compared to active patients with head and neck cancers (HR = 1.40, CI: 1.03-1.91). This was observed greater in PIA women (HR = 2.40, CI: 1.28-4.52), patients who were overweight/obese (HR = 1.76, CI: 1.09-2.85), patients with pharynx as the primary site (HR = 1.85, CI: 1.01-3.38), and patients with distant metastasis (HR = 5.19, CI: 1.37-19.65).

CONCLUSION

Physically inactive patients with head and neck cancers are at significantly greater risk of dying when compared to patients who are active.

A multiple risk factor program is associated with decreased risk of cardiovascular disease in 70-year-olds: A cohort study from Sweden

BACKGROUND

In individuals below 65 years of age, primary prevention programs have not been successful in reducing the risk of cardiovascular disease (CVD) and death. However, no large study to our knowledge has previously evaluated the effects of prevention programs in individuals aged 65 years or older. The present cohort study evaluated the risk of CVD in a primary prevention program for community-dwelling 70-year-olds.

METHOD AND FINDINGS

In 2012-2017, we included 3,613 community-dwelling 70-year-olds living in Umeå, in the north of Sweden, in a health survey and multidimensional prevention program (the Healthy Ageing Initiative [HAI]). Classic risk factors for CVD were evaluated, such as blood pressure, lipid levels, obesity, and physical inactivity. In the current analysis, each HAI participant was propensity-score-matched to 4 controls (n = 14,452) from the general Swedish population using national databases. The matching variables included age, sex, diagnoses, medication use, and socioeconomic factors. The primary outcome was the composite of myocardial infarction, angina pectoris, and stroke. The 18,065 participants and controls were followed for a mean of 2.5 (range 0-6) years. The primary outcome occurred in 128 (3.5%) HAI participants and 636 (4.4%) controls (hazard ratio [HR] 0.80, 95% CI 0.66-0.97, p = 0.026). In HAI participants, high baseline levels of blood pressure and lipids were associated with subsequent initiation of antihypertensive and lipid-lowering therapy, respectively, as well as with decreases in blood pressure and lipids during follow-up. In an intention-to-treat approach, the risk of the primary outcome was lower when comparing all 70-year-olds in Umeå, regardless of participation in HAI, to 70-year-olds in the rest of Sweden for the first 6 years of the HAI project (HR 0.87, 95% CI 0.77-0.97, p = 0.014). In contrast, the risk was similar in the 6-year period before the project started (HR 1.04, 95% CI 0.93-1.17, p = 0.03 for interaction). Limitations of the study include the observational design and that changes in blood pressure and lipid levels likely were influenced by regression towards the mean.

CONCLUSIONS

In this study, a primary prevention program was associated with a lower risk of CVD in community-dwelling 70-year-olds. With the limitation of this being an observational study, the associations may partly be explained by improved control of classic risk factors for CVD with the program.

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular risk-changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Evaluation of a Pharmacist-Managed Hypertension Clinic in a Rural Primary Care Setting

OBJECTIVE

To describe clinical pharmacy services provided in a rural North Carolina primary care clinic and assess the impact of these services on systolic and diastolic blood pressures in patients with uncontrolled hypertension.

METHODS

This single-center, retrospective study evaluated change in systolic and diastolic blood pressures from baseline, percentage of patients with blood pressure reductions, percentage at The Eight Joint National Committee (JNC 8) goal blood pressure, percentage at care gap closure defined as obtaining a blood pressure <140/90 mm Hg, and time to reach care gap closure.

RESULTS

The mean change in systolic blood pressure was -20.1 mm Hg (14.716-25.418, P < .0001) and the mean change in diastolic blood pressure was -8.8 mm Hg (5.449-12.117, P < .0001). Eighty percent of patients experienced blood pressure reductions from baseline, 51% met their respective JNC 8 goal blood pressure, and 48% met care gap closure. The average time to reach care gap closure was 23 weeks.

CONCLUSION

When embedded within a primary care clinic in a rural setting, a pharmacist-managed hypertension clinic significantly improved both systolic and diastolic blood pressures of patients with uncontrolled hypertension.

Differences in Frequency of Visits to Pediatric Primary Care Practices and Emergency Departments by Body Mass Index

OBJECTIVES

To examine differences in utilization across health care settings among children by body mass index (BMI) categories to help identify opportunities for interventions.

METHODS

A retrospective study was conducted using 1 year of electronic health records following an index primary care visit for children 3 to 17 years old in 2016. Index visits occurred at >40 pediatric practices affiliated with a Northeastern health system. Using normal BMI as a reference group, we examined the extent to which children's BMI percentile categories were associated with primary care visits, emergency department (ED) visits, hospitalizations, and ED visit acuity. Age, sex, race/ethnicity, and insurance status were used as covariates.

RESULTS

Of those with biologically plausible values for height and weight (n = 30,352), the prevalences of overweight, obesity, and severe obesity were 16.3%, 12.4%, and 5.7%, respectively. Children outside of the normal BMI range made more primary care visits; however, relative patterns of ED utilization were not consistent. Children with obesity versus normal BMI were less likely to have ED visits of high acuity. Risk of hospitalization was higher among children with overweight or severe obesity.

CONCLUSIONS

Children's BMI categories were associated with health care utilization, specifically primary care visits, ED visits, and hospitalizations. Further investigation is needed to explore the drivers of these differences in utilization, such as the impact of stigma and perceived weight bias on care-seeking patterns, and to examine the role of settings outside of primary care in pediatric weight management.

Long-term exposure to airborne particulate matter of 1 μm or less and blood pressure in healthy young adults: A national study with 1.2 million pregnancy planners

No evidence exists concerning the effect of airborne particulate matter of 1 μm or less (PM₁) on blood pressure of young adults planning for pregnancy. We collected health examination information of about 1.2 million couples (aged 18-45 years) from a national birth cohort in China from Jan 1, 2013 to Oct 1, 2014 and matched their home address to daily PM₁ and PM_2.5 concentrations, which were predicted by remote sensing information. Generalized additive mixed models were used to analyze associations between long-term exposure to PM and blood pressure, after controlling for individual factors. A 10 μg/m³ increase in PM₁ was associated with increased systolic blood pressure (SBP) for 0.26 (95%CI: 0.24, 0.29) mmHg in females and 0.29 (95%CI: 0.26, 0.31) mmHg in males, respectively. PM₁ was also associated with increased DBP for 0.22 (95%CI: 0.20, 0.23) mmHg in females and 0.17 (95%CI: 0.15, 0.19) mmHg in males, respectively. Similar effects on blood pressure were found for PM_2.5, meanwhile, the effect of PM_2.5 on SBP increased with the scale of PM₁ included in PM_2.5 (p for interaction term <0.01). In summary, long-term exposure to PM₁ as well as PM_2.5 was associated with increased SBP and DBP of Chinese young adults planning for pregnancy.

Influence of Asian Ethnicities on Short- and Mid-term Outcomes Following Laparoscopic Sleeve Gastrectomy

PURPOSE

Prevalence of obesity in Asia has been on the increasing trend, with corresponding increase in utilisation of bariatric surgery. The objective of this study was to examine differences in weight loss outcomes following bariatric surgery between Asian ethnicities.

MATERIALS AND METHODS

A retrospective database review was conducted of patients undergoing primary laparoscopic sleeve gastrectomy between 2009 and 2013 in 14 centres from Singapore, Malaysia, Taiwan, Hong Kong, Japan, Korea, India, Australia, Switzerland, and the USA. All patients with available follow-up data at 12 months and 36 months post-surgery were included in this study. Outcome measures used were percentage excess weight loss (%EWL) and percentage total weight loss (%TWL). Differences in outcomes between ethnicities were analysed after adjusting for age, gender, baseline body mass index (BMI), and presence of diabetes.

RESULTS

The study population (n = 2150) consisted of 1122 Chinese, 187 Malays, 309 Indians, 67 Japanese, 259 Koreans, and 206 Caucasians. 67.1% were female and 32.9% were male. Mean age was 37.1 ± 11.2 years. Mean pre-operative BMI was 40.7 ± 8.1 kg/m². With the Caucasian population as reference, Japanese had the best %TWL (3.90, 95% CI 1.16-6.63, p < 0.05) and %EWL (18.55, 95% CI 10.33-26.77, p < 0.05) while the Malays had the worst outcomes. Both Chinese and Koreans had better %EWL but worse %TWL as compared to Caucasians and there were no significant differences with the Indian study group.

CONCLUSION

There are differences in weight loss outcomes following bariatric surgery between Asian ethnicities.

How Behavior Change Strategies are Used to Design Digital Interventions to Improve Medication Adherence and Blood Pressure Among Patients With Hypertension: Systematic Review

BACKGROUND

Information on how behavior change strategies have been used to design digital interventions (DIs) to improve blood pressure (BP) control or medication adherence (MA) for patients with hypertension is currently limited.

OBJECTIVE

Hypertension is a major modifiable risk factor for cardiovascular diseases and can be controlled with appropriate medication. Many interventions that target MA to improve BP are increasingly using modern digital technologies. This systematic review was conducted to discover how DIs have been designed to improve MA and BP control among patients with hypertension in the recent 10 years. Results were mapped into a matrix of change objectives using the Intervention Mapping framework to guide future development of technologies to improve MA and BP control.

METHODS

We included all the studies regarding DI development to improve MA or BP control for patients with hypertension published in PubMed from 2008 to 2018. All the DI components were mapped into a matrix of change objectives using the Intervention Mapping technique by eliciting the key determinant factors (from patient and health care team and system levels) and targeted patient behaviors.

RESULTS

The analysis included 54 eligible studies. The determinants were considered at two levels: patient and health care team and system. The most commonly described determinants at the patient level were lack of education, lack of self-awareness, lack of self-efficacy, and forgetfulness. Clinical inertia and an inadequate health workforce were the most commonly targeted determinants at the health care team and system level. Taking medication, interactive patient-provider communication, self-measurement, and lifestyle management were the most cited patient behaviors at both levels. Most of the DIs did not include support from peers or family members, despite its reported effectiveness and the rate of social media penetration.

CONCLUSIONS

This review highlights the need to design a multifaceted DI that can be personalized according to patient behavior(s) that need to be changed to overcome the key determinant(s) of low adherence to medication or uncontrolled BP among patients with hypertension, considering different levels including patient and healthcare team and system involvement.

Rates of other-cause mortality after radical cystectomy are decreasing over time-A population-based analysis over two decades

BACKGROUND AND OBJECTIVES

To investigate other-cause mortality (OCM) rates over time according to several baseline characteristics in bladder cancer (BCa) patients treated with radical cystectomy (RC).

METHODS

Within the Surveillance, Epidemiology, and End Results database (1988-2011), we identified 7702 T_1-2 N₀ M₀ urothelial BCa patients treated with RC. Temporal trends and multivariable Cox regression (MCR) analyses assessed 5-year OCM. Data were stratified according to the year of diagnosis (1988-1995 vs 1996-2000 vs 2001-2004 vs 2005-2008 vs 2009-2011), age group (<60 vs 60-75 vs >75 years), sex, race, marital status, and socioeconomic status.

RESULTS

Overall, OCM rates decreased from 13.9% in 1988-1995 to 8.6% in 2009-2011. The greatest decrease was recorded in elderly (>75) patients (32%-16%, slope: -0.55% per year; P = .01), followed by patients aged 60 to 75 (21%-5%, slope: -0.35% per year; P = .01), unmarried patients (16%-10%, slope: -0.26% per year; P < .001), male patients (14%-8.9%, slope: -0.23% per year), and African Americans (16%-11%, slope: -0.27% per year; P < .001). MCR models corroborated these results.

CONCLUSIONS

Most important decrease in OCM after RC over the last decades was recorded in the elderly, unmarried, and male patients. Nonetheless, these three patient groups still represent ideal targets for efforts aimed at minimizing the morbidity and mortality after RC, as their risk of OCM is higher than in others.

Whole-Genome Promoter Profiling of Plasma DNA Exhibits Diagnostic Value for Placenta-Origin Pregnancy Complications

Placenta-origin pregnancy complications, including preeclampsia (PE), gestational diabetes mellitus (GDM), fetal growth restriction (FGR), and macrosomia (MA) are common occurrences in pregnancy, resulting in significant morbidity and mortality for both mother and fetus. However, despite their frequency, there are no reliable methods for the early diagnosis of these complications. Since cfDNA is mainly derived from placental trophoblasts and maternal hematopoietic cells, it might have information for gene expression which can be used for disease prediction. Here, low coverage whole-genome sequencing on plasma DNA from 2,199 pregnancies is performed based on retrospective cohorts of 3,200 pregnant women. Read depth in the promoter regions is examined to define read-depth distribution patterns of promoters for pregnancy complications and controls. Using machine learning methods, classifiers for predicting pregnancy complications are developed. Using these classifiers, complications are successfully predicted with an accuracy of 80.3%, 78.9%, 72.1%, and 83.0% for MA, FGR, GDM, and PE, respectively. The findings suggest that promoter profiling of cfDNA may be used as a biological biomarker for predicting pregnancy complications at early gestational age.

Hostility, depression and incident cardiac events in the GAZEL cohort

BACKGROUND

Psychological factors such as hostility and depression have been associated with cardiovascular disease. However, their role in predicting incident cardiac events independently one of another is not clear.

METHODS

Among 10,304 GAZEL middle-aged workers free of cardiovascular diseases in 1993, 581 incident cardiac events were validated from 1994-2014. Hostile traits (cognitive hostility, behavioral hostility, irritability and negativism) were assessed with the Buss and Durkee Hostility Inventory at baseline. Depressive symptoms were assessed at baseline and every three years with the Center for Epidemiological Studies Depression scale. We used Cox proportional hazards models to calculate hazard ratios (HR) of hostile traits for incident cardiac events adjusting for baseline self-reported socio-demographics and family history of coronary heart diseases (model 1), then additionally for time-dependent depressive symptoms (either as a binary or continuous variable) (model 2) and for yearly self-reported modifiable cardiovascular risk factors (physical activity, smoking, body mass index, diabetes, dyslipidemia and hypertension) (model 3).

RESULTS

In Model 1, the only hostile trait associated with incident cardiac events was irritability (HR for one interquartile range: 1.16, 95% confidence interval: 1.02-1.32). This association was no longer statistically significant when further adjusting for depressive symptoms. Depressive symptoms, in turn, remained significant predictors of cardiac events with HRs ranging from 1.40-1.49 (binary).

LIMITATIONS

Hostility traits were measured only once.

CONCLUSIONS

Depressive symptoms might explain the association between irritability and cardiac events and should therefore be prioritized in interventions aiming to prevent cardiovascular disease. Further research is needed to identify the mechanisms underlying this association.

Global and regional estimates and projections of diabetes-related health expenditure: Results from the International Diabetes Federation Diabetes Atlas, 9th edition

AIMS

Diabetes and its complications have a significant economic impact on individuals and their families, health systems and national economies.

METHODS

The direct health expenditure of diabetes was calculated relying on the following inputs: diagnosed and undiagnosed diabetes prevalence estimates, United Nations population estimates, World Health Organization health expenditure per capita and ratios of health expenditure for people with diabetes compared to people without diabetes.

RESULTS

The estimated global direct health expenditure on diabetes in 2019 is USD 760 billion and is expected to grow to a projected USD 825 billion by 2030 and USD 845 billion by 2045. There is a wide variation in annual health expenditures on diabetes. The United States of America has the highest estimated expenditure with USD 294.6 billion, followed by China and Brazil, with USD 109.0 billion and USD 52.3 billion, respectively. The age group with the largest annual diabetes-related health expenditure is 60-69 years with USD 177.7 billion, followed by 50-59 years, and 70-79 years with USD 173.0 billion and USD 171.5 billion, respectively. Slightly higher diabetes-related health expenditure is seen in women than in men (USD 382.6 billion vs. USD 377.6 billion, respectively). The same difference is expected to be present in 2030 and 2045.

CONCLUSIONS

There were large disparities between high-, middle- and low-income countries with total health expenditures in high-income countries being over 300 times those in low-income countries. The ratio for annual direct health expenditure per person between these groups of countries is more than 38-fold.

The impact of chronic liver disease in patients receiving active pharmacological therapy for opioid use disorder: One-year findings from a prospective cohort study

INTRODUCTION

Despite the demonstrated benefit of methadone, the incidence opioid-related overdose, and its associated mortality continues to rise at an alarming rate. The impact of high prevalence comorbid features such as chronic liver disease (CLD) on methadone treatment response remain unclear.

AIM

To determine whether CLD is associated with poor response to methadone treatment.

METHODS

Using a well-established multi-center cohort from the Genetics of Opioid Addiction Study (GENOA), we evaluated if presence of CLD among 1234 eligible patients with opioid use disorder receiving methadone treatment impacted health and behavioural responses to treatment. CLD was classified as any liver disorder/dysfunction present for a minimum period of six months. Serial urine toxicology assessments were used to determine treatment response. The effect of CLD was determined using a multi-variable logistic regression model.

RESULTS

CLD was present in 25 % (n = 314) of the population. On average, patients with CLD were found to be older (mean age 44 vs 36 years, p < 0.0001), unemployed (81.8 % vs 61 %, p < 0.0001), and receiving government disability benefits at significantly higher rates (21.9 % vs 11 %, p < 0.0001). Increased levels of physical craving, emotional stress, as well as health risk behaviors were noted in CLD patients. Findings from the multi-variable model demonstrate a 68 % increased risk for dangerous opioid consumption behaviors (Odds Ration [OR]: 1.68, 95 % Confidence Interval [CI] 1.22, 2.31, p = 0.001) among patients with CLD. Methadone dose (OR: 0.76, 95 % CI 0.70, 0.81, p < 0.0001) was shown to be protective with a significant risk reduction of 24 % per 20 mg increase in methadone. Duration in treatment was also found to be protective (OR: 0.99, 95 % CI 0.97, 0.99, p < 0.0001).

CONCLUSION

CLD poses a distinct risk for patients with opioid addiction. Closer drug monitoring, and substance use contingency management should be considered to reduce mortality risk in these patients.

Comparison of Ambulatory Tonometric and Oscillometric Blood Pressure Monitoring in Hypertensive Patients

Aim

Correct measurement of blood pressure (BP) is important for optimal diagnosis and treatment of patients with hypertension. The aim of this study was to compare a wrist-worn device using tonometric measurements of BP to a conventional device using oscillometric measurements of 24 h BP, diagnosing of hypertension, and non-dipping.

Methods

One-hundred patients in the Renal Outpatient Clinic had 24 h ambulatory BP monitoring performed with a tonometric device, BPro, and an oscillometric device, A&D, simultaneously.

Results

Twenty-four-hour and daytime systolic BP was significantly lower using tonometric monitoring compared to oscillometric (7 and 6 mmHg, respectively, p< 0.001). In the population of patients diagnosed with hypertension, the tonometric device diagnosed 90% of patients with uncontrolled hypertension correctly (positive predictive value), whereas 49% of patients classified as normotensive were uncontrolled hypertensive (negative predictive value). The mean difference between relative nocturnal BP decrease between tonometric and oscillometric was 2±8% (p< 0.01), and 33% of patients classified as dippers were non-dippers (negative predictive value).

Conclusion

Using the BPro device for tonometric monitoring of BP and classification of hypertension and non-dipping in patients diagnosed with hypertension leads to misclassification of patients. Therefore, the BPro device is not suitable for clinical practice in hypertensive patients from a Renal Outpatient Clinic.

A study to assess prevalence of anaemia among beneficiaries of Anaemia Mukt Bharat Campaign in Uttarakhand

Context:

Anaemia is defined as a decreased concentration of blood haemoglobin. It is one of the most common nutritional deficiency diseases observed globally affecting both developing and developed countries.

Aims:

To find out the prevalence of anaemia among the beneficiaries of Anaemia Mukt Bharat and its association with age and gender.

Settings and Design:

A cross-sectional study was conducted in Uttarakhand by AIIMS Rishikesh in a month-long campaign including 5,776 beneficiaries. Camps were organized at the hospital campus, schools, district hospitals, Community Health Centre (CHC), Primary Health Centre (PHC), subcentres (SC), Anganwadi Centres (AWCs), slum areas, adolescent health day celebration sites and Village Health and Nutrition Day (VHND) sites.

Methods and Material:

Data on age and gender along with haemoglobin level using HemoCue Haemoglobinometer was collected.

Statistical Analysis Used:

These data were entered into Microsoft Excel and analysed to calculate the prevalence of anaemia and its association with age and gender using Epi Info software version 7. Pearson's Chi-square test was applied. P value <0.05 was considered as significant.

Results:

Out of 5,776 participants 53.2% were anaemic. Females (54.6%) were more anaemic than males (45.1%). 33.5% of pregnant females were found to be anaemic.

Conclusions:

Prevalence of anaemia was very high among the study participants. It shows that anaemia is a major public health problem so efforts should be taken to reduce the prevalence of anaemia and promote the health of an individual, community as well as the country.

Micronutrients Potential of Underutilized Vegetables and Their Role in Fighting Hidden Hunger

BACKGROUND

Innumerable underutilized vegetable (UV) species have been utilized as food and as folklore medicine since time immemorial. Such vegetables have been part and parcel of the food dishes, especially to the ancient rural and periurban dwellers. However, researchers and agricultural scientists have given little or no attention to such vegetables, as to what constitutes their potentials in curbing hidden hunger. To achieve the global Sustainable Development Goals, Tanzania needs to address the issue of food insecurity through the use of not only grains, fruits, and edible insects but also through embracing the UVs. The overall objective of this study was to screen the indigenous vegetables with nutritional and health claims from communities in Kilimanjaro and Morogoro regions.

METHODS

Quantitative data were obtained by conducting laboratory nutrient and antinutrients composition analyses as per standard Association of Official Analytical Chemists (AOAC) methods. This was carried out to determine the moisture content, micronutrient, and antinutrients composition of the selected UVs.

RESULTS

The nutritional and medicinal claims of the selected UVs mentioned during interviews were validated by data obtained from laboratory nutrient and antinutrients composition analyses. Chemical analyses revealed that vitamin A, B1, B2, B3, and C contents ranged from 2.50-6.67, 18.94-182.95, 0.18-0.76, 0.09-0.43, and 46.52-198.08 mg/100 g, respectively. Minerals, on the other hand, Ca, Fe, Mg, and Zn contents ranged from 60.28-421.03, 4.28-21.05, 191.12-1151.91, and 4.28-21.10 mg/100, respectively. Moisture content, oxalates, and phytates contents ranged from 78.59-95.49%, 1.28-3.15, and 1.64-6.18 mg/100 g, respectively.

CONCLUSION

The findings from the study added credence to the selected UVs that they are rich sources of micronutrients and crucial in daily human diet to curb hidden hunger.

Blood pressure targets in chronic kidney disease: an update on the evidence

PURPOSE OF REVIEW

Hypertension is the leading modifiable cause of cardiovascular events and of mortality and is generally considered as a direct cause of chronic kidney disease. Defining optimal blood pressure targets in patients with chronic kidney disease is therefore of critical importance.

RECENT FINDINGS

Over the recent years, results and post-hoc analyses of several important trials comparing blood pressure targets which included patients with chronic kidney disease have been published. Although these results provide important means to understand the consequences of high blood pressure and to improve the management of hypertension in chronic kidney disease, they led to remarkably different interpretations and recommendations in the current guidelines.

SUMMARY

The present review summarizes the current evidence and areas of controversy for the definition of blood pressure targets in patients with chronic kidney disease.

Sex differences in the efficacy of antihypertensive treatment in preventing cardiovascular outcomes and reducing blood pressure: protocol for a systematic review and meta-analysis

INTRODUCTION

Hypertension is a leading cause of mortality worldwide and its prevalence is expected to rise over the next decade. Sex differences exist in the epidemiology and pathophysiology of hypertension. It is well established that antihypertensive treatment can significantly reduce the risk for stroke and other cardiovascular disease events. However, it remains unclear whether this effect is dependent on sex. In this protocol, we outlined a systematic review and meta-analysis to evaluate the effects of antihypertensive therapy in (1) reducing blood pressure and (2) preventing cardiovascular morbidity and mortality outcomes for each sex separately.

METHODS AND ANALYSIS

The following electronic databases will be searched: Medline, Embase, The Cochrane Library, PubMed, Cumulative Index of Nursing and Allied Health Literature Plus, Web of Science, grey literature (Google Scholar) and several trial registries. Search strategies will be designed to identify human adult (≥18) randomised (and non-randomised) controlled trials, prospective and retrospective cohort studies, and case-control studies concerning 'sex-specific differences associated with the efficacy of antihypertensive treatment'. A preliminary search strategy was developed for Medline (1946-16 September 2019). Two investigators will independently review each article included in the final analysis. Primary outcomes investigated are cardiovascular morbidity and mortality and systolic and diastolic blood pressure. Pooled analyses will be conducted using the random-effects model. Publication bias will be assessed by visual inspection of funnel plots and by Begg's and Egger's statistical tests. Between-studies heterogeneity will be measured using the I² test (p<0.10). Sources of heterogeneity will be explored by sensitivity, subgroup and metaregression analyses.

ETHICS AND DISSEMINATION

This is the first meta-analysis that will comprehensively compare the efficacy of antihypertensive treatment regimens between men and women. Findings will be shared through scientific conferences and societies, social media and consumer advocacy groups. Results will be used to inform the current guidelines for management of hypertension in men and women by demonstrating the importance of implementing sex-specific recommendations. Ethical considerations are not applicable for this protocol.

Sleep disturbances and back pain : Systematic review and meta-analysis

BACKGROUND

In today's society, sleep disturbances and back pain are both common problems which threaten health. Although some studies have focused on the effects of sleep disturbances on back pain, no meta-analysis has been done. The purpose of this study is to systematically review and perform a meta-analysis on the effects of sleep disturbances on back pain.

METHODS

A literature search in PubMed, Scopus and EMBASE with keywords until June 2019 was performed. The eligible articles were evaluated qualitatively and the results were pooled using random effects. The publication bias and the degree of heterogeneity were examined.

RESULTS

In all, 21 studies were included in the meta-analysis. Sleep disturbances were associated with back pain (odds ratio 1.52; confidence interval [CI] 1.37-1.68; P < 0.001). In men, the odds ratio was 1.49 (CI 1.34-1.65; P < 0.001). In women, the odds ratio was 1.56 (CI 1.33-1.81; P < 0.001). Begg's test (P = 0.856) and Egger test (P = 0.188) did not show any publication bias. A funnel plot and trim-and-fill method showed publication bias, and heterogeneity was also high.

CONCLUSIONS

Sleep disturbance is associated with risk of back pain. Improving sleep can be a deterrent against back pain. Therefore, interventions to reduce sleep disturbances can help to improve health. On the other hand, the relationship between sleep disturbances and back pain can be two-sided, and back pain can also lead to sleep disturbances. Not only in view of the lifetime prevalence and the multifactorial impairments of those affected, but also in consideration of social and economic burdens, this issue will remain of considerable importance.

BMI modified the association of current smoking with the incidence of hypertension in Chinese population: a 22-year cohort study

Background

There was little known on how the interaction effect between obesity and current smoking affected the incidence of hypertension. The aim of this study was to investigate how body mass index (BMI) modified the effect of current smoking on the incidence of hypertension.

Methods

Data were obtained from the China Health and Nutrition Survey (CHNS). According to the WHO recommendations for Chinese people, the normal weight, overweight, and obesity were defined using the BMI cutoff values 18.5 kg/m², 23.0 kg/m², and 27.5 kg/m, respectively. Current smokers were defined as having smoked at least 100 cigarettes or electronic cigarettes, 20 cigars, or 20 tobacco pipes and other type of tobacco in the last 30 days preceding the survey. Hypertension was defined as systolic blood pressure (SBP)/ diastolic blood pressure (DBP) ≥ 140/90 mmHg, use of anti-hypertensive medications, or a self-reported diagnosis.

Results

This study included 12,900 subjects. There were interaction effects between obesity and current smoking in females (P = 0.030) and the 50–59 years group (P = 0.049). Current smoking was a significant predictor of incident hypertension only in the total and female populations with normal weight (HR: 1.119 and 1.274; HR 95% CI: 1.013–1.236 and 1.143–1.415; and P = 0.027 and 0.040, respectively). Stratified by age, current smoking affected the development of hypertension only in the 50–59 years subjects with the normal weight (HR: 1.356; HR 95% CI: 1.084–1.697; and P = 0.008).

Conclusions

Current smoking was a significant predictor of incident hypertension only in the female and middle-age populations with normal weight but not in the overweight and obesity as well as the younger and elder populations.

Association between alcohol consumption and hypertension in Chinese adults: Findings from the CHNS

OBJECTIVES

To obtain information about alcohol consumption (henceforth "drinking") among Chinese adults from 1991 to 2011, and to explore the association between drinking behavior and hypertension.

METHODS

According to the longitudinal data obtained in the China Health and Nutrition Survey (1991-2011), 50,013 records of 12,577 adults were selected by applying eligibility criteria. The chi-test was employed to explore the association between drinking and hypertension, by considering the frequency of drinking, daily alcohol intake, alcohol type, and the prevalence of hypertension. A multilevel logistic regression model was used to analyze the longitudinal association between drinking frequency and the prevalence of hypertension.

RESULTS

The prevalence of hypertension was higher in participants with a high drinking frequency than in those with a low drinking frequency among both males and females (p < 0.001). A step increase in daily alcohol intake was not associated with any obvious changes in the prevalence of hypertension in males, but the prevalence in each drinking group was higher than that in the nondrinking group, the prevalence of hypertension in females was lowest among those with a daily alcohol intake below 15 g. The types of alcohol consumed differed significantly between males and females (p < 0.001). Longitudinal analysis results showed that compared with the nondrinking group, drinking frequency ≤2 times/week was positively correlated with hypertension in both males (OR = 1.51, 95% CI = 1.26-1.82, p < 0.001) and females (OR = 1.67, 95% CI = 1.08-2.58, p < 0.05) after adjusting for covariates, meanwhile, the same positive correlation also occurred in males with drinking frequency >2 times/week (OR = 2.13, 95% CI = 1.77-2.56, p < 0.05), the risk of hypertension increased with the increase in drinking frequency.

CONCLUSIONS

Drinking can increase the prevalence of hypertension in Chinese males and females. From the analysis results of longitudinal data, drinking alcohol is still an important risk factor for hypertension among Chinese subjects, especially those who drink with high frequency.

Multilevel analyses of related public health indicators: The European Surveillance of Congenital Anomalies (EUROCAT) Public Health Indicators

BACKGROUND

Public health organisations use public health indicators to guide health policy. Joint analysis of multiple public health indicators can provide a more comprehensive understanding of what they are intended to evaluate.

OBJECTIVE

To analyse variaitons in the prevalence of congenital anomaly-related perinatal mortality attributable to termination of pregnancy for foetal anomaly (TOPFA) and prenatal diagnosis of congenital anomaly prevalence.

METHODS

We included 55 363 cases of congenital anomalies notified to 18 EUROCAT registers in 10 countries during 2008-12. Incidence rate ratios (IRR) representing the risk of congenital anomaly-related perinatal mortality according to TOPFA and prenatal diagnosis prevalence were estimated using multilevel Poisson regression with country as a random effect. Between-country variation in congenital anomaly-related perinatal mortality was measured using random effects and compared between the null and adjusted models to estimate the percentage of variation in congenital anomaly-related perinatal mortality accounted for by TOPFA and prenatal diagnosis.

RESULTS

The risk of congenital anomaly-related perinatal mortality decreased as TOPFA and prenatal diagnosis prevalence increased (IRR 0.79, 95% confidence interval [CI] 0.72, 0.86; and IRR 0.88, 95% CI 0.79, 0.97). Modelling TOPFA and prenatal diagnosis together, the association between congenital anomaly-related perinatal mortality and TOPFA prevalence became stronger (RR 0.70, 95% CI 0.61, 0.81). The prevalence of TOPFA and prenatal diagnosis accounted for 75.5% and 37.7% of the between-country variation in perinatal mortality, respectively.

CONCLUSION

We demonstrated an approach for analysing inter-linked public health indicators. In this example, as TOPFA and prenatal diagnosis of congenital anomaly prevalence decreased, the risk of congenital anomaly-related perinatal mortality increased. Much of the between-country variation in congenital anomaly-related perinatal mortality was accounted for by TOPFA, with a smaller proportion accounted for by prenatal diagnosis.

Does the Polypill Improve Patient Adherence Compared to Its Individual Formulations? A Systematic Review

Many patients, especially those with a high pill burden and multiple chronic illnesses, are less adherent to medication. In medication treatments utilizing polypills, this problem might be diminished since multiple drugs are fused into one formulation and, therefore, the therapy regimen is simplified. This systematic review summarized evidence to assess the effect of polypills on medication adherence. The following databases were searched for articles published between 1 January 2000, and 14 May 2019: PubMed, Web of Science, Cochrane Library, and Scopus. Medication adherence was the only outcome assessed, regardless of the method of measuring it. Sixty-seven original peer-reviewed articles were selected. Adherence to polypill regimens was significantly higher in 56 articles (84%) compared to multiple pill regimens. This finding was also supported by the results of 13 out of 17 selected previously published systematic reviews and meta-analyses dealing with this topic. Adherence can be improved through the formulation of polypills, which is probably why the interest in researching them is growing. There are many polypills on the market, but the adherence studies so far focused mainly on a small range of medical conditions.

Early predictors of left ventricular dysfunction in hypertensive patients: comparative cross-section study

Identifying hypertensive patients who are at higher risk and thus to assess early echocardiographic markers of LV dysfunction in this population. Our comparative cross-section study included 100 patients divided into two groups; Group1: Hypertensive with preserved ejection fraction (EF) (n = 50) & Group 2: Normotensive (Control) (n = 50). Who underwent 2D Echo imaging with analysis of multible parameters of LV systolic and diastolic function including: left atrial volume index (LAVI), LV mass index, relative wall thickness, LV systolic function (EF%), diastolic function (trans-mitral pulsed and tissue Doppler study of E, A, e'-wave velocities& E/A, E/e' ratios), Global myocardial longitudinal strain (GLS) by speckle tracking echocardiography (STE) and the early diastolic driving force (DF) which calculated as (DF = mass × acceleration; DF = 0.004E²/DT). We reported significant differences between the two groups in LV mass, LA volume and DF, which were all elevated in the hypertensive group, as well as reduced GLS magnitude. We also reported that a GLS cutoff of > - 18.1% was able to accurately "predict subclinical LV systolic dysfunction". Finally, DF showed a moderate correlation (r = 0.33, which was established with statistical confidence) with E/e' ratio, and a DF cutoff of ≥ 0.25 N was able to accurately "predict subclinical diastolic dysfunction". GLS cutoff > - 18.1% could be used for early prediction of LV systolic dysfunction in hypertensive. The early diastolic DF cutoff ≥ 0.25 N could be a useful tool for early prediction of LV diastolic dysfunction in hypertensive. These sensitive parameters could be used for early diagnosis and proper management for better outcomes.

Bayesian Joint Modeling of Longitudinal and Survival Time Measurement of Hypertension Patients

BACKGROUND

High blood pressure is a health risk for all populations, worldwide. Globally the number of people with uncontrolled hypertension rose by 70% between 1980 and 2008.

OBJECTIVE

This paper aims to investigate the association of survival time and fasting blood sugar levels of hypertension patients and identify the risk factors that affect the survival time of the patient.

METHODS

We considered a total of 430 random samples of hypertension patients who were followed-up at Yekatit-12 Hospital in Ethiopia from January 2013 to January 2019. A linear mixed effects model was used for the longitudinal outcomes (fasting blood sugar) with normality assumption, although four parametric accelerated failure time distributions: exponential, Weibull, lognormal and loglogistic are studied for the time-to-event data. The Bayesian joint models were defined through latent variables and association parameters and with specified noninformative prior distributions for the model parameters. Simulations are conducted using Gibbs sampler algorithm implemented in the WinBUGS software. The model selection criteria DIC is employed to identify the model with best fit to the data.

RESULTS

The findings from Bayesian joint models are consistent. The association parameter in each Bayesian joint model is significant. This implies that there is dependence between the two processes: longitudinal fasting blood sugar level and the time-to-death event under joint models. With investigation of the model comparison criteria, the Bayesian-Weibull model was preferred to analysize the current data sets. Based on joint analysis the baseline age, place of residence, family history of hypertension, khat intake, blood cholesterol level of the patient, hypertension disease stage, adherence to the treatment and related disease were associated factors that affect the survival time of hypertension patients.

CONCLUSION

The analysis suggests that there is strong association between longitudinal process (fasting blood sugar) and time-to-event data. The researcher recommends that all stakeholders should be aware of the consequences of these factors which can influence the survival time of hypertension patients in the study area.

Interpretation of Population Health Metrics: Environmental Lead Exposure as Exemplary Case

Our objective was to gain insight in the calculation and interpretation of population health metrics that inform disease prevention. Using as model environmental exposure to lead (ELE), a global pollutant, we assessed population health metrics derived from the Third National Health and Nutrition Examination Survey (1988 to 1994), the GBD (Global Burden of Disease Study 2010), and the Organization for Economic Co-operation and Development. In the National Health and Nutrition Examination Survey, the hazard ratio relating mortality over 19.3 years of follow-up to a blood lead increase at baseline from 1.0 to 6.7 µg/dL (10th–90th percentile interval) was 1.37 (95% CI, 1.17–1.60). The population-attributable fraction of blood lead was 18.0% (10.9%–26.1%). The number of preventable ELE-related deaths in the United States would be 412 000 per year (250 000–598 000). In GBD 2010, deaths and disability-adjusted life-years globally lost due to ELE were 0.67 million (0.58–0.78 million) and 0.56% (0.47%–0.66%), respectively. According to the 2017 Organization for Economic Co-operation and Development statistics, ELE-related welfare costs were $1 676 224 million worldwide. Extrapolations from the foregoing metrics assumed causality and reversibility of the association between mortality and blood lead, which at present-day ELE levels in developed nations is not established. Other issues limiting the interpretation of ELE-related population health metrics are the inflation of relative risk based on outdated blood lead levels, not differentiating relative from absolute risk, clustering of risk factors and exposures within individuals, residual confounding, and disregarding noncardiovascular disease and immigration in national ELE-associated welfare estimates. In conclusion, this review highlights the importance of critical thinking in translating population health metrics into cost-effective preventive strategies.

Synthesis and biological evaluation of novel biphenyl-furocoumarin derivatives as vasodilator agents

A series of novel biphenyl-furocoumarin derivatives were synthesized based on the nuclear structure of imperatorin and identified by IR, ¹H NMR, ¹³C NMR and MS, and evaluated for their ability to relax vessel on isolated rat mesenteric artery, basilar artery and renal artery, respectively. The majority of compounds demonstrated potent vasodilatation, and compound 8e expressed the highest activity (EC₅₀ = 0.56 μM) in MA. Compounds with fluorine at 2-position of 5-phenyl get better activity than others with chlorine or bromine, and the compounds containing a bulky structure had relatively low activity, such as 8c (EC₅₀ = 22.39 μM) in MA. As a follow-up, 8e, 10e, and 8c were docked into L-calcium channel (PDB code: 3G43) to explain the difference in the activity of the compounds.

The Andean Latin-American burden of diabetes attributable to high body mass index: A comparative risk assessment

BACKGROUND

Body mass index (BMI) has increased in Latin-America, but the implications for the diabetes burden have not been quantified. We estimated the proportion and absolute number of diabetes cases attributable to high BMI in Bolivia, Ecuador and Peru (Andean Latin-America), with estimation of region-level indicators in Peru.

METHODS

We estimated the population attributable fraction (PAF) of BMI on diabetes (regardless of type 1 or 2) from 1980 to 2014, including the number of cases attributable to overweight (BMI 25-<30), class I (30-<35), class II (BMI 35-<40) and class III (BMI ≥ 40) obesity. We used age- and sex-specific prevalence estimates of diabetes and BMI categories (NCD-RisC and Peru's DHS survey) combined with relative risks from population-based cohorts in Peru.

FINDINGS

Across Andean Latin-America in 2014, there were 1,258,313 diabetes cases attributable to high BMI: 209,855 in Bolivia, 367,440 in Ecuador and 681,018 in Peru. Between 1980 and 2010, the absolute proportion of diabetes cases attributable to class I obesity increased the most (from 12.9% to 27.2%) across the region. The second greatest increase was for class II obesity (from 3.6% to 16.5%). There was heterogeneity in the fraction of diabetes cases attributable to high BMI by region in Peru, as coastal regions had the largest fractions, and so did high-income regions.

INTERPRETATION

Over one million diabetes cases are attributable to high BMI in Andean Latin-America. Public health efforts should focus on implementing population-based interventions to reduce high BMI and to develop focused interventions targeted at those at highest risk of diabetes.

Baseline diet modifies the effects of dietary change

The Dietary Approaches to Stop Hypertension (DASH) eating pattern has been shown to reduce blood pressure (BP) in previous clinical trials. In the PREMIER study, an established behavioural intervention, with or without DASH, promoted greater weight loss than an advice-only control group, but effects of the DASH intervention on BP were weaker. In these analyses, PREMIER data were used to evaluate whether change in dairy product or fruit and vegetable (FV) intake during the first six intervention months impacted changes in weight and/or BP. Study participants were classified as having low or high intakes of dairy products (<1·5 v. ≥1·5 servings/d) and FV (<5 v. ≥5 servings/d) at baseline and 6 months. For dairy products, in particular, participants with higher baseline intakes tended to decrease their intakes during the intervention. In these analyses, subjects consuming <1·5 dairy servings/d at baseline whose intake increased during the intervention lost more weight than those whose intake decreased or remained low throughout (10·6 v. 7·0 pounds (4·8 v. 3·2 kg) lost, respectively, P = 0·002). The same was true for FV intake (11·0 v. 5·9 pounds (5·0 v. 2·7 kg) lost, P < 0·001). We also found synergistic effects of dairy products and FV on weight loss and BP reduction. Specifically, subjects who increased their intakes of dairy products and also consumed ≥5 servings of FV/d lost more weight and had greater reductions in BP than other groups; in addition, higher FV intakes had the greatest benefit to BP among those consuming more dairy products. These results provide evidence that the DASH pattern was most beneficial to individuals whose baseline diet was less consistent with DASH.

Methylphenidate and Reduced Overweight in Children With ADHD

Objective: The objective of this study was to investigate odds ratios of overweight/obesity in children with ADHD and to compare the change in body mass index (BMI) after initiation of methylphenidate treatment in normal versus overweight/obese children. Method: This population-based study included 724 children (<18 years), of whom 197 were girls. Odds ratios for overweight and obesity were calculated, comparing the study group with a reference group from the same area. After initiation of methylphenidate treatment, changes in BMI were assessed for up to 3 years. Results: Children with ADHD had an odds ratio of 1.87 (95% confidence interval [CI]: [1.60, 2.19]) for overweight/obesity. A decrease in BMI standard deviation score was identified 1 to 3 years into treatment. The decrease was beneficially greater in overweight/obese as compared with normal weight children-mean (SD) -0.64 (0.80) versus -0.39 (0.68); p = .001-and greater in girls. Conclusion: Medication with methylphenidate may facilitate favorable weight development in children with ADHD and overweight/obesity.